2012 Patient Safety Goals

Reduce the likelihood of patient harm

associated with the use of

anticoagulation therapy. Anticoagulant

drugs can cause bleeding.

Case Study

Three neonates died at a hospital as aresult of accidental heparin overdoses.A pharmacy technician inadvertently filledthe automated dispensing cabinet with1ml vials of heparin containing10,000 units/ml instead of the1ml vials ofheparin10 units/ml. The nurses did not noticethe discrepancy and the heparin wasadministered to the neonates. ISMP Medication Safety Alert Oct 2006 4/10

RecommendationsIn order to prevent this tragedy from happening againthe following recommendations have been made:

1. Eliminate 10, 000 units/ml concentration vials stocked in the hospital. If this concentration remains in the pharmacy, keep the vials separate from other concentrations.

2. Require an independent double check of drug.3. Reduce look alike/ sound alike drug packaging The vials of heparin had similarities that may have

contributed to the error.

For all recommendations see reference

Unintended Medication Discrepancies at the Time of

Hospital Admission

6% Severe harm potential

61%

No harm potential

33%

Moderate harm potential

More than half of patient have 1 unintended medication discrepancy at hospital admission

Reference: http://www.ahrq.gov

Unintended Medication Discrepancies at the Time of

Hospital Admission

Cornish,Knowles & Marchensano(2005)found greater than 50% of patients had at least 1 medication discrepancy upon hospital admission. The most common error was omission of a regularly used medication. Obtaining an accurate medication history at the time of admission is critical to prevent such errors.

Reference: http://www.ahrq.gov

2012 National PatientSafety Goals

Goal 8- Accurately and completely Reconcile Medications across the continuum of care

2012 National PatientSafety Goals

Goal 7- Reduce the risk of health care associated infections

• A. Meeting Hand Hygiene Guidelines • B. Preventing Multidrug-Resistant Organism

Infections• C. Preventing Central Line–Associated Blood

Stream Infections• D. Preventing Surgical Site Infections

Centers for Disease Control (CDC) Report

• Health-care--associated infections (HAIs) account for a substantial portion of health-care--acquired conditions that harm patients receiving medical care. Nearly one in every 20 hospitalized patients in the United States each year acquires an HAI. Central line--associated blood-stream infections (CLABSIs) are one of the most deadly types of HAIs, with a mortality rate of 12%--25% .

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm?s_cid=mm6008a4_w

TEST YOUR KNOWLEDGE

Which is the most

frequently occurring

nosocomial

infection?A. Urinary tract infection

B. Pneumonia

C. Vascular Catheter related

Which of these are risk

factors for development

of nosocomial infections?A. Age

B. Urinary catheter >24hrs

C. Mechanical ventilation

D. Severe underlying disease

E. Extended stay in acute or chronic care facility

Answers on next slide

Additional considerations include:

• Overuse of antimicrobials

• Contaminated equipment-instruments

• Poor HANDWASHING

• Adherence to the CDC Hand

washing guidelines is critical

Urinary tract infections, all are risk factors

Definitions-CDC• Hand hygiene

– Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis

• Handwashing– Washing hands with plain soap and water

• Antiseptic handwash– Washing hands with water and soap or other detergents

containing an antiseptic agent

• Alcohol-based handrub– Rubbing hands with an alcohol-containing preparation

• Surgical hand hygiene/antisepsis– Handwashing or using an alcohol-based handrub before

operations by surgical personnel

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Indications for Hand Hygiene-CDC

When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial or antimicrobial soap and water.

If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands.

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Specific Indications for Hand Hygiene

• Before:– Patient contact – Donning gloves when inserting a CVC– Inserting urinary catheters, peripheral vascular

catheters, or other invasive devices that don’t require surgery

• After:– Contact with a patient’s skin – Contact with body fluids or excretions, non-intact

skin, wound dressings– Removing gloves

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Recommended Hand Hygiene Technique

• Handrubs– Apply to palm of one hand, rub hands

together covering all surfaces until dry

– Volume: based on manufacturer

• Handwashing – Wet hands with water, apply soap, rub hands

together for at least 15 seconds

– Rinse and dry with disposable towel

– Use towel to turn off faucet

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Additional Safety Concerns

Reduce the Potential of Patient Harm resulting from falls

Falls in the Elderly

• Falls are a leading cause of death in people 65 and older.

• Approximately 50% of those that fall suffer injuries that reduce mobility and independence. One third of those that sustain hip fractures require nursing home placement

• Ten percent of fatal falls for older adults occur in hospitals.

Fall Risk Factors

• >65 years of age• Inability to

understand or follow directions

• Confusion• Altered level of

consciousness/ delirium• Inability to use call

light

• Impaired vision or mobility

• Unsteady gait• Dizziness/fainting • Recent history of

falls

Fall Risk Factors

• Medication Therapy• Hx of

nocturnal/urgency/ frequency in elimination

• Hx of seizures

• Surgical Procedure• Orthostatic

hypotension or hypertension

• Children in cribs• Use of assistive

devices

Meds Requiring Fall Alert

• Tricyclic Antidepressants• Antipsychotics• Sedative-Hypnotics• Antihypertensives• Antihistamine/Anticholinergics• Hypoglycemic agents• Diuretics/Laxatives• Anticonvulsants• Muscle Relaxants

• Narcotic Analgesics

Fall Assessment-High Risk

• Identify high risk patients and communicate

to staff-Morse Fall Scale• Place yellow fall identification band on

patients wrist• Observe patients identified at risk for falls

every 2 hours• Review patient’s medications that may

increase the risk of falls on a daily basis.

Interventions- Initiate Safety Measures

• Dangle feet from bed prior to sitting/ambulation

• Assist with ambulation• Apply fall alert ID

armband• Place bed/chair in low

position• Ensure correct use of

least restraint

• Free environment of clutter

• Review medications• Consider

interdisciplinary consult• Document assessment,

interventions, response• Educate patient &

significant others

Additional Safety Concerns

Prevent health care–associated pressure

Ulcers

• Assess high risk patients

• Turn every 2 hours

• Keep patient dry and clean

• Promote good nutrition

2012 Patient Safety Goals

The organization identifies safety risks inherentin its patient population.

Nurses must identify individuals who are atincreased risk of injury and implement safety interventions.

High Risk Patient Populations

• Elderly

• Pediatric

• Language Barriers

• Vision Impairment

Case Study

An elderly blind patient was hospitalizedfor treatment of a deep vein thrombosis(clot).His discharge medications included injectionsof a anti coagulant. A nurse and pharmacistprovided the patient with written informationsheets and counseling regarding selfadministration of his medications. Neithernoticed that the patient was blind.

Reference: http://www.ahrq.gov

Case Study

Several days following discharge the

patient called the office and told the nurse

he had a bag full of medications including

injections, but he had not taken any of

them since he could not read the

instructions. The patient had to be

readmitted to the hospital for continuation

of anticoagulate therapy.

What Happened?

• False assumptions regarding the patients visual acuity

• Inadequate discharge teaching. Written information is insufficient.

• They did not have the patient return demonstrate the injection procedure.

• Over 1 million persons living in the US are legally blind. Proper assessment is essential to patient education.

Interventions For High Risk Patients

• Medication training/competency

• Interpreter use

• Available patient education materials

Large print

• Available outside resources

Case Study

Following an overdose a 26 year old

woman was admitted for observation with

a 72 hour hold by psychiatry. A 24 - hour

attendant was placed with the patient. The

patient was to go to x-ray but requested to go to

the bathroom first. She was left in the bathroom

alone. The attendant and transporter began to

talk. Reference: http://www.ahrq.gov

Case Study

Upon return to patients room, the nurse

became concerned and found patient with her

gown tied around her neck, standing on the

upside down garbage can. She was seconds

from stepping off and hanging herself.

Fortunately no harm came to the patient.

NEVER LEAVE PATIENT UNATTENDED

Psychiatric Patients

• Review of 76 cases found only 40% of inpatients who committed suicide were admitted for suicidal ideation.

• Prevention Strategies- Assessment, safe environments, use of a one to one attendant,

Never leave patient alone

2012 Patient Safety Goal

Conduct a pre procedure verification Process

• A. Conducting a Pre-Procedure Verification Process

• B. Marking the Procedure Site

• C. Performing a Time-Out

Patient Safety Considerations

Encourage patients’ active involvement in their own care as a patient safety strategy.

Improve recognition and response to change in a patients condition. Many hospitals have instituted rapid response teams which usually consist of a nurse, respiratory therapist and other health care team members who respond to a patient in need.

Patient/Family

Patients and family members can provide additional safety checks.

Encourage patients and families to ask questions.

Inform patients of their rights. Educate patients and family members on all

aspects of their care. Provide written material as well as verbal.

Available Resources for Patient Education include

• Institute for Safe Medication Practices

access www.ismp.org• Agency for Healthcare Research & Quality -

access www.ahrq.govhttp://www.ihi.org/IHI/• Institute for Healthcare Improvement access:

http://www.ihi.org/IHI/

TEAM WORK IS THE KEY