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Potential Team Members-all that are applicable to your organization: CEO COO CMO CNE Patient Safety Officer Department Managers Director of Quality/Performance Improvement Director of Nursing Education/Staff Development Medical Staff Department Chairs Concepts

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practice 1 create a healthcare culture of safety
Potential Team Members-all that are applicable to your organization:

CEO

COO

CMO

CNE

Patient Safety Officer

Department Managers

Director of Quality/Performance Improvement

Director of Nursing Education/Staff Development

Medical Staff Department Chairs

Concepts

Culture is the driver for all organizational frameworks and “eats everything else for lunch’.

Culture is more then “the way we do things around here”, culture drives all the subtle influences to decision making”.

High Reliability Organizations

Potential Paper Resources- any and all that apply:

C Level job descriptions, performance reviews and incentive plans: looking for language that pertains to establishing a culture of safety

Patient Safety Officer job description

Department Director job descriptions

Medical Staff Committee Chair responsibilities

Monthly Hospital Board Reports

Organizational Strategic Plan

Quality Improvement Plan

Risk Management /Patient Safety Plan

Quality Improvement Committee Minutes

Patient Safety Plan and Committee minutes

Risk Management Board Reports (may be restricted)

Staff Development files

Hospital Policies and Procedures specific to patient safety, adverse event reporting and “close call or near miss” reporting

Summary reports of action plans subsequent to Root Cause Analysis (RCA) Meetings

Staff meeting minutes that discuss patient safety and lessons learned from RCAs

Story Boards of Performance Improvement projects: including policy and system changes resulting from the project

Minutes of Pt Safety Officer/Chief Nurse Executive Board Reports

Is it listed in Org: Mission, vision, core values…do those documents incorporate language on patient safety or safe care

Organizational internal and external publications, newsletters and informational fliers to employees, physicians and public

Documentation for JCAHO that includes patient safety and culture

Documentation of implementation of Baldrige criteria is implemented

Practice #1:Create a Healthcare Culture of Safety
slide2
Potential Team Members-all that are applicable to your organization:

CEO

COO

CNE

Director of Nursing Education/Staff Development

Management Engineer

Human Resources

Patient Safety Officer

Nursing Department Managers

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to Nursing Staffing procedures including subjects pertaining to:

management of sick call,

ED diversion,

ICU diversion,

off shift and weekend staffing,

use of per diem staffing and “travelers”

Use of internal float pool,

Bed management system

Management Engineering or Staffing Acuity Reports as applicable; may include:

Unit specific patient acuity reports (12 months)

APACHE or similar acuity reports for critical care

Unit Staffing shift reports (12 months)

Nursing Supervisor Shift Staffing Reports (12 months)

ICU and ED Diversion Logs

JCAHO Staffing Effectiveness Indicators or Measures

Trends of Staffing Patterns ID’ed thru RCAs

Actual Staffing Patterns (ratios) for the past 12 months; including staffing mix (RNs. LPNs. CNAs, EMTs. Techs)

Strategic Plans for Nursing Staffing patterns

Documentation of Magnet Nursing Certification if implemented in your organization

Retention and Recruitment Plans

Employee Satisfaction Surveys

Community outreach actions and plans to enhance recruitment efforts

Documentation of performance improvement projects related to recruitment and retention and management of appropriate staffing patterns

Staff Development files and documentation of skills development seminars or on-site “skills fairs”, in-service education programs to specific skills

Staff development programs specific to skill development needs identified out of trend analysis of adverse events in the organization: Simulator training

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #3:Specify an explicit protocol to be used to ensure an adequate level of nursing care based on the institution's usual patient mix and the experience and training of its nursing staff.

slide3
Potential Team Members-all that are applicable to your organization:

COO

CNE

Director of Pharmacy

Directors Respiratory and Imaging

Staff Pharmacists

Nursing Staff

Medical Staff

Concepts:

Pharmacist Interventions: Interventions by pharmacists in an ordering process should be recorded and trended and performance improvement actions taken.

Resources:

Potential Paper Resources- any and all that apply:

Pharmacist job description (all that apply)

Hospital Policies and Procedures specific to:

the role of the hospital pharmacist

the role of a clinical pharmacist if a separate distinction applies

Pharmacy coverage when pharmacy is not open 24/7

Authority of the pharmacist in the medication management process

Multi-disciplinary rounds

Pharmacy tracking system reports of Pharmacist interventions on medication orders (i.e.: # of times a pharmacist calls an MD to clarify or question a medication order etc.)

P&T (Pharmacy and Therapeutics) Committee meeting minutes

Documentation Pharmacist activities to support this safe practice

Documentation of Pharmacists involvement in the Medication Reconciliation processes

Automated medication dispensing system (i.e. Pyxis) reports on pharmacist interventions, including frequency or incidence rates when system medication profiling is turned off

Robotic Filling/Dispensing System Reports

Bar Coding System reports (bar coding labeling and administration system – over rides and meds saved or held – potential errors avoided)

Documentation of performance improvement projects involving the role of the pharmacist outside the walls of the pharmacy or performance improvement project plans.

Interviews of nursing, clinical and medical staff on the (actual) role of the pharmacist in the organization

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Minutes Medication Error Review Committee

Data bases of findings from Executive Walk Rounds and Unit Briefings

Practice #5Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

slide4
Potential Team Members-all that are applicable to your organization:

COO

CNE

PSO

Director of Pharmacy

Director of Nursing Education/Staff Development

Department Directors

Clinical Staff

Medical Staff

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Verbal and telephone orders

Reporting of Lab Results or other Critical Test Results, including i.e: respiratory therapy or Imaging

Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to verbal and telephone orders

P&T (Pharmacy and Therapeutics) Committee meeting minutes which discuss the responsibilities of the MD in the use of verbal or telephone orders

Documentation of clinical staff education sessions or “skills fairs” that include information on verbal orders and a read-back process

Documentation of performance improvement or future performance improvement project plans that focus on use of verbal orders and the process of read-back for accuracy

Summary reports from risk management on incidence of adverse events related to verbal orders or reporting/communication of critical test results

Department Manager performance review requirements

Summary reports on frequency and severity to Administration

Measure of effectiveness and/or compliance with National Pt Safety Goal on verbal orders and critical test results

Practice #6:Verbal or telephone orders or critical test results should be recorded whenever possible and immediately read back to the prescriber i.e., a healthcare provider receiving a verbal or telephone order should read or repeat back the information the prescriber conveys in order to verify the accuracy of what was heard. 

practice 7 use only standardized abbreviations and dose designations
Potential Team Members-all that are applicable to your organization:

COO

CNE

Director of Pharmacy

Director of Nursing Education/Staff Development

Department Directors

Director of Information Management

Concepts:

Standardization of dose designations within an organization minimizes the risk of misinterpretation of medication orders.

Standardized abbreviations reduces the risk if misinterpretation of any written order.

Resources:

JCAHO List: “ A Minimum List of Dangerous Abbreviations, Acronyms and Symbols”

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Standardized Abbreviations and Dose Designations

Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to standardized abbreviations and/or dose designations

P&T (Pharmacy and Therapeutics) Committee meeting minutes

Medical Staff Peer Review Summary minutes that address actions dealing with frequent abusers of policy standardized abbreviations and dose designations

Documentation of Medical Staff education on hospital required standardized abbreviations and dose designations

Documentation of nursing education sessions or “skills fairs” that include information on standardized abbreviations

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Measure of effectiveness and/or compliance with National Pt Safety Goal on standardized abbreviations

Documentation of compliance with JCAHO standards related to this area

Practice #7:Use only standardized abbreviations and dose designations.  
practice 8 patient care summaries or other similar records should not be prepared from memory
Potential Team Members-all that are applicable to your organization:

COO

CNE

CIO

Medical Staff Department Chairs

Director of Information Management or Medical Records

Clinical Department Managers

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Dictation of patient care summaries or other components of the medical record

Documentation of Medical Staff education on hospital policies regarding preparation and dictation of patient care summaries and other information

Medical Staff Peer Review Summary minutes that address actions dealing with frequent abusers of policy standards on creation of patient care summaries.

Documentation of Medical Records process or procedure for finalizing medical record components for MD discharge summary or other dictation requirements

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Documentation of the dictation environments

Practice #8:Patient care summaries or other similar records should not be prepared from memory.  
slide7
Potential Team Members-all that are applicable to your organization:

COO

CNE

CIO

Medical Staff Department Chairs

Clinical Department Managers

Director of Information Management or Medical Records

Director of Quality/Performance Improvement

Director of Home Care

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

A medication reconciliation process

Documentation of medications the patient is taking upon admission

Documentation of prescriptions or a medication plan upon discharge

Patient education plans or materials specific to medication management and allergies

On diagnostic testing result reporting

Documentation of clinical staff education regarding:

admission assessment of medications,

communication of changing orders and diagnostic information on patients to caregivers involved in direct patient care

Performing a medication reconciliation process

Medical Staff Committee minutes

Staff Department Meeting minutes

Documentation of Home Care and Social Work or Case Management staff involvement in communicating changes in patient care to outpatient providers

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Documentation of this issue in individual department performance improvement plans, critical measures and reporting channels

Department Manager performance review requirements

Practice #9:Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient’s healthcare providers/professionals who need that information to provide care.

slide8
Potential Team Members-all that are applicable to your organization:

COO

CNE

Director of Risk Management

Director of Quality/Performance Improvement

Director Surgical Services

Clinical Department Managers as appropriate

Individual Nursing Department Directors

Director of Social Services or Case Management

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Obtaining Informed Consent

Communicating with the hearing, visually or literacy impaired; specific to provision of certified interpreters

Surrogate decision making

Disclosure

Informed Refusal

Sample of current informed consent document; review for reading level and literacy considerations

Summary reports from risk management regarding adverse events related to incomplete or lack of informed consent

Documentation of clinical staff education regarding:

The informed consent process

The process for obtaining interpreters for blind, deaf and patients with literacy challenges, including English as a second language or non-English speaking

Surrogate decision making

Documentation of Medical Staff Education on this issue

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #10:Ask each patient or legal surrogate to recount what he or she has been told during the informed consent discussion.
slide9
Potential Team Members-all that are applicable to your organization:

COO

CNE

Director of Risk Management

Director of Quality/Performance Improvement

Individual Nursing Department Directors

Director of Social Services or Case Management

Chairman of Clinical and Organizational Ethics Committee

Hospital Patient Advocate

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to documentation of:

End of Life Decision Making

Do Not Resuscitate (DNR) Orders

Living Wills or Advance Directives

Surrogate decision making

Sample of current hospital advance directive document; review for reading level and literacy considerations

Sample of Admission consent forms; review how it addresses documentation of the patient’s currently existing or non-existing advance directives

Minutes from Ethic Committee meetings which address this issue.

Summary reports from risk management regarding adverse events related to lack of communication of the patient’s wishes for care

Documentation of Nursing and Medicalstaff education regarding:

Assessment and documentation of the patient’s desires for life sustaining measures

Appropriate implementation of DNR orders

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #11:Ensure that written documentation of the patient's preference for life-sustaining treatments is prominently displayed in his or her chart.

practice 13 implement a standardized protocol to prevent the mislabeling of radiographs
Potential Team Members-all that are applicable to your organization:

COO

Imaging Department Director

Director of the Emergency Department

Chairman of the Medical Department of Radiology

Director of Quality/Performance Improvement

Director of Risk Management

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to documentation of:

Labeling of x-rays and other films

Management of x-rays during processing

Flash marking x-rays

Over reads and discrepancies

Imaging Department logs of incidence of mislabeled radiographs

Imaging Department staff meeting minutes that address this issue.

Summary reports from risk management regarding adverse events related to mislabeled radiographs

Documentation of imaging staff education regarding:

Labeling and management of radiographs

Performance improvement action plans based on trended data of mislabeling events within the department

Documentation of Medical Staff education of system changes implemented to reduce mislabeling of films

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #13:Implement a standardized protocol to prevent the mislabeling of radiographs.
slide11
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Director of Surgical Services

Individual Nursing Directors for Surgical Care Patients or other departments which perform invasive procedures

Chairman of the Department of Surgery

Director of Quality/Performance Improvement

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Identification of patients for surgery and confirmation of the intended procedure and site

Universal Protocol

Surgical Checklist for patient and site identification for surgery or invasive procedures

Documentation of clinical staff education sessions on hospital policy and universal protocol for identification of patients and sites for surgery and invasive procedures

Documentation of Medical Staff education of hospital policy and procedure or universal protocol for identification of patients and sites for surgery or invasive procedures

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Documentation of implementation of a Universal Protocol or plans to implement

Summary risk management reports of adverse events due to wrong patient, wrong procedure or wrong site during surgery or an invasive procedure

Report of summary of near misses

Department Manager performance review requirements

Minutes of Pt Safety Officer and/ or CNE Board Reports

Practice #14:Implement standardized protocols to prevent the occurrence of wrong-site procedures or wrong-patient procedures.
slide12
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Chief Medical Officer

Director of Surgical Services

Individual Nursing Directors for Surgical Care Patients

Chairman of the Department of Surgery and Cardiology

Director of Quality/Performance Improvement

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Performing a cardiac risk assessment of patients pre-operatively

Surgical Cardiac Risk Assessment form

Pre-Anesthesia risk assessment

Documentation of clinical staff education sessions on hospital policy and procedure for performing a pre-operative cardiac risk assessment

Documentation of Medical Staff education of hospital policy and procedure or protocol for pre-operative cardiac risk assessments and the available literature on the benefits and positive clinical outcomes related to the use of pre-intra and post-operative use of beta blockers.

Documentation of the volume of patients that are assessed and treated

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Summary risk management reports of adverse events associated with cardiac events during or immediately post-operative for surgical patients

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #15:Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment of high-risk patients with beta blockers.

slide13
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Wound Care Specialist

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing Admission Assessments

Nutritional Assessments

Mobility assessment

Plans for prevention of skin ulcers

Skin and Wound Assessments

Nursing Admission Assessment form and sample nursing skin ulcer prevention plan

Skin and Wound assessment forms

Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for developing skin ulcers and proper use of pressure relieving devices

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #16:Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventative methods should be implemented consequent to the evaluation.

slide14
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Department Chair for Vascular Surgery

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing Admission Assessments

Nursing Assessment for risk of developing DVT/VTE

Post-op prophylactic management of DVT

Medical Staff assessment of risk for DVT

Documentation of Standing Orders and/or protocols for DVT/VTE prevention

Nursing Admission Assessment form and nursing care plan for prevention of DVT/VTE

Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk assessment for DVT/VTE

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #17:Evaluate each patient upon admission, and periodically thereafter, for the risk of developing DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE.

slide15
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Chief Medical Officer

Vascular or Orthopedic Medical Staff

Director of Pharmacy

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Director of Laboratory Services

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Use of anticoagulation therapy

Laboratory policies on reporting coagulation times

Patient Education regarding anticoagulation

Documentation of a dedicated healthcare professional responsible to manage anti-coagualtion therapy services

Documentation of clinical staff education sessions on appropriate management of anticoagulation therapy

Documentation of procedure and standing orders or protocols for anticoagulation therapy

Pharmacy system reports on anticoagulation protocol use by physicians and frequency of outliers

Summary Medical Staff Peer Review Committee Minutes addressing the issue of consistent use of anticoagulation therapy protocols

Minutes of P&T (Pharmacy and Therapeutics) Committee Meetings that address this issue; specific to discharge instructions

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Documentation or sample Patient Education materials regarding the patient’s role in management of their anticoagulation therapy.

Documentation of processes and procedures to manage patient’s anticoagulation therapy after discharge

Department Manager performance review requirements

Minutes of Pt Safety Officer and/or CNE Board Reports

Practice #18:Utilize dedicated anti-thrombotic (anticoagulation) services that facilitate coordinated care management.
slide16
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Infection Control Practitioner

Director of Respiratory Therapy

Dieticians

Speech Therapist

Medical Staff Pulmonologist

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing Admission Assessments

Risk assessment for aspiration

Respiratory Assessment

Nursing Admission Assessment form and sample aspiration prevention plan

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources.

Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for aspiration, proper hand washing techniques, and sterile technique and the value of elevation of the Head of Bed

Documentation of Respiratory Assessment for risk of aspiration

Documentation of Speech Therapy assessment for gag reflex and swallowing capability, risk for aspiration

Documentation of Dietary Assessment for appropriate diet to avoid risk of aspiration

Nursing and PT Protocols specific to feeding patients at risk for aspiration

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Patient Safety Officer or Chief Nurse Executive Board Report Minutes

Practice #19:Upon admission, and periodically thereafter, evaluate each patient for the risk of aspiration.
slide17
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Risk Management

Director of Quality/Performance Improvement

Infection Control Practitioner

IV Therapy Team member

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Central Venous Line Placement and management

Use of sterile technique

Protocols for Infection Control related to Central Venous Lines

Assessment of patients to determine benefit of Central lines

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources.

Documentation of clinical staff education sessions on hospital policy and procedure for assisting with central line placement, proper hand washing techniques, sterile technique and long term management of central lines

Documentation of Medical Staff education on hospital protocols for selection of patients andcentral line placement and use of sterile technique.

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Documentation of Patient Safety Officer or Chief Nurse Executive Board Reports

Practice #20:Adhere to effective methods of preventing central venous catheter-related blood stream infections.
slide18
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Chief of Surgery

Director of Surgical Services

Individual Nursing Directors for Surgical patient care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Infection Control Practitioner

Note: Check PeriOp Change for antibiotic administration procedures

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing Pre-operative Assessments

Infection control procedures in the OR

Infection control procedures in equipment sterilization

Pre-operative skin prep for surgery

Core temperature and Oxygenation management

Use of prophylactic antibiotic therapy

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of surgical site infections.

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on results of infection control surveillance testing of all divisions of the surgical services department.

Documentation of clinical staff education sessions on hospital policy and procedure on proper hand washing techniques, sterile technique, cleaning procedures between OR cases, use of prophylactic antibiotic therapy

Documentation of trend reports on administration of pre and post-operative antibiotic administration timing and choice of antibiotic

Documentation of Medical Staff education on current literature review of the clinical outcomes of patients who are at risk of developing an SSI and the use of prophylactic antibiotic therapy.

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department of Surgery minutes

Department Manager performance review requirements

Documentation of Patient Safety Officer or Chief Nurse Executive Board Reports

Practice #21:Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of SSI, and implement appropriate antibiotic prophylaxis and other preventative measures based on that evaluation.

slide19
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Chief Medical Officer

Director of Imaging Services

Individual Nursing Directors for patient care areas

Chairman of the Department of Imaging

Director of Quality/Performance Improvement

Director of Laboratory Services

Director of Pharmacy Services

Note: May need a FAQ that speaks to the last bullet under P&Ps

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing and/or Imaging Admission Assessments

Nursing and/or Imaging Risk Assessment for potential contrast induced kidney failure

Documentation of compliance with completion of pre-procedure assessments

Medical Staff risk assessment for renal failure

Nursing risk assessment form

Review Department of Imaging Committee minutes regarding standardization of contrast media

Documentation of clinical staff education sessions on hospital policy and procedure for performing a risk assessment for potential kidney failure secondary to contrast media administration, signs and symptoms of acute renal failure,

Documentation of Medical Staff education of hospital policy and procedure or protocol for diagnostic risk assessment for potential contrast media induced renal failure and the positive clinical outcomes with implementation of appropriate prevention measures.

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Summary risk management reports of adverse events associated with contrast media induced renal failure.

Department Manager performance review requirements

Practice #22:Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the patient's kidney function evaluation.

slide20
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for Patient Care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Dieticians

Speech Therapist

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Nursing Admission Assessments

Nutritional Assessments

Malnutrition screening

Nursing Admission Assessment form and sample malnutrition prevention plan

Documentation of clinical staff education sessions on hospital policy and procedure for performing admission assessments with a focus on risk for malnutrition, assessment of ability to eat and appropriate implementation of dietary supplements

Documentation of Dietician risk assessment and screening for malnutrition, and plan of care

Documentation of the need for Speech Therapy risk assessment for swallowing risk and mastication capabilities based on Dietician or Nursing risk assessment.

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Documentation of Patient Safety Officer and/or Chief Nurse Executive Reports to the Board

Practice #23:Evaluate each patient upon admission, and periodically thereafter, for risk of malnutrition. Employ clinically appropriate strategies to prevent malnutrition.

slide21
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Directors of Surgical Services

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Medical Director for Surgery

Chairman of Anesthesiology

Director of Emergency Services

Chairman of Department of Emergency Services

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Use of pneumatic tourniquets in the OR and the ER

Medical Staff Risk Assessment

Nursing risk assessment for complications and prevention plan

Documentation of clinical staff education sessions on hospital policy and procedure for use of the pneumatic tourniquet, complications, nerve injury assessment, and prevention interventions

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #24:Whenever a pneumatic tourniquet is used, evaluate the patient for risk of ischemia and/or thrombotic complication and utilize appropriate prophylactic measures.

slide22
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for patient care areas

Director of Nursing Staff Education/ Staff Development

Director of Quality/Performance Improvement

Infection Control Practitioner

Director of Employee Health

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Proper Hand Washing

Infection control procedures

CDC Hand Hygiene Protocols

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on results of infection control hospital surveillance testing

Documentation of clinical staff education sessions on hospital policy and procedure on proper hand washing and aseptic technique, use of universal precautions

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Measures of compliance or effectiveness to National Patient Safety Goal

Environment of Care Committee minutes

Department Manager performance review requirements

Documentation of Patient Safety Officer or Chief Nurse Executive Reports to Administration

Practice #25:Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to and after direct contact with the patient or objects immediately around the patient.

slide23
Potential Team Members-all that are applicable to your organization:

CNE

Patient Safety Officer

Individual Nursing Directors for patient care areas

Director of Quality/Performance Improvement

Infection Control Practitioner

Director of Employee Health

Human Resources

Potential Paper Resources- any and all that apply:

Human Resource Policies and Procedures specific to:

Employee Vaccination

Infection Control Practitioner reports to Nursing Management and Patient Safety Committee on incidence of nosocomial infections and sources

Documentation of Human Resources or Employee Health reports on incidence of employee vaccination for influenza

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #26:Vaccinate healthcare workers against influenza to protect both them and patients from influenza.
slide24
Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Director of Pharmacy

Individual Directors of Patient Care areas

Director of Quality/Performance Improvement

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Medication preparation work areas

Summary reports from risk management on adverse events related to medication errors specific to preparation and administration

Environment of Care Committee minutes

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #27:Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction and noise.
practice 28 standardize the methods of labeling packaging and storing medications
Potential Team Members-all that are applicable to your organization:

COO

Patient Safety Officer

Director of Pharmacy

Director of Quality/Performance Improvement

Director of Materials Management

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Labeling, Packaging and storage of medications

Summary reports from risk management on adverse events related to medication errors specific to “look alike” medications or other labeling, packaging or storage issues

Minutes from P&T Committee specific to this issue

Documentation of clinical and pharmacy staff education sessions addressing the risks and issues associated with similar packaging of medications from various manufacturers, prevention measures, and forced function steps.

Strategic plans to address this issue with specific capital budget allocations as needed

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #28:Standardize the methods of labeling, packaging, and storing medications.
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Potential Team Members-all that are applicable to your organization:

COO

CNE

CMO

Patient Safety Officer

Director of Pharmacy

Clinical Directors of patient care areas

Director of Quality/Performance Improvement

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

High Alert medications

Removal of high concentration medications from clinical units

Standardization of drug concentrations

Independent verification

Summary reports from risk management on adverse events related to medication errors specific to high risk medications

Documentation of systematic measurement of adverse drugs events related to high risk, high alert medications.

Review of P&T Committee Minutes specific to this issue

Documentation of clinical and pharmacy staff education sessions addressing the risks and issues associated with high alert medications, prevention measures, and forced function steps.

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #29:Improve the safety of using high-alert medications (e.g., intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics and opiates).

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Potential Team Members-all that are applicable to your organization:

COO

CNE

Patient Safety Officer

Director of Pharmacy

Clinical Directors of patient care areas

Director of Quality/Performance Improvement

Potential Paper Resources- any and all that apply:

Hospital Policies and Procedures specific to:

Use of unit dose or unit-of-use medications

Summary reports from risk management on adverse events related to medication errors specific to dose administration errors

Review of P&T Committee minutes

Documentation of clinical and pharmacy staff education sessions addressing the use of unit dose medications and risks of bulk packaging

Documentation of strategic plans and allocation of capital dollars needed to address unit dose issues in the hospital

Documentation of performance improvement or future performance improvement project plans that focus on this issue

Department Manager performance review requirements

Practice #30:Dispense medications in unit-dose or when appropriate unit-of-use form, whenever possible.