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