QUICK REFERENCE for organizational staff and physicians
OUR MISSION
To provide high quality care and coordinated services that improve the health of our communities
OUR VISION
To be the choice for care and careers in the communities we serve
OUR VALUES
Safety, Compassion, Integrity, Excellence, Innovation, Accountability, Diversity, Equity and Inclusion
HUNTSVILLE HOSPITAL PRIORITIES
• Commit to Zero Harm
· Improve the Patient Identification Process
· Reduction of Hospital Associated Infections
· Reduction of Preventable Readmissions and Preventable Mortalities
• Antimicrobial Stewardship
• Pain Management (to include opioid safety and assessment/re-assessment)
PATIENT SAFETY PRIORITIES
• Alarm Safety
• Capacity Management
• Fall Safety
ENVIRONMENT OF CARE PRIORITY
• Increase the percentage of employees receiving workplace violence training
ADMISSION ASSESSMENT
• Organizational policy defines exactly what is required to be assessed. At a minimum, muscular skeletal, psycho-social, pain, barriers to learning, fall risk, abuse & neglect, nutritional status and a suicide assessment must be completed on all inpatients.
• Outpatients are required to have, at a minimum, abuse or neglect, pain, fall risk assessment as well as organization defined elements.
ABUSE AND NEGLECT
• Patient abuse, exploitation and/or neglect could be physical, sexual, emotional, and can include children, elderly, and all patients.
• Everyone is responsible for assessing patients for abuse and/ or neglect.
• Report suspected abuse or neglect to supervisor.
ADVANCE DIRECTIVES
• All Inpatients and Outpatients must be asked about Advance Directives.
• Advance Directives information and documentation forms will be available to all patients.
• Patients will be asked for a copy of their completed Advance Directives to be placed on their medical record. This request must be documented.
• When the patient has an Advanced Directive, but does not have it with them, document what actions were taken to obtain a copy.
• Examples of Advance Directives are: a living will, Durable Power of Attorney for Healthcare, or refusal of blood components.
BEHAVIORAL EVENTS
• Inappropriate actions by physicians towards patients, family, staff members, visitors, or other physicians should be documented on a Behavioral Event form.
• Behavioral Events are investigated by the Medical Staff Leadership.
BIOMED – MEDICAL EQUIPMENT MANAGEMENT DEPARTMENT
• Medical Equipment has a “maintenance due” date sticker on the equipment.
• Items with purple stickers do not require biomed to check.
• Always check equipment for structural integrity prior to use
• Any medical equipment that fails to operate as intended should:
· Be removed from service
· Complete a Medical Equipment Failure Report
· Taken to appropriate maintenance areas (Medical Equipment Management, Plant Operations, etc.)
CARE PLANS
• To provide consistency and communication in the planning and delivery of patient care, thus meeting the patients’ needs based on current standards of care.
• Patient care plans are multidisciplinary planning tools utilized for communicating the accomplishment of meeting patient care needs.
• Care plans are developed by completing:
· An assessment of patient needs to include pertinent past medical history.
· Goals must be measurable and contain current comorbidities.
· Nursing intervention for each identified need based on the standards of care
· The patient/family will participate in the patient’s Plan of Care.
· Care Plans are revised as the patient’s needs change.
COMPETENCIES
• All patient caregivers must have age-specific competencies.
• Competencies are evaluated annually or as scheduled by the organization
COMPLAINT VS. GRIEVANCE
A complaint is:
• An issue that can be resolved on the spot by staff present
• A billing or privacy issue that does not include quality of care issues
• A relatively minor issue that can be resolved quickly (i.e. change in bedding, housekeeping, food and beverage preference, parking, lost and found items)
• An issue that would have been routinely handled by staff if the communication had occurred during a hospital stay
A grievance is:
• A patient care complaint that cannot be resolved on the spot and is postponed for later resolution
• A billing issue where they refuse to pay because of care or treatment issues
• Patient’s requesting to file a formal complaint (i.e. allegation of abuse or neglect)
• A formal or informal written or verbal complaint that is made to the hospital by a patient (i.e. letter, fax, email)
CORE MEASURES
• Required by Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS)
• Core measures include data collection on:
· Sepsis
· Hospital Based Inpatient Psychiatric Services
· Perinatal Measures (baby & mom)
· Outpatient Endoscopy
· Emergency Department
More information can be found at medicare/hospitalcompare.gov
CORPORATE COMPLIANCE
• Corporate Compliance concerns may be reported to the Corporate Compliance Officer at 1-800-442-0959 or compliance@hhsys.org.
• Any employee, or physician, may contact Joint Commission on quality of care issues without fear of disciplinary or punitive action.
DISCLOSURE OF UNANTICIPATED ADVERSE OUTCOMES
• Provides a mechanism of communication to patients and, when appropriate, their families regarding unanticipated adverse outcomes.
• Defines unanticipated adverse outcome as an event that has caused an adverse outcome or injury to a patient including but not limited to patient suicide, patient abduction, and
surgery on the wrong patient or wrong body part (See Sentinel Event definition)
• Directs the attending physician who has responsibility for the overall care of the patient to handle disclosure in most instances
• Recommends that a hospital representative be present during the discussion
DNR (DO NOT RESUSCITATE) STATUS
• Physicians must document patient/family involvement in DNR decision.
• Physicians must document discussion of suspension of DNR orders (i.e. during surgery) with patient and/or significant other.
EMERGENCY CODES
General and Emergency Codes have been changed to reflect system standardization. A list of these codes can be found on the back cover of this reference booklet.
EMPLOYEE ASSISTANCE PROGRAM (EAP)
• EAP Office is located at extension 52600
• Offers counseling to employees for personal and emotional problems as well as referrals for drug and alcohol treatment
EMPLOYEE SAFETY COMMITTEE
• Investigates/Surveys/Analyzes issues related to Employee Safety and reports quarterly to the Environment of Care Committee.
• Employees are encouraged to attend Employee Safety Committee meetings with any questions or concerns. Employees are also encouraged to use the Safety Concerns link on the Pulse Page to report concerns, they can also report them anonymously.
ETHICS COMMITTEE
• Ethical issues are addressed by the Ethics Committee which is accessed through the Nursing Administration Staffing office.
• Use of video/audio equipment on patients or in patient care areas must follow hospital policies.
FIRE EXTINGUISHER OPERATION
• PASS - Pull, Aim, Squeeze, Sweep
FIRE RESPONSE
• Code Red – Fire
• Code Red All Clear – the fire emergency is over
• RACE - Rescue, Alert, Confine, Extinguish/Evacuate
HAZARDOUS MATERIAL
• For information on any material or chemical spill, call 5 “MSDS” (56737)
• For all Hazardous Spills, secure the area and call 52700 to report
• Plumbed eyewash stations should be checked weekly.
HISTORY AND PHYSICALS
(PHYSICIAN REQUIREMENTS)
• Must be completed within 24 hours of admission and prior to invasive procedure as outlined by the Medical Record Policy
• H&P’s completed prior to admission, and not over 30 days old, must be updated.
• H&P’s 31 days old, or greater, are not accepted.
• In an update, the following must be documented: The H&P was reviewed, another examination was completed, and there were no changes, unless noted.
INFECTION CONTROL
• Follow hospital Standard Precautions Policy: All human blood and body fluids are treated as if they were known to be infectious for hepatitis B, C, HIV, and other blood borne pathogens.
• Contact Infection Control with any questions or concerns by calling extension 52745.
• Medical staff and employees are to use the alcohol based hand sanitizer as they go in and out of the patient room or immediate care area. Examples of other times to perform hand hygiene would be before patient contact and after removing gloves.
• Use manufacturer’s instructions for guidance with cleaning and disinfecting equipment and devices.
• Follow the disinfecting wipe’s recommended contact time when performing low-level disinfection. Contact time is the
amount of time that the disinfectant should remain wet on the surface to achieve disinfection. (Contact time can be found on the wipe container.)
• When caring for patients with C-diff, use soap and water for hand hygiene, for 15 seconds. Do NOT use alcohol based hand sanitizer.
INFORMATION ON ISOLATION
Information on an isolation procedure can be found in the Isolation Manual, available on the Intranet.
INFORMED CONSENT
• Must include risks, benefits, and alternatives for blood administration, anesthesia/sedation, and procedures/surgery.
• Can only be obtained by a physician
• Must be documented in the medical record prior to patient procedures (via office notes, History and Physical, Progress Notes, “Yellow Sheet”, etc.)
IN-PERSON INTERPRETERS
*Hispanic inpatients
Main & W/C including ED’s- (256) 564-4000 (M-F 6a-6p, S&S 8a-4:30p)
*Hispanic outpatient locations- (256) 713-3578 (M-F 7:30a-5p) (also several other languages: Vietnamese, Chinese, Conhobal, etc.)
• Over the phone interpreters 1-855-837-8682, code- 52606. For any location and inpatient if needed.
• Video-Inpatient units have access to Martti (audio/video units). Can provide sign language also.
• If in-person sign language is needed try to call in advanceAIDB- (256) 539-7881.
Information is available on Pulse, Hot list, interpretive services. You can call (256) 265-8889 Nursing Admin for questions.
MEDICAL RECORD COMPLETION
• All entries in medical records must be dated, timed and signed.
• All entries in medical records must be readable.
• Correct errors made in written documentation by drawing a single line through the word(s) to be deleted.
• Initials, date and time are placed over the part to be deleted with the correction added. Do not use white out or erase an error.
• Completion of a Safety Event Report should not be documented in a patient’s medical record - only information regarding the patient event.
• All blanks on medical record forms must be addressed; document “N/A” if the blank does not require an entry.
• Physicians must sign a protocol or give verbal or telephone order prior to implementation of the protocol.
MEDICATION MANAGEMENT
• Required patient info: Height, weight, allergies, medication history, pregnancy/lactation status
• High-risk/high-alert meds: Know several examples…insulin, heparin, chemo, neuromuscular blockers (what have we done? - posters, warning stickers, education)
• HAZ-meds: many are hormonal agents that should not be handled in pregnancy, all chemo is designated a HAZ-med (what have we done? - posters, Pyxis pop-ups, orange stickers)
• Look-alike/sound-alike meds: be familiar with several examples… (what have we done? - posters, separation of confusable products, TALLman lettering, education) ** Pill-o-Talk link on Pulse takes you to all these lists and more medication info! **
• Medication storage: Meds must be stored as the manufacturer directs – room temp, refrigerator, frozen, etc. Meds can NEVER be carried in pockets! Meds must be secure at all times: either in your possession or under lock. If not used by end of shift, meds must be disposed of or returned to secure storage (e.g., Pyxis return bin, Pharmacy box). Keep internal and external meds separated. Sterile multi-dose injectable vials may be used for up to 28 days after opening (however insulin is only good for up to 28 days at room temp, whether opened or not). For most multi-dose vials (other than insulin and vaccines), it is recommended to dispose of them after one use (e.g., lidocaine, heparin vials, etc.); additionally, if a multi-dose vial is used in a direct patient
care area, it must be used for that patient only. If a multi-dose vial is appropriately reused, the NEW EXPIRATION DATE (not the date opened!) must be attached to the product. Never date or attempt to re-use a single dose medication – use once and discard.
• Sharps containers: Sharps containers must be stabilized (e.g., in a holder), contain no medications, and be emptied when <3/4 full. If tubing or vials are placed in the sharps, they must be emptied of all drug before doing so. Make sure that all items intended for the sharps container are placed inside it, not on top of or behind.
• If a medication is stored in a refrigerator, freezer, or warmer, the temp must be recorded daily (twice daily if vaccines are stored). Actions taken to correct temperature variances must be recorded.
• Emergency meds (crash cart): Crash carts must be stored in a location that is visible to staff. The crash cart log must be completed daily, it must have tamper-evident lock with the lot number on the tag matching the daily log, it must not contain expired meds, and the plastic locks cannot be stored on the unit.
• Medication preparation area: Med prep areas must be clean, uncluttered, and functionally separate. A ‘med prep’ sign should be placed behind the med prep area, nothing else should be stored in that area, and appropriate cleaning supplies should be kept nearby. All surfaces must be intact with no tape or adhesive residue present.
• Medication orders: All medication orders must be complete, containing drug name, strength, amount/quantity, route. PRN medication order must have an indication for use and clear directions for use. For orders to “taper” or “titrate” meds, see: ‘Titration-tapering of Medications’ guidelines on Pulse (Rx-for-Nursing).
• BLANKET ORDERS: Orders to “resume….” or “continue…” meds from a previous settings are prohibited – always clarify with the prescriber and get a complete order.
• RANGE/PRN ORDERS: Range orders are not supported in Cerner 1Chart; PRN orders for pain must specify the level of pain for each dose; all PRN orders must have an indication for use as part of the order
• Medication reconciliation: All patients must have a drug history recorded upon entry into HH & this list is compared to meds ordered at HH and discrepancies are addressed; at discharge, a list of meds to take at home is given to the patient.
• Review of med orders: A pharmacist must review all med orders unless (1) a documented emergency exists or (2) the physician is physically present and in control of the process. Pyxis overrides are tracked and results reported to the nurse manager.
• Preparation of IV drips: All sterile IV drips must be prepared in the Pharmacy…an exception is when a documented emergency exists – in that case, the nurse-prepared bag may hang no more than 12 hours (or until the Pharmacy-prepared bag arrives). Such bags must be labeled with drug name/ strength/amount, diluent, expiration date & time.
• Medication administration: Before giving meds, the nurse verifies drug name/dose/time, visually inspects for integrity, checks expiration date, verifies that no contraindications exist, and discusses all issues with the prescriber. Always check the hospital’s two unique identifiers (name and date of birth) and work off the MAR when administering medications. Always educate patients about meds (drug name, use, side effects, etc.) before administration. TJC has specific requirements for drug administration times, based on whether or not the drug is eligible for scheduled dosing and whether or not it is a “time critical” drug. Here are some basic guidelines:
Drugs
NOT ELIGIBLE for
scheduled
dosing
times (see 1 below)
· Stat (give as soon as available) · Now, including first doses of antibiotics (give within 2 hours of ordering
· Pre-procedural medication (including antibiotics per SCIP guidelines—give as directed by protocol/order)
Drugs ELIGIBLE for scheduled dosing times, but TIME CRITICAL
(see 2 below)
· Antibiotics given more often than once daily
· Anticoagulants given more often than once daily
· Insulin given more often than once daily (e.g., according to meals)
· Anticonvulsants given more often than once daily
· Pain medications (given per patient request or as scheduled) · Medications with a specified time per MD order
· Medications ordered more often than every 4 hours Drugs ELIGIBLE for scheduled dosing times and NOT time critical
· Medications prescribed daily or less frequently (see 3 below)
· Medications prescribed more frequently than daily but less frequently than every four hours (see 4 below)
1. Administer per policy based on ordered time
2. Administer within 30 minutes before/after scheduled time; if ordered no more frequently than once daily, may give within one hour before/after scheduled time
3. Administer within 2 hours before/after scheduled time
4. Administer within 1 hour before/after scheduled time
• Patient self-administration: In general, self-administration of meds and use of patient’s own meds is discouraged. If a patient is to self-administer, he/she: (1) must have a physician’s order, (2) patient/family must be judged competent to self-administer, (3) must sign a waiver (available on Pulse), (4) must keep an in-room MAR (which goes in the chart each day), (5) and must have meds identified. Meds should be kept out of sight (e.g., in bedside table). If the nurse is to administer a patient’s own meds, the meds are kept in the med room. See ‘Patient’s Own Meds’ guideline on Pulse.
• Patient education: Make sure patients understand what their medications are used for and what adverse reactions they might experience-especially with meds new to the patient
• Adverse drug reaction reporting: All adverse reactions must be reported in one of the following ways: (1) enter via the safety event reporting system (2) complete an orange card and return to Pharmacy, (3) contact your unit-based pharmacist, (4) contact the Drug Information Center at 58284, (5) answer YES to the Pyxis prompt when removing an antidote drug. When an ADR occurs, the nurse should notify the prescriber immediately. ADRs reports are shared with all staff to improve patient care.
• Labeling of medications: All medications and solutions (on and off the sterile field) must be labeled unless drawn up and administered immediately by the same person who prepared it. The label must contain drug name, strength, quantity if not apparent, diluent if diluted, & expiration date/ time if <24 hours. Pre-labeling and/or “batching” are not allowed - prepare one drug for one patient at a time and label it immediately. Note: taping of the vial to the syringe and other shortcuts are not acceptable. Non-sterile labels can be printed from Pulse (Rx-for-Nursing) and sterile labels and pens are available from Central Supply.
• Anticoagulants: All patients started on warfarin or a heparin product must have education documented in the clinical information system. Warfarin patients should watch the video on Channel 57.
• Perform hand hygiene frequently: before and after accessing Pyxis, upon entering and leaving a patient’s room, or anytime they appear dirty.
• Check out Rx-for-Nursing: this link on Pulse has a great deal of medication & TJC information!
HOSPITAL NATIONAL PATIENT SAFETY GOALS
Goal: Identify Patients Correctly
• Use two patient identifiers (Name and date of birth) to identify your patient to make sure the patient receives the correct medications, treatments or tests.
*Label specimens at the bedside in the presence of the patient
• Make sure the correct patient recieves the correct blood transfusion.
Goal: Improve Staff Communication
• Reporting Critical Values: Get important test results to the right staff person on time and then results to the right licensed practitioner on time. The lab has 15 minutes to report critical values; the nurse has 30 minutes to report critical values to the Provider. Total time = 45 minutes.
Also, related to Improving Communication Goal (NPSG):
• Write down and “read back” to the reporting person all orders and critical results reported to you.
• The following abbreviations are not acceptable for any documentation in the medical record: MS, MSO4, or MgSO4,
U or u, IU, QD, QOD, trailing zero (X.0mg), lack of leading zero (.Xmg), MS, MSO4, MgSO4.
• Effective communication and successful hand-off is an organizational priority
• Hand-off occurs:
· During shift report
· Transfer of patients from one unit to another
· Transfer from one level of care to another
· Ancillary transport between departments for diagnostics / procedures
· Transfer to other facilities
• Nursing hand-off occurs at the bedside and involves the patient / caregiver
• Methods of communication include:
· Face-to-face
· SBAR (situation, background, assessment, recommendation)
· Ticket To Ride - ancillary tool
• Communication Tools ensure critical information is not missed such as:
· Sender contact information
· Assessment / condition
· Reason for admission and plan of care
· To-do list (tasks/ orders)
· Contingency plans
· Allergies
· Code status
· Medications
· Labs & Vital Signs
• During hand-off ample time is given to ask questions
Goal: Use Medications Safely
• Label all medications and solutions removed from their original containers, if not used immediately on the patient and in its entirety.
• Take extra care with patients who take medicines to thin their blood.
• Obtain and pass along a list of the patient’s current medications. Ensure documentation of medications are current when transferring a patient to a different level of care or another provider of care.
• Make sure the patient knows what medications to take when they go home
• Tell the patient it is important to take a list of their medications with them every time they visit a doctor.
Related to Safe Medication Use (NPSG):
• Concentrated electrolytes should not be stored on the unit. Be aware of HH’s standard IV drip concentrations and use caution when administering medication on HH’s list of Looka-like Sound-a-like drugs.
Goal: Use Alarms Safely
• Ensure that alarms on medical equipment can be heard and staff responds to them on time.
Goal: Prevent Mistakes in Surgery
SITE MARKING
• Preoperatively, for cases that involve laterality or levels, the physician performing the procedure, physician, or licensed practitioner, privileged to do the procedure and remains in the room during the procedure, verifies the surgical site with the patient and marks the site with the word “YES” with an indelible, hypoallergenic, latex-free, skin marker, as close as possible to the incision site and to be visible after draping.
• This marking should take place with the patient, if possible, involved, awake and aware.
TIME OUT
• Completed immediately prior to any invasive procedure requiring a patient authorization (consent) and involve all relevant staff in the room to be in agreement.
• Required in all patient care areas including the Operating Room
• Must include the following elements:
· Correct Patient
· Correct Procedure
· Correct Place on the patient’s body
• A standardized list of available required items include:
· Relevant documentation (H&P, correct consent forms
· Informed Consent, pre-anesthesia assessment, etc.)
• Correct Images and results are properly labeled.
Goal: Identify Patients with Safety Risks (Suicide)
• Identify patients at risk for suicide through risk assessment. Screen all patients age 10 and above for suicidal risk by utilizing the Columbia-Suicide Severity Rating Scale (C-SSRS) upon entry into the organization, if behavior warrants, or when patient is able to respond to questions.
*Implement processes to help prevent patients from harming themselves. Patients screened as high risk are placed on continuous 1:1 observation with a competent sitter.
*Safety planning- Provide appropriate resource information and education at discharge and during transitions in care.
Goal: Prevent Infection
• Sanitize hands upon entering and exiting a patient room, also before and after direct patient contact.
Goal: Improve Healthcare Equity
• Improving health care equity is a quality and patient safety priority. For example, health care disparities in the patient population are identified and a written plan describes ways to improve health care equity.
NEAR MISS
“Near Miss” A patient safety event that did not reach the patient; also called close call or good catch. A Near Miss could have the potential to cause an adverse outcome if the process is not corrected.
ORGAN DONATION
The Alabama Organ Center must be notified of all hospital patient deaths at 1-800-252-3677.
OXYGEN SHUT-OFF PROCEDURE
• In the event of an emergency (i.e. fire), the oxygen and air valves will be shut off. Note patients who are on oxygen before shutting off the zone valves. Shutting off the zone valves helps confine the fire and can be done by turning the valve perpendicular to the gas line.
• Authorized individuals to perform this procedure include:
· Respiratory Therapist
· Plant Operations
· Any Trained individual who has completed the check off
PAIN ASSESSMENT AND MANAGEMENT
• Assess pain upon admission/presentation, prior to administering PRN pain medication, 30-60 minutes after giving pain medication, at discharge, and if a patient’s condition changes
• Use pain assessment tool appropriate for the patient (See “Pain Management” policy for adults and “Pain Management in Pediatric Patients” policy for children)
• Manage the patient’s pain using appropriate therapy, including multimodal (non-opiate) medications and nonpharmacologic interventions when applicable; patient specific factors, including risk of opiate dependency/abuse and patient goals, should be considered when developing the plan of care
• Minimize the risks associated with pain management by limiting the use of opiate medications, when appropriate and monitoring patients for adverse events
• At discharge, educate patients about pain management at home and safe use of pain medications (including appropriate disposal)
• The hospital collects and analyzes data on pain assessment/ management, including effectiveness and safety
PATIENT PRIVACY
• All patient information is strictly protected by HIPAA.
• Staff will only access patient information that is needed to perform their job.
• All suspected privacy violations should be reported to the Privacy Officer, 256-265-9257.
PATIENT RESTRAINTS
• Patient Restraint is the direct application of physical force to a patient, with or without the patient’s permission, to restrict his or her freedom of movement.
• Violent and Non-violent Restraints are the two types of patient restraints.
• All staff initiating or terminating patient restraints require specific competencies.
• If restraints are applied without a physician’s order (due to the immediate need), an order will be obtained within a few minutes of applying the restraint.
• Forensic Restraints are not clinical restraints and are only imposed by law enforcement or correction authorities.
• Non-violent restraint orders are per episode.
• No PRN Restrain Orders are permitted.
• Patient families/significant others are notified when a patient is restrained for any reason.
• Non-violent Restraints: do not include postural support, orthopedic appliances, or limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post-procedure care process (for example, surgical positioning, IV arm boards, radiotherapy procedures, protection of surgical and treatment sites in pediatric patients).
• Violent Restraints are used when a patient has exhibited violent or assaultive behavior such as hitting.
PATIENT SAFETY PROGRAM
• The Patient Safety Coordinator is located in the Quality Management Department at extension 52745.
• The Patient Safety Program investigates, surveys and analyzes data related to patient safety.
PERFORMANCE IMPROVEMENT INITIATIVES
• Each department must have department specific performance improvement initiatives.
• PDCA (Plan, Do, Check, and Act) is our performance improvement model.
PHYSICIAN PRIVILEGES
• Staff may access information on PULSE regarding those procedures a physician is privileged to perform.
• Contact the Nursing Administrative Supervisor, or the Medical Staff Office (58858) for information if computer information is not available
POLICIES AND PROCEDURES
Are located on Pulse, Hot List, Policies and Procedures
QUALITY EVENT
An event that has caused an adverse outcome or injury to a patient which does/does not meet the criteria/definition for a Sentinel Event. A Quality Event has the potential to cause an adverse outcome if the process is not corrected.
QUALITY MANAGEMENT PLAN
• Located on the Intranet under Quality Management Services Homepage, this document details the hospital’s quality improvement program.
• Includes the adverse incident reporting process through Safety Event Reports.
• The Sentinel Event Management Plan (including definitions of Quality Event)
QUALITY MANAGEMENT PROGRAM COMMITTEE
STRUCTURE (SEE QUALITY MANAGEMENT PLAN)
Involvement in reviewing patient quality issues includes hospital staff, Medical Staff and Board Members as appropriate.
SAFETY EVENT REPORT (SER)
Events which do or could adversely affect patient outcomes (Clinical events or near misses) are reported to the Quality Management Services Department electronically through the Safety Event Reporting System or downtime manual document.
READ BACK
• Verbal and telephone orders are discouraged, but allowed in specific circumstances.
• Verbal/telephone orders are entered directly into the EMR and read back to the provider for verification upon completion of order entry.
• EMR alerts generated during order entry are addressed with the provider’s participation; order entry cannot be completed until the alerts are resolved.
• The provider approves or rejects the order once the completed order has been read back.
• Transcription of verbal/telephone orders on paper is limited to situations where the EMR is unavailable, such as downtime; Read Back is still required.
REFRIGERATOR SAFETY
Refrigerators used to store medications and patient nourishments must have the temperature checked daily (twice a day if vaccines are stored), or use the Aeroscout central monitoring system. If the unit is closed, write “unit closed” in the day line. Electronic thermometers, or the Aeroscout System, are to be used in units that are not open 24/7. Any temperature
out of range must have the action taken and the temperature recheck documented.
SAFETY
• The Safety Officer is located in the Quality Management Services Department at extension 56904 or 52745.
• Investigates/Surveys/Analyses issues related to Patient and Environmental Safety through the Environment of Care Committee
• Employees and physicians are encouraged to attend monthly Environment of Care Committee meetings with any questions or concerns.
• The Environment of Care Committee reports safety issues quarterly to the Professional Affairs Quality and Safety Committee.
• Environment of Care Committee addresses Environmental Safety concerns, pertaining to:
· Utilities
· Hazardous Material
· Safety
· Emergency Preparedness
· Security
· Medical Equipment
· Life Safety
• Patient Safety Priority: Alarm Safety
• Environment of Care Priority: Workplace Violence Prevention
SEDATION
Three types of patient sedation:
• Light - Minimal • Moderate • Deep Requires all of the following:
• Competent staff to monitor patient, with no other duties during sedation.
• Specific monitoring equipment
• ASA class documentation
• Informed Consent (risk, benefits, and alternatives) obtained by a physician
• Discharge criteria
• Credentialed sedation provider
• Pre-sedation and immediately prior to sedation assessments are completed.