Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist...

39
Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions 6022 or 4037

Transcript of Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist...

Page 1: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Wm. Jennings Bryan Dorn VAMCPatient Safety Training

Billie Thompson RN Patient Safety SpecialistVelvet Cooper RN Patient Safety Specialist

Extensions 6022 or 4037

Page 2: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Patient Safety Is Everyone’s Job!

The goal of the Patient Safety Program is to create a Culture of Safety and awareness of patient safety issues for all VA Employees,

Patients and their Families.

Focus: Systems

Non-punitive

Open Communication

Process changes

Page 3: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Are Adverse Events?

Patient incidents such as:

Patient falls

Medication errors

Elopements (high elopement risk patients)

Delays in treatment

Suicides and attempts

Medical errors

Close calls (intercepted or resulted in no harm)

Page 4: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Is A Sentinel Event?

-Death or permanent loss of function resulting from a medication or other treatment error

-Suicide of a patient in a round-the-clock setting or within 72 hours of discharge

-Surgery on the wrong patient or body part

-Unintended retained surgical object

-Hemolytic transfusion reaction

-Unanticipated death resulting from an health care-acquired infection

Page 5: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

How Do I Report A Medical Error or Patient Safety Concern?

Call the Anonymous Incident Reporting

Hotline7964

Information needed:

1. Patient Name & Last 4 SSN #

2. Summary of what happened

3. Diagnoses 4. Location of incident 5. Time & date 6. *For Med. Errors

- Drug name

7. Outcome 8. Treatment required 9. Was the incident preventable? If yes, How? 10. Was a medical practitioner notified? 11. Was the patient or family

notified?

- Type of Error

Options: 1 – Medication Errors 2 – All Other Patient Incidents 3 – Rumor Busters 4 – Adverse Drug Reactions

Page 6: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Incidents Occur While Using Equipment

1. Record any settings before disconnecting/turning off equipment.

2. Save and label all suspect medical equipment, attachments, and packing materials (tubing, cables, pads, disposables etc.).

3. Remove immediately from service and place in a secure location (i.e. locked head nurse’s office). Do not send through normal channels for repair.

4. Report incident and equipment involved to the Patient Safety Officer (ext 6022) and Biomedical Engineer (ext 7582) as soon as possible.

5. Enter electronic work order describing the incident and Biomedical staff will pick up and secure devices until appropriate testing can be completed.

6. Notify VA Police (6804) to pick up and secure equipment & attachments during non-administrative hours as needed.

7. Initiate a VA Form 10-2633, Report of Special Incident Involving A Beneficiary displayed on next slide.

Page 7: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.
Page 8: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

How Do We Investigate Patient Incidents & Close Calls?

A Root Cause Analysis (RCA) team is initiated to determine:

What happened? Why? How to prevent it from happening in the future?

An RCA is a process designed to examine the systems vulnerabilities to prevent adverse events:

• non-punitive• multidisciplinary team approach• process for identifying basic or contributing causes• process for identifying what we can do to prevent

recurrence

Page 9: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Is An Intentional Unsafe Act?

An adverse event that results from:– criminal act– purposefully unsafe act– alcohol or substance abuse– impaired provider/staff– alleged patient abuse

Intentional unsafe acts should be reported to your supervisor and Quality Management immediately

Intentional Unsafe Acts are investigated by administration

Page 10: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Is A HFMEA?

HFMEA or Health Care Failure Mode and Effects Analysis (HFMEA) is a proactive risk assessment used to identify and correct process problems before they happen

JCAHO requires a minimum of one HFMEA every 18 months on a process related to all levels of care

2009 HFMEA Topic: Case Management

2008 HFMEA Topic: Hand-Off Communication

Page 11: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

National Patient Safety Goals 2010-Improve PATIENT IDENTIFICATION

-Improve COMMUNICATION among caregivers

-Improve MEDICATION SAFETY

-Reduce risk of HEALTH CARE-ASSOCIATED INFECTIONS

-Accurately RECONCILE MEDICATIONS

-Reduce the risk of patient HARM resulting from FALLS

-Promote Flu & Pneumonia VACCINES

-Encourage PATIENT INVOLVEMENT in their care, what we are doing to make them safe & how to report concerns

-Prevent nosocomial PRESSURE ULCERS

-Identify safety risks of SUICIDE & HOME O2 FIRES

-Improve RECOGNITION & RESPONSE to declining patient conditions - Universal Protocols – Time Out, mark the site, conduct

verification

Page 12: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Improve Patient Safety through Positive Identification

• Ask the patient or representative to state the patient’s full name & full social security number or date of birth (two identifiers)

• Verify the patient’s correct identification using VIC card, Picture ID or ID band:

– Accessing patient information– Checking patients in for care– Applying a patient ID band – two person check required– Giving medications or blood– Providing treatments– Performing procedures– Drawing blood– Obtaining other specimens– Labeling specimens - always in the presence of the pt.– Writing orders– Documenting in the patient recordI

Never use room numbers!

Page 13: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Improve Communication Among Caregivers

• DO NOT USE VERBAL ORDERS except in emergencies, when the physician/provider is NOT present in the medical center or is scrubbed in the Operating Room.

• When taking Verbal or telephone orders always:

Write it down in CPRS (verbal/telephone order) Read it back Confirm/verify the order with provider Provider signs order in CPRS within 24 hours

Page 14: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

DO NOT USE ABBREVIATIONS

DO NOT USE the following unacceptable abbreviations in any documentation , i.e. medication orders, progress notes regarding medications in CPRS or paper records.

Use InsteadDO Not Use

Write “morphine sulfate”Write “magnesium sulfate”

MSMSO4 and MgSO4

Write “X mg”Write “0.X mg”

Trailing zero (X.0 mg)Lack of leading zero (.Xmg)

Write “every other day”Q.O.D., QOD, q.o.d., qod

Write “daily”Q.D., QD, q.d., qd

Write “International unit”IU

Write “unit”U

Use InsteadDO Not Use

Write “morphine sulfate”Write “magnesium sulfate”

MSMSO4 and MgSO4

Write “X mg”Write “0.X mg”

Trailing zero (X.0 mg)Lack of leading zero (.Xmg)

Write “every other day”Q.O.D., QOD, q.o.d., qod

Write “daily”Q.D., QD, q.d., qd

Write “International unit”IU

Write “unit”U

Page 15: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

CRITICAL TESTs & REPORTING CRITICAL VALUES

Report critical test & test results/critical values ONLY

to the ordering provider/designee

Write it down in CPRSRead it backConfirm/verify the result with providerProvider acts on and documents in CPRS

• Critical tests: Troponins and frozen sections• Measure, assess, and take action to improve

timeliness of reporting and receipt of critical test results and values by responsible licensed caregiver.

Page 16: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

• Use I-SHARE to remember what information should be communicated & provide an opportunity to ask questions

• When? Changing shifts, providers, caregivers, transfer and discharge if provider relationship is known:

I Identification – Identify Patient & individuals

S Situation – Describe Situation/Clinical Status/ Code Status

H History – Background information/Current Medications

A Assessment - Most recent clinical findings

R Recommendation – STAT Orders, Plan/treatments needed

E Equipment – Devices needed/Settings prescribed

Improve Hand-Off Communications

Page 17: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Patient Hand-off Communication Tools

Page 18: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Avoid Medication Errors

“LASA” Look Alike/Sound Alike Medications

To Avoid Errors Double Check Labels Carefully

Reminders:• TALL MAN lettering• Blue strip at top of orders in CPRS• High alert stickers on medications• Colored bins• Segregated • BCMA

Know the High Alert Look Alike & Sound Alike Medication List - MCM 544-314-1

Page 19: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Label All Medications

Includes: medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in operative and other procedural settings. This applies to ALL medications

Drug name Strength Amount (if not apparent from the container) Expiration date when not used within 24 hours Expiration time when expiration occurs in less than 24 hours.

*Only Exception: Same person prepares and administers medication immediately one medication at a time.

• When the person preparing the medication is not the person who will be administering it, VERIFY both verbally and visually with a second qualified individual.

Page 20: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Reduce the likelihood of patient harm Associated with Anticoagulation

therapy • Weight based heparin protocolWeight based heparin protocol• Low-molecular weight heparin protocolLow-molecular weight heparin protocol• Heparin order sets in CPRSHeparin order sets in CPRS• Heparin therapy nursing noteHeparin therapy nursing note• Anticoagulants (IV & oral) are designated as Anticoagulants (IV & oral) are designated as

“High Alert”“High Alert”• Pharmacist on inpt units to monitorPharmacist on inpt units to monitor• Standardized doses for heparin & low-molecular Standardized doses for heparin & low-molecular

heparin heparin • Patient education (Coumadin booklets available)Patient education (Coumadin booklets available)• Mandatory training in LMS for all clinical staffMandatory training in LMS for all clinical staff

Page 21: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Universal Protocol for Ensuring Correct Site Surgery

1. Conduct a pre-procedure verification process to ensure all documents and related information are available before the start of the procedure using the Correct Site Checklist:

Correct Identifiers and labels

Patient two identifiers match documents

Procedure and site consistent with the patient’s expectations & the team members’

understanding of the intended

patient, procedure and site

Page 22: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Universal Protocol for Ensuring Correct Site Surgery

2. Mark the procedure site to identify without ambiguity the intended site for the procedure for all procedures that require a consent

Who? The provider performing the procedure with patient involvement

When? Before the patient is moved to location where procedure will be performedWhere? At or near the procedure or incision siteHow? Provider writes initials with permanent marker

For spinal procedures, the provider initials at the exact vertebral

Exceptions: Cases where it is technically or anatomically impossible or impractical i.e. mucosal surfaces, perineum

“JJB”

Page 23: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Universal Protocol for Ensuring Correct Site Surgery

3. Time Out immediately prior to incision, ideally before the patient receives anesthesia unless contraindicated.

A designated member of the procedural team (or provider if no assistant required) initiates the time out and confirm:

All team members’ name and role Correct patient identity using full name and SSN Correct site is marked & Consent is accurate Agreement on the procedure to be done Correct patient position History and physical, nursing assessment, and pre-anesthesia

assessment match consent for correct patient, site & procedure Correct diagnostic and radiology test results (i.e. radiology images and

scans, or pathology and biopsy reports) that are properly labeled and displayed

Ensure any required blood products, implants, devices and/or special equipment are available for the procedure.

Need for antibiotics or fluids for irrigation Safety precautions based on patient history, medication use and

equipment

Correct Site Checklist must be completed and signed as indicated on the form and scanned into the medical record after the procedure.

Page 24: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Correct Site Checklist

Step One Checked by: Date: Time:Name of Procedure(s):___________________________________________________________________*Consent obtained, includingsite/side/name of procedure/ ___________ _______ ________ reason for procedure No abbreviations on form*Should be completed prior to transport to Holding Area In Holding Area/procedure area, physician marks procedure site with initials; must be ___________ _______ ________ a member of the operating team assigned and consented by the patient to be present during the procedure; must include patient involvement

If step one not completed, explain reason:Step TwoPatient states name/full SS#/location of body procedure to _____________ _______ ________be performed. These responsesmust be checked by the circulating staff nurse against consent form/marked site/ID band Patient must state, not confirm by being asked. If patient unable and no next of kin available, 2 staff members will verify and sign. The Verifying nurse at this point must not leave the patient. This is the nurse that will be present during the procedure and again verify the patient’s identity during the time-out.[a requirement from the OIG report]If step two not completed prior to transport to the Operating Room, explain reason:

Step ThreeIf applicable, verification by 2 Signatures of 2 physicians physician OR team members (1 mustbe an attending) prior to start ofprocedure that imaging data is _________________________________Time: ___________available on correct patient, properlylabeled and properly presented __________________

“Time Out” in OR; prior to OR Team Verbal Confirmation signed by circulating nurse incision OR team (minimum of indicating name of other team members surgeon, circulating nurse,anesthesia provider) verifies Surgeon: __________________________Time: _________name of patient/procedure to be performed/site, including side/ Anesthesia: ______________________________________implant specifications and availability,and antibiotic administered if ordered. Circulating Nurse: _________________________________

Patient Identification: Time out procedures must be observed by all members of the operating team. Failure on any team members part to follow will result in documentation of non-compliance.

Full NameFull SSN

Page 25: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Reduce Healthcare Acquired Infections

• Comply with current CDC Hand Hygiene Guidelines.

• Manage unanticipated death or major permanent loss of function associated with a health care-associated infection as a sentinel event.

Page 26: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Hand Hygiene Is…

The #1 way to STOP transmission of infection!

– CDC estimates 30,000 deaths per year being a direct result of improper hand hygiene.

– Statistics indicate that ~ 40% of healthcare workers comply with hand hygiene!

Page 27: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Prevent Flu & Pneumonia

• Protect yourself…..get immunized!

• Protect your patients….

DID YOU KNOW….. With flu you are contagious 24 hours before you even know you are sick! DID YOU KNOW….Hospitals with high employee flu vaccination rates have lower patient mortality!

• Protect your families… don’t take germs home!

Why me?

Page 28: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Medication Reconciliation Process

The Provider:

• Develops complete/accurate list of patient’s medication with the patient &/or caregiver

• Compares (reconciles) the list of medications with new orders for medications.

• Updates list as orders change using the medication reconciliation note

• Communicates list to next provider(s) during Hand-Off

• Provides written discharge instructions with medication list to patient

The Pharmacist:

• Reviews and compares the current list with orders to help avoid duplications, interactions, omissions and incorrect doses.

• Notifies the ordering provider of any discrepancies immediately

Page 29: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Reduce Risk of Harm From Falls

*Hospital falls have a 30% risk of physical injury At risk populations: 1-4 and 85+ age groupsIncrease of injury-related deaths in the elderly

• Assess Fall Risk using Morse Scale on admission, each reassessment, and after a fall

• Use a Falling Leaf to indicate a patient is a high fall risk• Implement fall prevention devices, alarms and equipment• Correct spills or wet surfaces• Dispose of trash appropriately• Remove or report any trip hazards and environmental hazards

immediately• Examine for injury before moving the patient after a fall• Notify the provider• Complete Fall Review Note in CPRS & notify next of kin• Implement additional fall precautions as indicated• Complete a Post Fall Note within 24 hours after the fall

Page 30: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Encourage Active Patient Involvement

Encourage active involvement of patients and their families in the patient's care as a patient safety strategy”

• Inform patients to report any patient safety concerns to their provider, nurse or the patient representative is necessary

• Provide Speak Up Booklets with admission orientation packets

• Provide Patient Education Booklets and instructions to new veterans and to all inpatients and families during orientation containing information about how to report concerns about safety

• Check Education Resource Center (PERC) across from canteen

• Provide Joint Commission contact information

Joint Commission Complaint Hotline 1-800-994-6610

Page 31: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Prevent Pressure Ulcers

*1.3 - 3 Million adults have pressure ulcers costing $500- $40,000 per ulcer

• Identify at risk individuals (Braden Scale)• Maintain and improve tissue tolerance to prevent injury• Protect against adverse effects of external mechanical devices• Reduce the incidence of pressure ulcers through education • Use special mattresses as indicated

Page 32: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Reduce Risk for Suicide.

• Suicide risk screening to identify individuals at risk for suicide while under the care of or following discharge is an important step in protecting these at-risk individuals.

• Suicide risk assessments

• Address the patient’s immediate safety needs and most appropriate setting for treatment.

• High Risk List – Notify Suicide Prevention Coordinator

• Provide suicide prevention information on signs, symptoms, means reduction, the crisis hotline #, etc. to individuals at risk for suicide and their family members.

• Develop a Safety Plan with the patient &/or family members

Page 33: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Improve Recognition and Response to Changes in a Patient’s Condition

Goal: To mobilize a team at the first sign of impending crisis or doom, to reduce failure to rescue, improve patient safety, and reduce the number of code 5’s and medical crises.

Rapid Response Team - Code White• Team Composition—ACLS Nurse, Sr. Resident, Resp.

Tx. • Team Responsibilities- Quick assessment, work within

protocols, administer treatment, stabilize& transfer patient as indicated

• Response Times Established—5 minutesResponse Times Established—5 minutes• Implemented on all inpatient units 12/08Implemented on all inpatient units 12/08

Page 34: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

Criteria for Activation of Code White Dial 6555

Staff member concerned/worried about the patient (i.e.: decreased urine output, temperature > 101, or patient diaphoretic)

• Acute change in heart rate (less than 40 or greater than 130)

• Acute change in systolic blood pressure (less than 90 mm/Hg or greater than 170)

• Acute change in respiratory rate (less than 8 or greater than 34) or threatened airway

• Acute change in oxygen saturation which reflects the percentage of red blood cells saturated with oxygen (level is less than 90% despite oxygen being utilized on the patient)

• Acute change in level of consciousness• Acute significant bleed• Patient’s oxygen requirements increase to 50% or greater

(normal air breathed is 21% oxygen)• New, repeated, or prolonged seizures• Failure to respond to treatment for an acute

problem/symptom

Page 35: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Is A Code 5?

Code for Medical emergencies such as respiratory, cardiac arrest or other situations where someone is unresponsive or injured.

What is your role in a Code 5?– Ask the person “Are you OK?” and get help– Ask someone to call a Code 5 - Dial 6555 &

state the patient location & room # and get the closest AED or Emergency Cart

– Provide the Code 5 team with a history of events leading up to the code or observations, if known.

– Provide BLS/CPR if you are trained

Page 36: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Is Disclosure?• Telling the patient and or significant family members

clinically significant facts about the occurrence of an adverse event that resulted in patient harm, or could result in harm in the foreseeable future.

• Clinical Disclosure is a simple, informal process where the provider discloses all adverse events that occur in the routine course of medical practice even if there was no harm to the patient. Documentation of the facts and who was informed is the responsibility of the physician care for the patient.

• Institutional Disclosure is a formal process used where the Chief of Staff discloses a serious adverse events. Disclosure if required within 72 hours that the physician is aware of the adverse event. Documentation in Disclosure of Adverse Event Template in CPRS is required.

Page 37: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

What Can We Do?

• Observe your work environment for patient safety issues

• Report unsafe conditions & medical errors to your supervisor and the patient safety officer or the Anonymous Incident Reporting Hotline – 7964

• Comply with National Patient Safety Goals• Serve on a RCA, Aggregate Review, or HFMEA team• ASK your Patient Safety Officer or supervisor

Page 38: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

“Gentlemen, we are going to relentlessly

chase perfection, knowing full well we

will not catch it, because nothing is

perfect.

But we are going to relentlessly chase it,

because in the process we will catch

excellence.”“I am not remotely interested in just being good.”

Vince Lombardi, head coach Green Bay Packers, 1959 – 1967

Words of Encouragement

Page 39: Wm. Jennings Bryan Dorn VAMC Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions.

________________________________________________________________________Resident’s Signature

This is to certify that:

Enter Full Name here

has completed the Wm. Jennings Bryan Dorn VAMCPatient Safety Training Module

on ENTER DATE HERE