National Patient Safety Goals

2. National Patient Safety Goals Beth Downing, MSN, RN-BC, ONC

3. Objectives • Recognize The Joint Commission’s 2012 Hospital National Patient Safety Goals. • Apply The Joint Commission’s 2012 Hospital National Patient Safety Goals to clinical practice.

4. National Patient Safety Goals • Developed in 2002 to improve patient safety • Reviewed annually for updates/changes • 9 different NPSG Programs

5. NPSG Programs • Home Care • Hospitals** • Critical Access Hospitals • Behavioral Health Care • Ambulatory Health Care • Laboratory Services • Long Term Care • Long Term Care (Medicare/Medicaid) • Office Based Surgery ** This presentation will focus on 2012 Hospital NPSGs

6. Focus of 2012 NPSGs • Correctly identify patients • Improve staff communication • Use medications safely • Prevent infections • Identify patient safety risks • Prevent mistakes in surgery

7. NPSG.01.01.01 Use at least 2 patient identifiers to ensure that each patient gets the correct medications and treatments.

8. NPSG.01.03.01 To ensure that the correct patient gets the correct blood/blood component during a transfusion.

9. NPSG.02.03.01 Communicate important test results to the correct staff member in a timely manner.

10. NPSG.03.04.01 Correct labeling of medications before a procedure. For example: medicines in syringes, cups, and basins set-up prior to a procedure. Perioperative or Bedside Procedures

11. NPSG.03.05.01 Take additional care for patients who are receiving medications to thin their blood. Anticoagulant Use: Heparin Low molecular weight heparin or Warfarin (If patients coagulation labs are expected to be out of the normal range with this therapy)

12. NPSG.03.06.01 Record and communicate correct information about patient’s medications. Medication Reconciliation (Are there discrepancies?) Compare what the patient is taking at home with new medications Complete on admission & discharge Name, Dose, Frequency, Route, & Purpose Scheduled & PRN Medications

13. NPSG.07.01.01 Use hand hygiene guidelines from the Centers for Disease Control (CDC) OR World Health Organization (WHO); and set goals to improve the hand hygiene process. Hand hygiene is 1 of the most important ways to minimize healthcare associated infections (HAIs)

14. Additional Resources Links for CDC & WHO hand hygiene guidelines http://www.cdc.gov/handhygiene/ http://www.cdc.gov/HandHygiene/download/hand_hygiene_core_minus_notes.pdf http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf Facilities use guidelines from either the CDC or WHO to establish their policies

15. NPSG.07.03.01 Use proven guidelines to prevent infections that are difficult to treat. MDRO Multidrug Resistant Organisms Methicillin-Resistant Staphylococcus Aureus(MRSA) Clostridium Difficile(CDI) VancomycinResistant Enterococcus (VRE) Multidrug-Resistant Gram Negative Bacteria

16. MDRO’s • Risk assessment • Who is at risk? • Surveillance program • Monitor patients who are at risk or are positive • Educate staff upon hiring & annually • Educate patients diagnosed with a MDRO • Lab alert system • Identifying patients newly diagnosed with a MDRO • Alert system on readmission or transferof patients with a MDRO

17. NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines. CLABSI Central line associated bloodstream infections Short & long-term central venous catheters (CVC) such as: Multi-lumen, Hickman, Port-a-cath, Peripherally inserted central catheters (PICC)

18. CLABSI • Educate patients before insertion • Educate staff upon hiring & annually • Implement a checklist/protocol for insertion • Perform hand hygiene before insertion or care • For insertion: standardized kit/cart & antiseptic • Standardized protocol to disinfect hubs/ports • Evaluate central lines routinely

19. NPSG.07.05.01 Use proven guidelines to prevent infection after surgery SSI Surgical site infection

20. Surgical Site Infections • Use evidence based practice (EBP) to: • Educate staff upon hiring & annually • Educate patients about prevention • Determine antimicrobial agent for prophylaxis • Determine hair removal method • Measure SSI rates for 30 days after procedures • Conduct risk assessments • Evaluate effectiveness of protocols

21. NPSG.07.06.01 Use proven guidelines to prevent infections of the urinary tract that are cause by catheters. CAUTI Catheter associated urinary tract infections Full implementation on January 1, 2013 Doesn’t apply to pediatric patients

22. CAUTI • Use EBP to to determine: • Insertion protocol based on EBP • Aseptic technique for site prep & insertion • Limit use of catheters • Does the patient really need this catheter? • Secure catheter to maintain urine flow • Maintain sterility of system • Protocol for urine specimen collection

23. NPSG.15.01.01 Identify which patients are most likely to attempt to commit suicide. Applies to: Psychiatric Facilities Patients treated for emotional or behavioral disorders in general hospitals

24. Suicide Risk • Conduct a risk assessment • Who is at risk? • Address immediate safety needs • What is the most appropriate setting for the patient? • At discharge provide suicide prevention information (i.e. crisis hotline)

25. UP.01.01.01 Ensure that the correct surgery is done on the correct patient at the correct location.

26. Pre-Procedure Verification • Complete: • At preadmission testing • At admission • At time of procedure • Identify patient & involve them in the process • Verify: • History & Physical • Consent • Assessment • Diagnostic & laboratory results • Required equipment/supplies

27. UP.01.02.01 • Mark the procedure site • Involve patient • Site is marked by whoever is accountable for procedure (MD, APRN, PA) • Mark at or near the surgical site • Consistent marking method throughout the facility

28. UP.01.03.01 Pause before surgery to make sure an error is not being made.

29. Time Out Procedure Involve ALL procedural team members Agree on: Right Patient Right Site Right Procedure

30. The nurse enters the patient’s room to administer medications. Which could the nurse use to correctly identify the patient? (Select all that apply) • Full name • Date of birth • Room number • Telephone number • Medical record number TJC recommends using options A, B, D, E as identifiers; also a facility assigned ID number can be used.Room numbers and locations cannot be used.

31. Which activities require the nurse to verify 2 patient identifiers? (Select all that apply) • Collecting sputum specimen • Changing a dressing • Obtaining a blood sample • Inserting an intravenous line • Removing a urinary catheter All treatments, procedures, and medications require verification of patient identification. Options A&C also should be labeled in the patients presence.

32. A patient is ordered to receive a unit of packed red blood cells (PRBCs). What steps should be included in the verification process to prevent a transfusion error? Match the blood product to the physicians order Match the patient to the blood product Use a 2 person verification process OR Use a 1 person verification process with an automated identification system (barcoding) The verification should include patient identity, physicians order, consent, blood type, blood product, typenex number, & expiration date.

33. An adult patient’s initial laboratory report lists a panic low hemoglobin level of 6.1 g/dL. What is the nurses best action? • Notify the physician on the next round. • There is no need to notify, the patient was admitted with anemia, this result is expected. • The patient was already ordered to receive a blood transfusion, so it is not necessary to notify. • Call the physician immediately to notify of the result. Hospital policy will determine the reporting process –including who does the reporting , whom the report is called to, and an acceptable time frame for reporting.

34. The next time you are in the clinical setting review your clinical agency policy and procedure for reporting critical results of tests and diagnostic procedures. What is the time frame to report? What is the procedure for reporting? Who can report it? Is there an exception to reporting?

35. The nurse is setting up medications for a bedside procedure. Which label includes the correct information? Lidocaine 1% 50 mg Exp 6/1/12 @1800 Lidocaine 1% 50 mg/5 mL Prepared 5/31/12 @ 1800 Exp 6/1/12 @ 1800 Option B includes: medication name, strength, quantity, volume/diluent, and expiration date. Expiration time is a requirement if it occurs in less than 24 hours Lidocaine 50 mg/5 mL Exp 6/1/12 @ 1800 Lidocaine 1% 5mL Prepared 5/31/12 @ 1800

36. A patient is being started on Warfarin (Coumadin) after surgery to prevent a deep vein thrombosis. What should the nurse include in the plan of care when initiating this therapy? (Select all that apply) • Baseline INR result verification • Education regarding food & drug interactions • INR monitoring throughout the therapy • Reinforcing the importance of compliance • Education on adverse reactions & interactions with other drugs In addition to these 5 requirements, TJC requires hospitals to have approved protocols for intiating & maintaining anticoagulant therapy.

37. Medication reconciliation process for a newly admitted patient. What is omitted, duplicated, changed, contraindicated, or unclear? • Prilosec 20 mg po daily • Claritin 10 mg po daily • Multivitamin 1 tab po daily • Tylenol 650 mg po q4 hr prn mild pain or fever • Protonix 40 mg IV q12 hr • Keflex 500 mg po q6 hr • Prilosec 20 mg po daily • Claritin 10 mg po daily • Multivitamin 1 tab po daily • Aspirin 81 mg po daily • Tylenol 650 mg poprn Home Medications MD Orders Clarification would be necessary for: Prilosec & Protonix both are the same class of medications, Aspirin is omitted, Tylenol on home medication list does not have a prn indication or time, Keflex is a new medication is it appropriate for this patient?

38. The patient is now being discharged from the hospital with medication changes. What information is essential to be included in the discharge teaching? Medication Name Dose Route Frequency Reason why patient is taking it All of this information should be discussed with the patient to ensure correct administration at home and to improve patient knowledge of medications. Patients should be instructed to keep an accurate medication list with them at all times in the event of an emergency.

39. Match the hand hygiene methods to the time frames required for them to be effective. Soap & Water Alcohol Based Hand Rub Surgical Scrub • 60 Seconds • 2-6 Minutes • 15 Seconds • 10 Minutes • Until Dry These time frames determined by the CDC have been proven to be effective at providing hand hygiene. Completing these for a longer period of time had not proven to be any more effective.

40. In which situations is the use of alcohol based hand rub an appropriate hand hygiene method? (Select all that apply) • After removing gloves • Before inserting a urinary catheter • When hands are visibly soiled • Preoperatively before donning sterile gloves • Before taking a patients blood pressure If hands are visibly soiled, soap and water method of hand hygiene is recommended. For additional recommendations please refer to the hospital policy, CDC, or WHO. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf These guideline are from the CDC Hand Hygiene in Health Care Settings. Please review page 32 of this link for more information.

41. A patient is scheduled for a right knee replacement. Which documents should be included in the pre-procedure verification process? (Select all that apply) • History & Physical • Signed procedure consent form • Nursing assessment • X-ray result • Anesthesia assessment All of these documents should be verified prior to the procedure. These documents will assist in verifying that the correct patient is having the correct procedure (H&P) on the correct anatomical site (xray, nursing assessment) and the patients expectations of the procedure (signed consent, anesthesia assessment).

42. T F F T F T True or False: Site should be marked before the procedure The patient marks the site A small black dot is an appropriate mark PA or APRNcan mark the site Patients may choose the type of mark An alternative method is necessary for certain procedures The site should be marked by whomever is accountable for the procedure (MD, APRN, PA), the mark should be unambiguous and universal for the hospital. Certain procedures (involving teeth, through a natural orifice, mucosal surface, or perineum).

43. Time Out Procedure A circulating nurse completes a time out procedure, with the anesthesiologist, and surgeon, 2 hours before a patient is to undergo a right arm surgery. During the time out they verify the patients identity by having him state his full name, and verify that he is having an incision and drainage completed. What is correct & incorrect about this process?

44. Time Out Procedure • All relevant members were present • Type of procedure is verified • Too long before procedure • Name verification only using 1 method • Did not verify site of procedure The time out should be completed immediately prior to procedure or marking of the site. The procedure must be standardized for the hospital and initiated by a member of the team. Documentation of the time out must also be completed as determined by the hospital. CORRECT INCORRECT

45. References The Joint Commission (2012). National Patient Safety Goals. Retrieved June 10, 2012 from http://www.jointcommission.org/standards_information/npsgs.aspx

46. Photo References • http://www.patientidexpert.com/laserwristbandstyle.html • http://www.carefusion.com/medical-products/medication-management/point-of-care-verification/pyxis-transfusion-verification.aspx • http://www.cdc.gov/ncbddd/dba/transfusion.html • http://www.pregnancylab.net/critical-result/ • http://www.sandelmedical.com/products.asp?id=862 • http://www.blog.wheretofindcare.com/2010/02/how-does-wrong-site-surgery-happen-part.html • http://orthoinfo.aaos.org/topic.cfm?topic=A00269 • http://www.aorn.org/2012timeout/#axzz1yonOfy3V