2013 JCAHO Patient Safety Goals

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2013 JCAHO Patient Safety Goals

  1. 1. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. JCAHOJCAHO Hospital National Patient Safety GoalsHospital National Patient Safety Goals Effective January 1, 2013Effective January 1, 2013 JCAHO Mandatory Annual Competency Chesapeake Medical Staffing
  2. 2. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The purpose of the National Patient Safety Goals is toThe purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems inimprove patient safety. The goals focus on problems in health care safety and how to solve them.health care safety and how to solve them.
  3. 3. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Full Implementation of Policies & Procedures to DecreaseFull Implementation of Policies & Procedures to Decrease or Eliminate Catheter Associated Urinary Tract Infectionsor Eliminate Catheter Associated Urinary Tract Infections Effective January 1. 2013Effective January 1. 2013 • While there are no new NPSG for 2013, hospitals areWhile there are no new NPSG for 2013, hospitals are expected to have this goal implemented by January 1,expected to have this goal implemented by January 1, 2013. This particular patient safety goal focuses on2013. This particular patient safety goal focuses on catheter-associated urinary tract infection (CAUTI),catheter-associated urinary tract infection (CAUTI), requires organizations to fully implement the requirementsrequires organizations to fully implement the requirements of the goal by January 1, 2013.of the goal by January 1, 2013. • In order to comply with this goal, organizations must useIn order to comply with this goal, organizations must use evidence based guidelines to develop policies andevidence based guidelines to develop policies and procedures aimed at decreasing or eliminating catheter-procedures aimed at decreasing or eliminating catheter- associated urinary tract infections. TJC refersassociated urinary tract infections. TJC refers organizations to two evidence based guidelines fororganizations to two evidence based guidelines for CAUTI:CAUTI: Compendium of Strategies to Prevent Healthcare-Associated InfeCompendium of Strategies to Prevent Healthcare-Associated Infe and theand the Center for Disease Control’s Guideline for Prevention of CatheterCenter for Disease Control’s Guideline for Prevention of Catheter ..
  4. 4. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. According to the evidence-basedAccording to the evidence-based research, a comprehensive CAUTIresearch, a comprehensive CAUTI prevention program should include:prevention program should include: • Education on evidence-based best practices forEducation on evidence-based best practices for licensed independent practitioners and clinicallicensed independent practitioners and clinical staff inserting and or maintaining urinary tractstaff inserting and or maintaining urinary tract catheters.catheters. • Performance feedback, when possible, on thePerformance feedback, when possible, on the proportion of catheters placed by individualproportion of catheters placed by individual clinicians and whether the placement met facility-clinicians and whether the placement met facility- based criteria and other aspects related tobased criteria and other aspects related to catheter care and maintenance.catheter care and maintenance. • The appropriate supplies necessary for asepticThe appropriate supplies necessary for aseptic technique for catheter insertion.technique for catheter insertion.
  5. 5. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • A standardized documentation system whichA standardized documentation system which includes indications for catheter insertion, dateincludes indications for catheter insertion, date and time of catheter insertion, individual whoand time of catheter insertion, individual who inserted catheter, and date and time of catheterinserted catheter, and date and time of catheter removal.removal. • Policies and procedures should encouragePolicies and procedures should encourage minimal urinary catheter use and duration of useminimal urinary catheter use and duration of use in all patients, particularly those at higher risk forin all patients, particularly those at higher risk for CAUTI or mortality from catheterization, such asCAUTI or mortality from catheterization, such as women, the elderly and patients with impairedwomen, the elderly and patients with impaired immunity.immunity. • Performance improvement monitoring to assessPerformance improvement monitoring to assess appropriate use of indwelling catheters and toappropriate use of indwelling catheters and to reduce the risk of CAUTI.reduce the risk of CAUTI.
  6. 6. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 01.01.01National Patient Safety Goal 01.01.01 Use at least two patient identifiersUse at least two patient identifiers when providing care, treatment, and serviceswhen providing care, treatment, and services Wrong-patient errors occur in virtually all stages ofWrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal isdiagnosis and treatment. The intent for this goal is • to reliably identify the individual as the person forto reliably identify the individual as the person for whom the service or treatment is intended;whom the service or treatment is intended; • to match the service or treatment to that individual.to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, anAcceptable identifiers may be the individual’s name, an assigned identification number, telephone number, orassigned identification number, telephone number, or other person-specific identifier.other person-specific identifier.
  7. 7. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.01.01.01Elements of Performance for NPSG.01.01.01 • Use at least two patient identifiersUse at least two patient identifiers when administeringwhen administering medications, blood, or blood components; whenmedications, blood, or blood components; when collecting blood samples and other specimens forcollecting blood samples and other specimens for clinical testing; and when providing treatments orclinical testing; and when providing treatments or procedures.procedures. The patient's room number or physicalThe patient's room number or physical location is NOT used as an identifierlocation is NOT used as an identifier.. • Label containers used for blood and other specimens inLabel containers used for blood and other specimens in the presence of the patient.the presence of the patient.
  8. 8. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 01.03.01National Patient Safety Goal 01.03.01 Eliminate transfusion errors relatedEliminate transfusion errors related to patient misidentificationto patient misidentification Elements of Performance for NPSG.01.03.01Elements of Performance for NPSG.01.03.01 Before initiating a blood or blood component transfusion:Before initiating a blood or blood component transfusion: • Match the blood or blood component to the order.Match the blood or blood component to the order. • Match the patient to the blood or blood component.Match the patient to the blood or blood component. • Use a two-person verification process or a one-Use a two-person verification process or a one- person verification process accompanied byperson verification process accompanied by automated identification technology, such as barautomated identification technology, such as bar coding.coding.
  9. 9. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • When using a two-person verification process, oneWhen using a two-person verification process, one individual conducting the identification verification isindividual conducting the identification verification is the qualified transfusionist who will administer thethe qualified transfusionist who will administer the blood or blood component to the patient.blood or blood component to the patient. • When using a two-person verification process, theWhen using a two-person verification process, the second individual conducting the identificationsecond individual conducting the identification verification is qualified to participate in the process,verification is qualified to participate in the process, as determined by the hospital.as determined by the hospital.
  10. 10. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 02.03.01National Patient Safety Goal 02.03.01 Report critical results of tests andReport critical results of tests and diagnostic procedures on a timely basisdiagnostic procedures on a timely basis Critical results of tests and diagnostic procedures fallCritical results of tests and diagnostic procedures fall significantly outside the normal range and maysignificantly outside the normal range and may indicate a life-threatening situation. The objective isindicate a life-threatening situation. The objective is to provide the responsible licensed caregiver theseto provide the responsible licensed caregiver these results within an established time frame so that theresults within an established time frame so that the patient can be promptly treated.patient can be promptly treated.
  11. 11. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.02.03.01Elements of Performance for NPSG.02.03.01 Develop written procedures for managing the criticalDevelop written procedures for managing the critical results of tests and diagnostic procedures that addressresults of tests and diagnostic procedures that address the following:the following: • the definition of critical results of tests and diagnosticthe definition of critical results of tests and diagnostic procedures;procedures; • by whom and to whom critical results of tests andby whom and to whom critical results of tests and diagnostic procedures are reported;diagnostic procedures are reported; • the acceptable length of time between the availabilitythe acceptable length of time between the availability and reporting of critical results of tests and diagnosticand reporting of critical results of tests and diagnostic procedures.procedures.
  12. 12. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Implement the procedures for managing the criticalImplement the procedures for managing the critical results of tests and diagnostic procedures.results of tests and diagnostic procedures. • Evaluate the timeliness of reporting the critical resultsEvaluate the timeliness of reporting the critical results of tests and diagnostic procedures.of tests and diagnostic procedures.
  13. 13. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 03.04.01National Patient Safety Goal 03.04.01 Label all medications, medication containers, andLabel all medications, medication containers, and other solutions, on and off the sterile field, inother solutions, on and off the sterile field, in perioperative and other procedural settingsperioperative and other procedural settings Medications or other solutions in unlabeled containers areMedications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted fromunidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their originalmedications and other solutions removed from their original containers and placed into unlabeled containers. This unsafecontainers and placed into unlabeled containers. This unsafe practice neglects basic principles of safe medicationpractice neglects basic principles of safe medication management, yet it is routine in many organizations.management, yet it is routine in many organizations.
  14. 14. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The labeling of all medications, medication containers, andThe labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safeother solutions is a risk-reduction activity consistent with safe medication management.This practice addresses amedication management.This practice addresses a recognized risk point in the administration of medications inrecognized risk point in the administration of medications in perioperative and other procedural settings.perioperative and other procedural settings.
  15. 15. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.03.04.01Elements of Performance for NPSG.03.04.01 In perioperative and other procedural settings both on andIn perioperative and other procedural settings both on and off the sterile field, label medications and solutions that areoff the sterile field, label medications and solutions that are not immediately administered. This applies even if there isnot immediately administered. This applies even if there is only one medication being used.only one medication being used. Note: An immediately administered medication is one that anNote: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to aauthorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in thepatient, and administers to that patient without any break in the process.process.
  16. 16. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. In perioperative and other procedural settings both on and offIn perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication orthe sterile field, labeling occurs when any medication or solution is transferred from the original packaging to anothersolution is transferred from the original packaging to another container.container. In perioperative and other procedural settings both on and offIn perioperative and other procedural settings both on and off the sterile field, medication or solution labels include thethe sterile field, medication or solution labels include the medication name, strength, quantity, diluent and volume (ifmedication name, strength, quantity, diluent and volume (if not apparent from the container), expiration date when notnot apparent from the container), expiration date when not used within 24 hours, and expiration time when expirationused within 24 hours, and expiration time when expiration occurs in less than 24 hours.occurs in less than 24 hours. Note: The date and time are not necessary for short procedures, asNote: The date and time are not necessary for short procedures, as defined by the hospital.defined by the hospital.
  17. 17. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Verify all medication or solution labels both verbally andVerify all medication or solution labels both verbally and visually. Verification is done by two individuals qualified tovisually. Verification is done by two individuals qualified to participate in the procedure whenever the person preparingparticipate in the procedure whenever the person preparing the medication or solution is not the person who will bethe medication or solution is not the person who will be administering it.administering it. Label each medication or solution as soon as it is prepared,Label each medication or solution as soon as it is prepared, unless it is immediately administered.unless it is immediately administered. Immediately discard any medication or solution foundImmediately discard any medication or solution found unlabeled.unlabeled.
  18. 18. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Remove all labeled containers on the sterile field andRemove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.discard their contents at the conclusion of the procedure. Note: This does not apply to multiuse vials that are handledNote: This does not apply to multiuse vials that are handled according to infection control practices.according to infection control practices. All medications and solutions both on and off the sterileAll medications and solutions both on and off the sterile field and their labels are reviewed by entering andfield and their labels are reviewed by entering and exiting staff responsible for the management ofexiting staff responsible for the management of medications.medications.
  19. 19. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 03.05.01National Patient Safety Goal 03.05.01 Reduce the likelihood of patient harmReduce the likelihood of patient harm associated with the use ofassociated with the use of anticoagulant therapy.anticoagulant therapy. Note: This requirement applies only to hospitals that provide anticoagulantNote: This requirement applies only to hospitals that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis (for example, atrialtherapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratoryfibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirementvalues for coagulation will remain outside normal values. This requirement does not apply to routine situations in which short term prophylacticdoes not apply to routine situations in which short term prophylactic anticoagulation is used for venous thrombo-embolism prevention (foranticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinicalexample, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation willexpectation is that the patient’s laboratory values for coagulation will remainremain within, or close to, normal values.within, or close to, normal values.
  20. 20. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Anticoagulation therapy can be used as therapeuticAnticoagulation therapy can be used as therapeutic treatment for a number of conditions, the most common oftreatment for a number of conditions, the most common of which are atrial fibrillation, deep vein thrombosis, pulmonarywhich are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant. However, it isembolism, and mechanical heart valve implant. However, it is important to note that anticoagulation medications areimportant to note that anticoagulation medications are more likely than others to cause harm due to complexmore likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patientdosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety Goal has greatcompliance. This National Patient Safety Goal has great potential to positively impact the safety of patients on thispotential to positively impact the safety of patients on this class of medications and result in better outcomes.class of medications and result in better outcomes.
  21. 21. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. To achieve better patient outcomes, patient education is aTo achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy program.vital component of an anticoagulation therapy program. Effective anticoagulation patient education includes face-to-Effective anticoagulation patient education includes face-to- face interaction with a trained professional who works closelyface interaction with a trained professional who works closely with patients to be sure that they understand the riskswith patients to be sure that they understand the risks involved with anticoagulation therapy, the precautions theyinvolved with anticoagulation therapy, the precautions they need to take, and the need for regular Internationalneed to take, and the need for regular International Normalized Ratio (INR) monitoring. The use of standardizedNormalized Ratio (INR) monitoring. The use of standardized practices for anticoagulation therapy that include patientpractices for anticoagulation therapy that include patient involvement can reduce the risk of adverse drug eventsinvolvement can reduce the risk of adverse drug events associated with heparin (unfractionated), low molecularassociated with heparin (unfractionated), low molecular weight heparin, and warfarin.weight heparin, and warfarin.
  22. 22. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.03.05.01Elements of Performance for NPSG.03.05.01 • Use only oral unit-dose products, prefilled syringes, orUse only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products arepremixed infusion bags when these types of products are available.available. Note: For pediatric patients, prefilled syringe productsNote: For pediatric patients, prefilled syringe products should be used only if specifically designed for children.should be used only if specifically designed for children. • Use approved protocols for the initiation and maintenance ofUse approved protocols for the initiation and maintenance of anticoagulant therapy.anticoagulant therapy. • Before starting a patient on warfarin, assess the patient’sBefore starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receivingbaseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalizedwarfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status andRatio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record.current INR are documented in the medical record. Note: The patient’s baseline coagulation status can be assessedNote: The patient’s baseline coagulation status can be assessed in a number of ways, including through a laboratory test or byin a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency,identifying risk factors such as age, weight, bleeding tendency, and genetic factors.and genetic factors.
  23. 23. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Use authoritative resources to manage potential food andUse authoritative resources to manage potential food and drug interactions for patients receiving warfarin.drug interactions for patients receiving warfarin. • When heparin is administered intravenously andWhen heparin is administered intravenously and continuously, use programmable pumps in order to providecontinuously, use programmable pumps in order to provide consistent and accurate dosing.consistent and accurate dosing. • A written policy addresses baseline and ongoing laboratoryA written policy addresses baseline and ongoing laboratory tests that are required for heparin and low molecular weighttests that are required for heparin and low molecular weight heparin therapies.heparin therapies.
  24. 24. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Provide education regarding anticoagulant therapy to staff,Provide education regarding anticoagulant therapy to staff, patients, and families. Patient/family education includespatients, and families. Patient/family education includes the following:the following:  the importance of follow-up monitoringthe importance of follow-up monitoring  compliancecompliance  drug-food interactionsdrug-food interactions  the potential for adverse drug reactions and interactionsthe potential for adverse drug reactions and interactions • Evaluate anticoagulation safety practices, take action toEvaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of thoseimprove practices, and measure the effectiveness of those actions in a time frame determined by the organizationactions in a time frame determined by the organization
  25. 25. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 03.06.01National Patient Safety Goal 03.06.01 Maintain and communicate accurateMaintain and communicate accurate patient medication informationpatient medication information There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve Discrepancies - it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.
  26. 26. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.03.06.01Elements of Performance for NPSG.03.06.01 Obtain information on the medications the patient is currentlyObtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen intaking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a listan outpatient setting. This information is documented in a list Or other format that is useful to those who manageOr other format that is useful to those who manage medications.medications. Note 1:Note 1: Current medications include those taken atCurrent medications include those taken at scheduled times and those taken on an as needed basis.scheduled times and those taken on an as needed basis. Note 2:Note 2: It is often difficult to obtain complete information onIt is often difficult to obtain complete information on current medications from a patient. A good faith effort tocurrent medications from a patient. A good faith effort to obtain this information from the patient and/or other sourcesobtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.will be considered as meeting the intent of the EP.
  27. 27. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Define the types of medication information to be collected inDefine the types of medication information to be collected in non–24-hour settings and different patient circumstances.non–24-hour settings and different patient circumstances. Note 1:Note 1: Examples of non–24-hour settings include theExamples of non–24-hour settings include the emergency department, primary care, outpatient radiology,emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings.ambulatory surgery, and diagnostic settings. Note 2:Note 2: Examples of medication information that may beExamples of medication information that may be collected include name, dose, route, frequency, and purpose.collected include name, dose, route, frequency, and purpose.
  28. 28. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Compare the medication information the patient brought toCompare the medication information the patient brought to the hospital with the medications ordered for the patient bythe hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies.the hospital in order to identify and resolve discrepancies. Note: Discrepancies include omissions, duplications,Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. Acontraindications, unclear information, and changes. A qualified individual, identified by the hospital, does thequalified individual, identified by the hospital, does the comparison.comparison.
  29. 29. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Provide the patient (or family as needed) with writtenProvide the patient (or family as needed) with written information on the medications the patient should be takinginformation on the medications the patient should be taking when he or she is discharged from the hospital or at the endwhen he or she is discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route,of an outpatient encounter (for example, name, dose, route, frequency, purpose).frequency, purpose). Note: When the only additional medications prescribed areNote: When the only additional medications prescribed are for a short duration, the medication information the hospitalfor a short duration, the medication information the hospital provides may include only those medications.provides may include only those medications.
  30. 30. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Explain the importance of managing medication informationExplain the importance of managing medication information to the patient when he or she is discharged from the hospitalto the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.or at the end of an outpatient encounter. Note: Examples include instructing the patient to give a list toNote: Examples include instructing the patient to give a list to his or her primary care physician; to update the informationhis or her primary care physician; to update the information when medications are discontinued, doses are changed, orwhen medications are discontinued, doses are changed, or new medications (including over-the-counter products) arenew medications (including over-the-counter products) are added; and to carry medication information at all times in theadded; and to carry medication information at all times in the event of emergency situations.event of emergency situations.
  31. 31. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 07.01.01National Patient Safety Goal 07.01.01 Comply with either the current CDCComply with either the current CDC hand hygiene guidelines or the currenthand hygiene guidelines or the current WHO hand hygiene guidelinesWHO hand hygiene guidelines According to the Centers for Disease Control andAccording to the Centers for Disease Control and Prevention, each year, millions of people acquire anPrevention, each year, millions of people acquire an infection while receiving care, treatment, and services ininfection while receiving care, treatment, and services in a health care organization. Consequently, health care-a health care organization. Consequently, health care- associated infections (HAIs) are a patient safety issueassociated infections (HAIs) are a patient safety issue affecting all types of health care organizations. One ofaffecting all types of health care organizations. One of the most important ways to address HAIs is bythe most important ways to address HAIs is by improving the hand hygiene of health care staff.improving the hand hygiene of health care staff.
  32. 32. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Compliance with the World Health Organization (WHO)Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC)or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission ofhand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, therebyinfectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensuredecreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, ancompliance with this National Patient Safety Goal, an organization should assess its compliance with the CDCorganization should assess its compliance with the CDC and/or WHO guidelines through a comprehensiveand/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters aprogram that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance andculture of hand hygiene, and monitors compliance and provides feedback.provides feedback.
  33. 33. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.07.01.01Elements of Performance for NPSG.07.01.01 • Implement a program that follows categories IA, IB,Implement a program that follows categories IA, IB, and IC of either the current CDC or the current WHOand IC of either the current CDC or the current WHO hand hygiene guidelines.hand hygiene guidelines. • Set goals for improving compliance with handSet goals for improving compliance with hand hygiene guidelines.hygiene guidelines. • Improve compliance with hand hygiene guidelinesImprove compliance with hand hygiene guidelines based on established goals.based on established goals.
  34. 34. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 07.03.01National Patient Safety Goal 07.03.01 Implement evidence-based practices toImplement evidence-based practices to prevent health care–associated infectionsprevent health care–associated infections due to multidrug-resistant organisms indue to multidrug-resistant organisms in acute care hospitals.acute care hospitals. Note: This requirement applies to, but is not limited to,Note: This requirement applies to, but is not limited to, epidemiologically important organisms such asepidemiologically important organisms such as Methicillin resistant staphylococcus aureus (MRSA),Methicillin resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistantclostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-enterococci (VRE), and multidrug-resistant gram- negative bacteria.negative bacteria.
  35. 35. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Patients continue to acquire health care–associatedPatients continue to acquire health care–associated infections at an alarming rate. Risks and patientinfections at an alarming rate. Risks and patient populations, however, differ between hospitals.populations, however, differ between hospitals. Therefore, prevention and control strategies must beTherefore, prevention and control strategies must be tailored to the specific needs of each hospital based ontailored to the specific needs of each hospital based on its risk assessment. The elements of performance forits risk assessment. The elements of performance for this requirement are designed to help reduce or preventthis requirement are designed to help reduce or prevent health care–associated infections fromhealth care–associated infections from epidemiologically important multidrug-resistantepidemiologically important multidrug-resistant organisms (MDROs).organisms (MDROs).
  36. 36. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Hand hygiene, contact precautions, as well as cleaningHand hygiene, contact precautions, as well as cleaning and disinfecting patient care equipment and theand disinfecting patient care equipment and the patient’s environment are essential strategies forpatient’s environment are essential strategies for preventing the spread of health care–associatedpreventing the spread of health care–associated infections.infections. Implement evidence-based practices toImplement evidence-based practices to prevent health care–associated infections due toprevent health care–associated infections due to multidrug-resistant organisms in critical accessmultidrug-resistant organisms in critical access hospitals.This requirement applies to, but is not limitedhospitals.This requirement applies to, but is not limited to, epidemiologically important organisms such asto, epidemiologically important organisms such as • methicillin-resistant staphylococcus aureus(MRSA)methicillin-resistant staphylococcus aureus(MRSA) • clostridium difficile(CDI)clostridium difficile(CDI) • vancomycin-resistant enterococci (VRE)vancomycin-resistant enterococci (VRE) • multidrug-resistant gram-negative bacteria.multidrug-resistant gram-negative bacteria.
  37. 37. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.07.03.01:Elements of Performance for NPSG.07.03.01: • Conduct periodic risk assessments for multidrug-Conduct periodic risk assessments for multidrug- resistant organism acquisition and transmission.resistant organism acquisition and transmission. • Based on the results of the risk assessment, educateBased on the results of the risk assessment, educate staff and licensed independent practitioners aboutstaff and licensed independent practitioners about health care–associated infections, multidrug-resistanthealth care–associated infections, multidrug-resistant organisms, and prevention strategies at hire andorganisms, and prevention strategies at hire and annually thereafter.annually thereafter. • Note: The education provided recognizes the diverseNote: The education provided recognizes the diverse roles of staff and licensed independent practitionersroles of staff and licensed independent practitioners and is consistent with their roles within the hospital.and is consistent with their roles within the hospital.
  38. 38. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Educate patients, and their families as needed, whoEducate patients, and their families as needed, who are infected or colonized with a multidrug-resistantare infected or colonized with a multidrug-resistant organism about health care–associated infectionorganism about health care–associated infection strategies.strategies. • Implement a surveillance program for multidrug-Implement a surveillance program for multidrug- resistant organisms based on the risk assessment.resistant organisms based on the risk assessment. Note: Surveillance may be targeted rather thanNote: Surveillance may be targeted rather than hospital-wide.hospital-wide.
  39. 39. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Measure and monitor multidrug-resistant organismMeasure and monitor multidrug-resistant organism prevention processes and outcomes, including theprevention processes and outcomes, including the following:following:  Multidrug-resistant organism infection rates usingMultidrug-resistant organism infection rates using evidence-based metricsevidence-based metrics  Compliance with evidence-based guidelines or bestCompliance with evidence-based guidelines or best practicespractices  Evaluation of the education program provided to staffEvaluation of the education program provided to staff and licensed independent practitionersand licensed independent practitioners Note: Surveillance may be targeted rather than hospital-Note: Surveillance may be targeted rather than hospital- wide.wide. • Provide multidrug-resistant organism process andProvide multidrug-resistant organism process and outcome data to key stakeholders, including leaders,outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, andlicensed independent practitioners, nursing staff, and other clinicians.other clinicians.
  40. 40. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Implement policies and practices aimed at reducing theImplement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. Theserisk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements andpolicies and practices meet regulatory requirements and are aligned with evidence-based standards (for example,are aligned with evidence-based standards (for example, the CDC and/or professional organization guidelines).the CDC and/or professional organization guidelines). • When indicated by the risk assessment, implement aWhen indicated by the risk assessment, implement a laboratory-based alert system that identifies new patientslaboratory-based alert system that identifies new patients with multidrug-resistant organisms.with multidrug-resistant organisms. Note: The alert system may use telephones, faxes,Note: The alert system may use telephones, faxes, pagers, automated and secure electronic alerts, or apagers, automated and secure electronic alerts, or a combination of these methods.combination of these methods.
  41. 41. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • When indicated by the risk assessment, implement anWhen indicated by the risk assessment, implement an alert system that identifies readmitted or transferredalert system that identifies readmitted or transferred patients who are known to be positive for multidrug-patients who are known to be positive for multidrug- resistant organisms.resistant organisms. Note 1: The alert system information may exist in aNote 1: The alert system information may exist in a separate electronic database or may be integrated into theseparate electronic database or may be integrated into the admission system. The alert system may be either manualadmission system. The alert system may be either manual or electronic or a combination of both.or electronic or a combination of both. Note 2: Each hospital may define its own parameters inNote 2: Each hospital may define its own parameters in terms of time and clinical manifestation to determine whichterms of time and clinical manifestation to determine which re-admitted patients require isolation.re-admitted patients require isolation.
  42. 42. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 07.04.01National Patient Safety Goal 07.04.01 Implement evidence-based practices toImplement evidence-based practices to prevent central line–associatedprevent central line–associated bloodstream infections.bloodstream infections. Note: This requirement covers short and long-termNote: This requirement covers short and long-term central venous catheters and peripherally insertedcentral venous catheters and peripherally inserted central catheter (PICC) lines.central catheter (PICC) lines.
  43. 43. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.07.04.01Elements of Performance for NPSG.07.04.01 • Educate staff and licensed independent practitionersEducate staff and licensed independent practitioners who are involved in managing central lines aboutwho are involved in managing central lines about central line–associated bloodstream infections andcentral line–associated bloodstream infections and the importance of prevention. Education occurs uponthe importance of prevention. Education occurs upon hire, annually thereafter, and when involvement inhire, annually thereafter, and when involvement in these procedures is added to an individual’s jobthese procedures is added to an individual’s job responsibilities.responsibilities. • Prior to insertion of a central venous catheter,Prior to insertion of a central venous catheter, educate patients and, as needed, their families abouteducate patients and, as needed, their families about central line–associated bloodstream infectioncentral line–associated bloodstream infection prevention.prevention.
  44. 44. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Implement policies and practices aimed at reducingImplement policies and practices aimed at reducing the risk of central line–associated bloodstreamthe risk of central line–associated bloodstream infections. These policies and practices meetinfections. These policies and practices meet regulatory requirements and are aligned withregulatory requirements and are aligned with evidence-based standards (for example, the CDC)evidence-based standards (for example, the CDC) and/or professional organization guidelines).and/or professional organization guidelines). • Conduct periodic risk assessments for central line–Conduct periodic risk assessments for central line– associated bloodstream infections, monitorassociated bloodstream infections, monitor compliance with evidence-based practices, andcompliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. Theevaluate the effectiveness of prevention efforts. The risk assessments are conducted in time framesrisk assessments are conducted in time frames defined by the hospital, and this infection surveillancedefined by the hospital, and this infection surveillance activity is hospital-wide, not targeted.activity is hospital-wide, not targeted.
  45. 45. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Provide central line–associated bloodstream infectionProvide central line–associated bloodstream infection rate data and prevention outcome measures to keyrate data and prevention outcome measures to key stakeholders, including leaders, licensed independentstakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.practitioners, nursing staff, and other clinicians. • Use a catheter checklist and a standardized protocolUse a catheter checklist and a standardized protocol for central venous catheter insertion.for central venous catheter insertion. • Perform hand hygiene prior to catheter insertion orPerform hand hygiene prior to catheter insertion or manipulation.manipulation. • For adult patients, do not insert catheters into theFor adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.femoral vein unless other sites are unavailable.
  46. 46. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Use a standardized supply cart or kit that contains allUse a standardized supply cart or kit that contains all necessary components for the insertion of central venousnecessary components for the insertion of central venous catheters.catheters. • Use a standardized protocol for sterile barrier precautionsUse a standardized protocol for sterile barrier precautions during central venous catheter insertion.during central venous catheter insertion. • Use an antiseptic for skin preparation during centralUse an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literaturevenous catheter insertion that is cited in scientific literature or endorsed by professional organizations.or endorsed by professional organizations. • Use a standardized protocol to disinfect catheter hubs andUse a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.injection ports before accessing the ports. • Evaluate all central venous catheters routinely andEvaluate all central venous catheters routinely and remove nonessential catheters.remove nonessential catheters.
  47. 47. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 07.05.01National Patient Safety Goal 07.05.01 Implement evidence-based practice forImplement evidence-based practice for preventing surgical site infectionspreventing surgical site infections Elements of Performance for NPSG.07.05.01Elements of Performance for NPSG.07.05.01 Educate staff and licensed independent practitionersEducate staff and licensed independent practitioners involved in surgical procedures about surgical site infectionsinvolved in surgical procedures about surgical site infections and the importance of prevention. Education occurs uponand the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgicalhire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities.procedures is added to an individual’s job responsibilities. Educate patients, and their families as needed, who areEducate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infectionundergoing a surgical procedure about surgical site infection prevention.prevention.
  48. 48. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Implement policies and practices aimed at reducing theImplement policies and practices aimed at reducing the risk of surgical site infections. These policies andrisk of surgical site infections. These policies and practices meet regulatory requirements and are alignedpractices meet regulatory requirements and are aligned with evidence-based guidelines (for example, the CDCwith evidence-based guidelines (for example, the CDC and/or professional organization guidelines).and/or professional organization guidelines). • As part of the effort to reduce surgical site infections:As part of the effort to reduce surgical site infections:  Conduct periodic risk assessments for surgical siteConduct periodic risk assessments for surgical site infections in a time frame determined by the hospital.infections in a time frame determined by the hospital.  Select surgical site infection measures using best practicesSelect surgical site infection measures using best practices or evidence-based guidelines.or evidence-based guidelines.  Monitor compliance with best practices or evidence-basedMonitor compliance with best practices or evidence-based guidelines.guidelines.  Evaluate the effectiveness of prevention efforts.Evaluate the effectiveness of prevention efforts. Note: Surveillance may be targeted to certain procedures based onNote: Surveillance may be targeted to certain procedures based on the hospital’s risk assessment.the hospital’s risk assessment.
  49. 49. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. • Measure surgical site infection rates for the first 30 daysMeasure surgical site infection rates for the first 30 days following procedures that do not involve insertingfollowing procedures that do not involve inserting implantable devices and for the first year followingimplantable devices and for the first year following procedures involving implantable devices. The hospital’sprocedures involving implantable devices. The hospital’s measurement strategies follow evidence-basedmeasurement strategies follow evidence-based guidelines.guidelines. Note: Surveillance may be targeted to certainNote: Surveillance may be targeted to certain procedures based on the hospital's risk assessment.procedures based on the hospital's risk assessment. • Provide process and outcome (for example, surgical siteProvide process and outcome (for example, surgical site infection rate) measure results to key stakeholders.infection rate) measure results to key stakeholders. • Administer antimicrobial agents for prophylaxis for aAdminister antimicrobial agents for prophylaxis for a particular procedure or disease according to evidence-particular procedure or disease according to evidence- based best practices.based best practices. • When hair removal is necessary, use clippers orWhen hair removal is necessary, use clippers or depilatories.depilatories. Note: Shaving is an inappropriate hairNote: Shaving is an inappropriate hair removal method.removal method.
  50. 50. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 07.06.01National Patient Safety Goal 07.06.01 Implement evidence-based practices toImplement evidence-based practices to prevent indwelling catheter-associatedprevent indwelling catheter-associated urinary tract infections (CAUTI)urinary tract infections (CAUTI) Note: This NPSG isNote: This NPSG is newnew for 2012 and not applicable tofor 2012 and not applicable to pediatric populations.pediatric populations. Elements of Performance for NPSG.07.06.01Elements of Performance for NPSG.07.06.01 During 2012, plan for the full implementation of this NPSG by January 1, 2013. Note: Planning may include a number of different activities, such as assigning responsibility for implementation activities, creating time lines, identifying resources, and pilot testing.
  51. 51. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Insert indwelling urinary catheters according toInsert indwelling urinary catheters according to established evidence-based guidelines that address theestablished evidence-based guidelines that address the following:following: • limiting use and duration to situations necessary forlimiting use and duration to situations necessary for patient carepatient care • using aseptic techniques for site preparation,using aseptic techniques for site preparation, equipment, and suppliesequipment, and supplies
  52. 52. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Manage indwelling urinary catheters according toManage indwelling urinary catheters according to established evidence-based guidelines that address theestablished evidence-based guidelines that address the following:following: • securing catheters for unobstructed urine flow andsecuring catheters for unobstructed urine flow and drainagedrainage • maintaining the sterility of the urine collection systemmaintaining the sterility of the urine collection system • replacing the urine collection system when requiredreplacing the urine collection system when required • collecting urine samplescollecting urine samples
  53. 53. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Measure and monitor catheter-associated urinary tractMeasure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-infection prevention processes and outcomes in high- volume areas by doing the following:volume areas by doing the following: • selecting measures using evidence-based guidelinesselecting measures using evidence-based guidelines or best practicesor best practices • monitoring compliance with evidence-basedmonitoring compliance with evidence-based guidelines or best practicesguidelines or best practices • evaluating the effectiveness of prevention effortsevaluating the effectiveness of prevention efforts
  54. 54. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. National Patient Safety Goal 15.01.01National Patient Safety Goal 15.01.01 Identify patients at risk for suicideIdentify patients at risk for suicide Note: This requirement applies only to psychiatric hospitalsNote: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioraland patients being treated for emotional or behavioral disorders in general hospitals.disorders in general hospitals. Suicide of a patient while in a staffed, round-the-clock careSuicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event.setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under theIdentification of individuals at risk for suicide while under the care of or following discharge from a health care organizationcare of or following discharge from a health care organization is an important step in protecting these at-risk individuals.is an important step in protecting these at-risk individuals.
  55. 55. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for NPSG.10.01.01:Elements of Performance for NPSG.10.01.01: • Conduct a risk assessment that identifies specific patientConduct a risk assessment that identifies specific patient characteristics and environmental features that maycharacteristics and environmental features that may increase or decrease the risk for suicide.increase or decrease the risk for suicide. • Address the patient’s immediate safety needs and mostAddress the patient’s immediate safety needs and most appropriate setting for treatment.appropriate setting for treatment. • When a patient at risk for suicide leaves the care of theWhen a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as ahospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.crisis hotline) to the patient and his or her family.
  56. 56. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Introduction to the Universal ProtocolIntroduction to the Universal Protocol for Preventing Wrong Site, Wrongfor Preventing Wrong Site, Wrong Procedure, and Wrong PersonProcedure, and Wrong Person Surgery™Surgery™ The Universal Protocol applies to all surgical andThe Universal Protocol applies to all surgical and non-surgical invasivenon-surgical invasive procedures.procedures. Evidence indicatesEvidence indicates that procedures that place the patient at the most riskthat procedures that place the patient at the most risk include those that involve general anesthesia or deepinclude those that involve general anesthesia or deep sedation,sedation, although other procedures may also affectalthough other procedures may also affect patient safety. Hospitals can enhance safety bypatient safety. Hospitals can enhance safety by correctly identifying the patient, the appropriatecorrectly identifying the patient, the appropriate procedure, and the correct site of the procedure.procedure, and the correct site of the procedure.
  57. 57. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The Universal Protocol is based on the followingThe Universal Protocol is based on the following principles:principles: • Wrong-person, wrong-site, and wrong-procedure surgeryWrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.can and must be prevented. • A robust approach using multiple, complementaryA robust approach using multiple, complementary strategies is necessary to achieve the goal of alwaysstrategies is necessary to achieve the goal of always conducting the correct procedure on the correct person, atconducting the correct procedure on the correct person, at the correct site.the correct site. • Active involvement and use of effective methods toActive involvement and use of effective methods to improve communication among all members of theimprove communication among all members of the procedure team are important for success.procedure team are important for success. • To the extent possible, the patient and, as needed, theTo the extent possible, the patient and, as needed, the family are involved in the process.family are involved in the process. • Consistent implementation of a standardized protocol isConsistent implementation of a standardized protocol is most effective in achieving safety.most effective in achieving safety.
  58. 58. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The Universal Protocol is implemented most successfully inThe Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and wherehospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. Aall individuals feel empowered to protect patient safety. A hospital should consider its culture when designinghospital should consider its culture when designing processes to meet the Universal Protocol. In some hospitals,processes to meet the Universal Protocol. In some hospitals, it may be necessary to be more prescriptive on certainit may be necessary to be more prescriptive on certain elements of the Universal Protocol or to create processeselements of the Universal Protocol or to create processes that are not specifically addressed within these requirements.that are not specifically addressed within these requirements.
  59. 59. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Hospitals should identify the timing and location of the pre-Hospitals should identify the timing and location of the pre- procedure verification and site marking based on what worksprocedure verification and site marking based on what works best for their own unique circumstances. The frequency andbest for their own unique circumstances. The frequency and scope of the pre-procedure verification will depend on the typescope of the pre-procedure verification will depend on the type and complexity of the procedure. The three components of theand complexity of the procedure. The three components of the Universal Protocol are not necessarily presented inUniversal Protocol are not necessarily presented in chronological order (although the pre-procedure verification andchronological order (although the pre-procedure verification and site marking precede the final verification in the time out). Pre-site marking precede the final verification in the time out). Pre- procedure verification, site marking, and the time-outprocedure verification, site marking, and the time-out procedures should be as consistent as possible throughout theprocedures should be as consistent as possible throughout the hospital.hospital. Note: Site marking is not required when the individualNote: Site marking is not required when the individual doing the procedure is continuously with the patient from thedoing the procedure is continuously with the patient from the time of the decision to do the procedure through to thetime of the decision to do the procedure through to the performance of the procedure.performance of the procedure.
  60. 60. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Universal Precautions 01.01.01Universal Precautions 01.01.01 Conduct a Pre-Procedure VerificationConduct a Pre-Procedure Verification ProcessProcess Hospitals should always make sure that any procedureHospitals should always make sure that any procedure is what the patient needs and is performed on the rightis what the patient needs and is performed on the right person. The frequency and scope of the verificationperson. The frequency and scope of the verification process will depend on the type and complexity of theprocess will depend on the type and complexity of the procedure.procedure.
  61. 61. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The pre-procedure verification is an ongoing process ofThe pre-procedure verification is an ongoing process of information gathering and confirmation. The purpose ofinformation gathering and confirmation. The purpose of the pre-procedure verification process is to make surethe pre-procedure verification process is to make sure that all relevant documents and related information orthat all relevant documents and related information or equipment are:equipment are: • available prior to the start of the procedureavailable prior to the start of the procedure • correctly identified, labeled, and matched to thecorrectly identified, labeled, and matched to the patient’s identifierspatient’s identifiers • reviewed and are consistent with the patient’sreviewed and are consistent with the patient’s expectations and with the team’s understanding ofexpectations and with the team’s understanding of the intended patient, procedure and site.the intended patient, procedure and site.
  62. 62. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Pre-procedure verification may occur at more than onePre-procedure verification may occur at more than one time and place before the procedure. It is up to thetime and place before the procedure. It is up to the hospital to decide when this information is collected andhospital to decide when this information is collected and by which team member, but it is best to do it when theby which team member, but it is best to do it when the patient can be involved. Possibilities include thepatient can be involved. Possibilities include the following:following: • when the procedure is scheduledwhen the procedure is scheduled • at the time of preadmission testing and assessmentat the time of preadmission testing and assessment • at the time of admission or entry into the facility for aat the time of admission or entry into the facility for a procedureprocedure • before the patient leaves the preprocedure area or entersbefore the patient leaves the preprocedure area or enters the procedure roomthe procedure room • missing information or discrepancies are addressedmissing information or discrepancies are addressed before starting the procedure.before starting the procedure.
  63. 63. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for Universal Protocol.01.01.01Elements of Performance for Universal Protocol.01.01.01 Implement a pre-procedure process to verify the correct procedure,Implement a pre-procedure process to verify the correct procedure, for the correct patient, at the correct site.for the correct patient, at the correct site. Note: The patient isNote: The patient is involved in the verification process when possible.involved in the verification process when possible. Identify the items that must be available for the procedure and useIdentify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, thesea standardized list to verify their availability. At a minimum, these items include the following:items include the following: • relevant documentation (for example, history & physical,relevant documentation (for example, history & physical, signed procedure consent form, nursing assessment, and pre-signed procedure consent form, nursing assessment, and pre- anesthesia assessment)anesthesia assessment) • labeled diagnostic and radiology test results (for example,labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports)radiology images and scans, or pathology and biopsy reports) that are properly displayedthat are properly displayed
  64. 64. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Any required blood products, implants, devices, and/orAny required blood products, implants, devices, and/or special equipment for the procedure. Note: The expectationspecial equipment for the procedure. Note: The expectation of this element of performance is that the standardized list isof this element of performance is that the standardized list is available and is used consistently during the pre-procedureavailable and is used consistently during the pre-procedure verification. It is not necessary to document that theverification. It is not necessary to document that the standardized list was used for each patient.standardized list was used for each patient. Match the items that are to be available in the procedureMatch the items that are to be available in the procedure area to the patient.area to the patient.
  65. 65. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Universal Protocol 01.02.01Universal Protocol 01.02.01 Mark the procedure siteMark the procedure site Elements of Performance for UP.01.02.01Elements of Performance for UP.01.02.01 Identify those procedures that require marking of the incision orIdentify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there isinsertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and whenmore than one possible location for the procedure and when performing the procedure in a different location would negativelyperforming the procedure in a different location would negatively affect quality or safety.affect quality or safety. Note: For spinal procedures, in addition toNote: For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intra-preoperative skin marking of the general spinal region, special intra- operative imaging techniques may be used for locating and markingoperative imaging techniques may be used for locating and marking thethe exact vertebral level.exact vertebral level. Mark the procedure site before the procedureMark the procedure site before the procedure is performed and, if possible, with the patient involved.is performed and, if possible, with the patient involved.
  66. 66. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The procedure site is marked by a licensed independentThe procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedurepractitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. Inand will be present when the procedure is performed. In limited circumstances, the licensed independent practitionerlimited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permittedmay delegate site marking to an individual who is permitted by the organization to participate in the procedure and hasby the organization to participate in the procedure and has the following qualifications:the following qualifications: • An individual in a medical residency program who is beingAn individual in a medical residency program who is being supervised by the licensed independent practitioner performing thesupervised by the licensed independent practitioner performing the procedure, who is familiar with the patient, and who will be presentprocedure, who is familiar with the patient, and who will be present when the procedure is performedwhen the procedure is performed • A licensed individual who performs duties requiring a collaborativeA licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independentagreement or supervisory agreement with the licensed independent practitioner performing the procedure; that is, an advanced practicepractitioner performing the procedure; that is, an advanced practice registered nurse (A.P.R.N.) or physician assistant (P.A.), who isregistered nurse (A.P.R.N.) or physician assistant (P.A.), who is familiar with the patient, and who will be present when thefamiliar with the patient, and who will be present when the procedure is performed.procedure is performed.
  67. 67. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. The method of marking the site and the type of mark isThe method of marking the site and the type of mark is unambiguous and is used consistently throughout theunambiguous and is used consistently throughout the hospital. Note: The mark is made at or near the procedurehospital. Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skinsite and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the solepreparation and draping. Adhesive markers are not the sole means of marking the site.means of marking the site. A written, alternative process is in place for patients whoA written, alternative process is in place for patients who refuse site marking or when it is technically or anatomicallyrefuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example,impossible or impractical to mark the site (for example, mucosal surfaces or perineum).mucosal surfaces or perineum).
  68. 68. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Examples of other situations that involve alternativeExamples of other situations that involve alternative processes include:processes include: • minimal access procedures treating a lateralizedminimal access procedures treating a lateralized internal organ, whether percutaneous or through ainternal organ, whether percutaneous or through a natural orificenatural orifice • interventional procedure cases for which theinterventional procedure cases for which the catheter/instrument insertion site is notcatheter/instrument insertion site is not predetermined (for example, cardiacpredetermined (for example, cardiac catheterization, pacemaker insertion)catheterization, pacemaker insertion) • teethteeth • premature infants, for whom the mark may cause apremature infants, for whom the mark may cause a permanent tattoo.permanent tattoo.
  69. 69. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Universal Protocol Goal 01.03.01Universal Protocol Goal 01.03.01 A time-out if performed before the procedureA time-out if performed before the procedure The purpose of the time-out is to conduct a finalThe purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedureassessment that the correct patient, site, and procedure are identified. This requirement focuses on those minimumare identified. This requirement focuses on those minimum features of the time-out. Some believe that it is important tofeatures of the time-out. Some believe that it is important to conduct the time-out before anesthesia for several reasons,conduct the time-out before anesthesia for several reasons, including involvement of the patient.including involvement of the patient.
  70. 70. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. A hospital may conduct the time-out before anesthesiaA hospital may conduct the time-out before anesthesia or may add another time-out at that time. During aor may add another time-out at that time. During a timeout, activities are suspended to the extent possibletimeout, activities are suspended to the extent possible so that team members can focus on active confirmationso that team members can focus on active confirmation of the patient, site, and procedure. A designatedof the patient, site, and procedure. A designated member of the team initiates the time-out and it includesmember of the team initiates the time-out and it includes active communication among all relevant members ofactive communication among all relevant members of the procedure team. The procedure is not started untilthe procedure team. The procedure is not started until all questions or concerns are resolved. The time-out isall questions or concerns are resolved. The time-out is most effective when it is conducted consistently acrossmost effective when it is conducted consistently across the hospital.the hospital.
  71. 71. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Elements of Performance for UP.01.03.01Elements of Performance for UP.01.03.01 Conduct a time-out immediately before starting theConduct a time-out immediately before starting the invasive procedure or making the incision. The time-outinvasive procedure or making the incision. The time-out has the following characteristics:has the following characteristics: • It is standardized, as defined by the hospital.It is standardized, as defined by the hospital. • It is initiated by a designated member of the team.It is initiated by a designated member of the team. • It involves the immediate members of the procedureIt involves the immediate members of the procedure team, including the individual performing theteam, including the individual performing the procedure, the anesthesia providers, the circulatingprocedure, the anesthesia providers, the circulating nurse, the operating room technician, and othernurse, the operating room technician, and other active participants who will be participating in theactive participants who will be participating in the procedure from the beginning.procedure from the beginning.
  72. 72. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. When two or more procedures are being performed onWhen two or more procedures are being performed on the same patient, and the person performing thethe same patient, and the person performing the procedure changes, perform a time-out before eachprocedure changes, perform a time-out before each procedure is initiated. During the time-out, the teamprocedure is initiated. During the time-out, the team members agree, at a minimum, on the following:members agree, at a minimum, on the following: • correct patient identitycorrect patient identity • the correct sitethe correct site • the procedure to be donethe procedure to be done Document the completion of the time-out.Document the completion of the time-out. Note: The hospital determines the amount and type ofNote: The hospital determines the amount and type of documentation.documentation.
  73. 73. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. JCAHO Official “Do Not Use” ListJCAHO Official “Do Not Use” List Do Not UseDo Not Use Potential ProblemPotential Problem Use InsteadUse Instead U, u (unit)U, u (unit) Mistaken for “0” (zero),Mistaken for “0” (zero), Write “unit”Write “unit” the number “4” (four) or “cc”the number “4” (four) or “cc” IU (International Unit)IU (International Unit) Mistaken for IV (intravenous)Mistaken for IV (intravenous) Write “InternationalWrite “International or the number 10 (ten)or the number 10 (ten) Unit”Unit” Q.D., QD, q.d., qd (daily)Q.D., QD, q.d., qd (daily) Mistaken for each otherMistaken for each other Write “daily”Write “daily” Q.O.D., QOD, q.o.d, qodQ.O.D., QOD, q.o.d, qod Period after the Q mistaken forPeriod after the Q mistaken for Write “every otherWrite “every other (every other day)(every other day) “I” and the “O” mistaken for “I”“I” and the “O” mistaken for “I” day”day” Trailing zero (X.0 mg)*Trailing zero (X.0 mg)* Decimal point is missedDecimal point is missed Write X mgWrite X mg Lack of leading zero (.X mg)Lack of leading zero (.X mg) Write 0.X mgWrite 0.X mg MSMS Can mean morphine sulfate orCan mean morphine sulfate or Write "morphineWrite "morphine magnesium sulfatemagnesium sulfate sulfate"sulfate" MSO4 and MgSO4MSO4 and MgSO4 Confused for one anotherConfused for one another Write "magnesiumWrite "magnesium sulfate"sulfate"
  74. 74. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. JCAHO Official “Do Not Use” ListJCAHO Official “Do Not Use” List Applies to all orders and all medication-related documentation that isApplies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printedhandwritten (including free-text computer entry) or on pre-printed forms.forms. Exception:Exception: A “trailing zero” may be used only whereA “trailing zero” may be used only where required to demonstrate the level of precision of therequired to demonstrate the level of precision of the value being reported, such as for laboratory results,value being reported, such as for laboratory results, imaging studies that report size of lesions, orimaging studies that report size of lesions, or catheter/tube sizes.catheter/tube sizes. It may not be used in medicationIt may not be used in medication orders or other medication-related documentation.orders or other medication-related documentation.
  75. 75. This material is the private property of Chesapeake Medical Staffing. Any duplication or use by anyone other than an employee of Chesapeake Medical Staffing is prohibited. Additional Abbreviations, Acronyms and SymbolsAdditional Abbreviations, Acronyms and Symbols Do Not UseDo Not Use Potential ProblemPotential Problem Use InsteadUse Instead > (greater than)> (greater than) Misinterpreted as the number Write “greater than”Misinterpreted as the number Write “greater than” < (less than)< (less than) “7” (seven) or the letter “L”“7” (seven) or the letter “L” Write “less than”Write “less than” Confused for one anotherConfused for one another Abbreviations forAbbreviations for Misinterpreted due to Write drug names in fullMisinterpreted due to Write drug names in full drug namesdrug names similar abbreviations forsimilar abbreviations for multiple drugsmultiple drugs Apothecary unitsApothecary units Unfamiliar to many practitioners Use metric unitsUnfamiliar to many practitioners Use metric units Confused with metric unitsConfused with metric units @@ Mistaken for the number “2” (two) Write “at”Mistaken for the number “2” (two) Write “at” cccc Mistaken for U (units)Mistaken for U (units) Write “mL” or “ml”Write “mL” or “ml” when poorly writtenwhen poorly written or “milliliters”or “milliliters” (“mL” is preferred)(“mL” is preferred) μgμg Mistaken for mg (milligrams)Mistaken for mg (milligrams) Write "mcg" orWrite "mcg" or resulting in one thousand-fold overdose “micrograms”resulting in one thousand-fold overdose “micrograms”

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