Joint Commission
How do we ensure medicines are given safely?
- before a procedure label meds that are unlabeled (ex. syringes, cups, basins) -prevent errors due to unlabeled solutions , meds -all personal meds must be verified by pharmacy prior to admin. -ensure pt has order -reduce likelihood of pt harm associate w use of anticoagulant tx (baseline INR, patient education!!) -Maintain and communicate accurate pt med info (Thorough med list !!!)
How are patient safety goals chosen?
- chosen from a larger pool of safety goals identified by the JC sentinel event advisory group.
How do we prevent infection ??
- comply w. CDC or WHO hand hygiene. - appropriate disinfection of equipment -contact precautions -risk assess, alert system for readmits
What is the patient safety advisory group?
- comprised of a panel of widely recognized patient safety experts, including nurses ,physician , pharmacist, risk manager, clinical engineers, and other professionals with hands on experience in addressing patient safety issues in a wide variety of healthcare settings -advises the JC on the development and updating of NPSGs. - they advice the JC how to address emerging patient safety issues
How do we prevent mistakes in surgery?
- correct surgery performed on correct place on patients body ! - pre-procedure verification process -make the correct place on the pt body where surgery is to be done (surgeons initials ) -involve patient
How do we prevent infection after surgery?
- education! - monitor surgical incision -prophylaxis abx as indicated
How do we ensure alarms are being used safely?
- ensure alarms on medical equipment are heard and responded too ( difficult to detect, alarm fatigue, noncompliant w use) ** Personal equipment Brought in by pt must be inspected by biomed before use in the hospital (like a CPAP machine)
What happens if institutions dont comply?
- failure to demonstrate compliance will result in a Type 1 recommendation
What specific selection criteria is used for the patient safety goals?
- have potential for immediate improvement -evidence based or by expert consensus -practical, cost effective, and well defined enough to be actionable
Who can call a rapid?
- health care members or pt family , pt
What is the purpose of national patient safety goals?
- improve patient safety, making goals focused on problems in health are safety and how to solve them
How do we prevent CAUTIs?
- nursing protocol to ensure quick d/c -follow protocol for sterile technique
What are retired goals?
- previous goals that have been reached or "moved" to standards
nurse responsibilities for hand off shift report
- provide a concise , yet thorough and specific shift report -allow opportunity for questions between giver and receiver - include up to date info regarding care, tx, services, conditions, and any recent or anticipated changed -limit interruptions during hand off; if this does not occur, provide written report -no chance in care between 0645-0715 and 1845-1915
How do we ensure to improve staff communication?
- report critical results and diagnostic procedures on timely basis -promote timely tx to pt in possible life threatening situation.
How do we identify pt safety risks?
- routine risk assignment - address immediate safety concerns -provide resources -follow policy and procedures (1:1, supervisor notified, room check for safety, removed of belongings, in gown)
When to call RRT?
- tachycardia and bradycardia - SBP -SPO2 - RR - altered mental status or change in LOC - new or prolonged seizures -acute or significant bleeding - primary nurse has no real clinical indicators , however is concerned or worried about the patient
How do we ensure that we identify pt correctly>
- two patient identifiers. name and DOB -matching correct service or tx
What is the purpose of JC NPSG?
-Promote specific improvements in patient safety
Universal protocol for all surgical procedures?!
-TIME OUT! - consents -mark right location - not only in OR ( also chest tube insertion, central line insertion, cath lab)
What happens if a facility has a type 1 recommendation?
-can lead to loss of accreditation , would impact reimbursement of services and hence financial viability of institution.
Hand off for transfer
-do not assume the responsibility to give report to any receiving unit or institution - students are not permitted to relay info or hand off info to other disciplines- this is the responsibility of licensed personnel only
What are the benefits of JC accreditation and certification?
-helps organize and strengthen patient safety efforts -strengthens community confidence in the quality and safety of care, tx and services -provides a competitive edge in the market place -may reduce liability insurance cost -provides education to improve business operations -provides professional advice and counsel, enhancing staff education. * STRENGTHENS QUALITY !-
Who responds RRT?
-hospitalist -ENIT nurse -critical care nurse -respiratory therapist -primary nurse -EKG tech
How are phone / verbal orders improved?
-the individual giving the order verifies the complete order or test result by having the person receiving the info record and "read back" the complete order or test result
What are the national patient safety goals? (6)
1. Identifies Patients Correctly 2. Improves staff communication 3. Uses medicines safely 4. Use alarms safely 5. Prevent infection 6. Identify patient safety risks
What happens if a hospital does not get accredited?
no $!!
What are the 10 R's of Med Admin?
right med, right route, right dosage, right pt, right time, right documentation, right assess,. right eval, right client education, right to refuse
What is JC's mission?
to continuously improve health care for the public , in collaboration with other stakeholder by evaluating health care health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
What does accreditation and certification recognize?
a symbol of quality that reflects an organization's commitment to meeting certain performance standards
What is JC's vision?
all people always experience the safest, hight quality, best value health care across all settings
What is the joint commission ?
an independent not for profit organization that evaluates and accredits more team 20,000 health care organizations and programs in the U.S.
how often does JC survey team visit?
at least q 3 years