Notes

Module Two: Patient Safety- National Patient Safety Goals

Section 1: Patient ID

JCAHO's first of seven national patient safety goals is: "to improve the accuracy of patient identification." JCAHO has mandated that hospitals use at least two (2) 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.

Harborview policy states that name and date of birth are to be used as the primary patient identifiers. Other acceptable identifiers are the patient's medical record number (MRN), or social security number (you must match two). Example: MRN is the second identifier used for blood transfusion specimens and blood transfusion. Patients who cannot be positively identified by name are given a "DOE" full name and MRN.

Birth dates as second identifiers might pose special issues with our immigrant populations. Names may seem similar and countries that do not recognize birth dates are all given a common birth date of January 1, and the year of their immigration to the United State. Using a third identifier in these cases will ensure the right patient.

Section 2: Hand-offs

A new goal added to the list for 2006 is Implementing a standardized approach to "hand off" communications, including time for questions. In health care there are numerous types of patient hand offs, including but not limited to nursing shift changes, physicians transferring on-call responsibility, temporary responsibility for staff leaving the unit for a short time, anesthesiologist report to the PACU nurse, hospital transfers, and in house transportation and transfers.

Hand offs require a process for verification of the received information, including repeat-back or read-back as appropriate. The hand offs are interactive communications allowing an opportunity for questioning between the giver and receiver of the patient information. This includes up-to-date information regarding the patient's care, treatment and condition with any recent or anticipated changes. Interruptions during hand offs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten.

Section 3: DNUAs

In compliance with JCAHO's second safety goal, "improve the effectiveness of communication among caregivers" the DO NOT USE ABBREVIATIONS list was implemented at Harborview in January 2004. The following abbreviations have been commonly associated with misinterpretation and are unacceptable for use in orders and other forms of patient-specific clinical documentation:

DO NOT USE	IMPROVED COMMUNICATION:
Trailing zeros	Use 2 mg instead of 2.0 mg
Naked decimals (lack of leading zero)	Use 0.5 mg instead of .5 mg
U or u	Write out "unit"
MS, MgSO4, MSO4	Use complete spelling for drug names
I.U. or IU	Write out "International Unit"
QOD	Write out "every other day"
QD or Q/D or qd	Write out "every day" or "daily"

Any documentation involving medications or ANY order containing an abbreviation with which the reader is unfamiliar must be clarified with the author of the order.

Dangerous Abbreviations – Avoid Using

AU, AS, AD, OU, OS, OD	Write out "both ears/eyes," left ear/eye," "right ear/eye"
SC or SQ	Write out "sub-Q" or "subcutaneous"
D/C or DC	Write out "discharge" or "discontinue"
HS	Write out "half-strength" or "at bedtime"
Cc	Use "ml"
TIW	Write out "three times weekly"
ug	Write out "mcg"

Harborview implemented a "hard stop" where orders will not be accepted, except in a life threatening situation, if prohibited abbreviations are used. The ordering provider will need to rewrite the order.

Section 4: PSN Reporting

Two modes of thinking typically drive actions in clinical practice: automatic and problem solving. Different types of errors are associated with each of these modes.

In automatic mode, actions are given minimal attention. Usually this thinking occurs after the nurse has developed experience, skill, and an increased familiarity with the task at hand. It allows him/her to work with increased efficiency but can result in errors. An example of this type would be removing a tablet from a familiar pyxis drawer and not checking the medication or dose.

Problem solving mode requires mental concentration. It involves acquiring information, comparing it to stored knowledge and applying some decision rule. With each step of this complicated process, human beings are susceptible to making missteps. An example of this type of error would be giving the wrong dose for a heparin drip, based on miscalculating the patient's corrected body weight in the standing orders.

Human beings make errors! Systems that rely on error free performance are doomed to failure.
The reporting of errors and near misses is a critical part of identifying where the system is weak
Harborview has a "non-punitive event occurrence reporting" policy. This policy states that "competent and caring professionals may make mistakes and we support and encourage open reporting without fear of reprisal."

Any event or near miss that could cause or lead to a patient receiving inappropriate drug therapy should be reported. All healthcare providers are expected to report events and thus participate in developing improved processes.

To initiate a report after an occurrence or near miss, use the Patient Safety Net Incident Report or "PSN". The PSN is a quality improvement communication tool and is not used for performance evaluations or disciplinary purposes.

Click on the desktop icon "UW Medicine Online Incident Reporting".
Remember to click on the right hand corner to reset the timer if you need more time!
Contact psn help 722-9561 or psnhelp@u.washington.edu for any questions or problems.

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Last modified: 5/24/2006 3:28 PM