Quality Outcomes & Patient Safety
Quality Outcomes & Patient SafetyPDCANational Patient Safety GoalsWelcome to the lesson on Quality Outcomes, PatientSafety Goals and Event Reporting. In this lesson, wewill be describing: The Plan-Do-Check-Adjust (PDCA) qualityimprovement model The Joint Commission’s 2013 National PatientSafety Goals (NPSG) Safety Event ReportingEvent Reporting
Quality Improvement ModelPDCA1. Plan– Identify the goal of the improvement– Develop a plan (who, what, where,when)2. Do– Carry out the plan– Document problems and unexpectedobservations– Begin analysis of the dataWhen a problem is identifiedthat requires an improvement,LPCH applies the PDCAcontinuous improvement cycleto guide the work.Plan3. Check– Complete the analysis of the data– Compare the data to goal– Summarize what was learned4. Adjust– What changes are to be made?– What will be the next cycle?– Go back to Plan, and continue the cycleto improve the interventionAdjustDoCheck
National Patient Safety GoalsNational Patient Safety GoalsThe Joint Commission’s National Patient Safety Goals (NPSG) provide hospitals withspecific areas of focus as a result of problems identified that pose risk to healthcaresafetyIn 2013 there a 6 key areas of focus for the NPSG: Identify Patients CorrectlyImprove Staff CommunicationUse Medicines SafelyPrevent InfectionIdentify Patient Safety RisksPrevent Mistakes in Surgery
Identify Patients CorrectlyNational Patient Safety GoalsPatient Identification Use at least two patient identifiers whenproviding care, treatment and services(medications, breast milk and bloodproducts, procedures, etc.) Label containers used for blood and otherspecimens in the presence of the patient Make sure that the correct patient gets thecorrect blood when they get a bloodtransfusion– Use a 2 person verification process to include: Matching the blood or blood component to the orderMatching the blood or blood component to the patient,using the 2 patient identifiersFor inpatients, comparename and MRN with theidentification band onthe patientFor outpatients, comparename and date of birth
Improve Staff CommunicationNational Patient Safety GoalsGet important test results to the rightstaff person on timeCritical values: Verify the complete order or test result byhaving the person receiving theinformation write down and "read-back"the complete order or test result Communicate critical values to theresponsible licensed caregiver within onehour of availabilityFor example:The lab would report a critical result to a nurseon a unit within 15 minutes after the resultsare available. The nurse would communicatethe results to the licensed independentpractitioner within 45 minutes and documentthat the provider was notified.
Use Medications SafelyNational Patient Safety Goals Label all medications that are unlabeled,including those in procedural areas and on thesterile fieldLabels must include:Name of MedicationStrengthQuantityDiluent and VolumeExpiration date/time**Expiration date when not usedwithin 24 hours and expirationtime when expiration occurs 24 hours Take extra care with patients who takemedicines to thin their blood Maintain and communicate accurate patientmedication information (MedicationReconciliation)
Reduce Health Care- Associated InfectionsNational Patient Safety GoalsHealthcare-Associated Infections Use hand cleaning guidelines and setgoals to improve hand hygiene— Gel IN, Gel OUT with alcohol-based handrubfor at least 15 seconds— Wash with soap and water for at least 15seconds if hands are visibly soiled— Do not use alcohol-based handrub forpatients with c-difficile; wash with soap andwater only Use proven guidelines to prevent infections— Of the blood from central lines (CLABSI)— From surgery (SSI)— Of the urinary tract that are caused bycatheters (CAUTI)— That are difficult to treat (MDRO & Cdifficile)
Identify Patient Safety RisksNational Patient Safety GoalsSuicide Risk Reduction Find out which patients are most likelyto commit suicide– If a patient has suicidal behavior or intent, apsychiatric consult is required– Any inpatient who is identified as a risk forsuicide or attempts suicide will be placed onsuicide precautions with constant 1:1monitoring– When a patient at risk for suicide leaves thecare of the hospital, provide suicideprevention information (such as crisis hotline1-800-273-TALK) to the patient and his or herfamily*Suicide risk assessment applies only to patientsbeing treated for emotional or behavioraldisorders.
Prevent Mistakes in SurgeryNational Patient Safety GoalsUniversal Protocol Make sure the correct surgery isdone on the correct patient and atthe correct place on the patient’sbody Mark the correct place on thepatient’s body where the surgery isto be done Pause before the surgery to makesure that a mistake is not being made(Time Out)The goal of Universal Protocol is to prevent: wrong site wrong patient wrong procedure or surgery Active participation in the process byall members of the team is requiredIt is used for all surgical and nonsurgical invasiveprocedures
Reporting Safety EventsEvent ReportingReporting Safety EventsExample At Packard Children’s, our True North is toprovide extraordinary family centered care Integral to this goal is maintaining safety asour top priority We maintain a blame free (non-punitive)culture so that ALL staff feel comfortablereporting safety-related eventsA patient received 10 times the dose of oralmethadone than what was ordered. The RNsmiscalculated the dose and drew the dose froma bulk bottle in the Pyxis. The patient receivedthe wrong dose and had to be transferred to ahigher level of care to be monitored.Ultimately, the patient recovered withoutcomplications. The bedside nurse reported theevent in the Quantros occurrence reportingsystem. Reporting allows our organization to assessour opportunities for systemsimprovement, so we can developinterventions to prevent future safetyevents and improve safety.Through analyzing this error, a number ofsystem fixes were implemented, includingreplacing bulk bottles of methadone in thePyxis with 1 mL syringes. To have made thesame error, the nurse would have had to pullout 7 syringes, a trigger that something iswrong with the calculation.
Quantros Occurrence Reporting SystemEvent Reporting When a safety event occurs, it should be reported in Quantros When reporting events:– Think about the person reading the report; do they have enough information tounderstand what happened and to follow up?Think SBAR!S- Situation- What happened? What interventions wereneeded? Who did you tell?B- Background- What contributed to the error (distractions,new product or procedure, etc.)?A- Assessment- Was there harm? How often doesthis/could this happen?R- Recommendation- What could be done to keep this fromhappening again?2.4.2013 v.1
National Patient Safety Goals National Patient Safety Goals The Joint Commission’s National Patient Safety Goals (NPSG) provide hospitals with specific areas of focus as a result of problems identified that pose risk to healthcare safety In 2013 there a 6 key areas of focus for the NPSG:
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 .
Quality & Patient Safety Tasks Overview. 1. Board/Hospital Quality & Patient Safety Comm. 2. Annual Plan of Quality & Patient Safety . 3. Data Driven - Specific Metrics with periodic measurements -Constantly Analyze Data . 4. Data-driven Decisions better outcomes . 5. Audit Compliance with Regulations/Laws. 6. Where 'Gaps' emerge, use QI .
The Patient Safety and Quality Improvement Act of 2005 Authorizes “Patient Safety Organizations” (PSOs) Provides privilege & confidentiality protections for information when providers work with Federal PSOs to improve quality, safety and healthcare outcomes Authorizes establishment of “Common Formats” for reporting patient .
Analyze AMEDD Patient Safety cultural elements to drive program initiatives Integrate teamwork concepts , knowledge, skills and attitudes to improve the quality of Patient Safety Provide facilities with meaningful and useful data to identify safe practices, to mitigate potential risks and hazards and to improve clinical outcomes
Cape Fear Valley has a Performance Improvement (PI)/ Patient Safety Plan. The plan describes the structures and functions of the Patient Safety Program and defines the responsibilities necessary to assure that the Patient Safety Program is effective. It can be found on the InfoWeb under: - 2012-2013 Performance Improvement/Patient Safety Plan
An Approach to “QUALITY” – Cleveland Clinic Leadership: A hospital commitment that Quality & Patient Safety are important. A structure to coordinate “quality” activities Build a “TEAM” to develop and support a plan for Quality and Patient Safety. Involve the
including adults with RLS.9 These quality care measures focus on both outcomes, that is, what happens to a patient as a result of the care received, and processes, or the steps taken by a health-care provider in the care of an individual patient. Both outcomes and processes are important in the care of the patient. Outcomes
REVISION: ANIMAL NUTRITION & DIGESTION 19 JUNE 2013 Lesson Description In this lesson, we revise: nutrition in various animals o Herbivores, Carnivores and Omnivores the two different types of human digestion o Mechanical o Chemical Key Concepts Nutrition in Animals Nutrition is defined as the sum of the following processes – ingestion, digestion, absorption, assimilation and egestion. Some .
