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Report
Beth Downing, MSN, RN-BC, ONC
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Recognize The Joint Commission’s 2012
Hospital National Patient Safety Goals.
Apply The Joint Commission’s 2012 Hospital
National Patient Safety Goals to clinical
practice.
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Developed in 2002 to improve patient safety
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Reviewed annually for updates/changes
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9 different NPSG Programs
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Home Care
Hospitals**
Critical Access Hospitals
Behavioral Health Care
Ambulatory Health Care
Laboratory Services
Long Term Care
Long Term Care (Medicare/Medicaid)
Office Based Surgery
** This presentation will focus on 2012 Hospital NPSGs
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Correctly identify patients
Improve staff communication
Use medications safely
Prevent infections
Identify patient safety risks
Prevent mistakes in surgery
Use at least 2 patient identifiers to ensure that
each patient gets the correct medications and
treatments.
To ensure that the correct patient gets the
correct blood/blood component during a
transfusion.
Communicate important test results to the
correct staff member in a timely manner.
Correct labeling of medications before a
procedure. For example: medicines in
syringes, cups, and basins set-up prior to a
procedure.
Perioperative
or
Bedside
Procedures
Take additional care for patients who are
receiving medications to thin their blood.
Anticoagulant Use:
Heparin
Low molecular weight heparin
or Warfarin
(If patients coagulation labs are expected to be
out of the normal range with this therapy)
Record and communicate correct information
about patient’s medications.
Medication Reconciliation
(Are there discrepancies?)
Compare what the patient is taking at home with new medications
Complete on admission & discharge
Name, Dose, Frequency, Route, & Purpose
Scheduled & PRN Medications
Use hand hygiene guidelines from the Centers
for Disease Control (CDC) OR World Health
Organization (WHO); and set goals to improve
the hand hygiene process.
Hand hygiene is 1 of the most important ways
to minimize healthcare associated infections
(HAIs)
Additional Resources
Links for CDC & WHO hand hygiene guidelines
http://www.cdc.gov/handhygiene/
http://www.cdc.gov/HandHygiene/download/ha
nd_hygiene_core_minus_notes.pdf
http://whqlibdoc.who.int/publications/2009/97
89241597906_eng.pdf
Facilities use guidelines from either the CDC or WHO to establish their policies
Use proven guidelines to prevent infections that are
difficult to treat.
MDRO
Multidrug Resistant Organisms
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Clostridium Difficile (CDI)
Vancomycin Resistant Enterococcus (VRE)
Multidrug-Resistant Gram Negative Bacteria
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Risk assessment
◦ Who is at risk?
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Surveillance program
◦ Monitor patients who are at risk or are positive
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Educate staff upon hiring & annually
Educate patients diagnosed with a MDRO
Lab alert system
◦ Identifying patients newly diagnosed with a MDRO
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Alert system on readmission or transfer of
patients with a MDRO
Use proven guidelines to prevent infection of the
blood from central lines.
CLABSI
Central line associated bloodstream infections
Short & long-term central venous catheters (CVC)
such as:
Multi-lumen, Hickman, Port-a-cath,
Peripherally inserted central catheters (PICC)
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Educate patients before insertion
Educate staff upon hiring & annually
Implement a checklist/protocol for insertion
Perform hand hygiene before insertion or care
For insertion: standardized kit/cart &
antiseptic
Standardized protocol to disinfect hubs/ports
Evaluate central lines routinely
Use proven guidelines to prevent infection after
surgery
SSI
Surgical site infection
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Use evidence based practice (EBP) to:
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Educate staff upon hiring & annually
Educate patients about prevention
Determine antimicrobial agent for prophylaxis
Determine hair removal method
Measure SSI rates for 30 days after procedures
Conduct risk assessments
Evaluate effectiveness of protocols
Use proven guidelines to prevent infections of
the urinary tract that are cause by catheters.
CAUTI
Catheter associated urinary tract infections
Full implementation on January 1, 2013
Doesn’t apply to pediatric patients
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Use EBP to to determine:
Insertion protocol based on EBP
Aseptic technique for site prep & insertion
Limit use of catheters
◦ Does the patient really need this catheter?
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Secure catheter to maintain urine flow
Maintain sterility of system
Protocol for urine specimen collection
Identify which patients are most likely to
attempt to commit suicide.
Applies to:
Psychiatric Facilities
Patients treated for emotional or behavioral
disorders in general hospitals
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Conduct a risk assessment
◦ Who is at risk?
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Address immediate safety needs
What is the most appropriate setting for the
patient?
At discharge provide suicide prevention
information (i.e. crisis hotline)
Ensure that the correct surgery is done on the
correct patient at the correct location.
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Complete:
◦ At preadmission testing
◦ At admission
◦ At time of procedure
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Identify patient & involve them in the process
Verify:
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History & Physical
Consent
Assessment
Diagnostic & laboratory results
Required equipment/supplies
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Mark the procedure site
Involve patient
Site is marked by whoever is accountable for
procedure (MD, APRN, PA)
Mark at or near the surgical site
Consistent marking method throughout the
facility
Pause before surgery to make sure an error is
not being made.
Involve ALL procedural
team members
Agree on:
Right Patient
Right Site
Right Procedure
The nurse enters the patient’s room to
administer medications. Which could the
nurse use to correctly identify the patient?
(Select all that apply)
A. Full name
B. Date of birth
C. Room number
D. Telephone number
E. Medical record number
TJC recommends using options A, B, D, E as
identifiers; also a facility assigned ID
number can be used. Room numbers and
locations cannot be used.
Which activities require the nurse to verify 2
patient identifiers? (Select all that apply)
A. Collecting sputum specimen
B. Changing a dressing
C. Obtaining a blood sample
D. Inserting an intravenous line
E. Removing a urinary catheter
All treatments, procedures, and
medications require verification of
patient identification. Options A&C
also should be labeled in the patients
presence.
A patient is ordered to receive a unit of packed
red blood cells (PRBCs). What steps should be
included in the verification process to prevent
a transfusion error?
Match the blood product to the physicians
order
Match the patient to the blood product
Use a 2 person verification process OR
Use a 1 person verification process with an
automated identification system (barcoding)
The verification should include
patient identity, physicians order,
consent, blood type, blood product,
typenex number, & expiration date.
An adult patient’s initial laboratory report lists a
panic low hemoglobin level of 6.1 g/dL. What
is the nurses best action?
A. Notify the physician on the next round.
B. There is no need to notify, the patient was
admitted with anemia, this result is expected.
C. The patient was already ordered to receive a
blood transfusion, so it is not necessary to
notify.
D. Call the physician immediately to notify of
the result.
Hospital policy will determine the reporting
process –including who does the reporting ,
whom the report is called to, and an
acceptable time frame for reporting.
The next time you are in the clinical setting
review your clinical agency policy and
procedure for reporting critical results of
tests and diagnostic procedures.
What is the time frame to report?
What is the procedure for reporting?
Who can report it?
Is there an exception to reporting?
The nurse is setting up medications for a
bedside procedure. Which label includes the
correct information?
A.
Lidocaine 1% 50 mg
Exp 6/1/12 @1800
B.
Lidocaine 1% 50 mg/5 mL
Prepared 5/31/12 @ 1800
Exp 6/1/12 @ 1800
C.
Lidocaine 50 mg/5 mL
Exp 6/1/12 @ 1800
D.
Lidocaine 1% 5mL
Prepared 5/31/12 @ 1800
Option B includes:
medication name,
strength, quantity,
volume/diluent, and
expiration date.
Expiration time is a
requirement if it
occurs in less than
24 hours
A patient is being started on Warfarin
(Coumadin) after surgery to prevent a deep
vein thrombosis. What should the nurse
include in the plan of care when initiating this
therapy? (Select all that apply)
A.
B.
C.
D.
E.
Baseline INR result verification
Education regarding food & drug interactions
INR monitoring throughout the therapy
Reinforcing the importance of compliance
Education on adverse reactions &
interactions with other drugs
In addition to these 5 requirements, TJC requires
hospitals to have approved protocols for intiating &
maintaining anticoagulant therapy.
Home Medications
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Prilosec 20 mg po daily
Claritin 10 mg po daily
Multivitamin 1 tab po
daily
Aspirin 81 mg po daily
Tylenol 650 mg po prn
MD Orders
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Prilosec 20 mg po daily
Claritin 10 mg po daily
Multivitamin 1 tab po
daily
Tylenol 650 mg po q4 hr
prn mild pain or fever
Protonix 40 mg IV q12 hr
Keflex 500 mg po q6 hr
Clarification would be necessary for: Prilosec & Protonix both are the
same class of medications, Aspirin is omitted, Tylenol on home
medication list does not have a prn indication or time, Keflex is a new
medication is it appropriate for this patient?
Medication Name
Dose
Route
Frequency
Reason why patient is taking it
All of this information should be discussed with the
patient to ensure correct administration at home and
to improve patient knowledge of medications.
Patients should be instructed to keep an accurate
medication list with them at all times in the event of
an emergency.
Match the hand hygiene methods to the time
frames required for them to be effective.
Soap & Water
Alcohol Based Hand Rub
Surgical Scrub
These time frames determined by the
CDC have been proven to be effective at
providing hand hygiene. Completing
these for a longer period of time had not
proven to be any more effective.
60 Seconds
2-6 Minutes
15 Seconds
10 Minutes
Until Dry
In which situations is the use of alcohol based
hand rub an appropriate hand hygiene
method? (Select all that apply)
A. After removing gloves
B. Before inserting a urinary catheter
C. When hands are visibly soiled
D. Preoperatively before donning sterile gloves
E. Before taking a patients blood pressure
If hands are visibly soiled, soap and water method of hand hygiene is
recommended. For additional recommendations please refer to the hospital
policy, CDC, or WHO. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
These guideline are from the CDC Hand Hygiene in Health Care Settings.
Please review page 32 of this link for more information.
A patient is scheduled for a right knee
replacement. Which documents should be
included in the pre-procedure verification
process? (Select all that apply)
A. History & Physical
B. Signed procedure consent form
C. Nursing assessment
D. X-ray result
E. Anesthesia assessment
All of these documents should be verified prior to the procedure.
These documents will assist in verifying that the correct patient is
having the correct procedure (H&P) on the correct anatomical site
(xray, nursing assessment) and the patients expectations of the
procedure (signed consent, anesthesia assessment).
True or False:
T
Site should be marked before the procedure
F
The patient marks the site
F
A small black dot is an appropriate mark
T
PA or APRN can mark the site
F
Patients may choose the type of mark
T An alternative method is necessary for
certain procedures
The site should be marked by whomever is
accountable for the procedure (MD, APRN,
PA), the mark should be unambiguous and
universal for the hospital. Certain procedures
(involving teeth, through a natural orifice,
mucosal surface, or perineum).
A circulating nurse completes a time out
procedure, with the anesthesiologist, and
surgeon, 2 hours before a patient is to
undergo a right arm surgery. During the time
out they verify the patients identity by having
him state his full name, and verify that he is
having an incision and drainage completed.
What is correct & incorrect about this process?
CORRECT
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All relevant members
were present
Type of procedure is
verified
INCORRECT
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Too long before
procedure
Name verification only
using 1 method
Did not verify site of
procedure
The time out should be completed immediately prior to procedure or
marking of the site. The procedure must be standardized for the
hospital and initiated by a member of the team. Documentation of the
time out must also be completed as determined by the hospital.
The Joint Commission (2012). National Patient
Safety Goals. Retrieved June 10, 2012 from
http://www.jointcommission.org/standards_info
rmation/npsgs.aspx
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http://www.patientidexpert.com/laserwristbandstyle.html
http://www.carefusion.com/medical-products/medicationmanagement/point-of-care-verification/pyxis-transfusion-verification.aspx
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http://www.cdc.gov/ncbddd/dba/transfusion.html
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http://www.pregnancylab.net/critical-result/
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http://www.sandelmedical.com/products.asp?id=862
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http://www.blog.wheretofindcare.com/2010/02/how-does-wrong-sitesurgery-happen-part.html
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http://orthoinfo.aaos.org/topic.cfm?topic=A00269
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http://www.aorn.org/2012timeout/#axzz1yonOfy3V

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