Patient Safety Program
Healthcare employee education competency module
DMC Patient Safety Program
Detroit Medical Center©
Revised: February, 2010
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Patient Safety
 What is patient safety?
 Avoiding injuries to patients from the care that is
intended to help them.
 How can we accomplish this?
 By reducing risk and ensuring safety through
attention to systems that help prevent and lessen
errors.
 Patient Safety is everyone’s responsibility!
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Patient Safety Plan
 Basic safety considerations for all patients.
 Screening to identify patients at risk for altered safety
patterns.
 Use of recommended interventions for patients
assessed ‘at risk’ for altered safety patterns.
 Education of hospital employees in monitoring and
reporting unsafe patient behavior and environment
conditions.
 Processes for identifying opportunities to improve
patient outcomes and prevent injuries.
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Basic Safety Considerations for All Patients
1. Instruct patient to wear non-skid footwear when
ambulating.
2. Maintain bed/chair in lowest position. Lock wheels at all
times.
3. Ensure pathway to restroom is unobstructed and properly
lighted.
4. Place assistive devices (walker, cane) within patient’s
reach.
5. Ensure that call light and personal care items are within
patient’s reach.
6. Raise side rails as appropriate for access to bed controls,
support and repositioning.
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Basic Safety Considerations for All Patients
7. Raise all side rails on stretchers/bed for patients being
transported.
8. Educate patient to request assistance as needed.
9. Educate patients and family members regarding
treatments, tests, and medications.
10. Be sensitive to cultural or language barriers and assess
patient’s understanding of expectations.
11. Consider peak effect for medications that affect level of
consciousness (LOC), walking and elimination when
planning care.
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Basic Safety Considerations for All Patients
12. Observe environment for unsafe conditions. Notify
appropriate department of hazardous conditions.
13. Ensure that the presence of any individual in patient
care areas is appropriate to the setting.
14. Ensure that visitors are known to and approved by
the patient/family.
15. Include the patient’s family in development of an
individualized safety plan, considering age specific
criteria and patient cognition when planning care.
16. Collaborate with the patient and family to provide
assistance as needed while maintaining the patient’s
independent functioning.
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Assessing Patient’s Risk for Injury
 Refer to the Risk for Injury Algorithm (See policy 2 PC 401
Patient Safety Plan).
 Risks for injury includes:
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Falling
Wandering
Climbing
Pulling at tubes and dressings
Restlessness
Aggression
Suicide or elopement
Inappropriate use of side rails
Entrapment
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Assessing Patient’s Risk for Injury
 For patients assessed at risk for injury:
 Document the risk.
 Initiate risk reduction interventions (See policy 2 PC 401
Patient Safety Plan the Risk for Injury Algorithm).
 Communicate the patient’s ‘at risk for injury’ status:
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During shift report
Whenever patient is transported to another area
During hand-off
With other disciplines, as appropriate
 Do not leave ‘at risk’ patients unattended in diagnostic or
treatment areas.
 Initiate Safety Plan of Care.
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Risk for Injury - Entrapment
Entrapment is defined as:
 An event in which a patient is caught, trapped, or entangled
in the spaces in or about the bed rail, mattress, or hospital
frame. Entrapment can result in serious injury or death.
 Environmental Risk factors for entrapment include:
 Restraint use
 Use of mattress overlays
 Improperly sized mattresses
 Loose bed rails
 Wide spaces between the vertical
bars in the bed rails
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Risk for Injury – Use of Side Rails
Side rails may not be used as a
restraint device:
 Disoriented patients may view a
side rail as a barrier to climb over,
or may try to climb out of bed to
get around the side rail. This puts
the patient at great risk for
entrapment or injury.
 In most instances, it is safer to
leave the bottom side rail closet to
the bathroom down. Injuries may
occur if the patient attempts to
climb over the side rails to exit the
bed.
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Risk for Injury – Use of Side Rails
Having all 4 side rails up is considered a restraint and
is to be avoided; however, it is appropriate to raise all
side rails in some circumstances. These may include
but are not limited to:
 When using to assist with patient positioning
 During transports
 When the bed is elevated for tests or procedures
 When the patient is unconscious or immobile
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Risk for Injury - Falls
Patients are assessed for fall risk upon admission and
reassessed daily:
 A fall risk assessment tool is used to determine the patient’s
fall risk score.
 Fall risk assessment includes the patient’s:
 Mobility
 Mentation (Mental clarity)
 Medication
 Elimination
 Prior fall history
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Risk for Injury - Falls
Fall protocol – additional interventions for patients
assessed ‘at risk for falls’:
 Visual identification of patient ‘at risk for fall’ include:
 Yellow fall risk wristband
 Door/room sign
 Maintain and monitor the bed and mattress.
 Provide frequent toileting.
 Provide calming interventions and pain relief.
 Increase visual supervision of patient.
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Risk for Injury - Falls
 Older patients taking 3 or more medications of any
kind are at increased risk for recurrent falls.
 Categories of medications that pose a ‘high risk for
falls’ include:
 Antidepressants
 Antipsychotics
 Benzodiazepines
 Diuretics
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Preventing Patient Falls
N
O
Non-slip footwear (grips on sole of foot)
Obstruction-free environment
F
A
L
L
S
Functional assessment – on-going
Assistance while ambulating
Light – call light within reach
Leave personal articles within reach
Side rails up as appropriate
NOTE: Remember to always leave the rail at the foot of bed closest
to bathroom down.
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Transporting Patients
Key points to remember to ensure safe patient transport:
 Patients are positively identified immediately prior to the
transport.
 Patients receive the same level of care regardless of location.
 The patient is assessed prior to transport, properly prepared for
transport, and staff transporting and receiving the patient have
pertinent patient information including contact information for
the person sending the patient.
 The medical record, including bedside records and MAR,
accompanies the patient throughout the transport.
 The receiving department is notified when the patient
arrives; ‘at risk’ patients are never left unattended.
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Patient Hand-Off
Hand-off refers to the transfer of patient care, whether temporary
or permanent, from one healthcare provider/team member to
another (Examples of hand-offs include, but are 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.
 Communication of critical laboratory and radiology results.
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Hand-Off Communication
 Hand-off communication is an interactive communication
process that provides accurate information about a patient’s
care, treatment and services, current condition and any recent
or anticipated changes.
 The recipient of this communication has an opportunity to verify
the received information, including repeat-back or read-back
information, as appropriate.
 Whenever possible, hand-off communication should be face-toface.
 Hand-off communication should begin with introductions:
 Processes for identifying opportunities to improve patient
outcomes and prevent injuries.
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Hand-Off Communication
A proven and effective communication tool is SBAR:
S = Situation
 Specify the patient’s name and current condition or situation.
 Explain what has happened to trigger this conversation.
B = Background
 State the admission date, his or her diagnosis, and pertinent medical
history.
 Give a brief synopsis of what’s been done so far (e.g. lab test).
A = Assessment
 Give a summary of the patient’s condition or situation.
 Explain what you think the problem is.
 Expand upon your statement with specific signs and symptoms.
R = Recommendation
 Explain what you would like to see done (e.g., lab tests, treatments).
 State any new treatments or changes ordered.
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Rapid Response Intervention
 The DMC empowers staff, patients and/or families to
request additional assistance when they have a
concern regarding the medical condition of a patient.
 Clinical staff who request additional personnel for
assessment and intervention do so without hesitation
as soon as they become aware of a significant change
in the patient’s condition.
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Rapid Response Intervention
 Situations that may call for the activation of the rapid
response process may include, but are not limited to:
 The staff member, LIP, or physician is worried about the
patient.
 Clinically significant change in heart rate, blood
pressure, respiratory rate or O2 saturation.
 Change in level of consciousness or mental status,
including seizure activity.
 Acute significant bleeding.
 Clinically significant change in urine output.
 Patient and/or family member feel their condition is
deteriorating.
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IV Tubing/Catheter Safety
 Always trace a catheter or tube from the patient to the
point of origin before connecting any new device or
infusion.
 Recheck connections and trace all patient catheters or
tubes to their sources upon the patient’s arrival to a
new setting or service, as part of the hand-off process.
 Position catheters and tubes having different purposes
in different, standardized directions (e.g., IV lines
routed toward the head; enteric lines toward the feet).
This is especially important in the care of neonates.
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IV Tubing/Catheter Safety
 Inform non-clinical staff, patients and their families that
they must get help from clinical staff whenever there is a
real or perceived need to connect or disconnect devices
or infusions.
 For certain high-risk catheters (e.g., epidural, intrathecal,
arterial), label the catheter and do not use IV tubing that
has injection ports.
 Never use a standard luer syringe for oral medications or
enteric feedings, instead utilize non-luer-loci syringes
specific for this purpose.
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Infusion Pump Safety
Many unexpected clinical events occur from pump
programming errors and pump set-up errors:
 Always check rate and volume and make sure the pump is
programmed correctly for both.
 Ensure tubing is placed appropriately in the pump so that
fluid does not free flow through the tubing.
 When using PCA pumps, always confirm settings with
physician’s order and obtain independent verification by
another RN. Document on the Pain Management Flow
Sheet when the pump is set-up or the program/dose is
changed (See policy 2 PC 413 Pain Management Patient
Controlled Analgesic).
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National Patient Safety Goals
 The National Quality Forum and Joint Commission have
identified national priorities in regards to patient safety.
 Each National Patient Safety Goal has specific
recommendations for improving patient safety.
 Each year the goals and recommendations are reevaluated
and re-prioritized and modified as needed.
 The following slides outline the 2010 National Patient Safety
Goals.
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2010 National Patient Safety Goals (NPSG)
“Use at least two patient identifiers when providing
care, treatment and services”
 Use at least two unique patient identifiers (DOB, Name,
Patient ID# - never use room number).
 Label containers used for blood or other specimens in the
presence of the patient.
 Before initiating a blood product transfusion:
 Match the blood to the order’
 Match the patient to the blood
 Use a two-person verification process
 See policy 1 CLN 044 Patient Identification.
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2010 National Patient Safety Goals (NPSG)
“Report critical results of tests and procedures on a
timely basis”
 For verbal or telephone orders or for telephonic reporting of
critical test results, verify the complete order or test result by
having the person receiving it ‘read-back’ the complete order
or test result. Write it down then read it back:
 See policies 1 CLN 045 Telephone Reporting of Critical Value
Test Results and 1 CLN 045A Verbal and Telephone Orders
 Improve the timeliness of reporting and receipt of critical test
results.
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2010 National Patient Safety Goals (NPSG)
“Label all medications, medication containers, and other
solutions on and off the sterile field in the perioperative
and other procedural settings”
 Labeling occurs when any medication or solution is
transferred from the original packaging to another container:
 Drug name, strength, quantity, diluent and volume (if not
apparent), preparation date, expiration date and time
 Verify all medication or solution labels, both verbally and
visually.
 Label each medication or solution as soon as it is prepared,
unless it is immediately administered.
 All medications and solutions are reviewed by entering and
exiting staff.
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2010 National Patient Safety Goals (NPSG)
“Reduce the likelihood of patient harm associated
with the use of anticoagulant therapy”
 Use approved protocols for the initiation and maintenance of
anticoagulant therapy.
 Manage potential food and drug interactions for patients
receiving Warfarin.
 When Heparin is administered IV and continuously, use a
programmable pump.
 Provide patient education including:
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Importance of follow-up monitoring
Compliance
Drug-food interactions
The potential for adverse drug reactions and interactions
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2010 National Patient Safety Goals (NPSG)
“Comply with current Center for Diseases Control
and Prevention (CDC) hand hygiene guidelines”
 Wash your hands with soap and water or use a alcohol based
hand rub:
 See policy 2 IC 000 Hand Hygiene
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2010 National Patient Safety Goals (NPSG)
“Implement evidence-based practices to prevent health
care associated infections due to multiple drug-resistant
organisms”
 Perform hand hygiene before and after patient contact.
 Maintain good environmental and equipment cleaning practices.
 If isolation is required, maintain isolation procedures per infection
control policy 2 IC 005.
 Teach the patient and family about the organism and how the
healthcare staff will prevent infection and spread of the organism.
Provide the teaching fact sheet to the patient and family, if
applicable (available on the DMC Intraweb>Library>Patient and
Family Education>Infection Control).
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2010 National Patient Safety Goals (NPSG)
“Implement best practices or evidence-based guidelines
to prevent central line-associated bloodstream
infections”
 Perform hand hygiene prior to line manipulation and dressing
changes; use aseptic technique.
 Disinfect catheter hub and injection port when accessing.
 If assisting or supervising line insertion, maintain sterile technique
and speak-up if sterile technique is broken. Complete/or collect line
insertion checklist.
 Educate patient and/or family, if applicable prior to insertion
regarding prevention of central line infection and provide teaching
fact sheet (available on the DMC Intraweb>Library>Patient and
Family Education>Infection Control).
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2010 National Patient Safety Goals (NPSG)
“Implement best practices for preventing surgical
site infections”
 Teach the patient and family about surgical site infection
prevention. Provide the Safer surgery teaching fact
sheet to the patient and family, if applicable.
 Do not shave the operative site.
 Comply with pre-operative antibiotic administration
protocol.
 Maintain hand hygiene practices with patient care and
sterile technique with dressing changes.
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2010 National Patient Safety Goals (NPSG)
“A process exists for comparing the patient’s current medications
with those ordered for the patient while under the care of the hospital”
 Obtain and document a complete list of patient’s home medications,
including over the counter and herbal remedies, upon patient’s
entry into the system.
 A complete list of the patient’s medications is communicated to the
next provider of service when patient care is transferred.
 A complete list of medications is provided to the patient upon
discharge from the facility and the list is explained to the patient
and/or family. This list includes:
 Home medications to be continued
 Home medications to be discontinued
 New prescriptions
 In settings where medications are used minimally or prescribed for
a short duration, modified medication reconciliation processes are
performed (See policy 2 MED 499 Medication Reconciliation).
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2010 National Patient Safety Goals (NPSG)
“Identify patients at risk for suicide”
 Conduct a risk assessment that identifies specific
patient characteristics and environmental features that
may increase or decrease the risk for suicide.
 Address the patient’s immediate safety needs and most
appropriate setting for treatment.
 When a patient ‘at risk for suicide’ leaves the care of
the hospital, provide suicide prevention information
(such as a crisis hotline) to the patient and their family.
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Universal Protocol
 The Universal Protocol is a process that aims to prevent
wrong person, wrong site procedures.
 It is a formal process for verification of the correct patient,
procedure, operative/invasive site and, as applicable any
needed implants or special equipment/requirements for all
operative and invasive procedures that expose patients to
harm, including procedures done in settings other than the
operating room.
 The Universal Protocol includes:
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Pre-operative (or pre-procedure) site
Marking the operative (or procedure) site
‘Time-out’ immediately before starting the procedure
See policy 1 CLN 046 Universal Protocol for Operative and Other
Invasive Procedures
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A Brief Summary
The patient safety plan includes basic safety considerations for
all patients screening to identify patients at risk for altered safety
patterns and use of recommended interventions for patients
assessed “at risk” for altered safety patterns.
Hand-off communication is an interactive communication
process that provides accurate information about a patient’s
care, treatment and services, current condition and any recent or
anticipated changes.
Each National Patient Safety Goal has specific recommendations
for improving patient safety.
The Universal Protocol includes a pre-procedure verification of
correct patient, correct procedure, correct side or site and a
“Time-out” immediately prior to the start of the procedure.
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Summary
We hope this NetLearning course has been both
informative and helpful. Please feel free to review this
course until you are confident about your knowledge of
the material presented.
Click the Take Test button, located on the left side of
the screen, to complete the requirements for this course.
For future reference this module is available on the
NetLearning Library under the 2010 Core Compliance
category. The NetLearning Library link is found on the
DMC Intraweb screen under the NetLearning drop-down
list.
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