JCAHO Patient Safety Goal
Gerard X. Brogan Jr., MD FACEP

Section I:

Patient 's Identification

A: What is the procedure for initially identifying a patient in the Emergency Department?

Upon presentation to Triage, patients will receive an arm band that has the patient's name and date of birth. The patient's room number or bed position must not be used as an identifier.

B: What identifiers do you use?

Patients shall be identified using a minimum of 2 patient identifiers which will include patient's name and patient's date of birth. The patient's medical record number may be used as a 3rd patient identifier, if necessary. The patient's room number or bed position must not be used as an identifier. Prior to placement of identification data, a designated individual will ask the patient to state and spell his/her full name and his/her date of birth. If the patient's identifying band is removed or missing during hospitalization, the patient must be re-identified as described above prior to placement of new identification band.

C: How do you identify an unresponsive patient?

If a patient is unable to provide information for any reason, a designated individual will ask the family member, guardian, significant other or appropriate individual to state, spell the patient's full name and provide date of birth, if known, and confirm the patient's full name and date of birth on the patient's identification band as accurate. If the patient is unable to provide information and there is no family member, significant other or accompanying individual available, a designated individual will identify the patient as Jane/John Doe and use the admission date in place of a date of birth.

D: How do you identify a nursing home patient?

An identification band from the Emergency Department or other health care facility must be removed and replaced with a new identification band once the patient is admitted as an in-patient. Patient's arriving from a nursing home will be identified both by the patient's arm band with confirmation of the patient's transfer papers and medical record. In addition, the above procedures for identifying the patient will be utilized, including asking the patient for their name and date of birth. If the patient is unable to provide the information for any reason, a designated individual will ask the paramedic regarding significant other or accompanying individual to state and spell the patient's full name and provide the date of birth if known, and confirm that the patient's full name and date of birth on the identification band is accurate.

E: What is the procedure prior to medication, registration, diagnostic testing or basic procedure?

Prior to the patient receiving any treatments or procedures, any transportation, specimen collection, receiving medications, the administration of blood products, hospital personnel must identify the patient by asking the patient to state his/her full name and date of birth and verify by matching identifiers on the identification band, with the information on the appropriate requisition.

Section II:

Communication Among Caregivers

A: How do you provide for coordination among the health professionals and services or settings involved in patient care? Describe the processes for referral, transfer or discharge of patient to another level of care.

Coordination of care is accomplished by both clear and complete notes in the medical record as well as clear sign-outs and transfer reports from the Emergency Department to the floor and from shift-to-shift in the in-patient setting. When patients transfer from one unit to another, a new set of transfer orders and a transfer note is competed, in addition to verbal report from the sending unit to the receiving unit. Upon discharge there are written discharge instructions, in addition to verbal report to either the family or to the receiving institution (i.e. nursing home) is completed.

B: How do you provide for the change of appropriate patient care and clinical information when patients are admitted, referred, transferred or discharged?

When patients are admitted, referred, transferred or discharged, a written record is exchanged with the receiving facility, as well as a verbal report given.

C: Do you have a list of abbreviations that are not to be used?

Yes. The do not use abbreviations include:

• U (for Unit), instead write Unit.
• I.U. (International Unit), instead write International Unit.
• qd, qod . Instead write daily, or every other day.
• Trailing zeros, (x.0 ml), never write a zero by itself after a decimal.
• Lack of leading zero, always use a zero before a decimal (0.x)
• MS, MSO4, Mg SS4, instead write morphine sulfate, or magnesium sulfate, as the case may be.
• Micrograms (µ.g.) write mcg.
• T.i.w. Instead, write 3 times weekly
• AS, AD, AU. Instead, write left ear, right ear, both ears
• OS, OD, OU. Instead, write left eye, right eye, both eyes

D: What do you do when an order contains an abbreviation that is prohibited?

If a healthcare provider receives an order using an abbreviation on the "do not use" list that order must be clarified with the ordering practitioner. If confirming this order delays treatment or puts the patient at risk, and the order is clear and complete, than the order should be carried out and the confirmation obtained as soon as possible thereafter. (Please note that System-wide, the qd, µ, µ.g abbreviations are not to be used.) In addition, individual facilities have selected other Do Not Use abbreviations as described above.

E: What is the process for taking verbal or telephone orders and receiving reports of critical test results?

A verbal order may only be issued in an emergency when a clinician is unable to document such an order personally due to the condition of the patient or the emergent nature of the situation. The following clinicians may issue a verbal inpatient order:

The attending physician, dentist, podiatrist, physician assistant, nurse practitioner, nurse midwife, house staff and certified registered nurse anesthetist. Recipients of a verbal inpatient order may include a registered nurse, a licensed practical nurse, a registered therapist, a licensed, certified respiratory therapist and a licensed technologist within the scope of their practice. In an emergency situation, such as a code or in the operating room, a clinician may communicate a verbal order. The recipient must repeat back the order, clinical receive confirmation of the accuracy before administering the order. The clinician must sign the verbal order immediately following the completion of the emergent situation and/or scheduled procedure. No verbal or telephone orders may be issued for therapeutic agents or total parenteral nutrition. Verbal orders for laboratory testing must be followed up with a hard copy of the test requisition, as per Federal and State requirements. With respect to telephone orders, the process is as follows:

The clinician first issues a telephone order. The recipient documents the order on the physician order sheet and the patient's medical record. Documentation includes a purpose or indication of the order, if applicable, the drug name, dose, route, frequency and duration and the date and time the order was received by the clinician. The recipient then reads back the order to the clinician verbatim with each numerical digit articulated individually. Confirmation of the read-back from the clinician must be documented on the order sheet. The recipient then signs the order. For orders written on more than 1 page, there should be documentation of the read-back confirmation on each page. The clinician must sign the order within 48 hours after the order was issued. For telephone reporting of critical test results, test result accuracy must be verified by the person receiving the order, reading back the complete test results.

F: Do you have established time frames for reporting critical test results to the care provider and are they being met?

Yes. Critical test results are reported immediately to the care provider. This is documented in the lab information system by the lab technologist placing the call. including the person and time that the lab was spoke with them. This procedure is monitored by the laboratory.

Section III:

Medication Safety

A: Do you have standardized drugs/IV concentrations?

Concentrated electrolytes have been removed from patient care units, including but not limited to potassium chloride, potassium phosphate and sodium chloride greater than 0.9%. In addition, we have standardized and limited the number of drug concentrations available within the Health System. Patient care providers have been educated on high-risk, high-alert medications and ongoing monitoring will be conducted through the medication error in the reporting process. Each site will establish a process for pediatric review of its high-risk/high-alert verification and associated safety processes.

Section IV:

Eliminate Wrong Site, Wrong Patient, Wrong Procedure, Wrong Surgery

A: Describe the process for patient/ site, procedure verification procedure prior to performance of an invasive procedure.

For all procedures (in or out of the OR) involving right, left, distinction, multiple structures, such as fingers and toes or multiple levels such as spinal procedures, the intended site must be marked so that the mark will be visible after the patient has prepped and draped. Exceptions to this include single organ cases, interventional cases for which a catheter or instrument insertion at site has not been determined, premature infants, teeth (but indicate the operative tooth names on documentation or mark the operative tooth on the dental radiographs or dental diagrams), or for bedside procedure cases, in which the individual doing the procedure is in continuous attendance with the patient from the time of the decision to do the procedure and consent from the patient to the conduct of the procedure. Specific guidelines include that the person performing the procedure will mark the site prior to moving the patient into the room where the procedure will be done. The site marking will take place before the patient is sedated so that the patient can participate in the procedure. Following proper patient identification, the site will be marked by the person who will be performing the procedure with participation and verification by the patient, if the patient has the capacity. The site must be marked at or near the incision site. Every procedure will be marked in the same manner (an x may not be used). The mark should be made with a marker that is sufficiently permanent to remain visible after completion of the skin prep (stickers may not be used). The mark should be positioned to be visible after the patient is prepped and draped. Verification of the site mark will take place during the timeout.

Section V:

Infusion Pumps

A: Are your infusion pumps protected against free flow?

To improve the safety of infusion pumps, free-flow protection on all general use and PCA intravenous pumps is in place. Each facility will conduct an inventory to determine the type and number of infusion pumps used. All new equipment will be inspected by the biomedical engineering department to ensure that it is free flow protected.

Section VI:

Clinical Alarms

A: What kind of alarms do you have in the department?

Clinical alarm systems include alarms that are intended to protect patients and to alert staff of a risk or patient need. Examples include, but are not limited to, physiological monitor alarms, infusion pump alarms, ventilator alarms, infant security alarms, nurses call system alarms and patient monitoring alarms. The responsibility of the users to insure that the alarms systems are used appropriately and safely, and that sound levels are sufficient to notify staff in the event of an alarm. Patients and families will be educated regarding not tampering with or changing alarm settings.

Section VII:

Risk of Procedure for Responding to an Alarm

Any staff member aware of an alarm sounding must respond. If the staff member is competent to address the clinical situation that staff member will do just that. If that staff member is not competent to address the clinical situation, that staff member will insure that an appropriate person is notified and does respond.

A: What do you do when you hear an alarm sound?

Upon hearing an alarm sound, the healthcare provider must respond to the patient. That healthcare provider is not appropriate to respond to a clinical situation the healthcare provider will immediately identify a healthcare provider competent in managing the clinical scenario and insure that that person comes to the bedside. Alarms will not be turned off/muted or otherwise changed.

Section VIII:

Reduce Infections

A: What infection control procedures do you follow in evaluating patients?

Healthcare practitioners will comply with current CDC hand hygiene guidelines. In addition, any cases of unanticipated death or major permanent loss of function associated with loss of function associated with healthcare associated infection will be managed as a sentinel event.

B: Describe indications for using gloves.

Universal precautions should be utilized for all patients. Gloves should be utilized for each individual patient and discarded prior to leaving the room.

C: Describe the various types of isolation, in the cases the protective garments for each.

PRINCIPLES OF ISOLATION:
Isolation precautions are designed to prevent the spread of microorganisms among patients, personnel, and visitors. Since agent and host factors are more difficult to control, interruption of the chain of infection in the hospital is directed primarily at transmission. The isolation precautions recommended in this guideline are based on this concept.

There are two (2) tiers of precautions:

I. Standard Precautions

1. Designed for the care of all patients regardless of their diagnosis or presumed infection status
2. The use of Standard Precautions combines the major elements of Universal Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances).

II. Transmission - Based Precautions:

1. Used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Infection Control Department must be notified whenever isolation precautions are initiated.
2. There are three (3) types of transmission - based Precautions:

   1. Airborne Precautions
   2. Droplet Precautions
   3. Contact Precautions

STANDARD PRECAUTIONS
I. Standard Precautions apply to:

1. Blood
2. All body fluids, secretions and excretions, except sweat, whether or not they contain visible blood
3. non-intact skin
4. mucous membranes

II. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

1. Key components of Standard Infection Control Precautions:

Hand Washing - the single most important measure to reduce the risks of transmitting microorganisms from one person to another. placement. Alcohol gel is appropriate for hand antisepsis before and after patient care, except when hands are visibly soiled

1. Gloves

1. Wear clean, non-sterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items, before touching mucous membranes and non-intact skin.
2. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient. WASH HANDS immediately to avoid transfer of microorganisms to other patients and environments.

2. Masks, Eye Protection, Face Shields

Wear a mask, eye protection or a face shield to protect mucous membranes of the eyes nose and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.

3. Gowns

Wear a clean, non-sterile gown to protect skin and to prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood. Remove soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments.

4. Patient Care Equipment

Handle used patient care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Make sure single items are discarded properly.

5. Environmental Control

Ensure that the hospital has adequate procedures for the routine care, cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces, and insure that these procedures are being followed.

6. Linen

1. Handle, transport and process used linen soiled with blood, body fluids secretions and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments.

7. Occupational Health & Bloodborne Pathogens

1. Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices when handling sharp instruments after procedures, and when disposing or used needles.

8. Patient Placement - applies to patients that are hospitalized.

1. Private Room
   1. Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room. If a private room is unavailable, consult with infection control professionals regarding patient placement.
   2. A private room is indicated for patients with infections that are highly infectious or are caused by microorganisms that are likely to be virulent when transmitted.
   3. A private room may be indicated for patients colonized with microorganisms of special clinical or epidemiologic significance, for example, multi-resistant bacteria such as MRSA

    

2. Roommates for Patients on Isolation Precautions

   1. Infected patients shall not share a room with a patient who is likely to become infected or in whom consequences of infection are likely to be severe, such as a neutropenic patient.
   2. When an infected patient shares a room with non-infected patients, it is assumed that patients and personnel will take measures to prevent the spread of infection. For example, a patient whose fecal material is infective may be in a room with others as long as he or she is cooperative, washes hands carefully, and does not have such severe diarrhea or fecal incontinence that either roommates or objects used by the them become contaminated. When these conditions cannot be met, a private room is indicated.
   3. Patients infected by the same microorganisms may share a room. Cohorting of patients is especially useful during outbreaks when there is a shortage of private rooms.

    

AIRBORNE PRECAUTIONS
In addition to Standard Precautions, use Airborne Precautions, for patients known or suspected to be infected with pulmonary or laryngeal tuberculosis or known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue [5 µm or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air current within a room or over a long distance).

I. Patients Placement - applies to hospitalized patients.
Place the patient in a private room that has;

1. Monitored negative air pressure in relation to the surrounding areas.
2. 6 to 12 air changes per hour.
3. Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital.
4. Keep the room door closed, ensure room set for negative pressure and the patient in the room. Do not cover air vents.
5. For r/o Tuberculosis: patient must be housed in private negative pressure room.
6. For other cases: When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, unless otherwise recommended, but with no other infection.

II. Respiratory Protection
Wear respirator mask when entering room. Patient visitors wear a surgical mask.
Susceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear a mask. Persons immune to measles (rubeola) or varicella need not wear a mask.

III. Patient Transport
Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient, notify area ahead and go directly to designated area.

DROPLET PRECAUTION
In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for patients known or suspected to be infected with microorganisms transmitted by droplets (larger particle droplets [larger than 5 µm in size] that can be generated by the patient during coughing, sneezing, talking or the performance of procedures).

I. Patients Placement- applies to hospitalized patients.

1. Private room.
2. When a private room is not available, place the patient in a room with a patients(s) who has active infection with the same microorganisms, but with no other infection (cohorting).
3. When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient and other patients and visitors.
4. Special air handling and ventilation are not necessary and the door may remain open.

II. Mask
In addition to standard precautions wear a mask when working within 3 feet of the patient.

III. Patient Transport
Limit the movement and transport of the patient form the room to essential purposes only. Minimize patient dispersal of droplets by masking the patient if possible.

CONTACT PRECAUTIONS
In addition to Standard Precautions, use Contact Precautions for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient -care activities that require touching the patient's dry skin or indirect contact (touching) with environmental surfaces or patient - care items in the patient's environment.

I. Patients Placement - applies to hospitalized patients. Patients in psychiatric settings and ambulatory settings, do not require Contact Precautions, Standard Precautions is adequate. Contact Precautions in the psychiatric and ambulatory settings shall be used only in an outbreak situation and as directed by Infection Control.

1. Private room.
2. When a private room is not available, place the patient in a room with a patient(s) with the same microorganisms, but with no other infection (cohorting).
3. When a private room is not available and cohorting is not achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement. Consultation with infection control professionals is advised before patient placement.

II. Gloves and Hand Washing

1. In addition to wearing gloves as outlined under standard precautions, wear gloves (clean, non-sterile) when entering the room.
2. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and would drainage).
3. Remove gloves before leaving the patients environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent.
4. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patients' room to avoid transfer of microorganisms to other patients or environments.

III. Gown

1. In addition to wearing a gown under standard precautions, wear a gown (clean, non-sterile) when entering the room. Remove the gown before leaving the patients environment.

IV. Patient Transport

1. Limit movement and transport of the patient from the room to essential purposes only.
2. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.

V. Patient Care Equipment

1. When possible, dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients.
2. If use of common equipment or items is unavailable then adequately clean and disinfect them before use for another patient.

IMMUNOCOMPROMISED PATIENTS
Immunocompromised Patients vary in their susceptibility to nosocomial infections, depending on the severity and duration of immune-suppression. They are generally at increased risk for bacterial, fungal, parasitic, and viral infections from both endogenous and exogenous sources.

The use of Standard Precautions for all patients and Transmission - Based Precautions for specified patients, as recommended by the CDC Guidelines, should reduce the acquisition by these patients of institutionally acquired bacterial from other patients and environments.

A: Describe the process for putting on and removing protective garments.

Protective garments will be placed prior to entering the room. In addition, protective garments should be discarded of prior to exiting the room. Garments shall be discarded in such a way that the healthcare practitioner does not increase the risk self-contamination.

Section VIII:

Reconcile medications across the continuum of care.

A complete list of the patient's current medications upon the patient's admission to the healthcare facility will be obtained and documented with involvement of the patient and their family. The process includes a comparison of the medications the healthcare system provides to those on the list. A complete list of the patients medications is communicated to the next provider of service, when it refers or transfers a patient to another setting, service, practitioner or level of care within our outside the organization.

Section IX:

Reduce Patient Falls

A: Describe the process of evaluating the patients risk of falls and fall prevention technique.

Each patient will be assessed and periodically reassess for risk of falling, including the potential risk associated with the patient's medication regimen and take action to address any identified risks. A risk assessment tool (i.e. Morse scale) may be used to identify patients at risk. After clinical assessment, if the clinical presentation warrants, the nurse may institute a high-risk fall protocol for those patients who do not meet the scoring criteria, according to the Morse scale. Implementation of fall prevention protocols and interventions will be based on the initial assessment. Risk factors include, but are not limited to, history of fall, medication use and alteration of mental status, unsteady gait, balance problems, weakness, visual impairment, ambulation device, advanced age, desire for autonomy, post op/post sedation or urgency/incontinence. An ongoing assessment of the environment will include the following key elements: floors, lighting, equipment, furnishing, toilet, bath facilities, corridors. Identified risk factors will be addressed immediately. Environmental rounds will be conducted at least monthly. In addition, the staff will be educated regarding fall prevention and injury reduction in new employee orientation, as well as on-going educational and annual competency. All patients or residents were assessed as at risk for falls will have an individualized fall prevention plan of care to reduce the occurrence of falls and/or injury and promote safety. The plan will be made in conjunction with the patient and it will include the identified risk factors as well as the interventions, such as lowering the bed and providing ambulation device. There will be continual reassessment and in addition, there will be patient and family education regarding fall prevention.