nqf 34 patient safety practices for hospitals 2010 part 2 of 2
DESCRIPTION
NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2. Speaker. Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 [email protected] 614 791-1481. 2. 2. NQF 34 SAFE PRACTICES. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/1.jpg)
NQF 34 Patient Safety Practices for Hospitals 2010
Part 2 of 2
![Page 2: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/2.jpg)
2
Speaker Sue Dill Calloway RN, Esq.
CPHRM
AD, BA, BSN, MSN, JD
Medical Legal consultant
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1481
22
![Page 3: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/3.jpg)
NQF 34 SAFE PRACTICES
Released in 2003, updated 2006, 2009 and April 2010
These should followed in all healthcare facilities
All clinical care settings to reduce risk of harm to patients
A roadmap to preventing harm
States 10 years after IOM report, To Err Is Human, uniformly reliably safety in healthcare has not been achieved
3
![Page 4: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/4.jpg)
Culture SP 1
Information Management & Continuity of Care
Medication Management
Hospital Acquired Infections
Condition & Site Specific Practices
Consent & Disclosure
Wrong-siteSx Prevention
Periop. MIPrevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
Asp +VAP Prevention
Central V. CathBSI Prevention
Sx Site Inf.Prevention
Contrast Media Use
Hand Hygiene InfluenzaPrevention
PharmacistCentral Role
Med Recon.
Std. Med Labeling & Pkg
High AlertMeds
Unit DoseMedications
Evidence-Based Ref.
Culture
CPOE
OrderRead-back
Abbreviations Discharge System
CriticalCare Info.
LabelingStudies
Culture Meas.,F.B, & Interv.
Structures& Systems
ID Mitigation Risk & Hazards
Team Training& Team Interv.CHAPTER 1: Background
Summary, and Set of Safe Practices
CHAPTERS 2-8 : Practices By Subject
Nursing Workforce ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers
• ICU Care
CHAPTER 2: Creating and Sustaining a Culture of Patient Safety
• Leadership Structures & Systems• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions• Identification and Mitigation of Risks and Hazards
CHAPTER 5: Information Management & Continuity of Care
• Critical Care Information• Order Read-back• Labeling Studies
• Discharge Systems• Safe Adoption of Integrated Clinical Systems
including CPOE• Abbreviations
CHAPTER 6: Medication Management• Medication Reconciliation
• Pharmacist Role• Standardized Medication Labeling & Packaging
• High-Alert Medications• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections• Prevention of Aspiration and Ventilator-
Associated Pneumonia • Central Venous Catheter-Related Blood Stream
Infection Prevention • Surgical Site Infection Prevention
• Hand Hygiene• Influenza Prevention
CHAPTER 8:• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia Prevention
• Pressure Ulcer Prevention• DVT/VTE Prevention
• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention
Informed Consent
Life-Sustaining Treatment
Disclosure
CHAPTER 3: Informed Consent & Disclosure• Informed Consent
• Life-Sustaining Treatment• Disclosure
Consent & Disclosure
CHAPTER 7: Healthcare-Associated Infections• Hand Hygiene (Safe Practice 19)
• Influenza Prevention (Safe Practice 20)• Central Line Associated Blood Stream Infection Prevention (SP 21P
• Surgical Site Infection Prevention (Safe Practice 22)• Care of the Ventilated Patient (Safe Practice 23)
• Multidrug-Resistant Organism Prevention (Safe Practice 24)• Catheter-Associated Urinary Tract Infection Prevention (SP 25)
2010 NQF Report
4
![Page 5: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/5.jpg)
Safe Practice 19 Hand Hygiene
Comply with current Centers for Disease Control (CDC) and Prevention Hand Hygiene Guidelines
TJC has NPSG.07.01.01 to comply with CDC or WHO 2009 guidelines
TJC published document in 2009 on Measuring Hand Hygiene Adherence: Overcoming the Challenges and this is an important document
IHI publishes “How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers”
Very important issue in reducing HAI
5
![Page 6: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/6.jpg)
TJC Hand Hygiene NPSG.07.01.01
Comply with current CDC or WHO hand hygiene guidelines and has 3 EPs,
EP1 Implement a program that follows categories 1A, 1B, and 1C on one of the above,
EP2 Set goals for improving compliance with hand hygiene guidelines,
EP3 Improve compliance with hand hygiene guidelines based on established goals,
6
![Page 7: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/7.jpg)
7
![Page 8: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/8.jpg)
CDC Hand Hygiene Recommendations
CDC published guidelines Oct 25, 2002 at www.cdc.gov/handhygiene
In CDC MMWR Recommendations and Reports,Report available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm or go to www.cdc.gov
Also new admission video on hand hygiene
Hand hygiene interactive training class
Monitored during infection control tracer by TJC
8
![Page 9: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/9.jpg)
9
![Page 10: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/10.jpg)
10
![Page 11: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/11.jpg)
Hand Hygiene
WHO Guidelines on Hand Hygiene in Health Care; Clean Hands are Safer Hands at www.who.int/patientsafety/events/05/HH_en.pdf
Good website for children on importance of washing hands with colorful posters, puzzles, and quiz AT http://www.microbe.org/washup/Wash_Up.asp
Henry the Hand at henrythehand.com
Toolkits and posters at http://www.health.state.mn.us/handhygiene/materials.html
Clean your hand campaign at www.npsa.nhs.uk/cleanyourhands/resources
11
![Page 12: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/12.jpg)
Safe Practice 19 Hand Hygiene
Implement the CDC requirements with Category I requirements or WHO
Encourage compliance with category II
Ensure that all staff know what is expected of them with regard to hand hygiene
Ensure compliance with hand hygiene
12
![Page 13: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/13.jpg)
TJC NPSG FAQ
13
![Page 14: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/14.jpg)
Safe Practice 20 Influenza Prevention
Comply with current Centers for Disease Control and Prevention (CDC) recommendations for influenza vaccinations for healthcare personnel
and the annual recommendations of the CDC Advisory Committee on Immunization Practices for individual influenza prevention and control.
CDC has website at www.flu.gov
14
![Page 15: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/15.jpg)
www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm
15
![Page 16: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/16.jpg)
16
![Page 17: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/17.jpg)
17
![Page 18: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/18.jpg)
20 Flu Prevention Healthcare workers with direct patient contact
should be immunization against the flu
Unless contraindicated
Patients should be immunized as per current CDC recommendations
P&P on above along with flu program should be in place
Document immunization status of all employees
Implement CDC recommendations for flu prevention and control
18
![Page 19: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/19.jpg)
20 Flu Prevention
Educate staff on benefits of flu vaccine
Offer flu vaccine annually to all eligible healthcare personnel at no cost
Use strategies such as flu cart, access during shift, modeling etc
Also a TJC requirement
CMS allows protocols for flu and pneumovac for patients
19
![Page 20: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/20.jpg)
SP 21 Central Line -Associated Bloodstream Infection Prevention
Take actions to prevent central line-associated bloodstream infection (CLABSI) by implementing evidence-based intervention practices.
2011 CDC guidelines on recommendations
Hospital Quality Reporting Program for ICU and NICU to CDC National Healthcare Safety Network (NHSN)
Made popular by IHI How to Kit on central line bundle
Keystone project showed wisdom of using checklist
TJC 2011 NPSG Pa Patient Safety Authority has a toolkit on CLABSI risk
reduction at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/clabsi/Pages/home.aspx
20
![Page 21: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/21.jpg)
21
![Page 22: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/22.jpg)
CDC Resources
Has many resources on preventing catheter associated blood stream infection
Device association module
Central line insertion practices training course
Many resources on MDRO and CDAD
Note TJC requires the use of a checklist and need to place the checklist in the medical record or most hospitals have a checkbox that says central line checklist used
22
![Page 23: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/23.jpg)
CDC Website
23
![Page 24: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/24.jpg)
Keystone Project Changes Everything
24
![Page 25: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/25.jpg)
Pa Patient Safety Toolkit
25
![Page 26: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/26.jpg)
26
www.ihi.org
![Page 27: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/27.jpg)
Revised How to Kit Central Lines
27
![Page 28: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/28.jpg)
Safe Practice 21 Central Lines
Educate staff about central line-associated bloodstream infection (CLABSI) prevention who insert or maintain lines
Use checklist
Perform hand hygiene before you insert or manipulate
Avoid using femoral vein for access in adults
Use maximal sterile barrier precautions (mask, gloves, sterile gown, and cap by all involved in procedure)
28
![Page 29: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/29.jpg)
Safe Practice 21 Central Lines Use CHG alcohol if over two months of age and
allow to dry
Use protocol to disinfect catheter hubs, needless connectors and injection ports before accessing ports
Remove nonessential catheters
Perform surveillance and report data to nursing and medicine
Use standardized protocol for nontunneled CVCs in adults and adolescents as changing transparent dressings every five to seven days
29
![Page 30: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/30.jpg)
30
TJC NPSG Central Lines 07.04.01 Implement best practices to prevent central line
associated bloodstream infections,
13 EPS
IHI has how to guides and other resources at www.ihi.org (Keystone project)
EP1 Educate staff and LIPs involved in procedures about HAI, central line infection and importance of prevention
Must do education in orientation and annually and if procedure added to your job
![Page 31: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/31.jpg)
31
TJC NPSG Central Lines
Note that under reform law hospitals with ICUs or NICU must report central lines infections on the CDC National Healthcare Safety Network (NHSN)
2. Educate patients and families before inserting central line about central line associated bloodstream infection prevention (BSI), as needed
3. Implement P&Ps to reduce risk of BSI that meet regulatory and evidenced based standards
![Page 32: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/32.jpg)
Central Lines 07.04.01 P&P need to meet the regulatory requirements
Need to be aligned with the CDC requirements
And professional standards of care (APIC, AORN, SHEA, etc.)
4. Conduct periodic risk assessments for central line infection, measure BSI (blood stream infection) rate, and monitor compliance with best practices and how effective the prevention efforts are
Need to do risk assessment conducted in the time frames defined by the hospital
Surveillance is hospital wide and not targeted32
![Page 33: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/33.jpg)
33
TJC NPSG Central Lines
5. Provide CLAI (central line associated infection) rate data and prevention outcome measurement to staff and LIPs and clinicians
6. Use a catheter checklist and standard protocol for central line insertion
7. Perform hand hygiene before catheter insertion or manipulation
8. Do not put in femoral vein unless last resort for adult patients
9. Use standardized supply care or kit for central lines
![Page 34: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/34.jpg)
34
![Page 35: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/35.jpg)
35
TJC NPSG Central Lines
10. Use standardized protocol for maximum sterile barrier precautions during insertion
11. Use antiseptic for skin prep in patients during insertion that is cited in the scientific literature or endorsed by professional organizations
12. Use standardized protocol to disinfect catheter hubs and injection ports before accessing
Such as wipe vigorously for 15 sections and let dry
Surveyor will ask to see the protocol or P&P
13. Evaluate all central lines routinely and remove none essential catheters
![Page 36: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/36.jpg)
Safe Practice 22 Surgical Site Infection Surgical site infection prevention
Take actions to prevent surgical-site infections by implementing evidence-based intervention practices.
Safe Practice 22 is currently under ad hoc review by an expert panel.
This practice will be updated in the coming months to reflect the review decision.
CDC has guidelines
TJC has 2011 NPSG
36
![Page 37: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/37.jpg)
37
![Page 38: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/38.jpg)
Four Changes to TJC 2011 NPSG
38
![Page 39: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/39.jpg)
July 1, 2010 ChangesNPSG.03.05.01 EP 6: A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants
NPSG.07.04.01 EP 11: Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations (such as chlorahexidine alcohol and not povidone iodine but this specific wording removed)
39
![Page 40: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/40.jpg)
July 1, 2010 ChangesNPSG.07.05.01 EP 7: Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations
NPSG.07.05.01 EP 8: When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations (Such as clippers and not razors but this language removed)
40
![Page 41: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/41.jpg)
Proposed TJC NPSGs for 2012
TJC is seeking comments on NPSGs for 2012
Looking at two proposed additions
Ventilator-associated pneumonia (VAP) – Has seven elements of performance
Catheter-associated urinary tract infections (CAUTI)– Has four elements of performance
Comment period ended January 27, 2012
41
![Page 42: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/42.jpg)
42
TJC 2011 NPSG Surgical Site Infections
Implement best practices to prevent surgical site infections (SSI)
There are 8 EPs
1. Educate hospital staff and LIPs involved in procedures about HAI, surgical site, and the importance of prevention
Educate during orientation, annually, and if added to your job
![Page 43: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/43.jpg)
43
Surgical Site Infections
2. Educate patients and families, who are undergoing surgical procedures, about preventing surgical site infections (SSI)
3. Implement P&P to reduce SSI that meet regulations and evidenced based practice (such as the CDC and other professional organizations)
4. Conduct periodic risk assessments for SSI, select measures using best practices or evidence based guidelines and monitor compliance with them and how effective they are
![Page 44: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/44.jpg)
44
Surgical Site Infections
5. Measure surgical site infection rates for the first 30 days following a procedure that does not involve inserting implantable devices
Measure for the first year procedures involving implantable devices
Need to follow evidence based guidelines
Surveillance may to targeted to certain procedures based on hospital risk assessment
6. Provide process and outcome data on SSI to stakeholders etc, such as the SS infection rate
![Page 45: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/45.jpg)
45
Surgical Site Infections
7. Antimicrobial agents for prophylaxis are administered according to methods cited in the scientific literature or endorsed by professional organizations
Still want to be sure that prophylactic antibiotics are administered timely in the operating room and rebolused when indicated
8. When hair removal is necessary, use a method that is cited in the scientific literature or endorsed by professional organizations
![Page 46: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/46.jpg)
Safe Practice 23 Care of the Ventilated Patient
Take actions to prevent complications associated with ventilated patients:
specifically, ventilator-associated pneumonia (VAP), venous thromboembolism, peptic ulcer disease, dental complications, and pressure ulcers
VAP bundle also an IHI initiative
TJC NPSG 2011 standard
46
![Page 47: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/47.jpg)
23 Care of the Ventilated Patient
Educate healthcare workers on daily care of ventilated patient and complications such as VAP, VTE, PUD, dental complications, and pressure ulcers
Implement P&P on disinfection and sterilization of respiratory equipment
Active surveillance for VAP and maintain data
Educate patients and families about prevention measures
47
![Page 48: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/48.jpg)
23 Care of the Ventilated Patient Use checklist and standardized protocol
Hand hygiene
Regular antiseptic oral care
HOB 30-45 degrees
Daily assessment of readiness to wean and sedation interruption
Use weaning protocols
Implement PUD prophylaxis (still controversial)
VTE prophylaxis unless contraindicated
48
![Page 49: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/49.jpg)
Safe Practice 24 MDRO Prevention
Implement a systematic multidrug-resistant organism (MDRO) eradication program built upon the fundamental elements of infection control,
an evidence-based approach,
assurance of the hospital staff and independent practitioner readiness,
and a re-engineered identification and care process for those patients with or at risk for MDRO infections.
Also a TDC NPSG for 2011 and CMS CoP requirement49
![Page 50: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/50.jpg)
24 MDRO Prevention
Includes but is not limited to
Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) , and Clostridium difficile (C-diff)
Multidrug-resistant gram-negative bacilli, such as Enterobacter species, Klebsiella species, Pseudomonas species, and Escherichia coli (Ecoli), and vancomycin-resistant Staphylococcus aureus, should be evaluated for inclusion on a local system level based on organizational risk assessments
50
![Page 51: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/51.jpg)
24 MDRO Prevention LD assigns responsibility for oversight and coordination of the
development, testing, and implementation of a MDRO prevention program
Inf ection preventionist usually in charge of program
Conduct risk assessment for MDRO acquisition and transmission
Educate staff and LIPs about MDRO
Include risk factors, routes of transmission and outcomes associated with prevention
Educate patients with MRSA, VRE, or C-diff and their families or who are colonized with MRSA
51
![Page 52: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/52.jpg)
24 MDRO Prevention Implement a surveillance program based on risk
assessment and use contact precaution (MRSA)
Measure and monitor prevention processes and outcomes
Comply with evidenced based practices
Implement an alert system that identifies readmitted or transferred MRSA colonized or infected patients
Promote hand hygiene compliance
Ensure cleaning and disinfecting of equipement52
![Page 53: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/53.jpg)
53
TJC NPSGs 2011 Implement evidenced based practices to prevent
HAI due to multi-drug resistant organisms (MDROs),
NPSG 07.03.01 (7C)
9 EPs
Applies to, but not limited to, MRSA, VRE, C-Diff, and MDRO gram negative bacteria
Patients continue to acquire health care associated (HAI) infections at an alarming rate
Need prevention and control strategies
![Page 54: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/54.jpg)
Implement Evidenced Based Practices
Increased focus on cleaning and disinfecting equipment appropriately (IC.02.02.01)
Proper use of flash sterilization
Making sure all scopes are cleaned according to the manufacturer
Cleaning the patient environment is also important
54
![Page 55: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/55.jpg)
55
TJC NPSG MRDO1. Conduct periodic risk assessment for MDROs
acquisition and transmission
In time frame set by hospital
See IC.01.03.01, EPs 1-5 that talks about identifying the risk of acquiring and transmitting infections
Following slides on this provided for reference
TJC infection control chapter very important and dove tails with these infection control NPSGs
![Page 56: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/56.jpg)
56
Identify Risks for Transmitting Infections
IC.01.03.01 The hospital identifies risks for acquiring and transmitting infections EP1 Hospital identifies risks based on geographic
location, community, and population served– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time
frames set by hospital for multidrug-resistent organisms (MDRO) acquisitions and transmission
– MDRO includes methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella , and Acinetobacter
– CDC has free MDRO infection (and CDAD) surveillance and training on the National Healthcare Safety Network (NISN) 1
– 1 http://www.cdc.gov/nhsn/wc_MDRO_CDAD.html
![Page 57: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/57.jpg)
57
Identify Risks for Transmitting Infections IC.01.03.01
EP2 Hospital identifies risk for acquiring and transmitting infections based on the care and treatment it provides (on MDRO)
EP3 Look at risk for acquiring or transmitting an infection by doing an analysis of surveillance activities and other infection control data (including MRDO and adverse tissue reactions)
EP4 Review and identify risks annually and when there is a significant change and get input from IP, MS, nursing, and leadership including MRDO
EP5 Prioritize these risks
![Page 58: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/58.jpg)
58
TJC NPSG MRDO
2. Educate staff and LIPS about HAI, MDROs, and preventive strategies in orientation
At hire and annually
Use information from your risk assessment
Education must reflect their diverse roles
3. Educate patient and their families about HAI strategies who are infected or colonized with MRDO, as needed
![Page 59: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/59.jpg)
TJC NPSG MRDO
4. Implement a MDRO surveillance program based on your risk assessment
Surveillance may be targeted rather than hospital wide
CDC has MDRO surveillance training at http://www.cdc.gov/nhsn/wc_MDRO_CDAD.html
Has many resources including training videos on MDRO surveillance, slide sets, protocols, reporting plan etc.
59
![Page 60: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/60.jpg)
60
![Page 61: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/61.jpg)
61
![Page 62: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/62.jpg)
62
![Page 63: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/63.jpg)
63
TJC NPSG MRDO
5. Measure and monitor MDRO prevention processes and outcomes including; MDRO infection rates using evidence based metrics, compliance with evidenced based practice, and evaluate education provided
6. Provide MRDO process and outcome data to key stakeholders, nurses, doctors, LIPs and other clinicians
7. Implement P&Ps to reduce transmission of MRDOs which meet CDC and other professional organization standards (APIC,SHEA,OSHA, AORN)
![Page 64: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/64.jpg)
64
TJC NPSG MRDO
8. Implement a laboratory based alert system that identifies new patients with MDRO when indicated by the risk assessment
The alert system can be manual or electronic and can use faxes, pages, telephones etc.,
9. Implement an alert system that identifies readmitted or transferred MRDO positive patient when indicated by risk assessment
Alert system can be in a separate database or integrated and can manual or electronic
![Page 65: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/65.jpg)
65
MRDOs Resources CDC Management of MRDOs in Healthcare Settings
2006, 74 pages, at www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf,
Provides strategies and practices to prevent MRSA, VRE and other MDROs,
Includes gram neg bacilli (GNB), E. coli and Klebsiella pneumoniae, stenotrophomonas maltophilia, burkholderia cepacia, and ralstonia picketti,
![Page 66: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/66.jpg)
66
MRDOs Resources
CDC MRSA resources at www.cdc.gov/ncidod/dhqp/ar_mrsa.html,
Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices etc,
Isolation precaution 2007 at www.cdc.gov/ncidod/dhqp/gl_isolation.html,
VRE resources at www.cdc.gov/ncidod/dhqp/ar_vre.html,
Guidelines for Prevention of Surgical Site Infections,
![Page 67: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/67.jpg)
67
Resources
APIC resources at www.apic.org and see standards and guidelines,
Guidelines for Environmental Infection Control in Health Care Facilities,
Guidelines for Prevention of Surgical Site Infections,
Recommendations for Preventing the Spread of VRE,
Guidelines to Prevent Intravascular Catheter Related Infections,
![Page 68: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/68.jpg)
25. Catheter-Associated UTI Prevention Take actions to prevent catheter-associated urinary
tract infection by implementing evidence-based intervention practices.
UTI most common HAI
CDC issues Guidelines December 2009
TJC 2011 NPSG and 2011 SCIP Measure
AHRQ Patient Safety Handbook chapter at www.ahrq.gov/qual/nurseshdbk/
Pa Patient Safety Authority has toolkit on how to prevent CAUTI at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/cauti/Pages/home.aspx
68
![Page 69: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/69.jpg)
AHRQ Patient Safety Handbook Cp 42
69
![Page 70: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/70.jpg)
70
http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
![Page 71: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/71.jpg)
Pa Patient Safety Authority Toolkit
71
![Page 72: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/72.jpg)
Resources AORN article on the 2011 SCIP measure regarding
urinary catheter removal at https://www.aorn.org/News/Managers/November2009Issue/Catheter/
Urinary catheter removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero
Iowa Healthcare Collaborative toolkit for preventing UTIs at
http://www.ihconline.org/aspx/general/page.aspx?pid=5
has evidenced based guidelines, sample policies, provider information etc
72
![Page 73: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/73.jpg)
Resources
AHRQ has a website on “Efforts to Prevent and Reduce Healthcare-Associated Infections
at http://www.ahrq.gov/qual/haiflyer.htm
IDSA as the “Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infections in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America”
at http://cid.oxfordjournals.org/content/50/5/625.full
73
![Page 74: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/74.jpg)
Resources
IHI how to guide on preventing CAUTI
at http://www.ihi.org/IHI/Programs/ImprovementMap/PreventCatheterAssociatedUrinaryTractInfections.htm
Multiple tools on this website with slides and how to guide and APIC and SHEA documents etc
APIC has a guide called :Guide to the Elimination of Catheter-Associated Urinary Tract Infections”
at www.apic.org and see resources at http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/CAUTI_Guide1.htm
74
![Page 75: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/75.jpg)
25. Catheter-Associated UTI Prevention
Document the education of staff involved in insertion, care, and maintenance of urinary catheters and about CAUTI
Training should include alternatives
Train in orientation and annually
Prior to insertion of urinary catheter educate patient about CAUTI prevention
Identify patients on units where surveillance should be conducted
75
![Page 76: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/76.jpg)
25. Catheter-Associated UTI Prevention Implement P&P to reduce risk of CAUTI and that are
evidenced based
Perform hand hygiene before and after manipulation of catheter or apparatus
Ensure supplies are available for aseptic technique and use sterile equipment
Insert catheters using sterile technique
Obtain urine culture before starting antibiotics in patient with catheter
Measure compliance with best practices
Provide surveillance data to key stakeholders76
![Page 77: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/77.jpg)
Culture SP 1
Information Management & Continuity of Care
Medication Management
Hospital Acquired Infections
Condition & Site Specific Practices
Consent & Disclosure
Wrong siteSx Prevention
Peri-Op MIPrevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag Therapy
Asp +VAP Prevention
Central V. CathBSI Prevention
Sx Site Inf.Prevention
Contrast Media Use
Hand Hygiene InfluenzaPrevention
PharmacistCentral Role
Med Recon.
Std. Med Labeling & Pkg
High AlertMeds
Unit DoseMedications
EvidenceBased Ref.
Culture
CPOE
OrderRead-back
Abbreviations Discharge System
CriticalCare Info.
LabelingStudies
Culture Meas.,F.B., & Interv.
Structures& Systems
ID Mitigation Risk & Hazards
Team Training& Team Interv.CHAPTER 1: Background
Summary, and Set of Safe Practices
CHAPTERS 2-8 : Practices By Subject
Nursing Workforce ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers
• ICU Care
CHAPTER 2: Creating and Sustaining a Culture of Patient Safety
• Leadership Structures & Systems• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions• Identification and Mitigation of Risks and Hazards
CHAPTER 5: Information Management & Continuity of Care
• Critical Care Information• Order Read-back• Labeling Studies
• Discharge Systems• Safe Adoption of Integrated Clinical Systems
including CPOE• Abbreviations
CHAPTER 6: Medication Management• Medication Reconciliation
• Pharmacist Role• Standardized Medication Labeling & Packaging
• High-Alert Medications• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections• Prevention of Aspiration and Ventilator-
Associated Pneumonia • Central Venous Catheter-Related Blood Stream
Infection Prevention • Surgical Site Infection Prevention
• Hand Hygiene• Influenza Prevention
CHAPTER 8:• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia Prevention
• Pressure Ulcer Prevention• DVT/VTE Prevention
• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention
Informed Consent
Life-Sustaining Treatment
Disclosure
CHAPTER 3: Informed Consent & Disclosure• Informed Consent
• Life-Sustaining Treatment• Disclosure
Consent & Disclosure
CHAPTER 8: Condition- or Site-Specific Practices Wrong Site Surgery (Safe Practice 26)
• Pressure Ulcer Prevention (Safe Practice 27)• Venous Thromboembolism Prevention (Safe Practice 28)
• Anticoagulation Therapy (Safe Practice 29)• Contrast Media-Induced Renal Failure Prevention (SP 30)
• Organ Donation (Safe Practice 31)• Glycemic Control (Safe Practice 32)
• Fall Prevention (Safe Practice 33)• Pediatric Imaging (Safe Practice 34)
2007 NQF Report
77
![Page 78: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/78.jpg)
Safe Practice 26 Prevent WSS
Implement the Universal Protocol for Preventing Wrong Site (WSS), Wrong Procedure, Wrong Person Surgery for all invasive procedures
TJC has 2011 Universal Protocol Pa Patient Safety Authority has toolkit
at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/home.aspx
Patient Safety Handbook has chapter also at www.ahrq.gov/qual/nurseshdbk/
78
![Page 79: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/79.jpg)
Safe Practice 26 Prevent WSS
Create and use a verification process to ensure relevant preoperative tasks are done
Make sure information is correct and available
Mark the surgical site and involve the patient in the marking process
Use right/left distinction and multiple levels (spinal procedures)
Do time out before any invasive procedure and any required implants
79
![Page 80: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/80.jpg)
80
![Page 81: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/81.jpg)
81
![Page 82: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/82.jpg)
Pa Patient Safety Toolkit
82
![Page 83: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/83.jpg)
Time Out Towel
83
![Page 84: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/84.jpg)
TJC 2011 NPSG Universal Protocol
TJC has three sections in the NPSG on Universal Protocol
These are to prevent wrong site surgery
A copy of these standards are at the end of the presentation
Hospital P&P should be consistent with these standards
84
![Page 85: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/85.jpg)
Safe Practice 27 Pressure Ulcer Take actions to prevent pressure ulcers by
implementing evidence- based intervention practices.
www.guidelines.gov has 75 guidelines on pressure ulcers
AHRQ Patient Safety Handbook has chapter at www.ahrq.gov/qual/nurseshdbk/
Minnesota Hospital Association has many resources on Safe Skin campaign at www.mnhospitals.org/index/tools-app/tool.353
National Pressure Ulcer Advisory Panel (NPUAP) at http://www.npuap.org/
85
![Page 86: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/86.jpg)
MN Hospital Association Safe Skin
86
![Page 87: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/87.jpg)
AHRQ Patient Safety Handbook Chapter 12
87
![Page 88: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/88.jpg)
88
![Page 89: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/89.jpg)
NPUAP Staging System
89
![Page 90: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/90.jpg)
Safe Practice 27 Pressure Ulcer P&P on prevention of pressure ulcers (PU)
Plans are in place for risk assessment, prevention, and early treatment of PU
During admission identify patients at risk using a assessment guide
Document risk assessment and prevention plan in patient’s record
Assess and reassess skin for risk of developing a PU
Maintain and improve tissue tolerance to PU90
![Page 91: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/91.jpg)
Safe Practice 27 Pressure Ulcer
Protect against the adverse effects of external mechanical forces
Reduce the incidences of PU through staff education
Perform quarterly prevalence studies to evaluate the effectiveness of the PU prevention program
Educate about PU frequency and severity
Implement PU prevention interventions
Measure outcomes
91
![Page 92: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/92.jpg)
www.jcrinc.com/Pressure-Ulcer-Prevention-Project-Home/
92
![Page 93: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/93.jpg)
SP 28 Venous Thromboembolism (DVT) Prevention
Evaluate each patient upon admission, and regularly thereafter, for the risk of developing venous thromboembolism.
Utilize clinically appropriate, evidence-based methods of thromboprophylaxis.
TJC has NPSG on anticoagulants
93
![Page 94: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/94.jpg)
28 Venous Thromboembolism (DVT) Prevention
Multidisciplinary team develops evidence based protocols and have P&P
Ongoing PI to make sure practices are followed
Include risk assessment, prophylaxis, diagnosis and treatment
Provide education on prevention, care, diagnosis, and treatment
Document in medical record VTE risk assessment
Provide education to patients with VTE with monitoring, dietary restrictions etc.
94
![Page 95: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/95.jpg)
Safe Practice 29 Anticoagulant Therapy
Organizations should implement practices to prevent patient harm due to anticoagulant therapy.
TJC has anticoagulant NPSG
University of Washington has excellent resources
Number of other anticoagulant toolkits
95
![Page 96: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/96.jpg)
29 Anticoagulant Therapy
Need a defined anticoagulant management program to individualized the care
Document patient’s medication plan in the medication record
Clinical pharmacy medication review is conducted to ensure safe selection and to avoid drug-drug interactions
Use only oral unit dose products, prefilled syringes and premixed IV bags
INR for patients starting on Coumadin
96
![Page 97: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/97.jpg)
29 Anticoagulant Therapy
Dietary is notified of patient getting Coumadin so food/medication interaction program
Education is provided to all staff, prescribers and patients
Need written policy for baseline lab tests for patients on Heparin and low molecular weight heparin therapies
Hospital evaluates anticoagulation safety practices and takes action to improve its practice
97
![Page 98: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/98.jpg)
Resources
Source: AHRQ Press release, September 15, 2009, AHRQ Releases Two New Resources to Help Consumers and Clinicians Prevent Dangerous Blood Clots, at http://www.ahrq.gov/news/press/pr2008/blclotspr.htm
The clinician’s guide on Preventing Hospital-Acquired Venous Thromboembolism; A Guide for Effective Quality Improvement is available at http://www.ahrq.gov/qual/vtguide/
Patient Guide to Preventing and Treating Blood Clots at http://www.ahrq.gov/consumer/bloodclots.htm
![Page 99: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/99.jpg)
![Page 100: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/100.jpg)
![Page 101: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/101.jpg)
![Page 102: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/102.jpg)
![Page 103: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/103.jpg)
![Page 104: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/104.jpg)
![Page 105: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/105.jpg)
105
![Page 106: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/106.jpg)
![Page 107: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/107.jpg)
University of Washington Medical Center Some of the AHRQ resources were from U of
Washington Medical Center
Has an excellent website!
Coumadin (Warfarin) teaching booklet in 5 languages
Coumadin dosing charts, how to adjust, guidelines for dosing and monitoring Lovenox (Enoxaparin)
Treatment of VTE
Duration of anticoagulants, peri procedural anticoagulation
http://www.uwmcacc.org/index.html
![Page 108: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/108.jpg)
Perdue Toolkit
Anticoagulant Toolkit; Reducing Adverse Drugs and Potential Adverse Drug Events with Unfractionated Heparin, LMWH and Warfarin,
Includes resource tools, self assessment, how to improve the process, improvement and sustaining improvement, physician order forms
Available at http://www.purdue.edu/dp/rche/pharmatap/toolkit.pdf
![Page 109: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/109.jpg)
![Page 110: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/110.jpg)
![Page 111: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/111.jpg)
Anticoagulant Management Toolkit
Pa Patient Safety Authority has toolkit
Has IHI anticoagulant toolkit
Has ISMP self assessment tool for antithrombotic in hospitals
Has video on benefits of anticoagulant management services and more
At http://www.psa.state.pa.us/psa/cwp/view.asp?a=1293&q=446932#9
![Page 112: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/112.jpg)
SP30 Contrast Induced Renal Failure SP is Contrast Media-Induced Renal Failure
Prevention
Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure
and gadolinium-associated nephrogenic systemic fibrosis,
and utilize a clinically appropriate method for reducing the risk of adverse events based on the patient’s risk evaluations.
Pa Patient Safety Authority has toolkit
112
![Page 113: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/113.jpg)
SP30 Contrast Induced Renal Failure
Use evidenced based protocols that are approved by the MS for the prevention of CIN (contrast media-induced nephropathy)
based on the rapid evolution of contract agents and national guideline that is coming soon
Monitor and document use of evidenced based protocols and document risk assessment in chart
Document provider education
Specify qualifications of staff allowed to initiate protocols for imaging
113
![Page 114: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/114.jpg)
Pa Patient Safety Authority Toolkit
114
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/cin/Pages/home.aspx
![Page 115: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/115.jpg)
Contrast Induced Nephropathy
Kidney failure can occur from iodine dye used for x-rays (70 reports)
Hospitals should amend informed consent to include this
Especially with patients with known history of severe renal failure or impairment See ACR MRI Safety Guideline issued June, 2007
Consider doing a FMEA on this and they have a toolkit on this http://www.psa.state.pa.us/psa/lib/psa/advisories/
vol1no4_supplementary_march_2007/v4_s1_suppl_advisory_mar_30_2007.pdf 115
![Page 116: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/116.jpg)
Gadolinium Based Contrast
These can cause nephrogenic systemic fibrosis
Be aware of BUN creatinine when ordering Magnetic resonance angiography (MRA) that requires IV contras,
Uses MRI to take pictures of blood vessels
Dose for MRA may be 3x higher than dose for MRI
If patient being dialyzed do immediately after test
Patients with severe renal impairment at risk for NSF
Risk is 4% in this population- consider including in informed consent
New box warning now116
![Page 117: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/117.jpg)
Contrast Induced Nephropathy Angiography, IVP, and CT scans use iodine containing
contrast material
Can have allergic reaction or kidney damage
Be careful in patients with sever renal impairment
Make sure patient is adequately hydrated
Use low osmolar contrast in patients with renal failure
See ACR policy at www.acr.org
Check serum creatinine level prior to scheduling contrast studies
Make sure radiology department is aware if patient has severe renal failure before contrast is used
117
![Page 118: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/118.jpg)
Safe Practice 31 Organ Donation
Hospital policies that are consistent with applicable law and regulations should be in place and should address patient and family preferences for organ donation,
as well as specify the roles
and desired outcomes for every stage of the donation process
TJC and CMS have organ donation standards
TJC has transplant chapter
State laws on organ donation and procurement
118
![Page 119: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/119.jpg)
31 Organ Donation Hospitals and OPOs work together to maintain
program and develop protocols
Have a process to define roles and responsibilities of hospital and OPO including PI
Early donor evaluation and organ placement
OPO will review death records for donor opportunity
Organ donation performance outcomes at www.ustransplant.org
Address wishes to donate organs
119
![Page 120: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/120.jpg)
Safe Practice 32 Glycemic Control
Take actions to improve glycemic control by implementing evidence- based intervention practices that prevent hypoglycemia
and optimize the care of patients with hyperglycemia and diabetes
120
![Page 121: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/121.jpg)
32 Glycemic Control
Develop a process for improving glycemic control for patient
Monitor the quality of the management and report to stakeholders
Track glucose data
Evidenced based order sets to guild management of hypo and hyperglycemia
Written protocols for patient on insulin drips
121
![Page 122: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/122.jpg)
32 Glycemic Control
Reconcile patient medication on discharge
Education for newly diagnosed diabetics
Include in their plan of care exercise, nutritional management, signs and symptoms of hyper or hypoglycemia
Include instructions on use of blood glucose meter
Sick day guidelines
Who to contact in case of an emergency
122
![Page 123: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/123.jpg)
Safe Practice 33 Falls
Take actions to prevent patient falls and to reduce fall-related injuries by implementing evidence-based intervention practices
TJC standard
TJC sentinel event alert on falls
CMS CoP requirement
One of 10 CMS hospital acquired conditions with no additional pay
123
![Page 124: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/124.jpg)
Safe Practice 33 Falls
Have a fall reduction program
Program must do an appropriate evaluation of the patient
Must include interventions based on risk
Staff must be educated on fall reduction program
Patient and family is educated on program
Evaluate the effectiveness of the falls program
124
![Page 125: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/125.jpg)
125
2011 TJC Standard
Falls continue as a Joint Commission National Patient Safety Goal in 2009 but moved to standard in 201
0 under PC.01.02.08
PC.01.02.08 The hospital assesses and manages the patient’s risks for falls
EP1 Hospital must assess the patient’s risk for falls based on the patient population and setting (elderly, behavioral health, pediatric patients)
EP2 Hospital implements interventions to reduce falls based on the patient’s assessed risk
![Page 126: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/126.jpg)
126
Why Look at Falls?
Falls rate high on the list of sentinel events tracked by The Joint Commission (TJC)
6th leading cause of sentinel events
September 30, 2010 data of 7,147 SE shows 481 falls which is 6.5% of all sentinel events reported
Other Joint Commission standards that are applicable to falls are in EC and PI chapters (PI.01.01.01 number of falls and number and severity of fall related injuries)
TJC gives information on the root causes of falls
![Page 127: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/127.jpg)
127
![Page 128: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/128.jpg)
128
The Joint Commission Matrix for Falls RCA
TJC requires a RCA be done for reviewable sentinel events which includes a patient fall that results in death or major permanent loss of function as a direct
These are the elements that must be included in the RCA
So RCA must include area marked such as physical assessment process, medication management, staffing level etc.
![Page 129: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/129.jpg)
129
![Page 130: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/130.jpg)
130
CMS CoP Requirements
CMS requires hospitals in the hospital CoPs to have a safe environment/setting
CMS has this as hot spot in their Guidelines for Immediate Jeopardy
CMS requires the health and safety of patients at risk are identified, investigated and resolved
Having falls and no investigation would be a violation of this CoP which could come up during complaint or validation survey
Source: http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
![Page 131: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/131.jpg)
131
Intervention Strategies
Intervention
Level of Risk Area of Risk
High
Med Low Frequent Falls
Altered Elimination
Muscle Weakness
Mobility Problems
Multiple Medications
Depression
Low beds X X X X X X X X X
Non-slip grip footwear X X X X X X X X X
Assign patient to bed that allows patient to exit toward stronger side
X X X X X X X X X
Lock movable transfer equipment prior to transfer
X X X X X X X X X
Individualize equipment to patient needs
X X X X X X X X X
![Page 132: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/132.jpg)
132
High risk fall room setup
X X X X X X X X
Non-skid floor mat
X X X X X X X X
Medication review
X X X X X X X X
Exercise program
X X X X X X X X
Toileting worksheet
X X X
Color armband / Falling Star etc
X X X X X X X
Perimeter mattress
X X X X X
Hip protectors X X X X
Bed/chair alarms
X X X X
![Page 133: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/133.jpg)
34. Pediatric Imaging
When CT imaging studies are undertaken on children, “child-size” techniques should be used to reduce unnecessary exposure to ionizing radiation
Recently receiving a lot of attention
FDA issues guidelines on radiation exposure along with ACR
133
![Page 134: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/134.jpg)
34. Pediatric Imaging
Update protocols on CT imaging of children
Scan only when necessary
Reduce or child size the amount of radiation used
Scan only indicated area
See ACR standard
See www.imagegently.org
Shield radiosensitive areas such as reproductive organs
Scan once as single phase scan usually adequate in children
134
![Page 135: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/135.jpg)
135
The Radiation Exposure Issue August 2009 a team at Emory University in Atlanta reported
in NEJM that 4 million Americans are exposed to high doses of radiation
National Council on Radiation Protection and Measurement stated the US population is exposed to seven times more radiation each year for imaging exams than in 1980
GAO and JAMA reported that physicians refer patients to facility they have a financial interest in
Dr. Kriste Guite and colleagues studied 978 CT scans of the abdomen and pelvis and found that 52.2% were unnecessary (university of Wisconsin at Madison, 2010)
At that level 1 in 1,00 patients could get radiation-induced cancer
![Page 136: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/136.jpg)
136
![Page 137: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/137.jpg)
137
Radiation Exposure During CT
October 2009 disclosure by Cedars-Sinai Medical Center in LA that 206 patients were given up to eight times the normal radiation dose during a stroke scan (CT brain perfusion) over an 18 month period
FDA identifies 50 additional patients who were also exposed up to 8 times the normal dosage and reports from other states
Some patients had hair loss (40%) and skin redness
High doses can cause some kinds of cancer and cataracts
![Page 138: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/138.jpg)
138
Radiation Exposure During CT
A patient could get as much radiation from a CT scan then from 74 mammograms or 442 CXR from higher measurements
Hospitals rarely record how much radiation the patient receives
Doses can vary depending on the size of the patient, how large an area is scanned etc.
At NIH, doctors will record the information and patients can take it with them
FDA issues radiation recommendations Dec 2009
![Page 139: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/139.jpg)
139
![Page 140: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/140.jpg)
140
![Page 141: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/141.jpg)
141
5 FDA Recommendations Facilities assess whether patients who underwent CT
perfusion scans received excess radiation Facilities review their radiation dosing protocols for all CT
perfusion studies to ensure that the correct dosing is planned for each study
Facilities implement quality control procedures to ensure that dosing protocols are followed every time and the planned amount of radiation is administered
Radiologic technologists check the CT scanner display panel before performing a study to make sure the amount of radiation to be delivered is at the appropriate level for the individual patient
If more than one study is performed on a patient during one imaging session, practitioners should adjust the dose of radiation so it is appropriate for each study
![Page 142: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/142.jpg)
142
![Page 143: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/143.jpg)
143
![Page 144: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/144.jpg)
144
Recommendations
ACR, as part of Alliance for Radiation Safety, has imaging card for patients, especially kids1
They recommend patients should ask their doctors if they need the exam and if there are alternative
Radiology tech should check the CT scanner display panel before performing the study to make sure amount of radiation to be delivered is appropriate
The tech should check the dose indices displayed on the control panel after the CT scan is done
Follow the FDA and ACR recommendations Report serious problems to the FDA MedWatch program
1 www.pedrad.org/associations/5364/ig/index.cfm?page=591
![Page 145: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/145.jpg)
145
![Page 146: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/146.jpg)
146
![Page 147: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/147.jpg)
147
The End Questions Sue Dill Calloway RN, Esq.
CPHRM
AD, BA, BSN, MSN, JD
Medical Legal consultant
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1481
TJC NPSG UP and Resources 147147
![Page 148: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/148.jpg)
Patient Safety Material Resources
20 tips to prevent medication errors in children at http://www.ahrq.gov/consumer/20tipkid.htm,
5 steps to safer health care at http://www.ahrq.gov/consumer/5steps.htm,
20 tips to prevent medical errors at http://www.ahrq.gov/consumer/20tips.htm,
Quick Tips when getting medical tests at http://www.ahrq.gov/consumer/quicktips/tiptests.pdf,
148
![Page 149: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/149.jpg)
Patient Safety Material Resources
Ways you can help your family prevent medical errors at http://www.ahrq.gov/consumer/5tipseng/5tips.pdf,
When choosing healthcare at http://www.ahrq.gov/consumer/qualguid.pdf,
FDA’s tips on taking medication at http://www.fda.gov/fdac/reprints/medtips.html,
Preventing medications at http://www.safemedication.com/meds/medSafety.cfm,
149
![Page 150: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/150.jpg)
Resources
IHI (Institute for Healthcare Improvement) www.ihi.org,
FDA at www.fda.gov,
American Society for Healthcare Risk Managers (ASHRM) www.ashrm.org monograms on disclosure, patient safety curriculum,
John Hopkins Center for Public Awareness-patient safety modules www.jhsph.edu/ctlt/training/online/patient_safety.html,
150
![Page 151: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/151.jpg)
Resources
WHO Patient Safety website at http://www.who.int/patientsafety/en/,
WHO taxonomy at http://www.who.int/patientsafety/taxonomy/en/,
AHRQ PS Net or patient safety network with journal articles at http://www.psnet.ahrq.gov/ and see M&M at http://www.webmm.ahrq.gov/
AHRQ medical errors and patient safety website at http://www.ahrq.gov/qual/errorsix.htm,
151
![Page 152: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/152.jpg)
Resources
AHRQ TeamSTEPPES strategies and tools to enhance patient safety at http://www.ahrq.gov/qual/teamstepps/,
TMIT Safety leaders at http://www.safetyleaders.org/ has research and workshops and webinars,
FDA patient safety news at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm,
FDA Bad Bug Book at http://www.cfsan.fda.gov/~mow/intro.html
152
![Page 153: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/153.jpg)
Patient Education Resources
Five Steps to Safer Health Care,
10 Patient Safety Tips for Hospitals,
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet,
20 Tips to Help Prevent Medical Errors in Children,
30 Safe Practices for Better Health Care: Fact Sheet,
Available at http://www.ahrq.gov/qual/errorsix.htm#subscribe,
Also mistake proofing the design of health care process,
153
![Page 154: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/154.jpg)
Resources
Appropriate use of antibiotics, Mangram, AJ, Pearson, MI, Guidelines for Preventing Surgical Site Infections, 1999. Infection Control Hosp Epidemiol. 20:247-278.
Also includes information on avoidance of razors,
Perioperative glucose control in majory cardiac surgery patients see:
Furnary, Ap, Zerr, KJ, etc. Continuous intravenous insulin reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgery, Ann Thorac Surg, 1999;67:352-362,
Van den Berghe, Wouters, P, Weekers, F, Intensive insulin therapy in critically ill patients, N Engl J Med. 2001:345:1359-1367.
154
![Page 155: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/155.jpg)
Resources
Perioperative Normothermia in colorectal surgery patients see the following two articles,
Kurtz A, Sessler DI, Lenhardt R, Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospital stay, NEJM 1996,334:1209-1216,
Melling AC, Ali B Scott, Leaper DJ, Effects of preoperative warming on the incidence of wound infection after clean surgery;a randomized control trial, Lancet, 2001;358:876-880,
155
![Page 156: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/156.jpg)
Resources Sorry Works! Coalition at www.sorryworks.net with
sample hospital disclosure program and slides on disclosure,
Premier Patient Safety Institute- www.premiereinc.com and has section on framework for safety culture and reporting (www.premierinc.com/all/safety/resources/patient_safety/index_2.jsp)and data tool for doing survey on patient safety,
National Patient Safety Foundation at www.npsf.org- disclosure after adverse medical event and disclosure statement of principles,
156
![Page 157: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/157.jpg)
Resources
Joint Commission at www.jointcommission.org - national patient safety goals and International Center for Patient Safety at http://www.jcipatientsafety.org/
The patient safety group at www.patientsafetygroup.org,
AHRQ Patient Safety Network at http://www.psnet.ahrq.gov/ tons of great articles and research,
AHRQ Morbidity and Mortality Rounds on the web-http://webmm.ahrq.gov/,
157
![Page 158: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/158.jpg)
Resources
VIPCS Virginians Improving Patient Care and Safety at http://www.vipcs.org/,
NPSF National Patient Safety Foundation at www.npsf.org and resources at http://www.npsf.org/html/resources.html,
Patient Safety: Achieving a New Standard of Care; IOM Report 2003 at www.iom.edu,
158
![Page 159: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/159.jpg)
Resources
The Minnesota Alliance for Patient Safety (MAPS)- http://www.mnpatientsafety.org/,
National Quality Forum- http://www.qualityforum.org/home.htm,
National Quality Forum (NFQ) Serious Reportable Events in Healthcare: A Consensus Report -Serious Reportable Events in Healthcare http://www.qualityforum.org/publications.html
159
![Page 160: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/160.jpg)
Resources
New pressure ulcer prevention protocol and skin safety plan at http://www.mnpatientsafety.org/,
Safest in America http://www.safestinamerica.org/index.php?option=com_content&task=view&id=11&Itemid=0,
Anesthesia Patient Safety Foundation at www.apsf.org,
160
![Page 161: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/161.jpg)
Resources
Mass Coalition for the Prevention of Medical Errors at http://www.macoalition.org/,
ISMP List of Error Prone Abbreviations, Symbols and Dose Designations at http://www.ismp.org/tools/errorproneabbreviations.pdf,
University of Michigan Patient Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/ ,
AORN Patient Safety at http://www.patientsafetyfirst.org/,
161
![Page 162: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/162.jpg)
Resources
John Hopkins Center for Innovations in Quality Patient Care at http://www.hopkinsquality.com/cfi/default.asp,
CAPSLink at http://www.usp.org/patientSafety/newsletters/capsLink/,
Ohio Patient Safety Institute at www.ohiopatientsafety.org ,
162
![Page 163: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/163.jpg)
Resources
USP- US Pharmacopeia at www.usp.org-
Sign up for USP Patient Safety Newsletters at http://www.usp.org/patientSafety/newsletters/capsLink/,
VA National Center for Patient Safety NCPS at www.patientsafety.gov,
Sign up for human factors resources at http://www.patientsafety.gov/resources.html#HF,
163
![Page 164: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/164.jpg)
Resources
Leapfrog group at http://www.leapfroggroup.org/,
Canadian Patient Safety Institute athttp://www.patientsafetyinstitute.ca/index.html,
Australian Council for Safety and Quality in Health Care at http://www.safetyandquality.org/,
NPSA National Patient Safety Agency at http://www.npsa.nhs.uk/,
164
![Page 165: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/165.jpg)
Resources
State of NJ Patient Safety Report at http://www.nj.gov/health/hcqo/ps/,
Patient Safety Authority (PSA) in Pa- http://www.psa.state.pa.us/psa/site/default.asp,
Web M&M by AHRQ at http://webmm.ahrq.gov/,
http://highwire.stanford.edu/cgi/search free 999 journals and over 1.5 million articles,
165
![Page 166: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/166.jpg)
Resources
Consumers Advancing Patient Safety CAPS at www.patientsafety.org,
The Patient Safety and Quality Improvement Act of 2005 (PA 109-41) amended Title IX of the Public Health Service Act (42 USC 299 et seq), protection for patient safety work products,
166
![Page 167: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/167.jpg)
Resources
National Coordinating Council for Medication Error Reporting and Prevention- www.nccmerp.org,
Partnership for Patient Safetywww.p4ps.org,
"Beyond Blame" video: Order online at http://www.mederrors.com/home/blame.html, or call (959) 350-0100
167
![Page 168: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/168.jpg)
Disruptive Practitioner Resources
Joint Commission standards at www.jointcommission.org,
Rosenstein A, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians: nurses, physicians, and administrators say that clinicians’ disruptive behavior has negative effects on clinical outcomes. Nurs Manage 2005 Jan;36(1):18-29.
168
![Page 169: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/169.jpg)
Resources
Weber DO. Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician Exec. 2004 Sep-Oct;30 (5):16-7. Also available: http://findarticles.com/p/ articles/mi_m0843/is_5_30/ai_n6213537.
American Medical Association. Physicians with disruptive behavior. In: Code of medical ethics: current opinions and annotations. Chicago (IL): AMA: 2006. p. 279–80.
169
![Page 170: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/170.jpg)
Resources
Disruptive Behaviors in Physicians, CME course from Texas Medical Board at http://www.texmed.org/Template.aspx?id=4211 and gives CME credit,
Tennessee Medical Staff Foundation, Medical Staff Code of Conduct Policy, at http://www.e-tmf.org/code_of_conduct.asp,
170
![Page 171: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/171.jpg)
Resources
Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005;353:2673–82,
ECRI. Disruptive practitioner behavior. HRC Risk Analysis Supplement A. Plymouth Meeting (PA): ECRI; 2006.
171
![Page 172: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/172.jpg)
Resources
Disruptive Behavior, ACOG Committee Opinion, Number 366, May 2007.
Porto G, Lauve R. Disruptive clinician: a persistent threat to patient safety. Patient Saf Qual Healthc 2006;144: 107–15.
Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med 2006;144:107–115.
172
![Page 173: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/173.jpg)
Resources
Pfifferling J. The disruptive physician: a quality of professional life factor [online]. Physician Exec. 1999 Mar-Apr [cited 2005 Dec 5]. Available from Internet: http://www.findarticles.com/p/articles/mi_m0843/is_2_25/ai_102274361.
See HCA Code of Conduct, 38 pages, at www.hcahealthcare.com,
SOX, or Sarbanes-Oxley Act of 2002, and related Securities and Exchange Commission rules,
173
![Page 174: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/174.jpg)
Resources
Cassidy M. Third circuit reaffirms HCQIA immunity for professional review actions [online]. [cited 2005 Dec 5]. Available from Internet: http://www.tuckerlaw.com/pub/health/October%202005.html#3
Gordon v. Lewiston case,
174
![Page 175: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/175.jpg)
Resources
American Medical Association. Reports of the Council on Ethical and Judicial Affairs: physicians with disruptive behavior. Available from Internet:http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_rep_106_0104.pdf,
AMA Physicians and Disruptive Physician packet, July 2004, at http://www.ama-assn.org/ama1/pub/upload/mm/21/disruptive_physician.doc
175
![Page 176: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/176.jpg)
Fatigue Resources
Ruggiero, JS, Correlates of fatigue in critical care nurses. Res Nurs Health Dec 2003; 26(6):434-44.
Ahmed, DS, Fecik, S. The fatigue factor. When long shifts harm patients. Am J Nurs. Sep 1999, 99(9):12. Case Reports,
AHRQ Evidence Report 151, Nurse Staffing and Quality of Patient Care March of 2007, at http://www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf
176
![Page 177: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/177.jpg)
Fatigue Resources
Fatigue in Healthcare Workers, Healthcare Risk Control, January, 2006, ECRI Institute, Employment Issues 14,
Institute of Medicine (IOM) report on Keeping Patients Safe; Transforming the Work Environment of Nurses, 2004, at www.nap.edu,
Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002 Oct 17;347(16):1249-55.
177
![Page 178: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/178.jpg)
Fatigue Resources
West S. Circadian rhythm, shiftwork and you! Collegian 2001 Oct;8(4):14-21.
Eastridge BJ, Hamilton EC, O'Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003 Aug;186(2):169-74,
Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005 Jan 13;352(2):125-34.
178
![Page 179: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/179.jpg)
Fatigue Resources Scott, LD, Hwang, WT, Effects of critical care
nurses work hours on vigilance and patient safety. Am J Critical Care 2006 Jan:15(1):30-37,
Rogers, AE, Hwang, WT, The working hours of hospital staff nurses and patient safety. Health Aff (Milwood) 2004; 23:202-212.
179
![Page 180: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/180.jpg)
180
TJC NPSG Goal 1: UP Universal Protocol
Organization must meet expectation of UP
UP 01.01.01 Conduct a pre-procedure verification process,
Changed because of universal protocol that is now a standard, effective July 1, 2004 changed 2009 and 2010 and continue into 2011,
To prevent wrong site and wrong procedure surgery,
Process must be briefly documented,
TJC has great information on their website on this!
3 parts,
![Page 181: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/181.jpg)
181
![Page 182: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/182.jpg)
182
Pre-procedure verification process
It is an ongoing process that starts with decision to do procedure and continues up and includes time out before start of procedure,
Want to be sure all documents and equipment is available before the procedure,
That everything is correctly labeled and matched to the patient’ identifiers,
Reviewed and consistent with patient’s expectation and team’s understanding of the procedure and site,
![Page 183: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/183.jpg)
183
Pre-procedure verification process
1. Implement a pre-procedure process to verify correct patient, site, and procedure
2. Identify what needs to be available for the procedure and use a standardize list (check list) to verify their availability and must include
Relevant documentation (H&P, consent form, nursing assessment and pre-anesthesia assessment)
Labeled diagnostic and radiology films, pathology, and biopsy reports and make sure properly displayed
![Page 184: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/184.jpg)
184
Pre-procedure verification process
3. Match the items that are to be available in the procedure area to the patient
WHO has a surgical checklist
Can enlarge the individualized checklist to 2 by 3 feet and roll in before surgery and then do briefing and at end when you do debriefing
![Page 185: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/185.jpg)
185
Getting It Right
Do you verify that this is the right procedure at certain times to make sure you have it right such as;
Time procedure scheduled,
Time of PAT,
Time of admission or entry into facility,
Before patient leaves pre-procedure area,
Anytime responsibility is transferred to another member of procedure team (including anesthesia provider) at time of and during the procedure,
With the patient involved and awake and aware if possible,
![Page 186: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/186.jpg)
186
Mark the Site
UP 01.02.01 Mark the procedure site,
1. Procedure with incisions or percutaneous puncture or insertion, site is marked
when more than one possible location,
If performing in a different location would negatively affect quality or safety
For spinal procedures need special intraoperative image technique to mark the right spot
2. Mark before patient is moved to where procedure is to take place,
![Page 187: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/187.jpg)
187
Mark the Site Patient should be involved if possible when marking the
site.
3. Site marking by LIP or other provider who is ultimately accountable for the procedure
Must be present when the procedure is performed
In limited circumstances LIP can delegate to another who is permitted by hospital and who meets the following qualification
In medical residency program and is supervised by LIP performing the procedure
![Page 188: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/188.jpg)
188
Mark the Site
Licensed person who requires collaborating or supervising agreement with the LIP such as PA or NP
Must be familiar with the patient and present when the procedure is done
4. Method of marking the site is unambiguous and is used consistently through out the hospital
Mark is made at or near the site
Mark must be present after draped and prepped,
![Page 189: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/189.jpg)
189
Mark the Site
5. Alternative process if patient refuses or if anatomically impossible to mark
Put temporary unique wristband, draw on anatomical picture and also if impractical to mark the site (perineum),
Do not mark preemies as will be permanent.
For teeth mark on the dental x-rays or diagram,
![Page 190: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/190.jpg)
190
Mark the Site
Person doing the marking has to be present at time of final time out (this is usually the surgeon),
Has to clear marking and consistent through out the hospital,
Preferable the surgeon’s initials with or without proposed incision line marking,
![Page 191: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/191.jpg)
191
Time Out before Procedure UP.01.03.01
1. Time out is done before immediately before starting the procedure,
2. Characteristics of the time-out
Standardized process Done by designated team member,
Initiated by designated member of the team
Involves immediate members of the team including proceduralists, anesthesia providers, circulating nurse, OR tech, and other active participants involved in procedure,
![Page 192: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/192.jpg)
192
Time Out
Includes active communication,
Even if doing spinal or local,
Other activities suspended during time out,
Want all members to actively give thumbs up,
If more than one procedure, need to repeat process for each one,
![Page 193: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/193.jpg)
193
Time Out
4. Time out must address correct patient, correct site and procedure to be done
Be sure that the site is marked, accurate consent form, agreement on what is being done, correct position, x-rays are properly labeled and displayed,
need to administer antibiotics or fluids for irrigation, and safety precautions based on medication use,
5. Document the time out
![Page 194: NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2](https://reader035.vdocuments.us/reader035/viewer/2022070409/5681442f550346895db0c8b4/html5/thumbnails/194.jpg)
194
Resources
• Agency for Healthcare Research and Quality http://www.ahrq.gov/consumer/
• Consumers Advancing Patient Safety (CAPS) (http://www.patientsafety.org/)
• Partnership for Patient Safety (p4ps) (http://www.p4ps.org/)
Further information go to TJC International Center for Patient Safety http://www.jcipatientsafety.org/ and click on 13A,