Health Occupation Student
Orientation Module 4:
Provision of Care
Section 1
PATIENT SAFETY GOALS
Patient Safety Goals / Initiatives

Background

Patient Safety Goals were first established in 2002
by the Joint Commission to help accredited
hospitals address specific areas of concern in
regards to patient safety.

These goals are hospital regulatory requirements
that must be met. Accreditation surveys evaluate
hospitals for goal implementation.

Each year the list of patient safety goals is
reviewed and updated by a panel of widely
recognized patient safety experts.

The following slides describe our practices for
some of these goals.
Patient Safety Goal
Improve Accuracy of Patient Identification

Use 2 Patient Identifiers

Identifiers - Name and Date of Birth
 Check/scan armband and ask patient
to state their name

When to Check Patient Identifiers:

Ordering/delivering meals
 Collecting / labeling specimens

Administering Medications
 Blood Administration
 Prior to procedures, treatments and
transport
Patient Safety Goal
Improve Communication – Physician Orders

Validate Completeness and Accuracy
of Verbal or Telephone Orders

Write Down the order, Read Back the
order

Document as VORB or TORB

Verbal Med Orders limited to
emergencies only e.g codes
Patient Safety Goal
Improve Communication – Physician Orders


DO NOT USE
Abbreviations shown
at right which are known
to increase risk of errors.
Physician orders containing
an unapproved abbreviation
must be clarified with the
ordering physician.
UNACCEPTABLE
ACCEPTABLE
“IU”
Write out the words
“International units”
“QD” or “QOD“
Write “daily” or “every other day”
“MS”, “MS04”, “MgSO4”
Write Morphine Sulfate or
Magnesium Sulfate
Use of “Trailing” zero’s
(i.e. 5.0mg)
Omit trailing zero’s
(i.e. 5 mg)
Omission of leading zero’s
(i.e. .5mg)
Use leading zero’s
(i.e. 0.5mg)
“U” or “u”
Spell out the word “units
BIW
Write “twice a week”
DPT
Write Demerol-PhenerganThorazine
Dram
Write “ Teaspoonful”
Minum
Write “drop”
Patient Safety Goal
Improve Communication – Hand Off Report

Give an Effective “Handoff” Report

When To Do a Handoff:



Change of shift; transfer to different care
unit; sending patient to diagnostic imaging
etc.
Your Role: make sure you give a verbal
report to the primary RN before leaving
each day.
What To Include in Report:

Patient’s condition, treatments, medications,
services, Fall risk, isolation, code status and
any recent and/or anticipated changes

Limit interruptions, provide opportunity for
receiver to ask/respond to questions
An estimated 80 percent of
serious medical errors
involve miscommunication
between caregivers when
patients are transferred or
handed-off.
Patient Safety Goal
Improve Communication - Patients

What Needs Interpreting






Patient intake
H&P
Consent
Discharge instructions
Who Can Interpret:

Bilingual staff may interpret non-clinical
information only

Family members and friends should not be
used. However, if patient insists, a certified
interpreter must also be present
Hospital Approved Interpreters ask the primary RN or Charge RN about these

Language Barriers: Pacific Interpreters

Hearing Impairment: American Sign
Language; TTY and TDD devices available
Patient has the right to
make informed
decisions regarding
his/her care.
Patient Safety Goal
Improve Communication - Patients

Use Patient – Staff
Communication Boards

Purpose: keep patients
informed

Boards are located in inpatient
rooms – 1 per patient

Update beginning of shift
during handoff report
White Boards
Examples of What
to Record:
Date
Nurse
Care Partner
Doctor
Daily Goals
Patient Safety Goal
Improve Communication - Patients

Round on Patients:

When:

Every 1 – 2 hours

When providing services

Accomplish scheduled tasks

Address 4 P’s (pain, toileting,
positioning and personal items nearby –
call light, phone etc)

Conduct environmental assessment
(bed alarms set, IV pumps etc)

Ask “Is there anything else I can do for
you before I go?

Communicate unmet needs to nursing

Document the round on the white board
The Four P’s
Pain
Potty
Position
Personal
Patient Safety Goal
Improve Communication – Among Caregivers
Call Critical Test Results Promptly

Critical (emergent) test results have been
defined by the lab. These test results include
critical values for blood glucose testing.

All critical values must be called to the physician
within 60 minutes of being resulted.

Student Role: Notify the Primary RN immediately if
a critical value is obtained when performing blood
glucose testing.

Document: Date/time of notification; Who was
notified; Value reported; Readback obtained (RBO)
Patient Safety Goal
Improve Communication – Among Caregivers

Check Safety Arm Bands – look
for these high alert arm bands

Applied to same limb; exception: limb
restriction applied to affected limb.

Allergy Band: everyone one gets an
allergy band! If no allergies, write NKA on
the band. DO NOT list allergies on the
band.

DNR Band: optional - patient may decline
to wear armband. If declined, inform
patient that without the communication
band we may not be able to comply with
their preferences.

Document application / removal in nurses
notes.
Yellow
Fall Risk
Pink
Limb
Restriction
Red
Allergy
Blue
Isolation
Purple
Do Not
Attempt
Resuscitation
Patient Safety Goal
Improve Recognition/Response to Changes in Patient
Condition
Rapid Response Team

When to Call:
Concern about worsening patient condition:
airway/breathing problems, neuro changes,
circulation problems

Student Role:
If possible, check with the primary RN or
Charge RN immediately for change in patient
condition before calling RRT.

How to Call:

Who Responds:
ICU RN, RT, Admin Sup
Dial 7101 and enter 50.
State “Rapid Response Team to _________”
and identify location.
Patient Safety Goal
Prevent Hospital Acquired Conditions
The Center for Medicare Services
(CMS) has identified a number of
hospital – acquired conditions that are
high cost or high volume or both and
could reasonably be prevented with
implementation of evidenced-based
practice guidelines.
Occurrence of these conditions can
significantly impact patient quality of life
as well as hospital reimbursement for
care.
Current care guidelines are described
on the following slides.
Hospital Acquired
Conditions
Pressure Ulcers
Falls
Deep Vein
Thrombosis
Patient Safety Goal
Prevent Hospital Acquired Conditions – FALLS
Prevent Patient Falls

Who Is At Risk: patient with

History of falls

Unsteady gait; poor balance,
use of ambulatory aid

Multiple health problems e.g.
diabetes, lung disease, heart
problems

Mental status – overestimates
or forgets limitations
Patient Safety Goal
Prevent Hospital Acquired Conditions – FALLS
Standard Interventions for
All Patients

Maintain Safe Environment:

Monitor

Adequate lighting in room – night
lite or bathroom lite as indicated

Round Frequently (every 1-2
hours)

Room Free of Clutter /
Obstructions / trip hazards


Bed in low position, wheels
locked.
Be Alert - investigate noises in
patient areas


Call light within reach

Personal, frequently used objects
within reach
Directly (visual observation) or
indirectly (within hearing)
supervise patient while in
bathroom

Other

Provide non-skid foot ware

Obtain assist devices normally
used by patient.
Patient Safety Goal
Prevent Hospital Acquired Conditions – FALLS
Interventions for High Risk
Patient

Communicate Risk:



Yellow slippers, armbands and Fall Risk
door signage
Implement actions to prevent falls

Assist out of bed/chair

Use of mobility devices

Do not leave patient unattended in
bath room – keep within arms reach
Use Safety Devices

Activate Bed alarms: verify bed connected
to call light system and bed alarm
activated
Patient Safety Goal
Prevent Hospital Acquired Conditions – Pressure Ulcers
Prevent Pressure Ulcers

Who is At Risk: patients with

Limited ability to change or control body
position

Inadequate food intake

Sensory impairment in extremities;
limited responsiveness

Bed bound or chair bound – not
ambulating

Skin frequently moist due to urine or
stool
Patient Safety Goal
Prevent Hospital Acquired Conditions – Pressure Ulcers

Promptly Report to RN:

Observed red/pink areas or skin
breakdown especially over bony
prominences or under devices e.g.
nasal cannulas, SCDs, anti-embolic
hose etc.
Patient Safety Goal
Prevent Hospital Acquired Conditions – Pressure Ulcers

Preventive Interventions -
S
Surface
K
Keep Turning
I
Incontinence
N
Nutrition
Save Our Patients Skin
Keep linen wrinkle free.
Check for plastic caps in bed.
Monitor for device-related pressure areas e.g. O2
tubing, cervical collars, SCDs, anti-embolic hose.
Cushion / protect skin in high risk areas.
Float heels.
Turn, turn, turn.
Offer assistance with toileting.
Notify staff if patient incontinent.
Use skin cleansers/moisturizers promptly after
each episode of incontinence.
Provide assistance with meals.
Ensure access to supplements.
Accurately document intake and output.
Patient Safety Goal
Prevent Hospital Acquired Conditions – VTE

What is VTE:


Who is at Risk:








Venous thromboembolism (VTE) is a blood clot that
forms in the deep veins (DVT), breaks off and travels in
the veins to the lungs. It can become a life-threatening
pulmonary embolism (PE).
Older patient
Major surgery; orthopedic surgery
Immobility
Trauma
Central line
Obesity
Positive history for DVT or PE
If at High Risk:

Sequential Compression Devices (SCDs): If ordered, ensure
they are correctly applied and turned on when in bed and up in
chair;

Anti-Embolic Hose: if ordered, remove every shift x 30 minutes;
monitor skin for breakdown
Patient Safety Goal
Identify Patient Safety Risk - Suicide
Suicide of a patient while in a staffed, round-theclock care setting is a frequently reported type of
sentinel event.

Who is at Risk: appropriate patients are assessed
for mental illness, chemical impairment, suicidal
ideation or judgment deficits that pose risk of harm to
self or others.

Safety Precautions: Depending on Assessed
Risk Level, Precautions May Include:

Frequent close observation; sitter if indicated

Maintain safe environment: removal of equipment
and supplies and objects from patient room that
could be used for self harm; use of plastic utensils
and paper goods.

Provide prevention information (crisis hotline) at
time of discharge.
Patient Safety Goal
Prevent Wrong Site/Procedure/Person Surgery
The Universal Protocol Elements: apply to all settings
including bedside procedures where consent is required.
1.
Pre-Procedure Verification:
verify the following






Signed consent which matches
physician order
Updated history and physical;
pre-anesthesia assessment
Diagnostic test results available
Procedure prep requirements met
Any required blood products,
implants devices and/or special
equipment available
SCIP measures met e.g. antibiotics
given
2.
Surgical Site Marking

Required for all incisions,
punctures and insertions

Performed by Surgeon, PAs (SJH
only) or Proceduralist

Involves patient

Permanent marker used to write
initials near surgical site; Visible
after draping
Patient Safety Goal
Prevent Wrong Site/Procedure/Person Surgery
3.
Procedural Time Out

Every one participates

Correct patient, procedure, consent,

Correct position/site/side; visible site
mark

Antibiotics given; prep agent and fire
risk score; safety precautions for patient
history/med use taken

Relevant images and results

Implants, blood /blood products and
special equipment available if applicable
Recognition / Prevention – Malnutrition/Aspiration

Malnutrition and Aspiration


Who is at Risk: patients are
screened on admission for the risk
factors shown at right.
Measures to Reduce Risk:

Assist patients with meals as
indicated;

Provide / encourage consumption of
supplements etc.

Document diet intake – if it isn’t
documented we cannot evaluate
how are patient is doing.
Risk Factors
• Unintentional weight loss
• Decreased appetite
• Difficulty eating
• Contributing Minor/Chronic
Diseases or Factors
e.g. renal disease, pressure
ulcers, tube feeding,
Infection Recognition - Sepsis/Severe Sepsis

What is Sepsis:
Sepsis is a potentially life-threatening
complication of an infection. It occurs when
chemicals released into the bloodstream to
fight infection trigger inflammation throughout
the body. Inflammation can damage multiple
organ systems, causing them to fail.
If sepsis progresses to septic shock, blood
pressure drops dramatically, which may lead
to death.
Early recognition and treatment of sepsis is
essential.

Sepsis Screening is completed on
Admission and Every Shift by the
RN
Infection Recognition - Sepsis/Severe Sepsis

Your Role: Promptly report to the RN vital
sign changes that match sepsis criteria.
SIRS* Criteria
SIRS = 2 or more criteria met
SIRS*
Severe Sepsis Criteria
MAP
< 65 mmHg x2
> 2mg/dl
Heart Rate
>/=90
Creatinine
Temp
=/>38 C or < 36 C
ALOC
RR
>/= 20
SBP
<90 x2
WBC
<4 >12 or
>10% bands
SBP
 40 mmHg
Systemic Inflammatory Response Syndrome
New or  O2
Needs
UO
<5mg/kg/hr x >2 hrs
Bilirubin
> 2mg/dl
INR
>1.5 or PTT >60 sec
Lactate
> 4 mmol/L
Adverse Event Prevention – Tubing Misconnections

The Problem
The following events were reported by the Food
and Drug Administration.

Blood pressure tubing connected to IV line by
family member – patient died.

IV tubing connected to nasal cannula – patient
went into CHF.

IV tubing connected to feeding tube by family
member – no harm as identified quickly.

Feeding tube connected to trach tube –
patient died.

IV Tubing connected to trach cuff – patient
died.

Oxygen tubing attached to IV tubing – patient
died.
Adverse Event Prevention – Tubing Misconnections

The Solution

Increase lighting in a darkened room before
connecting or reconnecting tubes or devices.

Trace the tube or catheter from the patient to point
of origin.

Do NOT force connections

Never use a standard luer-lock syringe for oral
medications or enteric feedings – use slip tip
syringe.

Reconcile lines as part of handoff with change of
shift, patient transfer, return from procedure.

Patient / family education – DO NOT connect or
disconnect lines. Get help!
CENTRAL LINE
Attach to IV tubing going to
CL
PERIPHERAL LINE
Attach to IV tubing going to
peripheral line
ARTERIAL LINE
Attach to IV tubing going to
arterial line
ADDITIVE
Attach to IV tubing of any IV
solution that has med added
i.e. NS with KCL
IRRIGATION
Attach to irrigation tubing
DRAIN
Attach to drain – urinary
catheter, hemovac, jackson
pratt, penrose, NG
ENTERAL
FEEDING
Attach to formula tubing
FEEDING TUBE
Attach to feeding tube – Gtube, J-tube, nasal feeding,
PEG tube, Keofeed
Adverse Event Prevention

Use Tubing Labels


Place label on the
tubing adjacent to the
connection site – where
tubing connects to
patient
Continue to use IV
Tubing Change Stickers
(Mon, Tues etc.)
OTHER
Section 2
RESTRAINTS
RESTRAINT
Indications for Use
Patient behaviors that may lead to the use of restraints fall into two
categories as described below:

Non Violent Behavior


Attempting to pull out tubes,
drains, or other lines
medically necessary for
treatment and is unable to
comply with safety instructions
Attempting to get out of bed
and unsteady gait – at risk of
falling and is non compliant
with safety instructions.

Violent, Self Destructive
Behavior

Physically assaultive to
others or is highly agitated and
assaultive behavior is preeminent e.g. Code Grey type individuals

Physically harmful to self
(i.e. attempting suicide, selfmutilation, hurting self, etc.)
RESTRAINT
Indications for Use
Before restraints can be initiated for these patient atrisk behaviors:

Causal Factors are Considered:


Alternatives Considered / Attempted:


Identify medical problems that could be causing
behavioral changes e.g. increased temp, hypoxia,
low blood sugar, electrolyte imbalance, drug-drug
interactions
Hiding tubes/lines, frequent rounding, reorientation,
family intervention, companionship, mobility,
distraction e.g. folding wash cloths; use of alarm
devices
Physician Order is Obtained: only RN’s or
Physicians can initiate use of restraints;
RESTRAINT
Plan of Care – Student Role
Monitor / Assess for:

Observe patient/device for correct
application – doing no harm

Remove device and provide ROM

Provide for personal care needs –
toileting, food, fluids, pain medication

Take vital signs as ordered- Promptly
report any changes or concerns to RN
Non Violent

Observe for safety Q60
minutes

Monitor/Assess Every 2 Hours
Self Violent, Destructive


Observe for safety the patient
Q 15 minutes
Monitor/Assess Every 1 Hour
RESTRAINT
Devices / Safe Application


General Guidelines:

Proper body alignment

Call button can be used

Patient’s head is free to rotate when in the
supine position. When possible, head of bed
slightly elevated to reduce risk of aspiration.

Secure straps to bed or chair frame out of the
patient’s reach using quick-release ties. DO
NOT secure to mattress or side rail
Side Rails

Three side rails up equals safety

Four side rails up equals restraint except for
situations such as seizure precautions, age
appropriate, pre/post anesthetic/sedative
meds, vest restraint usage.

Note: gap in side rails must be covered when
used with vest.
RESTRAINT
Devices / Safe Application
Wrist Restraints

Apply Correctly:
Allow one finger width between skin and device to
ensure adequate circulation

Remember to remove restraint and provide ROM
every 2 hours.

Monitor Use: soft tissue not too tight cutting of
blood flow, causing limb swelling or skin abrasions.
Vest Restraints

Ensure right size and fit:
Must fit at the waist and enable one flat hand to
easily go under waist band.

Apply correctly:
Opening in the back; DO NOT criss-cross straps
directly behind patient; side rails up with gap pads

Monitor Use: device not “choking” patient or
impairing breathing
Section 3
Abuse, Assault and Neglect
Reporting
Abuse, Assault, Neglect Reporting

Who has Duty to Report?


All physicians and health care
providers
What Must be Reported:





Abuse of Patients Received from
Licensed Health Facilities
Abuse of Elders and Dependant
Adults
Child Abuse
Sexual Assault
Adult Patient Abuse or Assault
(includes spousal and domestic
abuse)
Abuse, Assault, Neglect Reporting
 How to Identify Possible Victims
Consider the possibility when:
THE PATIENT:

History is incompatible with injuries.

Has unusual injuries and/or
unexplained bruises, lacerations,
fractures or multiple injuries in various
stages of healing.



Presents with malnutrition or
dehydration (not illness related), failure
to thrive and/or poor physical hygiene.
Has repeated ER visits,
hospitalizations or a history of prior
physical abuse.
Delayed in seeking medical care.
THE PARENT / SPOUSE /
CAREPROVIDER:

Refuses to leave the patient’s
presence despite the patient’s wishes.

Offers conflicting, unconvincing or no
explanation for patient’s injury.

Delayed in getting medical care for the
patient.
Action to Take
Notify the primary RN immediately of
your suspicions.