National Patient Safety Goals

1. National Patient Safety Goals Mac Neal Hospital 2011

2. National Patient Safety GoalsPurpose • The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety • The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. • The Requirements focus on system-wide solutions, wherever possible.

3. 2011 NationalPatient Safety Goals • Approved by The Joint Commission’s Board of Commissioners • The Goals and Requirements are program-specific • Include improvements emanating from the Standards Improvement Initiative, including: • New numbering system for sorting in new electronic manuals • Minor language changes for consistency

4. Patient Identification • Improve the accuracy of patient identification Goals Goals Goals Goals Goals Goals Goals Goals Goals

5. Patient Identification • Use at least two patient identifiers (name & birth date) when providing care, treatment and services. • Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques

6. Patient Identification • Eliminate transfusion errors related to patient misidentification.

7. Improve Communication • Get the important test results to the right staff person. • For telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.

8. Improve Communication • There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. • The organization 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.

9. Improve Communication • The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. • At MacNeal we use SHARER (sketch, how, aim, rationale, exchange, & review).

10. Medication Safety • Improve the safety of using medications • The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications.

11. Medication Safety • Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions (including water on and off the sterile field. • Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

12. Health Care Associated Infections • 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.

13. 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. • Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

14. Health Care Associated Infections • Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. • Implement best practices for preventing surgical site infections.

15. Reconcile Medications • Find out what medications the patient is taking. Make sure that it is OK for the patient to take any new medication with their current medicines. • Give a list of the patient’s meds to their new care giver. Give the list to the patient’s primary doctor before the patient goes home. • Give a list of the patient’s medications to the patient and their family before they go home. Explain the list.

16. Reconcile Medications • In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.

17. Reduce Falls • Reduce the risk of patient harm resulting from falls. • The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

18. Influenza & Pneumococcal Disease • Reduce the risk of influenza and pneumococcal disease in institutionalized older adults. • The organization develops and implements protocols for administration of the flu vaccine. (Joint Commission, 2009)

19. Influenza & Pneumococcal Disease • The organization develops and implements protocols for administration of the pneumococcus vaccine. • The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. (Joint Commission, 2009)

20. Surgical Fires • Reduce the risk of surgical fires. • The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.

21. Patient Involvement • Encourage patients’ active involvement in their own care as a patient safety strategy • Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

22. Pressure Ulcers • Prevent health care associated pressure ulcers (decubitus ulcers) • Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.

23. Risk Assessment • The organization identifies safety risks inherent in its patient population. • The organization identifies patients at risk for suicide. • The organization identifies risks associated with home oxygen therapy such as home fires.

24. Changes in Patient Condition • Improve recognition and response to changes in a patient’s condition. • The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

25. Universal Protocol • The organization meets the expectations of the Universal Protocol. • Conduct a pre-procedure verification process. • Mark the procedure site. • Atime-out is performed immediately prior to starting procedures.

26. Utility Systems

27. Utility Failure-CODE GREEN • Oxygen/Medical Air/and Suction • Water • Electricity • Waste Removal (Sewage) • Natural Gas • Telephones

28. Utility Failure-CODE GREENReporting Utility Problems • If you come across problems or failures of any utility system • Report-call security at x 3163 • Security will call Facility Services • Notify your supervisor • Facility Services will • Inspect the situation • Initiate corrective action

29. Other Utility Failures • Contingency plans are in place for utility failures ...Ask supervisor for details

30. Power Failure- Main Campus • Main Campus power disruption • Emergency generators automatically start • Emergency power in 10 minutes or less • Generators • Provide power to the main campus in emergencies • For more than 24 hours • Coverage includes • Critical medical equipment • Emergency lighting • Designated elevators • Red outlets • Battery power lights • Provides illumination • Provides safety for generator turns on emergency power

31. Power Failure- Main Campus Connect critical components into RED outlet (IV’s etc..)

32. Power Failure – Off-Site Facilities • Battery powered lights • Illumination for up to 1 hour • limited illumination for exiting premises • Facilities with generators which support a limited amount of equipment • Harlem- Ogden bldg • Mid City Bank bldg

33. Telephone System FailureMain Campus • The red telephones may be the only working telephones • Used as a back up system • Separate phone numbers are attached to each red telephone

34. Oxygen/ Medical Air/ Suction Shut- off Valves • Shut-off valves are located throughout the hospital in areas where services at off valve used • Adjacent to the shut- off valves is a map indicating which rooms these valves serve and the emergency protocol • If you work in an area utilizing these services, familiarize yourself with this information • Only shut off the service in an emergency condition, following the approved protocol for medical gas shutdown

35. Medical Equipment & Electrical Safety

36. Electrical Safety Considerations • If a device has a power cord it must be safety tested by Facilities Services or Biomedical Engineering prior to being put into service • Patient owned electrical items (radios, hair dryers, etc..) are not allowed unless the device is battery operated

37. Don’t unplug equipment by pulling on the power cord; use the head of the plug Always check the condition of the plug before inserting it into the outlet Electrical Safety Considerations

38. Reporting Electrical Hazards • Immediately report any non-static electrical shocks to your supervisor • Unsafe equipment should also be reported immediately to: • Biomedical Services ( x3715) • Biomedical Services after hours pager (3715) • Facility Services ( x3137)

39. Safe Medical Device Act • The S.M.D.A. is a federal law designed to protect you and the patients • There are two important regulations in this act that could affect you • The Device Tracking Regulation • The Medical Device Reporting (MDR) Regulation

40. Definition of Medical Device • A Medical Device is: • Any device used in the treatment, therapy or diagnosis of patients

41. Medical Devices Include Hospital Bed Wheelchair Defibrillator • Infusion pumps, • defibrillators, monitors, • implantable devices • Beds, syringes, IV lines, • wheelchairs Syringe

42. Device Tracking Regulation • Certain Medical devices are required by the FDA to be tracked. • IV pumps • Implantable devices • pacemakers

43. Medical Device Reporting (MDR) Regulation • Medical Device Reporting is required • If a device may have contributed to a patient or employee’s • Death • Serious injury • Serious illness

44. General GuidelinesMedical Device Incident Management • Attend to the medical needs of the patient • Report the incident to the appropriate person • Notify Risk Management and/or the AOD • Complete an occurrence report within 24 hours

45. General GuidelinesMedical Device Incident Management • Remove the device from service • Contact security at x 3163 • Security will store the item in a secure location for further investigation

46. General GuidelinesMedical Device Incident Management • Do not change the settings on the device • Label the device • Do not use or discard • Describe the malfunction • State how you may be contacted • If the device is reusable- record • Serial numbers • Identification numbers

47. General GuidelinesMedical Device Incident Management • Save all the materials • Don’t take device apart • If you must take it apart –save everything • Save all original packing- if possible

48. Chemical and Hazardous Material Safety

49. MSDS for most Chemicals and Hazardous Materials • Every department is responsible for keeping corresponding MSDS for all hazardous chemicals used in their area • The Emergency Department will have a master inventory of all MSDS • The MSDS list is on the intranet, on the Pulse page.

50. Proper Labeling • The chemical should remain the original container • The original label must remain on all chemicals • If a chemical must be transferred to a different container, that new container must be properly labeled • Additional labels can be obtained by calling that vendor