National Patient

Safety Goals
September 8, 2017

Building Leaders – Transforming Hospitals – Improving Care

 1
45 YEARS OF DELIVERING RESULTS 1

HealthTechS3 is a 45 year old, award-winning healthcare

consulting and strategic hospital services firm based in
Brentwood, Tennessee with clients across the United
States.
We are dedicated to the goal of improving performance,
achieving compliance, reducing costs, and ultimately
improving patient care. Leveraging consultants with deep
healthcare industry experience, HealthTechS3 provides
actionable insights and guidance that supports informed
decision making and drives efficiency in operational
performance.
Our consultants are former hospital leaders and
executives. HealthTechS3 has the right mix of experienced
professionals that service hospital clients across the nation.
HealthTechS3 offers flexible and affordable services,
consulting, and technology as we focus on delivering
solutions that can be implemented and provide a
positive, measurable impact.
Strategy – Solutions - Support
GOVERNANCE &
STRATEGY
•Affiliation Consulting
•Executive & Management
Leadership Development
•Strategic Planning & Market
share Analysis
•Community Health Needs
Assessment
•Compliance Consulting Services
FINANCE
•Performance Optimization /
Margin Improvement
•Revenue Cycle & Business
Office Operations
•Productivity & Staffing
Consulting - Optimum
Productivity Toolkit
2
CLINICAL CARE & RECRUITMENT
OPERATIONS • Executive Recruitment
•Continuous Survey Readiness
•Quality Assurance Performance • Manager and Clinical
Improvement Positions
•Lean Culture
•Customer Experience • Physician / Provider
Recruitment
•Clinical Resource Management
•Care Coordination – Primary
Care Practice • Information Technology
Professionals
•Physician Practice & Clinic
Assessment
• Interim Placement
•Long Term Care Consulting
•Swing Bed Consulting
•Perioperative Services
Consulting
INSTRUCTIONS FOR TODAY’S WEBINAR 3

You may type a question in the text box if you have a question
during the presentation

We will try to cover all of your questions – but if we don’t get to

them during the webinar we will follow-up with you by e-mail

You may also send questions after the webinar to our team
(contact information is included at the end of the presentation)
www.healthtechs3.com
The webinar will be recorded and the recording will be
available on the HealthTechS3 web site:
www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this
information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such
information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding
policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or
their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of
this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare
reimbursement and regulatory matters.
 4
Speaker
Carolyn began her healthcare career as a staff nurse in Intensive
Care. She has worked in a variety of staff, administrative and consulting
roles and has been in her current position as Regional Chief Clinical
Officer with HealthTechS3 for the last fifteen years.

In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the

lead consultant for development of Community Health Needs
Assessments and conducts mock surveys for Critical Access Hospitals,
Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home
Carolyn Health and Hospice. Carolyn also provides assistance in developing
strategies for continuous survey readiness and developing plans of
St.Charles
correction.
Regional Chief
Clinical Officer
Agenda for Today 5

Why Should We Care (if we’re not TJC accredited)

Summary 2017/2018 National Patient Safety Goals

Goal 1: Improve the accuracy of patient and resident identification

Goal 2: Improve the effectiveness of communication among caregivers

Goal 3: Improve the safety of using medications

Goal 6: Reduce the harm associated with clinical alarm systems

 Next Time – October 13 6

Goal 7: Reduce the risk of health care-associated infections

Goal 9: Reduce the risk of patient harm resulting from falls (Nursing Care Center)

Goal 14: Prevent health care-associated pressure ulcers (Nursing Care Center)

Goal 15: The hospital identifies safety risks inherent in its patient population (Hospital

Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person
Surgery
 7

Right thing to do to improve

patient / resident safety
Evidence-Based Care

Adopted by many healthcare

organizations
Recognized as best practice

Specific guidance on elements of compliance

 8
TJC 2017/2018 National Patient Safety Goals
Goal 1: Improve the accuracy of patient and resident identification Hospital CAH Nursing
Care Center
NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, and X X X
services.
NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification. X X

Goal 2: Improve the effectiveness of communication among caregivers Hospital CAH Nursing
Care Center
NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis. X X

Goal 3: Improve the safety of using medications Hospital CAH Nursing

Care Center
NPSG.03,04.01 Label all medications, medication containers, and other solutions on and off the X X
sterile field in perioperative and other procedural settings.
NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant X X X
therapy.
NPSG.03.06.01 Maintain and communicate accurate patient and resident medication X X X
information.
 9
TJC 2017/2018 National Patient Safety Goals

Goal 6: Reduce the harm associated with clinical alarm systems Hospital CAH Nursing
Care Center
NPSG.06.01.01 Reduce the harm associated with clinical alarm systems. X X

Goal 7: Reduce the risk of health care-associated infections Hospital CAH Nursing
Care Center
NPSG.07.01.01 Comply with either the current CDC hand hygiene guidelines or the current X X X
WHO hand hygiene guidelines.
NPSG.07.03.01 Implement evidence-based practices to prevent health care-associated Revised Revised New
infections due to multidrug-resistant organisms. 1/1/18 1/1/18 1/1/18
NPSG.07.04.01 Implement evidence-based practices to prevent central line-associated Revised Revised Revised
bloodstream infections. 1/1/18 1/1/18 1/1/18
NPSG.07.05.01 Implement evidence-based practices for preventing surgical site infections. X X

NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated X X X

urinary tract infections (CAUTI).
 Page 10
TJC 2017/2018 National Patient Safety Goals
Goal 9: Reduce the risk of patient harm resulting from falls Hospital CAH Nursing
Care Center
NPSG.09.02.01 Reduce the risk of falls. X

Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers) Hospital CAH Nursing
Care Center
NPSG.14.01.01 Assess and periodically reassess each patient’s and resident’s risk for developing X
a pressure ulcer and take action to address any identified risks.
Goal 15: The hospital identifies safety risks inherent in its patient population Hospital CAH Nursing
Care Center
NPSG.15.01.01 Identify patients at risk for suicide. X

Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Hospital CAH Nursing
Person Surgery Care Center
UP.01.01.01 Conduct a preprocedure verification process. X X

UP.01.02.01 Mark the procedure site. X X

UP.01.03.01 A time-out is performed before the procedure. X X

 Goal 1: Improve the accuracy of patient and resident identification
NPSG.01.01.01: Use at least two patient identifiers when providing care, 11
treatment, and services

1. Use at least two patient or resident identifiers when administering

medications, blood, or blood components; when collecting blood samples
and other specimens for clinical testing; and when providing treatments or
procedures. The patient’s room number or physical location is not used as
an identifier.

2. Label containers used for blood and other specimens in the presence of the
patient or resident.

Applies to: Hospital – CAH - Nursing Care Center

 12
Myths About Patient Identification

• I’ve been in healthcare for 10 years and I’ve never had a patient
identification error.
• I’ve done it my way and it works for me.
• Double checking something when I am already certain is a waste of time.
• Patients feel the service I provide is not personal if I keep asking them to
say their name. They may feel like I keep forgetting.
• If I state the wrong patient’s name, they will correct me.
• The person who brought me the patient, SURELY must have already
identified the patient. Why would I need to double check someone else’s
work?

Procedure Example - Armband in Place
If patient is willing and able to participate:
Step 1:
• Ask, “For your safety, will you please
state your name and your date of
birth?” As the patient is responding,
confirm the armband is accurate
Step 2:
• Read back out loud the patients first
and last name and DOB from the
verifying document, (e.g. request,
label, MAR, Order, etc.) and ensure it
matches the armband
13
If patient is NOT willing or able to
participate (read it out loud twice):
Step 1:
• Confirm the armband is accurate by
reading out loud the patient’s first
and last name and DOB.
Step 2:
• Read back out loud the patients first
and last name and DOB from the
verifying document, (e.g. request,
label, MAR, Order, etc.) and ensure it
matches the armband
 14
Procedure Example - Armband NOT in Place

If patient is willing and able to participate: If patient is NOT willing or able to participate:

Step 1: Step 1:
• Ask, “For your safety will you please • Confirm patient’s first and last name and
state your name and your date of birth?” DOB with a photo in EMR or a photo ID
As the patient is responding, confirm
from the verifying document (request, Step 2:
label, MAR, order, Med label or photo ID)
that name and DOB are accurate. • Read back out loud the patients first and
last name and DOB from the request,
label, MAR, order, Med label or photo
Step 2: ID and ensure it matches the armband
• Read back out loud the patient’s first
and last name and DOB from the
request, label, MAR, order, Med label
or photo ID and ensure it matches the
armband
 Final Check Toolkit
http://www.thefinalcheck.org/toolkit/ 15
 16
Label Specimen in the Presence of the Patient / Resident

The incidence of patient identification errors, including mislabeled and misidentified specimens,
is much too high in clinical laboratories. The best data on errors in U.S. laboratories is derived
from three separate College of American Pathologists (CAP) Q-Probe studies, in which the
reported rates of mislabeled specimens were
• 0.39/1000 in 120 institutions (2006)
• 0.92/1000 in 147 clinical labs (2008), and
• 1.12% of blood bank specimens in 122 clinical labs (2010)

Source: Fixing the Problem of Mislabeled Specimens in Clinical Labs - Some Practical Suggestions—and One High Tech Solution. Author:
Charles D. Hawker, PhD, MBA, FACB and Bonnie L. Messinger, CMQ/OE (ASQ), CPHQ. Date: APR.1.2014 Source: Clinical Laboratory News
 17
Label Specimen in the Presence of the Patient / Resident
Typical interventions to reduce mislabeling, from weakest to strongest, are:

• Weak: Retrain the phlebotomist and nurse regarding following the proper policy
and procedure for blood collection.

• Weak, but slightly stronger: Retrain the phlebotomist and nurse and monitor their
behavior.

• Intermediate: Retrain all phlebotomists and nurses and monitor their behavior.

• Stronger: Standardization of phlebotomy procedures around a new process

(''single piece flow'') in which only one patient with one set of patient labels are
handled at a time, and a second patient is not phlebotomized until the first patient's
specimens are submitted to the lab. This is combined with optimization of staffing,
and coaching and monitoring phlebotomists and nurses regarding the new Not Just Lab
procedure.

• Strongest: All of the above, plus barcode-based, semi-automated patient

identification and specimen collection incorporating automated error-proofing
techniques to assure the correct patient, labels, specimen containers, and order of
draw.

Source: AHRQ: Right Patient, Wrong Sample. Commentary by Michael Astion, MD, PhD
 Goal 1: Improve the accuracy of patient and resident identification
NPSG.01.03.01: Eliminate transfusion errors related to patient
18
misidentification

1. Before initiating a blood or blood component transfusion:

– Match the blood or blood component to the order.
– Match the patient to the blood or blood component.
– Use a two-person verification process or a one-person verification process accompanied by automated
identification technology, such as bar coding.

2. When using a two-person verification process, one individual conducting the identification verification is the
qualified transfusionist who will administer the blood or blood components to the patient.

3. When using a two-person verification process, the second individual conducing the identification verification is
qualified to participate in the process, as determined by the organization.

Applies to: Hospital - CAH

 Carolyn’s Notes 19

1. Review to make sure your blood administration policy is the same as your
EMR documentation template (many times they are different)

2. If your lab isn’t staffed 24 hours - what is the process for accessing blood
afterhours?

3. Audit blood administration documentation

 Goal 2: Improve the effectiveness of communication among caregivers
NPSG.02.03.01: Report critical results of tests and diagnostic 20
procedures on a timely basis

1. Develop written procedures for managing the critical results of tests and diagnostic procedures that
address the following:
– The definition of critical results of tests and diagnostic procedures
– By whom and to whom critical results of tests and diagnostic procedures are reported
– The acceptable length of time between the availability and reporting of critical results of tests
and diagnostic procedures

2. Implement the procedures for managing the critical results of tests and diagnostic procedures.

3. Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

Applies to: Hospital - CAH

 21
Not Just Lab
 Carolyn’s Notes 22

• Does your policy / procedure include:

– time frame for reporting?
– what to do if timeframe is not met (i.e. cannot reach provider)?
– who is responsible for contacting provider?
– what to do if patient has been discharged?
– what to do if patient’s physician cannot be reached / contacted?
– read back?
– what to document in the medical record?

• Is timeliness measured and reported internally for ALL critical test results in all
departments? Consider:
– Order to test – especially if STAT
– Test to result
– Result to Nurse and Nurse to Provider (if that’s your process)
OR Clinician to Provider
 Goal 3: Improve the safety of using medications
NPSG.03.04.01: Label all medications, medication containers, and other solutions on and 23
off the sterile field in perioperative and other procedural settings
1. In perioperative and other procedural settings both 4. Verify all medication or solution labels both verbally
on and off the sterile field, label medications and and visually. Verification is done by two individuals
solutions that are not immediately administered. qualified to participate in the procedure whenever
This applies even if there is only one medication the person preparing the medication or solution is
being used. not the person who will be administering it.

2. In perioperative and other procedural settings both
on and off the sterile field, labeling occurs when any
medication or solution is transferred from the
original packaging to another container.
3. In perioperative and other procedural settings both
on, and off the sterile field, medication or solution
labels include the following:
– Medication or solution
– Strength
– Amount of medication or solution containing
medication (if not apparent from container)
– Diluent name and volume (if not apparent from
container)
– Expiration date when not used within 24 hours
– Expiration time when expiration occurs in less
than 24 hours
Applies to: Hospital - CAH
5. Label each medication or solution as soon as it is
prepared unless immediately administered.
6. Immediately discard any medications or solutions
found unlabeled.
7. Remove all labeled containers on the sterile field
and discard their contents at the conclusion of the
procedure.
8. All medications and solutions both on and off the
sterile field and their labels are reviewed by entering
and exiting staff responsible for the management of
medications.
 24
Mary McClinton

Mary L. McClinton died in 2004. Chlorahexidine, a chemical antiseptic used for skin
preparation, was injected instead of a local injection at Virginia Mason Medical Center in
Seattle, Washington. Both liquids were colorless and clear and the receptacles containing these
liquids were unlabeled.
 Carolyn’s Notes 25

1. Are you 100% sure this couldn’t happen in your facility?

2. Applies to all sites of care. The same practices should be adopted throughout the
hospital/clinics, procedural based departments and anesthesia.

3. Conduct audits within each department either by peer-to-peer or internal persons.

Not Just Surgery

 Goal 3: Improve the safety of using medications
NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of
anticoagulant therapy
1. Use only oral unit-dose products, prefilled syringes, or
premixed infusion bags when these types of products are
available.
2. Use approved protocols for the initiation and
maintenance of anticoagulant therapy.
3. Before starting a patient or resident on warfarin,
assess the patient’s baseline coagulation status; for all
patients receiving warfarin therapy, use a current INR to
adjust this therapy. The baseline status and current INR
are documented in the medical record.
4. Use authoritative resources to manage potential food
and drug interactions for patients receiving warfarin.
5. When heparin is administered intravenously and
continuously, use programmable pumps in order to
provide consistent and accurate dosing.
26
6. A written policy addresses baseline and ongoing
laboratory tests that are required for
anticoagulants.
7. Provide education regarding anticoagulant therapy
to prescribers, staff, patients, and families.
Patient/family education includes the following:
– The importance of follow-up monitoring
– Compliance
– Drug-food interactions
– The potential for adverse drug reactions and
interactions
8. Evaluate anticoagulation safety practices, take actions
to improve practices, and measure the effectiveness
of those actions in a time frame determined by the
organization.

Applies to: Hospital – CAH – Nursing Care Center

 TJC FAQs 27

1. The only anticoagulant drugs included currently under the requirement are warfarin, unfractionated heparin, and
low molecular weight heparins. Eventually, other anticoagulants may be added to the list in the future. However,
there is nothing that prevents an organization from including any other anticoagulant in their management
program. Such an approach is encouraged but not required.

2. The requirement only applies to patient's receiving "anticoagulation therapy". Thus, it only applies to patients
receiving these drugs for therapeutic purposes, and not for flushes, etc.

3. The term "defined anticoagulant management program" means a program, specified in writing, for individualizing
anticoagulation therapy for each patient that involves the use of standardized practices and patient involvement,
and which is specifically designed to reduce the risk of adverse drug events associated with the use of heparin
(unfractionated), low molecular weight heparin (LMWH), warfarin, and other anticoagulants.

4. NPSG.03.05.01 applies to those situations when anticoagulant is administered therapeutically and not
prophylactically regardless of the medication type (warfarin, heparin, low molecular weight heparin, etc.). However,
if it is usual practice for patients to be kept on therapeutic ranges of anticoagulant for several days as a
prophylactic strategy then NPSG.03.05.01 is applicable.
 Goal 3: Improve the safety of using medications
NPSG.03.06.01: Maintain and communicate accurate patient 28
medication information

1. Obtain information on the medications the patient or resident is currently taking when he or she is admitted to the
organization or is seen in an outpatient setting. This information is documented in a list or other format that is
useful to those who manage medications.

2. Define the types of medication information to be collected in non-24 hour settings and different patient
circumstances.

3. Compare the medication information the patient brought to the organization with the medications ordered for the
patient or resident by the organization in order to identify and resolve discrepancies.

4. Provide the patient or resident (or family as needed) with written information on the medication the patient should
be taking when he or she is discharged from the organization’s care or at the end of an outpatient encounter (for
example, name, dose, route, frequency, purpose).

5. Explain the importance of managing medication information to the patient or resident when he or she is leaves
the organization's care or at the end of an outpatient encounter.

Applies to: Hospital – CAH – Nursing Care Center

 Strategy 1 – Medication History 29

• The first step is to take a comprehensive medication history of the patient

• Start by looking at outpatient medical records or a discharge medication list if a patient was recently discharged
from a hospital. If the patient brings his or her own list and it matches with the medical record, or the patient can
explain all discrepancies, the first step is completed.

• More often, patients do not bring their own list or they do not match with other sources, and providers have to
contact the patient's pharmacy to determine what prescriptions have been filled

• If there is still uncertainty, a call to the patient's primary care physician or specialists may be necessary

• A final resource is to ask the family to bring in all the patients' pill bottles from home to confirm the medications the
patient is currently taking

Source: Beckers - Infection Control & Clinical Quality. 4 Steps to Improve Medication Reconciliation. Written by Sabrina Rodak | February 07, 2012
 30
Strategy 2 - Risk Stratification

• Determine Risk stratification based on their medication history including:

– A lack of a medical record containing the patient's medications
– The patient's inability to provide a list of medications or pill bottles from home
– The patient's use of 10 or more medications
– The patient's use of three or more high-risk medications, such as insulin or opiates
– The provider's suspicion of a medication problem

• Each patient's risk level will depend on how many of these factors are present

• High-risk patients will likely need a more in-depth medication history and reconciliation process,
such as having the history and reconciliation completed by a trained clinical pharmacist

Source: Beckers - Infection Control & Clinical Quality. 4 Steps to Improve Medication Reconciliation. Written by Sabrina Rodak | February 07, 2012
 31
Strategy 3 - Reconciliation at Discharge

• Reconciliation at discharge is one of the most critical components of a medication reconciliation program
because it can affect the patient's post-hospital safety and health, and thus the chance of readmission.

• Discharge orders should clearly categorize the medications that are:

– the same from pre-admission
– new medications
– medications that require a different dose or frequency.

• Show very clearly how the discharge regimen is different than what the patient was taking prior to
admission.

Source: Beckers - Infection Control & Clinical Quality. 4 Steps to Improve Medication Reconciliation. Written by Sabrina Rodak | February 07, 2012
 32
Strategy 4 - Education

• Patient and family education is the final step in medication reconciliation

• Clinicians need to explain to patients and their families what is different about their medications, why
those changes were made and possible side effects

• In addition, when discharging a patient, hospitals should give discharge instructions to the subsequent
caregiver(s) in both written and verbal forms to ensure comprehension and avoid adverse events

Source: Beckers - Infection Control & Clinical Quality. 4 Steps to Improve Medication Reconciliation. Written by Sabrina Rodak | February 07, 2012
 33
Cultural Competency

Cultural Competency in Health Services and Care published by the Washington State
Department of Health outlines six strategies for improving interpersonal communication with
culturally diverse patients or those with limited English proficiency or low health literacy rates:

• Slowing down your rate of speaking

• Using simple, non-medical language
• Showing, or drawing pictures
• Limiting the amount of information provided and repeating as necessary
• Using the “teach-back” or “show-me” technique
• Creating an accepting and respectful atmosphere

Source: Washington State Department of Health, Health Systems Quality Assurance. Cultural Competency in Health Services and Care, A Guide for Health
Care Providers. June, 2010
 34
Additional Strategies

1. Develop a single medication list ("One Source of Truth"), shared by all disciplines for documenting the patient's current
medications.

2. Clearly define roles and responsibilities for each discipline involved in medication reconciliation.

3. Standardize and simplify the medication reconciliation process throughout the organization, and eliminate unnecessary
redundancies (the flowchart of the current process can help you identify these redundancies).

4. Make the right thing to do the easiest thing to do within the patterns of normal practice.

5. Develop effective prompts or reminders for consistent behavior if true forcing functions (i.e., required reconciliation step presented
to the physician during admission order entry within an electronic health record [EHR] are not possible.

6. Educate patients and their families or caregivers on medication reconciliation and the important role they play in the process.

7. Ensure process design meets all pertinent local laws or regulatory requirements. Linking medication reconciliation to other
strategic goals (e.g., heart failure publicly reported process of care measures related to discharge instructions on medications)
and/or other initiatives (e.g., a hospital project working on improving patient satisfaction related to pain management or patient
communication regarding medications) when appropriate can also strengthen the importance of this process

Source: AHRQ: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Chapter 3. Developing Change: Designing
the Medication Reconciliation Process
 “One Source of Truth” 35

• Medication reconciliation process design should center on the concept of a single list to document patient's current medications.
This will be referred to as "one source of truth." This list should be shared and utilized by all physicians, nurses, pharmacists, and
others caring for the patient.

• All disciplines caring for the patient should be working from the same medication list, regardless of the format (electronic or paper-
based).

• The list should be centrally located and easily visible within the patient's medical record.

• This list becomes the reference point for ordering decisions and reconciliation, screening medications to be administered during a
procedure/episode of care, and determining the patient's medication regimen upon discharge.

• Each discipline should have the ability to update the home medications as new or more reliable information becomes available.

• In a paper-based format, old or modified information could be crossed out, new information can be added, and each change can be
dated, timed, and signed.

• In an electronic system, changes would be date and time stamped, and the prescriber's name automatically captured. If the
patient's medication list requires changes at discharge, updated information will remain stored for review and modification for future
admissions.

Source: AHRQ: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Chapter 3. Developing Change: Designing
the Medication Reconciliation Process
 Goal 6: Reduce the harm associated with clinical alarm systems
36
NPSG.06.01.01: Improve the safety of clinical alarm systems

1. Leaders establish alarm system safety as a critical access hospital priority.

2. Identify the most important alarm signals to manage based on the following:
– Input from medical staff and clinical departments
– Risk to patients if the alarm signal is not attended to or if it malfunctions
– Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
– Potential for patient harm based on internal incident history
– Published best practices and guidelines

3. Establish policies and procedures for managing the alarms identified in EP2 above that, at a minimum, address the following:
– When alarm signals can be disabled
– When alarm parameters can be changed
– Who in the organization has the authority to set alarm parameters
– Who in the organization has the authority to change alarm parameters
– Who in the organization has the authority to set alarm parameters to “off”
– Monitoring and responding to alarm signals
– Checking individual alarm signals for accurate settings, proper operation, and detectability

4. Educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

Applies to: Hospital - CAH

 37

Alarm fatigue or alert fatigue occurs when one is

exposed to a large number of frequent alarms (alerts)
and consequently becomes desensitized to them.
 38
Causes and Contributing Factors
1. Absent or inadequate alarm system

2. Improper alarm settings

3. Alarm signals not audible in all areas

4. Alarm signals inappropriately turned off

5. Alarm fatigue – the most common contributing factor

6. Alarm settings that are not customized to the individual patient or patient population

7. Inadequate staff training on the proper use and functioning of the equipment
(e.g., inconsistent team training, response, and interpretation of alarm signals)

8. Inadequate staffing to support or respond to alarm signals

9. Alarm conditions and settings that are not integrated with other medical devices

10. Equipment malfunctions and failures

Source: TJC Sentinel Alert: Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013
 39
Strategies

1. Leadership ensures that there is a process for safe alarm management and response in high-risk areas (as identified by
the organization)

2. Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and
identify the default alarm settings and the limits appropriate for each care area

3. Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical
conditions; include identification of situations when alarm signals are not clinically necessary

4. Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations
when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm
signals

5. Inspect, check, and maintain alarm-equipped devices to provide for accurate and appropriate alarm settings, proper
operation, and detectability. Base the frequency of these activities on criteria such as manufacturers’ recommendations,
risk levels, and current experience.

Source: TJC Sentinel Alert: Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013
 40
TJC Sentinel Alert Additional Strategies

Training and education

6. Provide all members of the clinical care team (as defined by the organization) with training on the organization’s process for safe alarm management and
response in high-risk areas (as identified by the organization), and on the safe use of the alarmed medical devices on which they rely. Also provide ongoing
training on new alarmed medical devices and updates to alarmed medical devices, and ensure that new members of the clinical care team receive training on
the alarmed medical devices on which they rely.

Equipment and physical environment

7. To help reduce nuisance alarm signals, change single-use sensors (for example, ECG leads) according to manufacturer’s recommendations, unless
contraindicated

8. Assess whether the acoustics in patient care areas allow critical alarm signals to be audible

Leadership and organizational planning

9. Re-establish priorities for the adoption of alarm technology; the priority-setting process should drive technology adoption rather than allowing technology to
drive the process

10. Establish a cross-disciplinary team that includes representation from clinicians, clinical engineering, information technology, and risk management, to
address alarm safety and the potential impact of alarm fatigue in all patient care areas.
– Establish a process for continual improvement and constant optimizing of alarm system policies and configurations.
– Review trends and patterns in alarm-related events to identify opportunities for improving alarm use.
– Implement an alarm system management policy, including the periodic review of alarm coverage processes and systems, and the development of
realistic, implementable strategies to address vulnerabilities.

11. Share information about alarm-related incidents, prevention strategies, and lessons learned with appropriate organizations, such as AAMI, ECRI Institute,
the FDA, and The Joint Commission

Source: TJC Sentinel Alert: Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013
 41
And A Few More

1. Provide proper skin preparation for electrocardiogram electrodes to improve conductivity and decrease the number
of false alarms

2. Change ECG electrodes daily

3. Customize alarm parameters and levels on ECG monitors

4. Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors

5. Provide initial and ongoing education about devices with alarms

6. Establish interprofessional teams to address issues related to alarms, such as the development of policies and
procedures

7. Monitor only those patients with clinical indications for monitoring

Source: American Association of Critical Care Nurses. 7 Alarm Management Strategies for Nurses
Written by Sabrina Rodak | June 21, 2013
 Goal 7: Reduce the risk of health care-associated infections
NPSG.07.01.01: Comply with either the current CDC hand hygiene 42
guidelines of the current WHO hand hygiene guidelines

1. Implement a program that follows categories 1A, 1B and 1C of either the current
CDC or the current WHO hand hygiene guidelines.

2. Set goals for improving compliance with hand hygiene guidelines.

3. Improve compliance with hand hygiene guidelines based on established goals

Applies to: Hospital – CAH – Nursing Care Center

 43
Key Causes of Hand Hygiene Noncompliance

• Ineffective placement of dispensers or sinks

• Hand hygiene compliance data are not collected or reported accurately or frequently

• Lack of accountability and just-in-time coaching

• Safety culture does not stress hand hygiene at all levels

• Ineffective or insufficient education

• Hands full

• Wearing gloves interferes with the process

• Perception that hand hygiene is not needed if wearing gloves

• Health care worker forgot

• Distractions

Source: The Joint Commission Journal on Quality and Patient Safety, January 2015, Volume 41, Number 1. Sustaining and Spreading Improvement in Hand
Hygiene Compliance
 44
Strategies

1. Start the culture change with leaders

2. Refresh the message

3. Connect the World Health Organization's five moments for hand hygiene to the whole patient journey

4. Provide actionable audit results

5. Empower patients to remind healthcare workers to wash their hands

6. Possibly reframe non-compliance with hand hygiene protocol as a healthcare error

7. Introduce penalties for non-compliance

Source: Becker’s Hospital Review: 7 ways to improve hand hygiene, from hospital managers Written by Heather Punke (November 21, 2014
 World Health Organization – Five Moments 45

1. BEFORE PATIENT CONTACT

WHEN? Clean your hands before touching a patient when approaching him or her
WHY? To protect the patient against harmful germs carried on your hands

2. BEFORE AN ASEPTIC TASK

WHEN? Clean your hands immediately before any aseptic task
WHY? To protect the patient against harmful germs, including the patient’s own germs, entering his or her body

3. AFTER BODY FLUID EXPOSURE RISK

WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal)
WHY? To protect yourself and the health-care environment from harmful patient germs

4. AFTER PATIENT CONTACT

WHEN? Clean your hands after touching a patient and his or her immediate surroundings when leaving
WHY? To protect yourself and the health-care environment from harmful patient germs

5. AFTER CONTACT WITH PATIENT SURROUNDINGS

WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving - even without touching the
patient
WHY? To protect yourself and the health-care environment from harmful patient germs
 Solutions Targeted to the Main Causes of Hand Hygiene Failures46
Main Causes Solutions
Ineffective placement of dispensers or sinks . • Provide easy access to hand hygiene equipment and dispensers
Hand hygiene compliance data are not • Data provide a framework for a systematic approach for improvement.
collected or reported accurately or frequently • Utilize a sound measurement system to determine the real score in real time.
• Scrutinize and question the data.
• Measure the specific, high-impact causes of hand hygiene failures in your facility and target
solutions to those causes.
Lack of accountability and just-in-time • Leadership commits to hand hygiene as an organizational priority and demonstrates support by
coaching role modeling consistent hand hygiene compliance.
• Train leaders as just-in-time coaches to reinforce compliance.
• Through just-in-time coaches, intervene to remind health care workers to wash their hands.
• Implement employee contracts to be signed by all health care workers to reinforce their
commitment to hand hygiene.
• Apply progressive disciplinary action against repeat offenders. Expectations should be applied
equally to all health care workers.

Safety culture does not stress hand hygiene at • Make hand hygiene a habit—as automatic as looking both ways when you cross the street or
all levels . fastening your seat belt when you get in your car.
• Ensure commitment of leadership to achieve hand hygiene compliance of 90+%
• Serve as a role model by practicing proper hand hygiene.
• Hold everyone accountable and responsible—physicians, nurses, food service staff,
housekeepers, chaplains, technicians, therapists.
 Solutions Targeted to the Main Causes of Hand Hygiene Failures47

Main Causes Solutions

Ineffective or insufficient education
Hands full
Wearing gloves interferes with the process
Perception that hand hygiene is not needed if • Provide discipline-specific education that puts hand hygiene within the context of an employee’s
wearing gloves
• Provide general education on hand hygiene expectations. Include information on infection
prevention, and stress the organization wide commitment to hand hygiene, highlighting strategies
deployed to reinforce compliance, such as posters and visual cues. Some organizations make this
part of annual training provided to new and existing employees.
• Provide discipline-specific education that puts hand hygiene within the context of an employee’s
daily work and processes.
• Reinforce education with just-in-time coaching.
Create a place for everything; for example, a health care worker with full hands needs a dedicated
space where he or she can place items while performing hand hygiene.
• Locate glove dispensers near hand-rub dispensers and sinks to facilitate the proper use of gloves.
• Provide training on glove use that incorporates hand cleansing and glove use within a specific
work flow.
• Use visual cues to reinforce and remind.
daily work and processes.
• Standardize the work processes that involve entry into a patient’s room, and specify when and
why hand hygiene is required; for example, standard processes for food tray delivery and room
cleanings.
• Provide discipline-specific education and training on glove use.
 Solutions Targeted to the Main Causes of Hand Hygiene Failures48

Main Causes Solutions

Health care workers forget or distractions
• Use a code word to be used among health care workers to signal to a peer that they missed an
opportunity and need to wash.
• Identify new technologies to make it easy for health care workers to remember to clean their
hands, such as RFID, automatic reminders, and warning systems.
• Train and deploy just-in-time coaches to provide real-time reinforcement and feedback to
health care workers. Just-in-time coaches are critical in creating a change in culture and
behavior.
• Visual cues reinforce hand hygiene messages and training. These include stickers, colors, and
posters. Visual cues need to be changed periodically so that they continue to be effective.
• Apply progressive disciplinary action against repeat offenders. Expectations should be applied
equally to all health care workers

Source: The Joint Commission Journal on Quality and Patient Safety, January 2015, Volume 41, Number 1. Sustaining and Spreading Improvement in Hand
Hygiene Compliance
 49
Methods for Measuring Handwashing Compliance

• Direct observation
– This method involves monitoring the actual hand hygiene actions of staff. It can be done manually — with an actual
person doing the monitoring — or it can be done with the assistance of technology such as smartphone apps. The
smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne
effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of
being observed.

• Measuring product use

– This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical
models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took
advantage of these opportunities.

• Electronic monitoring
– Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major
benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker's
interaction with patients.

Compliance with environmental hygiene can be measured by direct observation, fluorescent markers, ATP or environmental culture.
There are advantages and disadvantages for each of these measures, but according to the CDC Toolkit: Options to Evaluate
Environmental Hygiene, the goal is to optimize high touch surface cleaning using an objective monitoring and feedback method.
 Carolyn’s View 50

• Don’t rely on secret shoppers

• 3 observations is not enough

• Include ALL departments

• Observe
– Wound debridement
– PICC Line Insertion
– IV insertion
– Medication Administration
– Compounding
– Delivering meal trays
– Isolation
– Respiratory treatments
– Invasive procedures

• Give Immediate Feedback

 Next Time – October 13 51

Goal 7: Reduce the risk of health care-associated infections

Goal 9: Reduce the risk of patient harm resulting from falls (Nursing Care Center)

Goal 14: Prevent health care-associated pressure ulcers (Nursing Care Center)

Goal 15: The hospital identifies safety risks inherent in its patient population (Hospital

Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person
Surgery
52
 Page 53
TJC 2017/2018 National Patient Safety Goals
Goal 1: Improve the accuracy of patient and resident identification YES! Maybe NO

NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, and
services.
NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification.

Goal 2: Improve the effectiveness of communication among caregivers YES! Maybe NO

NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis.

Goal 3: Improve the safety of using medications YES! Maybe NO

NPSG.03,04.01 Label all medications, medication containers, and other solutions on and off the
sterile field in perioperative and other procedural settings.
NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant
therapy.
NPSG.03.06.01 Maintain and communicate accurate patient and resident medication
information.
 Page 54
TJC 2017/2018 National Patient Safety Goals

Goal 6: Reduce the harm associated with clinical alarm systems YES! Maybe NO

NPSG.06.01.01 Reduce the harm associated with clinical alarm systems.

Goal 7: Reduce the risk of health care-associated infections YES! Maybe NO

NPSG.07.01.01 Comply with either the current CDC hand hygiene guidelines or the current
WHO hand hygiene guidelines.
NPSG.07.03.01 Implement evidence-based practices to prevent health care-associated
infections due to multidrug-resistant organisms.
NPSG.07.04.01 Implement evidence-based practices to prevent central line-associated
bloodstream infections.
NPSG.07.05.01 Implement evidence-based practices for preventing surgical site infections.

NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated

urinary tract infections (CAUTI).
 Page 55
TJC 2017/2018 National Patient Safety Goals
Goal 9: Reduce the risk of patient harm resulting from falls YES! Maybe NO

NPSG.09.02.01 Reduce the risk of falls.

Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers) YES! Maybe NO

NPSG.14.01.01 Assess and periodically reassess each patient’s and resident’s risk for developing
a pressure ulcer and take action to address any identified risks.

Goal 15: The hospital identifies safety risks inherent in its patient population YES! Maybe NO

NPSG.15.01.01 Identify patients at risk for suicide.

Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong YES! Maybe NO
Person Surgery
UP.01.01.01 Conduct a preprocedure verification process.

UP.01.02.01 Mark the procedure site.

UP.01.03.01 A time-out is performed before the procedure.

 56

“And what is as important as knowledge?”

Asked the mind.
“Caring and seeing with the heart”
Answered the Soul
Flavia Weeden

Upcoming Webinars
8 Practical Approaches for Interim
Leaders
Mike Lieb, Vice President – Interim
Services
September 14, 12:00pm Central
http://bit.ly/2sDrO3A
The New Health Care Innovation Model:
Is It All Hocum?
Diane Bradley, Regional Chief Clinical
Officer
September 22, 12:00pm Central
http://bit.ly/2sDNKvF
57
Hiring Executives to Fit The Outcomes
Needed – Moving Way Beyond The Title
Peter Goodspeed, Vice President of
Executive Search
September 28, 2017, 12:00pm Central
http://bit.ly/2rkJCfS
National Patient Safety Goals – Part 2
Carolyn St.Charles, Regional Chief
Clinical Officer
October 13, 12:00pm Central
https://attendee.gotowebinar.com/register
/1133422051074822145
 58

Thank you! 58

Dallas Office Brentwood Office Our Phone Email / Website

2745 North Dallas Parkway, 5110 Maryland Way, Suite 200 Main Office: 615.309.6053 Carolyn St.Charles
Suite 100, Plano, TX 75093 Brentwood, TN 37027 Executive Placement: 972.265.4549 Carolyn.stcharles@healthtechs3.com
360-584-9868