1. ©2007 RUSH University Medical Center The Joint Commission: An Update Steve D. Barnes, M.D. Professor & Vice Chairman Director of Pediatric Anesthesiology Rush University Medical Center

2. ©2007 RUSH University Medical Center  The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety.  The Requirements highlight problematic areas in health care.  Goals and Requirements are directed and prioritized by the Sentinel Event Advisory Group.  Each year, the Sentinel Event Advisory Group works with The Joint Commission to undertake a systematic review of the medical literature and available health care databases to identify potential new Goals and Requirements. The Purpose of the Joint Commission

3. ©2007 RUSH University Medical Center Sentinel Events

4. ©2007 RUSH University Medical Center  Improve the accuracy of patient identification  Improve the effectiveness of communication among caregivers  Reduce the risk of health care acquired infections  Improves the safety of using medications  Accurately and completely reconcile patient medications across the continuum of care  Reduce the risk of patient harm from falls  Encourage patient’s active involvement in their own care as a patient safety strategy  The organization identifies safety risks inherent in its patient population  Improve recognition and response to changes in patient condition  Universal protocol The National Patient Safety Goals for 2009

5. ©2007 RUSH University Medical Center Mission The Mission of Rush University Medical Center is to provide the very best care to our patients. Vision Rush University Medical Center will be recognized as the Medical Center of choice in the Chicago area and among the very best clinical centers in the United States. Values Rush University Medical Center’s core values: innovation, collaboration, accountability, respect and excellence. The five values are known as the I CARE values. (RUMC website, 2009) Rush University Medical Center: ICARE

6. ©2007 RUSH University Medical Center The National Patient Safety Goals for 2009 Improve the Accuracy of Patient Identification

7. ©2007 RUSH University Medical Center  The two chosen patient identifiers that will be used for all areas of the hospital & out- patient areas are patient Name & Date of Birth (DOB).  In the event that a 3rd identifier is needed, the medical record number is used.  Proper patient ID occurs when the provider asks the patient to state their name & DOB while he/she compares that information to the information on the hospital ID band & the chart, requisition, or other source documentation being used to provide the service.  For non-verbal/non-responsive patients, verification is done as above, but without asking the patient. Patient Identification at the Point of Treatment & Procedure

8. ©2007 RUSH University Medical Center  In an emergency, verification can be completed as soon as reasonably possible following stabilization of the patient.  A patient ID bracelet must be in place & patient’s identity must be confirmed as stated above prior to all of the following: Administering medications Drawing specimens Performing procedures, diagnostic tests, &/or therapies Transporting patients Transfusing blood or blood components* *(Before initiating blood or blood component therapy the patient is matched to the blood or blood component therapy via two person verification process) (RUMC, OP-OO43) Patient Identification at the Point of Treatment & Procedure

9. ©2007 RUSH University Medical Center All boxes must be initialed by the ASU nurse prior to transport to the operating room  Full H&P Complete (H&P completed within 30 days of admission and H&P update done within 24 hours)  Consent (Signed by the patient or legal guardian, witnessed and affirmed) Holding Area: Final Check

10. ©2007 RUSH University Medical Center  Site Marking Complete (Definitive Right / Left distinction: multiple structures, specified levels such as surgery on the spine and unilateral organ surgery). Site Must Be Marked at The Point of Incision Holding Area: Final Check

11. ©2007 RUSH University Medical Center  Mark the procedure site: –The site is marked before the patient is moved to the location where the procedure will be performed and takes place with the patient involved, awake and aware (if possible). –The site is marked by a license practitioner who is privileged or permitted by the hospital to perform the intended surgical or nonsurgical procedure. This individual will be involved directly in the procedure and will be present at the time the procedure is performed. Improve the Accuracy of Patient Identification

12. ©2007 RUSH University Medical Center  Type and Screen Based on a list of identified surgical procedures A repeat type and screen sample must be drawn the day of surgery and must be received by the blood bank before the patient enters the operating room, even if the antibody screen that was done with the preoperative labs is negative If a preoperative antibody screen that was performed with the preoperative labs was not done or results were positive, the results of the type & screen sample the day of surgery must be available prior to entering the operating room Holding Area: Final Check

13. ©2007 RUSH University Medical Center  Pre-Anesthesia Evaluation Complete (Not applicable to local anesthesia case)  OR Documentation Complete in Epic Special equipment Implants Relevant diagnostic data and imaging Holding Area: Final Check

14. ©2007 RUSH University Medical Center  Units of Blood Ordered If the antibody screen is positive, the patient is not taken to the operating room until cross-matched blood is ordered and available Holding Area: Final Check

15. ©2007 RUSH University Medical Center  Nursing Assessment (Database and preoperative assessment)  ID Band on Non-operative Extremity (On non-operative extremity)  TED Hose on Non-operative Extremity (On non-operative extremity)  Bear Paw Pre-warming (All general surgery major open abdominal procedures and Gyne open abdominal procedures) Holding Area: Final Check

16. ©2007 RUSH University Medical Center Sample of correct and incorrect application of label Required contents on label: –Patient name –Medical Record # –Date of draw –Time of draw –Initial of person drawing specimen –Initial of witness to drawing and labeling Optional: –Date of Birth –Location or Room# Incorrect label position on tube Some data hidden where label overlaps itself. Contents of tube not visible Correct label position on tube ALL data visible 3-08 Ref: OP-0132 Blood Bank Specimen Labeling

17. ©2007 RUSH University Medical Center Holding Area: Final Check

18. ©2007 RUSH University Medical Center  Patient is interviewed by the operating room nurse to verify:  Patient identity  Consent  Procedure  NPO status  Allergies  Site  Implants Operating Room: Final Check

19. ©2007 RUSH University Medical Center Improve the Effectiveness of Communication Among Care Givers The National Patient Safety Goals for 2009

20. ©2007 RUSH University Medical Center  Verbal or telephone orders or for telephoning critical test results, the person receiving the information must “read back” the complete order or result even in an emergency situation  Must be reported within 1 hour  There is a standardized list of abbreviations, symbols and dose designations that are not to be used Improve Communication…

21. ©2007 RUSH University Medical Center  At Rush, we use the following hand-off communication process: Improve Communication… **D.R.U.M.R.O.L.L.** D.R.U.M.R.O.L.L. for Handoffs D emographics : Patient name, age, diagnostics, medical/ surgical/ anesthetic history/ allergies R ecent events : Surgery planned, anesthetic planned U nderway : Stage in surgery anesthesia status: lines, fluids, EBL, foley, urine M edications : Meds/ pressors/ antibiotics/ antiemetics given or due R esults : Labs back, pending or due O ther : Any concerns about: airway, hemodynamics, labs, extubation, transfer, family, other? L ist : To do: (eg. CXR, extubate, other) L isten : Any concerns from receiving staff

22. ©2007 RUSH University Medical Center Improve the safety of using medications The National Patient Safety Goals for 2009

23. ©2007 RUSH University Medical Center Medication Errors

24. ©2007 RUSH University Medical Center  Each year the Medical Center reviews a list of look-alike/sound- alike medications that are used within the hospital and takes action to prevent errors  Medications on and off the sterile field are labeled even if only one medication is used  Labeling of medication occurs when a medication or solution is transferred from the original packaging to another container  Medication or solution labels must include the name of the medication or solution concentration amount; if not apparent from the container expiration date when not used within 24 hours expiration time if expiration occurs in less than 24 hours Improve the Safety of Using Medications

25. ©2007 RUSH University Medical Center  All medication or solution labels are verified both verbally and visually by two qualified practitioners whenever the person preparing the medication or solution is not the person who will be administering it  No more than one medication or solution is labeled at one time  Any medications or solutions found unlabeled are immediately discarded  All original containers from medications or solutions should remain available for reference in the perioperative or pre-procedure area until the conclusion of the case or procedure  Specific questions regarding preparation, administration of medication or solution should be directly verified with the operating room pharmacy Improve the Safety of Using Medications

26. ©2007 RUSH University Medical Center Reduce the risk of health care-acquired infection Comply with the current World Health Organization hand hygiene guidelines: Wash hands (15 seconds) Utilize the alcohol hand rub Implement best practices for preventing surgical site infections and central line associated infections Sterile technique Antibiotic administration and documentation(review policy) The National Patient Safety Goals for 2009

27. ©2007 RUSH University Medical Center Infection-related Events

28. ©2007 RUSH University Medical Center Accurately and completely reconcile patient medications across the continuum of care The National Patient Safety Goals for 2009

29. ©2007 RUSH University Medical Center Reduce the risk of patient harm from falls The National Patient Safety Goals for 2009

30. ©2007 RUSH University Medical Center Patient Falls

31. ©2007 RUSH University Medical Center  The Medical Center has a patient fall prevention program  Every patient is at risk  Sedated,elderly, confused and pediatric patients at highest risk  Fall precautions are documented in Epic  Sedated patients in the preoperative, pre-procedure and recovery areas must be carefully monitored  When transferring patients: 1.It is a team process 2.Make sure that the OR or procedure table and cart are locked and a healthcare provider is on either side 3.Safety straps are utilized at all times 4.If an incident occurs there must be accurate documentation and efficient care provided to the patient Reduce the risk of patient harm from falls

32. ©2007 RUSH University Medical Center Encourage patients’ active involvement in their own care as a patient safety strategy The National Patient Safety Goals for 2009

33. ©2007 RUSH University Medical Center SPEAK UP

34. ©2007 RUSH University Medical Center

35. The organization identifies individuals at risk for suicide Organization utilizes a suicide risk assessment in patients who are being treated for emotional or behavioral disorders The National Patient Safety Goals for 2009

36. ©2007 RUSH University Medical Center Improve recognition and response to changes in patient condition  Code Blue Team  Rapid Response The National Patient Safety Goals for 2009

37. ©2007 RUSH University Medical Center Universal protocol for preventing wrong-site surgery The National Patient Safety Goals for 2009

38. ©2007 RUSH University Medical Center  Conduct pre-procedure verification process  Procedure site is marked  Time-out is performed before starting the procedure  Process is documented Universal Protocol to Prevent the Wrong Site Surgery

39. ©2007 RUSH University Medical Center  The time out has the following characteristics : –It is standardized –It is initiated by a member of the team –Involves immediate members of the procedure team –Involves interactive verbal communication between all members and any team member is able to express concerns about the procedure verification –It includes a defined process for reconciling differences in responses (Joint Commission, Universal Protocol, 2009) Time out…

40. ©2007 RUSH University Medical Center  Time out addresses the following : –Correct patient identity –Confirmation that the correct side and site are marked –An accurate procedure consent form –Agreement of the procedure to be done –Correct patient position –Relevant images and results are properly labeled and appropriately displaced –The need to administer antibiotics or fluid for irrigation purposes –Safety precautions based on patient history or medication use –The completed components of the universal protocol and time out are clearly documented (Joint Commission, Universal Protocol, 2009) Time out…

41. ©2007 RUSH University Medical Center  The time-out is conducted prior to starting the surgery or procedure and ideally prior to the induction of anesthesia process (including general/regional anesthesia, local anesthesia and spinal anesthesia).  Time outs are performed only by attending surgeons or fellows who have obtained this privilege.  When there is more than one procedure performed by a separate procedure team, there needs to be a time out prior to each team initiating their procedure.  This applies even when the surgeon is running multiple rooms.  Anesthesia time out is performed prior to initiation of regional anesthesia and is documented on the anesthesia record.  Time out applies to all procedures (ECTs, off-site) Time out… Patient Safety

42. ©2007 RUSH University Medical Center General Overview

43. ©2007 RUSH University Medical Center  Blue scrubs are authorized to be worn in the following departments only: Operating room Post-anesthesia care unit Ambulatory surgery area In-vitro fertilization lab Labor and delivery area Operating room sterile processing area Scrub Policy

44. ©2007 RUSH University Medical Center  Green scrubs are authorized for: Cardiac catheterization procedure area Electrophysiology lab Cardiac biopsy lab Interventional radiology areas Non-surgical house staff Medical students in the appropriate locations Scrub Policy

45. ©2007 RUSH University Medical Center Traveling outside the designated area:  Scrubs (blue or green) may NOT leave the hospital premises.  When traveling outside the designated area you must wear a buttoned white lab coat or cover gown and remove surgical hat, mask and gloves. Scrub Policy

46. ©2007 RUSH University Medical Center  Blue scrubs  Employee identification visible at all times  White lab coat or cover gown when outside of the operating room facility  No masks or surgical hats outside the operating room facility  Hair covered  No jewelry  Masks and gloves are not to be worn outside the operating room itself unless directly involve patient care: procedure in the holding area (regional block); must be removed when the procedure is finished  Do not walk around the operating room facility wearing gloves or masks unless you are in the operating room itself or are performing direct patient care. Operating Room

47. ©2007 RUSH University Medical Center  Anesthesia cart is locked when anesthesia team is not present  Narcotic box is locked  All syringes are labeled: concentration, date, time and initials  There are no open empty syringes with labels on them (considered now as part of medication preparation)  All I.V. bags and tubing is dated, timed, initialed, and locked in the anesthesia cart  I.V. start kits are all locked in the anesthesia cart  Equipment box is not on the floor and contains only equipment relevant to patient care  No tape on I.V. poles  No personal bags are allowed  No food or drinks; unless you are in the designated area  No items on floor or stored on the sharps container  No garbage on the floor  No direct patient care equipment on the floor Operating Room

48. ©2007 RUSH University Medical Center  Patient care is assumed by a qualified practitioner Post-anesthesia orders were entered Report was given Antibiotics were documented in Epic Patient’s pain level was assessed  All patients must have a post-surgical and/or post- procedure note written prior to leaving the recovery area  All post-anesthesia inpatients must have a post anesthesia note documented in Epic  All patient anesthesia complications must be promptly addressed Post-procedure

49. ©2007 RUSH University Medical Center  Proper attire  Universal precautions: eye protection/gloves and hand hygiene (alcohol-based hand product dispensers)  Legible and complete anesthesia record Signature, date and time Complete assessment and care documented  All syringes, needles and medications are labeled with date, time, concentration and initials  IV bags and IV insertion sites are appropriately labeled – date, time and initials  Anesthesia drug boxes and carts are locked when anesthesia personnel is not present  No storage of direct patient care equipment on the floor  Items are disposed of properly  All patient equipment is appropriately cleaned  All blood products or blood components are administered according to the Medical Center’s blood and blood products administration policy  Accurate Epic documentation of antibiotic administration  Documentation of post anesthesia visit and appropriate follow-up care  Hand-off communication between providers  Patient’s confidentiality is maintained In Summary…