nqf 34 patient safety practices for hospitals 2010 part 2 of 2

NQF 34 Patient Safety Practices for Hospitals 2010

Part 2 of 2

2

Speaker Sue Dill Calloway RN, Esq.

CPHRM

AD, BA, BSN, MSN, JD

Medical Legal consultant

5447 Fawnbrook Lane

Dublin, Ohio 43017

[email protected]

614 791-1481

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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

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Culture SP 1

Information Management & Continuity of Care

Medication Management

Hospital Acquired Infections

Condition & Site Specific Practices

Consent & Disclosure

Wrong-siteSx Prevention

Periop. MIPrevention

Press. Ulcer Prevention

DVT/VTE Prevention

Anticoag. Therapy

Asp +VAP Prevention

Central V. CathBSI Prevention

Sx Site Inf.Prevention

Contrast Media Use

Hand Hygiene InfluenzaPrevention

PharmacistCentral Role

Med Recon.

Std. Med Labeling & Pkg

High AlertMeds

Unit DoseMedications

Evidence-Based Ref.

Culture

CPOE

OrderRead-back

Abbreviations Discharge System

CriticalCare Info.

LabelingStudies

Culture Meas.,F.B, & Interv.

Structures& Systems

ID Mitigation Risk & Hazards

Team Training& Team Interv.CHAPTER 1: Background

Summary, and Set of Safe Practices

CHAPTERS 2-8 : Practices By Subject

Nursing Workforce ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers

• ICU Care

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

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

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 Ventilator-

Associated 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

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Informed Consent & Disclosure• Informed Consent

• Life-Sustaining Treatment• Disclosure


CHAPTER 7: Healthcare-Associated Infections• Hand Hygiene (Safe Practice 19)

• Influenza Prevention (Safe Practice 20)• Central Line Associated Blood Stream Infection Prevention (SP 21P

• Surgical Site Infection Prevention (Safe Practice 22)• Care of the Ventilated Patient (Safe Practice 23)

• Multidrug-Resistant Organism Prevention (Safe Practice 24)• Catheter-Associated Urinary Tract Infection Prevention (SP 25)

2010 NQF Report

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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

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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,

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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

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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

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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

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TJC NPSG FAQ

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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

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www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

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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

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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

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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.aspx

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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

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CDC Website

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Keystone Project Changes Everything

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Pa Patient Safety Toolkit

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www.ihi.org

Revised How to Kit Central Lines

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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)

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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

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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

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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

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 targeted32

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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

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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

Safe Practice 22 Surgical Site Infection Surgical site infection prevention

Take actions to prevent surgical-site infections by implementing evidence-based 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

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Four Changes to TJC 2011 NPSG

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July 1, 2010 ChangesNPSG.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)

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July 1, 2010 ChangesNPSG.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)

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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

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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

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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

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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

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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

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

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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

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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

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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 requirement49

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

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24 MDRO Prevention LD assigns responsibility for oversight and coordination of the

development, testing, and implementation of a MDRO prevention program

Inf ection 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

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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 equipement52

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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

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

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TJC NPSG MRDO1. 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

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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

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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

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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

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.

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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)

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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

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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,

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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,

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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,

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

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AHRQ Patient Safety Handbook Cp 42

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http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html

Pa Patient Safety Authority Toolkit

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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

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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

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Resources

IHI how to guide on preventing CAUTI

at http://www.ihi.org/IHI/Programs/ImprovementMap/PreventCatheterAssociatedUrinaryTractInfections.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/PracticeGuidance/APICEliminationGuides/CAUTI_Guide1.htm

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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

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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 stakeholders76

Culture SP 1

Information Management & Continuity of Care

Medication Management

Hospital Acquired Infections

Condition & Site Specific Practices


Wrong siteSx Prevention

Peri-Op MIPrevention

Press. Ulcer Prevention

DVT/VTE Prevention

Anticoag Therapy

Asp +VAP Prevention

Central V. CathBSI Prevention

Sx Site Inf.Prevention

Contrast Media Use

Hand Hygiene InfluenzaPrevention

PharmacistCentral Role

Med Recon.

Std. Med Labeling & Pkg

High AlertMeds

Unit DoseMedications

EvidenceBased Ref.

Culture

CPOE

OrderRead-back

Abbreviations Discharge System

CriticalCare Info.

LabelingStudies

Culture Meas.,F.B., & Interv.

Structures& Systems

ID Mitigation Risk & Hazards

Team Training& Team Interv.CHAPTER 1: Background

Summary, and Set of Safe Practices

CHAPTERS 2-8 : Practices By Subject

Nursing Workforce ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers

• ICU Care

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

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

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 Ventilator-

Associated 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

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Informed Consent & Disclosure• Informed Consent

• Life-Sustaining Treatment• Disclosure


CHAPTER 8: Condition- or Site-Specific Practices Wrong Site Surgery (Safe Practice 26)

• Pressure Ulcer Prevention (Safe Practice 27)• Venous Thromboembolism Prevention (Safe Practice 28)

• Anticoagulation Therapy (Safe Practice 29)• Contrast Media-Induced Renal Failure Prevention (SP 30)

• Organ Donation (Safe Practice 31)• Glycemic Control (Safe Practice 32)

• Fall Prevention (Safe Practice 33)• Pediatric Imaging (Safe Practice 34)

2007 NQF Report

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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/PatientSafetyTools/PWSS/Pages/home.aspx

Patient Safety Handbook has chapter also at www.ahrq.gov/qual/nurseshdbk/

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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

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Pa Patient Safety Toolkit

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Time Out Towel

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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

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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/

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MN Hospital Association Safe Skin

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AHRQ Patient Safety Handbook Chapter 12

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NPUAP Staging System

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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 PU90

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

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www.jcrinc.com/Pressure-Ulcer-Prevention-Project-Home/

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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

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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.

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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

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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

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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

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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

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

114

http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/cin/Pages/home.aspx

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_supplementary_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 now116

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 evidence- based 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

125

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

126

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

128

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.

130

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

131

Intervention Strategies

Intervention

Level of Risk Area of Risk

High

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

132

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 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

34. Pediatric Imaging

When CT imaging studies are undertaken on children, “child-size” 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

135

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

137

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

138

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

141

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

144

Recommendations

ACR, as part of Alliance for Radiation Safety, has imaging card for patients, especially kids1

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

147

The End Questions Sue Dill Calloway RN, Esq.

CPHRM

AD, BA, BSN, MSN, JD

Medical Legal consultant

5447 Fawnbrook Lane

Dublin, Ohio 43017

[email protected]

614 791-1481

TJC NPSG UP and Resources 147147

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.cfm,

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 Awareness-patient safety modules www.jhsph.edu/ctlt/training/online/patient_safety.html,

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. 2001:345:1359-1367.

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 Institute- www.premiereinc.com and has section on framework for safety culture and reporting (www.premierinc.com/all/safety/resources/patient_safety/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 web-http://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 Forum- http://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/capsLink/,

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/capsLink/,

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 Pa- http://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 Safetywww.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.e-tmf.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/pub/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.ama-assn.org/ama1/pub/upload/mm/369/ceja_rep_106_0104.pdf,

AMA Physicians and Disruptive Physician packet, July 2004, at http://www.ama-assn.org/ama1/pub/upload/mm/21/disruptive_physician.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/nursestaff/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

180

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,

182

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,

183


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

184


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

185

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,

186

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,

187

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

188

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,

189

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,

190

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,

191

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,

192

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,

193

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

194

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,

nqf 34 patient safety practices for hospitals 2010 part 2 of 2

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