1. Improve the accuracy of patient identification.
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Use at least two patient identifiers (neither to be patient's room number) Whenever taking blood samples or administering medications or blood products. For Adults & Pediatrics - MR# and Name. For infants -last name, sate of birth and mother's first name. This information located on the armband must be compared to either the Patient Care Summary. It must be performed each time you give medications, draw blood or administer blood.
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Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as "time out," to confirm the correct patient, procedure and site, using active - not passive communication techniques. This includes invasive procedures @ the bedside like LP's, CVL placements & chest tubes.
2. Improve the effectiveness of communication among caregivers.
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Implement a process for taking verbal orders or telephone orders that requires a verification "read - back" of the complete order by the person receiving the order. Remember, you must hear the order, write the order down, read the order back in its entirety and wait for confirmation that it is correct. Repeat is acceptable in emergent and surgical settings.
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Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use. Refer to the Charles Press Handbook on the SPP / SCR for approved abbreviations. A list of abbreviations that should not be used when handwriting medication orders is located at this site.
3. Improve the safety of using high-alert medications
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Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. All concentrated electrolytes have been removed from nursing unit floor-stock. A limited amount is available in dialysis units due to patient needs.
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Standardize and limit the number of drug concentrations available in the organization. This is controlled by pharmacy via the Hospital Formulary located on the SPP/SCR.
4. Eliminate wrong-site, wrong-patient and wrong-procedure surgery.
- Create and use a preoperative verification process, such as checklist, to confirm that appropriate documents, (e.g., medical records, imaging studies) are available. The Preoperative checklist is used for patients requiring surgery. The Sedation record is used for patients requiring moderate sedation. The ECT checklist is used for patients requiring ECTs.
- Implement a process to mark the surgical site and involve the patient in the marking process. The yellow surgical band is used to identify the surgical procedure and which side of the body the procedure is to be performed (when applicable). The surgeon or surgeons resident will additionally mark the site prior to surgery.
5. Improve the safety of using infusion pumps.
- Ensure free-flow protection on all general - use and PCA intravenous infusion pumps used in the organization. All general use pumps and PCA pumps used in the hospital have free - flow protection as well as the cassettes that are used with them.
6. Improve the effectiveness of clinical alarm systems.
- Implement regular preventive maintenance and testing of alarm systems. Biomed checks equipment on a regular basis. You can help by making sure that stickers are not outdated. If you find an outdated sticker, do not use the equipment. Call Biomed to check it before using it again.
- Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit. Make sure that any clinical alarms are always on and that you can hear them.
7. Reduce the Risk of Healthcare Acquired Infections
- Comply with current U.S. Centers for Disease Control and Prevention hand hygiene guidelines.
8. Document all home medications and immunizations.
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9. Reduce the risk of patient harm resulting from falls.
- Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regiment, and take action to address any identified risks.
10. Reduce the risks of influenza and pneumococcal disease in older adults.
.11. Reduce the risk of surgical fires.
.12. Implementation of applicable National Patient Safety Goals and associated requirements by components and practitioner sites.
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