National Patient Safety Goals

1. National Patient Safety Goals Mac Neal Hospital 2011

2. National Patient Safety GoalsPurpose The purpose of The Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. The Requirements focus on system-wide solutions, wherever possible.

3. 2011 National Patient Safety Goals Approved by The Joint Commission’s Board of Commissioners The Goals and Requirements are program-specific Include improvements emanating from the Standards Improvement Initiative, including: New numbering system for sorting in new electronic manuals Minor language changes for consistency

4. Patient Identification Improve the accuracy of patient identification

5. Patient Identification Use at least two patient identifiers (name & birth date) when providing care, treatment and services. Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques

6. Patient Identification Eliminate transfusion errors related to patient misidentification.

7. Improve Communication Get the important test results to the right staff person. For telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.

8. Improve Communication There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. The organization measures, assesses and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, and critical results and values by the responsible licensed caregiver.

9. Improve Communication The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. At MacNeal we use SHARER (sketch, how, aim, rationale, exchange, & review).

10. Medication Safety Improve the safety of using medications The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications.

11. Medication Safety Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions (including water on and off the sterile field. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

12. Health Care Associated Infections Reduce the risk of health care associated Infections. Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

13. Health Care Associated Infections Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care associated infection. Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

14. Health Care Associated Infections Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. Implement best practices for preventing surgical site infections.

15. Reconcile Medications Find out what medications the patient is taking. Make sure that it is OK for the patient to take any new medication with their current medicines. Give a list of the patient’s meds to their new care giver. Give the list to the patient’s primary doctor before the patient goes home. Give a list of the patient’s medications to the patient and their family before they go home. Explain the list.

16. Reconcile Medications In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.

17. Reduce Falls Reduce the risk of patient harm resulting from falls. The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

18. Influenza & Pneumococcal Disease Reduce the risk of influenza and pneumococcal disease in institutionalized older adults. The organization develops and implements protocols for administration of the flu vaccine. (Joint Commission, 2009)

19. Influenza & Pneumococcal Disease The organization develops and implements protocols for administration of the pneumococcus vaccine. The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. (Joint Commission, 2009)

20. Surgical Fires Reduce the risk of surgical fires. The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.

21. Patient Involvement Encourage patients’ active involvement in their own care as a patient safety strategy Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

22. Pressure Ulcers Prevent health care associated pressure ulcers (decubitus ulcers) Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.

23. Risk Assessment The organization identifies safety risks inherent in its patient population. The organization identifies patients at risk for suicide. The organization identifies risks associated with home oxygen therapy such as home fires.

24. Changes in Patient Condition Improve recognition and response to changes in a patient’s condition. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

25. Universal Protocol The organization meets the expectations of the Universal Protocol. Conduct a pre-procedure verification process. Mark the procedure site. A time-out is performed immediately prior to starting procedures.

26. Utility Systems

27. Utility Failure-CODE GREEN Oxygen/Medical Air/and Suction Water Electricity Waste Removal (Sewage) Natural Gas Telephones

28. Utility Failure-CODE GREENReporting Utility Problems If you come across problems or failures of any utility system Report-call security at x 3163 Security will call Facility Services Notify your supervisor Facility Services will Inspect the situation Initiate corrective action

29. Other Utility Failures Contingency plans are in place for utility failures ...Ask supervisor for details

30. Power Failure- Main Campus Main Campus power disruption Emergency generators automatically start Emergency power in 10 minutes or less Generators Provide power to the main campus in emergencies For more than 24 hours Coverage includes Critical medical equipment Emergency lighting Designated elevators Red outlets Battery power lights Provides illumination Provides safety for generator turns on emergency power

31. Power Failure- Main Campus Connect critical components into RED outlet (IV’s etc..)

32. Power Failure – Off-Site Facilities Battery powered lights Illumination for up to 1 hour limited illumination for exiting premises Facilities with generators which support a limited amount of equipment Harlem- Ogden bldg Mid City Bank bldg

33. Telephone System FailureMain Campus The red telephones may be the only working telephones Used as a back up system Separate phone numbers are attached to each red telephone

34. Oxygen/ Medical Air/ Suction Shut- off Valves Shut-off valves are located throughout the hospital in areas where services at off valve used Adjacent to the shut- off valves is a map indicating which rooms these valves serve and the emergency protocol If you work in an area utilizing these services, familiarize yourself with this information Only shut off the service in an emergency condition, following the approved protocol for medical gas shutdown

35. Medical Equipment & Electrical Safety

36. Electrical Safety Considerations If a device has a power cord it must be safety tested by Facilities Services or Biomedical Engineering prior to being put into service Patient owned electrical items (radios, hair dryers, etc..) are not allowed unless the device is battery operated

37. Electrical Safety Considerations Don’t unplug equipment by pulling on the power cord; use the head of the plug Always check the condition of the plug before inserting it into the outlet

38. Reporting Electrical Hazards Immediately report any non-static electrical shocks to your supervisor Unsafe equipment should also be reported immediately to: Biomedical Services ( x3715) Biomedical Services after hours pager (3715) Facility Services ( x3137)

39. Safe Medical Device Act The S.M.D.A. is a federal law designed to protect you and the patients There are two important regulations in this act that could affect you The Device Tracking Regulation The Medical Device Reporting (MDR) Regulation

40. Definition of Medical Device A Medical Device is: Any device used in the treatment, therapy or diagnosis of patients

41. Medical Devices Include

42. Device Tracking Regulation Certain Medical devices are required by the FDA to be tracked. IV pumps Implantable devices pacemakers

43. Medical Device Reporting (MDR) Regulation Medical Device Reporting is required If a device may have contributed to a patient or employee’s Death Serious injury Serious illness

44. General GuidelinesMedical Device Incident Management Attend to the medical needs of the patient Report the incident to the appropriate person Notify Risk Management and/or the AOD Complete an occurrence report within 24 hours

45. General Guidelines Medical Device Incident Management Remove the device from service Contact security at x 3163 Security will store the item in a secure location for further investigation

46. General Guidelines Medical Device Incident Management Do not change the settings on the device Label the device Do not use or discard Describe the malfunction State how you may be contacted If the device is reusable- record Serial numbers Identification numbers

47. General Guidelines Medical Device Incident Management Save all the materials Don’t take device apart If you must take it apart –save everything Save all original packing- if possible

48. Chemical and Hazardous Material Safety

49. MSDS for most Chemicals and Hazardous Materials Every department is responsible for keeping corresponding MSDS for all hazardous chemicals used in their area The Emergency Department will have a master inventory of all MSDS The MSDS list is on the intranet, on the Pulse page.

50. Proper Labeling The chemical should remain the original container The original label must remain on all chemicals If a chemical must be transferred to a different container, that new container must be properly labeled Additional labels can be obtained by calling that vendor

51. M.S. D. S. Hazard Rating Label Determination Red = Flammability Blue = Health Yellow = Reactivity White = Specific Hazard

52. Code Orange This code is used in the event of a large or extremely hazardous material spill If this were to occur in your area Move to a safe location Contact your supervisor Await further instructions

53. Biohazard Items Biohazard items include and are not limited to: Syringes Blood Blood and body fluid specimens

54. PNEUMATIC TUBE SYSTEM FOR TRANSPORTOF BLOOD PRODUCTS AND SPECIMENSPOLICY Due to the potential for leakage and/or contamination from certain blood products and specimens, the Pneumatic Tube System (PTS) will not be used for transporting the following specified substances: 24 hour urine specimens spinal fluid stool specimens surgical specimens biopsy specimens cytology specimens All other specimens not identified above, including blood specimens (i.e., tubes of blood) may be transported via the Pneumatic Tube System. PROCEDURE Transporting approved specimens via the PTS. All specimens must be placed in an appropriate container prior to transport. Assure that specimen is properly labeled and accompanied by appropriate requisitions. Specimens for which use of the PTS is contraindicated must be hand carried to the laboratory. All specimens must be placed in an appropriate, sealed container. (MacNeal Hospital Infection Control Policy and Procedure for the use of the pneumatic tube system for the transport of blood products and specimens , 2006).

55. PNEUMATIC TUBE SYSTEM FOR TRANSPORTOF BLOOD PRODUCTS AND SPECIMENSPOLICY Blood products: Only in the event of a transfusion reaction should all tubing's and infusates be returned to the blood bank in a zip lock impervious bag. If the blood product was infused with no transfusion reaction the used bag and tubing should be placed in the biohazard container. When sending a blood product back to the blood bank after a transfusion reaction, the roller clamp on the infusion set should be moved to a position immediately adjacent to the connection site of the bag and tightly closed. This will prevent leakage of residual fluid from the infusion bag. If the entire tubing does not have to be returned to the blood bank, the segment of tubing below the roller clamp should be cut off and discarded. The transfusion requisition must be securely attached to the outside of the bag prior to transport. Sterile Processing will decontaminate the zip lock bag and/or the tube in the event of contamination. (MacNeal Hospital Infection Control Policy and Procedure for the use of the pneumatic tube system for the transport of blood products and specimens , 2006).

56. Transporting Biohazard Specimens All specimens are considered BIOHAZARD All specimens sent through the tube system must be in a plastic specimen bag and wrapped in bubble wrap if breakable Hand Carry Specimen in plastic specimen bag Driving Transport specimen in closed protected container in back of car or trunk

57. Personal Protective Equipment Gloves Face Mask Goggles Lab Coat Apron Respirator Mask

58. Hazardous Materials: Receiving, Transporting, Storage, and Labels Policy The following precautions shall be observed in receiving, transporting, and storing hazardous drugs. Receiving No special precautions are necessary if cartons or containers are undamaged. If cartons or containers are damaged proceed as follows: Wear protective apparel (gown, gloves, mask, eye wear) as described in this policy. Open damaged shipping cartons of hazardous drugs in an isolated area. Place broken containers and contaminated materials in disposal containers as described in this policy. MacNeal Hospital, POLICY NUMBER: 04-11 revised 1-1-2008)

59. Hazardous Materials: Receiving, Transporting, Storage, and Labels Transporting Securely cap or seal hazardous drugs in specially labeled containers and protect them during transport. Do not transport hazardous drugs by any method that could increase the chance of breakage (e.g., pneumatic tube). Storage Facilities used for storing hazardous drugs should, if possible, be used for no other drugs. Storage methods shall prevent containers from falling to the floor, i.e., bins or shelves with barriers at the front. The Director of Pharmacy, if deemed necessary, shall designate a special area for the storage of these drugs and shall place warning label (s) at that area. Labels for hazardous substances Labels for hazardous substances shall indicate that the contents contain a hazardous drug (and other information that will assure safe handling and disposal). (MacNeal Hospital, POLICY NUMBER: 04-11 revised 1-1-2008)

60. When do I wear Personal Protective Equipment (PPE) ? Always wear PPE when working with or handling Hazardous Materials Each department has specific guidelines for PPE equipment according to the type of work performed

61. Disposal ? Chemicals and hazardous waste must be disposed of according to local regulations and MSDS guidelines

62. Code Event & Code Designation Code Red Fire Code Blue Medical Emergency-Cardiac Arrest Code Blue- Pediatrics Pediatric Emergency Code Yellow Trauma Team Activation Code Pink Infant abduction Code Grey Security Assistance Code Triage –Standby Disaster Plan Standby Code Triage Disaster Plan Activation Code Purple Evacuation Code Black Watch Severe Weather L-1 Code Black Warning Severe Weather L-2 Code Orange Hazardous Material Rel. Code Green Utility Failure Code Safe Safety Secured Code Navy Level I/ High bed census Service lines at capacity Code Bronze Level II/ High bed census Emergency Department 1 hour from bypass (Diversion) All Clear Situation Cleared/ All Clear

63. Questions ?

64. Cultural Diversity and Sensitivity Culturally sensitive care is the right of all clients. Everyone who represents MacNeal Health Network (employees, volunteers, students, contracted staff, licensed independent practitioners, etc.) is ethically obligated to the provision of culturally- sensitive care to all individuals that enter our health care system.

65. Cultural Diversity and Sensitivity Meeting this obligation requires we open our minds, an honest examination of one’s own values and beliefs, a willingness to learn and an awareness that each cultural and ethnic group has values, beliefs t are and practices that are specific to the group. We must always be mindful that each clients cultural needs must be assessed and addressed from an individual perspective.

66. Cultural Diversity and Sensitivity Various resources to aid your effectiveness in providing culturally sensitive care are readily available at MacNeal Health Network. These resources can be accessed on the Intranet and within the administrative policy manual. To access these resources, inquires can be made to the members of the management team.

67. Patients Rights and Responsibilities Policy: MacNeal Hospital recognizes and respects the rights of individuals to be involved in decisions about their care, treatment, and services and strives to maintain high standards as we care for our patients with compassion and skill. MacNeal Hospital believes patient rights deserve our greatest attention. MacNeal Hospital posts notices and provides informational material supportive of patient rights and patient responsibilities. In addition, the Hospital makes available to the patient and/or the family or legal representative the services of an Ethics Consultant, Interpreter Services, and a mechanism for handling complaints, grievances, and special needs. This includes providing current information on how to contact the Illinois Department of Public Health, the Joint Commission, and Hospital Administration. It is the responsibility of every member of the heath care team to ensure that every patient or their legal representative has the opportunity to exercise their rights in accordance with applicable law, Hospital policy, and accepted standards of patient care. (Joint Commission RI.1 Ethics, Rights, and Responsibilities. CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

68. Patients Rights and Responsibilities Patients have a right to care, treatment, and services that: Is medically indicated and accepted regardless of race, religion, sex, sexual orientation, age, national origin, linguistic abilities, physical and mental abilities or sources of payment for care. Is considerate of patient’s well being and respectful of their dignity. Allows freedom to exercise cultural and spiritual beliefs, that do not interfere with the well being of others, as the appropriate course of medical treatment Provides emergency services without deferral. Provides impartial access to available accommodations. Appropriately and aggressively manages pain. Is free from restraints unless medically necessary for safety. Gives them an opportunity to request a transfer to another room or facility. Allows access to visitors and written and/or verbal communication, unless such access impedes medical treatment. Is sensitive and responsive to issues surrounding terminal illness. May place a patient in protective care when necessary for personal safety. (Joint Commission RI.1 Ethics, Rights, and Responsibilities. CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

69. Patients Rights and Responsibilities Patients have the right to receive information about care, treatment, and services including: The Patient Bill of Rights that contains information for handling and resolving patient complaints and grievances. The assistance of a qualified foreign or sign language interpreter. A legally designated representative when unable to make decisions about treatment, or unable to communicate wishes regarding care. Knowing, by name, the physician's and other licensed independent practitioners primarily responsible for their care. Obtaining complete and current information concerning diagnoses, treatments, and prognoses from the physician, in language and terms that are understandable. (Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

70. Patients Rights and Responsibilities Receiving from the physician as much information as necessary to give informed consent prior to the start of care, treatment, and services. Except in emergencies, information should include the specific procedure and/or treatment, potential benefits and risks, the expected time for recovery, the likelihood of success, the possible results of no treatment and/or procedure, and any significant alternatives. Refusing treatment, including life-sustaining care, and information of the benefits, risks, and medical consequences of this action. Receiving information during the admission process regarding and describing Advance Directives. The Advance Directive will be maintained in the patient’s current medical record and will be periodically reviewed by physicians, the patient, the healthcare team, or the legally designated decision-maker. Information regarding ethical issues resolution. The opportunity to participate or refuse to participate in investigational studies or clinical trials after receiving all the necessary information with which to make a decision. Information about the outcome of care, treatment, and services, including whenever those outcomes differ significantly from the anticipated outcome. (Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

71. Patients Rights and Responsibilities Patients have a right to privacy and confidentiality including: An environment that is as safe and secure as possible. That disclosures made to the healthcare team are kept confidential and that any discussion or consultation is conducted discreetly. Receiving care in an environment that offers as much visual and auditory privacy as possible. Refusing contact with anyone not officially connected with the hospital, including visitors. Request the presence of members of their own sex during examinations or procedures performed by professionals of the opposite sex. Only disrobing when medically necessary. Maintaining contact with individuals outside the hospital through visitors or by written and/or verbal communication. Access, request amendment to, and receive an accounting of disclosures regarding his or her own health information as permitted under applicable law. (Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

72. Patients Rights and Responsibilities Patients have certain responsibilities including: Providing all needed information to the healthcare team to assist with treatment, including but not limited to: nature of illness, past illnesses and hospitalizations, medications, unexpected changes in medical condition. Informing the healthcare team whether or not they understand the proposed course of treatment and their role in the treatment plan. Understanding the consequences that may result if they refuse treatments or procedures, or do not follow the instructions from their healthcare team. Working with the healthcare team to find the best pain relief plan and treatment. Following Hospital rules and regulations including: respecting the rights and property of other patients and personnel, complying with the hospital’s visitor policies, complying with the hospital’s smoke free environment policy. Providing accurate information regarding sources of payment for care rendered. Understanding that no emergency services will be deferred pending receipt of this information. Fulfilling their financial obligation as promptly as possible. (Joint Commission RI.1 Ethics, Rights, and Responsibilities-CMS CoP Rule 482.13) (MacNeal Hospital Patients Rights and responsibilities, 2007).

73. Ethical Issues in Patient Care Purpose To provide a mechanism to address questions, conflict, or other dilemmas for patients, family/legal representatives, and the Hospital. MacNeal Hospital recognizes that making decisions about care, treatment, and services may, at times, present questions, conflicts, or other dilemmas for patients, family, other decision makers, and the Hospital. The Hospital is committed to working with patients, and when appropriate, their families to resolve such issues. Any employee, staff member, patient, family member, significant other, legal representative or surrogate decision maker has the right to raise ethical concerns related to patient care. The Hospital expects staff to be sensitive to ethical concerns raised in the course of patient care and promotes resolution to ethical issues in an atmosphere that is comfortable and respectful to all parties involved. The Hospital promotes ethics education and will assist staff gain expertise in managing ethical uncertainties. (MacNeal Hospital, Ethical issues in Patient Care, 2008).

74. Ethical Issues in Patient Care Procedure Staff should address ethical concerns (a) first, within the interdisciplinary team caring for the patient, (b) second, with the clinical Ethics Consultant. The Ethics Consultant is available 24 hours per day by contacting Telecommunications. Any staff member may request a clinical ethics consult. The attending physician should be notified of a consult request. Patients and family members, or other decision makers facing ethical dilemmas may contact any member of the health care team including pastoral care and social services and request an ethics consult. Ethics consults will be performed by a qualified Ethics Committee member or by the Ethics Consultant on call. The Ethics Committee member or Consultant will recuse themselves from cases they are involved in. MacNeal Hospital, Ethical issues in PatientCare,2008).

75. Ethical Issues in Patient Care The consultant will: Review the facts of the case via chart review and interviews with members of the medical, nursing, social services and pastoral care staff. Patient and family involvement in the consult is encouraged. The extent of their involvement is on a case-by-case basis. Analyze the ethical issues pertinent to the case. Provide conclusions and recommendations to the requesting individual(s) in a timely manner. Educate the health care team involved about the ethical issues identified. Document consultant activity in the medical record as appropriate. Provide follow-up as appropriate. Review consultant activity at the Ethics Committee. (MacNeal Hospital, Ethical issues in PatientCare,2008).

76. Health Insurance Portability & Accountability Act (HIPAA) What is the purpose of the HIPAA privacy standards? To provide patients with control over the use and disclosure of their patient identifiable information What does the abbreviation P.H.I mean? Protected Health Information (MacNeal Hospital, Notice Privacy Practices and HIPPA awareness program, 2008).

77. Protect all forms of patient information Where is the PHI in the organization? I

78. How to protect privacy of the patient information on paper Don’t leave paper on printer's fax machines or copiers Dispose paper, addressograph plates, labels by approved methods Always use a fax cover sheet with a confidentiality statement Only authorized staff should have access to the location where records are stored PHI on paper should never be left unattended in a non-secure area Visitors should obtain clearance upon entry and be escorted when in areas where patient information is stored or accessible Key, key cards or tokens should be kept securely stored

79. How to protect privacy of the patient information spoken Be sure you know to whom you are speaking BEFORE you release patient information Disclose information only to individuals with a business need to know & only the minimum necessary to accomplish the job Keep your voice down. Speak so others may not overhear Do not leave information in patient rooms Knock before entering a patient room Do not speak about patient information in hallways, cafeteria, elevators or any public area.

80. It’s a BIG Deal! You need to be very good at keeping PHI safely within your workspace, so it doesn’t get out where it doesn’t belong Our patients are counting on you and I to make sure their personal information is protected- It’s really up to us to make sure the right thing is happening

81. References Ethics, Rights, and Responsibilities. (2008). Joint Commission RI.1 CMS CoP Rule 482.13 MacNeal Hospital. (2008). Ethical issues in Patient Care: Patient care policy manual. MacNeal Hospital. (2008). Hazardous Materials: Receiving, Transporting, Storage and Labels. Policy number: 04-11 MacNeal Hospital: Notice Privacy Practices and HIPPA awareness program. (2008). MacNeal Hospital Infection Control (2006). Policy and Procedure for the use of the pneumatic tube system for the transport of blood products and specimens. MacNeal Hospital Patients Rights and responsibilities. (2007). Patient care policy NationalPatientSafetyGoals. (2011). http://www.jointcommission.org/PatientSafety/