Download Patient Safety

Quality and Patient Safety
Roberta Monson, MD
Jo Ellen Austin, PharmD
Judi McGuire, RN
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We are preparing for our triennial
JCAHO visit which will occur this fall.
We need everyone’s help in order to
have a successful survey.
Quality of care and Patient safety will
be the # 1 focus.
JCAHO Tracer Methodology
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Review all processes by tracing patient
care
Current patients will be selected
Patients will be chosen by clinical
services
Information will come from staff and
patient interviews
Repeat visits are possible
Documentation Issues
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History and Physical
Post Op/Post procedure notes
Legibility/Physician identification
Discharge Planning
Medication Issues
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Verbal orders – read back
Abbreviations – QUIT AM
Standard concentrations
Secure storage
Medication errors/Adverse Drug Events
Medication Order Review
Quality Improvement
Methodology
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Plan
Do
Check
Act
National Patient Safety Goals
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JCAHO requires 100%
compliance with the safety
goals.
Everyone in the organization
is expected to know and
meet these goals.
Accurate patient identification
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Improve the accuracy of patient
identification
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Use at least two patient identifiers (our
policy requires name and birth date)
to verify patient ID when performing
treatments or procedures.
Effective Communication
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Improve the effectiveness of
communication among caregivers
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Request a “Read-back” when giving verbal or
telephone orders or perform one when receiving
critical value test results.
Effective Communication
Do not use the following
abbreviations in orders:
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U (for unit)
IU (for international unit)
O.D or Q.O.D (for every day or every other day)
Trailing or leading zero (X.0 mg or 0.X mg)
MS, MS04 or MgS04 (morphine sulfate, mag sulfate)
Ug (for microgram)
A (for ear)
Investigational “nicknames” for commercially available
products, such as 5FU
Safe Medication Use
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Improve the safety of using
medications
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Use the standardized drug concentrations
available in e-chart.
Be alert to prevent errors involving lookalike or sound alike (SALAD) drugs.
Preventing Infections
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Reduce the risk of health-care
acquired infections
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Comply with CDC hand hygiene guidelines
Use Central Venous Line protocols to avoid infections
Treat all identified cases of unanticipated death or
permanent injury due to health-care acquired infection
as sentinel events.
Reconciliation of medications
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Work to accurately and completely
reconcile medications across the
continuum of care
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All home meds are addressed on admission.
At time of transfer to another unit meds are
reviewed and documented.
At discharge consider home and all new
medications.
Meds are communicated to patient and any care
providers.
Universal Protocol
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Eliminate wrong site, wrong side
and wrong procedure surgeries or
interventions
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Verification of consent and any supporting
information, such as x-rays prior to
procedure
Site marking when indicated
“Time out” when all are present
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Also applies to bedside procedures
Universal Protocol
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“Time out” includes:
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Right patient
Right procedure
Right positioning
Right side and site
Any special equipment needed, correct implants,
tubes or catheters
Use the procedure note form to assist with
documentation.
National Quality Measures
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JCAHO and the Center for Medicaid
and Medicare Services (CMS) have
joined forces in evaluating us on
accepted best practices for the
following diseases:
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Congestive heart failure
Acute Myocardial infarction
Pneumonia
OB and Pregnancy related
AMI Measures
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Aspirin at arrival
Aspirin at discharge
ACE inhibitor for LVSD
Smoking cessation
Beta blocker at arrival
Beta blocker at discharge
Time to thrombolysis less than 30 minutes
Time to PTCA less than 120 minutes
Heart Failure Measures
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LVF assessment documented
ACEI or ARB for LVSD
Smoking cessation (smoker within past 12 months)
Discharge teaching includes: (must include all)
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Home mediations
Activity
Diet
Follow up care
What to do if symptoms worsen or reoccur
Weight monitoring
Pneumonia Measures
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Oxygenation assessment
Blood culture prior to antibiotics
Antibiotics within 4 hours of arrival time
Smoking cessation
Pneumococcal screening and
vaccination
Pregnancy related Measures
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Inpatient neonatal mortality rate
Vaginal birth after c-section (VBAC) rate
Rate of third or fourth degree perineal
laceration
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These measures are only reported to
JCAHO
Results are now available to the public
at www.medicare.gov/hospital
2nd quarter 2004 data
And at the JCAHO web site
We need your help.