PATIENT SAFETY KNOWLEDGEBASE How to prepare for a Survey 1
DEFINITIONS Patient Safety v is a process that guards against any adverse condition occurring in a patient as a result of wrong diagnosis or treatment by the caregiver(s). Medical Error v is the failure of a planned action to be completed as intended and instead a negative outcome may be experienced (i.e., medication error, foreign body left after the surgery) 2
WHO IS RESPONSIBLE FOR PATIENT SAFETY? All Staff Members (from Leadership to the Front Line Staff ) We strive to provide a blame free culture of safety. Any employee who observes a patient safety risk should immediately report it to his/her direct supervisor. In addition, all employees have the right to report concerns about the safety or quality of care provided in the hospital to the Joint Commission. The hospital will take no disciplinary action because an employee reports safety or quality of care concerns to the Joint Commission. When an event occurs, appropriate interventions are done according to the patient s clinical conditions. Appropriate family member of the patient, physician, clinician and hospital leadership are notified. Information and/or equipment related to the event are secured and preserved. Hospital encourages/supports the staff to report any actual errors or potential events for errors (nearmiss) and to utilize the Incident Reporting System. 3
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NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #1: Improve Accuracy of Patient Identification " Use at least two patient identifiers: patient s full name (at least first and last name) and date of birth (not to be the patient s room number or location) when ordering and administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures, etc. " Eliminate transfusion errors related to patient misidentification. 7
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #2: Improve Communication Among Caregivers " Report critical results of tests and diagnostic procedures to the appropriate staff on time. " Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life threatening situation. " The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated. " During Hand-Off communication use S B A R (situation, background, assessment, recommendation) and document it in the medical record. " Avoid unauthorized abbreviations in any part of the medical record (i.e., QD, qd, U, u, trailing zero after decimal 3.0, or missing the leading zero before the decimal.3, avoid mso4 or mgso4 instead of morphine sulfate or magnesium sulfate, etc.) 8
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #3: Improve Medication Safety " Label all medications, medication containers (syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. " Reduce the likelihood of patient harm associated with the use of Anticoagulation therapy. " Maintain and communicate accurate patient medication Information through the Medication Reconciliation process. (Utilize our computerized prescriber order entry system -Health Bridge for inpatient or out patient & ambulatory care settings) 9
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #6: Reduce the Harm Associated with Clinical Alarm Systems 1. Improve the safety of Clinical alarm System 2. Input from the medical staff & clinical areas 3. Risk to patients if the alarm signal is unattended 4. Identify whether specific alarm is needed 5. Analyze incident history for potential harm 6. Establish clinically appropriate alarm setting 7. Staff education and proper orientation on the safety of alarm systems 10
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #7: Reduce the Risk of Infections " Hand Hygiene (Hand washing as per CDC guideline) " Implement evidence-based practices to prevent health careassociated infections " Multi Drug Resistant Organisms " Central Line Associated Bloodstream Infections " Surgical Site Infections " Catheter Associated Urinary Tract Infection 11
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY CAUSE PATIENT HARM DURING THE PATIENT CARE " Goal #15: Identifies Patient Safety Risks (Prevent patient harm from Suicidal Ideation) " The organization identifies patients at risk for suicide and prevents patient harm. " Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals. " When the patient at risk for suicide and leaves the care of the hospital, provide suicide prevention information- such as crisis hotline # 1-800- 273- TALK (8255) 12
NATIONAL PATIENT SAFETY GOALS ARE DEVELOPED BY TJC TO IDENTIFY & PREVENT THE MOST COMMON MEDICAL ERRORS THAT MAY LEAD TO PATIENT HARM DURING THE PATIENT CARE " UP1: Universal Protocol " Prevents any procedure on a wrong patient, wrong side and wrong site of the body part (wrong side surgery). " Ensures that the correct procedure (invasive or non-invasive) is done on the correct patient at correct side and at the correct site of the patient s body part. " Conduct a pre-procedure verification process. " Mark the correct site on the patient s body where the surgery is to be done. (if the procedure allows). " All team members must pause and Conduct a Time-Out immediately before starting the procedure. Reconfirm the correct patient and the correct procedure when a new member joins or a member rejoins the procedure at each time. If any implant is used check the specification of it at Time-Out. 13
CORE MEASURES & DOCUMENTATION OF CARE & USE THE BUILT IN ORDER SETS IN CPOE (DATE, TIME & SIGN IN EACH OF THE MEDICAL RECORD ENTRY) CORE MEASURES ARE A SET OF QUALITY MEASURES THAT ARE REQUIRED TO PROVIDE AT CERTAIN DISEASE CONDITIONS DOCUMENTATION IS REQUIRED FOR THE PROVIDED CARE " Acute myocardial infarction (AMI) [ i.e., Aspirin at arrival] " Heart failure (CHF) [ Left ventricular function test, beta blocker at discharge] " Pneumonia (PN) [ pneumococcal vaccine] " Pregnancy and related conditions (PR) " Hospital-based inpatient psychiatric services (HBIPS) " Children s asthma care (CAC) " Surgical care infection prevention (SCIP) [antibiotic prophylaxis] " Hospital outpatient measures (HOP) " Venous thromboembolism (VTE) [blood thinner drugs, Coumadin, Heparin, etc.] " Stroke (STK) 14
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