Quality and Patient Safety

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Quality and Patient Safety

• Roberta Monson, MD
• Jo Ellen Austin, PharmD
• Judi McGuire, RN

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• We are preparing for our triennial JCAHO visit
  which will occur this fall.
• We need everyones help in order to have a
  successful survey.
• Quality of care and Patient safety will be the
  1 focus.

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JCAHO Tracer Methodology

• Review all processes by tracing patient care
• Current patients will be selected
• Patients will be chosen by clinical services
• Information will come from staff and patient
  interviews
• Repeat visits are possible

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Documentation Issues

• History and Physical
• Post Op/Post procedure notes
• Legibility/Physician identification
• Discharge Planning

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Medication Issues

• Verbal orders read back
• Abbreviations QUIT AM
• Standard concentrations
• Secure storage
• Medication errors/Adverse Drug Events
• Medication Order Review

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Quality Improvement
Methodology

• Plan
• Do
• Check
• Act

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National Patient Safety Goals

• JCAHO requires 100 compliance with the safety
  goals.

• Everyone in the organization is expected to know
  and meet these goals.

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Accurate patient identification

• Improve the accuracy of patient identification
• Use at least two patient identifiers (our policy
  requires name and birth date) to verify patient
  ID when performing treatments or procedures.

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Effective Communication

• Improve the effectiveness of communication among
  caregivers
• Request a Read-back when giving verbal or
  telephone orders or perform one when receiving
  critical value test results.

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Effective Communication

• Do not use the following abbreviations in orders
  
• U (for unit)
• IU (for international unit)
• O.D or Q.O.D (for every day or every other day)
• Trailing or leading zero (X.0 mg or 0.X mg)
• MS, MS04 or MgS04 (morphine sulfate, mag sulfate)
• Ug (for microgram)
• A (for ear)
• Investigational nicknames for commercially
  available products, such as 5FU

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Safe Medication Use

• Improve the safety of using medications
• Use the standardized drug concentrations
  available in e-chart.
• Be alert to prevent errors involving look-alike
  or sound alike (SALAD) drugs.

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Preventing Infections

• Reduce the risk of health-care acquired
  infections
• Comply with CDC hand hygiene guidelines
• Use Central Venous Line protocols to avoid
  infections
• Treat all identified cases of unanticipated death
  or permanent injury due to health-care acquired
  infection as sentinel events.

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Reconciliation of medications

• Work to accurately and completely reconcile
  medications across the continuum of care
• All home meds are addressed on admission.
• At time of transfer to another unit meds are
  reviewed and documented.
• At discharge consider home and all new
  medications.
• Meds are communicated to patient and any care
  providers.

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Universal Protocol

• Eliminate wrong site, wrong side and wrong
  procedure surgeries or interventions
• Verification of consent and any supporting
  information, such as x-rays prior to procedure
• Site marking when indicated
• Time out when all are present
• Also applies to bedside procedures

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Universal Protocol

• Time out includes
• Right patient
• Right procedure
• Right positioning
• Right side and site
• Any special equipment needed, correct implants,
  tubes or catheters
• Use the procedure note form to assist with
  documentation.

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National Quality Measures

• JCAHO and the Center for Medicaid and Medicare
  Services (CMS) have joined forces in evaluating
  us on accepted best practices for the following
  diseases
• Congestive heart failure
• Acute Myocardial infarction
• Pneumonia
• OB and Pregnancy related

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AMI Measures

• Aspirin at arrival
• Aspirin at discharge
• ACE inhibitor for LVSD
• Smoking cessation
• Beta blocker at arrival
• Beta blocker at discharge
• Time to thrombolysis less than 30 minutes
• Time to PTCA less than 120 minutes

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Heart Failure Measures

• LVF assessment documented
• ACEI or ARB for LVSD
• Smoking cessation (smoker within past 12 months)
• Discharge teaching includes (must include all)
• Home mediations
• Activity
• Diet
• Follow up care
• What to do if symptoms worsen or reoccur
• Weight monitoring

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Pneumonia Measures

• Oxygenation assessment
• Blood culture prior to antibiotics
• Antibiotics within 4 hours of arrival time
• Smoking cessation
• Pneumococcal screening and vaccination

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Pregnancy related Measures

• Inpatient neonatal mortality rate
• Vaginal birth after c-section (VBAC) rate
• Rate of third or fourth degree perineal
  laceration
• These measures are only reported to JCAHO

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Results are now available to the public at
www.medicare.gov/hospital
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2nd quarter 2004 data
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And at the JCAHO web site
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We need your help.