Practice #1: Create a Healthcare Culture of Safety

1. Potential Team Members-all that are applicable to your organization: CEO COO CMO CNE Patient Safety Officer Department Managers Director of Quality/Performance Improvement Director of Nursing Education/Staff Development Medical Staff Department Chairs Concepts Culture is the driver for all organizational frameworks and “eats everything else for lunch’. Culture is more then “the way we do things around here”, culture drives all the subtle influences to decision making”. High Reliability Organizations Potential Paper Resources- any and all that apply: C Level job descriptions, performance reviews and incentive plans: looking for language that pertains to establishing a culture of safety Patient Safety Officer job description Department Director job descriptions Medical Staff Committee Chair responsibilities Monthly Hospital Board Reports Organizational Strategic Plan Quality Improvement Plan Risk Management /Patient Safety Plan Quality Improvement Committee Minutes Patient Safety Plan and Committee minutes Risk Management Board Reports (may be restricted) Staff Development files Hospital Policies and Procedures specific to patient safety, adverse event reporting and “close call or near miss” reporting Summary reports of action plans subsequent to Root Cause Analysis (RCA) Meetings Staff meeting minutes that discuss patient safety and lessons learned from RCAs Story Boards of Performance Improvement projects: including policy and system changes resulting from the project Minutes of Pt Safety Officer/Chief Nurse Executive Board Reports Is it listed in Org: Mission, vision, core values…do those documents incorporate language on patient safety or safe care Organizational internal and external publications, newsletters and informational fliers to employees, physicians and public Documentation for JCAHO that includes patient safety and culture Documentation of implementation of Baldrige criteria is implemented Practice #1:Create a Healthcare Culture of Safety

2. Potential Team Members-all that are applicable to your organization: CEO COO CNE Director of Nursing Education/Staff Development Management Engineer Human Resources Patient Safety Officer Nursing Department Managers Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to Nursing Staffing procedures including subjects pertaining to: management of sick call, ED diversion, ICU diversion, off shift and weekend staffing, use of per diem staffing and “travelers” Use of internal float pool, Bed management system Management Engineering or Staffing Acuity Reports as applicable; may include: Unit specific patient acuity reports (12 months) APACHE or similar acuity reports for critical care Unit Staffing shift reports (12 months) Nursing Supervisor Shift Staffing Reports (12 months) ICU and ED Diversion Logs JCAHO Staffing Effectiveness Indicators or Measures Trends of Staffing Patterns ID’ed thru RCAs Actual Staffing Patterns (ratios) for the past 12 months; including staffing mix (RNs. LPNs. CNAs, EMTs. Techs) Strategic Plans for Nursing Staffing patterns Documentation of Magnet Nursing Certification if implemented in your organization Retention and Recruitment Plans Employee Satisfaction Surveys Community outreach actions and plans to enhance recruitment efforts Documentation of performance improvement projects related to recruitment and retention and management of appropriate staffing patterns Staff Development files and documentation of skills development seminars or on-site “skills fairs”, in-service education programs to specific skills Staff development programs specific to skill development needs identified out of trend analysis of adverse events in the organization: Simulator training Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #3:Specify an explicit protocol to be used to ensure an adequate level of nursing care based on the institution's usual patient mix and the experience and training of its nursing staff.

3. Potential Team Members-all that are applicable to your organization: COO CNE Director of Pharmacy Directors Respiratory and Imaging Staff Pharmacists Nursing Staff Medical Staff Concepts: Pharmacist Interventions: Interventions by pharmacists in an ordering process should be recorded and trended and performance improvement actions taken. Resources: Potential Paper Resources- any and all that apply: Pharmacist job description (all that apply) Hospital Policies and Procedures specific to: the role of the hospital pharmacist the role of a clinical pharmacist if a separate distinction applies Pharmacy coverage when pharmacy is not open 24/7 Authority of the pharmacist in the medication management process Multi-disciplinary rounds Pharmacy tracking system reports of Pharmacist interventions on medication orders (i.e.: # of times a pharmacist calls an MD to clarify or question a medication order etc.) P&T (Pharmacy and Therapeutics) Committee meeting minutes Documentation Pharmacist activities to support this safe practice Documentation of Pharmacists involvement in the Medication Reconciliation processes Automated medication dispensing system (i.e. Pyxis) reports on pharmacist interventions, including frequency or incidence rates when system medication profiling is turned off Robotic Filling/Dispensing System Reports Bar Coding System reports (bar coding labeling and administration system – over rides and meds saved or held – potential errors avoided) Documentation of performance improvement projects involving the role of the pharmacist outside the walls of the pharmacy or performance improvement project plans. Interviews of nursing, clinical and medical staff on the (actual) role of the pharmacist in the organization Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Minutes Medication Error Review Committee Data bases of findings from Executive Walk Rounds and Unit Briefings Practice #5Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

4. Potential Team Members-all that are applicable to your organization: COO CNE PSO Director of Pharmacy Director of Nursing Education/Staff Development Department Directors Clinical Staff Medical Staff Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Verbal and telephone orders Reporting of Lab Results or other Critical Test Results, including i.e: respiratory therapy or Imaging Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to verbal and telephone orders P&T (Pharmacy and Therapeutics) Committee meeting minutes which discuss the responsibilities of the MD in the use of verbal or telephone orders Documentation of clinical staff education sessions or “skills fairs” that include information on verbal orders and a read-back process Documentation of performance improvement or future performance improvement project plans that focus on use of verbal orders and the process of read-back for accuracy Summary reports from risk management on incidence of adverse events related to verbal orders or reporting/communication of critical test results Department Manager performance review requirements Summary reports on frequency and severity to Administration Measure of effectiveness and/or compliance with National Pt Safety Goal on verbal orders and critical test results Practice #6:Verbal or telephone orders or critical test results should be recorded whenever possible and immediately read back to the prescriber i.e., a healthcare provider receiving a verbal or telephone order should read or repeat back the information the prescriber conveys in order to verify the accuracy of what was heard. 

5. Potential Team Members-all that are applicable to your organization: COO CNE Director of Pharmacy Director of Nursing Education/Staff Development Department Directors Director of Information Management Concepts: Standardization of dose designations within an organization minimizes the risk of misinterpretation of medication orders. Standardized abbreviations reduces the risk if misinterpretation of any written order. Resources: JCAHO List: “ A Minimum List of Dangerous Abbreviations, Acronyms and Symbols” Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Standardized Abbreviations and Dose Designations Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to standardized abbreviations and/or dose designations P&T (Pharmacy and Therapeutics) Committee meeting minutes Medical Staff Peer Review Summary minutes that address actions dealing with frequent abusers of policy standardized abbreviations and dose designations Documentation of Medical Staff education on hospital required standardized abbreviations and dose designations Documentation of nursing education sessions or “skills fairs” that include information on standardized abbreviations Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Measure of effectiveness and/or compliance with National Pt Safety Goal on standardized abbreviations Documentation of compliance with JCAHO standards related to this area Practice #7:Use only standardized abbreviations and dose designations.  

6. Potential Team Members-all that are applicable to your organization: COO CNE CIO Medical Staff Department Chairs Director of Information Management or Medical Records Clinical Department Managers Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Dictation of patient care summaries or other components of the medical record Documentation of Medical Staff education on hospital policies regarding preparation and dictation of patient care summaries and other information Medical Staff Peer Review Summary minutes that address actions dealing with frequent abusers of policy standards on creation of patient care summaries. Documentation of Medical Records process or procedure for finalizing medical record components for MD discharge summary or other dictation requirements Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Documentation of the dictation environments Practice #8:Patient care summaries or other similar records should not be prepared from memory.  

7. Potential Team Members-all that are applicable to your organization: COO CNE CIO Medical Staff Department Chairs Clinical Department Managers Director of Information Management or Medical Records Director of Quality/Performance Improvement Director of Home Care Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: A medication reconciliation process Documentation of medications the patient is taking upon admission Documentation of prescriptions or a medication plan upon discharge Patient education plans or materials specific to medication management and allergies On diagnostic testing result reporting Documentation of clinical staff education regarding: admission assessment of medications, communication of changing orders and diagnostic information on patients to caregivers involved in direct patient care Performing a medication reconciliation process Medical Staff Committee minutes Staff Department Meeting minutes Documentation of Home Care and Social Work or Case Management staff involvement in communicating changes in patient care to outpatient providers Documentation of performance improvement or future performance improvement project plans that focus on this issue Documentation of this issue in individual department performance improvement plans, critical measures and reporting channels Department Manager performance review requirements Practice #9:Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient’s healthcare providers/professionals who need that information to provide care.

8. Potential Team Members-all that are applicable to your organization: COO CNE Director of Risk Management Director of Quality/Performance Improvement Director Surgical Services Clinical Department Managers as appropriate Individual Nursing Department Directors Director of Social Services or Case Management Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Obtaining Informed Consent Communicating with the hearing, visually or literacy impaired; specific to provision of certified interpreters Surrogate decision making Disclosure Informed Refusal Sample of current informed consent document; review for reading level and literacy considerations Summary reports from risk management regarding adverse events related to incomplete or lack of informed consent Documentation of clinical staff education regarding: The informed consent process The process for obtaining interpreters for blind, deaf and patients with literacy challenges, including English as a second language or non-English speaking Surrogate decision making Documentation of Medical Staff Education on this issue Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #10:Ask each patient or legal surrogate to recount what he or she has been told during the informed consent discussion.

9. Potential Team Members-all that are applicable to your organization: COO CNE Director of Risk Management Director of Quality/Performance Improvement Individual Nursing Department Directors Director of Social Services or Case Management Chairman of Clinical and Organizational Ethics Committee Hospital Patient Advocate Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to documentation of: End of Life Decision Making Do Not Resuscitate (DNR) Orders Living Wills or Advance Directives Surrogate decision making Sample of current hospital advance directive document; review for reading level and literacy considerations Sample of Admission consent forms; review how it addresses documentation of the patient’s currently existing or non-existing advance directives Minutes from Ethic Committee meetings which address this issue. Summary reports from risk management regarding adverse events related to lack of communication of the patient’s wishes for care Documentation of Nursing and Medicalstaff education regarding: Assessment and documentation of the patient’s desires for life sustaining measures Appropriate implementation of DNR orders Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #11:Ensure that written documentation of the patient's preference for life-sustaining treatments is prominently displayed in his or her chart.

10. Potential Team Members-all that are applicable to your organization: COO Imaging Department Director Director of the Emergency Department Chairman of the Medical Department of Radiology Director of Quality/Performance Improvement Director of Risk Management Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to documentation of: Labeling of x-rays and other films Management of x-rays during processing Flash marking x-rays Over reads and discrepancies Imaging Department logs of incidence of mislabeled radiographs Imaging Department staff meeting minutes that address this issue. Summary reports from risk management regarding adverse events related to mislabeled radiographs Documentation of imaging staff education regarding: Labeling and management of radiographs Performance improvement action plans based on trended data of mislabeling events within the department Documentation of Medical Staff education of system changes implemented to reduce mislabeling of films Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #13:Implement a standardized protocol to prevent the mislabeling of radiographs.

11. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Director of Surgical Services Individual Nursing Directors for Surgical Care Patients or other departments which perform invasive procedures Chairman of the Department of Surgery Director of Quality/Performance Improvement Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Identification of patients for surgery and confirmation of the intended procedure and site Universal Protocol Surgical Checklist for patient and site identification for surgery or invasive procedures Documentation of clinical staff education sessions on hospital policy and universal protocol for identification of patients and sites for surgery and invasive procedures Documentation of Medical Staff education of hospital policy and procedure or universal protocol for identification of patients and sites for surgery or invasive procedures Documentation of performance improvement or future performance improvement project plans that focus on this issue Documentation of implementation of a Universal Protocol or plans to implement Summary risk management reports of adverse events due to wrong patient, wrong procedure or wrong site during surgery or an invasive procedure Report of summary of near misses Department Manager performance review requirements Minutes of Pt Safety Officer and/ or CNE Board Reports Practice #14:Implement standardized protocols to prevent the occurrence of wrong-site procedures or wrong-patient procedures.

12. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Chief Medical Officer Director of Surgical Services Individual Nursing Directors for Surgical Care Patients Chairman of the Department of Surgery and Cardiology Director of Quality/Performance Improvement Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Performing a cardiac risk assessment of patients pre-operatively Surgical Cardiac Risk Assessment form Pre-Anesthesia risk assessment Documentation of clinical staff education sessions on hospital policy and procedure for performing a pre-operative cardiac risk assessment Documentation of Medical Staff education of hospital policy and procedure or protocol for pre-operative cardiac risk assessments and the available literature on the benefits and positive clinical outcomes related to the use of pre-intra and post-operative use of beta blockers. Documentation of the volume of patients that are assessed and treated Documentation of performance improvement or future performance improvement project plans that focus on this issue Summary risk management reports of adverse events associated with cardiac events during or immediately post-operative for surgical patients Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #15:Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment of high-risk patients with beta blockers.

13. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Wound Care Specialist Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing Admission Assessments Nutritional Assessments Mobility assessment Plans for prevention of skin ulcers Skin and Wound Assessments Nursing Admission Assessment form and sample nursing skin ulcer prevention plan Skin and Wound assessment forms Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for developing skin ulcers and proper use of pressure relieving devices Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #16:Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventative methods should be implemented consequent to the evaluation.

14. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Department Chair for Vascular Surgery Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing Admission Assessments Nursing Assessment for risk of developing DVT/VTE Post-op prophylactic management of DVT Medical Staff assessment of risk for DVT Documentation of Standing Orders and/or protocols for DVT/VTE prevention Nursing Admission Assessment form and nursing care plan for prevention of DVT/VTE Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk assessment for DVT/VTE Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #17:Evaluate each patient upon admission, and periodically thereafter, for the risk of developing DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE.

15. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Chief Medical Officer Vascular or Orthopedic Medical Staff Director of Pharmacy Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Director of Laboratory Services Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Use of anticoagulation therapy Laboratory policies on reporting coagulation times Patient Education regarding anticoagulation Documentation of a dedicated healthcare professional responsible to manage anti-coagualtion therapy services Documentation of clinical staff education sessions on appropriate management of anticoagulation therapy Documentation of procedure and standing orders or protocols for anticoagulation therapy Pharmacy system reports on anticoagulation protocol use by physicians and frequency of outliers Summary Medical Staff Peer Review Committee Minutes addressing the issue of consistent use of anticoagulation therapy protocols Minutes of P&T (Pharmacy and Therapeutics) Committee Meetings that address this issue; specific to discharge instructions Documentation of performance improvement or future performance improvement project plans that focus on this issue Documentation or sample Patient Education materials regarding the patient’s role in management of their anticoagulation therapy. Documentation of processes and procedures to manage patient’s anticoagulation therapy after discharge Department Manager performance review requirements Minutes of Pt Safety Officer and/or CNE Board Reports Practice #18:Utilize dedicated anti-thrombotic (anticoagulation) services that facilitate coordinated care management.

16. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Infection Control Practitioner Director of Respiratory Therapy Dieticians Speech Therapist Medical Staff Pulmonologist Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing Admission Assessments Risk assessment for aspiration Respiratory Assessment Nursing Admission Assessment form and sample aspiration prevention plan Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources. Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for aspiration, proper hand washing techniques, and sterile technique and the value of elevation of the Head of Bed Documentation of Respiratory Assessment for risk of aspiration Documentation of Speech Therapy assessment for gag reflex and swallowing capability, risk for aspiration Documentation of Dietary Assessment for appropriate diet to avoid risk of aspiration Nursing and PT Protocols specific to feeding patients at risk for aspiration Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Patient Safety Officer or Chief Nurse Executive Board Report Minutes Practice #19:Upon admission, and periodically thereafter, evaluate each patient for the risk of aspiration.

17. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Risk Management Director of Quality/Performance Improvement Infection Control Practitioner IV Therapy Team member Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Central Venous Line Placement and management Use of sterile technique Protocols for Infection Control related to Central Venous Lines Assessment of patients to determine benefit of Central lines Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources. Documentation of clinical staff education sessions on hospital policy and procedure for assisting with central line placement, proper hand washing techniques, sterile technique and long term management of central lines Documentation of Medical Staff education on hospital protocols for selection of patients andcentral line placement and use of sterile technique. Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Documentation of Patient Safety Officer or Chief Nurse Executive Board Reports Practice #20:Adhere to effective methods of preventing central venous catheter-related blood stream infections.

18. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Chief of Surgery Director of Surgical Services Individual Nursing Directors for Surgical patient care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Infection Control Practitioner Note: Check PeriOp Change for antibiotic administration procedures Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing Pre-operative Assessments Infection control procedures in the OR Infection control procedures in equipment sterilization Pre-operative skin prep for surgery Core temperature and Oxygenation management Use of prophylactic antibiotic therapy Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of surgical site infections. Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on results of infection control surveillance testing of all divisions of the surgical services department. Documentation of clinical staff education sessions on hospital policy and procedure on proper hand washing techniques, sterile technique, cleaning procedures between OR cases, use of prophylactic antibiotic therapy Documentation of trend reports on administration of pre and post-operative antibiotic administration timing and choice of antibiotic Documentation of Medical Staff education on current literature review of the clinical outcomes of patients who are at risk of developing an SSI and the use of prophylactic antibiotic therapy. Documentation of performance improvement or future performance improvement project plans that focus on this issue Department of Surgery minutes Department Manager performance review requirements Documentation of Patient Safety Officer or Chief Nurse Executive Board Reports Practice #21:Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of SSI, and implement appropriate antibiotic prophylaxis and other preventative measures based on that evaluation.

19. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Chief Medical Officer Director of Imaging Services Individual Nursing Directors for patient care areas Chairman of the Department of Imaging Director of Quality/Performance Improvement Director of Laboratory Services Director of Pharmacy Services Note: May need a FAQ that speaks to the last bullet under P&Ps Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing and/or Imaging Admission Assessments Nursing and/or Imaging Risk Assessment for potential contrast induced kidney failure Documentation of compliance with completion of pre-procedure assessments Medical Staff risk assessment for renal failure Nursing risk assessment form Review Department of Imaging Committee minutes regarding standardization of contrast media Documentation of clinical staff education sessions on hospital policy and procedure for performing a risk assessment for potential kidney failure secondary to contrast media administration, signs and symptoms of acute renal failure, Documentation of Medical Staff education of hospital policy and procedure or protocol for diagnostic risk assessment for potential contrast media induced renal failure and the positive clinical outcomes with implementation of appropriate prevention measures. Documentation of performance improvement or future performance improvement project plans that focus on this issue Summary risk management reports of adverse events associated with contrast media induced renal failure. Department Manager performance review requirements Practice #22:Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the patient's kidney function evaluation.

20. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for Patient Care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Dieticians Speech Therapist Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Nursing Admission Assessments Nutritional Assessments Malnutrition screening Nursing Admission Assessment form and sample malnutrition prevention plan Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for malnutrition, assessment of ability to eat and appropriate implementation of dietary supplements Documentation of Dietician risk assessment and screening for malnutrition, and plan of care Documentation of the need for Speech Therapy risk assessment for swallowing risk and mastication capabilities based on Dietician or Nursing risk assessment. Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Documentation of Patient Safety Officer and/or Chief Nurse Executive Reports to the Board Practice #23:Evaluate each patient upon admission, and periodically thereafter, for risk of malnutrition. Employ clinically appropriate strategies to prevent malnutrition.

21. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Directors of Surgical Services Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Medical Director for Surgery Chairman of Anesthesiology Director of Emergency Services Chairman of Department of Emergency Services Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Use of pneumatic tourniquets in the OR and the ER Medical Staff Risk Assessment Nursing risk assessment for complications and prevention plan Documentation of clinical staff education sessions on hospital policy and procedure for use of the pneumatic tourniquet, complications, nerve injury assessment, and prevention interventions Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #24:Whenever a pneumatic tourniquet is used, evaluate the patient for risk of ischemia and/or thrombotic complication and utilize appropriate prophylactic measures.

22. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for patient care areas Director of Nursing Staff Education/ Staff Development Director of Quality/Performance Improvement Infection Control Practitioner Director of Employee Health Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Proper Hand Washing Infection control procedures CDC Hand Hygiene Protocols Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on results of infection control hospital surveillance testing Documentation of clinical staff education sessions on hospital policy and procedure on proper hand washing and aseptic technique, use of universal precautions Documentation of performance improvement or future performance improvement project plans that focus on this issue Measures of compliance or effectiveness to National Patient Safety Goal Environment of Care Committee minutes Department Manager performance review requirements Documentation of Patient Safety Officer or Chief Nurse Executive Reports to Administration Practice #25:Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to and after direct contact with the patient or objects immediately around the patient.

23. Potential Team Members-all that are applicable to your organization: CNE Patient Safety Officer Individual Nursing Directors for patient care areas Director of Quality/Performance Improvement Infection Control Practitioner Director of Employee Health Human Resources Potential Paper Resources- any and all that apply: Human Resource Policies and Procedures specific to: Employee Vaccination Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources Documentation of Human Resources or Employee Health reports on incidence of employee vaccination for influenza Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #26:Vaccinate healthcare workers against influenza to protect both them and patients from influenza.

24. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Director of Pharmacy Individual Directors of Patient Care areas Director of Quality/Performance Improvement Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Medication preparation work areas Summary reports from risk management on adverse events related to medication errors specific to preparation and administration Environment of Care Committee minutes Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #27:Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction and noise.

25. Potential Team Members-all that are applicable to your organization: COO Patient Safety Officer Director of Pharmacy Director of Quality/Performance Improvement Director of Materials Management Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Labeling, Packaging and storage of medications Summary reports from risk management on adverse events related to medication errors specific to “look alike” medications or other labeling, packaging or storage issues Minutes from P&T Committee specific to this issue Documentation of clinical and pharmacy staff education sessions addressing the risks and issues associated with similar packaging of medications from various manufacturers, prevention measures, and forced function steps. Strategic plans to address this issue with specific capital budget allocations as needed Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #28:Standardize the methods of labeling, packaging, and storing medications.

26. Potential Team Members-all that are applicable to your organization: COO CNE CMO Patient Safety Officer Director of Pharmacy Clinical Directors of patient care areas Director of Quality/Performance Improvement Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: High Alert medications Removal of high concentration medications from clinical units Standardization of drug concentrations Independent verification Summary reports from risk management on adverse events related to medication errors specific to high risk medications Documentation of systematic measurement of adverse drugs events related to high risk, high alert medications. Review of P&T Committee Minutes specific to this issue Documentation of clinical and pharmacy staff education sessions addressing the risks and issues associated with high alert medications, prevention measures, and forced function steps. Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #29:Improve the safety of using high-alert medications (e.g., intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics and opiates).

27. Potential Team Members-all that are applicable to your organization: COO CNE Patient Safety Officer Director of Pharmacy Clinical Directors of patient care areas Director of Quality/Performance Improvement Potential Paper Resources- any and all that apply: Hospital Policies and Procedures specific to: Use of unit dose or unit-of-use medications Summary reports from risk management on adverse events related to medication errors specific to dose administration errors Review of P&T Committee minutes Documentation of clinical and pharmacy staff education sessions addressing the use of unit dose medications and risks of bulk packaging Documentation of strategic plans and allocation of capital dollars needed to address unit dose issues in the hospital Documentation of performance improvement or future performance improvement project plans that focus on this issue Department Manager performance review requirements Practice #30:Dispense medications in unit-dose or when appropriate unit-of-use form, whenever possible.