Download NPSG - El Paso Community College

2014
National Patient Safety Goals
Improve Patient Safety
Reviewed 10/2014
2014
2014
National Patient Safety Goals
The goals focus on problems in health
care safety and how to solve them.
2014
History of NPSG’s…
The Joint Commission first implemented the
first set of NPSG’s for healthcare
organizations in January 1, 2003.
 Hospital Accreditation is dependent on
compliance with the NPSG’s.
2014
Identify Patients Correctly
NPSG.01.01.01: Identify Patients Correctly
Use at least two patient identifiers when providing care,
treatment, and services.
 Verbalization
 Last four numbers of Account Number(bolded)
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Patient’s room is not an identifier.
Elements of Performance (EP)
• Prior to administration of medications, blood, or collecting blood
sample & other specimens
• Treatments or procedures.
• Label containers used for blood & other specimens in the presence of
the patient
2014
Identify Patients Correctly
NPSG 01.03.01: Make sure that the correct patient gets
the correct blood when they get a blood transfusion.
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Match blood product to the order
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Match the patient to the blood product
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Use a two-person verification process
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Use BCTA: Bar Code Enabled Transfusion Administration
Elements of Performance (EP)
• Verification process (2) RN’s
• BCTA - Bar Code enabled Transfusion
Administration
2014
Improve Staff Communication
NPSG.02.03.01: Get important/critical test results to the
right staff person on a timely basis.
Elements of Performance
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Written procedures for critical results management
Implement procedures for critical results management
Evaluate the timeliness of reporting
2014
Use Medicines Safely
NPSG.03.04.01: Before a procedure, label medicines
that are not labeled.
Elements of Performance
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If not immediately administered
Labeling occurs when any medication or solution is transferred from original
packaging to another container
Labels include name, strength, quantity, dilutent and volume, prep date, exp date
when not used within 24 hours, exp time when less than 24 hours
Verify both verbally and visually.
2 people required if the person preparing is NOT the person administering.
Discard medication found unlabeled.
All meds reviewed by entering and exiting staff responsible for med management
2014
Use Medicines Safely
NPSG.03.05.01 Take extra care with patients who take
medicines to thin their blood (anticoagulants).
Elements of Performance
 Use unit-dose products, prefilled syringes, premixed bags when
available, programmable pumps.
 Use approved protocols for initiation and maintenance.
 Know baseline coagulation status (International Normalized Ration-INR)
 Manage FDI (Food and Drug Interactions)
 Staff and Patient/Family Education
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Monitoring
Compliance
Food-Drug Interactions
Potential Adverse Drug Reactions and interactions
Resources for Pt Education:
KRAMES ON DEMAND Discharge Instructions: Taking Anticoagulants &
Taking Coumadin(Warfarin)
2014
Use Medicines Safely
NPSG.03.06.01: Maintain and communicate accurate patient
medication information (record and pass along/change of shift
report).
Elements of Performance
 Find out what medicines the patient is taking.
 Compare those medicines to new medicines given to
medicines the patient is taking.
 Make sure the patient knows which medicines to take when
they are at home.
 Explain the importance of managing medication information
to the patient.
 Tell the patient it is important to bring their up-to-date list of
medicines every time they visit a doctor.
2014
Use Alarms Safely
NPSG.06.01.01 Make improvements to ensure that alarms on
medical equipment are heard and responded to on time.
Improve the safety of clinical alarm systems
Elements of Performance
A 1. As of July 1, 2014, establish alarm system safety as a
hospital priority.
A 2. During 2014, identify the most important alarm signals
to manage, based on criteria.
C4. As of January 1, 2016, educate staff and licensed
independent practitioners about the purpose and proper
operation of alarm systems for which they are
responsible.
2014
Prevent Infection
NPSG.07.01.01: Use the hand cleaning guidelines from the
Centers for Disease Control and Prevention or the World
Health Organization.
Reduce the risk of health care-associated infections.
 Set Goals for Improving hand cleaning.
 Use the goals to improve hand cleaning.
2014
Prevent Infection
NPSG.07.03.01 Use proven guidelines to prevent
infections that are difficult to treat.
 Some of the organisms to be aware of but not limited to:
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Methicillin-resistant staphylococcus aureus (MRSA)
Clostridium difficile (CDI)
Vancomycin-resistant enterococci (VRE)
Multiple drug- resistant gram negative bacteria
Elements of Performance
 Conduct periodic risk assessments
 Based on Risk Assessment Findings:
 Educate staff and practitioners
 Educate patients and their families
 Implement surveillance program
 Measure and monitor prevention processes
 Implement Policies and Practice
2014
Prevent Infection
NPSG.07.04.01 Use proven guidelines to prevent infection of the
blood from central lines.
Elements of Performance
11. Use of antiseptic for skin preparation during central venous
catheter insertion that is cited in specific literature by
professional organizations.
12. Use of standardized protocol to disinfect catheter hubs and
injection ports before accessing the ports.
2014
Prevent Infection
NPSG.07.05.01 Use proven guidelines to prevent infection
after surgery.
Elements of Performance
C7 Administer antimicrobial agents for prophylaxis for a
particular procedure or disease according to methods cited in
scientific literature.
C8 When hair removal is necessary, use a method that is cited in
scientific literature or endorsed by professional organizations
2014
Prevent Infection
NPSG.07.06.01 Use proven guidelines to prevent infections of the
urinary tract that are caused by catheters.
Elements of Performance
 Measure and monitor catheter-associated urinary tract
infection prevention processes.
 Manage indwelling urinary catheter according to established
guidelines.
 Insert indwelling urinary catheter according to established
guidelines.
 Limit use and duration
 Use aseptic techniques for site preparation, equipment
and supplies
2014
Identify Patient Safety Risks
NPSG.15.01.01 Find out which patients are most likely
to try to commit suicide.
Elements of Performance
 Risk assessment
 Address the patient’s immediate safety needs and most
appropriate setting for treatment
 Provide suicide prevention information(such as crisis hotline)
to patient and family.
 PC 209 Assessing and Protecting Patients with Suicidal
Ideation or Intent
2014
Prevent Mistakes in Surgery
UP.01.01.01 Make sure that the correct surgery is done on the
correct patient and at the correct place on the patient’s body.
Elements of Performance
 TIME OUT pre-procedure
– correct patient
– correct procedure
– correct site
Missing information or discrepancies are addressed before
the start of the procedure.
2014
Prevent Mistakes in Surgery
UP.01.02.01 Mark the correct place on the patient’s body
where the surgery is to be done.
Elements of Performance
 Mark the procedure site before the procedure is
performed. INVOLVE PATIENT WHEN POSSIBLE.
 The person who knows the most about the patient should
mark the site, in most cases which is the person
performing the procedure- Licensed independent
practitioner- fully accountable for procedure
2014
Prevent Mistakes in Surgery
UP.01.03.01 Pause before the surgery to make sure that
a mistake is not being made.
Elements of Performance
 Conduct a time-out immediately before starting that
correct patient, site, and procedure.
 Involves all the immediate members of the procedure
team.
 During the time-out, the team members agree:
correct patient
correct site
correct procedure
2014
PC 203 Universal Protocol Preventing
Wrong Site, Wrong Procedure, Wrong
Person Surgery/Procedures
Reference
The Joint Commission
http://www.jointcommission.org/joint_commission_announc
es_2014_npsg/
2014