Signature Leadership SeriesChecklists toImprovePatient SafetyJune 2013
Resources: For information related to patient safety and quality, visit www.hpoe.org,http://www.cynosurehealth.org/ and http://www.hret-hen.org/.Suggested Citation: Health Research & Educational Trust. (2013, June). Checklists to improve patientsafety. Chicago: IL. Illinois. Health Research & Educational Trust, Accessed at www.hpoe.org.Accessible at: etyContact: hpoe@aha.org or (877) 243-0027 2013 American Hospital Association. All rights reserved. All materials contained in this publication are availableto anyone for download on www.hret.org or www.hpoe.org for personal, noncommercial use only. No part of thispublication may be reproduced and distributed in any form without permission of the publisher, or in the case ofthird party materials, the owner of that content, except in the case of brief quotations followed by the abovesuggested citation. To request permission to reproduce any of these materials, please email HPOE@aha.org.1Checklists to Improve Patient Safety
Checklists to Improve Patient SafetyWhy a Checklist?To improve patient safety and quality outcomes, health care professionals are using multiple methods toreduce patient harm and eliminate medical errors. One method being implemented more and more isthe checklist. In his book “The Checklist Manifesto,” Atul Gawande, MD, analyzes the positive impact ofchecklists used in many fields, including health care, to handle “the volume and complexity of what weknow.”Know-how and sophistication have increased remarkably across almost all our realms ofendeavor, and as a result so has our struggle to deliver on them .Avoidable failures arecommon and persistent, not to mention demoralizing and frustrating, across many fields—frommedicine to finance, business to government. And the reason is increasingly evident: the volumeand complexity of what we know has exceeded our individual ability to deliver its benefitscorrectly, safely, or reliably. Knowledge has both saved us and burdened us. (Gawande, 2010)The development and use of checklists in health care has increased. In 2010, a HealthLeaders MediaIndustry Survey reported that 88.8 percent of quality leaders use checklists to prevent errors in hospitaloperating rooms. It is important to note that the effectiveness of a checklist depends on its quality andthoroughness, acceptance and compliance by staff, and a strong culture of safety in the organization.Types of ChecklistsDeveloping the structure and content of a checklist starts with identifying its purpose or goal. Table 1outlines several types of checklists and their uses in a medical environment.Table 1. Types of ChecklistsType of ChecklistLaundry listSequential or weaklysequential checklistIterative checklistDiagnostic checklistCriteria of meritchecklistDescriptionItems, tasks or criteria are grouped intorelated categories with no particularorder.The grouping, order and overall flow ofthe items, tasks or criteria are relevantin order to obtain a valid outcome.Items, tasks or criteria on the checklistrequire repeated passes or review inorder to obtain valid results, as earlycheckpoints may be altered by resultsentered in later checkpoints.Items, tasks or criteria on the checklistare formatted based on a “flowchart”model with the ultimate goal of drawingbroad conclusions.Commonly used for evaluativepurposes, in which the order,categorization and flow of informationare paramount for the objectivity andreliability of the conclusions drawn.ExampleMedical equipment checklistProcedure checklist (equipmentmust be gathered beforeprocedure begins)Continued rechecking of thepulse and blood pressure inchecklists for adultcardiopulmonary resuscitationClinical algorithmsChecklist for diagnosis ofbrain deathSource: Modified from Development of medical checklists for improved quality of patient care, International Journal for Quality in Health Care, 2008.2Checklists to Improve Patient SafetyWhy a Checklist?
Benefits of Checklists in Health CareChecklists used in the medical setting can promote process improvement and increase patient safety.Implementing a formalized process reduces errors caused by lack of information and inconsistentprocedures. Checklists have improved processes for hospital discharges and patient transfers as well asfor patient care in intensive care and trauma units. Along with improving patient safety, checklists createa greater sense of confidence that the process is completed accurately and thoroughly.Checklists can have a significant positive impact on health outcomes, including reducing mortality,complications, injuries and other patient harm. Working with the World Health Organization, Gawandeexamined how a surgical safety checklist was implemented and tested in eight hospitals worldwide. Withthis checklist, major post-surgical complications at the hospitals fell 36 percent and deaths decreased by47 percent.Checklists for Improving Patient CareThe Partnership for Patients Hospital Engagement Networks are designed to improve patient careacross 10 areas of patient harm through the implementation and dissemination of best practices inclinical quality. This guide includes checklists, developed by Cynosure Health, for these 10 areas:1.2.3.4.5.6.7.8.9.10.Adverse drug events (ADEs)Catheter-associated urinary tract infections (CAUTIs)Central line-associated blood stream infections (CLABSIs)Early elective deliveries (EEDs)Injuries from falls and immobilityHospital-acquired pressure ulcers (HAPUs)Preventable readmissionsSurgical site infections (SSIs)Ventilator-associated pneumonias (VAPs) and ventilator-associated events (VAEs)Venous thromboembolisms (VTEs)To prevent process breakdowns due to human factors, each checklist identifies the top 10 evidencebased interventions that health care organizations can implement and test to reduce harm. The AHA/HRET Hospital Engagement Network (HEN) supports each checklist topic with a change package thatcan be accessed at www.HRET-HEN.org. The change packages provide guidance for implementing bestpractices, including suggested aim statements, lists of change ideas and tools, detailed steps and driverdiagrams. These diagrams map the process to implement each intervention.Through the AHA/HRET HEN, quality improvement leaders and their teams are encouraged to use thechecklists to determine which key interventions they can test as part of their Plan-Do-Study-Actprocess. HEN staff reviews the interventions during site visits with state hospital association leaders andhospitals. With these tools, hospital improvement teams can identify and adopt the process change,assign staff responsibility and record a target date for completion.These checklists will assist hospitals and health care systems in their efforts to prevent inpatient harmand reduce preventable readmissions, which are the end goals of the Partnership for Patients initiative.3Checklists to Improve Patient SafetyBenefits of a Checklist
Checklist 1: Adverse Drug Events Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Identify “look-alike, sound-alike” medications andcreate a mechanism to reduce errors (e.g.,different locations, labels, alternate packaging)Standardize concentrations and minimize dosingoptions when feasibleSet dosing limits for insulin and narcoticsUse low-molecular-weight heparin or other agentsinstead of unfractionated heparin wheneverclinically appropriateUse alerts to avoid multiple prescriptions ofnarcotics/sedativesRequire new insulin orders when patient istransitioned from parenteral to enteral nutritionReduce sliding scale variation (or eliminate slidingscales)Minimize or eliminate pharmacist or nursedistraction during the medicationfulfillment/administration processUse data/information from alerts and overrides toredesign standardized processesCoordinate meal and insulin times4Checklists to Improve Patient SafetyChecklist 1
Checklist 2: Catheter-Associated Urinary Tract Infections Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Adopt insertion criteriaEnsure sterile technique (including hand hygiene,soap and water perineal care prior toinsertion, and appropriate-sized catheter) is used(i.e., through evaluating staff competency andperforming observation audits)Incorporate daily review of line necessity intoworkflow, such as charge nurse rounds, electronichealth care record prompt (e.g., take advantage ofhabits and patterns rather than create a new form)Do not change indwelling urinary cathetersroutinelyEnsure appropriate care and maintenance—closedsystem, perineal hygiene done routinely, keep urineflowing (no kinks, bag lower than bladder), regularemptying, use of securement deviceInclude RNs, MDs, nurse aids, PT, OT, transport,etc. in efforts to reduce CAUTI; they all have arole in care, maintenance and discontinuation ofthe catheterEngage emergency department and surgicalservices (and other invasive procedure areaswhere urinary catheters might be inserted) inadopting insertion criteria and insertion techniqueUse other tools, such as underpads that providea quick-drying surface and wick moisture away,toileting schedule, and purposeful rounding (goodalignment here with falls and HAPU prevention) tomanage incontinenceInvolve patient and family so they understand therisks associated with a urinary catheterEstablish CAUTI as a top priority by makingCAUTI data transparent5Checklists to Improve Patient SafetyChecklist 2
Checklist 3: Central Line-Associated Blood Stream Infections Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Implement insertion bundle: procedural pause,hand hygiene, aseptic technique for insertion andcare, site selection of subclavian (preferred),internal jugular (acceptable) and avoidance offemoral vein in adults, maximal sterile precautions,skin prep with 2% chlorhexidineImplement “stop the line” approach to insertionbundle; if there is an observed violation of infectioncontrol practices (maximal sterile barrierprecautions, break in sterile technique), lineplacement should stop and the violation correctedImplement insertion checklist to help withcompliance and monitoringIncorporate daily review of line necessity intoworkflow, such as charge nurse rounds, electronichealth care record promptAdopt maintenance bundle of dressing changes(every 7 days for transparent) line changes, and IVfluid changes; incorporate into daily assessmentand review. Can be part of charge nurse checklistalong with the daily review of line necessityUse a chlorhexidine-impregnated sponge dressingUse 2% chlorhexidine-impregnated cloths for dailyskin cleansingDo not routinely replace CVCs, PICCs,hemodialysis catheters or pulmonary arterycathetersUse a sutureless securement deviceUse ultrasound guidance to place lines if thistechnology is available6Checklists to Improve Patient SafetyChecklist 3
Checklist 4: Early Elective Deliveries Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible & ByWhen?)Educate hospital governing board about thedangers of early elective delivery and the hospital’srole in preventionUse prenatal classes as an opportunity to educatepatients about the dangers of early elective deliveryand the hospital’s policyFind a physician willing to champion the effort toreduce early elective delivery. This physician doesNOT have to be an obstetrician; a neonatologistor pediatrician can be very successful in this roleWhen writing a hard-stop policy, have physiciansand hospital leaders involved from the startEnsure the hard-stop policy is very prescriptive(stating the exact steps to be taken, and by whom,in the chain of command when an electivedelivery is being scheduled that does not meetcriteria determined by the medical staff)Use policies, scheduling forms, educationalmaterials and data collection tools that are alreadycreated and available publicly from the March ofDimes or California Maternal Quality CareCollaborativeDisplay data as concurrently as possible for allstakeholdersReview all early elective deliveries in the past 12months to determine if any were admitted toNICU; use those stories as motivationPick one system for determining gestational age inhospital policy and stick to it; the “line in the sand”is key to successDo not get stuck in developing the policy by tryingto be so prescriptive that any possible medicalindication is mentioned. Let the policy allow formedical judgment and a rate of less than 3% as agoal instead of zero7Checklists to Improve Patient SafetyChecklist 4
Checklist 5: Injuries from Falls and Immobility Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Conduct fall and injury risk assessment uponadmissionReassess risk daily and with changes in patientconditionImplement patient-specific intervention to preventfalls and injuryCommunicate risk across the team; use handoffforms, visual cues, huddlesRound every 1 to 2 hours for high-risk patients;address needs (e.g., 3Ps: pain, potty,position-pressure). Combine with other tasks(vital signs)Individualize interventions. Use non-skid floormats, hip protectors, individualized toiletingschedule; adjust frequency of roundsReview medications (by pharmacist); avoidunnecessary hypnotics, sedativesIncorporate multidisciplinary input for fallsprevention from PT, OT, MD, RN and PharmDInclude patients, families and caregivers in effortsto prevent falls. Educate regarding fall preventionmeasures; stay with patientHold post-fall huddles immediately after event;analyze how and why; implement change toprevent other falls8Checklists to Improve Patient SafetyChecklist 5
Checklist 6: Hospital-Acquired Pressure Ulcers Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Implement head-to-toe skin evaluation and riskassessment tool; assess the skin and risks within4 hours of admission; risk and skin assessmentshould be age appropriateDevelop and implement an individualized plan ofcare based on skin and risk assessmentAssess skin and risk at least daily and incorporateinto other routine assessmentsAvoid skin wetness by protecting and moisturizingas needed; use underpads that provide aquick-drying surface and wick away moisture; usetopical agents that hydrate the skin and form amoisture barrier to reduce skin damageSet specific time frames or create remindersystems to reposition patient, such as hourly orevery- two-hours rounding with a purpose (the3 P’s: pain, potty, position-pressure). This alignsnicely with fall preventionMonitor weight, nutrition and hydration status; forhigh-risk patients, generate an automatic registereddietician consult.Use special beds, mattresses, and foam wedges toredistribute pressure (pillows should only be usedfor limbs)Cover operating room tables with special overlaymattresses for long cases (greater than 4 hours;some hospitals choose cases greater than 2 hours)and high-risk patients.Use breathable glide sheets and/or lifting devices toprevent shear and frictionInvolve licensed and unlicensed staff, i.e., RNs,LVNs and nurse aides, in HAPU reduction effortssuch as rounding with a purpose9Checklists to Improve Patient SafetyChecklist 6
Checklist 7: Preventable Readmissions Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeConduct enhanced admission assessment ofdischarge needs and begin discharge planning atadmissionInNotplace doneWilladoptNotes(Responsible &By When?)Conduct formal risk of readmission assessment.Align interventions to patient’s needs and riskstratification levelPerform accurate medication reconciliation atadmission, at any change in level of care and atdischargeProvide patient education that is culturallysensitive, incorporates health literacy concepts andincludes information on diagnosis and symptommanagement, medications and post-discharge careneedsIdentify primary caregiver, if not the patient, andinclude him/her in education and discharge planningUse teach-back to validate patient and caregiver’sunderstandingSend discharge summary and after-hospital careplan to primary care provider within 24 to 48hours of dischargeCollaborate with post-acute care and communitybased providers including skilled nursingfacilities, rehabilitation facilities, long-term acutecare hospitals, home care agencies, palliative careteams, hospice, medical homes, and pharmacistsBefore discharge, schedule follow-up medical appointments and post-discharge tests / labs. Forpatients without a primary care physician, workwith health plans, Medicaid agencies and othersafety-net programs to identify and link patient toa PCPConduct post-discharge follow-up calls within 48hours of discharge; reinforce components of afterhospital care plan using teach-back and identify anyunmet needs, such as access to medication,transportation to follow-up appointments, etc.10Checklists to Improve Patient SafetyChecklist 7
Checklist 8: Surgical Site Infections Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInNotplace doneWilladoptNotes(Responsible &By When?)Develop and follow standardized order sets foreach surgical procedure to include antibiotic name,timing of administration, weight-based dose,re-dosing (for longer procedures) anddiscontinuationEnsure preoperative skin antisepsis, such as basicsoap and water shower; use chlorhexidinegluconate showersDevelop standardized perioperative skin antisepticpractices utilizing the most appropriate skinantiseptic for the type of surgery performedDevelop a standardized procedure to assurenormothermia by warming ALL surgical patientsDevelop and implement protocol to optimizeglucose control in ALL surgical patientsDevelop protocol to screen and/or decolonizeselected patients with Staphylococcus aureusAdhere to established guidelines (e.g., HICPAC,AORN) to ensure basic aseptic technique (e.g.,traffic control, attire) is adhered to uniformlyEstablish a culture of safety that provides anenvironment of open and safe communicationamong the surgical teamEstablish system so surgical site infection data isanalyzed and sharedDevelop a protocol to provide guidance on bloodtransfusion practices, as a unit of packed red bloodcells should be considered a transplant/immunemodulator and has been linked to a higher riskof SSIs11Checklists to Improve Patient SafetyChecklist 8
Checklist 9: Ventilator-Associated Pneumonias and Ventilator-Associated Events Top 10 ChecklistTop 10 Evidence-Based InterventionsProcess ChangeInclude all elements of the bundle in charge nurserounds and nurse-to-charge-nurse reportsInNotplace doneWilladoptNotes(Responsible &By When?)Multidisciplinary approach is key: RN and RT staffcan work together to ensure bundle items such asHOB, SAT/SBT and oral care are done accordingto recommendationsElevate head of the bed to between 30–45 degrees(use visual cues, designate one person to check forHOB every one to two hours, involve family)Conduct routine oral care every 2 hours withantiseptic mouthwash and chlorhexidine 0.12%every 12 hours (create visual cues, partner withrespiratory therapy in performing oral care bymaking it a joint RN and RT function). Make theabove oral care part of the ventilator order setas an automatic order that requires the MD toactively exclude itInclude peptic ulcer disease prophylaxis on ICUadmission and ventilator order sets as an automaticorder that requires the MD to actively exclude itInclude venous thromboembolism (VTE)prophylaxis on ICU admission and ventilator ordersets as an automatic order that would require theMD to actively exclude itSpontaneous awakening and breathing trials (SAT/SBT): designate one time of day for the SAT andSBT to b
Checklists for Improving Patient Care The Partnership for Patients Hospital Engagement Networks are designed to improve patient care across 10 areas of patient harm through the implementation and dissemination of best practices in clinical quality. This guide includes checklists, developed by Cynosure Health, for these 10 areas: 1.
This pdf contains 77 electrical inspection checklists taken from the 2014 Electrical Inspection Manual with Checklists. The checklists are in PDF format and can be completed electronically or printed and used as hard copy. The checklists are intended to help inspectors keep track of the numerous aspects of an electrical installation
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Safety Inspections and Sample Safety Inspection Checklists . Another way of conducting inspections is to use the information you have in your head and just walk around looking at what is going on. You do not use a pre-made checklist for this type of inspection. . walk-through, and customize the generic checklists upon request (call 543-0467 .
may be substantially higher (James, 2013, JPS) Crossing the Quality Chasm: A New Health System . National Patient Safety Goals IHI’s 100K lives Campaign 2004 2005 Patient Safety . Patient Quality & Safety Movement: Worldwide 2000 An Organization with a Memory NHS forms National Patient Safety Agency 2001 NPSF’s launches Patient Safety .
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REACHING AND KEEPING VISITORS CHECKLISTS REACHING AND KEEPING VISITORS CHECKLISTS o DEVELOP A STAFF RESPONSE STRUCTURE Develop a staff response structure that guarantees follow-up w
Refer to API RP 500 and NFPA 70 for guidance. When loading liquids that can accumulate static charges, refer to the precautions described in the International Safety Guide for Oil Tankers and Terminals, Safety of Life at Sea, API MPMS Ch. 3, and API RP 2003. Care must be taken with all liquid-in-glass thermometers to prevent breakage, which will result in a safety hazard. If the liquid in the .