Health Occupation Student Orientation Module 4: Provision of Care

Health Occupation Student

Orientation Module 4: Provision of Care

PATIENT SAFETY GOALSSection 1

Patient Safety Goals / Initiatives

Background

Patient Safety Goals were first established in 2002 by the Joint Commission to help accredited hospitals address specific areas of concern in regards to patient safety.

These goals are hospital regulatory requirements that must be met. Accreditation surveys evaluate hospitals for goal implementation.

Each year the list of patient safety goals is reviewed and updated by a panel of widely recognized patient safety experts.

The following slides describe our practices for some of these goals.

Patient Safety GoalImprove Accuracy of Patient Identification

Use 2 Patient Identifiers Identifiers - Name and Date of Birth Check/scan armband and ask patient

to state their name

When to Check Patient Identifiers: Ordering/delivering meals Collecting / labeling specimens Administering Medications Blood Administration Prior to procedures, treatments and

transport

Patient Safety GoalImprove Communication – Physician Orders

Validate Completeness and Accuracy of Verbal or Telephone Orders Write Down the order, Read Back the

order

Document as VORB or TORB

Verbal Med Orders limited to emergencies only e.g codes

Patient Safety GoalImprove Communication – Physician Orders

UNACCEPTABLE ACCEPTABLE

“IU”Write out the words “International units”

“QD” or “QOD“ Write “daily” or “every other day”

“MS”, “MS04”, “MgSO4”Write Morphine Sulfate or Magnesium Sulfate

Use of “Trailing” zero’s (i.e. 5.0mg)

Omit trailing zero’s (i.e. 5 mg)

Omission of leading zero’s (i.e. .5mg)

Use leading zero’s (i.e. 0.5mg)

“U” or “u” Spell out the word “units

BIW Write “twice a week”

DPT Write Demerol-Phenergan-Thorazine

Dram Write “ Teaspoonful”

Minum Write “drop”

DO NOT USE Abbreviations shown at right which are known to increase risk of errors.

Physician orders containing an unapproved abbreviation must be clarified with the ordering physician.

Patient Safety GoalImprove Communication – Hand Off Report

Give an Effective “Handoff” Report When To Do a Handoff:

Change of shift; transfer to different care unit; sending patient to diagnostic imaging etc.

Your Role: make sure you give a verbal report to the primary RN before leaving each day.

What To Include in Report:

Patient’s condition, treatments, medications, services, Fall risk, isolation, code status and any recent and/or anticipated changes

Limit interruptions, provide opportunity for receiver to ask/respond to questions

An estimated 80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off.

Patient Safety Goal

Improve Communication - Patients

What Needs Interpreting Patient intake H&P Consent Discharge instructions

Who Can Interpret: Bilingual staff may interpret non-clinical

information only

Family members and friends should not be used. However, if patient insists, a certified interpreter must also be present

Hospital Approved Interpreters - ask the primary RN or Charge RN about these

Language Barriers: Pacific Interpreters

Hearing Impairment: American Sign Language; TTY and TDD devices available

Patient has the right to make

informed decisions

regarding his/her care.

Patient Safety GoalImprove Communication - Patients

Use Patient – Staff Communication Boards Purpose: keep patients

informed

Boards are located in inpatient rooms – 1 per patient

Update beginning of shift during handoff report

White BoardsExamples of What

to Record:

Date

Nurse

Care Partner

Doctor

Daily Goals

Patient Safety GoalImprove Communication - Patients

Round on Patients: When:

Every 1 – 2 hours When providing services

Accomplish scheduled tasks

Address 4 P’s (pain, toileting, positioning and personal items nearby – call light, phone etc)

Conduct environmental assessment (bed alarms set, IV pumps etc)

Ask “Is there anything else I can do for you before I go?

Communicate unmet needs to nursing

Document the round on the white board

The Four P’s

Pain

Potty

Position

Personal

Patient Safety GoalImprove Communication – Among Caregivers

Call Critical Test Results PromptlyCritical (emergent) test results have been defined by the lab. These test results include critical values for blood glucose testing.

All critical values must be called to the physician within 60 minutes of being resulted.

Student Role: Notify the Primary RN immediately if a critical value is obtained when performing blood glucose testing.

Document: Date/time of notification; Who was notified; Value reported; Readback obtained (RBO)

Patient Safety GoalImprove Communication – Among Caregivers

Check Safety Arm Bands – look for these high alert arm bands

Applied to same limb; exception: limb restriction applied to affected limb.

Allergy Band: everyone one gets an allergy band! If no allergies, write NKA on the band. DO NOT list allergies on the band.

DNR Band: optional - patient may decline to wear armband. If declined, inform patient that without the communication band we may not be able to comply with their preferences.

Document application / removal in nurses notes.

Yellow Fall Risk

Pink Limb Restriction

Red Allergy

Blue Isolation

Purple Do Not Attempt Resuscitation

Patient Safety GoalImprove Recognition/Response to Changes in Patient Condition

Rapid Response TeamWhen to Call: Concern about worsening patient condition: airway/breathing problems, neuro changes, circulation problems

Student Role: If possible, check with the primary RN or Charge RN immediately for change in patient condition before calling RRT.

How to Call: Dial 7101 and enter 50. State “Rapid Response Team to _________” and identify location.

Who Responds: ICU RN, RT, Admin Sup

Patient Safety GoalPrevent Hospital Acquired Conditions

The Center for Medicare Services (CMS) has identified a number of hospital – acquired conditions that are high cost or high volume or both and could reasonably be prevented with implementation of evidenced-based practice guidelines.

Occurrence of these conditions can significantly impact patient quality of life as well as hospital reimbursement for care.

Current care guidelines are described on the following slides.

Hospital Acquired Conditions

Pressure Ulcers

Falls

Deep Vein Thrombosis

Patient Safety GoalPrevent Hospital Acquired Conditions – FALLS

Prevent Patient Falls

Who Is At Risk: patient with

History of falls

Unsteady gait; poor balance, use of ambulatory aid

Multiple health problems e.g. diabetes, lung disease, heart problems

Mental status – overestimates or forgets limitations

Patient Safety GoalPrevent Hospital Acquired Conditions – FALLS

Standard Interventions for All Patients

Maintain Safe Environment: Adequate lighting in room – night

lite or bathroom lite as indicated Room Free of Clutter /

Obstructions / trip hazards Bed in low position, wheels

locked. Call light within reach Personal, frequently used objects

within reach

Monitor Round Frequently (every 1-2

hours)

Be Alert - investigate noises in patient areas

Directly (visual observation) or indirectly (within hearing) supervise patient while in bathroom

Other Provide non-skid foot ware Obtain assist devices normally

used by patient.

Patient Safety GoalPrevent Hospital Acquired Conditions – FALLS

Interventions for High Risk Patient

Communicate Risk: Yellow slippers, armbands and Fall Risk

door signage

Implement actions to prevent falls Assist out of bed/chair

Use of mobility devices

Do not leave patient unattended in bath room – keep within arms reach

Use Safety Devices Activate Bed alarms: verify bed connected

to call light system and bed alarm activated

Patient Safety GoalPrevent Hospital Acquired Conditions – Pressure Ulcers

Prevent Pressure UlcersWho is At Risk: patients with

Limited ability to change or control body position

Inadequate food intake Sensory impairment in extremities;

limited responsiveness Bed bound or chair bound – not

ambulating Skin frequently moist due to urine or

stool

Patient Safety GoalPrevent Hospital Acquired Conditions – Pressure Ulcers

Promptly Report to RN:

Observed red/pink areas or skin breakdown especially over bony prominences or under devices e.g. nasal cannulas, SCDs, anti-embolic hose etc.

Patient Safety GoalPrevent Hospital Acquired Conditions – Pressure Ulcers

Preventive Interventions - Save Our Patients Skin

SSurface

Keep linen wrinkle free.

Check for plastic caps in bed.

Monitor for device-related pressure areas e.g. O2 tubing, cervical collars, SCDs, anti-embolic hose.

Cushion / protect skin in high risk areas.

KKeep Turning

Float heels.

Turn, turn, turn.

IIncontinence

Offer assistance with toileting.

Notify staff if patient incontinent.

Use skin cleansers/moisturizers promptly after each episode of incontinence.

NNutrition

Provide assistance with meals.

Ensure access to supplements.

Accurately document intake and output.

Patient Safety GoalPrevent Hospital Acquired Conditions – VTE What is VTE:

Venous thromboembolism (VTE) is a blood clot that forms in the deep veins (DVT), breaks off and travels in the veins to the lungs. It can become a life-threatening pulmonary embolism (PE).

Who is at Risk: Older patient Major surgery; orthopedic surgery Immobility Trauma Central line Obesity Positive history for DVT or PE

If at High Risk: Sequential Compression Devices (SCDs): If ordered, ensure

they are correctly applied and turned on when in bed and up in chair;

Anti-Embolic Hose: if ordered, remove every shift x 30 minutes; monitor skin for breakdown

Patient Safety GoalIdentify Patient Safety Risk - Suicide

Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Who is at Risk: appropriate patients are assessed for mental illness, chemical impairment, suicidal ideation or judgment deficits that pose risk of harm to self or others.

Safety Precautions: Depending on Assessed Risk Level, Precautions May Include:

Frequent close observation; sitter if indicated

Maintain safe environment: removal of equipment and supplies and objects from patient room that could be used for self harm; use of plastic utensils and paper goods.

Provide prevention information (crisis hotline) at time of discharge.

Patient Safety GoalPrevent Wrong Site/Procedure/Person Surgery

1.Pre-Procedure Verification: verify the following

Signed consent which matches physician order

Updated history and physical; pre-anesthesia assessment

Diagnostic test results available Procedure prep requirements met Any required blood products,

implants devices and/or special equipment available

SCIP measures met e.g. antibiotics given

2. Surgical Site Marking

Required for all incisions, punctures and insertions

Performed by Surgeon, PAs (SJH only)

or Proceduralist

Involves patient

Permanent marker used to write initials near surgical site; Visible after draping

The Universal Protocol Elements: apply to all settings including bedside procedures where consent is required.

Patient Safety GoalPrevent Wrong Site/Procedure/Person Surgery

3. Procedural Time Out Every one participates

Correct patient, procedure, consent,

Correct position/site/side; visible site mark

Antibiotics given; prep agent and fire risk score; safety precautions for patient history/med use taken

Relevant images and results

Implants, blood /blood products and special equipment available if applicable

Recognition / Prevention – Malnutrition/Aspiration

Malnutrition and Aspiration Who is at Risk: patients are

screened on admission for the risk factors shown at right.

Measures to Reduce Risk:

Assist patients with meals as indicated;

Provide / encourage consumption of supplements etc.

Document diet intake – if it isn’t documented we cannot evaluate how are patient is doing.

Risk Factors

•Unintentional weight loss

•Decreased appetite

•Difficulty eating

•Contributing Minor/Chronic Diseases or Factors e.g. renal disease, pressure ulcers, tube feeding,

Infection Recognition - Sepsis/Severe Sepsis

What is Sepsis: Sepsis is a potentially life-threatening complication of an infection. It occurs when chemicals released into the bloodstream to fight infection trigger inflammation throughout the body. Inflammation can damage multiple organ systems, causing them to fail.

If sepsis progresses to septic shock, blood pressure drops dramatically, which may lead to death.

Early recognition and treatment of sepsis is essential.

Sepsis Screening is completed on Admission and Every Shift by the RN

Infection Recognition - Sepsis/Severe Sepsis

Your Role: Promptly report to the RN vital sign changes that match sepsis criteria.

Severe Sepsis Criteria

MAP < 65 mmHg x2

Creatinine > 2mg/dl

ALOC

SBP <90 x2

SBP 40 mmHg

New or O2 Needs

UO <5mg/kg/hr x >2 hrs

Bilirubin > 2mg/dl

INR >1.5 or PTT >60 sec

Lactate > 4 mmol/L

SIRS* Criteria

SIRS = 2 or more criteria met

Heart Rate >/=90

Temp =/>38 C or < 36 C

RR >/= 20

WBC <4 >12 or >10% bands

SIRS* Systemic Inflammatory Response Syndrome

Adverse Event Prevention – Tubing Misconnections

The ProblemThe following events were reported by the Food

and Drug Administration. Blood pressure tubing connected to IV line by

family member – patient died. IV tubing connected to nasal cannula – patient

went into CHF. IV tubing connected to feeding tube by family

member – no harm as identified quickly. Feeding tube connected to trach tube –

patient died. IV Tubing connected to trach cuff – patient

died. Oxygen tubing attached to IV tubing – patient

died.

Adverse Event Prevention – Tubing Misconnections

The Solution Increase lighting in a darkened room before

connecting or reconnecting tubes or devices. Trace the tube or catheter from the patient to point

of origin. Do NOT force connections Never use a standard luer-lock syringe for oral

medications or enteric feedings – use slip tip syringe.

Reconcile lines as part of handoff with change of shift, patient transfer, return from procedure.

Patient / family education – DO NOT connect or disconnect lines. Get help!

Adverse Event Prevention

Use Tubing Labels

Place label on the tubing adjacent to the connection site – where tubing connects to patient

Continue to use IV Tubing Change Stickers (Mon, Tues etc.)

CENTRAL LINE Attach to IV tubing going to CL

PERIPHERAL LINE Attach to IV tubing going to peripheral line

ARTERIAL LINE Attach to IV tubing going to arterial line

ADDITIVE Attach to IV tubing of any IV solution that has med added i.e. NS with KCL

IRRIGATION Attach to irrigation tubing

DRAIN Attach to drain – urinary catheter, hemovac, jackson pratt, penrose, NG

ENTERAL FEEDING

Attach to formula tubing

FEEDING TUBE Attach to feeding tube – G-tube, J-tube, nasal feeding, PEG tube, Keofeed

OTHER

RESTRAINTSSection 2

RESTRAINT

Indications for Use

Non Violent Behavior

Attempting to pull out tubes, drains, or other lines medically necessary for treatment and is unable to comply with safety instructions

Attempting to get out of bed and unsteady gait – at risk of falling and is non compliant with safety instructions.

Violent, Self Destructive Behavior

Physically assaultive to others or is highly agitated and assaultive behavior is pre-eminent e.g. Code Grey - type individuals

Physically harmful to self (i.e. attempting suicide, self-mutilation, hurting self, etc.)

Patient behaviors that may lead to the use of restraints fall into two categories as described below:

RESTRAINT

Indications for Use

Before restraints can be initiated for these patient at-risk behaviors:

Causal Factors are Considered: Identify medical problems that could be causing

behavioral changes e.g. increased temp, hypoxia, low blood sugar, electrolyte imbalance, drug-drug interactions

Alternatives Considered / Attempted: Hiding tubes/lines, frequent rounding, reorientation,

family intervention, companionship, mobility, distraction e.g. folding wash cloths; use of alarm devices

Physician Order is Obtained: only RN’s or Physicians can initiate use of restraints;

RESTRAINT

Plan of Care – Student Role

Non Violent Observe for safety Q60

minutes

Monitor/Assess Every 2 Hours

Self Violent, Destructive Observe for safety the patient

Q 15 minutes

Monitor/Assess Every 1 Hour

Monitor / Assess for:

Observe patient/device for correct application – doing no harm

Remove device and provide ROM

Provide for personal care needs – toileting, food, fluids, pain medication

Take vital signs as ordered- Promptly report any changes or concerns to RN

RESTRAINT RESTRAINT

Devices / Safe Application

General Guidelines: Proper body alignment Call button can be used Patient’s head is free to rotate when in the supine

position. When possible, head of bed slightly elevated to reduce risk of aspiration.

Secure straps to bed or chair frame out of the patient’s reach using quick-release ties. DO NOT secure to mattress or side rail

Side Rails Three side rails up equals safety Four side rails up equals restraint except for

situations such as seizure precautions, age appropriate, pre/post anesthetic/sedative meds, vest restraint usage.

Note: gap in side rails must be covered when used with vest.

RESTRAINT RESTRAINT

Devices / Safe Application

Wrist Restraints Apply Correctly: Allow

one finger width between skin and device to ensure adequate circulation

Remember to remove restraint and provide ROM every 2 hours.

Monitor Use: soft tissue not too tight cutting of blood flow, causing limb swelling or skin abrasions.

Vest Restraints Ensure right size and fit: Must

fit at the waist and enable one flat hand to easily go under waist band.

Apply correctly: Opening in the back; DO NOT criss-cross straps directly behind patient; side rails up with gap pads

Monitor Use: device not “choking” patient or impairing breathing

Abuse, Assault and Neglect Reporting

Section 3

Abuse, Assault, Neglect Reporting

Who has Duty to Report? All physicians and health care providers

What Must be Reported: Abuse of Patients Received from

Licensed Health Facilities Abuse of Elders and Dependant Adults Child Abuse Sexual Assault Adult Patient Abuse or Assault (includes

spousal and domestic abuse)

Abuse, Assault, Neglect Reporting

THE PATIENT:

History is incompatible with injuries.

Has unusual injuries and/or unexplained bruises, lacerations, fractures or multiple injuries in various stages of healing.

Presents with malnutrition or dehydration (not illness related), failure to thrive and/or poor physical hygiene.

Has repeated ER visits, hospitalizations or a history of prior physical abuse.

Delayed in seeking medical care.

THE PARENT / SPOUSE / CAREPROVIDER:

Refuses to leave the patient’s presence despite the patient’s wishes.

Offers conflicting, unconvincing or no explanation for patient’s injury.

Delayed in getting medical care for the patient.

Action to TakeNotify the primary RN immediately of

your suspicions.

How to Identify Possible Victims

Consider the possibility when: