Patient Safety Program

Employee education competency module 2009 DMC Quality Department Detroit Medical Center © December, 2008 1 of 36

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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A

ssessing Patient’s Risk for Injury

  Refer to the

Risk for Injury Algorithm

Plan) (see 2 PC 401 Patient Safety     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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A

ssessing 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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F A L L S

Preventing Patient Falls

N O

Non-slip footwear (grips on sole of foot) Obstruction-free environment 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 re prioritized 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.



New

Before initiating a blood product transfusion, the patient is matched to the blood product during a 2 person bedside/chair 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 25 of 36

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” S

ound

-A

like

, L

ook

-A

like 

D

rugs 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 29 of 36

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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