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Quality of Care Statement and
Patient Safety Goals
Any physician who has a
concern regarding the safety or quality of care provided in
the hospital may report these concerns to a Unit Supervisor,
Director, Risk Management, Corporate Compliance or the Joint
Commission. Lee Memorial Healthcare System (LMHS)
demonstrates our commitment to reporting of safety or
quality concerns by taking no retaliatory disciplinary
action against physicians who report safety or quality
concerns.
THE JOINT COMMISSION
2008 National Patient Safety Goals
PATIENT
IDENTIFICATION
Two Patient Identifiers
Use at least two patient identifiers (Patient's name
and date of birth/account number) whenever:
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Providing
treatments/procedures
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Collecting lab or
blood samples
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Giving medications
or blood products
COMMUNICATION
"Read-Back" process
For verbal or telephone orders or for telephonic
reporting of critical test results:
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Write order first,
and then read back for verification
Timeliness of
Critical Test Results
Improve the timeliness of reporting and receipt of
critical test results to the responsible licensed caregiver
by:
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Measuring the
timeliness
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Assessing for
improvements
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Taking action to
improve the process
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GOAL: 45 minutes
PATIENT FALLS
Fall Prevention Program
Identify patients who are at risk to falls and
implement fall prevention interventions.
COMMUNICATION
"Hand-off Communication"
Standardize the approach to "hand-off"
communications, and ensure:
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Opportunity for
questions/answers
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Minimal
interruptions
"DRAW"
a Picture of our Patient
-
Diagnoses/procedures
and current condition,
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Recent
changes in condition or treatment,
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Anticipated
changes in condition or treatment, and
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What
to watch for in the next interval of care
MEDICATIONS SAFETY
Look-alike/Sound-alike Drugs
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Look-alike/sound-alike drugs list on IntraLee website
under Pharmacy
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Medications such as
"Insulin" should be segregated
Medication
Labeling
Label all medications, medication containers, or
other solutions as follows:
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Whenever medication
is transformed from original packaging
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Include drug name,
strength, amount, and expiration date/time if applicable
Reduce Patient
Harm (NEW)
Reduce the likeliness of patient harm associated
with the use of anticoagulation therapy.
HEALTHCARE -
ASSOCIATED INFECTIONS
Healthcare associated infection related sentinel events
Manage as sentinel events all identified cases of
unanticipated death or major permanent loss of function
associated with a healthcare infection.
Hand Hygiene
Alcohol rub for 15-25 seconds for hands to dry. Soap
and water required for C.diff and visible dirt.
MEDICATION
RECONCILIATION
Reconciliation on Admission/Entry
Create a complete list of the patient's current
medications at admission/entry:
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Involve the patient
in the process
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Compare hospital
medications to those on the list
Reconciliation on
Transfer/Discharge
Provide a complete list of the patient's medications
to the next service provider:
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Referral, transfer,
change in level of care (internal or external), or
discharge
ENCOURAGE PATIENT
INVOLVEMENT
Define and communicate means for patients and families
to report safety concerns.
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Actively involve
patients in their care
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Educate on
reporting methods
IDENTIFY SUICIDAL
RISK PATIENTS
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Perform suicide
risk assessment
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Address immediate
safety needs
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Provide crisis
hotline information
CHANGE IN PATIENT'S
CONDITION (NEW)
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Healthcare staff
members can call Medical Emergency Team (MET) directly
to request additional assistance from a specially
trained individual(s) when the patient's condition
appears to be worsening.
STROKE PROGRAM ONLY:
INFLUENZA AND PNEUMOCOCCAL VACCINE
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Assess all patients
for vaccine status
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When indicated fax
order set to Pharmacy
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Administration and
documentation of the Influenza and Pneumococcal vaccines
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