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Patient Safety Program
Employee education competency module 2009
DMC Quality Department
Detroit Medical Center©
December, 2008
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Patient Safety
 What is patient safety?
 Avoiding injuries to patients from the care that is
intended to help them.
 How can we accomplish this?
 By reducing risk and ensuring safety through
attention to systems that help prevent and lessen
errors.
 Patient Safety is everyone’s responsibility!
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Patient Safety
The Patient Safety Plan:
 Basic safety considerations for all patients
 Screening to identify patients at risk for altered safety patterns
 Use of recommended interventions for patients assessed “at
risk” for altered safety patterns
 Education of hospital employees in monitoring and reporting
unsafe patient behavior and environment conditions
 Processes for identifying opportunities to improve patient
outcomes and prevent injuries
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Basic Safety Considerations for All Patients
1. Instruct patient to wear non-skid footwear when ambulating
2. Maintain bed/chair in lowest position. Lock wheels at all times.
3. Ensure pathway to restroom is unobstructed and properly
lighted.
4. Place assistive devices (walker, cane) within patient’s reach.
5. Ensure that call light and personal care items are within
patient’s reach.
6. Raise side rails as appropriate for access to bed controls,
support and repositioning.
7. Raise all side rails on stretchers/bed for patients being
transported.
8. Educate patient to request assistance as needed.
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Basic Safety Considerations for All Patients con’t.
9. Educate patients and family members regarding treatments,
tests, and medications.
10. Be sensitive to cultural or language barriers and assess
patient’s understanding.
11. Consider peak effect for medications that affect level of
consciousness (LOC), walking and elimination when planning
care.
12. Observe environment for unsafe conditions. Notify appropriate
department of hazardous conditions.
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Basic Safety Considerations for All Patients con’t.
13. Ensure that the presence of any individual in patient care areas is
appropriate to the setting.
14. Ensure that visitors are known to and approved by the patient/family.
15. Include the patient’s family in development of an individualized safety
plan, considering age specific criteria and patient cognition when
planning care.
16. Collaborate with the patient and family to provide assistance as needed
while maintaining the patient’s independent functioning.
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Assessing Patient’s Risk for Injury
 Refer to the Risk for Injury Algorithm (see 2 PC 401 Patient Safety
Plan)
 Risks for injury includes:
 Falling
 Wandering
 Climbing
 Pulling at tubes and dressings
 Restlessness
 Aggression
 Suicide or elopement
 Inappropriate use of side rails
 Entrapment
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Assessing Patient’s Risk for Injury

For patients assessed at risk for injury:
 Document the risk
 Initiate risk reduction interventions (Refer to 2 PC 401 Patient
Safety Plan the Risk for Injury Algorithm)
 Communicate the patient’s “at risk for injury” status
•
•
•
•
During shift report,
Whenever patient is transported to another area,
During hand-off, and
With other disciplines as appropriate
 Do not leave “at risk” patients unattended in diagnostic or treatment
areas.
 Initiate Safety Plan of Care.
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Risk for Injury
Entrapment
 Entrapment is defined as:
 An event in which a patient is caught, trapped, or entangled
in the spaces in or about the bed rail, mattress, or hospital
frame. Entrapment can result in serious injury or death.
 Environmental Risk factors for entrapment include:
 Restraint use
 Use of mattress overlays
 Improperly sized mattresses
 Loose bed rails
 Wide spaces between the vertical bars in the bed rails
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Risk for Injury: Use of Side Rails
Sides rails may not be used as a restraint device.
Disoriented patients may view a side rail as a barrier to climb over, or
may try to climb out of bed to get around the side rail. This puts the
patient at great risk for entrapment or injury.
In most instances, it is safer to leave the bottom side rail closest to the
bathroom down. Injuries may occur if the patient attempts to climb
over the side rails to exit the bed.
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Risk for Injury: Use of Side Rails
 Having all 4 side rails up is considered a restraint and is to
be avoided, however, it is appropriate to raise all side rails in
some circumstances. These may include, but are not limited
to:
 When used to assist with patient positioning
 During transports
 When the bed is elevated for tests or procedures
 When the patient is unconscious or immobile
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Risk for Injury
Falls
 Patients are assessed for fall risk upon admission and
reassessed daily.
 A fall risk assessment tool is used to determine the patient’s
fall risk score.
 Fall risk assessment includes the patient’s:
•
•
•
•
•
Mobility
Mentation
Medication
Elimination
Prior fall history
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Risk for Injury
Falls
 Fall Protocol – additional interventions for patients assessed “at
risk for falls”
 Visual identification of patient at risk for fall (includes):
• Fall risk wristband
• Door/room sign




Maintain and monitor the bed and mattress
Provide frequent toileting
Provide calming interventions and pain relief
Increase visual supervision of patient
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Risk for Injury
Falls
 Drugs commonly associated with patient falls:

 Benzodiazepines (e.g.alprazolam, lorazepam)
 Antidepressants (e.g. fluoxetine, venlafazine, amitriptyline)
 Anticonvulsants (e.g. pregabalin, tiagabine)
 Sleep Aids (e.g. zolpidem, diphenhydramine)
 Narcotic Analgesics (e.g. morphine, codeine, propoxyphene)
 Muscle Relaxants (e.g.baclofen, cyclobenzaprine)
 Antiarrthymics (e.g. procainamide, disopyramide, quinidine)
 Digoxin
 Diuretics (e.g. hydrochlorothiazide, furosemide)
 ACE Inhibitors (e.g. lisinopril, captopril)
 Nitrates
 Quinolones (e.g. Ciprofloxacin, moxifloxacin)
Risk for a drug-induced fall increases when more than one of the above
medications are prescribed for the same patient.
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Preventing Patient Falls
N
O
Non-slip footwear (grips on sole of foot)
Obstruction-free environment
F
A
L
L
S
Functional assessment – on-going
Assistance while ambulating
Light – call light within reach
Leave personal articles within reach
Side rails up as appropriate
(remember to always leave the rail at the foot of bed closest to bathroom down)
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Transporting Patients
 Key Points to remember to ensure safe patient transport:
 Patients are positively identified immediately prior to the
transport.
 Patients receive the same level of care regardless of
location.
 The patient is assessed prior to transport, properly prepared
for transport, and staff transporting and receiving the patient
have pertinent patient information including contact
information for the person sending the patient.
 The medical record, including bedside records and MAR,
accompanying the patient throughout the transport.
 The receiving department is notified when the patient
arrives. At risk patients are never left unattended.
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Patient Hand-offs
 Hand-off refers to the transfer of patient care, whether temporary or
permanent, from one healthcare provider/team member to another.
Hand-offs include, but are not limited to:
 Nursing shift changes,
 Physicians transferring complete responsibility for a patient,
 Physicians transferring on-call responsibility,
 Temporary responsibility for staff leaving the unit for a short time,
 Anesthesiologist report to post-anesthesia recovery room nurse,
 Nursing and physician hand off from the emergency department
to inpatient units, different hospitals, nursing homes and home
health care,
 Communication of critical laboratory and radiology results.
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Hand-off communication
 Hand-off communication is an interactive communication process
that provides accurate information about a patient’s care, treatment
and services, current condition and any recent or anticipated
changes.
 The recipient of this communication has an opportunity to verify the
received information, including repeat–back or read–back
information, as appropriate.
 Whenever possible, hand-off communication should be face-to-face
 Hand-off communication should begin with introductions
 Introduce yourself and your role in the patient’s care
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2009 National Patient Safety Goals (NPSG)
A proven and effective communication tool is SBAR
S = Situation
 Specify the patient’s name and current condition or situation
 Explain what has happened to trigger this conversation
B = Background
 State the admission date, his or her diagnosis, and pertinent medical history
 Give a brief synopsis of what’s been done so far (e.g. lab test)
A = Assessment
 Give a summary of the patient’s condition or situation
 Explain what you think the problem is
 Expand upon your statement with specific signs and symptoms.
R = Recommendation
 Explain what you would like to see done (e.g., lab tests, treatments)
 State any new treatments or changes ordered
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IV Tubing/Catheter Safety






Always trace a catheter or tube from the patient to the point of origin
before connecting any new device or infusion
Recheck connections and trace all patient catheters or tubes to their
sources upon the patient’s arrival to a new setting or service as part
of the hand-off process
Route catheters and tubes having different purposes in different,
standardized directions (e.g., IV lines routed toward the head; enteric
lines toward the feet). This is especially important in the care of
neonates.
Inform non-clinical staff, patients and their families that they must get
help from clinical staff whenever there is a real or perceived need to
connect or disconnect devices or infusions.
For certain high-risk catheters (e.g., epidural, intrathecal, arterial),
label the catheter and do not use catheters that have injection ports.
Never use a standard luer syringe for oral medications or enteric
feedings
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Patient Incidents:
Patient Incidents are any events that have caused or have the
potential to cause patient harm. This includes, but is not limited
to:
• Patient injury including
•
•
•
•
•falls
•hospital associated pressure ulcers
•hospital associated infection
Missed, delayed or wrong treatment or procedure.
Medication errors and adverse drug reactions.
Breach of patient confidentiality (HIPPA violations).
Near miss events
Report all patient incidents using the DMC web-base incident
reporting system.
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National Patient Safety Goals
 The National Quality Forum and Joint Commission have identified
national priorities in regards to patient safety.
 Each National Patient Safety Goal has specific recommendations
for improving patient safety.
 Each year the goals and recommendations are reevaluated and reprioritized and modified as needed.
 The following slides outline the 2009 National Patient Safety Goals
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2009 National Patient Safety Goals (NPSG)
“Improve Accuracy of Patient Identification”
 Use at least two unique patient identifiers (DOB, Name, Pt ID# –
never use room #) when administering medications or blood,
collecting specimens, or providing any treatments.
 Label containers used for blood or other specimens in the
presence of the patient.
 Before initiating a blood product transfusion, the patient is
matched to the blood product during a 2 person bedside/chairNew
side verification process. At least two unique identifiers are used
in the process, and it is conducted after the blood product has
been dispensed.

See Policy 1 CLN 044 Patient Identification
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2009 National Patient Safety Goals (NPSG)
“Improve Effectiveness of communication among caregivers”
 For verbal or telephone orders or for telephonic reporting of critical test
results, verify the complete order or test result by having the person receiving
it “read-back” the complete order or test result. Write it down then read it
back!
• See policies 1 CLN 045 “Telephone Reporting of Critical Value Test Results”
and 1 CLN 045A “Verbal and Telephone Orders”
 Standardize the abbreviations, acronyms and symbols that are not to be
used throughout the organization.
• Do not use abbreviations: U, IU, μg, TIW, QD, QOD, MS, MSO4, MgSO4,
o (degree/hour symbol), use of trailing zero, lack of leading zero.
 Improve the timeliness of reporting and receipt of critical test results.
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2009 National Patient Safety Goals (NPSG)
“Improve Effectiveness of communication among caregivers”
continued
 Implement a standardized approach to “hand off”
communications, including an opportunity to ask and respond
to questions
 Hand-off communications:
• Opportunity exists for questioning between giver and receiver of
information
• Hand-off information includes up-to-date information
• Limit interruptions during hand-offs
• Hand-offs must include verification of information, such as read back
• Receiver of hand-off has opportunity to review information
 See 1CLN 053 Hand-off Communication
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2009 National Patient Safety Goals (NPSG)
“Improve Safety Using High-Alert Medications”
Exercise caution when using high alert/high risk medications
 High Alert/High Risk Medications – “CHHIPPS”
 C – Chemotherapeutic agents
 H – Heparin
 H – HYDROmorphone
 I – Insulin
 P – PCA and epidural opiates
 P – Potassium and/or Phosphate, concentrated
 S – Sodium, concentrated
Be aware of “SALAD” Sound-Alike, Look-Alike Drugs
 Prevent errors by separating/segregating sound-alike, look-alike
medications
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2009 National Patient Safety Goals (NPSG)
“Improve Safety Using High-Alert Medications”
con’t.
 Label all medications, medication containers (e.g., syringes,
medicine cups, basins), or other solutions on and off the sterile
field in perioperative and other procedural settings.
• Include on label:
– Drug name, dose, route, date
 Reduce the likelihood of patient harm associated with the use of
anticoagulation therapy (blood thinners i.e, heparin and
coumadin).
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2009 National Patient Safety Goals (NPSG)
“Reduce the risk of health care associated infections”
 Comply with CDC recommendations for hand hygiene guidelines
• WASH YOUR HANDS with soap and water or use alcohol based
hand rub! (See policy 2 IC 000 Hand Hygiene)
New
 Implement evidence-based practices to prevent health care associated
infections due to multiple drug-resistant organisms.
 Implement best practices or evidence-based guidelines to prevent central
line-associated bloodstream infections.
 Implement best practices for preventing surgical site infections.
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2009 National Patient Safety Goals (NPSG)
“Accurately and completely reconcile medications across the
continuum of care”



Obtain and document a complete list of patient’s home medications,
including over the counter and herbal remedies, upon patient’s entry into
the system.
A complete list of the patient’s medications is communicated to the next
provider of service when patient care is transferred.
A complete list of medications must be provided to the patient upon
discharge from the facility.
•
This includes:
–
–
–

Home medications to be continued
Home medications to be discontinued
New prescriptions
See 2MED 499 Medication Reconciliation
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2009 National Patient Safety Goals (NPSG)
“Reduce the risk of patient harm resulting from falls”
 Implement a fall reduction program and evaluate the effectiveness of
the program.
• See policy 2 PC 401 Patient Safety Plan and Risk for Injury
Algorithm
• Assess patients for altered safety patterns including increased risk
for falls using a fall risk assessment tool
• Implement “fall protocol” for those patients assessed at risk.
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2009 National Patient Safety Goals (NPSG)
“Encourage patients’ active involvement in their own care
as a patient safety strategy”

Define and communicate the means for patients and their families to
report concerns about safety and encourage them to do so.
• Give patient and family members the “Patient Safety”
Brochure
• Individualize care plans to meet patient needs
• Assess for language or cultural barriers to ensure patient
understanding.
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2009 National Patient Safety Goals (NPSG)
“The organization identifies safety risks inherent in
its’ patient population ”
 The organization identifies patients at risk for suicide.
 Complete risk assessments.
 Implement precautions.
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2009 National Patient Safety Goals (NPSG)
“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.
• See 1 CLN 056
• Any concerned staff member can initiate their site’s rapid
response process at any time for:
• Clinically significant changes in:
•
•
•
•
•
Heart or respiratory rate
Blood pressure
O2 saturation
Level of consciousness
Other causes of concern
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Universal Protocol
 The “Universal Protocol” is a process that aims to
prevent wrong person, wrong site procedures.
 It is formal process for verification of the correct patient, procedure,
operative/invasive site, and, as applicable, any needed implants or
special equipment/requirements for all operative and invasive
procedures that expose patients to harm, including procedures done in
settings other than the operating room.
 The Universal Protocol includes:
–
–
–
–
Pre-operative (or pre-procedure) verification process
Marking the operative (or procedure) site
“Time out” immediately before starting the procedure
See 1 CLN 046: Universal Protocol for Operative and Other
Invasive Procedures
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Patient Safety Summary
The patient safety plan includes basic safety considerations for all patients
screening to identify patients at risk for altered safety patterns and use of
recommended interventions for patients assessed “at risk” for altered safety
patterns.
Hand-off communication is an interactive communication process that
provides accurate information about a patient’s care, treatment and services,
current condition and any recent or anticipated changes.
Each National Patient Safety Goal has specific recommendations for
improving patient safety.
The Universal Protocol includes a pre-procedure verification of correct patient,
correct procedure, correct side or site and a “Time-out” immediately prior to
the start of the procedure.
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