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The absence of the potential for patient harm Involves all Health care givers, All job descriptions Involves all Departments Time frame: 24/7
The GOAL
TJH strives to provide an environment that ensures the safety of all individuals by promoting a Culture which is proactive and nonnonpunitive to facilitate the reporting of hazards, errors, near-misses, nearconcerns and otherwise unsafe conditions within the Hospital. Employees are required to report Patient Safety issues or concerns to their Manager Compliance hotline 0543168843. Employees may report a Patient Safety or quality of care concern directly to the Quality Manager of Hospitals at 311. Reporting of Patient Safety or quality of care concerns will not result in retaliation or discipline.
Unanticipated death or permanent loss of function Healthcare acquired infection Unanticipated patient outcome Any adverse event involving a patient, patient care or patient environment. Any near miss Any safety concerns you have
Patient Safety Policy Hospital Safety Policies Facilities Policies Pharmacy Policies Unit Policies Medical, Nursing and Other Staff Policies
1. Patient Identification
Badges for Employees, Volunteers, Visitors Patients wear ID Bands Name band Blood transfusion Allergy band Fall risk band ID Patients by full name/ DOB or MRN Never use room number
2. Improve Communication
Verify verbal and phone orders by writing first and then reading back. Verbal orders only in emergencies Avoid use of prohibited abbreviations Document, Notify and Communicate clearly critical lab values Report up the chain of command Document hand off communications complete transfer forms
3. Safety of Medications
Standardizing drug concentrations Reducing potential for error related to looklookalike and sound alike meds. Insulin all types Chemotherapy Ambulatory medications Label all medications and med containers or other solutions on or off the sterile field in operative and procedural areas.
Perform hand hygiene before and after patient care per CDC guidelines. Use hand foam or soap and water. Manage as sentinel events, those cases of unanticipated death or permanent loss of function related to healthcare associated infection. Common (HAI) - MRSA, VRE, or C. diff
5. Patient Medications
Medication reconciliation - document meds on admission Medication brought in by family members Herbals, supplements, OTC drugs Develop a process for communicating patient medications to all providers Provide list of medications to patient upon discharge from facility.
Report on OVR Time of most inpatient falls - 1pm and 6-8 pm 6Place of Fall - at bedside, transitioning from bed to bathroom Ages any age, not just the elderly Diagnosis Psych, behavioral, head injury AntiAnti-psychotics, Sedatives, Diuretics, Heart drugs, Anti-epileptics, Narcotics, Poly AntiPharmacy > 5 of any medications
Encourage patients and their families to report concerns about safety to: Quality Director at ext.311
Identify patients at risk for suicide. Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
Adverse events are often associated with patient transport. Does the patient need oxygen for transport? Was an order obtained to discontinue telemetry? Did you give a complete report on this patient? Checklists help. Complete transfer forms.
VITAL SIGNS
Document so others can see them. This is a major form of Communication. Count respirations accurately. Know VS parameters for your patient. You must notify up the chain of command for vital signs outside parameters.
LABELING SPECIMENS
Check Pt ID band and lab form Label all specimens at the patient s side. Transport STATs and cultures immediately Call the Lab to alert them, when sending a STAT specimen
Call switch board for any life threatening emergency. Call 0 and give the Operator the following: Your exact location, including room number/ward. Is patient adult or child? Your name and callback extension Complete all portions of the Resuscitation Form and send to Risk Management.
PATIENT ENVIRONMENT
Clean up spills and wet surfaces immediately. Rehearse What IF! What do we do if? This helps staff to be prepared when it does happen. Know how to manage facility disruptions
Power loss Weather emergencies Water outages
DOCUMENT
I
did it, I just forgot to write it down .. Would you be able to give a legal account of your care if it is not documented?
Be a Patient Advocate