Front Cover
 Table of Contents
 Patient safety at Shands
 Risk management
 National patient safety goals
 Quality initiatives
 Patient safety structure

Title: Patient safety
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00090034/00001
 Material Information
Title: Patient safety
Physical Description: Book
Language: English
Creator: Shands HealthCare, University of Florida
Publisher: Shands HealthCare, University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2005
 Record Information
Bibliographic ID: UF00090034
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.


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Table of Contents
    Front Cover
        Page 1
    Table of Contents
        Page 2
    Patient safety at Shands
        Page 3
    Risk management
        Page 4
        Page 5
        Page 6
    National patient safety goals
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
    Quality initiatives
        Page 17
        Page 18
    Patient safety structure
        Page 19
Full Text


Patient Safety

You are the key...


Table of Contents

Topic Page

Patient Safety Program 3 4

Risk Management 4 6

List of National Patient Safety Goals 7

Goal # 1 8

Goal # 2 9-11

Goal# 3 12

Goal#4 13

Goal # 5 14

Goal #6 15

Goal # 7 16

Quality Initiatives 17- 18

Patient Safety Structure 19

Patient Safety at SHANDS

SHANDS Healthcare has an organizational commitment to
improving patient safety and quality. A well designed
program includes activities that help identify, minimize and
prevent health care accidents and incidents (sentinel events)
by creating a culture that values safety.

The comprehensive program within SHANDS HealthCare
involves a wide variety of activities that focus on:
Patient Satisfaction
Risk Management/Loss Prevention
Environment of Care/Safety Management
Infection Control
Performance Improvement/CQI Activities
Regulatory Compliance/Continuous Survey Readiness
Utilization Management

All of these program components work together to ensure
and improve patient, physician, employee and visitor safety.

Key Concepts:

Human error is a reality placing blame on the individual
does not correct the systems that allow mistakes to occur

Errors occur because of flawed systems, not individuals.

Every employee has the ability to identify actual and

potential flaws, or systems failures, that can impact patient

safety. Report all errors or situations that are potential

safety risks to your supervisor and complete a Patient

Safety Report form. At Shands at the University of Florida,

there is an electronic version of this form located on the

Shands intranet web site. In all other locations, the form is

printed and available in all patient care areas.

F, Ia Edit ]4 i, S i.dr. s --s 3.17->6O5>3-51bE ltl5A E s *-- e-5 je yG1:o Llib.k-
Ba E. F.:.,. l f S top

Incident/Medication Variance Form SH.AN DS
VYou onlf hIv 30 minlitrla 1to ,ltir your dara You cannot HealthCare
Submit atter h3 mn No adartional earningss can bq provided
rnd-nRapoit' R EZZ l Writ down JnumJerUGr l Itertl wence.1
1. Demographic Informaton
C Hospital. ,-,UF -I, AGH ,. Lake Snore
.Starks i.. uLo Oak _ISnarnds Renab
Vista C~ Home Care
If non-patlient related. enter "NONE" for Lastnamne and "0" for MRN.
Pt" I N, mi
Lasriarne Firsriame
MRN: ---

UnhidArea reporting the Incident. L Unit L0-ilkLna~vn
Patent Type ,C-Inparsnl .Oulpalaeit C. ED i_- Visior
0 Volunlaer _HornaCare C, Studaent _- Otler

InpatidnllOutpaienUiED ONLY
1I 4 1 -1. 1':, i 1 F- t 1ir. E I HM _J
1 o,-ne I I I Ir .er
,StaI *NC-. t- A[. 1y[:1 .. UP, .IA iti C. ht... i .. -A,,: .1 J P' F41NOl E, 1.PN.

Report #:

Patient Safety Report Form

1. Demographic Information

Hospital:O UF

Pt Name:

0 Lake Shore
0 Starke

0 Live Oak 0 Vista
0 Shands Rehab 0 HomeCare

last, first

MRN: I I I Birthday: I / /1 I / I Age: Z


Gender: 0 Male 0 Female

Patient Type: O Inpatient 0 Outpatient 0 ED 0 Visitor 0 HomeCare 0 Student 0 Volunteer 0 Other
Only comDlete the section for the specific Datient tvDe below:


Unit: or Dept/Clinic
{IP} {OP/ED}

Att MD:
Adm Date: I 1/ I/ E
Adm DX:
I Go to Section #2. I

2. Incident/Med Variance and Discovery Dates
Date Incident: Time Incident: How soon was the variance discovered?
0 0-30 min 0 61 min 6 hrs
Date Discovery: Z / I / I Time Discovery: I 0 31-60 min 0 > 6 hrs
3. Incident/Med Variance Information
Describe objectively what happened:

What measures) was/were taken
following the discovery of this incident?

4. Location of Incident
Room: Unit: Dept/Clinic: Other:
5. Injury Information
Was the subject injured? 0 No 0 Yes, complete SECTION 8 on the back. 0 Do Not know
Was the injury treated? O No O Yes: Explain treatment:
Was the MD notified? O No O Yes 0 Do Not know MD Name:
Was the RM notified? O No Date
ph: (352) 265-8028 O Yes Notified: / I / I Person rpt to at RM:

6. Staff Involved/Witnessed

Staff Wit or Inv

Staff Wit or Inv

Staff Wit or Inv

k Mgmt Team Mgmt Team Mgmt Team
Wor New 6 mo.) New 6 mo.) New mo.)
Status PRN Pool/CSO Q PRN Pool/CSO Q PRN Pool/CSO
ency Agency 8 o Agency
at Rev Fat F0403at
Rev 04.03

7. Type of Incident
After choosing the tvye(s) of Incident, turn overand
complete the section on back.
O Skin Integrity [section 8]
0 Fall [section 9]
O Trmt/Test/Proc Variance [section 10]
O Patient Action [section 11]
O Personal Property Loss/Damage [section 12]
O Medication Error [section 13]
O Equipment/Device Related [section 14]
O Otherspecify:

(Turn Over to Continue)

city state zip code
phone e-mail
Reason for presence in hospital
I Go to Section #2. I


What Should Be Reported?

* Actual errors with or without injury
Wrong patient procedures
Medication errors wrong patient, wrong medication

* Potential errors or safety risks
Patient equipment issues malfunctions, defects,
Unsafe practices hand hygiene; unattended
housekeeping carts; unlocked medication carts

* Complaints about the quality of care
* Threats to litigate/sue
* Suspected injuries
* Anything out of the ordinary

All patient related events must be reported within 3
business days. Immediately notify your supervisor and then
complete the electronic, or paper form and submit it to the
Quality, Accreditation & Licensure Department.

The National Patient Safety Goals

The National Patient Safety Goals have been in place since
2003. Each year, additional goals are added to help
healthcare facilities focus on improving processes that can
affect patient care quality and safety.

The current goals for 2006 address:

1) Improving the accuracy of patient identification.
2) Improving the effectiveness of communication among
3) Improving the safety of using medications.
4) Reduce the risk of health care-associated infections.
5) Accurately and completely reconcile medications across
the continuum of care.
6) Reduce the risk of patient harm resulting from falls.

Goal #1: Improving the accuracy of patient identification.
A. Use two identifierss" to make sure you have the right patient! For inpatients
this means checking the name and medical record number (or account number)
with the armband of the patient EACH TIME they receive medications, have
blood drawn, receive blood/blood products, when collecting specimens for
clinical testing or providing any treatments or procedures.
Areas like HomeCare, clinics, or other ambulatory or out-patient settings need
to ASK the patient their name and either their date of birth or address and
compare it to printed material to verify their identity.




Compare name
AND medical
record number
(or Acct
Number) with
armband EACH



Goal # 2: Improve the effectiveness of communication among
caregivers. Implement a process for taking verbal or telephone orders or
critical test results, which include a "read back."

Verbal/Telephone Orders:

a Write it down completely on the physician order sheet or on a
telephone/verbal order sticker, or stamp, when the prescriber
is giving the order.
a Read back the entire specific order. You must READ the
order as you have WRITTEN it. DO NOT just repeat back
what was said.
SDrug name: Spell it back and/or have the prescriber spell it
to you
Dose: Say back the numbers (one five, rather than fifteen)
SRead back the route, frequency, and prn indications
Record the prescriber's name and MC, ARNP, or PA number.

Use Verbal or Telephone Order Labels!
a Place on order sheet in patient's chart
a Process through the HIS computer system as with all Verbal

Example of Verbal Order Label:

Verbal Orear Label:
DIate Tie___

Room PatieNt Name
MR_ Nuter








[] PLce bcickrnart when emered it SMS
', -l 'Telephaore Order From
SPthyacian Number
Signraue 01 PEson Taking Order Sialus
SSftM caMa MW*M nnt iftwo fm dhV ofwt MR eta1 NwM m MsfiMM4 f"W & aniaftm bikpk- *, cubAi


Critical DiaQnostic Test Results:

a Write down the critical test result completely on the critical
test result label.

a Read back the entire test result as you have WRITTEN it

down. DO NOT just repeat back what was said.

Example of Critical Diagnostic Test Results Label:

Critical Diagnostic Test Result Communication

Patient Name
MR Number

Diagnostic Test Result(s)

Verbal Order Label:
Dateo Time

Room __ Patib Name
MR Number

S] PEace cicknmark wh~ emnred h SMS
SVarnmle .'epn c.rl Or1er Frc.ir.
Physician Number
: Sminaliue Fol Prn Taking Order I Stlrus
d fW. air-l "wM" L Mv ftww ali 1M6VM1K luam *Mf NK it b Ml .10poki. (um ai krhri9**Pt

B. Standardize a list of abbreviations, acronyms or symbols NOT
to be used in the organization.

The following list includes the abbreviations that must be banned
in all health care facilities.


"Qb"or *"daily" or
"QOb" every other day"

S"MS04" or "MS" "morphine"

S"MgSO4" *"magnesium sulfate"

"U" units

"IU" *l International units

S".2" "0.2" use leading zero

"2.0" 1 *"2" avoid trailing zeros

DO NOT use any of the prohibited abbreviations in medical
orders, medication related ENTRIES in the medical record. In
addition, the banned abbreviations may not be used in pre-
printed order sets.

C. Implement a standardized approach to "hand-off"
communications, including an opportunity to ask and respond
to questions.

The purpose of this goal is to ensure the smooth transition of
patient care between providers and to make sure pertinent
information about the patient's care needs is communicated to
the next care provider before that provider assumes
responsibility for the patient.

"Hand-off" communications may occur:

when a patient is transferred from one unit to
during shift changes;
when a patient goes to, or returns from, surgery or
other procedural areas;
when the attending physician changes;
when housestaff rotations occur; or
when patient's are discharged to other health care
facilities (Rehab; Skilled nursing units) or providers
such as Home Care.

Goal #3: Improve the safety of using medications.

A. Standardize and limit the number of drug concentrations available V
in the organization.
Only set concentrations of drugs are made or purchased d
(e.g. 10 mcg/ml fentanyl pca).

B. Identify and, at a minimum, annually review a list of look-
alike/sound-alike drugs used by the organization, and take action
to prevent errors involving the interchange of these drugs. f

C. Label all medications, medication containers (e.g., syringes,
medicine cups, basins), or other solutions on and off the
sterile filed in perioperative and other procedural settings.



13 y

Goal #4: Reduce the risk of health care-associated

A. Comply with current CDC (Centers for Disease
Control) hand hygiene guidelines.

1. Wash your hands when they are visibly soiled!

2. Use an alcohol based hand rub to disinfect hands when they
are not visibly soiled.

Note: A CbC recommendation since 2002 states:

Health care personnel should avoid wearing artificial
nails and keep natural nails less than one quarter of an
inch long if they care for patients at high risk of
acquiring infections.

B. Manage as a sentinel event any identified case of
unanticipated death or major permanent loss of function
associated with a health care acquired infection.

1. Report any case of unanticipated death or major permanent loss
of function associated with a health care acquired infection by
completing a written, or electronic, Patient Safety Report. (See
Core Policy CP1.35)

Goal #5 Accurately and completely reconcile medications
across the continuum of care.

A. During 2005, develop a process for obtaining
and documenting a complete list of the
patient's current medications upon the
patient's entry to the organization and with
the involvement of the patient.

Admission Note: Current Med list:
1. ___
Information obtained from
Nurse Unit

Reconcile Medication to next
practitioner or level of care.
Nurse Unit
Nurse Unit

B. A complete list of the patient's medications
is communicated to the next provider of
services when it refers or transfers a
patient to another setting, service,
practitioner or level of care within or outside
the organization.

Goal #6: Reduce the risk of patient harm resulting from

A. Assess and periodically reassess each
patient's risk for falling, including the
potential risk associated with the patient's
medication regimen, and take action to
address any identified risks.

B. Develop and implement a fall reduction
program and evaluate the effectiveness of
the program.

Patient Safety Initiatives K

The hospital has implemented a process to
improve the effectiveness of clinical alarm l
systems. O

A. Implement preventative maintenance and testing
of alarms. w
B. Assure that alarms are activated with the
correct settings and are able to be heard with y
respect to distance and other noises in the unit.
Know your alarms. Make sure you can hear them. 0
Check equipment alarms frequently to be sure they
have not been turned off! Know your responsibility
when you hear an alarm. Never ignore an alarm, no
matter who you are! r




The Universal Protocol

Use a preoperative verification process such as a checklist before
the start of surgical or other invasive procedures. ALL participants
on the team need to take a "Time Out" and verbally agree on the
right patient, right procedure and performing the procedure on the
right site. This includes procedures such as ECT, cardiac cath,
endoscopy, bronchoscopy, radiology, BMTU and those done in the
ED or at the bedside, not just in the operating room! All of these
steps help to ensure the right procedure is done right.

Befr e we stat l Hum. This isn't Mr.
Before we start, let'S Allen's x-ray. I better
take just a 'Time- check the other x-rays
out" to check and be again before we start.
sure we have the right -
patient and are doing
the right surgery. C


Mark the surgical site and involve the patient in the marking process. O

Yes, the surgery
should be on my left ,
eye. This one. 18d

YOU are the KEY to Patient Safety

cG 0

Performance Improvement

Medication Safety

Quality Processes lead to
Improved Outcomes of
Care &

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