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Use at Least Two Patient Identifiers
Name & MRN WHEN
 Administering meds, blood, or blood components
 Transfusions require 2 person check
 Collecting blood samples & other specimens
 Label containers used for blood & other specimens in the
presence of the pt.
 Providing other treatments or procedures
Eliminate Transfusion Errors
Before initiating a blood or blood component transfusion:
 Match the blood or blood component to the order
 Match the patient to the blood or blood component
 Patient identifiers: two licensed individuals (RN, LVN, MD,
CRNA, etc.) must positively identify blood products
with patient’s name and medical record number as
printed on the patient’s ID band in the presence of the
patient.
 Check the blood against tag on unit for patient's name, medical
record number, group and type of blood, number of unit and date
of expiration.
 RN enters second verifier’s name into Health Connect prior to
transfusion
 Any discrepancies Stop - send unit back to Blood Bank
Improve the Effectiveness of
Communication among Caregivers
 Verbal Orders & Test Results
 Write down (pull up from computer screen) orders/results
 Read them back to the person providing them
 Get confirmation from the person
 Critical Tests & Results
 Communicate results ASAP to Provider
 Document TIME of notification
 Provider must respond to values within ONE hr.
 Escalate if response is not received in timely manner
when paging Provider to give results
Improve the Effectiveness of
Communication among Caregivers
 Follow Hand-off Communications
 Must include opportunity to ask & respond to questions
 Use SBAR whenever possible
 Review anything pertinent to pt’s care
 Give next caregiver a better idea of what to expect
 Teamwork
 Patient & nursing personnel at ease
 Does not replace written report or physical assessment of the pt.
 SBAR – Situational Briefing




Situation – State the problem clear and concise
Background – Provide Info that is brief and to the point
Assessment – What do you think/know
Recommendation – Proposed action (What do you want & when)
Improve the Effectiveness of Communication among
Caregivers: Do Not Use/Accept Abbreviation List
Do Not Use
Potential Problem
Use Instead
U, u (unit)
Mistaken for “0” (zero), the Write (or accept order)
number “4” (four) or “cc”
"unit"
IU (International Unit)
Mistaken for IV
(intravenous) or the
number 10 (ten)
Write (or accept order)
"International Unit"
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d, qod
(every other day)
Mistaken for each other
Period after the Q mistaken
for "I" and the "O" mistaken
for "I
Write (or accept order)
"daily"
Write (or accept order)
"every other day"
Trailing zero (X.0 mg)
Lack of leading zero (.X
mg)
Decimal point is missed
Write (or accept order)
X mg
Write 0.X mg
MS
MSO4 and MgSO4
Can mean morphine sulfate Write (or accept
or magnesium sulfate
order)"morphine
Confused for one another
sulfate"
Write "magnesium
sulfate"
Joint Commission, 2004
7 RIGHTS of Medication Safety
1.
RIGHT Patient (2-identifiers!)
2.
RIGHT Route
3.
RIGHT Dose
4.
RIGHT Time
5.
RIGHT Medication
6.
RIGHT Reason
7.
RIGHT Documentation
Improve the Safety of Medication Use
 Be familiar with steps to prevent errors due to look-
alike/sound-alike meds & high alert meds
 Be AWARE of look-alike/sound-alike medications
 Be AWARE of high alert medications
 Label all meds/solutions containers on & off sterile field
 Review safety measures for anticoagulation therapy
 Properly Label & dispose Multi-dose & Single-use vials
 Be familiar with Black Box Warnings
 Practice the 7 Rights of medication safety
LABEL Requirements
Labeling MUST occur when any med or solution is
transferred from the original package to another
container
1.
2.
3.
4.
5.
Name of drug/solution
Strength of medication
Amount
Expiration Date: 28 days
Initials of preparer
Look-Alike Sound-Alike Medications
General Recommendations
 Verbal & phone orders are
 Discouraged unless truly necessary
 Must be read-back per required verbal order procedure
 Products are NOT stored next to each other in
pharmacies, pt. care units, clinics, & pt. homes
 Report errors or potentially hazardous conditions by
completing a UOR
 Assure meds are clearly labeled
High Alert Medications: Safety Practices
 Independent Double Check - Performed independently by two qualified
licensed practitioners
 Right Pt identification using two identifiers (name, MRN)
 Right Drug
 Right Dose, Right Route & Time of administration
 Verify setting, rate on IV pump (use guardian mode)
 Document on the MAR & Health Connect
 Time Out – a period of time immediately before administration /procedure when
two qualified practitioners, at pt’s side,
 Check special equipment or requirements
 Correct pt identity, side/site, pt. position
 Agreement on the med administration/procedure with pt./family
 Document Time Out on medical record
 Medication Safety Verification Record – documentation tool to record
Independent Double Checks & Time Outs
 Hand-off – an interactive process of passing pt. specific info
from one caregiver to another
Improve the Effectiveness of
Communication among Caregivers
 Follow Hand-off Communications
 Must include opportunity to ask & respond to questions
 Use SBAR whenever possible
 Review anything pertinent to pt’s care
 Give next caregiver a better idea of what to expect
 Teamwork
 Patient & nursing personnel at ease
 Does not replace written report or physical assessment of the pt.
 SBAR – Situational Briefing




S
B
A
R
Situation
Background
Assessment
Recommendation (or Request)
Anticoagulation Therapy Safety
 Pts. on warfarin receive baseline International Normalized
Ration (INR) to monitor & adjust therapy
 IV Heparin is administered using an IV pump
 Independent Double Check required for IV Heparin – before start,
with each change of container or rate, & at change of shift handoffs
 Document “Double Check Required” on the eMAR (Health Connect)
 Baseline & ongoing lab tests required for heparin therapies
 Pt./Family Education
 Follow-up monitoring
 Compliance
 Dietary restrictions
 Potential adverse drug reactions & interactions
Specimen Equipment and Supplies
Obtain containers, labels, requisition forms, and the
preservative or fixative appropriate for the type of testing or
delivery.
Collection containers must be impervious
and of an adequate size to easily contain
a specimen
Sterile receptacles and equipment must be used for specimens
when sterility must be maintained
Specimen Labeling
Identify patient using two
verifiers:
Verify with specimen
collector
• Name
• Source/site of specimen
• Medical Record Number
• Name of test to be done
• Timing of test: Routine or Stat
Specimen Labeling Key Steps:
The specimen label is applied by the collector or clinical
support staff witnessing the collection
Label any specimen collected in the back office in the
presence of the patient
Unlabeled specimens cannot be removed from the
collection area (e.g. exam room) to another area for
labeling
Labels may be printed or handwritten
Handwritten labels must be legible and written in black
ink
Requisition/Transmittal Slip and
Label Criteria
Reacquisition/Transmittal Slip must contain:
Full name, MR number,
Date, time of collection,
Specimen source/type, name of the collector, clinical staff
Initials.
Use pencil to label slides and slides must contain the patient’s
complete name and MRN
Label is placed on each specimen container and NOT on the
lid or transport bag
Unlabeled or mislabeled specimens will not be tested
unless they meet the “exceptions list criteria”
e.g. .body fluids other than blood or urine, tissue, bone
marrow, blood for drug levels, blood cultures, specimens)
Chain of Custody
Establish mechanisms for chain of custody to ensure
accountability
Complete transmittal slip and send with
specimen to lab
Consistent communication patterns should be established
between personnel at change of shift or relief
Multi Dose Vials
Proper Labeling & Disposal
Write date
28 days
from initial
opening
 Write date 28 days from initial
opening
 Discard on 28th day or if sterility
compromised
 Examine vial for visible signs of
contamination or deterioration
Multidose Vial Adapter
Good for 24hrs only
 Withdrawals from vial MUST
 Use sterile technique
 DO NOT leave needle or needle
sheath in the vial top for ease of access!
Single-Dose Vials
Proper Labeling & Disposal
 Contain ONLY ONE dose of
medication, use ONCE &
DISCARD after use!
Single-
dose vials are
meant for
 Check mfr. exp. Date BEFORE use
ONE time
 DO NOT use SINGLE-use vials as
MULTI-dose vials!
 All withdrawals require
sterile technique
use ONLY!
Black Box Warnings
Emphasize the potential health risk of a drug
FDA requires drugs with serious, life-threatening side effects, or there are
more risks than most other prescription drugs carry a black box
warning!
 Black box warnings have a heavy bold line
or
box
box around the warning.
Black Box Warning
 These drugs are effective, although high risk, its
benefits outweigh the risks.
 KP HealthConnect provides a hyperlink that links to
drug information – this is where the Black Box warning will
appear.
 Contact Pharmacy for questions.
Accurately & Completely Reconcile
Medications Across the Continuum
of Care
 All pt’s must have complete list of current meds, including
herbal remedies, vitamins, OTCs, etc., as part of initial
assessment
 Medication reconciliation must be complete at every visit
 Medication reconciliation must occur whenever a pt. is
transferred or there is a change in the level of care
Reduce the Risk of Health Care Associated
Infections
Wash hands for 15 seconds when
visibly soiled or contaminated,
otherwise use waterless gel,
alcohol based hand rub
 Keep nails short and clean
 Use only approved lotion
 Wear gloves – Latex-free
 Prevent surgical site infections:
Use appropriate sterile/aseptic
technique, wash hands, use electric
clipper for hair preps
Decontaminate hands BEFORE
 Contact w/pt’s
 Donning sterile gloves
associated urinary tract
infections
 Secure catheters for
unobstructed urine flow and
drainage
 Maintaining the sterility of the
urine collection system

Decontaminate hands AFTER
 Contact with pt. & objects
close to pt.
 Removing gloves
 Taking a break
 Prevent indwelling catheter-
Reduce the Risk of Health Care Associated
Infections
Be AWARE!
WASH with CARE!
1. WET hands with water
2. Apply hand wash – 1 pump
3. Lather & Wash – 15 seconds
4. Rinse both sides of hands with
water
5. Dry hands
6. Shut off faucet with hand towel
Follow the Universal Protocol
 Conduct pre-procedure verification process
 Involve patient, verify consent for procedure
 Check for correct patient, site, procedure
 Mark procedure site – done by licensed
practitioner performing procedure
 “X” marks the site!
 TIME-OUT performed prior to starting
procedures
 DOCUMENT Universal Protocol & Time-out
Improve the Safety of
Clinical Alarms
Clinical alarm systems are intended to alert caregivers of
potential patient problems, but if they are not properly
managed, they can compromise patient safety. This is a
multifaceted problem. In some situations, individual
alarm signals are difficult to detect.
Many patient care areas have numerous alarm signals
and the resulting noise and displayed information tends to
desensitize staff and cause them to miss or ignore alarm
signals or even disable them.
Monitor and respond to alarms. Do not turn off alarms
unless you have authority to do so.
Identify patients at Risk
for Suicide
Suicide of a patient while in a staffed, round-the-clock
care setting is a frequently reported type of sentinel
event.
Identification of individuals at risk for suicide while under
the care of or following discharge from a health care
organization is an important step in protecting these atrisk individuals.
1. Conduct a risk assessment that identifies specific
patient characteristics and environmental features that
may increase or decrease the risk for suicide.
2. Address the patient’s immediate safety needs and most
appropriate setting for treatment.
3. When a patient at risk for suicide leaves the care of the
hospital, provide suicide prevention information (such
as a crisis hotline) to the patient and his or her family.