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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:
- Providing treatments / procedures
- Collecting lab or blood samples
- Giving medications or blood products
COMMUNICATION
"Read-Back" process
For verbal or telephone orders or for telephonic reporting of critical
test results:
- 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:
- Measuring the timeliness
- Assessing for improvements
- Taking action to improve the process
- 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:
- Opportunity for questions / answers
- Minimal interruptions
"DRAW" a Picture of our Patient
- Diagnoses/procedures
and current condition,
- Recent changes
in condition or treatment,
- Anticipated changes
in condition or treatment, and
- What to watch for
in the next interval of care
MEDICATIONS SAFETY
Look-alike / Sound-alike Drugs
- Look-alike/sound-alike drugs list on IntraLee website under Pharmacy
- Medications such as "Insulin" should be segregated
Medication Labeling
Label all medications, medication containers, or other solutions as
follows:
- Whenever medication is transferred from original packaging
- 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:
- Involve the patient in the process
- 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:
- 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.
- Actively involve patients in their care
- Educate on reporting methods
IDENTIFY SUICIDAL RISK PATIENTS
- Perform suicide risk assessment
- Address immediate safety needs
- Provide crisis hotline information
CHANGE IN PATIENT'S CONDITION (NEW)
- 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: INFULENZA AND PNEUMOCOCCAL
VACCINE
- Assess all patients for vaccine status
- When indicated fax order set to Pharmacy
- Administration and documentation of the Influenza and Pneumococcal vaccines
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