A major focus of the survey will be centered on BWH’s compliance with the national safety goals established by JCAHO. Throughout this five-day survey, we can expect that the surveyors will ask questions related to these goals in order to evaluate the extent to which these goals have been integrated into our daily practice.
q Improve the accuracy of patient identification
1a. Use at least two identifiers, neither to be the
patient’s room number, whenever taking blood samples, administering medications or blood products.
Status: Any caregiver, who takes blood samples, administers medications or blood products, checks the patient’s wristband to compare the patient’s name and medical record number against the medication record or lab requisition. Those administering blood products check these two identifiers and check other identifiers to match the correct unit of blood with the correct patient. In ambulatory areas where the patients do not wear an ID band, patient identifiers will include: patient’s medical record number and date of birth. If a patient is unable to state his or her name, the patient should provide a photo identification.
1b. Prior to the start of any surgical or invasive procedure, conduct a final “time out” or “Safety Pause” verification process to confirm the correct patient, procedure and site.
Status: The Operating Room staff performs a “time out or safety pause” process prior to all procedures. The procedure team pauses before the incision is made to review the patient identification, procedure and site. This allows the team to discuss any discrepancies or misunderstandings to ensure that the correct patient is having the correct procedure. Non-OR areas performing invasive procedures such as the CDIC, Interventional Radiology have also adopted this practice. The Safety Pause also applies to invasive procedures at the bedside.
w Improve the effectiveness of communication among caregivers
2a. Implement a process for taking verbal orders or telephone orders that requires a verification “read back¸” of the complete order by the person receiving the order. This has been extended to include all critical lab results.
Status: Verbal orders are kept to a minimum and are only accepted for urgent situations. However, if a verbal or telephone order is taken, the person receiving the order writes down the information and then reads back the order for verification. Physicians should anticipate this verbal order “read back” during those urgent situations when verbal orders are necessary. Laboratory Services created a lab slip for critical values that can be used by the person receiving the results to aid communication of accurate information.
2b. Standardize abbreviations, acronyms and symbols used throughout the organization, including a list of approved terms and unapproved terms.
Status: Pharmacy, Nursing and Patient Safety have created a draft of the unapproved list of terms. This list of unacceptable abbreviations has been approved by the Medical Staff Executive Commit-tee and is available on line at the BWH intranet site. Laminated cards to help you identify these terms to avoid are available from the Patient Safety office at extension 2-7543.
e Improve the safety of high alert medications
3a. Remove concentrated electrolytes including potassium chloride, potassium phosphate, sodium chloride greater than 0.9 percent from patient care areas.
Status: Pharmacy has removed these high alertmedications from patient care units.
3b. Standardize and limit drug concentrations
Status: Drug concentrations are limited through the Alaris IV pump drug libraries.
r Eliminate wrong site, wrong patient and wrong procedure surgery
4a. Create and use a pre-operative verification process such as a checklist to confirm that appropriate documents are available.
Status: The OR has created a pre-procedure checklist to confirm congruence with patient information. Non-OR areas such as CDIC and Interventional Radiology have also adopted this practice.
4b. Implement a process to mark the surgical site and involve the patient in the process.
Status: Marking surgical sites that involve laterality has been and continues to be our practice.
t Improve the safety of using infusion pumps
5a. Ensure free-flow protection on all general and PCA IV pumps
Status: The Alaris IV pump is approved to ensure
free-flow protection. The IV pumps used for PCA and Epidural use are free flow protected by the tubing sets used.
y Improve the effectiveness of clinical alarms systems
6a. Implement regular preventative maintenance and testing of alarms
Status: Biomedical Engineering performs routine maintenance and testing. The caregiver can look at the green biomed sticker on the equipment to see when it was last maintained.
6b. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distance.
Status:All critical alarms will be tested for alert settings and audible volume alarms with respect to distance of the caregiver. Each clinical department-/service is responsible for assuring that clinical alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
When assuming care for a patient, the clinician will ensure/confirm that the alarms are activated with appropriate settings and are sufficiently audible with respect to distance and ambient noise within the unit. The clinician will adjust the parameters as appropriate for the patient’s condition. Patient care personnel, within the scope of their practice, are responsible for responding promptly to the clinical alarm of a patient, irrespective of whether they are assigned to the individual patient.
u Comply with current CDC hand hygiene guidelines
7a. Comply with current CDC hand hygiene guidelines
Status: Infection Control measures the effectivenessof hand hygiene in each ICU. The hospital will follow the recommendations set by the JCAHO and the CDC regarding appropriate nail care. Natural nails must be kept short (less than 1/4 inch beyond fingertip), and polish, if worn, must be free of chipping. Artificial nails are prohibited. In the OR and Labor & Delivery, there is a more specific policy.
7b. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health care-acquired infections.
Status: All sentinel events related to health care-acquired infections are reported to the Risk Management Department and are investigated by using the Root Cause Analysis process.