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NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2.

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1 NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2

2 2 Speaker  Sue Dill Calloway RN, Esq. CPHRM  AD, BA, BSN, MSN, JD  Medical Legal consultant  5447 Fawnbrook Lane  Dublin, Ohio  

3 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

4 Culture SP 1 Information Management & Continuity of Care Medication Management Hospital Acquired Infections Condition & Site Specific Practices Consent & Disclosure Wrong-site Sx Prevention Periop. MI Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Asp +VAP Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Central Role Med Recon. Std. Med Labeling & Pkg High Alert Meds Unit Dose Medications Evidence- Based Ref. Culture CPOE Order Read-back Abbreviations Discharge System Critical Care Info. Labeling Studies 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 Care Direct 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

5 Safe Practice 19 Hand Hygiene  Comply with current Centers for Disease Control (CDC) and Prevention Hand Hygiene Guidelines  TJC has NPSG 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

6 TJC Hand Hygiene NPSG  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

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8 CDC Hand Hygiene Recommendations  CDC published guidelines Oct 25, 2002 at  In CDC MMWR Recommendations and Reports,  Report available at or go to  Also new admission video on hand hygiene  Hand hygiene interactive training class  Monitored during infection control tracer by TJC 8

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11 Hand Hygiene  WHO Guidelines on Hand Hygiene in Health Care; Clean Hands are Safer Hands at  Good website for children on importance of washing hands with colorful posters, puzzles, and quiz AT  Henry the Hand at henrythehand.com  Toolkits and posters at  Clean your hand campaign at 11

12 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

13 TJC NPSG FAQ 13

14 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 14

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18 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

19 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

20 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 20

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22 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

23 CDC Website 23

24 Keystone Project Changes Everything 24

25 Pa Patient Safety Toolkit 25

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27 Revised How to Kit Central Lines 27

28 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

29 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

30 30 TJC NPSG Central Lines  Implement best practices to prevent central line associated bloodstream infections,  13 EPS  IHI has how to guides and other resources at (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

31 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

32 Central Lines  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 targeted 32

33 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

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35 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

36 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

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38 Four Changes to TJC 2011 NPSG 38

39 July 1, 2010 Changes  NPSG EP 6: A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants  NPSG 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

40 July 1, 2010 Changes  NPSG 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 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

41 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,

42 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

43 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

44 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

45 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

46 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

47 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

48 23 Care of the Ventilated Patient  Use checklist and standardized protocol  Hand hygiene  Regular antiseptic oral care  HOB degrees  Daily assessment of readiness to wean and sedation interruption  Use weaning protocols  Implement PUD prophylaxis (still controversial)  VTE prophylaxis unless contraindicated 48

49 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 requirement 49

50 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

51 24 MDRO Prevention  LD assigns responsibility for oversight and coordination of the development, testing, and implementation of a MDRO prevention program  Infection 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

52 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 equipement 52

53 53 TJC NPSGs 2011  Implement evidenced based practices to prevent HAI due to multi-drug resistant organisms (MDROs),  NPSG (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

54 Implement Evidenced Based Practices  Increased focus on cleaning and disinfecting equipment appropriately (IC )  Proper use of flash sterilization  Making sure all scopes are cleaned according to the manufacturer  Cleaning the patient environment is also important 54

55 55 TJC NPSG MRDO 1. Conduct periodic risk assessment for MDROs acquisition and transmission  In time frame set by hospital  See IC , 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

56 56 Identify Risks for Transmitting Infections  IC The hospital identifies risks for acquiring and transmitting infections  EP1 Hospital identifies risks based on geographic location, community, and population served –NPSG 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

57 57 Identify Risks for Transmitting Infections IC  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

58 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

59 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  Has many resources including training videos on MDRO surveillance, slide sets, protocols, reporting plan etc. 59

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63 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)

64 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

65 65 MRDOs Resources CDC  Management of MRDOs in Healthcare Settings 2006, 74 pages, at  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,

66 66 MRDOs Resources  CDC MRSA resources at  Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices etc,  Isolation precaution 2007 at  VRE resources at  Guidelines for Prevention of Surgical Site Infections,

67 67 Resources  APIC resources at 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,

68 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  Pa Patient Safety Authority has toolkit on how to prevent CAUTI at 68

69 AHRQ Patient Safety Handbook Cp 42 69

70 70 hqp/dpac_uti_pc.html

71 Pa Patient Safety Authority Toolkit 71

72 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   has evidenced based guidelines, sample policies, provider information etc 72

73 Resources  AHRQ has a website on “Efforts to Prevent and Reduce Healthcare-Associated Infections  at  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 73

74 Resources  IHI how to guide on preventing CAUTI  at CatheterAssociatedUrinaryTractInfections.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 and see resources at ance/APICEliminationGuides/CAUTI_Guide1.htm 74

75 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

76 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 stakeholders 76

77 Culture SP 1 Information Management & Continuity of Care Medication Management Hospital Acquired Infections Condition & Site Specific Practices Consent & Disclosure Wrong site Sx Prevention Peri-Op MI Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag Therapy Asp +VAP Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Central Role Med Recon. Std. Med Labeling & Pkg High Alert Meds Unit Dose Medications Evidence Based Ref. Culture CPOE Order Read-back Abbreviations Discharge System Critical Care Info. Labeling Studies 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 Care Direct 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

78 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 s/PWSS/Pages/home.aspx  Patient Safety Handbook has chapter also at 78

79 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

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84 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

85 Safe Practice 27 Pressure Ulcer  Take actions to prevent pressure ulcers by implementing evidence- based intervention practices.  has 75 guidelines on pressure ulcers  AHRQ Patient Safety Handbook has chapter at  Minnesota Hospital Association has many resources on Safe Skin campaign at  National Pressure Ulcer Advisory Panel (NPUAP) at 85

86 MN Hospital Association Safe Skin 86

87 AHRQ Patient Safety Handbook Chapter 12 87

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89 NPUAP Staging System 89

90 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 PU 90

91 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

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93 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

94 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

95 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

96 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

97 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

98 Resources  Source: AHRQ Press release, September 15, 2009, AHRQ Releases Two New Resources to Help Consumers and Clinicians Prevent Dangerous Blood Clots, at  The clinician’s guide on Preventing Hospital-Acquired Venous Thromboembolism; A Guide for Effective Quality Improvement is available at  Patient Guide to Preventing and Treating Blood Clots at

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107 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 

108 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

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111 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 #9

112 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

113 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

114 Pa Patient Safety Authority Toolkit 114 tyTools/cin/Pages/home.aspx

115 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  ntary_march_2007/v4_s1_suppl_advisory_mar_30_2007.pdf 115

116 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 now 116

117 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  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

118 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

119 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  Address wishes to donate organs 119

120 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

121 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

122 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

123 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

124 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

125 TJC Standard  Falls continue as a Joint Commission National Patient Safety Goal in 2009 but moved to standard in 201  0 under PC  PC 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

126 126 Why Look at Falls?  Falls rate high on the list of sentinel events tracked by The Joint Commission (TJC)  6 th 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 number of falls and number and severity of fall related injuries)  TJC gives information on the root causes of falls

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128 128 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.

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130 130 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:

131 131 Intervention Strategies Intervention Level of RiskArea of Risk H ig h MedLowFrequent Falls Altered Elimination Muscle Weakness Mobility Problems Multiple Medications Depression Low beds XXXXXXXXX Non-slip grip footwear XXXXXXXXX Assign patient to bed that allows patient to exit toward stronger side XXXXXXXXX Lock movable transfer equipment prior to transfer XXXXXXXXX Individualize equipment to patient needs XXXXXXXXX

132 132 High risk fall room setup XXXXXXXX Non-skid floor mat XXXXXXXX Medication review XXXXXXXX Exercise program XXXXXXXX Toileting worksheet XXX Color armband / Falling Star etc XXXXXXX Perimeter mattress XXXXX Hip protectors XXXX Bed/chair alarms XXXX

133 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

134 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  Shield radiosensitive areas such as reproductive organs  Scan once as single phase scan usually adequate in children 134

135 135 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

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137 137 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

138 138 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

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141 141 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

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144 144 Recommendations  ACR, as part of Alliance for Radiation Safety, has imaging card for patients, especially kids 1  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

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147 147 The End Questions  Sue Dill Calloway RN, Esq. CPHRM  AD, BA, BSN, MSN, JD  Medical Legal consultant  5447 Fawnbrook Lane  Dublin, Ohio    TJC NPSG UP and Resources 147

148 Patient Safety Material Resources  20 tips to prevent medication errors in children at  5 steps to safer health care at  20 tips to prevent medical errors at  Quick Tips when getting medical tests at 148

149 Patient Safety Material Resources  Ways you can help your family prevent medical errors at  When choosing healthcare at  FDA’s tips on taking medication at  Preventing medications at fm, 149

150 Resources  IHI (Institute for Healthcare Improvement)  FDA at  American Society for Healthcare Risk Managers (ASHRM) monograms on disclosure, patient safety curriculum,www.ashrm.org  John Hopkins Center for Public Awareness- patient safety modules ml, 150

151 Resources  WHO Patient Safety website at  WHO taxonomy at  AHRQ PS Net or patient safety network with journal articles at and see M&M at  AHRQ medical errors and patient safety website at 151

152 Resources  AHRQ TeamSTEPPES strategies and tools to enhance patient safety at  TMIT Safety leaders at has research and workshops and webinars,  FDA patient safety news at /index.cfm,  FDA Bad Bug Book at 152

153 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  Also mistake proofing the design of health care process, 153

154 Resources  Appropriate use of antibiotics, Mangram, AJ, Pearson, MI, Guidelines for Preventing Surgical Site Infections, Infection Control Hosp Epidemiol. 20:  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: ,  Van den Berghe, Wouters, P, Weekers, F, Intensive insulin therapy in critically ill patients, N Engl J Med. 2001:345:

155 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: ,  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: , 155

156 Resources  Sorry Works! Coalition at with sample hospital disclosure program and slides on disclosure,www.sorryworks.net with  Premier Patient Safety Institute- and has section on framework for safety culture and reporting (www.premierinc.com/all/safety/resources/patient_s afety/index_2.jsp)and data tool for doing survey on patient safety,  National Patient Safety Foundation at disclosure after adverse medical event and disclosure statement of principles, 156

157 Resources  Joint Commission at - national patient safety goals and International Center for Patient Safety at -  The patient safety group at  AHRQ Patient Safety Network at tons of great articles and research,  AHRQ Morbidity and Mortality Rounds on the web- 157

158 Resources  VIPCS Virginians Improving Patient Care and Safety at  NPSF National Patient Safety Foundation at and resources at  Patient Safety: Achieving a New Standard of Care; IOM Report 2003 at 158

159 Resources  The Minnesota Alliance for Patient Safety (MAPS)-  National Quality Forum-  National Quality Forum (NFQ) Serious Reportable Events in Healthcare: A Consensus Report -Serious Reportable Events in Healthcare National Quality Forum (NFQ) 159

160 Resources  New pressure ulcer prevention protocol and skin safety plan at  Safest in America =com_content&task=view&id=11&Itemid=0, =com_content&task=view&id=11&Itemid=0  Anesthesia Patient Safety Foundation at 160

161 Resources  Mass Coalition for the Prevention of Medical Errors at  ISMP List of Error Prone Abbreviations, Symbols and Dose Designations at pdf, pdf  University of Michigan Patient Safety Toolkit at  AORN Patient Safety at 161

162 Resources  John Hopkins Center for Innovations in Quality Patient Care at  CAPSLink at sLink/, sLink/  Ohio Patient Safety Institute at 162

163 Resources  USP- US Pharmacopeia at  Sign up for USP Patient Safety Newsletters at Link/, Link/  VA National Center for Patient Safety NCPS at  Sign up for human factors resources at 163

164 Resources  Leapfrog group at  Canadian Patient Safety Institute athttp://www.patientsafetyinstitute.ca/index.html,  Australian Council for Safety and Quality in Health Care at  NPSA National Patient Safety Agency at 164

165 Resources  State of NJ Patient Safety Report at  Patient Safety Authority (PSA) in Pa-  Web M&M by AHRQ at  free 999 journals and over 1.5 million articles, 165

166 Resources  Consumers Advancing Patient Safety CAPS at  The Patient Safety and Quality Improvement Act of 2005 (PA ) amended Title IX of the Public Health Service Act (42 USC 299 et seq), protection for patient safety work products, 166

167 Resources  National Coordinating Council for Medication Error Reporting and Prevention-  Partnership for Patient Safety  "Beyond Blame" video: Order online at or call (959)

168 Disruptive Practitioner Resources  Joint Commission standards at  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):

169 Resources  Weber DO. Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician Exec Sep-Oct;30 (5):16-7. Also available: articles/mi_m0843/is_5_30/ai_n  American Medical Association. Physicians with disruptive behavior. In: Code of medical ethics: current opinions and annotations. Chicago (IL): AMA: p. 279–

170 Resources  Disruptive Behaviors in Physicians, CME course from Texas Medical Board at and gives CME credit,  Tennessee Medical Staff Foundation, Medical Staff Code of Conduct Policy, at tmf.org/code_of_conduct.asp, 170

171 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;

172 Resources  Disruptive Behavior, ACOG Committee Opinion, Number 366, May  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–

173 Resources  Pfifferling J. The disruptive physician: a quality of professional life factor [online]. Physician Exec Mar-Apr [cited 2005 Dec 5]. Available from Internet: 2_25/ai_  See HCA Code of Conduct, 38 pages, at  SOX, or Sarbanes-Oxley Act of 2002, and related Securities and Exchange Commission rules, 173

174 Resources  Cassidy M. Third circuit reaffirms HCQIA immunity for professional review actions [online]. [cited 2005 Dec 5]. Available from Internet: ub/health/October% html#3  Gordon v. Lewiston case, 174

175 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_1 06_0104.pdf,  AMA Physicians and Disruptive Physician packet, July 2004, at assn.org/ama1/pub/upload/mm/21/disruptive_ph ysician.doc 175

176 Fatigue Resources  Ruggiero, JS, Correlates of fatigue in critical care nurses. Res Nurs Health Dec 2003; 26(6):  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 rsestaff/nursestaff.pdf 176

177 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  Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002 Oct 17;347(16):

178 Fatigue Resources  West S. Circadian rhythm, shiftwork and you! Collegian 2001 Oct;8(4):  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):

179 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:

180 180 TJC NPSG Goal 1: UP Universal Protocol  Organization must meet expectation of UP  UP 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,

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182 182 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,

183 183 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

184 184 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

185 185 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,

186 186 Mark the Site  UP 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,

187 187 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

188 188 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,

189 189 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,

190 190 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,

191 191 Time Out before Procedure UP 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,

192 192 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,

193 193 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

194 194 Resources Agency for Healthcare Research and Quality 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 and click on 13A,


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