Emergency Department
Medication reconciliation is initiated for all clients with a decision to admit.
A Best Possible Medication History is generated in partnership with clients, families or caregivers and documented
PHAR-NUR-I-49
An initial pressure ulcer risk assessment is conducted for clients upon admission, using a validated, standardized risk assessment tool
Braden scale is used
Admission Checklist
There is a written venous thromboembolism (VTE) prophylaxis policy or guideline
“Venous Thromboembolism (VTE) Prophylaxis” INP-AMB-33
There is a policy for the management of high-alert medications
PHAR-NUR-I-64
EMER-UPL-II-22
Clients at risk of suicide are identified; Risk of suicide is assessed regularly; The immediate needs of a client identified at risk of suicide are addressed; Treatment and monitoring strategies are identified and implemented for such clients
What is:
Safe Room- EMER-UPL-69
Transfer of Custody Form
NUR-AMD-GA-11-17
The client, community-based health care provider, and community pharmacy (as appropriate) are provided with an accurate and up-to-date list of medications the client should be taking following discharge
PHAR-NUR-I-49
Documented protocols and procedures based on best practice guidelines are implemented to prevent the development of pressure ulcers. These may include interventions to prevent skin breakdown; minimize pressure; shear, and friction; reposition; manage moisture; optimize nutrition and hydration; and enhance mobility and activity
Move on program
Mobility level documented on Meditech
Mobility level documented on white board for communication with patient and care partners.
Prevention of pressure ulcer RNAO guideline implementation
Braden scale
The effectiveness of pressure ulcer prevention is evaluated, and results are used to make improvements when needed.
Incident reports are filed for hospital acquired pressure injury and reviewed at weekly patient safety meeting
Audits completed by guideline champion for skin assessment on admission
Stocking the following narcotic products is avoided in client service areas:
Fentanyl: ampoules or vials with total dose greater than 100 mcg per container
HYDROmorphone: ampoules or vials with total dose greater than 2 mg
Morphine: ampoules or vials with total dose greater than 15 mg in adult care areas and 2 mg in paediatric care areas
N/A for fentanyl we don’t carry that high of dosage
Hydromorphone and morphine are located in automatic dispensing cabinets only and not in client service areas
At least 2 person-specific identifiers are used to confirm that clients receive services or procedures intended for them, in partnership with clients and families
Patient ID: INP-AMB-60
Universal fall precautions, applicable to the setting, are identified and implemented to ensure a safe environment that prevents falls and reduces the risk of injuries from falling
Falls Prevention and Risk Screening- NUR-ADM-GA-II-24
Team members, clients, families, and caregivers are provided with education about the risk factors and protocols and procedures to prevent pressure ulcers
Nurse manager rounding
Prevention of pressure ulcer RNAO guideline implementation
Braden scale
Whiteboard communication of mobility level
Information shared at care transitions is documented
Meditech and forms discharge package
Documented on ER face sheet as well as nursing notes
Take home medication labels are photocopied and attached to the ER chart
the organization’s ‘Do Not Use’ list is inclusive of the abbreviations, as identified by an ISMP list of error-prone abbreviations, symbols, and dose designations
PHAR-NUR-I-60
The information that is to be shared at care transitions is defined and standardized for care transitions where clients experience a change in team membership or location: admission, handover, transfer and discharge.
INP-AMB-62; ADM-GA-11-02; Neonatal Transfer Protocol- L&D-UPL-I-20; INP-AMB-58BPMH & Discharge Med Rec; Meditech and Forms discharge package
Team members and volunteers are educated, and clients, families, and caregivers are provided with information to prevent falls and reduce injuries from falling
Nursing Orientation: Falls Prevention; Move On program; Fall risk symbol posted in patient room; Patient and family handbook
Nursing team including Nurse Manager work with patients and family when gaps are identified ie. Proper footwear, mobility devices are required.
The effectiveness of pressure ulcer prevention is evaluated, and results are used to make improvements when needed.
Incident reports are filed for hospital acquired pressure injury and reviewed at weekly patient safety meeting.
Audits completed by guideline champion for skin assessment on admission.
During care transitions, clients and families are given information that they need to make decisions and support their own care
BPMH & Discharge med rec
Medivac information pamphlets
ER discharge forms
‘Up to date’ handouts (diagnosis, treatment, medications, etc.)
Safety plan
The organization’s ‘Do Not Use’ list is updated and necessary changes are implemented to the medication management processes
PHAR-NUR-I-60
SBAR; Forms Discharge- interfacility /transfer; Medevac Information Pamphlet; Circle of Care Restrictions; Report System; Feedback from other hospitals; ER Audits; ER Survey Results
The effectiveness of fall prevention and injury reduction precautions and education/information are evaluated, and results are used to make improvements when needed
NM audits Falls Assessment/ admission
Falls are recorded by DOR and included in a patient safety report which is shared with staff, leadership and quality committee of the Board.
PTA conducts post falls assessment audit as a part of the falls prevention RNAO guideline implementation
Clients at risk for VTE are identified and provided with VTE prophylaxis
Measures for appropriate VTE prophylaxis are established, VTE prophylaxis is audited, and the information is used to make improvements to services
Venous Thromboembolism (VTE) Prophylaxis, Risk Assessment Tool and Physician’s Orders
Admission checklist
“Admission – Inpatient” INP-AMB-57
Nurse Manager audits 20 inpatient charts/month
Documentation tools and communication strategies are used to standardize information transfer at care transitions
Admission and discharge checklists
ER discharge forms
Emergent and scheduled transfer form
Safety plan
SBAR, AIDET, teachback
Compliance with the organization's DO NOT USE LIST is audited and process changes are implemented based on identified issues
PHAR-NUR-I-60
Procedure 8 Nurse Audit