Communication NPSG Data.pdf
National Patient Safety Goal Data: Communication
NPSG 2: Improving Effectiveness of Communication— Critical Results
63 58
62
75 68
56 57
82
77 78 82 80
0
25
50
75
100
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Hospital-Wide Compliance of Reporting Critical Results within 60 Minutes as Evidenced by Documentation
January–December
NPSG 2: Improving Effectiveness of Communication— Verbal Orders/Read-Backs
97 97
62
96 91
100 98 99
0
25
50
75
100
%
CC U
Te le
O rt ho
M ed
ic al U
ni t
Su rg
ic al U
ni t
ED
En do
sc op
y
PA CU
Verbal Order/Read Back Audits
Fiscal Year to Date
NPSG 2: Improving Effectiveness of Communication— Unacceptable Abbreviations
99.6%
Universal Protocol
Communication Preprocecure Handoff.pdf
Preprocedure Hand-Off
Y N
Identification / allergy armband on patient’s arm?
Do Not Resuscitate (DNR) status: ___________________________________________________
Allergies :
Latex allergy?
Isolation Status?
Patient seen by Anesthesia?
Consent form signed?
History & physical on chart?
Lab, chest x-ray, electrocardiogram on chart if ordered?
Medication Administration Record (MAR) / transfer medication form on chart?
Type and screen completed?
Units of blood ordered?
Transport sheet prepared?
Intravenous sites / tubing labeled?
Preop medications given and time? __________________________________________________
Preop antibiotic administered to patient on unit @ what time?_______________________________
Preop antibiotic sent to OR with patient?_______________________________________________
Dentures removed?
Glasses / contacts removed?
Hearing aid removed?
Metal implants? If yes, where?
Jewelry removed or Patient refused to sign “Jewelry Removal” form to be placed on chart?
Clothing / underwear removed?
Primary language is English. If no, primary language is ______________________________________
Patient’s contact person /information?
“NPO” (since ________________)
Voided? (@ _________________)
Operative site marked?
Time: Last Vital Signs: Temperature? Blood Pressure?
Respirations? Pulse?
Messages to Operating Room ?________________________________________________________
Nurse HANDING OFF patient : ____________________________Date: _________ Time: _______
Nurse ACCEPTING patient: ____________________________Date: _________ Time: _______
Communication Site Identification Policy.pdf
Site Identification and Verification (Universal Protocol)
Policy
Wrong-site, wrong-procedure, and wrong-person surgery can be prevented. This universal protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and endorsed by hospital administration.
In developing this protocol, consensus was reached on the following principles:
Wrong-site, wrong-procedure, wrong-person surgery can and must be prevented.
A robust approach—using multiple, complementary strategies—is necessary to achieve the goal of eliminating wrong-site, wrong -procedure, wrong-person surgery.
Active involvement and effective communication among all members of the patient care team is important for success.
To the extent possible, the patient (or legally designated representative) should be involved in the process.
Consistent implementation of a standardized approach using a universal, consensus-based protocol will be most effective.
The protocol should be flexible enough to allow for implementation with appropriate adaptation when required to meet specific patient needs.
A requirement for site marking should focus on cases involving right/left distinction, multiple structures (fingers, toes), or levels (spine).
The policy/procedure should be applicable or adaptable to all operative and other invasive procedures that expose patients to harm, including procedures done in settings other than the operating room.
Preoperative/Preprocedure Verification Process
Verification of the correct person, procedure, and site will occur (as applicable):
1. At the time of admission/entry to the facility 2. Anytime the responsibility for care of the patient is transferred to another caregiver 3. With the patient awake and aware, if possible 4. Before the patient leaves the preoperative/preprocedural area 5. Immediately prior to beginning the operative/invasive procedure
Marking the Operative/Invasive Site:
1. All patients undergoing operative or invasive procedures will identify and mark the operative/invasive site prior to the procedure when applicable. 2. Site marking should be done for any procedure that involves laterality, multiple structures, or levels. 3. The mark should be made with a permanent marker that will remain visible after skin prep. 4. X-ray may be used as reference for identifying levels of the spine. 5. Needle localization may be used as reference for identifying breast lesions. 6. In the event any patient refuses to mark the operative/invasive procedure site, the physician will be notified. 7. Sites/procedures exempt from marking include the following:
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Endoscopic procedures
Nasal procedures
Rectal procedures
Cystoscopies
Perineal surgery
T&A’s and M&T’s
Single organ cases (e.g., cesarean section, cardiac surgery)
Abdominal surgery when site is not specified
Interventional sites where insertion site is not determined (e.g., cardiac catheterization, catheter placement)
8. Justification for not marking the site must be documented in the preoperation checklist. 9. If the patient/guardian is unable to mark the site or if there is any confusion concerning the appropriate site/sites, the physician will be notified to identify and mark the site. 10. Patients undergoing procedures that will require sedation or anesthesia will not be transported to the operative suite/procedural room until the site is marked as indicated. 11. Straight local procedures, using no sedation/anesthesia may be taken to OR/Minor Room and marked by the physician. 12. Laterality will be marked by writing RT for right, LT for left or BIL for bilateral as appropriate. 13. Place a “” on visible or palpable lesions (e.g., lipoma, mass, mole) Exception: Breast lesions/masses will be identified by the surgeon. 14. Spines will be marked by writing “C” (cervical), “T” (thoracic), “L” (lumbar), “S” (sacral) in the area of the back representing location and on the side of the spine the patient identifies as having greater pain. Radiographic films may be used intra-operatively to identify precise levels. 15. Teeth do not require marking, however, dental radiographs or diagrams must be marked and available at the time of the procedure.
Patient, Procedure, and Site Verification
Preprocedurally or preoperatively, the nurse providing care to the patient will complete the following:
1. Verify the operative/invasive procedure and site with the patient/guardian 2. Verify the order for the informed consent with the actual informed consent document. If discrepancy exists, notify the physician. 3. If no discrepancies exist between the informed consent and the physician’s order indicating the procedure to be performed, provide the patient/guardian with a permanent black marker and instruct him or her in the following:
When side (right, left, bilateral) is indicated, mark RT (right), LT (left) or BIL (bilateral) to indicate the correct side on which the procedure is being performed.
When a mass or lesion is being removed, place a check mark ( ) on the mass/lesion to identify the appropriate site(s). Exception: Breast lesions/masses will be identified by the surgeon
Care should be taken not to obscure visualization of the lesion.
Markings should be visible once the patient is prepped and draped.
Time-Out Procedure
Immediately prior to beginning the procedure, the nurse or technologist is responsible for calling the time-out. All members of the team have the responsibility to ensure a time-out is called prior to beginning the procedure. The duration and participants of the time-out are documented in the record.
1. The patient’s chart will be used as a reference when calling the time-out. 2. At this time, all personnel involved in the procedure audibly and verbally agree on the following:
Correct patient identity
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Correct side and site
Correct procedure to be done
Correct patient position
Availability of correct implants and any special equipment
Any and all members of the team may request clarification of the correct side or site at any time.
3. In the case of any discrepancies between the consent, medical records, x-rays, imaging studies, pathology reports or any discrepancies between the patient, the patient’s representative, or members of the team, all activities will be halted immediately until verifications can be completed. 4. Patients who are awake during the time-out process should be active participants.
Bedside Procedures
The above policy and procedure must be followed for any procedure that involves laterality, multiple structures, or levels. The site marking is not required if the individual performing the procedure is in continuous attendance with the patient from the time of decision and consent from the patient through to the beginning of the procedure.
Approved by Surgery Leadership Committee
Infection Control Data.pdf
Infection Control Data
Multidrug-Resistant Organisms
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
# o
f In
fe c ti
o n
s
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
R a
te /1
0 0 0
p a
ti e
n t
d a
y s
Rate # of MDRO Rolling Rate
Central Line-Blood Stream Infection
0
1
2
3
4
5
6
7
8
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
# o
f in
fe c ti
o n
s
R a te
/1 0 0 0 p
a ti
e n
t d
a y s
Rate # of CL-BSI Rolling Rate
Page 2
93 92 92 92
96 96
91
94
80
90
100
Hospital-Wide Nursing Ancillary Physician
Hand Hygiene Observed Compliance
Last Year
Current YTD
84 85
97
83
87
75
80
85
90
95
100
Q1 Q2 Q3 Q4 Year End
Central Line Bundle Compliance (Compliance with Evidence-Based Care Standards)
Page 3
78 85 89
95 88
0
20
40
60
80
100
Q1 Q2 Q3 Q4 Year End
MDRO Bundle Compliance (Compliance with Evidence-Based Care Standards)
Infection Control Environmental Rounds Data.pdf
Infection Control: Environmental Rounds Data
Infection Control Management
All Depts Initial
Rounds
Clinical Depts Bi- Annual Rounds
Previous Year 1
Previous Year 2
Previous Year 3
General environment is dust-free including air vents. 79.2% 66.7% 73.0% 83.7% 84.1%
Staff is compliant with food/drink restrictions. 61.5% 53.8% 57.7% 84.6% 80.2%
Refrigerators have appropriate items stored per guidelines (labeled, dated, not expired, etc.). 65.2% 75.0% 70.1% 81.8% 82.8%
All refrigerator temperatures are checked daily. Refrigerators are clean. 79.2% 68.0% 73.6% 76.8% 79.1%
Ice machine is clean. 71.4% 85.7% 78.6% 82.1% 89.0%
Isolation cabinet is on door with appropriate sign and is stocked. 66.7% 80.0% 73.3% 62.5% 92.9%
Negative pressure rooms are @ negative pressure (tissue test) and alarms are functioning at approved settings. 100.0% 100.0% 100.0% 100.0% 100.0%
Patient rooms/bathrooms are clean and free of dust, spills, and excessive trash; walls are clean and rooms are in good repair. 89.5% 80.0% 84.7% 82.5% 61.2%
Clean linen is properly stored. 81.8% 86.4% 84.1% 88.6% 92.5%
Alcohol foam/gel is easily accessible and has not expired. 88.9% 85.2% 87.0% 98.1% 88.5%
Hopper in dirty utility room does not have stagnant water (has been recently flushed). 90.0% 90.0% 90.0% 95.8% 90.0%
Preparation areas/carts are clean and free of any med ‘remnants’. 90.9% 91.3% 91.1% 97.6% 97.2%
Multidose vials are within expiration date; insulin vials are dated. 89.5% 94.4% 92.0% 87.8% 78.0%
Supplies are not expired (e.g.., hemocult, specimen containers/tubes). 94.2% 88.9% 91.6% 91.1% 96.1%
Staff members are compliant with hand hygiene guidelines. 95.7% 100.0% 97.8% 100.0% 100.0%
BGM kits are clean and reagents are not expired. 94.1% 78.6% 86.3% 83.3% 78.6%
Hospital-wide average 83.6% 82.7% 83.2% 88.1% 88.2%
Infection Control SSI Data.pdf
Infection Control: SSI Data
98 100
99 100 100
96 95
97 98 98
97 96
75
80
85
90
95
100
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Antibiotic Selection
50
100 100 100 100 100 97 99
100 100 99 100
50
60
70
80
90
100
Jan Feb M ar Apr M ay Jun Jul Aug Sep Oct Nov Dec
Normathermia
98 99 100 100 100 100 100 99 100 100 100 100
50
60
70
80
90
100
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Appropriate Hair Removal
(Clipping)
98 96 98
87 94 95 94
90 85
92 91 94
50
60
70
80
90
100
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Recommended VTE Prophylaxis
Ordered
Infection Control SSI Focus Review.pdf
CONFIDENTIAL
Executive Summary of Surgical Site Infection Focus Review
The following is the result of the Surgical Site Infection Focus Review from the Joint Commission.
Excellent Patient Care
Rates of surgical site infection (SSI) following colon surgery, abdominal hysterectomy, total hip replacement and spinal fusion were similar to or lower than the mean rates of SSI for similar procedures performed by comparable hospitals. We believe these encouraging data can be used to reinforce and improve on your infection surveillance and prevention efforts.
Areas to Monitor
The rate of SSI following total knee replacement was higher than the mean rate of SSI following similar procedures at comparable hospitals. The difference, however, did not reach statistical significance. We will continue to monitor rates of SSI following these procedures.
In particular, we recommend implementing a system to ensure that appropriate perioperative antimicrobial agents are provided within one hour of incision. In addition, weight-based dosing in obese patients and redosing of antibiotics for prolonged procedures may help reduce rates of SSI. If these high rates continue despite strict adherence with these recommendations, we will assist you in performing a more detailed analysis of the issue.
Areas for Improvement
The rate of SSI in general surgery procedures was statistically higher than the mean rate of SSI following general surgery at comparable hospitals (p=0.0001).
Given this statistically significant difference, we performed additional analyses after stratifying the rate of SSI by the NNIS risk index. The most notable difference was found among patients at highest risk for SSI (NNIS risk index of 2 or greater). While case-mix may have contributed to the overall increase in the rate of SSI following general surgery, highest risk patients had an almost two-times higher rate of SSI following general surgery at Nightingale Memorial Hospital compared to highest risk patients undergoing general surgery at comparable hospitals (4.96/100 procedures vs. 1.79/100 procedures; p=0.01).
Thus, we recommend strict adherence to appropriate antimicrobial prophylaxis, including administering an appropriate agent within one hour prior to incision. In addition, you may consider administering an additional dose if the procedure is greater than 3 hours in length. Finally, we recommend weight-adjusting doses of antibiotics for obese patients.
Infection Control SSI Patient Education.pdf
Infection Control Surveillance Objectives.pdf
Infection Control: Surveillance Objectives
Date: April 23 rd
After reviewing the previous fiscal year data and performing the infection control risk assessment for the hospital, the following will be the surveillance objectives for the coming year:
1. Primary Bloodstream Infections: House-wide surveillance for 12 months. With implementation of infection reduction strategies including six-sigma project, reporting central line infections per 1000 patient days and 1000 central line days house wide, implementing CHG bathing in ICU. Goal: Reduce the CL-BSI rate to < 0.1/1000 patient days by the end of the year
2. ICU Nosocomial Infections: All device-related nosocomial infections for 12 months including central line and ventilator bundle compliance. Goal: “Zero” for CL-BSI and VAP infections and <1.0 FR-UTI/1000 Foley Days.
3. Nosocomial transmission of Multidrug-Resistant Organisms: MRSA/VRE/ESBL/KPC infection surveillance for 12 months. Decrease transmission through extensive MDRO education with focus on patient education, monitor isolation, environmental and equipment practice compliance. Goal: < 0.15 infections/1000 patient days.
4. Nosocomial transmission of C. Diff infection surveillance for 12 months. Reduction in transmission through environmental cleanliness, equipment cleanliness, and proper antibiotic utilization. Goal: < 0.25 infections/1000 patient days.
5. Surgical Site Infections: All clean, surgical procedures per NHSN followed by means of surgeon surveys, lab reports, referrals, unit rounds and coders (readmissions) utilizing the risk adjusted SSI database. Focus reviews of any noted clusters. Goal: < 0.75 infections/100 cases.
6. Surgical Care Infection Prevention: Facilitate committee to include implementing changes to processes to allow Nightingale Community Hospital to meet targets. Improve Evidence Based Score (EBS) compliance related to antibiotic administered within 1 hour, Beta blockers, and VTE prophylaxis. Goal: EBS >90% before the end of the fiscal year.
7. Hand Hygiene Guidelines: Monitor compliance to the hand hygiene policy including use of artificial nails for direct caregivers by direct observations and increased usage of alcohol foam/gel on units and in surgical services. Develop unit ownership and expand availability of products. Evaluate staff’s preference of gel vs. foam and convert if gel preferred. Goal: > 90% compliance rate to hand hygiene through observations.
8. Employee Health: Communicable disease surveillance to include but not limited to TB exposures and immunization compliance including influenza. Goal: “Zero” PPD conversions from TB exposures.
9. Employee Health: Influenza prevention program expansion with 2009–2010 goal of overall 90% immunization rate with each nursing unit reaching at least 75%.
10. Employee Health: Decrease in blood and body fluid exposures through staff awareness and sharps safety compliance with review of safety devices focusing on medical staff exposures. Goal: < 1.2 exposures per 1000 patient days.
11. Nonemployee Health Screening: Continued compliance with nonemployee (LIP, Allied Health Staff, clinical contract) staff for all health requirements with a focus on contract staff. Goal: >95% of staff compliant with employee health requirements prior to beginning employment or contract.
12. CSR PI: Continued monitoring of sterilization documentation and flash utilization in CSR. Goal: Flash rates of < 80 loads/1000 cases.
13. National Patient Safety Goals Compliance: Fully implement and monitor compliance to the National Patient Safety Goals related to Infection Prevention.
Information Management Abbreviation Policy.pdf
Patient Care Policy: Prohibited Abbreviations
Policy
The use of abbreviations and symbols in the medical record is discouraged to prevent errors.
Prohibited abbreviations and/or symbols can be associated with misinterpretation, resulting in medical errors and patient harm. If the intended meaning of an abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification.
See Addendum 1 for a list of medical staff-approved prohibited abbreviations.
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Addendum 1
Information Management Admission Orders A.pdf
NIGHTINGALE COMMUNITY HOSPITAL ADMISSION ORDERS
Authorization is hereby given to dispense the generic equivalent unless otherwise indicated by the physician.
1.
Admit to service of Dr. ________________________ Inpatient Observation Med/Surg Tele ICU
Allergies ___________________________________________________________________________________
Please notify primary care physician of admission (courtesy call)
2. Consults/Education
Cardiologist ______________________Reason____________________ A.M. Routine STAT Hospitalist Reason____________________ A.M. Routine STAT Cardiac Rehab Nutrition Consult Smoking Cessation Education (if applicable): CMS criteria
Case Management Consult
Other consults ________________________________ Reason___________________________________
3. Diet
NPO NPO except medications Low fat 2 grams NA (Sodium) Other (Specify) __________________________________________________________________________ p.o. fluid restriction of: ________________ ml/day
4. Activity
Bed rest with HOB elevated Other:________________________________________________________ Activity as tolerated
5. Vital signs with pulse oximetry
Per unit standard Every 4 hours and as needed □ Cardiac monitor 6. Medications
Tylenol 650 mg p.o. / pr q 4 hours prn mild pain. Do not exceed 4 grams Acetaminophen in 24 hours
Hydrocodone-Help write my thesis – APAP (Norco 5/325 mg) 1-2 tablets p.o. q 6 hours prn moderate pain.
Morphine 2 mg – 4 mg IV q _________ hours prn moderate pain.
Ambien 5mg – 10 mg p.o. qhs prn sleep.
Phenergan 6.25 mg – 12.5 mg IV or 12.5 mg p.o. q 4 hours prn nausea.
Laxative of Choice Antacid of Choice
7. Weigh immediately on admission and every a.m.
8. Intake & Output every shift
9. Labs/Tests May travel off monitor
EKG on admission (if not done in Emergency Department) CBC Basic metabolic panel Magnesium Phosphate Calcium Urinalysis Other____________________________________________________________________
V.O. __________________________________ RB by/______________ Signature ________________________________ M.D. Date ________ Time _______ (All verbal orders must be authenticated within 48 hours)
Patient Identification
ADMISSION ORDERS
PHYSICIAN ORDER FORM
Patient A
Information Management NPSG Data.pdf
1
Number of times it was reported that a labeling error occurred
22
3
Medication Management Medication Administration Policy.pdf
Patient Care Policy: Medication Administration
Policy
Medications are to be administered upon order of a qualified physician, podiatrist, dentist, or other practitioner duly licensed or authorized to prescribe by the state and who has been approved as a member of the medical or allied health staff of Nightingale Community Hospital (NCH). All orders for medication shall be written into the medical record of the patient.
Authority to administer medications is based on formalized education and training, past work experience, in- house training and annual performance appraisals.
Medication Administration at NCH is limited to professional healthcare practitioners listed below within the specifications of established hospital policies and procedures and approved job descriptions:
Physicians
Podiatrists
Physician Assistants
Licensed Nurse Practitioners
Registered Nurses
Licensed Practical Nurse
Nursing students (with instructor supervision)
CRN Anesthetists
EEG Technicians
Physical Therapists
Respiratory Therapists
Radiology Technicians
Nuclear Technologists
CT Scan Technicians
MRI Technicians
Ultrasound Technicians
Registered nurses (RNs) and licensed practical nurses (LPNSs) may administer all parenteral, oral, rectal, and topical medication including blood and blood products if not specifically excluded elsewhere by medical staff by- laws or hospital policy and procedure.
The following policies will govern administration of medication in this institution:
The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label.
The individual administering a medication will be aware of the following information concerning each medication before administration:
o Therapeutic action
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o Uptoward actions or side effects
o Antidote (if applicable) and its location
o Route and frequency of administration
o Appropriate timing of medication administration
o Normal dosage and maximum safe dosage
o Signs of medication deterioration
o Precautions
o Any contraindications that would preclude the administration of the medication
o The expiration date of the medication to ensure it has not been exceeded
The individual administering a new medication will advise the patient, or if appropriate the patient’s family, about the purpose of the medication and what to expect from the medication.
The individual administering a medication will discuss any unresolved, significant concerns about the medication with the patient’s physician, prescriber (if different from the physician), and/or relevant staff involved with the patient’s care, treatment, and services.
Questions regarding medication compatibility will be referred to the pharmacist or research in available compatibility references.
There must be a specific order written by the physician before medication can be left at the patient’s bedside. Drugs for PRN use at the bedside consist primarily of sublingual antianginal products and antacids. See “Patient Self-Administration of Medications and Bedside Medications” in the Patient Care Policy for procedures.
Dose preparation will be performed in well-lit areas.
Positive identification of the patient will be ascertained by the individual administering the medication by reading the identification wristband and following the organizational Patient Identification for Clinical Care and Treatment policy which requires the use of two (2) patient identifiers prior to administration of all medications.
All medications, including mixed solutions will be observed to assure that the medication is stable and that there are no signs of precipitation, discoloration, or particulate matter prior to patient administration.
Medications will be prepared immediately prior to administration, particularly medications prepared for parenteral administration, according to unit dose protocol. To the maximum extent possible, drugs are to be administered by the person preparing the dose.
The nurse administering the medication will stay with the patient until the medication is taken. If a medication has been opened and is refused by a patient it is to be destroyed. This also applies to medications held because of nurse discretion. (If a medication is held or refused, a notation is made on the patient’s medical record.) Wasted control drugs will be witnessed and cosigned.
The nurse assigned to a patient coming from surgery will review PACU and anesthesia records of patients returning from surgery to ascertain doses and times of medications administered in surgery and PACU. This also applies to patients transported from the emergency department.
Medication orders that …
