1. Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions 6022 or 4037

2. Patient Safety Is Everyone’s Job! The goal of the Patient Safety Program is to create a Culture of Safety and awareness of patient safety issues for all VA Employees, Patients and their Families. Focus: Systems Non-punitive Open Communication Process changes

3. What Are Adverse Events? Patient incidents such as: Patient falls Medication errors Elopements (high elopement risk patients) Delays in treatment Suicides and attempts Medical errors Close calls (intercepted or resulted in no harm)

4. What Is A Sentinel Event? -Death or permanent loss of function resulting from a medication or other treatment error -Suicide of a patient in a round-the-clock setting or within 72 hours of discharge -Surgery on the wrong patient or body part -Unintended retained surgical object -Hemolytic transfusion reaction -Unanticipated death resulting from an health care- acquired infection

5. How Do I Report A Medical Error or Patient Safety Concern?

6. Incidents Occur While Using Equipment 1. Record any settings before disconnecting/turning off equipment. 2. Save and label all suspect medical equipment, attachments, and packing materials (tubing, cables, pads, disposables etc.). 3.Remove immediately from service and place in a secure location (i.e. locked head nurse’s office). Do not send through normal channels for repair. 4.Report incident and equipment involved to the Patient Safety Officer (ext 6022) and Biomedical Engineer (ext 7582) as soon as possible. 5. Enter electronic work order describing the incident and Biomedical staff will pick up and secure devices until appropriate testing can be completed. 6. Notify VA Police (6804) to pick up and secure equipment & attachments during non-administrative hours as needed. 7. Initiate a VA Form 10-2633, Report of Special Incident Involving A Beneficiary displayed on next slide.

8. How Do We Investigate Patient Incidents & Close Calls? A Root Cause Analysis (RCA) team is initiated to determine: What happened? Why? How to prevent it from happening in the future? An RCA is a process designed to examine the systems vulnerabilities to prevent adverse events: non-punitive multidisciplinary team approach process for identifying basic or contributing causes process for identifying what we can do to prevent recurrence

9. What Is An Intentional Unsafe Act? An adverse event that results from: –criminal act –purposefully unsafe act –alcohol or substance abuse –impaired provider/staff –alleged patient abuse Intentional unsafe acts should be reported to your supervisor and Quality Management immediately Intentional Unsafe Acts are investigated by administration

10. What Is A HFMEA? HFMEA or Health Care Failure Mode and Effects Analysis (HFMEA) is a proactive risk assessment used to identify and correct process problems before they happen JCAHO requires a minimum of one HFMEA every 18 months on a process related to all levels of care 2009 HFMEA Topic: Case Management 2008 HFMEA Topic: Hand-Off Communication

11. National Patient Safety Goals 2010 - Improve PATIENT IDENTIFICATION -Improve COMMUNICATION among caregivers -Improve MEDICATION SAFETY -Reduce risk of HEALTH CARE-ASSOCIATED INFECTIONS -Accurately RECONCILE MEDICATIONS -Reduce the risk of patient HARM resulting from FALLS -Promote Flu & Pneumonia VACCINES -Encourage PATIENT INVOLVEMENT in their care, what we are doing to make them safe & how to report concerns -Prevent nosocomial PRESSURE ULCERS -Identify safety risks of SUICIDE & HOME O2 FIRES -Improve RECOGNITION & RESPONSE to declining patient conditions - Universal Protocols – Time Out, mark the site, conduct verification

12. Improve Patient Safety through Positive Identification Ask the patient or representative to state the patient’s full name & full social security number or date of birth (two identifiers) Verify the patient’s correct identification using VIC card, Picture ID or ID band: –Accessing patient information –Checking patients in for care –Applying a patient ID band – two person check required –Giving medications or blood –Providing treatments –Performing procedures –Drawing blood –Obtaining other specimens –Labeling specimens - always in the presence of the pt. –Writing orders –Documenting in the patient record I Never use room numbers!

13. Improve Communication Among Caregivers DO NOT USE VERBAL ORDERS except in emergencies, when the physician/provider is NOT present in the medical center or is scrubbed in the Operating Room. When taking Verbal or telephone orders always:  Write it down in CPRS (verbal/telephone order)  Read it back  Confirm/verify the order with provider  Provider signs order in CPRS within 24 hours

14. DO NOT USE ABBREVIATIONS DO NOT USE the following unacceptable abbreviations in any documentation, i.e. medication orders, progress notes regarding medications in CPRS or paper records.

15. CRITICAL TESTs & REPORTING CRITICAL VALUES Report critical test & test results/critical values ONLY to the ordering provider/designee  Write it down in CPRS  Read it back  Confirm/verify the result with provider  Provider acts on and documents in CPRS Critical tests: Troponins and frozen sections Measure, assess, and take action to improve timeliness of reporting and receipt of critical test results and values by responsible licensed caregiver.

16. Use I-SHARE to remember what information should be communicated & provide an opportunity to ask questions When? Changing shifts, providers, caregivers, transfer and discharge if provider relationship is known: I Identification – Identify Patient & individuals S Situation – Describe Situation/Clinical Status/ Code Status H History – Background information/Current Medications A Assessment - Most recent clinical findings R Recommendation – STAT Orders, Plan/treatments needed E Equipment – Devices needed/Settings prescribed Improve Hand-Off Communications

17. Patient Hand-off Communication Tools

18. Avoid Medication Errors “LASA” Look Alike/Sound Alike Medications To Avoid Errors Double Check Labels Carefully Reminders: TALL MAN lettering Blue strip at top of orders in CPRS High alert stickers on medications Colored bins Segregated BCMA Know the High Alert Look Alike & Sound Alike Medication List - MCM 544-314-1

19. Label All Medications Includes: medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in operative and other procedural settings. This applies to ALL medications Drug name Strength Amount (if not apparent from the container) Expiration date when not used within 24 hours Expiration time when expiration occurs in less than 24 hours. *Only Exception: Same person prepares and administers medication immediately one medication at a time. When the person preparing the medication is not the person who will be administering it, VERIFY both verbally and visually with a second qualified individual.

20. Reduce the likelihood of patient harm Associated with Anticoagulation therapy Weight based heparin protocolWeight based heparin protocol Low-molecular weight heparin protocolLow-molecular weight heparin protocol Heparin order sets in CPRSHeparin order sets in CPRS Heparin therapy nursing noteHeparin therapy nursing note Anticoagulants (IV & oral) are designated as “High Alert”Anticoagulants (IV & oral) are designated as “High Alert” Pharmacist on inpt units to monitorPharmacist on inpt units to monitor Standardized doses for heparin & low-molecular heparinStandardized doses for heparin & low-molecular heparin Patient education (Coumadin booklets available)Patient education (Coumadin booklets available) Mandatory training in LMS for all clinical staffMandatory training in LMS for all clinical staff

21. Universal Protocol for Ensuring Correct Site Surgery 1. Conduct a pre-procedure verification process to ensure all documents and related information are available before the start of the procedure using the Correct Site Checklist: Correct Identifiers and labels Patient two identifiers match documents Procedure and site consistent with the patient’s expectations & the team members’ understanding of the intended patient, procedure and site

22. Universal Protocol for Ensuring Correct Site Surgery 2. Mark the procedure site to identify without ambiguity the intended site for the procedure for all procedures that require a consent Who? The provider performing the procedure with patient involvement When? Before the patient is moved to location where procedure will be performed Where? At or near the procedure or incision site How? Provider writes initials with permanent marker For spinal procedures, the provider initials at the exact vertebral Exceptions: Cases where it is technically or anatomically impossible or impractical i.e. mucosal surfaces, perineum “JJB”

23. Universal Protocol for Ensuring Correct Site Surgery 3. Time Out immediately prior to incision, ideally before the patient receives anesthesia unless contraindicated. A designated member of the procedural team (or provider if no assistant required) initiates the time out and confirm: All team members’ name and role Correct patient identity using full name and SSN Correct site is marked & Consent is accurate Agreement on the procedure to be done Correct patient position History and physical, nursing assessment, and pre-anesthesia assessment match consent for correct patient, site & procedure Correct diagnostic and radiology test results (i.e. radiology images and scans, or pathology and biopsy reports) that are properly labeled and displayed Ensure any required blood products, implants, devices and/or special equipment are available for the procedure. Need for antibiotics or fluids for irrigation Safety precautions based on patient history, medication use and equipment Correct Site Checklist must be completed and signed as indicated on the form and scanned into the medical record after the procedure.

24. Correct Site Checklist Step One Checked by: Date: Time: Name of Procedure(s):___________________________________________________________________ *Consent obtained, including site/side/name of procedure/ ___________ _______________ reason for procedure No abbreviations on form *Should be completed prior to transport to Holding Area In Holding Area/procedure area, physician marks procedure site with initials; must be ___________ _______ ________ a member of the operating team assigned and consented by the patient to be present during the procedure; must include patient involvement If step one not completed, explain reason: Step Two Patient states name/full SS#/ location of body procedure to _____________ _______ ________ be performed. These responses must be checked by the circulating staff nurse against consent form/marked site/ID band Patient must state, not confirm by being asked. If patient unable and no next of kin available, 2 staff members will verify and sign. The Verifying nurse at this point must not leave the patient. This is the nurse that will be present during the procedure and again verify the patient’s identity during the time-out.[a requirement from the OIG report] If step two not completed prior to transport to the Operating Room, explain reason: Step Three If applicable, verification by 2Signatures of 2 physicians physician OR team members (1 must be an attending) prior to start of procedure that imaging data is_________________________________Time: ___________ available on correct patient, properly labeled and properly presented __________________ “Time Out” in OR; prior toOR Team Verbal Confirmation signed by circulating nurse incision OR team (minimum ofindicating name of other team members surgeon, circulating nurse, anesthesia provider) verifiesSurgeon: __________________________Time: _________ name of patient/procedure to be performed/site, including side/Anesthesia: ______________________________________ implant specifications and availability, and antibiotic administered if ordered.Circulating Nurse: _________________________________ Patient Identification: Time out procedures must be observed by all members of the operating team. Failure on any team members part to follow will result in documentation of non-compliance. Full Name Full SSN

25. Reduce Healthcare Acquired Infections Comply with current CDC Hand Hygiene Guidelines. Manage unanticipated death or major permanent loss of function associated with a health care-associated infection as a sentinel event.

26. Hand Hygiene Is… The #1 way to STOP transmission of infection! –CDC estimates 30,000 deaths per year being a direct result of improper hand hygiene. –Statistics indicate that ~ 40% of healthcare workers comply with hand hygiene!

27. Prevent Flu & Pneumonia Protect yourself ….. get immunized! Protect your patients …. DID YOU KNOW….. With flu you are contagious 24 hours before you even know you are sick! DID YOU KNOW…. Hospitals with high employee flu vaccination rates have lower patient mortality ! Protect your families… don’t take germs home! Why me?

28. Medication Reconciliation Process The Provider: Develops complete/accurate list of patient’s medication with the patient &/or caregiver Compares (reconciles) the list of medications with new orders for medications. Updates list as orders change using the medication reconciliation note Communicates list to next provider(s) during Hand-Off Provides written discharge instructions with medication list to patient The Pharmacist: Reviews and compares the current list with orders to help avoid duplications, interactions, omissions and incorrect doses. Notifies the ordering provider of any discrepancies immediately

29. Reduce Risk of Harm From Falls *Hospital falls have a 30% risk of physical injury At risk populations: 1-4 and 85+ age groups Increase of injury-related deaths in the elderly Assess Fall Risk using Morse Scale on admission, each reassessment, and after a fall Use a Falling Leaf to indicate a patient is a high fall risk Implement fall prevention devices, alarms and equipment Correct spills or wet surfaces Dispose of trash appropriately Remove or report any trip hazards and environmental hazards immediately Examine for injury before moving the patient after a fall Notify the provider Complete Fall Review Note in CPRS & notify next of kin Implement additional fall precautions as indicated Complete a Post Fall Note within 24 hours after the fall

30. Encourage Active Patient Involvement Encourage active involvement of patients and their families in the patient's care as a patient safety strategy” Inform patients to report any patient safety concerns to their provider, nurse or the patient representative is necessary Provide Speak Up Booklets with admission orientation packets Provide Patient Education Booklets and instructions to new veterans and to all inpatients and families during orientation containing information about how to report concerns about safety Check Education Resource Center (PERC) across from canteen Provide Joint Commission contact information Joint Commission Complaint Hotline 1-800-994-6610

31. Prevent Pressure Ulcers *1.3 - 3 Million adults have pressure ulcers costing $500- $40,000 per ulcer Identify at risk individuals (Braden Scale) Maintain and improve tissue tolerance to prevent injury Protect against adverse effects of external mechanical devices Reduce the incidence of pressure ulcers through education Use special mattresses as indicated

32. Reduce Risk for Suicide. Suicide risk screening to identify individuals at risk for suicide while under the care of or following discharge is an important step in protecting these at-risk individuals. Suicide risk assessments Address the patient’s immediate safety needs and most appropriate setting for treatment. High Risk List – Notify Suicide Prevention Coordinator Provide suicide prevention information on signs, symptoms, means reduction, the crisis hotline #, etc. to individuals at risk for suicide and their family members. Develop a Safety Plan with the patient &/or family members

33. Improve Recognition and Response to Changes in a Patient’s Condition Goal: To mobilize a team at the first sign of impending crisis or doom, to reduce failure to rescue, improve patient safety, and reduce the number of code 5’s and medical crises. Rapid Response Team - Code White Team Composition—ACLS Nurse, Sr. Resident, Resp. Tx. Team Responsibilities- Quick assessment, work within protocols, administer treatment, stabilize& transfer patient as indicated Response Times Established—5 minutesResponse Times Established—5 minutes Implemented on all inpatient units 12/08Implemented on all inpatient units 12/08

34. Criteria for Activation of Code White Dial 6555 Staff member concerned/worried about the patient (i.e.: decreased urine output, temperature > 101, or patient diaphoretic) Acute change in heart rate (less than 40 or greater than 130) Acute change in systolic blood pressure (less than 90 mm/Hg or greater than 170) Acute change in respiratory rate (less than 8 or greater than 34) or threatened airway Acute change in oxygen saturation which reflects the percentage of red blood cells saturated with oxygen (level is less than 90% despite oxygen being utilized on the patient) Acute change in level of consciousness Acute significant bleed Patient’s oxygen requirements increase to 50% or greater (normal air breathed is 21% oxygen) New, repeated, or prolonged seizures Failure to respond to treatment for an acute problem/symptom

35. What Is A Code 5? Code for Medical emergencies such as respiratory, cardiac arrest or other situations where someone is unresponsive or injured. What is your role in a Code 5? –Ask the person “Are you OK?” and get help –Ask someone to call a Code 5 - Dial 6555 & state the patient location & room # and get the closest AED or Emergency Cart –Provide the Code 5 team with a history of events leading up to the code or observations, if known. –Provide BLS/CPR if you are trained

36. What Is Disclosure? Telling the patient and or significant family members clinically significant facts about the occurrence of an adverse event that resulted in patient harm, or could result in harm in the foreseeable future. Clinical Disclosure is a simple, informal process where the provider discloses all adverse events that occur in the routine course of medical practice even if there was no harm to the patient. Documentation of the facts and who was informed is the responsibility of the physician care for the patient. Institutional Disclosure is a formal process used where the Chief of Staff discloses a serious adverse events. Disclosure if required within 72 hours that the physician is aware of the adverse event. Documentation in Disclosure of Adverse Event Template in CPRS is required.

37. What Can We Do? Observe your work environment for patient safety issues Report unsafe conditions & medical errors to your supervisor and the patient safety officer or the Anonymous Incident Reporting Hotline – 7964 Comply with National Patient Safety Goals Serve on a RCA, Aggregate Review, or HFMEA team ASK your Patient Safety Officer or supervisor

38. “Gentlemen, we are going to relentlessly chase perfection, knowing full well we will not catch it, because nothing is perfect. But we are going to relentlessly chase it, because in the process we will catch excellence.” “I am not remotely interested in just being good.” Vince Lombardi, head coach Green Bay Packers, 1959 – 1967 Words of Encouragement

39. ________________________________________________________________________ Resident’s Signature This is to certify that: Enter Full Name here has completed the Wm. Jennings Bryan Dorn VAMC Patient Safety Training Module on ENTER DATE HERE