Professional Documents
Culture Documents
COMPLIANCEWITHTHE
NATIONALPATIENTSAFETYGOALS
NPSG1:IMPROVEPATIENTIDENTIFICATION
Whenprovidingcare,treatmentandservicestoapatientwearetoverifywehavetherightpatient.
WeuseNAMEandDATEOFBIRTH.
Anytimeaspecimeniscollectedwemustlabelthecontainerinthepresenceofthepatient.
NPSG2:IMPROVECOMMUNICATION
Anytimeaverbalortelephonicorderisgivenortelephonereportingofcriticaltestresults,theperson
receivingtheordermustREADBACKthecompleteorderortestresult.
StandardizealistofabbreviationsNOTtousethroughoutthefacility.
UWriteunit
IUWriteinternationalunit
Q.D.Writeeveryday
Q.O.D.Writeeveryotherday
TrailingzeroWrite5mgdonotuse5.0mg
LackofleadingzeroWrite0.5mgdonotuse.5mg
MSWritecompletenameofmedication
MSO4Writecompletenameofmedication
MgSO4Writecompletenameofmedication
Implementastandardizedapproachtohandoffcommunication.OurprocessiscalledBSTAR
(background,situation,treatment,assessment,recommendation).
NPSG3:IMPROVESAFETYOFUSINGMEDICATIONS
Identifyalistoflookalike/soundalikemedicationsandtakeactiontopreventerrorsinvolvingthese
medications.
EphedrineandEpinephrine
ClonidineandClonazepam
Insulin(Novologvs.Novolin)
CelebrexandCelexaandCerebyx
OxycontinandOxycodone
ZyprexaandZyrtecandZantac
DilaudidandDuramorph
ToprolXLandTopamax
LamisilandLamictaland
PrilosecandProzac
Levetiracetam(Keppra)
WellbutrinSRandWellbutrinXL
MetforminandMetronidazole
Abilify(Arripiprazole)and
AvandiaandCoumadinandCardura
OmeprazoleandEsomeprazole
Labelallmedications,medicationcontainersorothersolutionsonandoffthesterilefield.Whenyou
takeamedicationorsolutionoutofitsoriginalcontainerandplaceitinanother,thecontainerwillbelabeled.
Reducethelikelihoodofpatientharmassociatedwiththeuseofanticoagulanttherapy.Use
approvedprotocols(foundonthesharepoint);forpatientsreceivingwarfarinacurrentINRisavailableand
usedtomonitorandadjusttherapy;followwrittenpolicy;provideeducation;anduseprogrammableinfusion
pumpsinordertoprovideconsistentandaccuratedosingofheparin.
NPSG7:REDUCETHERISKOFHEALTHCAREASSOCIATEDINFECTIONS
ComplywithcurrentWorldHealthOrganizationorCentersforDiseaseControlhandhygiene
guidelines.Allstaffpracticeproperhandwashinganduseofhandgel(Purell).
Implementevidencebasedpracticestopreventhealthcareassociatedinfectionsduetomultidrug
resistantorganisms(InfectionControlmeasures).
Implementbestpracticestopreventcentrallineassociatedbloodstreaminfections(InfectionControl
measures).
Preventsurgicalsiteinfections(InfectionControlmeasures).
NPSG8:ACCURATELLYANDCOMPLETELYRECONCILEMEDICATIONSACROSSCONTINUUMOFCARE
Aprocessexistsforcomparingthepatientscurrentmedicationswiththoseorderedwhileunderthe
careoftheorganization.Printoutthe508(CHCS)andhavethepatientannotateanyoverthecounteror
othermedsnotlisted,thenproviderwillgooverthecompletelistwiththepatientandaddanyadditional
medstobegiventothepatient.Patientwillbegiventhecompletelistofreconciledmedswhendepartingthe
facility.Alsoifapatientistransferredthecompletereconciledlistisprovidedtothenextprovider.
NPSG9:REDUCETHERISKOFPATIENTHARMFROMFALLS
Implementafallreductionprogram.Inpatientsareassessedforfallsriskateachshift.Ifpatientis
identifiedasbeingafallrisk,ayellowwristbandisplacedonthepatient.
NPSG13:ENCOURAGEPATIENTINVOLVEMENTINCARE
Asapatientsafetystrategy,wearetoencouragepatientstobeinvolvedintheircare.Encourage
patientstoreportanysafetyissuestheyseeinthefacility.Wehaveapatienttrifoldthateducatespatients
onthepatientsafetystrategieswehaveimplementedinthefacility.
NPSG15:IDENTIFYSAFETYRISKSINHERENTINOURPATIENTPOPULATION
Weidentifypatientsatriskforsuicide.Weprovideinformationsuchasacrisishotline18002738255.
NPSG16:IMPROVERECOGNITIONANDREPONSETOCHANGESINPATIENTSCONDITION
Wearetoselectasuitablemethodthatenableshealthcarestaffmemberstodirectlyrequest
additionalassistancefromspeciallytrainedindividuals.OurmethodistheRapidResponseTeam(RRT).Adult
RRTmembersincludeMOD,ICURN,RespiratoryTherapy,andNursingSupervisor;PediatricRRTmembers
includePOD,RespiratoryTherapy,AssignedRN,NursingSupervisor,andStaff,andPediatricianduringnormal
dutyhours.TheRRTisaninpatientfunctionandcriteriaforcallingaRRTcanbefoundonpostershangingin
theinpatientareas.
UNIVERALPROTOCOL
Conductapreoperativeverificationprocessverifythecorrectperson,correctsite,andcorrect
procedure;ensureallrelevantdocumentationanditemsareavailable:H&P,assessments,signedconsent
form,diagnosticandradiologytestresults,andanyrequiredbloodproducts,implants,devicesandspecial
equipmentneededforprocedure.
Marktheproceduresitemarkingtheproceduresiteallowsstafftoidentifywithoutambiguitythe
intendedsitefortheprocedureandifpatientrefusestobemarked,useanalternativemarkingband.
Conductatimeoutimmediatelybeforestartingtheprocedureeachteammemberwillpauseand
verballyconfirmcorrectpatientidentification,agreeonproceduretobedone,correctsiteandsideare
marked,andrelevantdocumentation,imagesandresultsareavailable.