Start and end date of Rotation: GW Program: BIOGRAPHICAL INFORMATION. Name: (you will be asked to provide SSN

The GWU School of Medicine & Health Sciences - Office of Graduate Medical Education Visiting (Non-GW) Resident Information Form Instructions: Please complete this form, attach ALL required paperwork and submit to the GW Residency Coordinator no later than NINETY DAYS (90) in advance of your start date. Start and end date of Rotation: GW Program: BIOGRAPHICAL INFORMATION Name: (you will be asked to provide SSN when you check in with the GME Office on the first day of the rotation) NPI #: Phone: Pager: E-Mail Address: (please provide your university/hospital email; do not list a personal email address) MEDICAL SCHOOL / ECFMG INFORMATION NAME OF MEDICAL SCHOOL DATE OF GRADUATION ARE YOU A FOREIGN MEDICAL GRADUATE? YES NO (If yes, ECFMG Certificate must be attached) CURRENT RESIDENCY/FELLOWSHIP INFORMATION (CV MUST INDICATE OTHER ACGME POST GRADUATE TRAINING) INDICATE INSTITUTION THAT YOU ARE ROTATING FROM (Name & Location): INDICATE TRAINING PROGRAM, PGY LEVEL & START/END DATE (Must be ACGME Accredited): Required Paperwork: Copy of CV (Must be current and include training program at the time of this rotation) Proof of HIPPA Compliance Proof of OSHA Compliance Training Module Attestation Liability Insurance Certificate from Risk Management Office (Must show GWU SMHS as Certificate Holder; minimum coverage required is $1 million per occurrence/$3 million aggregate) Approval Letter from Program Director at home institution ( must include the following): 1) Rotation Dates 2) Statement that the resident is in good standing and will continue to be paid salary and benefits during rotation DC Medical Board Requirement: YOU MUST BE APPROVED BY THE DC BOARD PRIOR TO THE START OF THE GWU ROTATION o Medical Training Registrant process (submit directly to the DC Board with a copy to GWU GME) o D.C. Medical Board Criminal Background Check (CBC) You must schedule CBC at time of application To be completed by GW Program Director: Approved by: Date: GME Form rev. 11/2016

Medication Reconciliation National Patient Safety Goal 8 A Process for Performance Improvement The George Washington University Hospital April 16, 2013 1 Medication Reconciliation Presently we document medication reconciliation on paper, Salar computer system and Cerner computer system In July 2013 Medication Reconciliation will be occur in Cerner and Salar computer systems only. Training will occur for Cerner and Salar Computer Entry 2 Medication Reconciliation Forms 1. The Medication Reconciliation form is now an order sheet, not just a list of the patient s home medications. 2. The Admitting team will complete this form for all patients admitted, by addressing all of the following areas: 3. Allergies, Height, and Weight 4. A complete list of the patient s home medications should be listed. 3 1

Ordering the Home Medications Write the home medications legibly to include the following: Dose, route, frequency, indication, and whether or not the patient should continue the medication on admission or not. Document the source of the information obtained (patient, family, medication bottles, etc.) Sign, Date, and Time your order Make sure you include your beeper number just in case someone has questions. 4 MD, follow the steps: 1-3. 5 This section will be removed on the new form. Please address until the new form arrives. We will be going to 3 pages instead of 4. 6 2

MD, please follow steps 1-3 7 This section will be removed on the discharge form. Send the patient home on the appropriate medication if CHF or AMI diagnoses. We will be going to 3 pages instead of 4. 8 New Orders Place additional new orders on a regular order sheet. These orders will include medications, treatments, therapies, etc. Sign, date, and time these orders as well. Place your beeper number in case questions arise. The Medication Reconciliation Form is only for home medications until you list the medications to continue at discharge. 9 3

During Discharge Please note that you DO NOT have to rewrite the home medications. They are already on the form. Decide whether or not you want the patient to continue these medications when discharged. Continue Medications After Discharge? Yes or No? Does this patient need immunizations prior to discharge? Yes or No? 10 During Discharge Document the new medications the patient will be prescribed at discharged. Document the dose, how to take, how often, and the reason for the medication. Please sign the discharge Physician area with the date, time, and a contact number just in case the next provider of care has questions. Make sure the patient knows which medicines to take when they are at home. 11 Making a Referral or Transferring a Patient? When a patient is referred to or transferred from one hospital to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented (TJC, 2009). 12 4

Medication Reconciliation in Salar Enter the home medications in Salar and include the following: Dose, route, frequency, indication, and whether or not the patient should continue the medication on admission or not. Document the source of the information obtained (patient, family, medication bottles, etc.) You must order medications you wish to continue using on the regular order sheet. Salar progress notes will document the patient s home medication and current medications 13 Minimal Use Settings Several patient care settings exist in which medications are not used, are used minimally, or are prescribed for only a short duration (ER, urgent and emergent care, outpatient radiology, ambulatory care, and behavioral health care) (TJC, 2009) During short-term medication therapy, and no changes are made in the medication list, a list is provided to the patient and family containing short-term medication additions the patient will continue after leaving the hospital. 14 Minimal Use Settings A complete documented medication reconciliation process is needed when: Any new long term (Chronic) medications are prescribed. There is a prescription change for any of the patient s current, known long-term medications. The patient is required to be subsequently admitted to an organization from these settings for ongoing care. The patient and/or family member and the primary care provider will receive the complete list of reconcile medications (TJC, 2009) 15 5

The Joint Commission recognizes that medication reconciliation problems continue to put patients at risk. However, they expect organizations to continue to address and improve this process within their organizations (TJC, 2009). 16 6

GME Module on the 2009 NPSGsPiera Palazzolo The Joint Commission s 2013 National Patient Safety Goals for Hospitals Prepared by: Shirna Gullo RN, MSN, Eve Early, MT, MA, CIC and Martine Biamby, RN, BSN, JD Department of Quality and Infection Control The George Washington University Hospital GOAL 1: Improve the accuracy of patient identification Use at least two patient identifiers when providing care, treatment, and service. Name and Date of Birth are the two identifiers at GWUH. GOAL 1: Improve the accuracy of patient identification Eliminate transfusion errors related to patient misidentification. Use a third patient identifier- Name, DOB, MRN or FIN number National Patient Ssafety Goals 1

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 2: Improve the effectiveness of communication among caregivers For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and read-back the complete order or test result. GOAL 2: Improve the effectiveness of communication among caregivers There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the hospital. U,u, IU, QD, qd, QOD, qod, Trailing zero (X.0 mg), Lack of leading zero (.X mg), MS, MSO4, MgSO4. GOAL 2: Improve the effectiveness of communication among caregivers The hospital measures, assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver. National Patient Ssafety Goals 2

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 2: Improve the effectiveness of communication among caregivers The hospital implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. Remember the acronym: SBAR Situation, Background, Assessment, Recommendations. GOAL 3: Improve the safety of using medications The hospital identifies and, at a minimum, annually reviews a list of lookalike/sound-alike medications used by the hospital and takes action to prevent errors involving the interchange of these medications. GWUH Specific Look-Alike / Sound-Alike Medications Medications on this list marked with an asterisk (*) will be flagged with a lookalike/sound-alike alert sticker. Hydralazine*...Hydroxyzine* Ephedrine vials*....epinephrine ampoules* Hydromorphone*... Morphine* Metformin 500mg* Metronidazole 500mg* Heparin Hespan * Lamivudine *... Lamotrigine * Folic acid... Folinic acid (Leucovorin)* Dobutamine... Dopamine Morphine IR15mg (immediate release)* Morphine ER 15mg (extended release) * Glipizide *.... Glyburide * Nifedipine 30mg.. Nimodipine 30mg * Prednisone.. Prednisolone* Lidocaine(preservative-free). Lidocaine (with preservative)* National Patient Ssafety Goals 3

GME Module on the 2009 NPSGsPiera Palazzolo GWUH Specific High Alert Medications *High Alert Medications are those medications that have the highest risk of causing injury when misused. Heparin Insulin Narcotics and Opiates Phosphate Salts Potassium Chloride Sodium Chloride Solutions (greater than 0.9%) Chemotherapeutic Medications Thrombolytic Agents GOAL 3: Improve the safety of using medications Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. GOAL 3: Improve the safety of using medications Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. *Anticoagulation therapy poses risks to patients and often leads to adverse drug events due to complex dosing, requisite follow-up monitoring, and inconsistent patient compliance (TJC, 2013) National Patient Ssafety Goals 4

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 7: Reduce the risk of health care associated infections Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Using Hand Sanitizer Specific Indications for Hand Hygiene Before: Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don t require surgery After: Contact with a patient s skin Contact with body fluids or excretions, non-intact skin, wound dressings Removing gloves Specific Indications for Hand Hygiene Always use Soap And Water: If Hands are visibly soiled Before eating and after performing bodily functions After caring for patients with Clostridium difficile National Patient Ssafety Goals 5

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 7: Reduce the risk of health care associated infections Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care associated infection. Report healthcare associated deaths to Infection Prevention @ ext 4415 GOAL 7: Reduce the risk of health care associated infections Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms (MDRO s) in acute care hospitals. Evidence-based practices for Preventing multiple drug-resistant organisms (Tier I) Education and training of personnel Judicious use of antimicrobial agents Standard precautions for all patients Contact Precautions for patients known to be infected or colonized (masks not routinely recommended) Monitoring of trends over time to determine whether additional interventions are needed National Patient Ssafety Goals 6

GME Module on the 2009 NPSGsPiera Palazzolo Evidence-based practices for Preventing multiple drug-resistant organisms (Tier II) Active surveillance cultures from patients in populations at risk at the time of admission to high-risk area, and at periodic intervals as needed to assess transmission. Contact Precautions until surveillance culture known to be negative. Dedicated staff to care for MDRO patients only. Enhanced environmental measures. Consult with experts on case-by-case basis regarding use of decolonization therapy for patients or staff. If transmission continues despite full implementation of above, stop new admissions to the unit. GOAL 7: Reduce the risk of health care associated infections Implement best practices or evidencebased guidelines to prevent central lineassociated bloodstream infections (CLABSI). Best practices for preventing central lineassociated bloodstream infections (CLABSI). 1. Use a catheter checklist to ensure adherence to infection prevention practices at the time of CVC insertion. 2. Perform hand hygiene before catheter insertion or manipulation. 3. Avoid using the femoral vein for central venous access in adult patients. National Patient Ssafety Goals 7

GME Module on the 2009 NPSGsPiera Palazzolo Best practices for preventing central lineassociated bloodstream infections (CLABSI). 4. Use an all-inclusive catheter cart or kit. 5. Use maximal sterile barrier precautions during CVC insertion. 6. Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age. 7. Perform daily assessment of line necessity and remove line. GOAL 7: Reduce the risk of health care associated infections Implement best practices for preventing surgical site infections (SSI). Best practices for preventing surgical site infections (SSI). Prevention of surgical site infections (SSI) can be achieved by implementing evidence-based strategies such as: Appropriate use of antibiotics Appropriate hair removal Maintenance of postoperative glucose control for major cardiac surgery patients National Patient Ssafety Goals 8

GME Module on the 2009 NPSGsPiera Palazzolo Best practices for preventing surgical site infections (SSI). Maintenance of postoperative normothermia. Education of surgeons, perioperative staff, patients, and families. The above strategies are not intended to be a comprehensive list of elements of care related to surgical site prevention Goal 7: Reduce Health Care Associated Infections NEW Prevent Indwelling Catheter-Associated Urinary Tract Infections-CAUTI Limit duration and use of foley catheter Complete foley catheter bundle protocol Discontinue foley catheter if not needed GOAL 8: Accurately and completely reconcile medications across the continuum of care. A process exist for comparing the patient s current medications with those ordered for the patient while under the care of the hospital (Medication Reconciliation). Fill out the form or enter in computer system completely with the name of the medication, dose, route, frequency, indication, whether to continue or not, immunizations, source of information, signature, beeper number, date, and time. National Patient Ssafety Goals 9

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 8: Accurately and completely reconcile medications across the continuum of care. When a patient is referred to or transferred from one hospital to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the hospital s care directly to his or her home, the complete and reconciled list of medications is provided to the patient s known PCP, or the original referring provider, or a known next provider of service. GOAL 8: Accurately and completely reconcile medications across the continuum of care. When a patient leaves the hospital s care, a complete and reconciled list of the patient s medications is provided directly to the patient, and the patient s family as needed, and the list is explained to the patient and/or family. The patient receives (2) copies of the form GOAL 8: Accurately and completely reconcile medications across the continuum of care. In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. National Patient Ssafety Goals 10

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 9: Reduce the risks of patient harm resulting from falls. The hospital implements a fall reduction program that includes an evaluation of the effectiveness of the program. Staff will use a Watchful Eye symbol on the chart, door, and armband. Patients wear yellow gowns if they are a high fall risk Instruct patient to ask for assistance before getting out of bed. GOAL 13: Encourage patients active involvement in their own care as a patient safety strategy. It s Okay to Ask We encourage our patients to ask questions about why something is being done, to ask for more information about their medical condition, or even to ask the healthcare provider if they have washed their hands. SPEAK UP program Patient s are encouraged to Speak UP! Speak up if you have questions or concerns. Pay attention to the care you get. Educate yourself about your illness. Ask a trusted family member or friend to be your advocate. Know what medicines you take and why you take them. Use a hospital, clinic, surgery center that is Joint Commission accredited. Participate in all decisions about your treatment (TJC & CMS, 2002) National Patient Ssafety Goals 11

GME Module on the 2009 NPSGsPiera Palazzolo GOAL 15: The organization identifies safety risks inherent in its patient population. The hospital identifies patients at risk for suicide. Know the Risk Factors for Suicide! A diagnosable mental disorder Separation from family Anxiety or hopelessness (TJC, 2008) Severe stress Significant medical illnesses A previous attempt. Emotional loss Family history Access to materials that can be used to attempt suicide GOAL 16: Improve recognition and response to changes in a patient s condition. The hospital selects a suitable method that enables the health care staff members to directly request additional assistance from a specially trained individual(s) when the patient s condition appears to be worsening. Rapid Response (Call ext. 4100) National Patient Ssafety Goals 12

GME Module on the 2009 NPSGsPiera Palazzolo Universal Protocol. The organization meets the expectations of the Universal Protocol. Conduct a pre-procedure verification process.(checklists, Passport) Mark the procedure site. A time-out is performed immediately prior to starting procedures. All members of the time are involved in the time-out process. National Patient Ssafety Goals 13

11/17/2015 Everything GWUH Residents Need to Know about Regulatory Compliance Presented as Painlessly as Possible by the GWUH Quality Dept. Reasons for Regulatory Oversight 1. Improve the Quality of Care 2. Improve the Quality of Care 3. Improve the Quality of Care The Regulatory Environment Has Changed 1980-2000 Managed Care Financial focus 2000-Forward Hospital Compare Quality focus 1

11/17/2015 Why this is important? The Old Days Accreditation reviews were primarily chart audits Interviewed Hospital Administrators Rewarded intricate and voluminous Policy Manuals Today Scrutinize care being given to current inpatients Talk to staff and patients Stress practice over policy Less focus on Structuremuch more on Process and Outcomes In case you are not convinced No Outcomes- No Income 2

11/17/2015 What to look for in this presentation. Action Needed items in Red Key phrases to know and repeat back to The Joint Commission (TJC) when they ask YOU in Blue Medication Reconciliation The process by which a new patient s medications (including herbals and OTCs) are reviewed (reconciled) to ensure there are no potential adverse reactions with proposed therapy. What TJC says Goal 8 Accurately and completely reconcile medications across the continuum of care. 3

11/17/2015 And this is what TJC wants 1. The organization, with the patient s involvement, creates a complete list of the patient s current medications at admission/entry. 2. The medications ordered for the patient while under the care of the organization are compared to those on the list and any discrepancies (e.g., omissions, duplications, potential interactions) are resolved. 3. The patient s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside the organization 4. The next provider of service should check over the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed. 5. The complete list of medications is also provided to the patient on discharge from the facility. And this is how we implement Medication Reconciliation at GWUH. Medication Reconciliation Needs to happen whenever a patient changes location. Admission Transfer to or from ICU Transfer from another floor Discharge 4

11/17/2015 Medication Reconciliation The Medication Reconciliation form was designed to facilitate med rec for Admissions and Discharge Complete the form entirely Medication Reconciliation is also documented in Salar after the physician orders the current medications. You can view the Home/Outpatient Medications which is below the Current Medications section Medication Reconciliation For Transfers include in your Accept Note a list of the patient s previous meds and that all new meds have been reconciled. Hand Off Communication Currently goes by these names: Report, Sign Off, Sign Out, Run the List 5

11/17/2015 What TJC says Goal 2 Improve the effectiveness of communication among caregivers. And this is what TJC wants 1. The organization s process for effective hand off communication includes: Interactive communications allowing for the opportunity for questioning between the giver and receiver of patient information. 2. The organization s process for effective hand off communication includes: Up-to-date information regarding the patient s care, treatment and services, condition and any recent or anticipated changes. 3. The organization s process for effective hand off communication includes: A process for verification of the received information, including repeat-back or read-back, as appropriate. 5. Interruptions during hand offs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten. And this is how we implement Hand Off Communication at GWUH. 6

11/17/2015 Hand Off Communication Purpose To provide a standardized approach for communication across the care continuum in an effort to reduce errors and enhance patient safety which includes the opportunity to ask and respond to questions regarding the patient s care. The general purpose of this communication approach is to confirm responsibility for patient care, provide critical shift change updates and enhance continuity of care. What goes in Hand Off?? Think SBAR Situation: Patient name, age and gender Provider name / Attending / Consulting Chief complaint / Diagnosis / Admission date 7

11/17/2015 Background: Allergies Code status (Full, Modified, DNR) Pertinent medical history Surgery / Procedures, post-op day/date Assessment: Current information: vital signs / current medications / lab results Patient mobility / Fall Risk Activity tolerance / Disabilities / Special equipment Respiratory status Types of catheters, drains, tubes and/or wounds Special dietary needs: NPO, fluid restrictions, etc. Health acquired infections (MRSA/VRE) / Isolation type Emotional status/psychosocial dynamics Family/legal guardian/significant others presence/location Need for interpreter/cultural, spiritual concerns Recommendations: Plan of care Pending tests or procedures / specimens needed Anticipated changes in condition Anticipated discharge needs Other (as indicated) 8

11/17/2015 Medication Indications Real Simple: Whenever you write an order for a medication Write the Indication for the medication. Medication Indications Real Reason Nationwide there are thousands of injuries each year due to wrong med and/or wrong patient. Indications are a safeguard. Medication Safety TJC states label all medications if they are not used immediately Keep all medications secured or locked away after use in all areas 9

11/17/2015 National Patient Safety Goal No. 2 (cont) Goal 2 Improve the effectiveness of communication among caregivers. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. In other words. Do Not Use 10

11/17/2015 These abbreviations PLEASEEEEEEEE!!!!!!!! U, u use instead Unit IU use instead International Unit QD, qd use instead Daily Trailing zero (X.0 mg) use instead X mg Lack of leading zero (.X mg) use instead 0.X mg MS, MSO4 use instead morphine sulfate MgSO4 use instead magnesium sulfate Big One Coming Up Universal Protocol Otherwise known as the Time Out 11

11/17/2015 What TJC Says Universal Protocol Wrong site, wrong procedure, wrong person surgery can be prevented. This universal protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations. What TJC Says Conduct a time out immediately before starting the procedure as described in the Universal Protocol. And this is how we implement Universal Protocol at GWUH. 12

11/17/2015 When doing any invasive procedure on the wards: (peripheral iv, foley, ng tube, and g-tube replacement are not included) 1. Conduct a Time Out by verifying: 1. Time Out Performed at (time): 2. Correct patient 3. Correct procedure 4. Correct side and/or site 5. Correct patient position 6. Correct implants/special equipment or requirements are available N/A 7. The above information was verified and all in attendance are in agreement 2. Complete the Invasive Procedure Worksheet and place in chart. The Time Out was instituted several years ago in O.R.s nationwide resulting in a significant reduction in surgical errors. TJCO is now extending it to all invasive procedures. (If we do not document it it was not done.) What else? Documentation should be complete and reflect the plan of care H&P are completed for all patients admitted to GW within 24 hours Verbal or telephone orders are signed within 72 hours 13

Restraint Information for Physicians The least restrictive type of restraint will be selected commensurate with the patient's current situation/condition. The type of restraint employed will be determined by patient assessment, monitoring of the patient, and patient and staff safety. Medical/Surgical Restraints Medical/surgical restraints: are applied when the intent for use is to assist a patient s tolerance toward medical interventions that would inhibit medical healing and/or seriously place the patient at risk of injury, when all other less restrictive interventions have been determined to be ineffective. The Physician must perform an examination of the patient within 24 hours of the initiation of the restraints. A new order is issued at least once each calendar day based upon the physician s examination of the patient and continued clinical justification. Behavioral Health Restraint and Seclusion Behavioral reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self or others because of an emotional or behavioral disorder. Restraints will be used only in a humane, safe, and effective manner, protecting the patient's rights, respectful of the patient's dignity, and without intent to harm, cause pain, or create undue discomfort for the patient. Restraints are used only as a therapeutic measure and will not be used as a convenience for staff or as a punishment. Before any restraint device is applied, a determination will be made by the RN or physician as to whether use of restraint to prevent injury is necessary to control behavior in an emergency situation. No later than one hour after initiation of restraint or seclusion, the licensed practitioner is to perform the following: Review with the staff the physical and psychological status of the patient Determine the relevance of restraint/ seclusion Guide the staff in identifying ways that the patient may regain control to expedite the discontinuing t restraint/seclusion Complete the order form See and evaluate the patient in person NOTE: Regardless of how the order was obtained (verbal or written), the LIP must see the patient in person no later than one hour after the initiation of restraint or seclusion. Verbal and written orders for restraint/seclusion are to be time limited as follows: 4 HOURS for patient s 18 and older 2 HOURS for patient s ages 9 to 17 1 HOUR for patients under 9 years of age If the need for restraint/seclusion continues past the above specified time limitations, a face to face evaluation must be performed every 8 hours.