Na#onal Pa#ent Safety Goals 2017
www.ahrq.gov
What are Na#onal Pa#ent Safety Goals? The purpose of Na2onal Pa2ent Safety Goals is to improve pa2ent safety. The goals relate to problems in healthcare safety and how to solve them. By implemen2ng the goals Hospitals can ensure that events that should never happen, DO NOT happen.
Improve Accuracy of Pa#ent Iden#fica#on Use at least two ways to iden2fy pa2ents. During administra2on of medica2ons, blood or blood components, collec2ng blood specimens, and when providing treatments or procedures. Example: Pa2ents name and date of birth (verbalized by pa2ent) checking against the wrist band.
Improve Accuracy of Pa#ent Iden#fica#on Ensure that the correct pa2ent receives the correct blood when requiring a blood transfusion. Label containers used for blood and other specimens in the presence of the pa2ent. Correct verifica2on process: Use of two licensed personnel to ensure accuracy (One must be a Registered Nurse) Match the blood or blood component to the order Match the pa2ent to the blood or blood component
Improve the Effec#veness of Communica#on Among Caregivers Cri2cal test results: abnormal to a degree that may indicate a life- threatening situa2on. Ensure that cri2cal test results and diagnos2c procedures are reported to the correct staff person in a 2mely manner. Follow protocol and procedures for MSHA - Lab to call licensed caregiver within 15 minutes of cri2cal result. - Licensed caregiver to verify and contact the provider immediately and every 10 minutes un2l fail safe 2me is reached. - Fail safe 2me is one hour is allowed for the provider to acknowledge receipt of no2fica2on.
Use Medica#ons Safely Before a procedure ensure that all medica2ons are labeled. Example: medica2ons in syringes, cups and basins. Label these medica2ons as they are drawn up and individually. Do not wait un2l axer all medica2ons have been prepared. Do this is the area where medica2ons and supplies are set up. Take extra care of pa2ents who take medica2ons that thin their blood. Follow appropriate protocols for ini2a2on and maintenance of an2coagula2on therapy. Provide effec2ve pa2ent/family educa2on to include monitoring, compliance, drug- food interac2ons and poten2al adverse drug reac2ons and interac2ons.
Use Medica#ons Safely Con#nued Record and pass along correct informa2on about pa2ent medica2ons. Find out what medica2ons the pa2ent currently takes. Compare medica2ons to new medica2ons ordered for the pa2ent. Ensure the pa2ent receives wrizen informa2on on which medica2ons to con2nue to use and which to stop when returning home. Educate the pa2ent on the importance of upda2ng their medica2on list with each doctor s visit.
Reduce Harm Associated with Clinical Alarm Systems Iden2fy the most important alarm signals to manage. Iden2fy high risk alarms Assess contribu2on to alarm fa2gue/necessity Assess pa2ent harm Ensure best prac2ces are u2lized Establish policies and procedures to manage alarms to meet required standards Determine when alarms can be disabled Appropriate se]ngs for alarm signals Monitoring and response to alarms When parameters can be altered Educate team members and medical staff on alarm safety and alarm fa2gue
Prevent Infec#on Follow Center for Disease Control Handwashing Procedures. Set Hand Cleaning Goals Use the hand cleaning guidelines from the Centers for Disease Control and Preven2on (CDC) or the World Health Organiza2on (WHO) to improve hand hygiene. Implement evidence- based prac2ces to prevent health care- associated infec2ons due to mul2drug- resistant organisms. Use evidence based prac2ce to prevent infec2ons of the blood from central lines. Use evidence based prac2ce guidelines to prevent infec2on axer surgery. use evidence based prac2ce guidelines to prevent indwelling catheter- associated urinary tract infec2ons.
Iden#fy Pa#ent Safety Risks Hospital iden2fies safety risks in its pa2ent popula2on Iden2fy pa2ents at risk for suicide. Iden2fy specific pa2ent characteris2cs and environmental features that influence suicide risk. Address immediate pa2ent needs Provide suicide preven2on informa2on for pa2ent and family. Example: crisis hotline
Prevent Surgical Mistakes Preven2ng Wrong Site, Wrong Procedure, and Wrong Person Surgery Ensure pre procedure verifica2on - Involve the pa2ent in the verifica2on process - Missing informa2on should be addressed prior to beginning procedure Mark the procedure site where the surgery is to be done. U2lize 2me- out immediately before star2ng the procedure or making an incision. - involves all members of the procedure team - review and verify the correct procedure, pa2ent and site
A pa2ent safety event not related to the natural course of a pa2ents illness, resul2ng in: Death Permanent harm Severe temporary harm Examples of sen2nel events include: Suicide Incorrect medica2on route or dose Wrong site or procedure Wrong pa2ent Sen#nel Events
Accredi#ng/Regulatory Agencies Centers for Medicare & Medicaid is a federal program that have standards of par2cipa2on that all healthcare organiza2ons must follow. CMS holds all healthcare en22es accountable for their condi2ons and standards. The Joint Commission and Healthcare Facili2es Accredita2on Program are agencies that survey hospitals against na2onally recognized standards for healthcare facili2es. The TJC and HFAP review our policies, procedures and processes to assure we provide the safest care to our pa2ents.