Overview of the 2006 National Patient Safety Goals Hospitals

1
Overview of the 2006 National Patient Safety
Goals Hospitals Critical Access Hospitals

• Webinar Presentation 03/01/06
• Jacqueline Childers, MPH, CPHQ
• jchilders_at_gha.org
• [phone]

2
Overview

• The purpose of the Joint Commissions National
  Patient Safety Goals (NPSGs) is to promote
  specific improvements in patient safety.
• The NPSGs and Requirements are program-specific

3
The Requirements

• Highlight problematic areas in health care and
  describe evidence and expert-based solutions to
  these problems.
• Focus on system-wide solutions, wherever
  possible.

4
National Patient Safety Goals

• Goals and Requirements are guided by a panel of
  experts called the Sentinel Event Advisory Group.
• Each year, the Sentinel Event Advisory Group
  works with the JCAHO to systematically review the
  literature and available databases to identify
  potential new Goals and Requirements.
• 2006 NPSGs approved by the Joint Commissions
  Board of Commissioners on May 20, 2005
• The Goals and their Requirements are published by
  mid-year.

5
Top Root Causes of Sentinel Events

• 1995-2004 - All categories N 3044 events

• Communications gt 60
• Orientation/Training gt 50
• Patient Assessment gt 40
• Staffing
• Availability of Information
• Competency/Credentialing
• Procedural Compliance
• Environmental Safety/Security
• Leadership
• Continuum of Care
• Care Planning
• Organization Culture

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Implementation Expectations, FAQs, Examples of
Alternative Approaches

• The Goals
• http//www.jcaho.org/accreditedorganizati
  ons/patientsafety/06_npsg/06_npsg_cah_hap.htm
• Implementation Expectations
• Rationale
• Performance expectations requirements
• FAQs
• Interpretation of terms, scope, applicability
• Suggestions and recommendations for how to
• Self-assessment and survey process insights

7
Summary of 2006 NPSGs Hospitals CAHs

• 1a Use at least two patient identifiers
• 2a For verbal or telephone orders - "read-back"
  the complete order or test result.
• 2b List of unapproved abbreviations
• 2c Timeliness of reporting and receipt by the
  responsible licensed caregiver, of critical test
  results and values.
• 2e Implement a standardized approach to hand
  off communications, including an opportunity to
  ask and respond to questions.
• 3b Standardize and limit the number of drug
  concentrations available in the organization
• 3c Look-alike/sound-alike drugs used in the
  organization
• 3d Label all medications, medication containers
  or other solutions
• 7a Comply with current (CDC) hand hygiene
  guidelines
• 7b Manage as sentinel events all identified
  cases of unanticipated death or major permanent
  loss of function associated with a health
  care-associated infection
• 8a Complete list of the patients current
  medications
• 8b A complete list of the patients medications
  is communicated to the next provider of service
• 9b Implement a fall reduction program and
  evaluate the effectiveness of the program

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Patient Identification
9
Patient Identification

• Requirement 1A Use at least two patient
  identifiers (neither to be the patient's room
  number) whenever administering medications or
  blood products taking blood samples and other
  specimens for clinical testing, or providing any
  other treatments or procedures.
• Applies to CAH, Hosp, Lab

10
Implementation Expectations 1A

• It is the person-specific information that is
  the identifier, not the medium on which that
  information resides. Acceptable identifiers may
  be the individual's name, an assigned
  identification number, telephone number,
  photograph or other person-specific identifier.
  Bar coding that includes two or more
  person-specific identifiers (not room number)
  will comply with this requirement.

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Improve Communication
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Rationale for Goal 2A

• Ineffective communication is the most frequently
  cited category of root causes of sentinel events.
  
• Effective communication, which is timely,
  accurate, complete, unambiguous, and understood
  by the recipient, reduces error and results in
  improved patient/client/resident safety.

13
Applies to CAH, Hosp, Lab
14
Implementation Expectations 2A

• Simply repeating back the order or test result is
  not sufficient. Whenever possible, the receiver
  of the order should write down the complete order
  or test result or enter it into a computer, then
  read it back, and receive confirmation from the
  individual who gave the order or test result.
• "Critical test results are defined by the
  individual health care organization and will
  typically include "stat" tests, "panic value"
  reports, and other diagnostic test results that
  require urgent response.

15
Applies to CAH, Hosp, Lab
16
Implementation Expectations 2B

• An official list of dangerous abbreviations,
  acronyms, and symbols has been approved by the
  JCAHO and must be included on each organizations
  Do not use list. The official list is available
  at
• http//www.jcaho.org/accreditedorganizations/pat
  ientsafety/dnu.htm.
• Additional items may be added to an
  organizations do not use list at the
  organizations discretion.

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Implementation Expectations 2B

• The do not use list applies to all orders and
  other medication-related documentation when
  handwritten, entered as free text into a
  computer, or on pre-printed forms.
• It does not currently apply to computer-generated
  forms or displays.

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Implementation Expectations 2B

• The minimum expected level of compliance for
  handwritten documentation and free-text entry is
  90 percent.
• The minimum expected level of compliance for
  pre-printed forms is 100 percent.

19
Implementation Expectations 2B Cont

• Clarification of an order prior to implementation
  is expected but does not eliminate that
  occurrence from being counted. Similarly,
  after-the-fact correction of the order by the
  clinician does not eliminate that occurrence from
  being counted.
• Surveyors will count occurrences of Do Not Use
  Abbreviations.
• o One occurrence equals one or more slips per
  clinician per record.
• o Three occurrences equal a Requirement for
  Improvement. (Revised 1/21/05)
• o There is no partial compliance for NPSGs.

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Implementation Expectations 2B

• Trailing zeros may be used in non-medication
  related documentation when there is a clear need
  to demonstrate level of precision, such as for
  laboratory values, imaging study measurement of
  lesion sizes, or catheter and therapeutic tube
  sizes. It may not be used in medication orders or
  other medication-related documentation.

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Official Do Not Use List

• Do Not Use Potential Problem Use Instead
• U (unit) Mistaken for 0 (zero), Write
  "unit"
• the number 4 (four) or cc
• --------------------------------------------------
  --------------------------------------------------
  -------
• IU (International Unit) Mistaken for IV
  (intravenous) Write "International Unit"
• or the number 10 (ten)
• --------------------------------------------------
  --------------------------------------------------
  -------
• Q.D., QD, q.d., qd (daily) Mistaken for each
  other Write "daily"
• Q.O.D., QOD, q.o.d, qod Period after the Q
  mistaken for Write "every other day"
• (every other day) "I" and the "O" mistaken for
  "I"
• --------------------------------------------------
  --------------------------------------------------
  ----------
• Trailing zero (X.0 mg) Decimal point is missed
  Write X mg
• Lack of leading zero (.X mg) Write 0.X mg
• --------------------------------------------------
  --------------------------------------------------
  ----------
• MS Can mean morphine sulfate or Write
  "morphine sulfate"
• magnesium sulfate Write "magnesium sulfate"
  
• MSO4 and MgSO4 Confused for one another

22
Applies to CAH, Hosp, Lab
23
Implementation Expectations 2C

• The organization will need to determine its
  current turnaround time for reporting. The JCAHO
  expects an organization to define the acceptable
  length of time
• a) between the ordering of critical tests and
  reporting the test results and values, and
• b) between the availability of critical
  results/values and receipt by the responsible
  licensed care giver.

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Implementation Expectations 2C Cont

• The organization then assesses these data,
  determines whether there is a need for
  improvement in the timeliness of reporting and,
  if so, takes appropriate action to improve and
  measures the effectiveness of those actions.

25
New for 2006
Applies to CAH, Hosp, Lab
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Rationale 2E

• The primary objective of a hand off is to
  provide accurate information about a
  patients/clients/residents care, treatment and
  services, current condition and any recent or
  anticipated changes.
• The information communicated during a hand off
  must be accurate in order to meet patient safety
  goals.

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Rationale 2E Cont

• Types of patient hand offs, including but not
  limited to nursing shift changes, physicians
  transferring complete responsibility for a
  patient, physicians transferring on-call
  responsibility, temporary responsibility for
  staff leaving the unit for a short time,
  anesthesiologist report to post anesthesia
  recovery room nurse, nursing and physician hand
  off from the emergency department to inpatient
  units, different hospitals, nursing homes and
  home health care, critical laboratory and
  radiology results sent to physician offices

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Implementation Expectations 2E

• Attributes of effective
• hand off communications
• Hand offs are interactive communications allowing
  the opportunity for questioning between the giver
  and receiver of patient/client/resident
  information.
• Hand offs include up-to-date information
  regarding the patients/clients/residents care,
  treatment and services, condition and any recent
  or anticipated changes.

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Implementation Expectations 2E

• Attributes of effective
• hand off communications
• Interruptions during hand offs are limited to
  minimize the possibility that information would
  fail to be conveyed or would be forgotten.
• Hand offs require a process for verification of
  the received information, including repeat-back
  or readback, as appropriate.

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Implementation Expectations 2E

• Attributes of effective
• hand off communications
• The receiver of the hand off information has an
  opportunity to review relevant patient/client/resi
  dent historical data, which may include previous
  care, treatment and services.

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Hand-off Communication

• A hand-off communication is an interactive
  process of passing patient-specific information
  from one caregiver to another or from one team of
  caregivers to another for the purpose of ensuring
  the continuity and safety of the patients care.
• Examples
• Nursing change-of-shift report
• Physician sign-out to a covering physician
• Anesthesia provider or circulating nurse
  reporting to the PACU staff
• ED staff communicating with staff at a receiving
  facility

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Developing a Standardized Approach to Hand-off
Communications

• A standardized approach should identify
• The hand-off situations that it applies to
• Who is, or should be, involved in the
  communication
• What information should be communicated
• Diagnoses and current condition of the patient
• Recent changes in condition or treatment
• Anticipated changes in condition or treatment
• What to watch for in the next interval of care
• Opportunities to ask and respond to questions
• When to use certain techniques (repeat-back
  SBAR)
• What print or electronic information should be
  available

33
Medication Safety
New for 2006
Applies to CAH, Hosp
34
Rationale For NPSG 3

• When medications are part of the
  patient/client/resident treatment plan,
  appropriate management is critical to ensuring
  patient/client/resident safety.
• The development of standardized and redundant
  systems has been shown to decrease error and
  improve outcomes.

35
Implementation Expectations 3B

• When more than one concentration is necessary,
  the number of concentrations should be limited to
  the minimum if required to meet patient care
  needs, such as may be the case in pediatrics or
  neonatal care, and those concentrations should be
  standardized.

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Rule-of-6 Phase-out Rules

• The Rule-of-6 does not comply with Goal 3
• Organizations using the Rule-of-6 must transition
  to standardized concentrations by the end of 2008
• During the transition period, continued use of
  the Rule-of-6 may be approved as an alternative
  approach if the following criteria are met
• All Ro6 admixtures are prepared in the pharmacy
• All Ro6 calculations are independently validated
• All Ro6 preparations are labeled w/ Drug
  wt./volume
• Special aids are available if 2 systems are used
• If Ro6 is used in NICU, must have 24o pharmacy
• Must use smart pumps

37
Implementation Expectations 3C

• There are multiple strategies to identify a list
  of lookalike/sound-alike drugs used in the
  organization. Three tables of look-alike/sound-ali
  ke drugs have been issued by the JCAHO, and are
  posted on the Joint Commission website at
• (http//www.jcaho.org/accreditedorganizations/pat
  ientsafety/npsg.htm).

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Implementation Expectations 3C

• An organization must include on its own list a
  minimum of 10 look-alike/sound-alike drug
  combinations from these tables, in accordance
  with the instructions accompanying the tables.
• The tables include both generic and drug
  combination specific prevention measures.
• Surveyors will expect to see several of the
  applicable prevention measures in place for each
  drug combination on the organizations list.

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Requirement 3.d.

• Label all medications, medication containers
  (e.g., syringes, medicine cups, basins), or other
  solutions on and off the sterile field in
  perioperative and other procedural settings.

New for 2006
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Label all medications

• See standard MM.4.30 Medications are
  appropriately labeled
• Includes all medications and solutions
• Even if there is only one
• Even if it is obvious
• It also applies to anesthesia medications
• It applies to the O.R. and other procedural
  settings, not just invasive procedures

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Rationale 3D

• This risk reduction activity is consistent with
  safe medication practices and addresses a
  recognized risk point in the safe administration
  of medications in perioperative settings.

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Implementation Expectations 3D

• Medications include any prescription medications
  sample medications herbal remedies vitamins
  nutriceuticals over-the-counter drugs vaccines
  diagnostic and contrast agents used on or
  administered to persons to diagnose, treat, or
  prevent disease or other abnormal conditions
  radioactive medications respiratory therapy
  treatments parenteral nutrition blood
  derivatives intravenous solutions (plain, with
  electrolytes and/or drugs), and any product
  designated by the FDA as a drug.

43
Implementation Expectations 3D

• Solutions include chemicals and reagents such as
  formaline, saline, sterile water, Lugols
  solution, radiopaque dyes, glutaraldehyde and
  chlorhexidine.

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Health Care-Associated Infections
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Rationale 7

• Compliance with the CDC hand hygiene guidelines
  will reduce the transmission of infectious agents
  by staff to patients/clients/residents, thereby
  decreasing the incidence of healthcare associated
  infections.

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Applies to CAH, Hosp, Lab
47
Implementation Expectations 7A

• Staff should know what is expected of them with
  regard to hand hygiene and should practice it
  consistently.
• Implementation of all CDC guidelines with
  category IA, IB or IC evidence is required.
• (http//www.cdc.gov/handhygiene/).

48
Applies to CAH, Hosp, Lab
49
Implementation Expectations 7B

• A significant percentage of patients/clients/resid
  ents who unexpectedly die or suffer major
  permanent loss of function, have healthcare
  associated infections.
• These unanticipated deaths and injuries meet the
  definition of a sentinel event and, therefore,
  are required to undergo a root cause analysis.

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Implementation Expectations 7B Cont

• The root cause analysis should attempt to answer
  the questions, why did the patient acquire an
  infection and, given the fact of the infection,
  why did the patient die or suffer permanent loss
  of function?

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Reconcile Medications
Applies to CAH, Hosp
52

Requirement 8.a.

• Implement a process for obtaining and documenting
  a complete list of the patient's current
  medications upon the patient's admission to the
  organization and with the involvement of the
  patient.
• This process includes a comparison of the
  medications the organization provides to those on
  the list.

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Implementation Expectations 8A

• Organizations must implement a standardized
  method for creating an accurate list of
  medications at admission/entry and transfer.
• Development of a medication reconciliation form,
  to be used as a template for gathering
  information about current medications, is one
  method that can be used to standardize care and
  prevent errors.

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Which Medications Must Be Reconciled?

• Medications include in the list
• Prescription medications
• Sample medications
• Vitamins
• Nutriceuticals
• Over-the-counter drugs
• Vaccines
• Diagnostic and contrast agents
• Radioactive medications
• Respiratory therapy-related medications
• Parenteral nutrition
• Blood derivatives
• Intravenous solutions (plain or with additives)
• Any product designated by the FDA as a drug

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Requirement 8.b.

• A complete list of the patient's medications is
  communicated to the next provider of service when
  it refers or transfers a patient to another
  setting, service, practitioner or level of care
  within or outside the organization.

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Implementation Expectations 8B

• The patients accurate medication reconciliation
  list (complete with medications prescribed by the
  first provider of service) is communicated to the
  next provider of service, whether it be within or
  outside the organization.

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Implementation Expectations 8B Cont

• Thereafter, the next provider of service should
  check over the medication reconciliation list
  again to make sure it is accurate and in concert
  with any new medications to be ordered/prescribed.
  

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Implementation Expectations 8B Cont

• At a minimum, reconciliation must occur any time
  the organization requires that orders be
  rewritten and any time the patient changes
  service, setting, provider or level of care and
  new medication orders are written.
• For transitions not involving new medications or
  rewriting of orders, the organization should
  determine whether reconciliation must occur.

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Steps in the Reconciliation Process

• Develop a complete and accurate list of the
  patients medications
• Compare (reconcile) the listed medications with
  any new orders for medications
• Omission
• Duplication
• Interaction
• Name/dose/route confusion
• Update the list as orders change during the
  episode of care
• Communicate the updated list to the next
  provider(s) of care

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When Should Reconciliation Occur?

• Whenever the organization
• refers or transfers a patient to another
  setting, service, practitioner, or level of care
  within or outside the organization.
• At a minimum
• Any time the organization requires that orders
  be rewritten
• Any time the patient changes service, setting,
  provider or level of care and new medication
  orders are written
• For transitions not involving new medications or
  rewriting of orders, the organization determines
  whether reconciliation must occur.

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Reduce Falls
Applies to CAH, Hosp
62
Implementation Expectations 9B

• As appropriate to the population served, the
  services provided, and the environment of care, a
  fall reduction program may include risk
  assessment and periodic reassessment of
  individual patients/clients/residents or of the
  environment of care.

63
Implementation Expectations 9B Cont

• The program should include risk reduction
  strategies, in-services, involving
  patients/families in education and environment of
  care redesign. The program should also include
  development and implementation of transfer
  protocols (e.g., bed to chair), when relevant.

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Requesting Review of an Alternative Approach

• Requests for review of an alternative approach to
  one of the NPSG requirements must be submitted
  prior to survey
• Request form and procedure available on
  www.jcaho.org
• Review by Sentinel Event Advisory Group
• Decision by the Joint Commission on acceptability
  of the alternative approach
• Evaluation of implementation by surveyor

65
Surveying and Scoring theNational Patient Safety
Goals

• Compliance with applicable Requirements (or an
  acceptable alternative) will be scored as an
  element of performance in the NPSGs chapter of
  each standards manual.

66
Public Disclosure of Compliance with the National
Patient Safety Goals

• Aggregate data
• Compliance with applicable Requirements 2003-2005
  posted on Joint Commission web site
• (whether scored in the standards or NPSGs)
• NPSG Page included in Quality Reports on
  www.qualitycheck.org on web site since mid-year
  2004

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Surveying and Scoring theNational Patient Safety
Goals

• Must implement all applicable Goals
  Requirements or implement an acceptable
  alternative(s)
• Evaluated in the PPR and during all full
  accreditation surveys and for-cause surveys
• Surveyors evaluate actual performance, not just
  intent
• Failure to comply with one or more requirements
  of a Goal will result in a Requirement for
  Improvement
• NPSG requirements that are also in the standards
  will only be scored once (no double jeopardy)

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