UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Chapter 7
Quality Improvement Activities
Sections
Performance
Improvement Plan
Risk Management Plan
Utilization Management
Plan
Patient Care Variance
Reporting Process
Medication Error
Reporting Process
Occurrence Reporting
Process
Administrative AlertAfter Hours/Weekends
Sentinel and High Risk
Events
Medical Emergencies/
Cardiopulmonary
Resuscitation
Elopement of Patients
Fall Prevention and
Management Program
Fall
Prevention/Intervention
Strategies
Medication Policy
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Performance Improvement Plan
Section A
Performance Improvement Plan
Performance Improvement Plan
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Section B
Risk Management
Topics
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7-3
UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Patient Care Variance Reporting Process
Date of Last Revision/Review 10/01/02
Introduction
This topic provides information about completing and distributing the Patient Care
Variance Report.
Purpose
The Patient Care Variance Report provides a mechanism for collecting detailed inhouse information to study the quality of services provided at UTHCPC.
Who
All patient care staff use this report.
When
Use of above form to report the following occurrence types:
Occurrence Types
 Injury
– Abrasion
– Bite
– Bruise
– Burn
– Contusion
– Laceration
– Needle stick
– Sprain
– Strain
– Other (specify)
 High Risk Event
– Alleged sexual activity
– AWOL
– Code blue
– Elopement
– Elopement attempt
– Medical emergency
– Seizure activity
– Sexual aggression
– Suicide attempt
– Other (specify)
 Personal Belongings Damage/Loss
– Money
– Clothes
– Wallet
– Other (specify)
 Falls
– With injury
– Without injury
 Miscellaneous
– AMA/discharge
– Refusing discharge
– Refusal of treatment
 High risk events of the above occurrences, see Sentinel and High Risk Events
 Sentinel events, see Sentinel and High Risk Events
 Other, provide description
Note: When the incident does not fall into the categories listed above, or does not
involve a patient, use the Occurrence Report form.
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Patient Care Variance Reporting Process, Continued
Reporting
sentinel/high risk
events
Follow these steps to report sentinel or high risk events:
Who
Completing the
form
Action
Staff
 Immediately contacts her/his manager or nursing supervisor
and verbally reports high risk events prior to filling out the
Patient Care Variance Report
 Go to Completing the form
Manager/Nursing
Supervisor
 After notification by staff, immediately contacts the
Administrator on duty or on-call and verbally reports
 If after 5:00 p.m. daily and on weekends:
– Fills out an Administrative Alert form
– See related procedure Administrative Alert – After
Hours/Weekends
 Go to Distributing the form
This table describes the process for completing the Patient Care Variance Report
form by an assigned staff member:
Stage
Description
1
Stamps the patient’s addressograph card on the top, right-hand corner of
the form.
2
Completes Sections I-V (only categories A & B under Section 5) of the
Patient Care Variance Report form to include:
 General information
 Occurrence type
 Brief description
 Immediate action
 Proactive implementations
 Referral to other involved departments
3
Staff member completes the “MD Implementation/Recommendations”
under Section IV as applicable.
4
Documents a progress note in the patient’s medical record.
Note: Do not refer to the form in the patient’s medical record.
5
As warranted, the physician documents findings and treatments in the
medical record (e.g. physician orders, progress notes).
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Patient Care Variance Reporting Process, Continued
Completing the
form (continued)
This table describes the process for completing the Patient Care Variance Report
form by an assigned staff member (continued):
Stage
6
Distributing the
form
Description
The Risk Manager completes Section 5, Category C to include:
 Corrective action
 Implementation plans
 Quality/Risk issues
 Recommendations
This table describes the process for distributing the Patient Care Variance Report
form:
Stage
Description
1
Staff member submits the completed variance form to the Department
Manager/Nursing Supervisor before the end of her/his shift
2
Department Manager/Nursing Supervisor accomplishes the following:
 Reviews the report, concurring with or correcting the category(ies) of the
variance and staff members actions
 Adds any comments (documents resolution status or action plan)
 Signs the form and sends it to the Department Director or Director of
Nursing for review prior to the end of the shift
3
The Department Director/Director of Nursing:
 Reviews variance for trends and initiates appropriate corrective actions
 Identifies improvement opportunities
 Forwards form to Risk Manager within 24 to 48 hours of receipt
4
The Risk Manager:
 Reviews variance for trends and initiates appropriate corrective actions
 Identifies improvement opportunities
 Forwards form to Data Management
 Quarterly, reports safety-related data to Safety Committee
References
Patient Care Variance Report form
Sentinel and High Risk Events
Administrative Alert form (for reporting high risk events after normal working hours)
Related standards
JCAHO MA 3, JCAHO PI 3.1.1, PI 4-5, JCAHO RI 1.3.4
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Error Reporting Process
Date of Last Revision/Review 10/01/02
Introduction
All medication errors are identified and reviewed. Measures are taken to:
 Reduce the likelihood of harm to the patient
 Prevent a medication error from occurring
Definition
A medication error is defined as follows:
“Any preventable event that may cause or lead to inappropriate medication use or
patient harm, while the medication is in the control of the health care professional.
Such events may be related to professional practice, health care products, procedures,
and systems including: prescribing, order communication, product labeling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use.”
Medication error
reporting
Clinical staff report medication errors as follows:
Step
Action
1
The staff member who discovers a medication error immediately completes
the Medication Error Report form.
Note: The report is for administrative purposes only. Do not place in the
medical record.
2
Forwards the form to the Nurse Manager.
3
Determines whether or not the patient has an allergy to the medication
given.
Note: Notations of known drug allergies are found in the Initial Nursing
Assessment.
4
Checks the patient for any reactions possibly caused by the drug or dose
given.
5
Contacts the pharmacy to determine whether the medication error has a
potentiating effect on other medications being taken by the patient.
6
Documents in the medical record the medication administered, any adverse
effects, and time of physician notification as appropriate.
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Error Reporting Process, Continued
Performance
improvement
All medication errors are reviewed as part of the performance improvement program
as follows:
Step
Related standards
03/08/16
Action
1
After the Director of Nursing and the Pharmacy Director have signed the
form, she/he forwards the form to the Risk Manager.
2
The Risk Manager reviews the form and forwards to Management of
Information Systems (MIS) for data entry before the end of the month.
3
MIS reports data to the Pharmacy and Therapeutics Committee and to the
Nursing department.
4
The Performance Improvement Coordinating Council is responsible for
reviewing the medication error process.
JCAHO MA 3
JCAHO PI 3.1.1, PI 4-5
JCAHO RI 1.3.4
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Occurrence Reporting Process
Date of Last Revision/Review 01/24/03
Introduction
Occurrence tracking and reporting is part of UTHCPC’s Performance Improvement
Plan.
Purpose
This report is used to help identify areas needing improvement or recognition.
When to use
Use the Occurrence report form to document:
 Injury to visitors or volunteers while on the premises
Note: Employee injuries are reported on the Supervisor’s First Report of Injury
form and sent to the UTHCPC Safety Office, Room 2E58.
 Other occurrences that cannot be documented on another approved report form
Who reports
The following report occurrences using the Occurrence Report:




Employees
Medical staff
Students
Patients
Note: The occurrence report is for reporting purposes only. Do not place in a
reporting patient’s medical record.
 Visitors
What to report
Report any of the following:
 Compliments
 Complaints
 Other miscellaneous incidents
 If significant occurrences happen after 5:00 p.m. or on weekends, see p0rocedure
Administrative Alert – After Hours/Weekends
Distribution
Distribute copies of the form as follows:
Color of Form
Recipient
White
Assistant Administrator (whichever one
is most appropriate for follow-up)
Yellow
Department Manager
Pink
Informant
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Occurrence Reporting Process, Continued
Occurrence
reporting
This table describes the occurrence reporting process:
Stage
Description
1
Informant obtains a blank Occurrence Report form from one of the
following:
 Reception desk
 Any department manager
 Nursing Supervisor
 Any unit
2
Informant completes the form following the directions on the back of the
form.
3
Informant keeps the pink copy of the report and uses this table to determine
to whom to give the other two copies:
WHEN the
informant is
a…
4
THEN s/he gives the other two copies to...
Visitor
The staff at the reception desk
Result: Reception desk staff forwards the copies to
their department manager
Patient
A unit nurse
Result: The unit nurse forwards the copies to the
Director for Nursing
Staff member
or other
His/her department manager
The department manager keeps the yellow copy and forwards the white
copy to the appropriate Assistant Administrator within 48 hours.
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Occurrence Reporting Process, Continued
Occurrence
reporting
(continued)
This table describes the occurrence reporting process (continued):
Stage
Related standards
03/08/16
Description
5
The Assistant Administrator:
 Notifies the appropriate department manager(s) of the report
 Ensures follow-up on the report
 Reports trends/patterns to the Performance Improvement Coordinating
Council
6
The department manager(s) designated by the Assistant Administrator
investigate and report their findings to:
 Assistant Administrator
 Applicable hospital committees/departments, as needed
JCAHO LD 1.3.3, LD 4.3 - 4.4, MA 3, MA 4, RI 1.1-1.2, RI 1.2.2-1.2.3, RI 1.3.4
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Administrative Alert – After Hours/Weekends
Date of Last Revision/Review 10/01/02
Introduction
After 5:00 p.m. daily and on weekends UTHCPC staff report any untoward event or
significant occurrence potentially resulting in an adverse event involving patients
and/or staff.
Significant events
The following are significant events that require administrative alert:
 All potential high risk or sentinel events, see procedure on Sentinel and High Risk
Events
 All elopements
 Significant visitor occurrences
 Regulatory body contacts
 Hazardous/safety events
 Significant agency/community contacts
 Other events that could be significant
Administration
notification
Employees report as follows:
Who is responsible…
Staff
Tasks to perform…
 Contacts her/his manager or nursing supervisor and
verbally reports
 Fills out Patient Care Variance Report or Occurrence
Report as appropriate
 See related procedures:
– Patient Care Variance Reporting Process
– Occurrence Reporting Process
Manager/Nursing
Supervisor
 Notifies the Administrator on-call see Verbal
notification
 Fills out the Administrative Alert form
 Forwards the form during the next working day to the
appropriate director/Director of Nursing and the Risk
Manager
Appropriate
director/Director of
Nursing
Forwards form to Management of Information Systems
(MIS)
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Administrative Alert – After Hours/Weekends, Continued
Verbal notification
Verbal notification to the Administrator on-call occurs within 60 minutes of the event
occurrence.
Exception: Sentinel and high risk events are reported immediately
Administrator oncall duties
The Administrator on-call has the following duties:
 Meets with the appropriate director/Director of Nursing the morning of the next
working day from the incident
 Is responsible for notification and follow-up of the incident and action taken with
the following:
– Administrator
– Medical Director
– Appropriate manager/director
Forms
Administrative Alert
Patient Care Variance Report
Occurrence Report
Related standard
JCAHO MA 3
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Sentinel and High Risk Events
Date of Last Revision/Review 10/01/02
Introduction
UT-Harris County Psychiatric Center is committed to improving the quality of
patient care. The occurrence of a sentinel or high risk event identifies an opportunity
for improvement.
A quality improvement/peer review process is used to assess the root cause of the
event and opportunities for improvement.
Sentinel event alerts published by JCAHO are used to assist in formulating action
plans and preventive measures.
Definitions
The following are definitions of sentinel and high risk events:
 Sentinel event – is an unexpected occurrence involving death or serious physical or
psychological injury
Note: For questions regarding the definition of a sentinel event, contact the
JCAHO Sentinel Event Hotline at 630-792-3700.
 High risk event – Includes any process variation for which a recurrence would
carry a significant chance of a serious adverse outcome, including delay of
diagnosis or treatment
Sentinel event
criteria
The following describes criteria for identifying sentinel events:
 Any unexpected death that is not the result of the patient’s underlying condition
 Impairment (major permanent loss of bodily function that is not the result of the
patient’s underlying condition)
 Child abduction or discharge to the wrong family
 Rape (confirmed after outside medical exam)
 Homicide
 Suicide
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Sentinel and High Risk Events, Continued
High risk event
criteria
The following describes criteria for identifying high risk events:
 Code blue
 Medication error resulting in transfer
 Adverse reaction to medication resulting in medical transfer
Example: Neuroleptic Malignant Syndrome (NMS)
 Suicidal gesture (i.e. completed behaviors that indicate intent to harm but not kill
self such as superficial cuts, etc.) while on one-to-one
 Patient-to-patient injury resulting in discharge to a medical facility
 Elopement of a unit-restricted patient
 Suicide attempt by hanging, asphyxiation, deep laceration, or self-administered
overdose
 Inappropriate use of restraint or seclusion (confirmed by Patient Relations)
 Falls resulting in discharge to a medical facility
Notification
process
When a sentinel or high risk event occurs it is reported as follows:
Who
Staff
Action
 Immediately contacts her/his manager or nursing supervisor
and verbally reports
 Submits a completed Patient Care Variance Report to the
Department Manager before the end of her/his shift, see
procedure on Patient Care Variance Reporting Process
Note: If a medical device is involved, provide the name, model
number and serial number of the device.
Manager/Nursing  Immediately contacts the Administrator on duty or on-call and
Supervisor
verbally reports, see Patient Care Variance Reporting Process
 If after 5:00 p.m. daily and on weekends:
– Fills out an Administrative Alert form
– See related procedure Administrative Alert – After
Hours/Weekends
Investigating
The Administrator calls a meeting of the Sentinel and High Risk Event Committee
who investigates events using the following models:
 JCAHO Root Cause Analysis
 Process Improvement
See Sentinel or High Risk Events and Root Cause Analysis
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Sentinel and High Risk Events, Continued
Related references
Patient Care Variance Reporting Process
Administrative Alert – After Hours/Weekends
Occurrence Reporting Process
Patient Safety Plan
Related standard
JCAHO LD 4.3.1
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medical Emergencies/Cardiopulmonary Resuscitation
Date of Last Revision/Review 04/08/03
Introduction
In the event of a life-threatening medical emergency, UTHCPC provides patients
with basic life support and immediate transfer to a facility to serve their emergency
needs.
Advance directive
If the patient has an Out of Hospital Do Not Resuscitate (DNR) order see below:
 UTHCPC honors DNR orders, if and only if, notice of the directive is provided
 Notice may be in the form of:
– A completed DNR form
– An officially recognized DNR identification device such as a bracelet or pendant
Exception: If a patient who has executed a DNR order, stops breathing under
unnatural or suspicious circumstances, the DNR is automatically revoked and CPR is
applied. For more information, see Advance Directives.
Acute medical
assessment
Nursing staff immediately notifies the physician and nursing supervisor when the
patient is assessed to be in need of acute medical care.
Advanced life
support
UTHCPC does not provide advance life support.
Example: tracheal intubation
Life-threatening
situation
If the situation is life-threatening (e.g. non-responsive, cyanotic, absence of pulse,
etc.), nursing staff must do the following:
Stage
Description
1
Implement Cardiopulmonary Resuscitation (CPR) using a non-rebreathing
resuscitation mask.
2
Page a Code Blue (Ext. 2633). The operator pages the on-call attending of
the week. The following persons respond to the Code Blue:
 Unit resident and attending – must also be paged
 On-call attending of the week (must notify the Medical Director in
advance if unable/unavailable to perform this duty during any specific
timeframe of the work day)
 The on-call resident is the only physician available to respond during the
“off” hours
3
Call 911 and direct the ambulance to the side entrance on the corner of W.
Leland Anderson and 2800 South MacGregor.
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medical Emergencies/Cardiopulmonary Resuscitation, Continued
Life-threatening
situation
(continued)
Non lifethreatening
situation
If the situation is life-threatening (e.g. non-responsive, cyanotic, absence of pulse,
etc.), nursing staff must do the following (continued):
Stage
Description
4
Continue implementation of life saving measures to include the following as
deemed necessary:
 Basic life support
– Cardiopulmonary resuscitation (CPR)
– Use of automated external defibrillator (AED)
 Establishment of intravenous line
 Administration of emergency medication as approved for use by P&T
committee
 Oxygen administration
 Record process: Nursing staff completes Code Blue/Medical Emergency
Documentation Record
5
 Nursing staff and MD ensure completion of the Memorandum of
Transfer (MOT) form
 Nursing or Case Management notifies family/significant other of the
individual’s transfer and documents on MOT. Further attempts to notify
are put in the progress note after the individual’s transfer.
6
Nursing staff retains copy of the MOT form and sends to the Nursing
Supervisor with the shift report.
A non life-threatening situation is not of Code Blue severity, and may include
psychiatric emergencies. Staff proceed as follows:
Step
Documentation
03/08/16
Action
1
Call the unit resident and/or unit attending
2
If no resident is available, or if the unit attending is off premises and
without a back-up, the on-call attending examines the patient and directs
intervention following a telephone request to her/him by the unit attending.
Staff report the medical emergency using one of the following procedures, as
applicable:
 Occurrence Reporting Process
 Patient Care Variance Reporting Process
Continued on next page
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medical Emergencies/Cardiopulmonary Resuscitation, Continued
Security duties
Security/designee meets the ambulance and accompanies emergency personnel to the
unit.
Evaluation process
The Nursing Supervisor, manager, or designee:
 Completes the Code Blue Evaluation form
 Forwards the completed form to Nursing Administration who forwards it to the
Safety Committee
Further questions
If a staff member has further questions regarding medical emergencies, s/he should
contact her/his supervisor.
Related standard
JCAHO TX 1.1
Texas Health and Safety Code, Chapter 166
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Elopement of Patients
Date of Last Revision/Review 10/01/02
Introduction
The following procedures are to be followed when a patient leaves the hospital
grounds, or leaves the presence of staff during an off-campus appointment, without
permission (unauthorized).
Policy
When any patient elopes or is believed to be missing, it is the policy of the hospital to
act in accordance with the welfare of the patient and the public while respecting the
patient’s rights.
Elopement process
When it becomes reasonably certain that a patient is missing without authorization,
the person making the observation must initiate action to locate the patient.
Step
03/08/16
Action
1
The employee immediately contacts UT Police/Security, providing them
with a patient description and other pertinent information.
2
 Security assists in searching on the grounds for the patient. The Security
officers conducting the search determine its scope.
 Unit staff familiar with the patient may be required to accompany
Security on any search.
3
If the patient is located in the building by Security, Security calls a special
team to the location.
4
UT Police/Security is responsible for contacting the appropriate police
agency as deemed necessary.
5
The staff/designee notifies the Nurse Manager, Monday-Friday (8 am-5
pm), and at all other times, notifies the Nursing Supervisor.
6
The Nurse Manager/Nursing Supervisor notifies the Director
Nursing/designee Monday-Friday (8 am-5 pm), and at all other times the
Administrator on-call.
7
The Shift Lead notifies the attending physician Monday-Friday (8 am-5
pm), and at all other times the House Officer.
8
If the patient cannot be found and is deemed suicidal/homicidal at the time
of elopement, contact UT Dispatch 713-792-2890 immediately.
9
See additional procedures related to the following:
 Involuntary Patients
 Voluntary Patients
 Child/Adolescent Subacute Voluntary
 Child/Adolescent General
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Elopement of Patients, Continued
Involuntary
patients
Patients who are hospitalized by court order are classified as involuntary.
Examples of court orders: Order of Emergency Detention or Protective Custody,
Court-Ordered Temporary and Extended Mental Health Services
If an involuntary patient elopes, staff follow these steps immediately:
Step
Action
1
Follow Elopement Process instructions.
2
Initiate Certificate of Return process.
3
As appropriate per patient consent, notify the emergency contact person as
follows:
 Monday-Friday 8am to 5pm, contact is made by the Social Service
Clinician and at all other times the Charge Nurse
 Staff notifies the contact person within an hour of the time the patient is
discovered missing
 If staff is unable to reach the contact person, then a contact attempt is
repeated at 2-hour intervals up until 9:00 p.m.
 If the contact person has not been reached when the staff member leaves
for the day, inform the Charge Nurse
 Staff asks the emergency contact person to contact UTHCPC if any
information on the patient’s whereabouts is received.
4
Staff documents notification/attempted notification in the progress notes
daily until the:
 Emergency contact person is reached
 Patient returns
 Patient is discharged
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Elopement of Patients, Continued
Voluntary patients
Voluntary patients are those who have signed themselves into the hospital and upon
elopement have no commitment papers or other documentation on file changing their
status to involuntary.
Step
03/08/16
Action
1
Follow Elopement Process instructions, except for Step 5.
2
As appropriate per patient consent, notify the emergency contact person as
follows:
 Monday-Friday 8am to 5pm, contact is made by the Social Service
Clinician and at all other times the Charge Nurse
 Staff notifies the contact person within an hour of the time the patient is
discovered missing
 If staff is unable to reach the contact person, then a contact attempt is
repeated at 2-hour intervals up until 9:00 p.m.
 If the contact person has not been reached when the staff member leaves
for the day, inform the Charge Nurse
3
Staff documents notification/attempted notification in the progress notes
daily until the:
 Emergency contact person is reached
 Patient returns
 Patient is discharged
4
It is the responsibility of the family to request police assistance in locating
the patient.
5
The physician discharges the absent patient after 48 hours or sooner if
deemed appropriate.
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Elopement of Patients, Continued
Child/adolescent
patients
For Child and Adolescent services, additional procedures are needed as follows:
Child/Adolescent
Services
Subacute
voluntary
Action
 Staff follows Elopement Process instructions except for Step 5
 For patients admitted under the Juvenile Probation
Department (JPD) – The Manager, Assistant Nurse Manager,
or designee notifies the JPD first to coordinate filing a missing
person’s report with the Houston Police Department
 Notification of emergency contact: Staff notifies the parents
(unless contraindicated) and/or legal guardian (ex. Children’s
Protective Services or JPD) as follows:
– Monday-Friday 8am to 5pm, contact is made by the Social
Service Clinician and at all other times the Charge Nurse
– Staff notifies the contact person within an hour of the time
the patient is discovered missing
– If staff is unable to reach the contact person, then a contact
attempt is repeated at 2-hour intervals up until 9:00 p.m.
– If the contact person has not been reached when the staff
member leaves for the day, inform the Charge Nurse
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Elopement of Patients, Continued
For Child and Adolescent services, additional procedures are needed as follows:
Child/adolescent
patients (continued)
Child/Adolescent
Services
Action
General voluntary
 Staff follows Elopement Process instructions except for Step 5
 Notification of emergency contact: Staff notifies the parents
(unless contraindicated) and/or legal guardian (ex. Children’s
Protective Services or JPD) as follows:
– Monday-Friday 8am to 5pm, contact is made by the Social
Service Clinician and at all other times the Charge Nurse
– Staff notifies the contact person within an hour of the time
the patient is discovered missing
– If staff is unable to reach the contact person, then a contact
attempt is repeated at 2-hour intervals up until 9:00 p.m.




Involuntary
Related standards
03/08/16
– If the contact person has not been reached when the staff
member leaves for the day, inform the Charge Nurse
Parents/guardian notifies police
Staff instructs parents to notify the hospital when the patient is
located
UT Police, in collaboration with the unit initiates a Missing
Person Report and assists in locating the patient
If the child is located, his or her parents/guardian is contacted
to take custody of the child. It is then the parents’
responsibility to return the child to the hospital.
Staff follows instructions for Involuntary Patients.
JCAHO CC 6-6.1, MA 3
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Fall Prevention and Management Program
Date of Last Revision/Review: 08/07/03
Definition
A fall is considered an unintentional event that results in a person coming to rest on the ground or other lower
level.
Purpose
 To promote patient safety by:
– Effectively identifying patients who are at risk of falls
– Providing early intervention to the patient at risk
– Communicating to appropriate staff the plan of care
– Staff training to increase awareness of the high risk patient and prevention strategies
 To prevent further injury and/or falls by:
– Effectively managing patients who fall
– Analyzing fall data for trends and patterns.
– Educating patients and families on measures to prevent falls and promote safety.
Process
03/08/16
The following are processes involved in assessing patients for fall risk:
Step
Action
1
Patients will be assessed by a Registered Nurse at the time of admission to
determine their risk for falling. Based on this assessment score (5 or
above), the patient will be identified as a potential risk for falls and Fall
Precaution will be initiated.
2
In initiating the Fall Precaution, this will trigger the nurse to address the
problem to the MPA section of the Master Treatment Plan.
3
Reassessment of fall risk is recommended in the event the patient’s
condition changes during the course of the hospital stay.
4
An individualized fall prevention plan will be develop for each patient
based on the patient’s risk of falls. Precautions included in the treatment
may be identified as: Fall Precaution, Direct Observation, and 1:1
Supervision.
5
The individualized plan of care may include nursing interventions from
Fall Precaution Protocol:
 Enter Fall Precaution to plan of care
 Communication high risk fall status at shift report
 Placement of color-coded armband
 Place Fall Risk sign on the chart cover
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities









6
Procedure
Provide non-skid footwear
Reorient to surroundings and environment as needed
Maintain beds in low position
Place frequently used items within patient’s reach
Offer bedpan, urinal, or assistance to bathroom before meal time,
bedtime, and upon awakening (Initiate bladder and bowel program
(toileting q 2hrs or as needed)
Obtain patient assistive device (cane, walker, or wheel chair) if patient
used them prior to hospitalization
Discuss benefit of continuous observation with treatment team --- 1:1
supervision
Teach patient fall prevention plan
Family education (if applicable)
Required documentation for patient fall risk assessment must be noted in
the following areas: MTP, Progress Notes, Education Cover Sheet (if
teaching was done)
Follow these steps to assess patients for fall risk:
Step
03/08/16
Risk Management
Action
1
Assess the patient at the time of admission using the fall risk assessment.
2
Initiate Fall Precaution if the fall risk assessment is 5 or above. Trigger
problem to to MPA.
3
Physician Order to maintain the Fall Precaution or initiate additional
observation (i.e., Direct Observation, or 1:1 Supervision).
4
Develop plan of care that includes the Fall Precaution Protocol (nursing
interventions).
5
Educate patients and/or family about fall prevention plan. Document on
the Education Cover sheet.
6
If the patient falls:
 Ensure patient safety. Do not move the patient until injuries are
identified, and until safety of movement is assured by the licensed staff.
 If no injuries that prevent movement, assist the patient to bed or chair
 Get help from other staff
 Take vital signs
 Ask the patient about injury or pain
 Assess the environment for safety issues
 Notify physician
 Notify Nursing Supervisor
7
The following will be completed once the patient’s immediate needs are
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Risk Management
met:
 Fall Variance Report
 Document specific facts in the Progress Notes
 Document in treatment plan the required interventions
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Fall Prevention/Intervention Strategies
Date of Last Revision/Review 08/07/03
The most common approach to fall prevention is the use of a program of multiple interventions that aims to
minimize the patient's risk of falling. The following summarizes these interventions, representing bestavailable evidence based on expert opinion.
Assessment
Some form of assessment of a patient's risk of falling was utilized in most studies, particularly in the
following situations:




On admission to the hospital
All confused and elderly before settling at night
Post operative patients
All elderly on prescribed analgesics, sedatives, anti-hypertensive, etc
Risk of Falling Diagnosis
Some studies have specifically targeted high-risk patients in the following ways:
 Incorporating a problem such as "At Risk of Falling" or "Potential for Injury" in the patient's records and
charts.
 Implementing a clinical treatment and rehabilitation program to reduce falls (if applicable)
 Interviewing all patients within 24 hours of a fall to assess the patient’s risk and to plan their rehabilitation.
Education
Educational activities were a common component of fall prevention programs, and examples of how this has
been utilized include:





Staff training to increase awareness of high risk patients and prevention strategies
Educating the patient and family about the risk of falling, safety issues and their mobility limitations
Teaching patients to make position changes slowly
Orientating patients to their bed area, ward facilities and how to get assistance
Education programs for all new and high risk patients
Environmental Issues
Activities that aim to reduce environmental risks include:
 Decreasing environmental risks, obstacles and clutter
 Install anti-slip tape/strips
 Ensure walk areas have adequate lighting
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Organizational Functions - Quality Improvement Activities
Risk Management
 Stabilizing beds and bedside furniture
 Having grab bars near toilets which are fitted vertically rather than in a horizontal position
 Alarms or call bells
Elimination
Interventions to support the patient's elimination needs were common to many programs of fall prevention,
and include:




Placing patients with urgency near toilets
Checking patients who are receiving laxatives and diuretics
Toileting at risk patients routinely
Instructing male patients prone to dizziness to void while sitting
Medications
Activities related to medication that have been utilized include:
 Reviewing prescribed medications frequently (e.g., antihypertensives, antidepressants)
 Checking patients receiving laxatives and diuretics
 Limiting combinations of medications when possible (e.g. sedatives, analgesics, etc)
Mobility
Interventions related to mobility that have been used in studies include:





Non-skid footwear
Providing physical therapy
Instructing patients to rise slowly
Walking high risk patients
Repeating activity limits to patient and family
Mental State
Altered mental status was the most commonly identified risk factor for falling and interventions used in
studies to address this problem include:





Re-orientating confused patients
Orienting patients to the hospital environment
Moving confused patients near nurses station
Using family members to sit with confused patients
Provide low bed positioning for confused
Bed rest
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Interventions that aim to reduce the risk of falling while the patient is in their bed include ensuring:
 Bed is in a low position
 Bed brakes are on
 Patient can reach necessary items
Wheelchairs and Chairs
Falls involving wheelchairs have been reported in descriptive studies, and interventions used to reduce this
risk include:




Using safety straps or seat belts in chairs and wheelchairs
Using geriatric chairs
Using latex mesh in chairs to prevent patients slipping
Selecting suitable chairs that have arm rests and are of appropriate height for rising and sitting
Staffing Concern
Many other interventions have been used to reduce the risk of falling and include:






Using colored identification arm bands and stickers for doors and patient charts
Revising staffing procedures (1:1, direct observation, fall precautions)
Demonstrating the use of call bell to patients and ensuring it is within reach of patient
Involving family in care
Reassessing staffing needs in relation to high risk patients
Follow-up with individual caregivers
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy
Date of Last Revision/Review 9/30/03
Introduction
Medication is an important part of treatment. Policies have been developed to
promote safety and accuracy in:
 Physician’s orders
 Transcription of physician’s orders
 Handling medications
 Dispensing and administering of medications
Physician’s orders
The following policies must be adhered to when ordering:
For…
Policies are…
Authorization  Only medications ordered by a member of the UTHCPC medical
staff or an authorized member of the house staff shall be
administered
 Orders for research drugs can only be written or given verbally by
the physician involved in that research protocol. See Physician’s
Tasks
Signatures
 A licensed physician prior to transcription must cosign all orders
written by consulting physicians
 Medical Student’s orders must be cosigned by an active member of
the UTHCPC Medical Staff or an authorized member of the House
Staff
 All signatures and medication orders must be written legibly. See
Legibility
General rules
for orders
 Use hard-tipped pens (ball-point) and not soft-tipped pens (felt-tip,
marks-a-lot, etc.) Orders written in felt-tip, marks-a-lot, cannot be
processed since no copy is available.
 All orders must start with the date and time the order is written
 All allergies must be in red ink on the Physician’s Orders form and
Medication Administration Record (MAR). Allergy tape must be
placed on the outside of the chart.
 Any order questioned by nursing or Pharmacy shall be recalculated
and checked with the prescribing physician and/or attending
physician. The hospital chain of command will be activated if
necessary.
 See Abbreviations and Symbols for Charting for further
information
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Physician’s orders
(continued)
The following policies must be adhered to when ordering (continued):
For…
Medication
orders
Policies are…
 Orders must include the name of the drug, dose, route, frequency,
and licensed physician’s signature
 All medication order doses written for pediatric patients shall be
based on age, weight, etc.
 All orders for a drug dose less than one shall have a zero
preceding the decimal amount.
Example: Write 0.25mg instead of .25mg.
 Do not use decimal points or trailing zeros.
Example: Write 2mg instead of 2.0mg. See Unacceptable
Abbreviations
 All orders for microgram amounts shall be clearly written as
“microgram” to clearly distinguish from milligrams (mg).
Unacceptable Abbreviations, symbols, Greek letters, and other
conventions are not to be used in orders.
 All orders for units shall be clearly written as “units”. See
Unacceptable Abbreviations
 Orders calculated in either milligrams or microgram doses shall be
left in the units in which the calculation was made to avoid
possible decimal errors
 Medication hold orders must have a specified duration (e.g. hold
for one dose, hold for twenty-four hours) or the hold order will be
considered a stop order
 Abbreviations for drug names will not be accepted. Acceptable
drug names include: Generic name, brand name.
 Prescriptions written for discharge medications are to be given to
the patient or family member prior to discharge and documented in
the patient record
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Physician’s orders
(continued)
The following policies must be adhered to when ordering (continued):
For…
Telephone
orders
03/08/16
Policies are…
 Telephone orders for medications shall be used only when
necessary. Telephone orders will be read back to the prescriber to
assure accuracy. Numbers will be stated as words and as the
count.
Example: 15 will be verbalized as fifteen, one-five to assure
accuracy.
 A Registered Nurse records/documents the telephone order in red
ink. The Registered Nurse should sign the telephone order
immediately after receiving the order with the name of the
physician giving the order preceding the signature.
Example: Dr. John Smith/Jane Doe, R.N. See procedure on
Physician’s Orders.
7-34
UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Transcription of
physician’s orders
The following policies should be adhered to when transcribing physician’s orders:
 Orders transcribed and initialed by the Support Specialist must be cosigned by a
licensed nurse
 “Stat” or “Now” orders must be transcribed immediately. The physician is to
notify the nursing staff when “Now” or “Stat” orders are written.
 Medication orders may not be transcribed may not be transcribed and verified by
the same staff member
 One staff member transcribes the order. Transcribing staff may be a licensed staff,
Support Specialist, or staff who have demonstrated competency regarding
transcription of physician orders
– Individuals(s) transcribing the order will document initials on the upper portion
of the slash (i.e. AM / ___) on MAR in the box corresponding with transcribed
medication(s)
–
Transcribing staff must document signature/initial in the legend on the bottom
of the MAR
 A different staff member verifies transcription of the order. Verifying staff must
be licensed
– Individual(s) verifying the order will document initials on the lower portion of
the slash (i.e. ___ / AM) on the MAR in the box corresponding with the
transcribed medication(s)
–
Verifying staff must document signature/initial in the legend on the bottom of
the MAR
 Telephone orders must be recorded by a Registered Nurse. The physician order
form is stamped with the patient’s addressograph and allergies recorded prior to
transcription. Orders that are illegible or improperly written will be clarified by the
registered nurse with the physician prior to transcription. See Telephone Orders
for additional rules.
 Orders shall be transcribed in sequence and exactly as written. The Support
Specialist/Licensed Staff will initial, in red, each order as transcribed.
 When transcription is complete, nursing staff proceeds as follows:
– Original of the physician order goes in the chart
– Yellow copy goes to the Pharmacy
– Pink copy goes to the medication nurse
– The medication nurse places the pink copy on the MAR for 24 hours
 If a medication order is discontinued or changed, highlight the entry in yellow and
write in the date, time, and initial the entry
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Handling
medications
If a label on a container from the Pharmacy is in error, difficult to read, or
accidentally removed, the container will be returned to the Pharmacy for correction.
Follow these policies when handling medications:
For…
Open vials
Policies are…
 Open multi-dose vials of medications will expire on the
manufacturer’s expiration date listed on the vial
 Open vials without preservatives must be discarded after usage
Medication in  Parenteral medications packaged in glass ampules shall be
glass ampules
discarded if not completely utilized a the time of opening
 Controlled medications packaged in glass ampules shall be
discarded and witnessed with two signatures if not completely
utilized at the time of opening
Medication
cart
 The medication cart is used in the preparation and passage of
medications on the units
 The cleanliness of the medication cart is important for infection
control and safety
 It is the responsibility of the nurses on each unit to clean the
medication cart weekly or more frequently if needed
 The unit medication cart will be locked at all times when not in the
designated medication room or when not attended. See
Emergency Medical Supplies Verification
Storage and
 Controlled substances, Class II and floor stock Class III, will be
accounting of
stored in a designated locked area on the nursing units and
medications
accounted for according to Pharmacy controlled procedures. See
Controlled Substance Audit
 Unit stock medications will be accounted for according to
Pharmacy policies
 Patient chargeable stock medications are charged to the individual
patient according to policy, every shift
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Handling
medications
(continued)
If a label on a container from the Pharmacy is in error, difficult to read, or
accidentally removed, the container will be returned to the Pharmacy for correction.
Follow these policies when handling medications (continued):
For…
Medication
variances
Dispensing and
administering
Policies are…
 Medication variances including errors and adverse reactions must
be reported by a health professional
 See Medication Error Reporting Process and Reporting Adverse
Drug Reactions for procedures and appropriate reporting forms
 In addition, for adverse reactions or errors with potential or actual
patient impact, the health professional will report the reaction or
error to the physician, nurse manager, Pharmacy, and activate
departmental or nursing chain of command communication
procedures
Rules for dispensing and administering medications are as follows:
For…
Dispensing
Policies are…
 Only medications that have been dispensed by the UTHCPC
Pharmacy may be administered. All medications not approved
by the Pharmacy and Therapeutics Committee for
administration by the nurses are so labeled by the Pharmacy
(i.e., research drugs are stipulated by protocol.)
 If at all possible, medications brought from home should be
taken home by the patient’s family. If this is not possible, the
medications are forwarded to the Pharmacy for temporary
storage. Licensed staff will document the information about
the medication.
 Under rare and unusual circumstances when an item is not
attainable through normal channels (specific allergy antigen,
birth control pills, etc.), the drug must be brought to the
Pharmacy where it will be labeled and distributed in the usual
manner.
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Dispensing and
administering
(continued)
Rules for dispensing and administering medications are as follows (continued):
For…
Policies are…
Authorization to
administer
 Only licensed nursing personnel, graduate nurses with valid
permits, and physicians may administer medications
Exception: LVN’s may not administer any IV medications.
 Licensed staff who have completed the educational training
class for the particular protocol can only administer research
protocol meds
 Nursing students and Medical students under the direct
supervision of their instructor or licensed person may also
administer medications
 RN’s may administer IV piggyback medications and IV main
line fluids
Exception: Licensed staff may not administer IV push
medications. See Insertion and Maintenance of Peripheral
Intravenous Infusion
Rules of
administering
meds
 All personnel administering medications shall demonstrate
competency prior to administering approved medications
 Self-administered medications will not be utilized at UTHCPC
 Insulin dosage must be verified by (2) licensed staff prior to
administration. Verification should include correct
dose/insulin.
 The person preparing the medication should administer the
medications.
Note: Medications shall not be pre-poured.
 Medication administration will follow the five rights: right
drug, right dose, right route, right time, and right patient
 Prior to medication administration, patients must be identified
by using two of three patient identifiers:
– Armband
– Photo
– Another staff member
 All patients must have signed consent for each class of
psychoactive medications administered (scheduled/PRN)
except in emergencies. In the case of an emergency, refer to
Consent to Treatment with Psychoactive Medication
procedure.
 Document administration of medications on the Medication
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Administration Record (MAR)
Standard
administration
times
See Chart below.
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
Dispensing and
administering
(continued)
Standard
medication
schedule
Rules for dispensing and administering medications are as follows (continued):
For…
Policies are…
Patient education
Licensed staff and/or the physician must instruct the
patient/family on drugs administered and on discharge
prescription medications. Documentation of teaching should be
noted in the appropriate part of the patient’s record (i.e. progress
notes, Patient/Family Education Sheet).
Below is a chart depicting the standard medication administration times for staff use:
How Often
Standard Administration Times
DAILY
BID
0900, 1700
TID
0900,
QID
0900, 1300 1700 2100
Q2H
2400,
0200,
0400,
0600,
Q3H
0300,
0600,
0900,
1200, 1500,
1800,
Q4H
0100,
0500,
0900,
1300,
2100
Q6H
2400,
0600,
1200,
1800
Q8H
0600,
1400,
2200
Q12H
0900,
2100
BEDTIME (HS)
2100
AC
30 minutes before mealtime
PC
30 minutes after mealtime
BIDMEALS
Twice a day with scheduled meals
TIDMEALS
Three times a day with scheduled meals
1300,
1700
0800,
1700,
etc.
2100, 2400
Continued on next page
03/08/16
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UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Risk Management
Medication Policy, Continued
References
Physician’s Tasks
Legibility
Physician’s Orders Form
Abbreviations and Symbols for Charting
Unacceptable Abbreviations
Physician’s Orders Procedure
Medication Orders Automatic Stop
Multiple-Use Sterile Drugs
Emergency Medical Supplies Verification
Controlled Substance Audit
Medication Error Reporting Process
Reporting Adverse Drug Reactions
Insertion and Maintenance of Peripheral Intravenous Infusion
Consent to Treatment with Psychoactive Medication
Patient/Family Education Sheet
Related standards
03/08/16
JCAHO TX 3, PE 4.3
7-41
Utilization Management Plan
UTHCPC Policies and Procedures
Organizational Functions - Quality Improvement Activities
Section C
Utilization Management Plan
Utilization Management Plan
03/08/16
7-42