|
Quality and Satisfaction
The Joint Commission
2009 National Patient Safety Goals for Hospitals
Goal 1
Patient Identification
- Use 2 patient identifiers whenever providing care, treatment, or services and blood transfusions
- Blood transfusions require 2 person check
- When involvement of patient not possible, involve the family
- Full Name and birth date
- Verify against something; chart, MAR, ID
Goal 2
Communication
- Read back the complete order or critical test result. VORB date and time orders
- DOCUMENT critical lab called/to whom/when called
- Be familiar with the “do not use” abbreviations
- Situation, background, assessment, recommendation
- (SBAR) give concise hand-off communications
Goal 3
Medication Safety
- Standardize and limit drug concentrations available
- Identify a list of look-alike/sound-alike drugs
- Label all medications, med containers, or other solutions on or off sterile field. Do not draw up more than one syringe at a time. Draw up one--label one
- Reduce harm with anticoagulant therapy
|
Quality and Patient Satisfaction Data
Faith Regional Awards
National Patient Safety Goals
Speak Up Program: Help Prevent Errors in Your Care
Patient Safety Guide
Quality and Patient Safety Resources |
Goal 7
Health Care-Associated Iinfection
- Comply with hand washing guidelines
- Use hand gel
- Wash hand for 15 seconds
- NO HAND GEL for C-diff patients
- Sanitize hands before and after procedures,
IV’s, medications, etc.
- Practices to prevent Central blood stream infections: use of maximum sterile barrier with insertion, avoidance of femoral vein for access, use of chlorohexidine antiseptic, disinfect hubs and injection ports before accessing
- Practices to prevent surgical site infections: follow SCIP core measure indicators; no razors-clippers only
Goal 8
Medication Reconciliation
- Complete list of medications compiled on entry to facility, inclusive of dose, route and freq**
- Home Medications reconciled with those given during visit. Discrepancies documented on chart
- Transfer reconciliation required/handoff communication needed
- Reconciled discharge med list given to patient on departure, with documentation of education given to patient and copy forwarded to next provider of care
Goal 9
Reduce the Risk of Harm from Falls
- Implement a fall reduction program to reduce the risk of patient harm from falls
- Risk assessment on entry to facility
- Risk assessment will be done in ED, outpatient as well as inpatient areas
- Reassess fall risk every shift
- Falling Star for Fall Risk
- Use bed alarms as needed
Goal 13
Patient Involvement
- Encourage patient’s active involvement in their own care as a patient safety strategy
- Documentation of pt educ on hand hygiene, resp hygiene, contact precautions within 48 hrs of admit. Pt educ re: surgical adverse events/infections
- SPEAK UP
Goal 15
Identify Safety Risks
- Identify safety risks inherent in our patient population, especially patients at risk for suicide
- Home oxygen safety/fire safety
Universal Protocol
- Procedure verification use pre-procedure checklist for OR, cath lab
- Site marking for procedures involving incision or percutaneous puncture, completed by person DOING procedure. Site marking done prior to moving to procedure area and with patients involvement
- Time outs active communication with whole team verifying correct patient, correct site, correct procedure, correct equipment, informed consent done, prophylactic antibiotics
- within 1 hour of incision. Time outs must be documented.
Goal 16
Rapid Response Teams
- Improve recognition and response to changes in a patient’s condition
- Rapid response teams (RRT Teams) enable staff and families to request assistance from specially trained individuals when the patient’s condition appears to be worsening
Last Updated: 10/10/2008
|
