National Patient Safety Goals

National Patient Safety Goals 2009 Sanford USD Medical Center Working together to keep our patients safe

Dear Sanford Associates: The Patient Safety movement is the most important and transforming phenomena that has affected the healthcare industry in my lifetime. The national focus on patient safety is changing how medicine is practiced. Medical treatments are more effective, but also more complicated and dangerous today than they used to be. It is estimated that 40 to 50 patient injuries occur per 100 hospital admissions. Harm from these injuries reach both inpatients and outpatients (who might be your precious family member). To prevent harm we need to completely rethink how we approach health care. We must use what is termed a human-factors approach which looks at how we as human beings function in complex systems and how such systems can cause harm. The National Patient Safety Goals (NPSG s) are just one response to a national call to action to prevent patient harm. NPSG s are established by The Joint Commission to which we are each held accountable. The safety goals were formed in response to incidents of actual patient harm and patient deaths. We owe it to our patients to provide each one with the safest possible care. This booklet outlines goals for safe care which must be applied to every patient, every time, everywhere. Safe care can only be achieved with your commitment to work together as a team on behalf of those we serve. More than simply following a list of things to do however, the safety movement (including the NPSG s) calls medicine back to its reason for existence; a focus on safety. 1. Restores the interest of the patient as the only interest to be considered 2. Exposes any agenda that places the patient s interest at risk 3. Reminds us that this exclusive focus on the patient has deep roots in the great tradition of medicine (whatever we do, we must at least DO NO HARM Hippocrates) 4. Demands that the patient s interest can only be achieved through total transparency, exposing harm at every level. Transparency then is the touchstone of 21 st century healthcare delivery (the hero if you will) which has enemies both external and internal, but mainly internal (that s right me, you and us). These National Patient Safety Goals will further a culture of transparency. Please make time to learn these safety goals and personally commit to implementing them for every patient, every time, everywhere. Thank you for practicing safely! Wendell W. Hoffman, M.D., F.A.C.P. Patient Safety Officer Sanford USD Medical Center

National Patient Safety Goals What are they? Where did they come from? The Joint Commission established the NPSG s to help accredited organizations address specific areas of concern in regards to patient safety. They are based on ACTUAL patient events; reported from hospitals across the nation. Implementing the SAFETY GOALS for every patient, every time, everywhere is the right thing to do! Who is responsible to follow the Safety Goals? All hospital employees in areas where safety goals apply Members of the Medical Staff and other independent practitioners granted privileges to provide care to patients in the organization. *Please contact or email the Sanford Patient Safety Team with any questions, concerns, or ideas related to Patient Safety at Sanford! *Additional information on the National Patient Safety Goals may be found by accessing the Joint Commission website; www.jointcommission.org

IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION Use at least two patient identifiers (name and birth date) whenever: Administering medications Administering blood products Taking blood samples and other specimens for clinical testing Delivering dietary trays Providing any other treatments or procedures Transporting a patient to another care area ---------------------------------------------------------------------------------------------------- Steps to check patient identification: With Medication Administration Record (MAR) open, or test requisition/lab label, diet order in hand: 1. While looking at the patient ID armband, ask the patient Please state your name and date of birth 2. Compare what the patient says and the ID armband to the requisition in your hand or MAR on the computer screen at patient bedside. If patient is unable to state their name and date of birth, compare the name and date of birth on their armband to the MAR/requisition in your hand. Any individual removing a patient identification band, blood band, or allergy band will immediately replace it (on the patient) per Sanford policy. Remember: Every ID Armband must be reviewed AND initialed by the patient/patient spokesperson prior to application! (If patient/patient spokesperson is unable to participate; 2 staff members must verify that the ID band is correct and initial it themselves prior to application). See policy (P-025). -------------------------------------------------------------------------------------------------------------------------------------------------------------- WHEN DRAWING BLOOD OR OBTAINING A LAB SPECIMEN: Label all blood tubes/specimens at the PATIENT S BEDSIDE to prevent mislabeling errors!

IMPROVE THE EFFECTIVENESS OF COMMUNICATION TELEPHONE & VERBAL ORDERS Q: What is V.O.R.B and T.O.R.B.? A: Verbal order READ back & Telephone order READ back! Hint: In order to READ back an order, you must first have written it down! For VERBAL or TELEPHONE ORDERS or for reporting of CRITICAL TEST RESULTS via the telephone: verify the complete order or test result by having the person receiving the order or test result read back the complete order or test result. VERBAL ORDERS: If physician is present, ask him/her to write the order directly into the medical record If a physician is unable to write the order (i.e. during a procedure) then a nurse may transcribe the order, read it back to the physician, and then document accordingly: (V.O.R.B. Dr. J Smith/N.Nurse, RN) VERBAL & TELEPHONE ORDERS: 1. WRITE down what was said 2. READ BACK what you have written to ensure accuracy Repeating back an order is not effective. You must WRITE it down and READ it back! S Situation (What is the situation?) B Background (How did we get here?) A Assessment (What is the problem?) Let s all use the same language R Recommendation (What do we need to do to fix it? When is that going to happen?) Did you know??? Communication breakdown accounts for 70% of all Healthcare errors (patient falls, medication errors, VAP, infections, etc.) Lets all use the same language for our patients

IMPROVE THE EFFECTIVENESS OF COMMUNICATION CRITICAL TEST RESULTS 1. WRITE DOWN the lab test/result 2. READ BACK what you have written down to ensure accuracy. Give the person reporting the results your name as requested. 3. Document the critical result on the yellow critical value sticker or follow your department protocol as defined. 4. Report the critical result to the physician as appropriate per policy. Refer to the Critical Values Reference Sheet Administrative SOP C-100 See examples of labs that must be reported to a physician AND documented within 30 minutes: CRITICAL TEST RESULT (NATIONAL PATIENT SAFETY GOAL 2A) Write it down, read it back Critical Values of the following tests are to be called to a MD within 30 minutes of result receipt: ABGs (Blood Gases * Potassium * Spinal Fluid Glucose * HgB*/HcT* * Call first instance only Magnesium (OB patients) * Platelets Patient Name: Critical Result: Date: Time: o o Pre-written orders/protocol followed MD Notified: Date: Time: Date AND Time Required! Orders Received? Yes No RN Signature Place Sticker in Physician Progress Note Refer to policy for additional Nuclear Medicine and Imagining Tests that are included. Measure, access, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver.

IMPROVE THE EFFECTIVENESS OF COMMUNICATION ABOLISHED ABBREVIATIONS Standardize a list of abbreviations, acronyms, symbols and dose designations that are not to be used throughout the organization. The following abbreviations have been shown to contribute to significant medical errors and must NOT be used. Abbreviation to be eliminated QD QOD U or u IU or iu MgSO4 MS MSO4 Approved Alternative Daily Every other day Units International Units Magnesium Sulfate Morphine Morphine Do not use trailing zeroes, (i.e.4.0) 1 unit (i.e. 4) Do use a leading zero T.I.W. or TIW ug gr H 0.1 unit 3 times weekly Mcg Do not use Humulin or Humalog This list applies to all orders and all medication related documentation when handwritten or entered as free text into a computer. If an abolished abbreviation is found: you must contact the prescriber to verify the meaning of the abbreviation. Then rewrite the clarified order without the abolished abbreviation. Refer to administrative SOP A-005: Abbreviation Reference

IMPROVE THE EFFECTIVENESS OF COMMUNICATION HAND-OFF COMMUNICATION Implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. Key information about a patient must be exchanged every time the patient is handed over to another caregiver. Examples include: Upon admission Shift Change (Involve the patient in the bedside report when appropriate!) Temporary transfer of care during lunch, breaks, when primary staff leaves, etc. Transferring of care between physicians (including transfer of complete responsibility to another physician and transfer of on-call responsibilities). Transition between departments (Anesthesia to PACU, ER to Critical Care, etc.) Upon transfer of patient between departments for tests/procedures/therapies Upon discharge to transitional facilities (i.e. nursing home) Ticket to Ride EVERY PATIENT MUST HAVE A TICKET TO RIDE If a patient is transferring to another department for a test/procedure/therapy and the nurse is unable to accompany the patient, the patient must have a TICKET TO RIDE! 1. Night shift RN completes a Ticket to Ride and places it in the holder outside the room or inside the patient chart (department discretion). 2. Transporter is to read the Ticket to Ride (ensure that the RN name & phone number are present) & inform the patient s RN that the patient is leaving the unit. The transporter must have the opportunity to ask the RN questions if needed. 3. Transporter gives the Ticket to Ride to the next caregiver. 4. Next caregiver reads/reviews the Ticket to Ride prior to test/procedure/therapy. 5. Ticket to Ride is returned with patient to their room following the test/procedure/therapy.

IMPROVE THE SAFETY OF USING MEDICATIONS LOOK ALIKE/SOUND ALIKE DRUGS Identify and, at a minimum, annually review a list of look-alike/sound-alike medications used by the organization, and take action to prevent errors involving the interchange of these medications. Examples of LOOK-ALIKE/SOUND-ALIKE drugs at Sanford: Metformin Metronidazole Hydroxazine Hydralazine Epinephrine Ephedrine Zyvox Zosyn Heparin Hespan Celebrex Celexa Novolin Novolog Be extra vigilant when you are administering one of these medications! (Notice the TALL MAN Lettering above!) Be aware of look-alike/sound-alike drugs Report any identified look-alike/sound-alike medications to the Pharmacy or Medication Variance Hotline at #3-4567. Review lists of common look-alike/sound-alike drugs at medication stations and near the Pyxis machines. The Medication Safety Subcommittee reviews the list of look-alike/sound-alike medications used by the organization every year and takes action to prevent errors involving the interchange of these medications.

HIGH ALERT MEDICATIONS What is a High Alert Medication? These drugs bear a heightened risk of causing significant patient harm when they are used in error. Use EXTREME CAUTION when administering these medications! The following examples of High Alert Medications are those that Sanford has identified and has processes/policies in place to help prevent errors. Heparin Low molecular weight heparin (Lovenox) Ketorolac (Toradol) Chloral Hydrate Insulin (IV and SubQ) Propofol Magnesium Sulfate Ibutilide (Corvert) The following medications are common classes of High- Alert Medications Cardioplegic Solutions Chemotherapy Agents Dialysis Solutions Electrolytes Epidural or Intrathecal Medications Inotropic and Vasoactive Medications Liposomal/Non-Liposomal Medications Moderate Sedation Agents Narcotics/Opiates Neuromuscular Blocking Agents Radiocontrast Agents Total Parenteral Nutrition (TPN) Thrombolytics/Fibrinolytics This list is not all inclusive and is updated on an annual basis. Please contact our Medication Safety Officer if you have any questions regarding the medications that have been listed.

MEDICATION LABELING Label all medications, medication containers (i.e. syringes, medicine cups, basins) or other solutions on and off the sterile field. Every time a medication or solution is removed from its original container and placed in another container (syringe, basin or cup), that container must be labeled. Medications and solutions both on and off the sterile field are labeled even if there is only one medication being used. Labeling occurs when any medication or solution is transferred from the original packaging to another container. Medication or solution labels include the medication name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours. All medication or solution labels are verified both verbally and visually by two qualified individuals whenever the person preparing the medication or solution is not the person administering it. No more than one medication or solution is labeled at one time. Any medications or solutions found unlabeled are immediately discarded. All original containers from medications or solutions remain available for reference in the peri-operative/procedural area until the conclusion of the procedure. All labeled containers on the sterile field are discarded at the conclusion of the procedure.

ANTICOAGULATION THERAPY Reduce the likelihood of [patient] harm associated with the use of anticoagulant therapy. Notice that Heparin is a Look Alike/Sound Alike drug! Heparin is also a HIGH ALERT drug meaning that errors associated with Heparin use are more likely to have devastating effects for patients! Safety Strategies: When questions arise involving the use of anticoagulants, collaborate with the physician, nurse, and pharmacist to assure safe care is being delivered. Ensure that the standard heparin infusion orders are used for all patients on intravenous heparin. Assure patients being started on warfarin (Coumadin) have a baseline INR prior to the first dose. Assure that programmable pumps are utilized every time intravenous heparin is administered. Assure that patients being started on enoxaparin, dalteparin, tinzaparin and fondaparinux have a baseline serum creatinine prior to starting therapy. Assure patient/family education includes the importance of follow-up monitoring, compliance issues, dietary restrictions, and potential for adverse drug reactions and interactions. Document that you have provided education to your patients receiving anticoagulation therapy in the Education tab in Doc Z this is a new Joint Commission requirement! Notify the Program Director for Anticoagulation Services or Medication Safety Officer of any unsafe practices with anticoagulants so new systems can be designed to eliminate risk.

REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS Reduce the risk of health care-associated infections. Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Hand hygiene is the single most important factor in preventing transmission of disease causing organisms. HANDWASHING WITH SOAP AND WATER IS REQUIRED When hands are visibly dirty or contaminated. Before eating After using the restroom Upon entering and leaving the hospital. After contact with a patient with C-Difficile USE WATERLESS ANTISEPTIC OR SOAP AND WATER Before having direct contact with patients. After contact with patient s intact skin, as in taking a pulse, blood pressure, or lifting a patient. After contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressing if not visibly soiled. If visibly soiled wash first with plain soap and water followed by waterless antiseptic hand rub. If moving from a potentially contaminated body site to a clean body site during a patient s care. After contact with contaminated equipment. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Before donning sterile gloves for procedures requiring sterile technique. Before inserting indwelling urinary catheters, intravascular catheters or other devices that do not require a surgical procedure. To decontaminate hands upon removal of gloves or other personal protective equipment. The use of gloves does not eliminate the need for hand hygiene. *When working with patients with Clostridium Difficile, use only soap and water to clean hands.

REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS There is concern for the transmission of multidrug-resistant organisms in acute care hospitals. This requirement applies to, but is not limited to, epidemiologically important organisms such as: Methicillin-resistant Staphylococcus aureus (MRSA) Clostridium difficile (CDI) Vancomycin-resistant Enterococci (VRE) Extended-spectrum Beta Lactamase producing organisms (ESBL). Preventing transmission depends on these essential strategies: o Proper Hand Hygiene o Contact Precautions o Cleaning/disinfection of patient care equipment o Cleaning/disinfection of the environment Reporting Sentinel Events related to health care associated infections: Goal: Manage sentinel events related to health care-associated infections. A sentinel event is a case of unanticipated death or major loss of function related to a health care-associated infection. Staff is to report the following to Infection Prevention and Control: Any patient who unexpectedly dies or suffers a major permanent loss of function associated with a health care-associated infection. o o Unanticipated deaths and injuries that meet the definition of a sentinel event will undergo a root cause analysis. These unanticipated deaths and injuries will undergo a root cause analysis that should answer the following questions: Why did the patient acquire an infection? Why did the patient die or suffer permanent loss of function?

REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS GOAL: Prevention of central line-associated bloodstream infections. Complete the line insertion checklist to reduce bloodstream infection rates! Follow the Central Line Bundle (ALL COMPONENTS MUST BE PERFORMED): Central Line Bundle for every central line placed: Hand hygiene Maximal barrier precautions for insertion o Sterile gown and gloves o Cap o Mask o Full body sterile drape Chlorhexadine for skin antisepsis Optimal catheter site selection o The subclavian vein is the preferred site for nontunneled catheters in adults Daily review of line necessity and removal of nonessential catheters Injection ports and catheter hubs are disinfected with alcohol prior to accessing the ports. Sanford also has Infection Prevention Bundles developed for: o Ventilator Associated Pneumonia (VAP) o Catheter Associated Urinary Tract Infections (CAUTI) Every Infection Prevention Bundle begins with HAND HYGIENE!

ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE What is Med Rec??? Med Reconciliation is simply obtaining an accurate & complete home medication list, comparing that list to medications we are giving the patient in the hospital, and sending the new, complete list of medications home with the patient on discharge. 1. Obtain a complete & accurate home medication list/history. At the time the patient enters the hospital or is ADMITTED, a complete list of medications (including dose, route, frequency, last dose taken and reason for taking) must be obtained and documented. o Medications include: All prescription medications Sample and Over-The-Counter (OTC) medications Herbals/Vitamins/Supplements Often Forgotten: Inhalers/Nebulizers, Patches, Eye/Ear Drops, Creams/Ointments, Injections, Oxygen, Implanted Pain Pumps o Sources of Information to obtain medication list from: Patient/ Family/Caregiver Patient s medication bottles and/or medication list (always verify that the information on the bottles/list is accurate and up-to-date) Patient s community pharmacy(s) Patient s primary care physician Past Medical Records 2. Reconcile the home medication list with new orders. Next, compare the patient s home medication list to the medications ordered in the hospital. If any discrepancies are found (omissions, duplications, wrong doses/frequencies etc.), notify the provider to review and reconcile the list. Anytime a patient TRANSFERS within the hospital, a patient s medication list must be communicated to the next provider of service. This communication must be documented. 3. Reconcile medications on discharge. At DISCHARGE, a complete list of the medications the patient is to take following discharge is: o Provided to the patient and/or family AND o Provided to the next provider of care (receiving facility or provider/physician) and this communication must be documented. Some short-stay areas may have a modified medication reconciliation process based on their patient population and this will be communicated to those specific areas as needed.

REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS Goal: Implement a fall reduction program including an evaluation of the effectiveness of the program. SANFORD S FALL PREVENTION PROGRAM Both inpatients and outpatients are screened for fall risk. Implement Risk for Falls DocZ plan of care when necessary. The fall risk screen is specific to each patient population or department. A yellow star symbolizes fall risk and a red star identifies a patient who has fallen. Patients and Families are Educated on fall risk with individualized fall reduction strategies (bed alarm, wheel chair seat belt, walk only with help). Link interventions to area of risk. For example, if patient is confused, the interventions might include moving patient closer to nurses station, hourly rounds, family presence, and bed alarm. Universal Fall Prevention is for ALL patients! Keep environment free of hazards such as wet floors or clutter in the room. Keep items within reach of patient: call light, telephone, television remote control, water. Patients need to be reminded that they may be weaker due to surgery or a procedure or new medications. Patients should not walk alone until staff state they are independent. Patients should wear their glasses, hearing aids, and bring assistive devices from home such as canes or walkers. At each handoff: Staff communicates fall risk and safety interventions being used. Example: Patient is very weak and a high fall risk with score of 17. Interventions are therapy referral, walk 3X/day, gait belt, TABS monitor when in chair. Bones and Bleeds: o Be on High Alert for patients on blood thinners or anticoagulants (Coumadin, Heparin, Lovenox, Plavix or Aspirin) beyond therapeutic limits. o Be on High Alert for patients with Osteoporosis. They have an increased risk for an injury related to a bone fracture.

Reduce the risk of influenza and pneumococcal disease in institutionalized older adults GOAL: Develop & implement a protocol for administration and documentation of the flu vaccine. 1. Assess all adult inpatients for influenza (during flu season) and pneumococcal immunization status during admission assessment with completion of the Navigator on DocZ. 2. If patients are eligible to receive either vaccination (and they have not already received) offer to administer vaccinations during hospitalization. 3. If consent is obtained, administer vaccinations per SMC Medical Staff protocol. 4. If patient refuses, be sure to document the refusal! If you could do one thing to help prevent 36,000 deaths and 320,000 hospitalizations every year... Would you do it? The Flu Vaccine saves Lives Dr. Wendell W. Hoffman

Encourage patients active involvement in their own care as a patient safety strategy Encourage patients active involvement in their care to help prevent medical errors and adverse events. Instruct every patient to: Please tell us if something doesn t seem right to you Inform patients and families how they may report concerns related to care, treatment, services, and patient safety issues: o Tell a member of the patient s care team o Tell the Clinical Care Coordinator o CONDITION H (3-1234) Condition H was created to encourage patients involvement in their care! Every patient has the right to activate the Rapid Response Team! Involve patients in planning their care each shift! Involve patients in the bedside report when appropriate & ask for their input! Have all patients watch Dr. Aspaas video on the LodgeNet system (video follows Dr. O Brien s welcome video). After turning T.V. on, just hit channel up or down button to get to the videos. This is a great way to advocate for your patients!

The Organization identifies safety risks inherent in its patient population SUICIDE PREVENTION Did you know??? Suicide of a care recipient while in a staffed, round the clock care setting has been the #1 most frequently reported type of sentinel event to the Joint Commission! Yes Sanford has had patients who have attempted suicide while in our hospital. The 2 most frequent ways that patients commit/attempt suicide in a hospital: Elopement and Jumping (Look up!) If a Code Exit is called overhead, be aware that this could indicate a Suicide Attempt and these patients may be looking for a structure or height where they can jump from. Strangulation Be aware of Bed Linens, I.V. Tubing, Call light, Respiratory/Nebulizer tubing, etc. What do you need to know??? Patients are screened through the DocZ Navigator questions Implement Risk for Suicide DocZ plan of care as necessary Patients identified at risk are then screened by a Mental Health Counselor Staff members can request ANY patient they are concerned about to be screened by a Mental Health Counselor (this service is free of charge & does not require a MD order). A Mental Health Counselor can be reached 24/7 by pager #2182 If you identify a patient at risk DO NOT LEAVE THE PATIENT ALONE! Stay with the patient until the Mental Health Counselor arrives. Utilize a Constant Observer & be extra vigilant to ensure the safety of our at risk patients! Please refer to Suicide Watch policy (S-050) for additional information

Improve recognition and response to changes in a patient s condition. Call the Rapid Response Team by dialing #3-1234 anytime You are worried about a patient Acute change in heart rate <40 or >130bpm Acute change in SBP <90mmHg Acute change in RR <8 or >28 per min Acute change in O2 saturation <90% despite O2 and/or O2 >50% Acute change in level of consciousness Acute change in Urine Output to <50mL in 4 hours Significant Bleeding Signs or symptoms of a Stroke Signs or Symptoms of an Acute MI Any staff member may activate the Rapid Response Team! Please do not hesitate to call if you feel it is necessary the sooner we act, the better! Sanford has both an Adult and Pediatric Rapid Response Team! Patients/Families may activate the Rapid Response Team through Condition H

Universal Protocol Prevent wrong site, wrong procedure, wrong person surgeries Universal Protocol is required for: Operating Room Non-OR settings Bedside Procedures Procedural areas Universal Protocol Preoperative Verification Marking the Site Time Out Preoperative Verification 1. Complete the Continuity of Care checklist (Pre-op checklist) 2. VERIFY: Correct Person Correct Procedure Site (as applicable) Verify this information at the time procedure is scheduled, at the time of admission into the facility, anytime the patient is transferred to another caregiver, and before the patient leaves for the procedure. DO THIS WITH THE PATIENT INVOLVED, AWAKE & AWARE, IF POSSIBLE!!! Ensure that all necessary documentation is complete & available (H&P, consent, preoperative labs/diagnostic tests, relevant images, special equipment, etc.) Utilize the appropriate DocZ flowsheet template OR surgical/procedural checklist or OP/IP Procedure Record.

Marking the Operative Site The operative site must be marked prior to the procedure for the following: o Procedures involving Right/Left distinction (such as Right Nephrectomy) o Multiple Structures (such as fingers and toes) o Multiple Levels (such as spinal procedures) The Proceduralist MUST do the site marking: o This must occur prior to the patient going to the Operating Room o The patient must be involved, awake and aware if possible o R.N. must verify the site marked with the patient, against the consent form, and procedure schedule whenever possible Examples of Bedside Procedures requiring Site Marking Chest Tube Insertion Needle Aspiration Thoracentesis Biopsy This list is not all inclusive please refer to policy for additional information. Exceptions to site marking: o Single organ cases (i.e. Cesarean section, Cardiac Surgery) o Interventional Cases when the site is not determined (i.e. Cardiac Catheterization or Central Line Insertion) o Teeth BUT, Indicate the operative tooth/teeth on a dental radiograph/diagram o Premature Infants for whom a mark may cause permanent tattoo Refer to Universal Protocol policy O-030 for additional information Why do we mark Operative Sites??? To prevent wrong site surgeries! Yes this has frequently happened in hospitals across the country! Marking the operative site with the patient/family involved will help prevent wrong site surgeries! -------------------------------------------------------------------------------------------------------------------------------

Time Out Active Communication among ALL members of the team to prevent wrong site, wrong procedure, wrong person surgeries. Time Out o Correct patient identity* o Correct side and site (as applicable) o Agreement on the procedure to be done o Correct patient position o Correct equipment/implants present *NOTE: When verifying correct patient identity at this point, you must recheck the patient ID Band or ID source for name and date of birth! (See Patient Identification NPSG). All team members must be present for this! Active Communication all members of the procedure team must participate The Time Out must be Fail Safe the procedure will not start until ALL questions/concerns are addressed and resolved Document the Time Out on the consent form, in the progress notes, or approved location per protocol The Time Out is required for Surgery/Procedures AND Bedside procedures! IF ANY MEMBER OF THE TEAM (OR THE PATIENT) HAS A CONCERN ABOUT ANY OF THE INFORMATION INCLUDED DURING THE TIME OUT, THE PROCEDURE WILL NOT START UNTIL RESOLUTION IS REACHED AMONG EVERYONE! Examples of Procedures Requiring Time Out Bronchoscopy Biopsy Chest tube Insertion Epidural Lumbar Puncture PICC Line Insertion Cardioversion Central Line Insertion Circumcision Thoracentesis Surgery Bronchoscopy This list is not all inclusive please see policy O-030 for additional information

National Patient Safety Goals 2009 Sanford USD Medical Center Working together to keep our patients safe