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MARTINARMYCOMMUNITYHOSPITAL

COMPLIANCEWITHTHE
NATIONALPATIENTSAFETYGOALS

NPSG1:IMPROVEPATIENTIDENTIFICATION

Whenprovidingcare,treatmentandservicestoapatientwearetoverifywehavetherightpatient.
WeuseNAMEandDATEOFBIRTH.

Anytimeaspecimeniscollectedwemustlabelthecontainerinthepresenceofthepatient.

NPSG2:IMPROVECOMMUNICATION

Anytimeaverbalortelephonicorderisgivenortelephonereportingofcriticaltestresults,theperson
receivingtheordermustREADBACKthecompleteorderortestresult.

StandardizealistofabbreviationsNOTtousethroughoutthefacility.
UWriteunit
IUWriteinternationalunit
Q.D.Writeeveryday
Q.O.D.Writeeveryotherday
TrailingzeroWrite5mgdonotuse5.0mg
LackofleadingzeroWrite0.5mgdonotuse.5mg
MSWritecompletenameofmedication
MSO4Writecompletenameofmedication
MgSO4Writecompletenameofmedication

Implementastandardizedapproachtohandoffcommunication.OurprocessiscalledBSTAR
(background,situation,treatment,assessment,recommendation).

NPSG3:IMPROVESAFETYOFUSINGMEDICATIONS

Identifyalistoflookalike/soundalikemedicationsandtakeactiontopreventerrorsinvolvingthese
medications.

EphedrineandEpinephrine

ClonidineandClonazepam
Insulin(Novologvs.Novolin)

CelebrexandCelexaandCerebyx

OxycontinandOxycodone

ZyprexaandZyrtecandZantac

DilaudidandDuramorph

ToprolXLandTopamax

LamisilandLamictaland

PrilosecandProzac

Levetiracetam(Keppra)

WellbutrinSRandWellbutrinXL

MetforminandMetronidazole

Abilify(Arripiprazole)and

AvandiaandCoumadinandCardura
OmeprazoleandEsomeprazole

Labelallmedications,medicationcontainersorothersolutionsonandoffthesterilefield.Whenyou
takeamedicationorsolutionoutofitsoriginalcontainerandplaceitinanother,thecontainerwillbelabeled.

Reducethelikelihoodofpatientharmassociatedwiththeuseofanticoagulanttherapy.Use
approvedprotocols(foundonthesharepoint);forpatientsreceivingwarfarinacurrentINRisavailableand
usedtomonitorandadjusttherapy;followwrittenpolicy;provideeducation;anduseprogrammableinfusion
pumpsinordertoprovideconsistentandaccuratedosingofheparin.


NPSG7:REDUCETHERISKOFHEALTHCAREASSOCIATEDINFECTIONS

ComplywithcurrentWorldHealthOrganizationorCentersforDiseaseControlhandhygiene
guidelines.Allstaffpracticeproperhandwashinganduseofhandgel(Purell).

Implementevidencebasedpracticestopreventhealthcareassociatedinfectionsduetomultidrug
resistantorganisms(InfectionControlmeasures).

Implementbestpracticestopreventcentrallineassociatedbloodstreaminfections(InfectionControl
measures).

Preventsurgicalsiteinfections(InfectionControlmeasures).

NPSG8:ACCURATELLYANDCOMPLETELYRECONCILEMEDICATIONSACROSSCONTINUUMOFCARE

Aprocessexistsforcomparingthepatientscurrentmedicationswiththoseorderedwhileunderthe
careoftheorganization.Printoutthe508(CHCS)andhavethepatientannotateanyoverthecounteror
othermedsnotlisted,thenproviderwillgooverthecompletelistwiththepatientandaddanyadditional
medstobegiventothepatient.Patientwillbegiventhecompletelistofreconciledmedswhendepartingthe
facility.Alsoifapatientistransferredthecompletereconciledlistisprovidedtothenextprovider.

NPSG9:REDUCETHERISKOFPATIENTHARMFROMFALLS

Implementafallreductionprogram.Inpatientsareassessedforfallsriskateachshift.Ifpatientis
identifiedasbeingafallrisk,ayellowwristbandisplacedonthepatient.

NPSG13:ENCOURAGEPATIENTINVOLVEMENTINCARE

Asapatientsafetystrategy,wearetoencouragepatientstobeinvolvedintheircare.Encourage
patientstoreportanysafetyissuestheyseeinthefacility.Wehaveapatienttrifoldthateducatespatients
onthepatientsafetystrategieswehaveimplementedinthefacility.

NPSG15:IDENTIFYSAFETYRISKSINHERENTINOURPATIENTPOPULATION

Weidentifypatientsatriskforsuicide.Weprovideinformationsuchasacrisishotline18002738255.
NPSG16:IMPROVERECOGNITIONANDREPONSETOCHANGESINPATIENTSCONDITION

Wearetoselectasuitablemethodthatenableshealthcarestaffmemberstodirectlyrequest
additionalassistancefromspeciallytrainedindividuals.OurmethodistheRapidResponseTeam(RRT).Adult
RRTmembersincludeMOD,ICURN,RespiratoryTherapy,andNursingSupervisor;PediatricRRTmembers
includePOD,RespiratoryTherapy,AssignedRN,NursingSupervisor,andStaff,andPediatricianduringnormal
dutyhours.TheRRTisaninpatientfunctionandcriteriaforcallingaRRTcanbefoundonpostershangingin
theinpatientareas.
UNIVERALPROTOCOL

Conductapreoperativeverificationprocessverifythecorrectperson,correctsite,andcorrect
procedure;ensureallrelevantdocumentationanditemsareavailable:H&P,assessments,signedconsent
form,diagnosticandradiologytestresults,andanyrequiredbloodproducts,implants,devicesandspecial
equipmentneededforprocedure.

Marktheproceduresitemarkingtheproceduresiteallowsstafftoidentifywithoutambiguitythe
intendedsitefortheprocedureandifpatientrefusestobemarked,useanalternativemarkingband.

Conductatimeoutimmediatelybeforestartingtheprocedureeachteammemberwillpauseand
verballyconfirmcorrectpatientidentification,agreeonproceduretobedone,correctsiteandsideare
marked,andrelevantdocumentation,imagesandresultsareavailable.