JCAHO's first of seven national patient safety goals is: "to improve the accuracy of patient identification." The mandate states that all caregivers use at least two (2) patient identifiers whenever providing any treatments or procedures such as administering medications or blood products, taking blood samples and other specimens for clinical testing.  Harborview policy states that the primary identifiers are:

• Name
• Date of Birth 

 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.  The patient room number cannot be used.

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.

. Deliberately practicing the 5 R's of medication administration can greatly reduce your risk of making a medication error.  Almost all of the medication errors at HMC are due to a violation of one of the 5 patient rights.

Shortcuts should be avoided when giving medications

·        The Right Patient – 2 IDs for patient verification, this means every patient, every time

·        The Right Drug – check for misfills in pyxis, review multi-ingredient items (ie TPN)

·        The Right Dose – check drip/pump rates

·        The Right Time – first dose NOW for antibiotics, standard doses & times

·        The Right Route – includes giving the appropriate dosage form

Looking up information about the med to be administered may prevent an error. To look up a medication quickly, the "Clinical Toolkit" icon on the desktop contains a link to the on-line reference MICROMEDEX.

A nurse should never hesitate to question an order that looks incorrect.

Patients should be taught about the medications they're receiving. The patient who notices a discrepancy between the order and what he or she is familiar with may trigger the discovery of an error.

 24hour medication/allergy checks improve accuracy of patient profile, communication and prevent errors.

Send allergy information/allergy updates to pharmacy.  Double check patient allergies before medication administration.

Another JCAHO safety goal is to improve the safety of using High-Alert Medications. High alert medications are drugs that have a "heightened risk of causing significant patient harm when they are used in error" (Institute for Safe Medication Practices, Dec 2003).  Orders for high alert medications should trigger closer attention to indications for use, appropriate dosing, and possible complications, as well as the usual safety practices used for medication administration. Example: The nurse notes an order for continuous IV heparin in a patient less than 2 days post surgery, and verifies with the physician that the indication for anticoagulation outweighs the risk of hemorrhage.

You should be able to list two of the most common medications given on your unit that are classified as "high-alert" medications due to heightened risk for causing significant harm if administered incorrectly.

 Those that are commonly prescribed in the hospital setting include: 

A New JCAHO Requirement:  An Upcoming Part of the Nursing Assessment. 

     JCAHO has developed new requirements for patient safety.  These include identification of patients at risk for suicide, including those being treated for emotional or behavioral disorders in non-psychiatric areas of the hospital.

     Specifically, suicide risk must be identified in patients with a primary diagnosis or primary complaint of a psychiatric disorder, including diagnoses of chemical dependency.  The requirement does not include patients with a secondary psychiatric or chemical dependency diagnosis.  It also does not include patients being treated for illness or injury related to a known suicide attempt, because the suicide risk for these patients is already clearly identified.

• However, because so many of our patients have psychiatric or chemical dependency disorders, suicide risk assessment will soon be part of the admission nursing assessment.  This assessment will consist of four questions:

1. Have you felt suicidal within the last two years?
2. Do you have suicidal feelings or thoughts of suicide now?

• If the answers to these questions is "No", the assessment may be stopped.  If the answer to item #2 is "Yes", the following questions will be asked:

3. Do you have a plan for committing suicide?
4. Do you have a means of doing so?

If the patient answers "Yes" to two or more of these four questions, an order for a psychiatric consultation must be obtained within two hours.  Precautions should be taken to maintain patient safety, including maintenance of a safe environment, while awaiting psychiatric consultation.  These precautions may include removal of potentially dangerous items, and addition of a sitter.

     Because patients with active substance abuse may become suicidal as they withdraw from these substances, this assessment will also be required when a patient who has been an inpatient for longer than 24 hours has a new CIWA order, or is determined to be in withdrawal from other chemicals of abuse.

     The assessment will be instituted soon, when the policy detailing these changes is distributed.

The American Nurses Association (ANA) Code of Ethics for nurses mandates workplace advocacy and promotion of nurses' well being. The Code of Ethics contains this statement: "The nurse's duty of compassion and caring extends to ourselves and our colleagues, as well as to our patients."

 Healthcare providers tend to view themselves as caregivers rather than the recipients of care and frequently deny their own vulnerability.

Impairment is defined as a decrease in physical or cognitive ability which affects the performance of the provider to perform the essential duties of their job and may jeopardize patient safety. Impairment may result from many causes including but not limited to alcohol or substance abuse, sleep deprivation, undiagnosed physical illness or personal stressors. Unfortunately, statistics report that one out of ten healthcare providers will be challenged by substance abuse at some time over the course of their career which may lead to an impairment in their work performance.

Appropriate and effective treatment can save a professional's career, license, and even his/her life. If you desire more information or suspect you have a problem, confidential resources are available to assist you in caring for yourself.

1. The Employee Assistance Program (EAP). Call 1-866-598-3978 or contact the UW Care Link online at http://www.washington.edu/admin/hr/benefits/worklife/carelink/.
2. Your Primary Care Provider is obligated to provide confidential care.

If you would like more information regarding this topic, you can obtain?a publication from the Department of Health.???A Guide for Assisting Colleagues Who Demonstrate Impaired Performance.? To obtain a copy, you may call 360-236-2880 or email at whps@doh.wa.gov.

State law requires that hospitals report any Stage III and Stage IV pressure ulcer acquired after admission to the Department of Health, within 48 hours of discovering the wound. In addition, within 45 days of discovering the pressure ulcer, HMC must investigate why the pressure ulcer occurred and develop an action plan for implementing any necessary changes.

            A pressure ulcer develops from constant pressure applied to skin over a bony prominence.  The pressure ulcer is staged according to depth of injury:

• Stage I – non-blanchable with skin intact
• Stage II – partially through skin; usually red, moist, and painful; blistered
• Stage III – through skin into SQ tissue
• Stage IV – through fascia
• Unstageable – eschar
• Suspected Deep Tissue Injury (New 2007) – Localized area of discolored intact skin or blood-filled blister.

Those at risk for developing a pressure ulcer include the following individuals:

• Impaired sensory perception where the person lacks the mental ability or neural connection to understand and respond to pressure related discomfort.
• Frequent moisture exposure which causes maceration of the skin as do irritants in the liquid. 
• Immobility where the person lacks the ability to move or is confined to the bed or chair.
• Low Activity where person may not be independent
• Friction/ Shear, from two surfaces moving across each other, reduces tissue tolerance to pressure by abrading and damaging the skin
• Poor Nutrition and/ or dehydration are associated with altered tissue regeneration and the inflammatory response.

Risk assessment

The Braden scale is a validated risk assessment tool used to identify individuals who are at-risk for developing pressure ulcers.  The scale has six general risk factors:

1. Sensory/Perceptual Impairment
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction/Shear

The patient is rated and the summative score indicates level of risk for developing a pressure ulcer. Interventions should be based on any low score(s).

The Quiz