Commission National Patient Safety Goal Research Articles

Using a Patient Identification Checklist: How to Make This a Never Safety Event in Perioperative Services

<h3>Background Information</h3> Patient identification is one of the Joint Commission National Patient Safety Goals. Positive patient identification involves accuracy, verification and two-way communication. Occasionally, patient armbands did not match patient labels or paperwork, leading to incorrect patient identification. Safety Events were placed and reviewed at the executive level as high-risk safety events that achieved institutional support. Preoperatively, errors in patient identification can lead to potentially serious errors. The check-in area was able to identify workflow inconsistencies, interview techniques and equipment locations as opportunities for improvement. The focus was on patient wristbands during check in, leading to the development of a checklist and subsequent audits to measure compliance. <h3>Objectives of Project</h3> To maintain a trend of overall reported patient ID events, to sustain no high harm and reduce patient ID reported procedures events, as they relate to safety culture and accountability by 25% six months after training in Just Culture and accountability. <h3>Process of Implementation</h3> A review of current workflow and observation audits were completed prior to beginning the pilot. A Patient Identification Checklist supporting hospital policy was developed. Education to staff and 50 in-person audits were completed to observe the wristband check-in process, using an electronic audit. The checklist was laminated and posted at eye level of the Patient Service Coordinator (PSC). The wristband and label printer were relocated closer to the workstation for ease of use. The patient charts filing order was changed from OR room number to alphabetical order (by last name) to reduce chart adjustments. The level of lighting was also adjusted to improve visualization by patients and staff. <h3>Statement of Successful Practice</h3> The baseline data included five patient ID safety events for PACU/Preop and the implementation of the new workflow resulted in zero patient ID events after the pilot. The patient ID wristband checklist helped reduce the number of patient ID events related to wristbands but is dependent on the employee adhering to the checklist. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Not verifying patient information is a top causal factor for patient ID overall. Reminding staff about the importance of adhering to the checklist and following best practice standards for patient identification can help ensure this becomes a Never Event in Perioperative Services.

Impact of Pharmacy-Driven Medication Reconciliation upon Admission to Improve Patient Safety in a Family Medicine Unit

Introduction: Medication reconciliation is the process of comparing a patient’s ordered medications to what the patient is actually taking. For several years, it has been included as part of The Joint Commission National Patient Safety Goals for improving medication safety. Our study investigated the impact of pharmacy personnel involvement in the medication reconciliation process on a family medicine unit in a large, urban, academic medical center. Materials and Methods: A prospective, non-randomized, cross-sectional study was conducted from November 2017 through March 2018. The number of medication discrepancies identified as well as the characteristics of the patients, types and medication classes most commonly associated with discrepancies were assessed. Results: Approximately 104 out of 134 or 78% of patients had at least one discrepancy at the time of admission. The most common discrepancy type was related to the electronic medical record followed by omissions, patient non-compliance and the drug being held. The medication classes mostly commonly associated with discrepancies were over the counter medications, cardiac medications and analgesics. Of the 104 patients that had at least one discrepancy, 31 (30%) required an intervention by a member of the pharmacy team. Conclusion: Pharmacy interns identified additional prescription and non-prescription medication discrepancies after the medication reconciliation process had already been completed. Involving pharmacy interns in a formal, standardized medication reconciliation process can help maintain and communicate accurate patient information.

Implementing a safety plan intervention as part of suicide risk screening

Several months ago, this commentary focused on implementation of the Joint Commission requirement to begin suicide screenings for behavioral health patients as of July 2019, and last month's commentary by Dr. Alex Bettis described strides made in suicide prevention for children and adolescents in Rhode Island. As part of the suicide prevention initiative, she gave a brief description of the structured safety plan used to ensure a safe transition home. With consultation from this team, we have continued work on the implementation of safety planning for patients that screen in the moderate or high risk for suicide category using the Columbia Suicide Severity Rating Scale Screener. The Joint Commission national patient safety goal for suicide prevention specifies that the “plan to mitigate the risk for suicide” be documented, but there is little specific guidance on the process. This may in part be due to the paucity of research on “contracting for safety” and “safety planning” (Knesper et al., 2011).

The Joint Commission National Patient Safety Goals (NPSG) directing anticoagulation safety in the United States

Implemented in 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, later known as just Joint Commission) implemented required initiatives for accredited institutions that provide health care services for improving patient safety. The first six National Patient Safety Goals (NPSG) required these institutions to address and improved the identified short comings associated with patient misidentification, communications between caregivers, use of high-alert medications and drug infusion devices, reduction of surgical errors, and clinical alerts. In 2005, JCAHO implemented a new NPSG, labeled as Goal #3c, designed to improve safety of medication use, and in 2008 specifically addressing anticoagulants. The purpose of this review is to describe the laboratory and pharmacy department roles addressing the current eight required NPSG elements related to anticoagulation safety.

Surgical Services Hair Removal Protocol “To Clip or Not to Clip”

The Joint Commission National Patient Safety Goal 07.05.01.8 states: When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations. Upon literature review, best practice related to surgical hair removal includes; •Hair shall NOT be removed from the operative site unless it physically interferes with the surgical incision or procedure •If hair is to be removed it shall be done by single use clipper head using the surgical clipping method which best preserves skin integrity •Hair removal should be kept at a minimum •Hair removal shall be done as near to the time of surgery as practical •Hair removal shall take place outside of the operating room

Standardizing Central Venous Catheter Lab Collection Process to Reduce Risk of Central Line Associated Blood Stream Infection

According to the Centers for Disease Control CDC, an estimated 30,100 central line associated bloodstream infections (CLABSI) occur in acute care facilities each year. The Joint Commission National Patient Safety Goals recommends implementing proven guidelines to prevent CLABSI. In a major cancer center, with an average of 60 to 80 surgical procedures performed daily, the risk of CLABSI is significant considering the immunocompromised patient population. Post Anesthesia Care Unit (PACU) nurses committed to infection control developed a standardized process for collecting lab samples from the Central Venous Catheter (CVC).

Spotlight on the 2016 National Patient Safety Goals for hospitals

In Brief The 2016 Joint Commission National Patient Safety Goals (NPSGs) for hospitals required full implementation by January 1, 2016. The purpose of the NPSGs is to improve patient safety by applying evidence- and expert-based solutions to high-risk, problem-prone areas with a significant risk to patient safety and the potential for patient harm. This article describes the new NPSG requirements for 2016 and provides an overview of the pre-existing goals. This article describes the new National Patient Safety Goal requirements for 2016 and provides an overview for implementation.

Spotlight on the 2016 National Patient Safety Goals for hospitals.

Abstract:The 2016 Joint Commission National Patient Safety Goals (NPSGs) for hospitals required full implementation by January 1, 2016. The purpose of the NPSGs is to improve patient safety by applying evidence- and expert-based solutions to high-risk, problem-prone areas with a significant risk to

Impact of a pharmacist-driven warfarin management protocol on achieving therapeutic International Normalized Ratios.

Warfarin is a high alert medication and a challenge to dose and monitor. Pharmacist-driven warfarin management has been shown to decrease the time international normalized ratio (INR) is out of range, which may reduce undesired outcomes. The purpose of this study is to assess the effect of the implementation of a pharmacist-driven warfarin management protocol on the achievement of therapeutic INRs. A warfarin management protocol was developed using evidence based literature and similar protocols from other institutions. Pharmacists utilized the protocol to provide patient specific warfarin dosing upon provider referral. To evaluate the protocol's impact, a retrospective chart review pre- and post-implementation was completed for admitted patients receiving warfarin. Three hundred twenty-seven charts were reviewed for pre- and post-implementation data. INRs within therapeutic range increased from 27.8% before protocol implementation to 38.5% after implementation. There was also a reduction in subtherapeutic INRs (55.3% pre to 39% post) and supratherapeutic INRs 5 or above (3.7% pre to 2.6% post). Supratherapeutic INRs between 3 and 5 did increase from 13.2% before protocol implementation to 19.9% in the pharmacist managed group. In addition to reducing the time to achievement of therapeutic INRs by 0.5 days, implementation of the protocol resulted in an increased the number of patients with at least one therapeutic INR during admission (35% pre to 40% post). The implementation of a pharmacist-driven warfarin dosing protocol increased therapeutic INRs, and decreased the time to therapeutic range, as well as the proportion of subtherapeutic INRs and supratherapeutic INRs 5 or greater. Additional benefits of the protocol include documentation of Joint Commission National Patient Safety Goal compliance, promotion of interdisciplinary collaboration and increased continuity of care.

Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project.

BackgroundClinical alarm systems safety is a national concern, specifically in intensive care units (ICUs) where alarm rates are known to be the highest. Interventional projects that examined the effect of changing default alarm settings on overall alarm rate and on clinicians’ attitudes and practices toward clinical alarms and alarm fatigue are scarce.ObjectiveTo examine if (1) a change in default alarm settings of the cardiac monitors and (2) in-service nursing education on cardiac monitor use in an ICU would result in reducing alarm rate and in improving nurses’ attitudes and practices toward clinical alarms.MethodsThis quality improvement project took place in a 20-bed transplant/cardiac ICU with a total of 39 nurses. We implemented a unit-wide change of default alarm settings involving 17 parameters of the cardiac monitors. All nurses received an in-service education on monitor use. Alarm data were collected from the audit log of the cardiac monitors 10 weeks before and 10 weeks after the change in monitors’ parameters. Nurses’ attitudes and practices toward clinical alarms were measured using the Healthcare Technology Foundation National Clinical Alarms Survey, pre- and postintervention.ResultsAlarm rate was 87.86 alarms/patient day (a total of 64,500 alarms) at the preintervention period compared to 59.18 alarms/patient day (49,319 alarms) postintervention (P=.01). At baseline, Arterial Blood Pressure (ABP), Pair Premature Ventricular Contractions (PVCs), and Peripheral Capillary Oxygen Saturation (SpO2) alarms were the highest. ABP and SpO2 alarms remained among the top three at the postproject period. Out of the 39 ICU nurses, 24 (62%) provided complete pre- and postproject survey questionnaires. Compared to the preintervention survey, no remarkable changes in the postproject period were reported in nurses’ attitudes. Themes in the narrative data were related to poor usability of cardiac monitors and the frequent alarms. The data showed great variation among nurses in terms of changing alarm parameters and frequency of replacing patients' electrodes. Despite the in-service, 50% (12/24) of the nurses specified their need for more training on cardiac monitors in the postproject period.ConclusionsChanging default alarm settings and standard in-service education on cardiac monitor use are insufficient to improve alarm systems safety. Alarm management in ICUs is very complex, involving alarm management practices by clinicians, availability of unit policies and procedures, unit layout, complexity and usability of monitoring devices, and adequacy of training on system use. The complexity of the newer monitoring systems requires urgent usability testing and multidimensional interventions to improve alarm systems safety and to attain the Joint Commission National Patient Safety Goal on alarm systems safety in critical care units.

Impact of an electronic alert notification system embedded in radiologists’ workflow on closed-loop communication of critical results: a time series analysis

IntroductionOptimal critical test result communication is a Joint Commission national patient safety goal and requires documentation of closed-loop communication among care providers in the medical record. Electronic alert notification systems...

Understanding Clinical Alarm Safety.

Patient safety organizations and health care accreditation agencies recognize the significance of clinical alarm hazards. The Association for the Advancement of Medical Instrumentation, a nonprofit organization focused on development and use of safe and effective medical equipment, identifies alarm management as a major issue for health care organizations. ECRI Institute, a nonprofit organization that researches approaches for improving patient safety and quality of care, identifies alarm hazards as the most significant of the "Top Ten Health Technology Hazards" for 2014. A new Joint Commission National Patient Safety Goal focusing on clinical alarm safety contains new requirements for accredited hospitals to be fully implemented by 2016. Through a fictional unfolding case study, this article reviews selected contributing factors to clinical alarm hazards present in inpatient, high-acuity settings. Understanding these factors improves contributions by nurses to clinical alarm safety practice.

Nurses' Perceptions and Practices Toward Clinical Alarms in a Transplant Cardiac Intensive Care Unit: Exploring Key Issues Leading to Alarm Fatigue.

BackgroundIntensive care units (ICUs) are complex work environments where false alarms occur more frequently than on non-critical care units. The Joint Commission National Patient Safety Goal .06.01.01 targeted improving the safety of clinical alarm systems and required health care facilities to establish alarm systems safety as a hospital priority by July 2014. An important initial step toward this requirement is identifying ICU nurses’ perceptions and common clinical practices toward clinical alarms, where little information is available.ObjectiveOur aim was to determine perceptions and practices of transplant/cardiac ICU (TCICU) nurses toward clinical alarms and benchmark the results against the 2011 Healthcare Technology Foundation’s (HTF) Clinical Alarms Committee Survey.MethodsA quality improvement project was conducted on a 20-bed TCICU with 39 full- and part-time nurses. Nurses were surveyed about their perceptions and attitudes toward and practices on clinical alarms using an adapted HTF clinical alarms survey. Results were compared to the 2011 HTF data. Correlations among variables were examined.ResultsAll TCICU nurses provided usable responses (N=39, 100%). Almost all nurses (95%-98%) believed that false alarms are frequent, disrupt care, and reduce trust in alarm systems, causing nurses to inappropriately disable them. Unlike the 2011 HTF clinical alarms survey results, a significantly higher percentage of our TCICU nurses believed that existing devices are complex, questioned the ability and adequacy of the new monitoring systems to solve alarm management issues, pointed to the lack of prompt response to alarms, and indicated the lack of clinical policy on alarm management (P<.01). Major themes in the narrative data focused on nurses’ frustration related to the excessive number of alarms and poor usability of the cardiac monitors. A lack of standardized approaches exists in changing patients’ electrodes and individualizing parameters. Around 60% of nurses indicated they received insufficient training on bedside and central cardiac monitors. A correlation also showed the need for training on cardiac monitors, specifically for older nurses (P=.01).ConclusionsFalse and non-actionable alarms continue to desensitize TCICU nurses, perhaps resulting in missing fatal alarms. Nurses’ attitudes and practices related to clinical alarms are key elements for designing contextually sensitive quality initiatives to fight alarm fatigue. Alarm management in ICUs is a multidimensional complex process involving usability of monitoring devices, and unit, clinicians, training, and policy-related factors. This indicates the need for a multi-method approach to decrease alarm fatigue and improve alarm systems safety.

Suicide Attempts After Emergency Room Visits: The Effect of Patient Safety Goals.

In 2007 the Joint Commission National Patient Safety Goals included a requirement addressing risks associated with patient suicidality. The rational for this requirement was that suicide has been the most frequently reported sentinel event since the inception of the Sentinel Event Policy in 1996. The Patient Safety Goals on suicide required hospitals implement actions to assess suicide risk, meet client's immediate safety needs and provide information such as a crisis hotline to individuals and family members for crisis situations. This study performed a secondary data analysis to assess the effect of the 2007 Joint Commission Patient Safety Goals on suicide attempts among patients following treatment at hospital emergency rooms among individuals enrolled in the Florida Medicaid program. A difference-in-difference approach compared changes in rates of suicide attempts for individuals with a primary mental health diagnosis and individuals with a physical health diagnosis after emergency room treatment. In the 6 months following treatment, suicide rates declined after implementation of the goals among patients treated for a primary mental health diagnosis, and increased among patients with a poisoning diagnosis, compared to individuals with a physical health diagnosis. The goals were associated with a reduction in suicide attempts after emergency room treatment.

Utility of a dedicated pediatric cardiac anticoagulation program: the Boston Children's Hospital experience.

Congenital heart disease is the leading cause of stroke in children. Warfarin therapy can be difficult to manage safely in this population because of its narrow therapeutic index, multiple drug and dietary interactions, small patient size, high-risk cardiac indications, and lack of data to support anticoagulation recommendations. We sought to describe our institution's effort to develop a dedicated cardiac anticoagulation service to address the special needs of this population and to review the literature. In 2009, in response to Joint Commission National Patient Safety Goals for Anticoagulation, Boston Children's Hospital created a dedicated pediatric Cardiac Anticoagulation Monitoring Program (CAMP). The primary purpose was to provide centralized management of outpatient anticoagulation to cardiac patients, to serve as a disease-specific resource to families and providers, and to devise strategies to evolve clinical care with rapidly emerging trends in anticoagulation care. Over 5 years the CAMP Service, staffed by a primary pediatric cardiology attending, a full-time nurse practitioner, and administrative assistant with dedicated support from pharmacy and nutrition, has enrolled over 240 patients ranging in age from 5 months to 55 years. The most common indications include a prosthetic valve (34 %), Fontan prophylaxis (20 %), atrial arrhythmias (11 %), cardiomyopathy (10 %), Kawasaki disease (7 %), and a ventricular assist device (2 %). A patient-centered multi-disciplinary cardiac anticoagulation clinic was created in 2012. Overall program international normalized ratio (INR) time in therapeutic range (TTR) is favorable at 67 % (81 % with a 0.2 margin) and has improved steadily over 5 years. Pediatric-specific guidelines for VKOR1 and CYP2C9 pharmacogenomics testing, procedural bridging with enoxaparin, novel anticoagulant use, and quality metrics have been developed. Program satisfaction is rated highly among families and providers. A dedicated pediatric cardiac anticoagulation program offers a safe and effective strategy to standardize anticoagulation care for pediatric cardiology patients, is associated with high patient and provider satisfaction, and is capable of evolving care strategies with emerging trends in anticoagulation.

Avoiding risky business: supporting optimal home medication administration for children with cancer.

Correct administration of medication at home to a child undergoing cancer treatment is critical to both curing the disease and minimizing adverse effects of treatment. The most common childhood cancer, acute lymphoblastic leukemia, relies on home administration of mercaptopurine, methotrexate, and corticosteroids for 2 or more years of treatment. Less than 95% adherence to nightly mercaptopurine administration during a 6-month period of observation was associated with a 2.5-fold increase in the risk of relapse compared with adherent patients. If this finding translates to other drugs and other diseases, strategies to maximize adherence will become a critical part of childhood cancer treatment. Walsh et al have already shown that medication errors in the home of children with cancer are common. If we consider the home setting carefully, we should not be surprised that there are challenges with both adherence and safety. Caregivers, usually parents, are expected to carry out a complex medication administration process in the home. These caregivers usually have far less education about medication and none of the tools to support performance provided for nurses giving medications in the hospital. Parents do not have medication administration records (updated each time a medication is added, changed, or discontinued) with prompts for each medication with a specific dose, route, and time of day or interval since last dose and records of doses given. We also ask parents to serve as pharmacists and ensure that only the correct medication products are available for administration. Parents of a child with cancer not only do not have such supports but also face additional challenges. A common approach to reduce medication error is to focus on the so-called five rights: the right patient, the right drug, the right dose, the right route, and the right time. Parents are highly likely to give the medication to the right patient since there is usually only one child with cancer in the home. Since the vast majority of home medications are given by the oral route, the odds are high that medications will be given by the right route. However, as shown in Table 1, there are many factors in the home that can decrease the probability of the right drug, the right dose, and the right time. Some of these issues are unique to pediatrics because they involve ability to swallow pills, potential poor cooperation with care, lack of availability of appropriate pill strengths for pediatric dosing, and issues related to parent as caregiver. One strategy to decrease error could be to focus on patient education about medication as in the 2014 Joint Commission National Patient Safety Goals, Stage 1 of the federal Meaningful Use criteria for electronic health records, and the American Society for Clinical Oncology/Oncology Nursing Society chemotherapy safety standards. Education alone, however, is likely insufficient to achieve reliable performance of a complex task such as medication administration in the home. In the article that accompanies this commentary, Walsh et al describe the development of a tool to support parents and other caregivers in the home to ensure that each child with cancer receives the right dose of the right drug at the right time via the right route. Walsh et al deserve kudos for this effort which includes a three-part product with a Web site for general information and decision-support tools, a communication guide to maximize understanding of information provided by caregivers, and a patientand cycle-specific medication calendar, available in a paper or electronic format. Critical to their work was the inclusion of the many parents who contributed to the design and testing of the final product. As the authors acknowledge, this is a preliminary effort whose impact has yet to be shown. Larger studies and studies at multiple centers are needed to determine if this specific strategy will decrease medication error in the home or if additional strategies will be needed. As the field of pediatric oncology moves forward, more work is needed to ensure parents of children with cancer have the exact supports needed for safe and reliable medication administration in the home in order to maximize cure and minimize harm.

Commentary on: Effectiveness of Prophylactic Antibiotics in Outpatient Plastic Surgery

Surgical site infections (SSI) remain the second most common type of hospital-acquired infection (after urinary tract infections). Prophylactic antimicrobial use has been demonstrated to reduce SSI rates for many surgical procedures. Prevention of SSI remains a Joint Commission National Patient Safety Goal.1,2 The indications, efficacy, and proper utilization of systemic prophylactic antimicrobial agents to reduce SSI incidence have been debated in the surgical literature for many years. The appropriate use of prophylactic antibiotics in plastic surgery has been discussed by others in this journal and elsewhere.2⇓⇓-5 With this interesting article evaluating prophylactic antimicrobial use in outpatient plastic surgical procedures, Anigian and colleagues6 contribute to this ongoing conversation. A significant limitation of available literature on antimicrobial prophylaxis is the difficulty in establishing statistically significant differences in efficacy between the prophylactic agent(s) utilized and control groups due to study design issues, as well as a low SSI rate for most surgical procedures. Ideally, a study should be placebo controlled and randomized with a sufficient sample size in each group to avoid type II error. Such publications are uncommon. Furthermore, based on “expert opinion,” antimicrobial prophylaxis is occasionally recommended …

Implementing medication reconciliation from the planner's perspective: a qualitative study.

BackgroundMedication reconciliation can reduce adverse events associated with prescribing errors at transitions between sites of care. Though a U.S. Joint Commission National Patient Safety Goal since 2006, at present organizations continue to have difficulty implementing it. The objective of this study was to examine medication reconciliation implementation from the perspective of individuals involved in the planning process in order to identify recurrent themes, including facilitators and barriers, that might inform other organizations’ planning and implementation efforts.MethodsWe performed semi-structured interviews with individuals who had a role in planning medication reconciliation implementation at a large urban academic medical center in the U.S. and its affiliated Veterans Affairs hospital. We queried respondents’ perceptions of the implementation process and their experience with facilitators and barriers. Transcripts were coded and analyzed using a grounded theory approach. The themes that emerged were subsequently categorized using the Consolidated Framework for Implementation Research (CFIR).ResultsThere were 13 respondents, each with one or more organizational roles in quality improvement, information technology, medication safety, and education. Respondents described a resource- and time- intensive medication reconciliation planning process. The planning teams’ membership and functioning were recognized as important factors to a successful planning process. Implementation was facilitated by planners’ understanding of the principles of performance improvement, in particular, fitting the new process into the workflow of multiple disciplines. Nevertheless, a need for significant professional role changes was recognized. Staff training was recognized to be an important part of roll-out, but training had several limitations. Planners monitored compliance to help sustain the process, but acknowledged that this did not ensure that medication reconciliation actually achieved its primary goal of reducing errors. Study findings fit multiple constructs in the CFIR model.ConclusionsStudy findings suggest that to improve the likelihood of a successful implementation of medication reconciliation, planners should, among other considerations, involve a multidisciplinary planning team, recognize the significant professional role changes that may be needed, and consider devoting resources not just to compliance monitoring but also to monitoring of the process’ impact on prescribing.

A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals

ObjectivesThe Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint...

Alarm Fatigue

Research has demonstrated that 72% to 99% of clinical alarms are false. The high number of false alarms has led to alarm fatigue. Alarm fatigue is sensory overload when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms and missed alarms. Patient deaths have been attributed to alarm fatigue. Patient safety and regulatory agencies have focused on the issue of alarm fatigue, and it is a 2014 Joint Commission National Patient Safety Goal. Quality improvement projects have demonstrated that strategies such as daily electrocardiogram electrode changes, proper skin preparation, education, and customization of alarm parameters have been able to decrease the number of false alarms. These and other strategies need to be tested in rigorous clinical trials to determine whether they reduce alarm burden without compromising patient safety.