Wm.

Jennings Bryan Dorn VAMC

Patient Safety Training

Billie Thompson RN Patient Safety Specialist

Velvet Cooper RN Patient Safety Specialist
Extensions 6022 or 4037
Patient Safety Is Everyone’s Job!

The goal of the Patient Safety Program is to

create a Culture of Safety and awareness of
patient safety issues for all VA Employees,
Patients and their Families.

Focus: Systems
Non-punitive
Open Communication
Process changes
 What Are Adverse Events?
Patient incidents such as:
Patient falls

Medication errors

Elopements (high elopement risk patients)

Delays in treatment

Suicides and attempts

Medical errors

Close calls (intercepted or resulted in no harm)

What Is A Sentinel Event?
-Death or permanent loss of function resulting from
a medication or other treatment error

-Suicide of a patient in a round-the-clock setting or

within 72 hours of discharge

-Surgery on the wrong patient or body part

-Unintended retained surgical object

-Hemolytic transfusion reaction

-Unanticipated death resulting from an health care-

acquired infection
How Do I Report A Medical Error
or Patient Safety Concern?
Call the Anonymous Incident Reporting
Hotline7964
Options:
1 – Medication Errors
2 – All Other Patient Incidents
3 – Rumor Busters
4 – Adverse Drug Reactions

Information needed:
1. Patient Name & Last 4 7. Outcome
SSN # 8. Treatment required
2. Summary of what 9. Was the incident
happened preventable? If yes, How?
3. Diagnoses 10. Was a medical
4. Location of incident practitioner notified?
5. Time & date 11. Was the patient or family
6. *For Med. Errors notified?
- Drug name
- Type of Error
 Incidents Occur While Using
Equipment
1. Record any settings before disconnecting/turning off
equipment.
2. Save and label all suspect medical equipment, attachments,
and packing materials (tubing, cables, pads, disposables
etc.).
3. Remove immediately from service and place in a secure
location (i.e. locked head nurse’s office). Do not send
through normal channels for repair.
4. Report incident and equipment involved to the Patient
Safety Officer (ext 6022) and Biomedical Engineer (ext
7582) as soon as possible.
5. Enter electronic work order describing the incident and
Biomedical staff will pick up and secure devices until
appropriate testing can be completed.
6. Notify VA Police (6804) to pick up and secure equipment &
attachments during non-administrative hours as needed.
7. Initiate a VA Form 10-2633, Report of Special Incident
Involving A Beneficiary displayed on next slide.
 How Do We Investigate Patient
Incidents & Close Calls?
A Root Cause Analysis (RCA) team is initiated to
determine:

What happened?
Why?
How to prevent it from happening in the future?

An RCA is a process designed to examine the systems

vulnerabilities to prevent adverse events:

• non-punitive
• multidisciplinary team approach
• process for identifying basic or contributing causes
• process for identifying what we can do to prevent
recurrence
 What Is An Intentional
Unsafe Act?
An adverse event that results from:
– criminal act
– purposefully unsafe act
– alcohol or substance abuse
– impaired provider/staff
– alleged patient abuse

Intentional unsafe acts should be reported to your

supervisor and Quality Management immediately

Intentional Unsafe Acts are investigated by

administration
 What Is A HFMEA?

HFMEA or Health Care Failure Mode and Effects

Analysis (HFMEA) is a proactive risk assessment
used to identify and correct process problems
before they happen

JCAHO requires a minimum of one HFMEA every 18

months on a process related to all levels of care

2009 HFMEA Topic: Case Management

2008 HFMEA Topic: Hand-Off Communication
 National Patient Safety Goals 2010
-Improve PATIENT IDENTIFICATION
-Improve COMMUNICATION among caregivers
-Improve MEDICATION SAFETY
-Reduce risk of HEALTH CARE-ASSOCIATED INFECTIONS
-Accurately RECONCILE MEDICATIONS
-Reduce the risk of patient HARM resulting from FALLS
-Promote Flu & Pneumonia VACCINES
-Encourage PATIENT INVOLVEMENT in their care, what
we are doing to make them safe & how to report concerns
-Prevent nosocomial PRESSURE ULCERS
-Identify safety risks of SUICIDE & HOME O2 FIRES
-Improve RECOGNITION & RESPONSE to declining patient
conditions
- Universal Protocols – Time Out, mark the site, conduct
verification
 Improve Patient Safety through
Positive Identification
• Ask the patient or representative to state the patient’s full name &
full social security number or date of birth (two identifiers)
• Verify the patient’s correct identification using VIC card, Picture ID
or ID band:

– Accessing patient information

– Checking patients in for care
– Applying a patient ID band – two person check required
– Giving medications or blood
– Providing treatments
– Performing procedures
– Drawing blood
– Obtaining other specimens
– Labeling specimens - always in the presence of the pt.
– Writing orders
– Documenting in the patient record
I

Never use room numbers!

 Improve Communication Among
Caregivers

• DO NOT USE VERBAL ORDERS except in

emergencies, when the physician/provider is NOT
present in the medical center or is scrubbed in the
Operating Room.

• When taking Verbal or telephone orders always:

 Write it down in CPRS (verbal/telephone order)
 Read it back
 Confirm/verify the order with provider
 Provider signs order in CPRS within 24 hours
 DO NOT USE ABBREVIATIONS

DO NOT USE the following unacceptable abbreviations in any

documentation , i.e. medication orders, progress notes
regarding medications in CPRS or paper records.

DO Not Use Use Instead

U Write “unit”
IU Write “International unit”
Q.D., QD, q.d., qd Write “daily”
Q.O.D., QOD, q.o.d., qod Write “every other day”
Trailing zero (X.0 mg) Write “X mg”
Lack of leading zero (.Xmg) Write “0.X mg”
MS Write “morphine sulfate”
MSO4 and MgSO4 Write “magnesium sulfate”
 CRITICAL TESTs & REPORTING
CRITICAL VALUES
Report critical test & test results/critical values ONLY
to the ordering provider/designee

 Write it down in CPRS

 Read it back
 Confirm/verify the result with provider
 Provider acts on and documents in CPRS
• Critical tests: Troponins and frozen sections
• Measure, assess, and take action to improve
timeliness of reporting and receipt of critical test
results and values by responsible licensed
caregiver.
 Improve Hand-Off Communications
• Use I-SHARE to remember what information should be
communicated & provide an opportunity to ask questions
• When?
Changing shifts, providers, caregivers, transfer and
discharge if provider relationship is known:

I Identification – Identify Patient & individuals

S Situation – Describe Situation/Clinical Status/ Code Status
H History – Background information/Current Medications
A Assessment - Most recent clinical findings
R Recommendation – STAT Orders, Plan/treatments needed
E Equipment – Devices needed/Settings prescribed
Patient Hand-off
Communication Tools
 Avoid Medication Errors
“LASA” Look Alike/Sound Alike Medications
To Avoid Errors Double Check Labels Carefully

Reminders:
• TALL MAN lettering
• Blue strip at top of orders in CPRS
• High alert stickers on medications
• Colored bins
• Segregated
• BCMA

Know the High Alert Look Alike & Sound Alike

Medication List - MCM 544-314-1
 Label All Medications
Includes: medication containers (e.g., syringes, medicine cups,
basins), or other solutions on and off the sterile field in operative and
other procedural settings. This applies to ALL medications
 Drug name
 Strength
 Amount (if not apparent from the container)
 Expiration date when not used within 24 hours
 Expiration time when expiration occurs in less than 24 hours.

*Only Exception: Same person prepares and administers medication

immediately one medication at a time.

• When the person preparing the medication is not the person who will be
administering it, VERIFY both verbally and visually with a second qualified
individual.
Reduce the likelihood of patient harm
Associated with Anticoagulation
therapy
• Weight based heparin protocol
• Low-molecular weight heparin protocol
• Heparin order sets in CPRS
• Heparin therapy nursing note
• Anticoagulants (IV & oral) are designated as
“High Alert”
• Pharmacist on inpt units to monitor
• Standardized doses for heparin & low-molecular
heparin
• Patient education (Coumadin booklets available)
• Mandatory training in LMS for all clinical staff
 Universal Protocol for Ensuring
Correct Site Surgery
1. Conduct a pre-procedure verification process to ensure
all documents and related information are available
before the start of the procedure using the Correct Site
Checklist:

 Correct Identifiers and labels

 Patient two identifiers match documents
 Procedure and site consistent with the
patient’s expectations & the team members’
understanding of the intended
patient, procedure and site
Universal Protocol for Ensuring Correct
Site Surgery
2. Mark the procedure site to identify without
ambiguity the intended site for the procedure for
all procedures that require a consent

Who? The provider performing the procedure with patient

involvement
When? Before the patient is moved to location where
procedure will be performed
Where? At or near the procedure or incision site
How? Provider writes initials with permanent marker “JJB”

For spinal procedures, the provider initials at the exact vertebral

Exceptions: Cases where it is technically or anatomically
impossible or impractical i.e. mucosal surfaces, perineum
 Universal Protocol for Ensuring
Correct Site Surgery
3. Time Out immediately prior to incision, ideally
before the patient receives anesthesia unless
contraindicated.
A designated member of the procedural team (or provider if no assistant
required) initiates the time out and confirm:
 All team members’ name and role
 Correct patient identity using full name and SSN
 Correct site is marked & Consent is accurate
 Agreement on the procedure to be done
 Correct patient position
 History and physical, nursing assessment, and pre-anesthesia
assessment match consent for correct patient, site & procedure
 Correct diagnostic and radiology test results (i.e. radiology images and
scans, or pathology and biopsy reports) that are properly labeled and
displayed
 Ensure any required blood products, implants, devices and/or special
equipment are available for the procedure.
 Need for antibiotics or fluids for irrigation
 Safety precautions based on patient history, medication use and
equipment
Correct Site Checklist must be completed and signed as indicated on the form
and scanned into the medical record after the procedure.
 Correct Site Checklist

Step One Checked by: Date: Time:

Name of Procedure(s):___________________________________________________________________
*Consent obtained, including
site/side/name of procedure/ ___________ _______ ________
reason for procedure No abbreviations on form
*Should be completed prior to transport to Holding Area
In Holding Area/procedure area,
physician marks procedure site with initials; must be ___________ _______ ________
a member of the operating team assigned and consented by the patient to be present during the procedure; must include patient involvement

If step one not completed, explain reason:

Step Two
Patient states name/full SS#/
location of body procedure to _____________ _______ ________
be performed. These responses
must be checked by the circulating staff nurse against consent form/marked site/ID band Patient must state, not confirm by being asked. If patient
unable and no next of kin available, 2 staff members will verify and sign. The Verifying nurse at this point must not leave the patient. This is the nurse
that will be present during the procedure and again verify the patient’s identity during the time-out.[a requirement from the OIG report]
If step two not completed prior to transport to the Operating Room, explain reason:

Step Three
If applicable, verification by 2 Signatures of 2 physicians
physician OR team members (1 must
be an attending) prior to start of
procedure that imaging data is _________________________________Time: ___________
available on correct patient, properly
labeled and properly presented __________________

“Time Out” in OR; prior to OR Team Verbal Confirmation signed by circulating nurse
incision OR team (minimum of indicating name of other team members
surgeon, circulating nurse,
anesthesia provider) verifies Surgeon: __________________________Time: _________
name of patient/procedure to be
performed/site, including side/ Anesthesia: ______________________________________
implant specifications and availability,
and antibiotic administered if ordered. Circulating Nurse: _________________________________

Patient Identification: Time out procedures must be observed by all members of the operating team.
Failure on any team members part to follow will result in documentation of non-compliance.
Full Name
Full SSN
 Reduce Healthcare
Acquired Infections

• Comply with current CDC Hand

Hygiene Guidelines.

• Manage unanticipated death or major

permanent loss of function associated
with a health care-associated infection
as a sentinel event.
 Hand Hygiene Is…

The #1 way to STOP transmission of infection!

– CDC estimates 30,000 deaths per year

being a direct result of improper hand
hygiene.

– Statistics indicate that ~ 40% of healthcare

workers comply with hand hygiene!
 Prevent Flu & Pneumonia Why me?

• Protect yourself…..get immunized!

• Protect your patients….

DID YOU KNOW….. With flu you are contagious 24 hours
before you even know you are sick!
DID YOU KNOW….Hospitals with high employee flu
vaccination rates have lower patient mortality!

• Protect your families… don’t take germs home!

 Medication Reconciliation Process

The Provider:
• Develops complete/accurate list of patient’s medication with the patient &/or
caregiver
• Compares (reconciles) the list of medications with new orders for medications.
• Updates list as orders change using the medication reconciliation note
• Communicates list to next provider(s) during Hand-Off
• Provides written discharge instructions with medication list to patient

The Pharmacist:
• Reviews and compares the current list with orders to help
avoid duplications, interactions, omissions and incorrect doses.
• Notifies the ordering provider of any discrepancies immediately
 Reduce Risk of Harm From Falls
*Hospital falls have a 30% risk of physical injury
At risk populations: 1-4 and 85+ age groups
Increase of injury-related deaths in the elderly

• Assess Fall Risk using Morse Scale on admission, each

reassessment, and after a fall
• Use a Falling Leaf to indicate a patient is a high fall risk
• Implement fall prevention devices, alarms and equipment
• Correct spills or wet surfaces
• Dispose of trash appropriately
• Remove or report any trip hazards and environmental hazards
immediately
• Examine for injury before moving the patient after a fall
• Notify the provider
• Complete Fall Review Note in CPRS & notify next of kin
• Implement additional fall precautions as indicated
• Complete a Post Fall Note within 24 hours after the fall
 Encourage Active Patient Involvement

Encourage active involvement of patients and their families in the

patient's care as a patient safety strategy”

• Inform patients to report any patient safety concerns to their

provider, nurse or the patient representative is necessary
• Provide Speak Up Booklets with admission orientation packets
• Provide Patient Education Booklets and instructions to new
veterans and to all inpatients and families during orientation
containing information about how to report concerns about safety
• Check Education Resource Center (PERC) across from canteen
• Provide Joint Commission contact information

Joint Commission
Complaint Hotline 1-800-994-6610
 Prevent Pressure Ulcers

*1.3 - 3 Million adults have pressure ulcers costing

$500- $40,000 per ulcer

• Identify at risk individuals (Braden Scale)

• Maintain and improve tissue tolerance
to prevent injury
• Protect against adverse effects of external mechanical devices
• Reduce the incidence of pressure ulcers through education
• Use special mattresses as indicated
 Reduce Risk for Suicide.

• Suicide risk screening to identify individuals at risk for suicide

while under the care of or following discharge is an important
step in protecting these at-risk individuals.

• Suicide risk assessments

• Address the patient’s immediate safety needs and most

appropriate setting for treatment.

• High Risk List – Notify Suicide Prevention Coordinator

• Provide suicide prevention information on signs, symptoms,

means reduction, the crisis hotline #, etc. to individuals at risk
for suicide and their family members.

• Develop a Safety Plan with the patient &/or family members

 Improve Recognition and Response
to Changes in a Patient’s Condition
Goal: To mobilize a team at the first sign of
impending crisis or doom, to reduce failure to
rescue, improve patient safety, and reduce the
number of code 5’s and medical crises.

Rapid Response Team - Code White

• Team Composition—ACLS Nurse, Sr. Resident, Resp.
Tx.
• Team Responsibilities- Quick assessment, work within
protocols, administer treatment, stabilize& transfer
patient as indicated
• Response Times Established—5 minutes
• Implemented on all inpatient units 12/08
Criteria for Activation of Code White
Dial 6555
Staff member concerned/worried about the patient (i.e.:
decreased urine output, temperature > 101, or patient
diaphoretic)
• Acute change in heart rate (less than 40 or greater than
130)
• Acute change in systolic blood pressure (less than 90
mm/Hg or greater than 170)
• Acute change in respiratory rate (less than 8 or greater than
34) or threatened airway
• Acute change in oxygen saturation which reflects the
percentage of red blood cells saturated with oxygen (level is
less than 90% despite oxygen being utilized on the patient)
• Acute change in level of consciousness
• Acute significant bleed
• Patient’s oxygen requirements increase to 50% or greater
(normal air breathed is 21% oxygen)
• New, repeated, or prolonged seizures
• Failure to respond to treatment for an acute
problem/symptom
 What Is A Code 5?
Code for Medical emergencies such as
respiratory, cardiac arrest or other situations
where someone is unresponsive or injured.
What is your role in a Code 5?
– Ask the person “Are you OK?” and get help
– Ask someone to call a Code 5 - Dial 6555 &
state the patient location & room # and get
the closest AED or Emergency Cart
– Provide the Code 5 team with a history of
events leading up to the code or
observations, if known.
– Provide BLS/CPR if you are trained
 What Is Disclosure?
• Telling the patient and or significant family members
clinically significant facts about the occurrence of an
adverse event that resulted in patient harm, or could result
in harm in the foreseeable future.

• Clinical Disclosure is a simple, informal process where the

provider discloses all adverse events that occur in the
routine course of medical practice even if there was no
harm to the patient. Documentation of the facts and who
was informed is the responsibility of the physician care for
the patient.

• Institutional Disclosure is a formal process used where the

Chief of Staff discloses a serious adverse events.
Disclosure if required within 72 hours that the physician is
aware of the adverse event. Documentation in Disclosure
of Adverse Event Template in CPRS is required.
 What Can We Do?

• Observe your work environment for patient safety

issues
• Report unsafe conditions & medical errors to your
supervisor and the patient safety officer or the
Anonymous Incident Reporting Hotline – 7964
• Comply with National Patient Safety Goals
• Serve on a RCA, Aggregate Review, or HFMEA team
• ASK your Patient Safety Officer or supervisor
 Words of Encouragement
“Gentlemen, we are
going to relentlessly
chase perfection,
knowing full well we
will not catch it,
because nothing is
perfect.

But we are going to

relentlessly chase it,
because in the
process we will catch
“I am not remotely interested excellence.”
in just being good.”
Vince Lombardi, head coach Green Bay Packers, 1959 – 1967
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Wm. Jennings Bryan Dorn VAMC
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