NATIONAL PATIENT SAFETY GOALS (PSG)

and

OTHER REQUIRED NURSING DOCUMENTATION

2012

 

Directions: New Staff must check off each item after it is reviewed by Orienteer, and both will sign at bottom         

                  This will be placed in new employees personnel file.

 

□   IMPROVE ACCURACY OF PATIENT IDENTIFICATION:

       Staff must have 2 patient identifiers when giving meds, taking specimens or doing procedures/treatments.

         For meds: look at the patient’s picture and ask them their name.

         For specimens: Blood draws-Nurse must look at the patient picture and ask patient their name

                           Specimen’s labels must include patient name and DOB.

Specimen containers must be labeled in the presence of the patient and initialed by patient    

           For procedures/Treatments: EKG; tech/nurse must look at the patient’s picture and ask them their name

              * It is recommended that all staff follow this procedure with any patient contact.

 

□   IMPROVE EFFECTIVENESS OF COMMUNICATION AMONG CARE GIVERS: READ BACK (Prior PSG)

Read back and confirmation of telephone orders and critical test results.                                   

Phone orders and critical test results must be written out completely, then read back, and the Nurse must                   receive confirmation that the order/test result is correct.

Document- read back and confirmation on the order sheet after reading back all phone orders to the ordering

     Physician.    

Document the read back and confirmation of all critical test results on the lab result form as well as in the

              progress notes.

 

□   ABBREVIATIONS THAT CAN NOT BE USED IN THE MEDICAL RECORD: (Prior PSG)

         DO NOT USE                                                      WRITE

         U for Units                                                      Units

         IU for International Units                                    International Units

         QD or QOD for every day or every other day         Daily or every other day

         Trailing zero/lack of leading zero                           Place 0 before a decimal point-not after

         MS,MS04, MgS04                                             Morphine sulfate or magnesium sulfate

 

□ TIMELY REPORTING OF CRITICAL TEST RESULTS TO THE ORDERING PHYSICIAN: (Prior PSG)

     Critical test results must be reported to the facility by the lab within 4hrs of the test being done.

     Documentation that the ordering physician was informed of critical test results within 1hr of receipt of the results must occur. If the ordering physician is not available inform the CMO/Medical Director and document this on the Lab form and Progress notes.

 

□ HAND OFF OF ACCURATE INFORMATION: (Prior PSG)

Staff shift report is given and received in person by off going and on coming Nurses and Techs.

All staff who are required to attend report/staffing meeting must sign/initial the Hand Off sheet, to indicate that they participated in this report process.

 

□ USE OF ANTICOAGULATION THERAPY: (Prior PSG)

         See anticoagulation therapy policy in policy manual. ( Nursing #1121)

Anticoagulation medication decreases the ability of Blood to clot. This information is valuable for all staff.

                    Patients who are Self Harmers and/or any Injuries with individuals on this medication. Please have

            these individuals assessed by Nursing staff ASAP.

 

 

 

 

 

 

□ REDUCE THE RISK OF HEALTH CARE-ASSOCIATED INFECTIONS

         COMPLY WITH THE CDC HAND HYGIENE GUIDELINES:

Staff are in serviced on CDC hand hygiene guidelines upon hire and annually. Monthly observation of staff washing their hands in appropriate situations is done and reported to the PI Committee.

                  Hand sanitizer is available in various locations around the facility.

 

□ACCURATELY/COMPLETELY RECONCILE MEDICATIONS:

A List of current patient meds on admit is created by Nursing and put on the Medication Regimen Form.

Meds ordered throughout their stay are added to the form by Nursing. Discontinued meds are noted on the form during the patient’s stay. All Meds Recommended to be continued upon Discharge are marked by Nursing at discharge. A Copy of the Medication Regimen Form must be given to patients at Discharge after obtaining their signature confirming their understanding.

 

□ REDUCE RISK OF HARM TO PATIENT FROM FALLS: (Prior PSG)

Fall Risk assessments are completed on Admit Nursing assessment. Reassessment is done daily with vital signs/wt. assessment, as reviewed by Techs with Nursing Staff

 

□ PATIENT’S INVOLVEMENT IN THEIR OWN PATIENT SAFETY STRATEGY: (Prior PSG)

         Patient and family education on how to report concerns about safety, is found in the Patient handbook.

Patient Safety surveys are given to patients just prior to discharge. This Form has a comments section for patients to document their safety concerns.

 

□ IDENTIFY SAFETY RISKS INHERENT IN ITS PATIENT POPULATION:

         A suicide assessment is done as part of the Admission Nursing assessment.

 

____________________________________________                  ________________

New Staff’s Signature                                                               Date

____________________________________________                  ________________

Orientor’s Signature                                                               Date