NPG #1
CORRECT PATIENT/CORRECT CARE
CORRECT PATIENT/CORRECT CARE
Full name/DOB (if DOB IS not available: MR#; Acct#; Photo ID; Blood band#) BUT NEVER ROOM NUMBER
WHAT ARE: Two correct forms of identification
This policy/plan addresses safety from all types of violence and states staff will have education upon hire & yearly. Staff identified at a higher risk will have additional training.
WHAT IS: Workplace Violence Prevention Plan.
Using proven protocols for specific diagnoses with the goal of the best outcomes and the prevention of sentinel events. (Results of these are reported to CMS.)
WHAT ARE: Core Measures using Evidence Based Practice
Initial pain assessment; inclusion of subjective/objective data; age appropriate pain scale; pain reassessment at specified intervals; patient education; pain assessment documented.
WHAT ARE: Aspects of Gritman’s PAIN MANAGEMENT POLICY
Outside doors locked; stairwells/elevator access limited “after hours”; badge swipes required for some doors; “buzzing-in” to specific areas; cameras in certain areas; name “banding” for FBC.
WHAT IS: Processes to control access and promote safety within the hospital
From phone call: read back patient name & THE value; Provider to receive THE value within 60 minutes; “read back” details documented iN final report; Lab Director evaluates timeliness.
WHAT IS: Gritman’s policy for reporting/receiving CRITICAL lab results & diagnostic procedures
Per Gritman’s violence prevention plan, if you experience/witness abusive language; physical assault; sexual harassment, you should call THIS Code. If you see a gun/weapon present, you should call THIS Code.
WHAT IS: Code Gray and Code Silver.
The designated individual who leads activities to improve healthcare equity for Gritman’s patients.
WHO IS: Connie Osborn, Chief Quality Officer
Repositioning; visual imagery; swaddling; skin to skin contact for babies; warm/cool packs; elevation; distraction; music; aroma therapy; controlled breathing; meditation.
WHAT ARE: Non-pharmacological modalities for pain management
Fall Prevention assessments at regular intervals/PRN; fall risk patients identified by Falling Star/yellow arm band. Interventions: alarms/gait belt/observations/ night lights/re-orientation.
WHAT ARE: Processes of Gritman’s Fall Prevention Program
Use of detailed SBAR; in-person report; opportunity to ask questions; patient input; name of person assuming responsibility for care.
WHAT IS: Process for hand-off communication & managing flow of patients throughout the hospital
Gritman’s Safety Committee is established and maintained by Leadership committed to a safe environment for staff/patients. Members of the Safety Committee include (give titles of 3 members):
WHO ARE: Chief Quality Officer; Director of Safety; Infection Prevention Nurse; Risk Management Officer; Director of Environmental Services; Director of Engineering; Director of Risk Management; Occupational Health.
Referrals for follow-up care; SDOH assessments; daily social service presence in ED/FBC; community partnerships/community education.
WHAT ARE: Ways Gritman is meeting NPG #4: high quality outcomes for ALL.
Pyxis: YOU “pull” narcotic; YOU give narcotic; YOU waste narcotic.
WHAT IS: Safe medication administration/management practice
Generator drills; planned maintenance of equipment; timely repair of utility systems; team approach to upgrade technology; utility failure plan; emergency backup for essential medication dispensing & refrigeration; staff education.
WHAT ARE: Processes within the Utility Management Plan
Initial/focused assessments; hourly rounding; shift/shift report; attention to CC; attention to labs/imaging/medications; implementing Code Rapid Response
WHAT IS: Ways to recognize and respond to changes in a patient’s condition.
The Policy describing how leadership will plan, direct, & coordinate services (includes safety; conflict of interest; mission; vision; values; scope of services)
WHAT IS: Provision of Care Policy
Awareness of signs of abuse upon admit/during hospital visit. Ensuring access to resources/agencies that provide support in the community.
WHAT IS: Ensuring a patient’s safety inside AND outside of the hospital.
Medications prepared but not immediately administered; medications taken out of original packaging; syringes containing medications; medications taken from one area to another.
WHAT ARE: Instances requiring labeling of medications (name/strength/amount/expiration date/time)
C-SSRS
WHAT IS: The Columbia-Suicide Rating Scale. Gritman uses this triage rating scale on all patients presenting to the hospital.
Consent forms signed; site marked; time-outs; wrist band/consent/radiograph verification; questions asked; H&P in chart.
WHAT ARE: Ways to prevent mis-identification (mistakes) in surgery & with invasive procedures. Preprocedural Verification Process.
Leadership encourages/ensures Gritman has a process which focusses on improvement vs placing blame of a “near miss” or sentinel event. It is meant to encourage staff to report without fear of retaliation.
WHAT IS: Clarity
Benefits, risks & side effects; likelihood of achieving the goal; reasonable alternatives/risks of alternatives; who will perform the treatment; provided in a language/at a level the patient understands; right to refuse; not needed in an emergency.
WHAT ARE: Aspects of INFORMED Consent
Upon admit, compare medications taken at home to those ordered in the hospital; reconcile medications at each care transition; instruct patients on safe medication practices at home (written instructions given upon discharge); educate patient of importance of taking medication list to all MD visits.
WHAT ARE Safe medication management processes.
1:1/patient:staff; disposable tear-away scrubs; placement in strategic visual rooms; belongings logged & removed; use of “Observation Documentation” form; use of “Safety Checklist”.
WHAT ARE: Processes under BEHAVIORAL HEALTH POLICY to reduce the risk of death by suicide.