2010 National Patient Safety Goals

Presentation for Clinical Staff

Sue Fuller, RN, CPSOPatient Safety Specialist

Georgia Hospital AssociationPartnership for Health & Accountability

Goal 1Improve the accuracy of patient identification

• NPSG 01.01.01– Use at least two patient identifiers– Acceptable identifiers may be the individual’s name, date of

birth, an assigned ID number, telephone number, or other personal ID

Please tell me your name and date of birth

Goal 1Improve the accuracy of patient identification

• NPSG 01.01.01– Use at least two patient identifiers– Acceptable identifiers may be the individual’s name, date of

birth, an assigned identification number, telephone number, or other personal identification

When “active patient involvement” is not possible or the patient’s reliability is in question, hospital policy will document the designated caregiver responsible for the patient’s identity verification

Goal 1Improve the accuracy of patient identification

• NPSG 01.01.01 cont.– Use at least two patient

identifiers– Acceptable identifiers may

be the individual’s name, DOB, an assigned ID number, telephone number, or other personal identification

• Use patient identifiers when administering meds, collecting blood samples, or other specimens

Goal 1Improve the accuracy of patient identification

• NPSG 01.03.01– Eliminate transfusion errors related to patient misidentification

Before initiating a blood or blood component transfusion:

• Match the blood or blood component to the order

• Match the patient to the blood or blood component

• Use a two-person verification process

Goal 2Improve the effectiveness of communication among caregivers

• NPSG 02.03.01– Addressing timely reporting of critical tests and critical results– NEW (Orion conference 01/2010)

• Revised to focus on critical test results (as defined by the organization)

• The organization determines how to evaluate the effectiveness of the program

Goal 3Improve the safety of using medications

• NPSG 03.04.01– Label all medications, medication containers, and other

solutions on and off the sterile field in peri-operative and other procedural settings.

– NEW (Orion conference 01/2010)• EP 7 which requires the retention of medication vials until

completion of the procedure is now deleted)

• Label meds and solutions not immediately administered

• Label when the med or solution is transferred from the original package to another container

• Verify all meds and solutions verbally and visually

• Immediately discard meds or solutions found unlabeled

Goal 3Improve the safety of using medications

• NPSG 03.05.01– Reduce the likelihood of patient harm associated with the use of

anticoagulant therapy– Assess baseline coagulation status– Use programmable pumps for consistent and accurate dosing– Provide written evidence based policies/protocols– Evaluate anticoagulation safety practices– Educate staff, patients/families

Goal 7Reduce the risk of health care-associated infections

• NPSG 07.01.01– Comply with either the Center for Disease Control and

Prevention (CDC) and hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines

• Use soap and water for:•Visibly soiled hands•Clostridium difficile (C-Diff)

• Use alcohol based hand rub for all other situations

Goal 7Reduce the risk of health care-associated infections

• NPSG 07.03.01– Implement evidence based

practices to prevent health care associated infections due to multidrug-resistant organisms.

• Hand hygiene

• Contact precautions

• Cleaning and disinfecting patient care equipment

• Environmental cleaning and disinfecting

Goal 8Medication Reconciliation

• NPSG 8 is still under revision but let’s not forget the intent of the goal and the patient safety implications if not met.– Gather a complete list of medications on admission (involve the

patient and family) and include dose, route, frequency and last dose taken. Be sure to consider all points of entry.

From the office From the ED From the ICU From non ICU In-patient area To home, LTC, Hospice

Goal 8Medication Reconciliation cont.

– Identify a process to compare this patient list to the admission list of meds and reconcile any differences at that point.

– As the patient moves through the continuum, with changes in LOC and acuity, and when transferred off of one area and moved to another, the meds must be reconciled again. (IV changed to PO, paralytics D/C’d after extubated, etc.)

IV

PO

Home meds

Goal 8Medication Reconciliation cont.

– Upon discharge or transfer to another facility, the original list and the discharge med list must be reconciled.

– Remember, the patient still has all of the original meds at home and new instructions may need to be given if these meds have changed or if the instructions have changed.

Goal 15Suicide Prevention

• NPSG 15.01.01– The hospital identifies patients at risk for suicide

• Conduct a risk assessment including environmental features

• Address patient’s immediate safety needs

• Upon discharge, provide crisis hotline information

Warning signs of suicide include:Observable signs of serious depression:Unrelenting low moodPessimismHopelessnessDesperationAnxiety, psychic pain and inner tensionWithdrawalSleep problems

www.ASFP.org

Goal: Universal ProtocolStandardized List

Time Out Prior to Incision

Bedside Invasive Procedures

Site Markers

OR Team Participation