NQF 34 Patient Safety
Practices for Hospitals 2010
Part 2 of 2
Speaker
 Sue Dill Calloway RN, Esq.
CPHRM
 AD, BA, BSN, MSN, JD
 Medical Legal consultant
 5447 Fawnbrook Lane
 Dublin, Ohio 43017
 sdill1@columbus.rr.com
 614 791-1481
2
NQF 34 SAFE PRACTICES
 Released in 2003, updated 2006,
2009 and April 2010
 These should followed in all
healthcare facilities
 All clinical care settings to reduce risk
of harm to patients
 A roadmap to preventing harm
 States 10 years after IOM report,
To Err Is Human, uniformly reliably
safety in healthcare has not been
achieved
3
Culture
2010Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B, & Interv.
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
Disclosure
Workforce
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Information
Management & Continuity of Care Infections
CHAPTER
7: Healthcare-Associated
• Hand Hygiene (Safe Practice 19)
• Influenza Prevention (Safe Practice 20)
• Central Line Associated Blood
Stream Infection Prevention (SP 21P
Medication Management
• Surgical Site Infection Prevention
(Safe Practice 22)
.
• Care of the Ventilated Patient (Safe Practice 23)
• Multidrug-Resistant Organism Prevention (Safe Practice 24)
• Catheter-Associated Hospital
Urinary
Tract
Infection Prevention (SP 25)
Acquired
Infections
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CPOE
Abbreviations
•
Med Recon
Pharmacist
Central Role
High Alert
Meds
Std. Med
Labeling & Pkg
Unit Dose
Medications
•
Asp +VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition & Site Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
4
Safe Practice 19 Hand Hygiene
 Comply with current Centers for Disease Control
(CDC) and Prevention Hand Hygiene Guidelines
 TJC has NPSG.07.01.01 to comply with CDC or WHO
2009 guidelines
 TJC published document in 2009 on Measuring Hand
Hygiene Adherence: Overcoming the Challenges and this
is an important document
 IHI publishes “How-to Guide: Improving Hand Hygiene. A
Guide for Improving Practices among Health Care
Workers”
 Very important issue in reducing HAI
5
TJC Hand Hygiene NPSG.07.01.01
 Comply with current CDC or WHO hand hygiene
guidelines and has 3 EPs,
 EP1 Implement a program that follows categories
1A, 1B, and 1C on one of the above,
 EP2 Set goals for improving compliance with
hand hygiene guidelines,
 EP3 Improve compliance with hand hygiene
guidelines based on established goals,
6
7
CDC Hand Hygiene Recommendations
CDC published guidelines Oct 25, 2002 at
www.cdc.gov/handhygiene
In CDC MMWR Recommendations and Reports,
Report available at
www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm or
go to www.cdc.gov
Also new admission video on hand hygiene
Hand hygiene interactive training class
Monitored during infection control tracer by TJC
8
9
10
Hand Hygiene
 WHO Guidelines on Hand Hygiene in Health Care; Clean
Hands are Safer Hands at
www.who.int/patientsafety/events/05/HH_en.pdf
 Good website for children on importance of washing hands
with colorful posters, puzzles, and quiz AT
http://www.microbe.org/washup/Wash_Up.asp
 Henry the Hand at henrythehand.com
 Toolkits and posters at
http://www.health.state.mn.us/handhygiene/materials.html
 Clean your hand campaign at
www.npsa.nhs.uk/cleanyourhands/resources
11
Safe Practice 19 Hand Hygiene
Implement the CDC requirements with
Category I requirements or WHO
Encourage compliance with category II
Ensure that all staff know what is expected
of them with regard to hand hygiene
Ensure compliance with hand hygiene
12
TJC NPSG FAQ
13
Safe Practice 20 Influenza Prevention
 Comply with current Centers for
Disease Control and Prevention
(CDC) recommendations for
influenza vaccinations for healthcare
personnel
 and the annual recommendations of
the CDC Advisory Committee on
Immunization Practices for individual
influenza prevention and control.
 CDC has website at www.flu.gov
14
www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm
15
16
17
20 Flu Prevention
 Healthcare workers with direct patient contact
should be immunization against the flu
 Unless contraindicated
 Patients should be immunized as per current CDC
recommendations
 P&P on above along with flu program should be in
place
 Document immunization status of all employees
 Implement CDC recommendations for flu
prevention and control
18
20 Flu Prevention
 Educate staff on benefits of flu vaccine
 Offer flu vaccine annually to all eligible
healthcare personnel at no cost
 Use strategies such as flu cart, access during shift,
modeling etc
 Also a TJC requirement
 CMS allows protocols for flu and pneumovac for
patients
19
SP 21 Central Line -Associated Bloodstream Infection Prevention
 Take actions to prevent central line-associated
bloodstream infection (CLABSI) by implementing
evidence-based intervention practices.
 2011 CDC guidelines on recommendations
 Hospital Quality Reporting Program for ICU and NICU to
CDC National Healthcare Safety Network (NHSN)
 Made popular by IHI How to Kit on central line bundle
 Keystone project showed wisdom of using checklist
 TJC 2011 NPSG
 Pa Patient Safety Authority has a toolkit on CLABSI risk
reduction at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/clabsi/Pages/home.aspx20
21
CDC Resources
 Has many resources on preventing catheter
associated blood stream infection
 Device association module
 Central line insertion practices training course
 Many resources on MDRO and CDAD
 Note TJC requires the use of a checklist and need
to place the checklist in the medical record or most
hospitals have a checkbox that says central line
checklist used
22
CDC Website
23
Keystone Project Changes Everything
24
Pa Patient Safety Toolkit
25
www.ihi.org
26
Revised How to Kit Central Lines
27
Safe Practice 21 Central Lines
 Educate staff about central line-associated
bloodstream infection (CLABSI) prevention who
insert or maintain lines
 Use checklist
 Perform hand hygiene before you insert or
manipulate
 Avoid using femoral vein for access in adults
 Use maximal sterile barrier precautions (mask,
gloves, sterile gown, and cap by all involved in
procedure)
28
Safe Practice 21 Central Lines
 Use CHG alcohol if over two months of age and
allow to dry
 Use protocol to disinfect catheter hubs, needless
connectors and injection ports before accessing
ports
 Remove nonessential catheters
 Perform surveillance and report data to nursing and
medicine
 Use standardized protocol for nontunneled CVCs in
adults and adolescents as changing transparent
dressings every five to seven days
29
TJC NPSG Central Lines 07.04.01

Implement best practices to prevent central line
associated bloodstream infections,

13 EPS

IHI has how to guides and other resources at
www.ihi.org (Keystone project)

EP1 Educate staff and LIPs involved in
procedures about HAI, central line infection and
importance of prevention

Must do education in orientation and annually
and if procedure added to your job
30
TJC NPSG Central Lines

Note that under reform law hospitals with ICUs
or NICU must report central lines infections on
the CDC National Healthcare Safety Network
(NHSN)
2. Educate patients and families before inserting
central line about central line associated
bloodstream infection prevention (BSI), as
needed
3. Implement P&Ps to reduce risk of BSI that meet
regulatory and evidenced based standards
31
Central Lines 07.04.01
 P&P need to meet the regulatory requirements
 Need to be aligned with the CDC requirements
 And professional standards of care (APIC, AORN,
SHEA, etc.)
 4. Conduct periodic risk assessments for central
line infection, measure BSI (blood stream infection)
rate, and monitor compliance with best practices
and how effective the prevention efforts are
 Need to do risk assessment conducted in the time frames
defined by the hospital
 Surveillance is hospital wide and not targeted
32
TJC NPSG Central Lines
5. Provide CLAI (central line associated infection)
rate data and prevention outcome measurement to
staff and LIPs and clinicians
6. Use a catheter checklist and standard protocol for
central line insertion
7. Perform hand hygiene before catheter insertion or
manipulation
8. Do not put in femoral vein unless last resort for
adult patients
9. Use standardized supply care or kit for central lines
33
34
TJC NPSG Central Lines
10. Use standardized protocol for maximum sterile
barrier precautions during insertion
11. Use antiseptic for skin prep in patients during
insertion that is cited in the scientific literature or
endorsed by professional organizations
12. Use standardized protocol to disinfect catheter
hubs and injection ports before accessing

Such as wipe vigorously for 15 sections and let dry

Surveyor will ask to see the protocol or P&P
13. Evaluate all central lines routinely and remove
none essential catheters
35
Safe Practice 22 Surgical Site Infection
 Surgical site infection prevention
 Take actions to prevent surgical-site
infections by implementing evidencebased intervention practices.
 Safe Practice 22 is currently under ad hoc
review by an expert panel.
 This practice will be updated in the coming
months to reflect the review decision.
 CDC has guidelines
 TJC has 2011 NPSG
36
37
Four Changes to TJC 2011 NPSG
38
July 1, 2010 Changes
NPSG.03.05.01 EP 6: A written policy
addresses baseline and ongoing laboratory
tests that are required for anticoagulants
NPSG.07.04.01 EP 11: Use an antiseptic for
skin preparation during central venous
catheter insertion that is cited in scientific
literature or endorsed by professional
organizations (such as chlorahexidine
alcohol and not povidone iodine but this
specific wording removed)
39
July 1, 2010 Changes
NPSG.07.05.01 EP 7: Administer
antimicrobial agents for prophylaxis for a
particular procedure or disease according to
methods cited in scientific literature or
endorsed by professional organizations
NPSG.07.05.01 EP 8: When hair removal is
necessary, use a method that is cited in
scientific literature or endorsed by
professional organizations (Such as clippers
and not razors but this language removed)
40
Proposed TJC NPSGs for 2012
 TJC is seeking comments on NPSGs for 2012
 Looking at two proposed additions
 Ventilator-associated pneumonia (VAP)
– Has seven elements of performance
 Catheter-associated urinary tract infections
(CAUTI)
– Has four elements of performance
 Comment period ended January 27, 2012
41
TJC 2011 NPSG Surgical Site Infections
 Implement best practices to prevent
surgical site infections (SSI)
 There are 8 EPs
 1. Educate hospital staff and LIPs involved
in procedures about HAI, surgical site, and
the importance of prevention
 Educate during orientation, annually,
and if added to your job
42
Surgical Site Infections
2. Educate patients and families, who are
undergoing surgical procedures, about
preventing surgical site infections (SSI)
3. Implement P&P to reduce SSI that meet
regulations and evidenced based practice
(such as the CDC and other professional
organizations)
4. Conduct periodic risk assessments for SSI,
select measures using best practices or
evidence based guidelines and monitor
compliance with them and how effective they
are
43
Surgical Site Infections
5. Measure surgical site infection rates for the
first 30 days following a procedure that does
not involve inserting implantable devices

Measure for the first year procedures involving
implantable devices

Need to follow evidence based guidelines

Surveillance may to targeted to certain procedures
based on hospital risk assessment
6. Provide process and outcome data on SSI to
stakeholders etc, such as the SS infection
rate
44
Surgical Site Infections
7. Antimicrobial agents for prophylaxis are
administered according to methods cited in the
scientific literature or endorsed by professional
organizations

Still want to be sure that prophylactic antibiotics are
administered timely in the operating room and
rebolused when indicated
8. When hair removal is necessary, use a method
that is cited in the scientific literature or endorsed
by professional organizations
45
Safe Practice 23 Care of the Ventilated Patient
 Take actions to prevent
complications associated with
ventilated patients:
 specifically, ventilator-associated
pneumonia (VAP), venous
thromboembolism, peptic ulcer
disease, dental complications, and
pressure ulcers
 VAP bundle also an IHI initiative
 TJC NPSG 2011 standard
46
23 Care of the Ventilated Patient
 Educate healthcare workers on daily care of
ventilated patient and complications such as VAP,
VTE, PUD, dental complications, and pressure
ulcers
 Implement P&P on disinfection and sterilization of
respiratory equipment
 Active surveillance for VAP and maintain data
 Educate patients and families about prevention
measures
47
23 Care of the Ventilated Patient
 Use checklist and standardized protocol
 Hand hygiene
 Regular antiseptic oral care
 HOB 30-45 degrees
 Daily assessment of readiness to wean and sedation
interruption
 Use weaning protocols
 Implement PUD prophylaxis (still controversial)
 VTE prophylaxis unless contraindicated
48
Safe Practice 24 MDRO Prevention
 Implement a systematic multidrug-resistant
organism (MDRO) eradication program built upon
the fundamental elements of infection control,
 an evidence-based approach,
 assurance of the hospital staff and independent
practitioner readiness,
 and a re-engineered identification and care
process for those patients with or at risk for MDRO
infections.
 Also a TDC NPSG for 2011 and CMS CoP requirement
49
24 MDRO Prevention
 Includes but is not limited to
 Methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci
(VRE) , and Clostridium difficile (C-diff)
 Multidrug-resistant gram-negative bacilli, such as
Enterobacter species, Klebsiella species,
Pseudomonas species, and Escherichia coli
(Ecoli), and vancomycin-resistant
Staphylococcus aureus, should be evaluated for
inclusion on a local system level based on
organizational risk assessments
50
24 MDRO Prevention
 LD assigns responsibility for oversight and
coordination of the development, testing, and
implementation of a MDRO prevention program
 Infection preventionist usually in charge of program
 Conduct risk assessment for MDRO acquisition and
transmission
 Educate staff and LIPs about MDRO
 Include risk factors, routes of transmission and outcomes
associated with prevention
 Educate patients with MRSA, VRE, or C-diff and
their families or who are colonized with MRSA
51
24 MDRO Prevention
 Implement a surveillance program based on risk
assessment and use contact precaution (MRSA)
 Measure and monitor prevention processes and
outcomes
 Comply with evidenced based practices
 Implement an alert system that identifies
readmitted or transferred MRSA colonized or
infected patients
 Promote hand hygiene compliance
 Ensure cleaning and disinfecting of equipement
52
TJC NPSGs 2011
 Implement evidenced based practices to prevent
HAI due to multi-drug resistant organisms (MDROs),
 NPSG 07.03.01 (7C)
 9 EPs
 Applies to, but not limited to, MRSA, VRE, C-Diff,
and MDRO gram negative bacteria
 Patients continue to acquire health care associated
(HAI) infections at an alarming rate
 Need prevention and control strategies
53
Implement Evidenced Based Practices
Increased focus on cleaning and disinfecting
equipment appropriately (IC.02.02.01)
Proper use of flash sterilization
Making sure all scopes are cleaned
according to the manufacturer
Cleaning the patient environment is also
important
54
TJC NPSG MRDO
1. Conduct periodic risk assessment for
MDROs acquisition and transmission
 In time frame set by hospital
 See IC.01.03.01, EPs 1-5 that talks about
identifying the risk of acquiring and transmitting
infections
 Following slides on this provided for reference
 TJC infection control chapter very important and
dove tails with these infection control NPSGs
55
Identify Risks for Transmitting Infections
 IC.01.03.01 The hospital identifies risks for
acquiring and transmitting infections
 EP1 Hospital identifies risks based on geographic
location, community, and population served
– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time
frames set by hospital for multidrug-resistent organisms (MDRO)
acquisitions and transmission
– MDRO includes methicillin-resistant Staphylococcus Aureus
(MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella ,
and Acinetobacter
– CDC has free MDRO infection (and CDAD) surveillance and
training on the National Healthcare Safety Network (NISN) 1
–
1
http://www.cdc.gov/nhsn/wc_MDRO_CDAD.html
56
Identify Risks for Transmitting Infections IC.01.03.01
 EP2 Hospital identifies risk for acquiring and
transmitting infections based on the care and
treatment it provides (on MDRO)
 EP3 Look at risk for acquiring or transmitting an
infection by doing an analysis of surveillance
activities and other infection control data (including
MRDO and adverse tissue reactions)
 EP4 Review and identify risks annually and when
there is a significant change and get input from IP,
MS, nursing, and leadership including MRDO
 EP5 Prioritize these risks
57
TJC NPSG MRDO
2. Educate staff and LIPS about HAI, MDROs, and
preventive strategies in orientation

At hire and annually
 Use information from your risk assessment
 Education must reflect their diverse roles
3. Educate patient and their families about HAI
strategies who are infected or colonized with
MRDO, as needed
58
TJC NPSG MRDO
 4. Implement a MDRO surveillance program based
on your risk assessment
 Surveillance may be targeted rather than hospital
wide
 CDC has MDRO surveillance training at
http://www.cdc.gov/nhsn/wc_MDRO_CDAD.html
 Has many resources including training videos on
MDRO surveillance, slide sets, protocols,
reporting plan etc.
59
60
61
62
TJC NPSG MRDO
5. Measure and monitor MDRO prevention processes
and outcomes including; MDRO infection rates
using evidence based metrics, compliance with
evidenced based practice, and evaluate education
provided
6. Provide MRDO process and outcome data to key
stakeholders, nurses, doctors, LIPs and other
clinicians
7. Implement P&Ps to reduce transmission of MRDOs
which meet CDC and other professional
organization standards (APIC,SHEA,OSHA, AORN)
63
TJC NPSG MRDO
8. Implement a laboratory based alert system that
identifies new patients with MDRO when
indicated by the risk assessment

The alert system can be manual or electronic
and can use faxes, pages, telephones etc.,
9. Implement an alert system that identifies
readmitted or transferred MRDO positive patient
when indicated by risk assessment

Alert system can be in a separate database or
integrated and can manual or electronic
64
MRDOs Resources CDC
 Management of MRDOs in Healthcare Settings
2006, 74 pages, at
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf,
 Provides strategies and practices to prevent
MRSA, VRE and other MDROs,
 Includes gram neg bacilli (GNB), E. coli and
Klebsiella pneumoniae, stenotrophomonas
maltophilia, burkholderia cepacia, and ralstonia
picketti,
65
MRDOs Resources
 CDC MRSA resources at
www.cdc.gov/ncidod/dhqp/ar_mrsa.html,
 Includes fact sheet on MRSA, MRSA in healthcare
setting 2007, educational material, data, lab testing
and practices etc,
 Isolation precaution 2007 at
www.cdc.gov/ncidod/dhqp/gl_isolation.html,
 VRE resources at www.cdc.gov/ncidod/dhqp/ar_vre.html,
 Guidelines for Prevention of Surgical Site Infections,
66
Resources
 APIC resources at www.apic.org and see
standards and guidelines,
 Guidelines for Environmental Infection Control in
Health Care Facilities,
 Guidelines for Prevention of Surgical Site
Infections,
 Recommendations for Preventing the Spread of
VRE,
 Guidelines to Prevent Intravascular Catheter
Related Infections,
67
25. Catheter-Associated UTI Prevention
 Take actions to prevent catheter-associated urinary
tract infection by implementing evidence-based
intervention practices.
 UTI most common HAI
 CDC issues Guidelines December 2009
 TJC 2011 NPSG and 2011 SCIP Measure
 AHRQ Patient Safety Handbook chapter at
www.ahrq.gov/qual/nurseshdbk/
 Pa Patient Safety Authority has toolkit on how to prevent
CAUTI at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/cauti/Pages/home.aspx
68
AHRQ Patient Safety Handbook Cp 42
69
http://www.cdc.gov/ncidod/d
hqp/dpac_uti_pc.html
70
Pa Patient Safety Authority Toolkit
71
Resources
 AORN article on the 2011 SCIP measure regarding
urinary catheter removal at
 https://www.aorn.org/News/Managers/November2009Issue/Catheter/
 Urinary catheter removed on Postoperative Day 1 (POD1)
or Postoperative Day 2 (POD2) with day of surgery being
day zero
 Iowa Healthcare Collaborative toolkit for preventing
UTIs at
 http://www.ihconline.org/aspx/general/page.aspx?pid=5
 has evidenced based guidelines, sample policies, provider
information etc

72
Resources
 AHRQ has a website on “Efforts to Prevent and
Reduce Healthcare-Associated Infections
 at http://www.ahrq.gov/qual/haiflyer.htm
 IDSA as the “Diagnosis, Prevention, and Treatment
of Catheter-Associated Urinary Tract Infections in
Adults: 2009 International Clinical Practice
Guidelines from the Infectious Disease Society of
America”
 at
http://cid.oxfordjournals.org/content/50/5/625.full
73
Resources
 IHI how to guide on preventing CAUTI
 at
http://www.ihi.org/IHI/Programs/ImprovementMap/Prevent
CatheterAssociatedUrinaryTractInfections.htm
 Multiple tools on this website with slides and how to guide
and APIC and SHEA documents etc
 APIC has a guide called :Guide to the Elimination of
Catheter-Associated Urinary Tract Infections”
 at www.apic.org and see resources at
http://www.apic.org/Content/NavigationMenu/PracticeGuid
ance/APICEliminationGuides/CAUTI_Guide1.htm
74
25. Catheter-Associated UTI Prevention
 Document the education of staff involved in
insertion, care, and maintenance of urinary
catheters and about CAUTI
 Training should include alternatives
 Train in orientation and annually
 Prior to insertion of urinary catheter educate patient
about CAUTI prevention
 Identify patients on units where surveillance should
be conducted
75
25. Catheter-Associated UTI Prevention
 Implement P&P to reduce risk of CAUTI and that are
evidenced based
 Perform hand hygiene before and after manipulation of
catheter or apparatus
 Ensure supplies are available for aseptic technique and
use sterile equipment
 Insert catheters using sterile technique
 Obtain urine culture before starting antibiotics in patient
with catheter
 Measure compliance with best practices
 Provide surveillance data to key stakeholders
76
Culture
2007Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
Disclosure
Workforce
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Information
Management
Continuity of Care Practices
CHAPTER 8:
Conditionor&Site-Specific
Wrong Site Surgery (Safe Practice 26)
• Pressure Ulcer Prevention (Safe Practice 27)
• Venous Thromboembolism
Prevention (Safe Practice 28)
Medication Management
• Anticoagulation Therapy
(Safe Practice 29)
.
• Contrast Media-Induced Renal Failure Prevention (SP 30)
• Organ Donation (Safe Practice 31)
• GlycemicHospital
Control
(Safe
Practice 32)
Acquired
Infections
• Fall Prevention (Safe Practice 33)
• Pediatric Imaging (Safe Practice 34)
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CPOE
Abbreviations
•
Med Recon
Pharmacist
Central Role
High Alert
Meds
Std. Med
Labeling & Pkg
Unit Dose
Medications
•
Asp +VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition & Site Specific Practices
Evidence
Based Ref.
Press. Ulcer
Prevention
Anticoag
Therapy
Wrong site
Sx Prevention
Peri-Op MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
77
Safe Practice 26 Prevent WSS
 Implement the Universal Protocol for
Preventing Wrong Site (WSS), Wrong
Procedure, Wrong Person Surgery for
all invasive procedures
 TJC has 2011 Universal Protocol
 Pa Patient Safety Authority has toolkit
at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTool
s/PWSS/Pages/home.aspx
 Patient Safety Handbook has chapter
also at www.ahrq.gov/qual/nurseshdbk/
78
Safe Practice 26 Prevent WSS
 Create and use a verification process to ensure
relevant preoperative tasks are done
 Make sure information is correct and available
 Mark the surgical site and involve the patient in
the marking process
 Use right/left distinction and multiple levels (spinal
procedures)
 Do time out before any invasive procedure and
any required implants
79
80
81
Pa Patient Safety Toolkit
82
Time Out Towel
83
TJC 2011 NPSG Universal Protocol
 TJC has three sections in the NPSG on Universal
Protocol
 These are to prevent wrong site surgery
 A copy of these standards are at the end of the
presentation
 Hospital P&P should be consistent with these
standards
84
Safe Practice 27 Pressure Ulcer
 Take actions to prevent pressure ulcers by
implementing evidence- based intervention
practices.
 www.guidelines.gov has 75 guidelines on pressure
ulcers
 AHRQ Patient Safety Handbook has chapter at
www.ahrq.gov/qual/nurseshdbk/
 Minnesota Hospital Association has many resources
on Safe Skin campaign at www.mnhospitals.org/index/tools-app/tool.353
 National Pressure Ulcer Advisory Panel (NPUAP) at
http://www.npuap.org/
85
MN Hospital Association Safe Skin
86
AHRQ Patient Safety Handbook Chapter 12
87
88
NPUAP Staging System
89
Safe Practice 27 Pressure Ulcer
 P&P on prevention of pressure ulcers (PU)
 Plans are in place for risk assessment, prevention,
and early treatment of PU
 During admission identify patients at risk using a
assessment guide
 Document risk assessment and prevention plan
in patient’s record
 Assess and reassess skin for risk of developing
a PU
 Maintain and improve tissue tolerance to PU
90
Safe Practice 27 Pressure Ulcer
 Protect against the adverse effects of external
mechanical forces
 Reduce the incidences of PU through staff
education
 Perform quarterly prevalence studies to evaluate
the effectiveness of the PU prevention program
 Educate about PU frequency and severity
 Implement PU prevention interventions
 Measure outcomes
91
www.jcrinc.com/Pressure-Ulcer-PreventionProject-Home/
92
SP 28 Venous Thromboembolism (DVT) Prevention
 Evaluate each patient upon
admission, and regularly
thereafter, for the risk of
developing venous
thromboembolism.
 Utilize clinically appropriate,
evidence-based methods of
thromboprophylaxis.
 TJC has NPSG on anticoagulants
93
28 Venous Thromboembolism (DVT) Prevention
 Multidisciplinary team develops evidence based
protocols and have P&P
 Ongoing PI to make sure practices are followed
 Include risk assessment, prophylaxis, diagnosis
and treatment
 Provide education on prevention, care, diagnosis,
and treatment
 Document in medical record VTE risk assessment
 Provide education to patients with VTE with
monitoring, dietary restrictions etc.
94
Safe Practice 29 Anticoagulant Therapy
 Organizations should
implement practices to prevent
patient harm due to
anticoagulant therapy.
 TJC has anticoagulant NPSG
 University of Washington has
excellent resources
 Number of other anticoagulant
toolkits
95
29 Anticoagulant Therapy
 Need a defined anticoagulant management
program to individualized the care
 Document patient’s medication plan in the
medication record
 Clinical pharmacy medication review is conducted
to ensure safe selection and to avoid drug-drug
interactions
 Use only oral unit dose products, prefilled syringes
and premixed IV bags
 INR for patients starting on Coumadin
96
29 Anticoagulant Therapy
 Dietary is notified of patient getting Coumadin so
food/medication interaction program
 Education is provided to all staff, prescribers and
patients
 Need written policy for baseline lab tests for
patients on Heparin and low molecular weight
heparin therapies
 Hospital evaluates anticoagulation safety practices
and takes action to improve its practice
97
Resources
 Source: AHRQ Press release, September 15, 2009, AHRQ
Releases Two New Resources to Help Consumers and
Clinicians Prevent Dangerous Blood Clots, at
http://www.ahrq.gov/news/press/pr2008/blclotspr.htm
 The clinician’s guide on Preventing Hospital-Acquired Venous
Thromboembolism; A Guide for Effective Quality Improvement
is available at http://www.ahrq.gov/qual/vtguide/
 Patient Guide to Preventing and Treating Blood Clots at
http://www.ahrq.gov/consumer/bloodclots.htm
105
University of Washington Medical Center
 Some of the AHRQ resources were from U of
Washington Medical Center
 Has an excellent website!
 Coumadin (Warfarin) teaching booklet in 5 languages
 Coumadin dosing charts, how to adjust, guidelines for
dosing and monitoring Lovenox (Enoxaparin)
 Treatment of VTE
 Duration of anticoagulants, peri procedural anticoagulation
 http://www.uwmcacc.org/index.html
Perdue Toolkit
 Anticoagulant Toolkit; Reducing Adverse Drugs
and Potential Adverse Drug Events with
Unfractionated Heparin, LMWH and Warfarin,
 Includes resource tools, self assessment, how to
improve the process, improvement and sustaining
improvement, physician order forms
 Available at
http://www.purdue.edu/dp/rche/pharmatap/toolkit.pdf
Anticoagulant Management Toolkit
 Pa Patient Safety Authority has toolkit
 Has IHI anticoagulant toolkit
 Has ISMP self assessment tool for antithrombotic in
hospitals
 Has video on benefits of anticoagulant
management services and more
 At
http://www.psa.state.pa.us/psa/cwp/view.asp?a=1293&q=
446932#9
SP30 Contrast Induced Renal Failure
 SP is Contrast Media-Induced Renal Failure
Prevention
 Utilize validated protocols to evaluate patients who
are at risk for contrast media-induced renal failure
 and gadolinium-associated nephrogenic systemic
fibrosis,
 and utilize a clinically appropriate method for
reducing the risk of adverse events based on the
patient’s risk evaluations.
 Pa Patient Safety Authority has toolkit
112
SP30 Contrast Induced Renal Failure
 Use evidenced based protocols that are approved
by the MS for the prevention of CIN (contrast
media-induced nephropathy)
 based on the rapid evolution of contract agents and
national guideline that is coming soon
 Monitor and document use of evidenced based
protocols and document risk assessment in chart
 Document provider education
 Specify qualifications of staff allowed to initiate
protocols for imaging
113
Pa Patient Safety Authority Toolkit
http://patientsafetyauthority.org/EducationalTools/PatientSafe
tyTools/cin/Pages/home.aspx
114
Contrast Induced Nephropathy
 Kidney failure can occur from iodine dye used for
x-rays (70 reports)
 Hospitals should amend informed consent to
include this
 Especially with patients with known history of
severe renal failure or impairment
 See ACR MRI Safety Guideline issued June, 2007
 Consider doing a FMEA on this and they have a
toolkit on this
 http://www.psa.state.pa.us/psa/lib/psa/advisories/vol1no4_suppleme
ntary_march_2007/v4_s1_suppl_advisory_mar_30_2007.pdf
115
Gadolinium Based Contrast
 These can cause nephrogenic systemic fibrosis
 Be aware of BUN creatinine when ordering Magnetic
resonance angiography (MRA) that requires IV contras,
 Uses MRI to take pictures of blood vessels
 Dose for MRA may be 3x higher than dose for MRI
 If patient being dialyzed do immediately after test
 Patients with severe renal impairment at risk for NSF
 Risk is 4% in this population- consider including in informed
consent
 New box warning now
116
Contrast Induced Nephropathy
 Angiography, IVP, and CT scans use iodine containing
contrast material
 Can have allergic reaction or kidney damage
 Be careful in patients with sever renal impairment
 Make sure patient is adequately hydrated
 Use low osmolar contrast in patients with renal failure
 See ACR policy at www.acr.org
 Check serum creatinine level prior to scheduling contrast
studies
 Make sure radiology department is aware if patient has
severe renal failure before contrast is used
117
Safe Practice 31 Organ Donation
 Hospital policies that are consistent with applicable
law and regulations should be in place and should
address patient and family preferences for organ
donation,
 as well as specify the roles
 and desired outcomes for every stage of the
donation process
 TJC and CMS have organ donation standards
 TJC has transplant chapter
 State laws on organ donation and procurement
118
31 Organ Donation
 Hospitals and OPOs work together to maintain
program and develop protocols
 Have a process to define roles and responsibilities
of hospital and OPO including PI
 Early donor evaluation and organ placement
 OPO will review death records for donor opportunity
 Organ donation performance outcomes at
www.ustransplant.org
 Address wishes to donate organs
119
Safe Practice 32 Glycemic Control
 Take actions to improve glycemic
control by implementing evidencebased intervention practices that
prevent hypoglycemia
 and optimize the care of patients
with hyperglycemia and diabetes
120
32 Glycemic Control
 Develop a process for improving glycemic control
for patient
 Monitor the quality of the management and report to
stakeholders
 Track glucose data
 Evidenced based order sets to guild management
of hypo and hyperglycemia
 Written protocols for patient on insulin drips
121
32 Glycemic Control
 Reconcile patient medication on discharge
 Education for newly diagnosed diabetics
 Include in their plan of care exercise, nutritional
management, signs and symptoms of hyper or
hypoglycemia
 Include instructions on use of blood glucose meter
 Sick day guidelines
 Who to contact in case of an emergency
122
Safe Practice 33 Falls
 Take actions to prevent patient falls
and to reduce fall-related injuries by
implementing evidence-based
intervention practices
 TJC standard
 TJC sentinel event alert on falls
 CMS CoP requirement
 One of 10 CMS hospital acquired
conditions with no additional pay
123
Safe Practice 33 Falls
 Have a fall reduction program
 Program must do an appropriate evaluation of the
patient
 Must include interventions based on risk
 Staff must be educated on fall reduction program
 Patient and family is educated on program
 Evaluate the effectiveness of the falls program
124
2011 TJC Standard
 Falls continue as a Joint Commission National
Patient Safety Goal in 2009 but moved to
standard in 201
 0 under PC.01.02.08
 PC.01.02.08 The hospital assesses and manages
the patient’s risks for falls
 EP1 Hospital must assess the patient’s risk for
falls based on the patient population and setting
(elderly, behavioral health, pediatric patients)
 EP2 Hospital implements interventions to reduce
falls based on the patient’s assessed risk
125
Why Look at Falls?
 Falls rate high on the list of sentinel events tracked
by The Joint Commission (TJC)
 6th leading cause of sentinel events
 September 30, 2010 data of 7,147 SE shows 481
falls which is 6.5% of all sentinel events reported
 Other Joint Commission standards that are
applicable to falls are in EC and PI chapters
(PI.01.01.01 number of falls and number and
severity of fall related injuries)
 TJC gives information on the root causes of falls
126
127
The Joint Commission Matrix for Falls RCA
 TJC requires a RCA be done for reviewable
sentinel events which includes a patient fall that
results in death or major permanent loss of
function as a direct
 These are the elements that must be included in
the RCA
 So RCA must include area marked such as
physical assessment process, medication
management, staffing level etc.
128
129
CMS CoP Requirements
 CMS requires hospitals in the hospital CoPs to
have a safe environment/setting
 CMS has this as hot spot in their Guidelines for
Immediate Jeopardy
 CMS requires the health and safety of patients at
risk are identified, investigated and resolved
 Having falls and no investigation would be a
violation of this CoP which could come up during
complaint or validation survey
Source: http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
130
Intervention Strategies
Level of Risk
Area of Risk
Intervention
H
ig
h
Med
Low
Frequent
Falls
Altered
Elimination
Muscle
Weakness
Mobility
Problems
Multiple
Medications
Depression
Low beds
X
X
X
X
X
X
X
X
X
Non-slip grip footwear
X
X
X
X
X
X
X
X
X
Assign patient to bed
that allows patient to exit
toward stronger side
X
X
X
X
X
X
X
X
X
Lock movable transfer
equipment prior to
transfer
X
X
X
X
X
X
X
X
X
Individualize equipment
to patient needs
X
X
X
X
X
X
X
X
X
131
High risk fall
room setup
X
X
X
X
X
X
X
X
Non-skid floor
mat
X
X
X
X
X
X
X
X
Medication
review
X
X
X
X
X
X
X
X
Exercise
program
X
X
X
X
X
X
X
X
Toileting
worksheet
X
X
Color armband /
Falling Star etc
X
X
X
X
X
X
X
Perimeter
mattress
X
X
X
X
X
Hip protectors
X
X
X
X
Bed/chair alarms
X
X
X
X
X
132
34. Pediatric Imaging
 When CT imaging studies are
undertaken on children, “childsize” techniques should be
used to reduce unnecessary
exposure to ionizing radiation
 Recently receiving a lot of
attention
 FDA issues guidelines on
radiation exposure along with
ACR
133
34. Pediatric Imaging
 Update protocols on CT imaging of children
 Scan only when necessary
 Reduce or child size the amount of radiation used
 Scan only indicated area
 See ACR standard
 See www.imagegently.org
 Shield radiosensitive areas such as reproductive organs
 Scan once as single phase scan usually adequate
in children
134
The Radiation Exposure Issue
 August 2009 a team at Emory University in Atlanta reported
in NEJM that 4 million Americans are exposed to high doses
of radiation
 National Council on Radiation Protection and Measurement
stated the US population is exposed to seven times more
radiation each year for imaging exams than in 1980
 GAO and JAMA reported that physicians refer patients to
facility they have a financial interest in
 Dr. Kriste Guite and colleagues studied 978 CT scans of the
abdomen and pelvis and found that 52.2% were
unnecessary (university of Wisconsin at Madison, 2010)
 At that level 1 in 1,00 patients could get radiation-induced
cancer
135
136
Radiation Exposure During CT

October 2009 disclosure by Cedars-Sinai Medical
Center in LA that 206 patients were given up to
eight times the normal radiation dose during a
stroke scan (CT brain perfusion) over an 18 month
period

FDA identifies 50 additional patients who were
also exposed up to 8 times the normal dosage
and reports from other states

Some patients had hair loss (40%) and skin
redness

High doses can cause some kinds of cancer and
cataracts
137
Radiation Exposure During CT
 A patient could get as much radiation from a CT
scan then from 74 mammograms or 442 CXR
from higher measurements
 Hospitals rarely record how much radiation the
patient receives
 Doses can vary depending on the size of the
patient, how large an area is scanned etc.
 At NIH, doctors will record the information and
patients can take it with them
 FDA issues radiation recommendations Dec 2009
138
139
140
5 FDA Recommendations
 Facilities assess whether patients who underwent CT
perfusion scans received excess radiation
 Facilities review their radiation dosing protocols for all CT
perfusion studies to ensure that the correct dosing is
planned for each study
 Facilities implement quality control procedures to ensure
that dosing protocols are followed every time and the
planned amount of radiation is administered
 Radiologic technologists check the CT scanner display
panel before performing a study to make sure the amount of
radiation to be delivered is at the appropriate level for the
individual patient
 If more than one study is performed on a patient during one
imaging session, practitioners should adjust the dose of
radiation so it is appropriate for each study
141
142
143
Recommendations
 ACR, as part of Alliance for Radiation Safety, has
imaging card for patients, especially kids
1
 They recommend patients should ask their doctors if
they need the exam and if there are alternative
 Radiology tech should check the CT scanner display
panel before performing the study to make sure amount
of radiation to be delivered is appropriate
 The tech should check the dose indices displayed on the
control panel after the CT scan is done
 Follow the FDA and ACR recommendations
 Report serious problems to the FDA MedWatch program

1 www.pedrad.org/associations/5364/ig/index.cfm?page=591
144
145
146
The End
Questions
 Sue Dill Calloway RN, Esq.
CPHRM
 AD, BA, BSN, MSN, JD
 Medical Legal consultant
 5447 Fawnbrook Lane
 Dublin, Ohio 43017
 sdill1@columbus.rr.com
 614 791-1481
 TJC NPSG UP and Resources
147
147
Patient Safety Material Resources
 20 tips to prevent medication errors in children
at http://www.ahrq.gov/consumer/20tipkid.htm,
 5 steps to safer health care at
http://www.ahrq.gov/consumer/5steps.htm,
 20 tips to prevent medical errors at
http://www.ahrq.gov/consumer/20tips.htm,
 Quick Tips when getting medical tests at
http://www.ahrq.gov/consumer/quicktips/tiptests.pdf
,
148
Patient Safety Material Resources
 Ways you can help your family prevent medical
errors at
http://www.ahrq.gov/consumer/5tipseng/5tips.pdf,
 When choosing healthcare at
http://www.ahrq.gov/consumer/qualguid.pdf,
 FDA’s tips on taking medication at
http://www.fda.gov/fdac/reprints/medtips.html,
 Preventing medications at
http://www.safemedication.com/meds/medSafety.c
fm,
149
Resources
 IHI (Institute for Healthcare Improvement)
www.ihi.org,
 FDA at www.fda.gov,
 American Society for Healthcare Risk Managers
(ASHRM) www.ashrm.org monograms on
disclosure, patient safety curriculum,
 John Hopkins Center for Public Awarenesspatient safety modules
www.jhsph.edu/ctlt/training/online/patient_safety.ht
ml,
150
Resources
 WHO Patient Safety website at
http://www.who.int/patientsafety/en/,
 WHO taxonomy at
http://www.who.int/patientsafety/taxonomy/en/,
 AHRQ PS Net or patient safety network with
journal articles at http://www.psnet.ahrq.gov/ and
see M&M at http://www.webmm.ahrq.gov/
 AHRQ medical errors and patient safety website at
http://www.ahrq.gov/qual/errorsix.htm,
151
Resources
 AHRQ TeamSTEPPES strategies and tools to
enhance patient safety at
http://www.ahrq.gov/qual/teamstepps/,
 TMIT Safety leaders at http://www.safetyleaders.org/
has research and workshops and webinars,
 FDA patient safety news at
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn
/index.cfm,
 FDA Bad Bug Book at
http://www.cfsan.fda.gov/~mow/intro.html
152
Patient Education Resources
 Five Steps to Safer Health Care,
 10 Patient Safety Tips for Hospitals,
 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet,
 20 Tips to Help Prevent Medical Errors in Children,
 30 Safe Practices for Better Health Care: Fact Sheet,
 Available at http://www.ahrq.gov/qual/errorsix.htm#subscribe,
 Also mistake proofing the design of health care process,
153
Resources
 Appropriate use of antibiotics, Mangram, AJ, Pearson, MI,
Guidelines for Preventing Surgical Site Infections, 1999.
Infection Control Hosp Epidemiol. 20:247-278.
 Also includes information on avoidance of razors,
 Perioperative glucose control in majory cardiac surgery
patients see:
 Furnary, Ap, Zerr, KJ, etc. Continuous intravenous insulin
reduces the incidence of deep sternal wound infection in
diabetic patients after cardiac surgery, Ann Thorac Surg,
1999;67:352-362,
 Van den Berghe, Wouters, P, Weekers, F, Intensive insulin
therapy in critically ill patients, N Engl J Med. 2001:345:13591367.
154
Resources
 Perioperative Normothermia in colorectal surgery
patients see the following two articles,
 Kurtz A, Sessler DI, Lenhardt R, Perioperative
normothermia to reduce the incidence of surgical
wound infection and shorten hospital stay, NEJM
1996,334:1209-1216,
 Melling AC, Ali B Scott, Leaper DJ, Effects of
preoperative warming on the incidence of wound
infection after clean surgery;a randomized control
trial, Lancet, 2001;358:876-880,
155
Resources
 Sorry Works! Coalition at www.sorryworks.net with
sample hospital disclosure program and slides on
disclosure,
 Premier Patient Safety Institutewww.premiereinc.com and has section on
framework for safety culture and reporting
(www.premierinc.com/all/safety/resources/patient_s
afety/index_2.jsp)and data tool for doing survey on
patient safety,
 National Patient Safety Foundation at
www.npsf.org- disclosure after adverse medical
event and disclosure statement of principles,
156
Resources
 Joint Commission at www.jointcommission.org national patient safety goals and International
Center for Patient Safety at
http://www.jcipatientsafety.org/
 The patient safety group at
www.patientsafetygroup.org,
 AHRQ Patient Safety Network at
http://www.psnet.ahrq.gov/ tons of great articles
and research,
 AHRQ Morbidity and Mortality Rounds on the webhttp://webmm.ahrq.gov/,
157
Resources
 VIPCS Virginians Improving Patient Care and
Safety at http://www.vipcs.org/,
 NPSF National Patient Safety Foundation at
www.npsf.org and resources at
http://www.npsf.org/html/resources.html,
 Patient Safety: Achieving a New Standard of
Care; IOM Report 2003 at www.iom.edu,
158
Resources
 The Minnesota Alliance for Patient Safety
(MAPS)- http://www.mnpatientsafety.org/,
 National Quality Forumhttp://www.qualityforum.org/home.htm,
 National Quality Forum (NFQ)
Serious Reportable Events in Healthcare: A
Consensus Report -Serious Reportable Events in
Healthcare
http://www.qualityforum.org/publications.html
159
Resources
 New pressure ulcer prevention protocol and skin
safety plan at http://www.mnpatientsafety.org/,
 Safest in America
http://www.safestinamerica.org/index.php?option
=com_content&task=view&id=11&Itemid=0,
 Anesthesia Patient Safety Foundation at
www.apsf.org,
160
Resources
 Mass Coalition for the Prevention of Medical
Errors at http://www.macoalition.org/,
 ISMP List of Error Prone Abbreviations, Symbols
and Dose Designations at
http://www.ismp.org/tools/errorproneabbreviations.
pdf,
 University of Michigan Patient Safety Toolkit at
http://www.med.umich.edu/patientsafetytoolkit/ ,
 AORN Patient Safety at
http://www.patientsafetyfirst.org/,
161
Resources
 John Hopkins Center for Innovations in Quality
Patient Care at
http://www.hopkinsquality.com/cfi/default.asp,
 CAPSLink at
http://www.usp.org/patientSafety/newsletters/cap
sLink/,
 Ohio Patient Safety Institute at
www.ohiopatientsafety.org ,
162
Resources
 USP- US Pharmacopeia at www.usp.org Sign up for USP Patient Safety Newsletters at
http://www.usp.org/patientSafety/newsletters/caps
Link/,
 VA National Center for Patient Safety NCPS at
www.patientsafety.gov,
 Sign up for human factors resources at
http://www.patientsafety.gov/resources.html#HF,
163
Resources
 Leapfrog group at http://www.leapfroggroup.org/,
 Canadian Patient Safety Institute
athttp://www.patientsafetyinstitute.ca/index.html,
 Australian Council for Safety and Quality in
Health Care at http://www.safetyandquality.org/,
 NPSA National Patient Safety Agency at
http://www.npsa.nhs.uk/,
164
Resources
 State of NJ Patient Safety Report at
http://www.nj.gov/health/hcqo/ps/,
 Patient Safety Authority (PSA) in Pahttp://www.psa.state.pa.us/psa/site/default.asp,
 Web M&M by AHRQ at http://webmm.ahrq.gov/,
 http://highwire.stanford.edu/cgi/search free 999
journals and over 1.5 million articles,
165
Resources
 Consumers Advancing Patient Safety CAPS at
www.patientsafety.org,
 The Patient Safety and Quality Improvement Act
of 2005 (PA 109-41) amended Title IX of the
Public Health Service Act (42 USC 299 et seq),
protection for patient safety work products,
166
Resources
 National Coordinating Council for Medication Error
Reporting and Prevention- www.nccmerp.org,
 Partnership for Patient Safety
www.p4ps.org,
 "Beyond Blame" video: Order online at
http://www.mederrors.com/home/blame.html, or call
(959) 350-0100
167
Disruptive Practitioner Resources
 Joint Commission standards at
www.jointcommission.org,
 Rosenstein A, O’Daniel M. Disruptive behavior and
clinical outcomes: perceptions of nurses and
physicians: nurses, physicians, and administrators
say that clinicians’ disruptive behavior has negative
effects on clinical outcomes. Nurs Manage 2005
Jan;36(1):18-29.
168
Resources
 Weber DO. Poll results: doctors’ disruptive
behavior disturbs physician leaders. Physician
Exec. 2004 Sep-Oct;30 (5):16-7. Also available:
http://findarticles.com/p/
articles/mi_m0843/is_5_30/ai_n6213537.
 American Medical Association. Physicians with
disruptive behavior. In: Code of medical ethics:
current opinions and annotations. Chicago (IL):
AMA: 2006. p. 279–80.
169
Resources
 Disruptive Behaviors in Physicians, CME course
from Texas Medical Board at
http://www.texmed.org/Template.aspx?id=4211
and gives CME credit,
 Tennessee Medical Staff Foundation, Medical
Staff Code of Conduct Policy, at http://www.etmf.org/code_of_conduct.asp,
170
Resources
 Papadakis MA, Teherani A, Banach MA, Knettler
TR, Rattner SL, Stern DT, et al. Disciplinary action
by medical boards and prior behavior in medical
school. N Engl J Med 2005;353:2673–82,
 ECRI. Disruptive practitioner behavior. HRC Risk
Analysis Supplement A. Plymouth Meeting (PA):
ECRI; 2006.
171
Resources
 Disruptive Behavior, ACOG Committee Opinion,
Number 366, May 2007.
 Porto G, Lauve R. Disruptive clinician: a persistent
threat to patient safety. Patient Saf Qual Healthc
2006;144: 107–15.
 Leape LL, Fromson JA. Problem doctors: is there
a system-level solution? Ann Intern Med
2006;144:107–115.
172
Resources
 Pfifferling J. The disruptive physician: a quality of
professional life factor [online]. Physician Exec.
1999 Mar-Apr [cited 2005 Dec 5]. Available from
Internet:
http://www.findarticles.com/p/articles/mi_m0843/is_
2_25/ai_102274361.
 See HCA Code of Conduct, 38 pages, at
www.hcahealthcare.com,
 SOX, or Sarbanes-Oxley Act of 2002, and related
Securities and Exchange Commission rules,
173
Resources
 Cassidy M. Third circuit
reaffirms HCQIA immunity
for professional review
actions [online]. [cited 2005
Dec 5]. Available from
Internet:
http://www.tuckerlaw.com/p
ub/health/October%202005
.html#3
 Gordon v. Lewiston case,
174
Resources
 American Medical Association. Reports of the
Council on Ethical and Judicial Affairs:
physicians with disruptive behavior. Available
from Internet:http://www.amaassn.org/ama1/pub/upload/mm/369/ceja_rep_1
06_0104.pdf,
 AMA Physicians and Disruptive Physician
packet, July 2004, at http://www.amaassn.org/ama1/pub/upload/mm/21/disruptive_ph
ysician.doc
175
Fatigue Resources
 Ruggiero, JS, Correlates of fatigue in critical care
nurses. Res Nurs Health Dec 2003; 26(6):434-44.
 Ahmed, DS, Fecik, S. The fatigue factor. When long
shifts harm patients. Am J Nurs. Sep 1999,
99(9):12. Case Reports,
 AHRQ Evidence Report 151, Nurse Staffing and
Quality of Patient Care March of 2007, at
http://www.ahrq.gov/downloads/pub/evidence/pdf/nu
rsestaff/nursestaff.pdf
176
Fatigue Resources
 Fatigue in Healthcare Workers, Healthcare Risk
Control, January, 2006, ECRI Institute, Employment
Issues 14,
 Institute of Medicine (IOM) report on Keeping
Patients Safe; Transforming the Work Environment of
Nurses, 2004, at www.nap.edu,
 Gaba DM, Howard SK. Patient safety: fatigue among
clinicians and the safety of patients. N Engl J Med
2002 Oct 17;347(16):1249-55.
177
Fatigue Resources
 West S. Circadian rhythm, shiftwork and you!
Collegian 2001 Oct;8(4):14-21.
 Eastridge BJ, Hamilton EC, O'Keefe GE, et al. Effect
of sleep deprivation on the performance of simulated
laparoscopic surgical skill. Am J Surg 2003
Aug;186(2):169-74,
 Barger LK, Cade BE, Ayas NT, et al. Extended work
shifts and the risk of motor vehicle crashes among
interns. N Engl J Med 2005 Jan 13;352(2):125-34.
178
Fatigue Resources
 Scott, LD, Hwang, WT, Effects of critical care
nurses work hours on vigilance and patient safety.
Am J Critical Care 2006 Jan:15(1):30-37,
 Rogers, AE, Hwang, WT, The working hours of
hospital staff nurses and patient safety. Health Aff
(Milwood) 2004; 23:202-212.
179
TJC NPSG Goal 1: UP Universal Protocol
Organization must meet expectation of UP
UP 01.01.01 Conduct a pre-procedure verification process,
Changed because of universal protocol that is now a
standard, effective July 1, 2004 changed 2009 and 2010 and
continue into 2011,
To prevent wrong site and wrong procedure surgery,
Process must be briefly documented,
TJC has great information on their website on this!
3 parts,
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181
Pre-procedure verification process
 It is an ongoing process that starts with decision to
do procedure and continues up and includes time
out before start of procedure,
 Want to be sure all documents and equipment is
available before the procedure,
 That everything is correctly labeled and matched to
the patient’ identifiers,
 Reviewed and consistent with patient’s expectation
and team’s understanding of the procedure and
site,
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Pre-procedure verification process
1. Implement a pre-procedure process to verify
correct patient, site, and procedure
2. Identify what needs to be available for the
procedure and use a standardize list (check list)
to verify their availability and must include

Relevant documentation (H&P, consent form, nursing
assessment and pre-anesthesia assessment)

Labeled diagnostic and radiology films, pathology, and
biopsy reports and make sure properly displayed
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Pre-procedure verification process
3. Match the items that are to be available in the
procedure area to the patient

WHO has a surgical checklist

Can enlarge the individualized checklist to 2
by 3 feet and roll in before surgery and then
do briefing and at end when you do debriefing
184
Getting It Right
 Do you verify that this is the right procedure at certain
times to make sure you have it right such as;
 Time procedure scheduled,
 Time of PAT,
 Time of admission or entry into facility,
 Before patient leaves pre-procedure area,
 Anytime responsibility is transferred to another member of
procedure team (including anesthesia provider) at time of
and during the procedure,
 With the patient involved and awake and aware if possible,
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Mark the Site

UP 01.02.01 Mark the procedure site,
1. Procedure with incisions or percutaneous
puncture or insertion, site is marked

when more than one possible location,

If performing in a different location would negatively
affect quality or safety

For spinal procedures need special intraoperative
image technique to mark the right spot
2. Mark before patient is moved to where
procedure is to take place,
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Mark the Site

Patient should be involved if possible when marking the
site.
3. Site marking by LIP or other provider who is
ultimately accountable for the procedure

Must be present when the procedure is performed

In limited circumstances LIP can delegate to another
who is permitted by hospital and who meets the
following qualification

In medical residency program and is supervised by LIP
performing the procedure
187
Mark the Site
 Licensed person who requires collaborating or
supervising agreement with the LIP such as
PA or NP
 Must be familiar with the patient and present
when the procedure is done
4. Method of marking the site is unambiguous and is
used consistently through out the hospital
 Mark is made at or near the site
 Mark must be present after draped and
prepped,
188
Mark the Site
5. Alternative process if patient
refuses or if anatomically
impossible to mark

Put temporary unique wristband,
draw on anatomical picture and
also if impractical to mark the site
(perineum),

Do not mark preemies as will be
permanent.

For teeth mark on the dental x-rays
or diagram,
189
Mark the Site
 Person doing the marking has to be present at time
of final time out (this is usually the surgeon),
 Has to clear marking and consistent through out
the hospital,
 Preferable the surgeon’s initials with or without
proposed incision line marking,
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Time Out before Procedure UP.01.03.01
1. Time out is done before immediately before
starting the procedure,
2. Characteristics of the time-out

Standardized process Done by designated team
member,

Initiated by designated member of the team

Involves immediate members of the team including
proceduralists, anesthesia providers, circulating nurse,
OR tech, and other active participants involved in
procedure,
191
Time Out
 Includes active communication,
 Even if doing spinal or local,
 Other activities suspended during time out,
 Want all members to actively give thumbs up,
 If more than one procedure, need to repeat
process for each one,
192
Time Out
4. Time out must address correct patient, correct
site and procedure to be done

Be sure that the site is marked, accurate consent
form, agreement on what is being done, correct
position, x-rays are properly labeled and
displayed,

need to administer antibiotics or fluids for
irrigation, and safety precautions based on
medication use,
5. Document the time out
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Resources
• Agency for Healthcare Research and Quality
http://www.ahrq.gov/consumer/
• Consumers Advancing Patient Safety (CAPS)
(http://www.patientsafety.org/)
• Partnership for Patient Safety (p4ps)
(http://www.p4ps.org/)
 Further information go to TJC International
Center for Patient Safety
http://www.jcipatientsafety.org/ and click on 13A,
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