Practice #1: Create a Healthcare Culture of Safety

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Transcript of Practice #1: Create a Healthcare Culture of Safety

  • Practice #1:Create a Healthcare Culture of Safety

    Potential Team Members-all that are applicable to your organization:

    CEOCOOCMOCNEPatient Safety OfficerDepartment ManagersDirector of Quality/Performance ImprovementDirector of Nursing Education/Staff DevelopmentMedical Staff Department Chairs

    ConceptsCulture is the driver for all organizational frameworks and eats everything else for lunch.Culture is more then the way we do things around here, culture drives all the subtle influences to decision making.High Reliability Organizations

    Potential Paper Resources- any and all that apply:C Level job descriptions, performance reviews and incentive plans: looking for language that pertains to establishing a culture of safetyPatient Safety Officer job descriptionDepartment Director job descriptionsMedical Staff Committee Chair responsibilitiesMonthly Hospital Board ReportsOrganizational Strategic PlanQuality Improvement PlanRisk Management /Patient Safety PlanQuality Improvement Committee MinutesPatient Safety Plan and Committee minutesRisk Management Board Reports (may be restricted)Staff Development filesHospital Policies and Procedures specific to patient safety, adverse event reporting and close call or near miss reportingSummary reports of action plans subsequent to Root Cause Analysis (RCA) MeetingsStaff meeting minutes that discuss patient safety and lessons learned from RCAsStory Boards of Performance Improvement projects: including policy and system changes resulting from the projectMinutes of Pt Safety Officer/Chief Nurse Executive Board ReportsIs it listed in Org: Mission, vision, core valuesdo those documents incorporate language on patient safety or safe careOrganizational internal and external publications, newsletters and informational fliers to employees, physicians and publicDocumentation for JCAHO that includes patient safety and cultureDocumentation of implementation of Baldrige criteria is implemented

  • Practice #3:Specify an explicit protocol to be used to ensure an adequate level of nursing care based on the institution's usual patient mix and the experience and training of its nursing staff.

    Potential Team Members-all that are applicable to your organization:

    CEOCOOCNEDirector of Nursing Education/Staff DevelopmentManagement EngineerHuman ResourcesPatient Safety OfficerNursing Department Managers

    Potential Paper Resources- any and all that apply:Hospital Policies and Procedures specific to Nursing Staffing procedures including subjects pertaining to: management of sick call, ED diversion, ICU diversion, off shift and weekend staffing, use of per diem staffing and travelersUse of internal float pool,Bed management system

    Management Engineering or Staffing Acuity Reports as applicable; may include:Unit specific patient acuity reports (12 months)APACHE or similar acuity reports for critical careUnit Staffing shift reports (12 months)Nursing Supervisor Shift Staffing Reports (12 months)ICU and ED Diversion Logs

    JCAHO Staffing Effectiveness Indicators or Measures

    Trends of Staffing Patterns IDed thru RCAs

    Actual Staffing Patterns (ratios) for the past 12 months; including staffing mix (RNs. LPNs. CNAs, EMTs. Techs)

    Strategic Plans for Nursing Staffing patterns

    Documentation of Magnet Nursing Certification if implemented in your organization

    Retention and Recruitment Plans

    Employee Satisfaction Surveys

    Community outreach actions and plans to enhance recruitment efforts

    Documentation of performance improvement projects related to recruitment and retention and management of appropriate staffing patterns

    Staff Development files and documentation of skills development seminars or on-site skills fairs, in-service education programs to specific skills

    Staff development programs specific to skill development needs identified out of trend analysis of adverse events in the organization: Simulator training

    Department Manager performance review requirements

    Minutes of Pt Safety Officer and/or CNE Board Reports

  • Practice #5Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

    Potential Team Members-all that are applicable to your organization:

    COOCNEDirector of PharmacyDirectors Respiratory and ImagingStaff PharmacistsNursing StaffMedical Staff

    Concepts:Pharmacist Interventions: Interventions by pharmacists in an ordering process should be recorded and trended and performance improvement actions taken.

    Resources:

    Potential Paper Resources- any and all that apply:Pharmacist job description (all that apply)

    Hospital Policies and Procedures specific to:the role of the hospital pharmacistthe role of a clinical pharmacist if a separate distinction appliesPharmacy coverage when pharmacy is not open 24/7Authority of the pharmacist in the medication management processMulti-disciplinary rounds

    Pharmacy tracking system reports of Pharmacist interventions on medication orders (i.e.: # of times a pharmacist calls an MD to clarify or question a medication order etc.)

    P&T (Pharmacy and Therapeutics) Committee meeting minutes

    Documentation Pharmacist activities to support this safe practice

    Documentation of Pharmacists involvement in the Medication Reconciliation processes

    Automated medication dispensing system (i.e. Pyxis) reports on pharmacist interventions, including frequency or incidence rates when system medication profiling is turned off

    Robotic Filling/Dispensing System Reports

    Bar Coding System reports (bar coding labeling and administration system over rides and meds saved or held potential errors avoided)

    Documentation of performance improvement projects involving the role of the pharmacist outside the walls of the pharmacy or performance improvement project plans.

    Interviews of nursing, clinical and medical staff on the (actual) role of the pharmacist in the organization

    Department Manager performance review requirements

    Minutes of Pt Safety Officer and/or CNE Board Reports

    Minutes Medication Error Review Committee

    Data bases of findings from Executive Walk Rounds and Unit Briefings

    2004 TMIT Leapfrog Survey 1.32.11.04 1500 ET

    Practice #6:Verbal or telephone orders or critical test results should be recorded whenever possible and immediately read back to the prescriber i.e., a healthcare provider receiving a verbal or telephone order should read or repeat back the information the prescriber conveys in order to verify the accuracy of what was heard.

    Potential Team Members-all that are applicable to your organization:

    COOCNEPSODirector of PharmacyDirector of Nursing Education/Staff DevelopmentDepartment DirectorsClinical StaffMedical Staff

    Potential Paper Resources- any and all that apply:

    Hospital Policies and Procedures specific to:Verbal and telephone ordersReporting of Lab Results or other Critical Test Results, including i.e: respiratory therapy or Imaging

    Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to verbal and telephone orders

    P&T (Pharmacy and Therapeutics) Committee meeting minutes which discuss the responsibilities of the MD in the use of verbal or telephone orders

    Documentation of clinical staff education sessions or skills fairs that include information on verbal orders and a read-back process

    Documentation of performance improvement or future performance improvement project plans that focus on use of verbal orders and the process of read-back for accuracy

    Summary reports from risk management on incidence of adverse events related to verbal orders or reporting/communication of critical test results

    Department Manager performance review requirements

    Summary reports on frequency and severity to Administration

    Measure of effectiveness and/or compliance with National Pt Safety Goal on verbal orders and critical test results

    2004 TMIT Leapfrog Survey 1.32.11.04 1500 ET

    Practice #7:Use only standardized abbreviations and dose designations.

    Potential Team Members-all that are applicable to your organization:

    COOCNEDirector of PharmacyDirector of Nursing Education/Staff DevelopmentDepartment DirectorsDirector of Information Management

    Concepts:Standardization of dose designations within an organization minimizes the risk of misinterpretation of medication orders.Standardized abbreviations reduces the risk if misinterpretation of any written order.

    Resources: JCAHO List: A Minimum List of Dangerous Abbreviations, Acronyms and Symbols

    Potential Paper Resources- any and all that apply:

    Hospital Policies and Procedures specific to:Standardized Abbreviations and Dose Designations

    Nursing and other direct care giving staff (i.e. imaging, respiratory) unit meeting minutes specific to standardized abbreviations and/or dose designations

    P&T (Pharmacy and Therapeutics) Committee meeting minutes

    Medical Staff Peer Review Summary minutes that address actions dealing with frequent abusers of policy standardized abbreviations and dose designations

    Documentation of Medical Staff education on hospital required standardized abbreviations and dose designations

    Documentation of nursing education sessions or skills fairs that include information on standardized abbreviations

    Documentation of performance improvement or future performance improvement project plans that focus on this issue

    Department Manager performance review requirements

    M