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National Patient Safety Goals Jan2019
Health & Well Across Lifespan (NUR 1020)
Florida SouthWestern State College
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Hospital Accreditation Program
National Patient Safety Goals Effective January 2019
Goal 1
Improve the accuracy of patient identification.
Use at least two patient identifiers when providing care, treatment, and services.
NPSG.01.
Elements of Performance for NPSG.01.
Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.
Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable features. In addition to well-known misidentification errors such as wrong patient/wrong procedure, misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system among all providers is necessary to prevent error.
--Rationale for NPSG.01.01--
Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient's room number or physical location is not used as an identifier. (See also MM.05.01, EPs 7 and 10; NPSG.01.03, EP 1)
1.
Label containers used for blood and other specimens in the presence of the patient. (See also NPSG.01.03, EP 1)
2.
Use distinct methods of identification for newborn patients. Note: Examples of methods to prevent misidentification may include the following:
- Distinct naming systems could include using the mother’s first and last names and the newborn’s gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
- Standardized practices for identification banding (for example, using two body sites and/or bar coding for identification).
- Establish communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names).
3.
Eliminate transfusion errors related to patient misidentification.
NPSG.01.
Elements of Performance for NPSG.01.
Before initiating a blood or blood component transfusion:
- Match the blood or blood component to the order.
- Match the patient to the blood or blood component.
- Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding. (See also NPSG.01.01, EPs 1 and 2)
1.
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When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient.
2.
When using a two-person verification process, the second individual conducting the identification verification is qualified to participate in the process, as determined by the hospital.
3.
Goal 2
Improve the effectiveness of communication among caregivers.
Report critical results of tests and diagnostic procedures on a timely basis.
NPSG.02.
Elements of Performance for NPSG.02.
Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life- threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.
--Rationale for NPSG.02.03--
Develop written procedures for managing the critical results of tests and diagnostic procedures that address the following:
- The definition of critical results of tests and diagnostic procedures
- By whom and to whom critical results of tests and diagnostic procedures are reported
- The acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures
1.
Implement the procedures for managing the critical results of tests and diagnostic procedures.
2.
- Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.
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Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Note: This requirement applies only to hospitals that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirement does not apply to routine situations in which short- term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation will remain within, or close to, normal values.
NPSG.03.
Elements of Performance for NPSG.03.
Anticoagulation therapy can be used as therapeutic treatment for a number of conditions, the most common of which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant. However, it is important to note that anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety Goal has great potential to positively impact the safety of patients on this class of medications and result in better outcomes.
To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy program. Effective anticoagulation patient education includes face-to-face interaction with a trained professional who works closely with patients to be sure that they understand the risks involved with anticoagulation therapy, the precautions they need to take, and the need for regular International Normalized Ratio (INR) monitoring. The use of standardized practices for anticoagulation therapy that include patient involvement can reduce the risk of adverse drug events associated with heparin (unfractionated), low molecular weight heparin, and warfarin.
--Rationale for NPSG.03.05--
Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available. Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children.
1.
- Use approved protocols for the initiation and maintenance of anticoagulant therapy.
Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record. Note: The patient’s baseline coagulation status can be assessed in a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency, and genetic factors.
3.
Use authoritative resources to manage potential food and drug interactions for patients receiving warfarin.
4.
When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing.
5.
A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants.
6.
Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. Patient/family education includes the following:
- The importance of follow-up monitoring
- Compliance
- Drug-food interactions
- The potential for adverse drug reactions and interactions
7.
Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization.
8.
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Maintain and communicate accurate patient medication information.
NPSG.03.
Elements of Performance for NPSG.03.
There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.
--Rationale for NPSG.03.06--
Introduction to Reconciling Medication Information
The large number of people receiving health care who take multiple medications and the complexity of managing those medications make medication reconciliation an important safety issue. In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies.
The Joint Commission recognizes that organizations face challenges with medication reconciliation. The best medication reconciliation requires a complete understanding of what the patient was prescribed and what medications the patient is actually taking. It can be difficult to obtain a complete list from every patient in an encounter, and accuracy is dependent on the patient’s ability and willingness to provide this information. A good faith effort to collect this information is recognized as meeting the intent of the requirement. As health care evolves with the adoption of more sophisticated systems (such as centralized databases for prescribing and collecting medication information), the effectiveness of these processes will grow.
This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation. The elements of performance in this NPSG are designed to help organizations reduce negative patient outcomes associated with medication discrepancies. Some aspects of the care process that involve the management of medications are addressed in the standards rather than in this goal. These include coordinating information during transitions in care both within and outside of the organization (PC.02.02), patient education on safe medication use (PC.02.03), and communications with other providers (PC.04.02).
In settings where medications are not routinely prescribed or administered, this NPSG provides organizations with the flexibility to decide what medication information they need to collect based on the services they provide to patients. It is often important for clinicians to know what medications the patient is taking when planning care, treatment, and services, even in situations where medications are not used. A new requirement in this NPSG addresses the patient’s role in medication safety: it requires organizations to inform the patient about the importance of maintaining updated medication information.
Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications. Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.
1.
Define the types of medication information to be collected in non-24-hour settings and different patient circumstances. Note 1: Examples of non-24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose.
2.
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Goal 6
Reduce the harm associated with clinical alarm systems.
Improve the safety of clinical alarm systems.
NPSG.06.
Elements of Performance for NPSG.06.
Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within different units in a single hospital.
There is general agreement that this is an important safety issue. Universal solutions have yet to be identified, but it is important for a hospital to understand its own situation and to develop a systematic, coordinated approach to clinical alarm system management. Standardization contributes to safe alarm system management, but it is recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual patients. This NPSG focuses on managing clinical alarm systems that have the most direct relationship to patient safety. As alarm system management solutions are identified, this NPSG will be updated to reflect best practices. *
Footnote *: Additional information on alarm safety can be found on the AAMI website aami/htsi/alarms/. Also, the ECRI Institute has identified alarm hazards as one of the top technology hazards for 2013; more information on this hazard list can be found at ecri/Forms/Pages/Alarm_Safety_Resource.aspx.
--Rationale for NPSG.06.01--
- Leaders establish alarm system safety as a hospital priority.
Identify the most important alarm signals to manage based on the following:
- Input from the medical staff and clinical departments
- Risk to patients if the alarm signal is not attended to or if it malfunctions
- Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
- Potential for patient harm based on internal incident history
- Published best practices and guidelines (For more information on managing medical equipment risks, refer to Standard EC.02.04.)
2.
Establish policies and procedures for managing the alarms identified in EP 2 above that, at a minimum, address the following:
- Clinically appropriate settings for alarm signals
- When alarm signals can be disabled
- When alarm parameters can be changed
- Who in the organization has the authority to set alarm parameters
- Who in the organization has the authority to change alarm parameters
- Who in the organization has the authority to set alarm parameters to “off”
- Monitoring and responding to alarm signals
- Checking individual alarm signals for accurate settings, proper operation, and detectability (For more information, refer to Standard EC.02.04)
3.
Educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.
4.
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Goal 7
Reduce the risk of health care–associated infections.
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
NPSG.07.
Elements of Performance for NPSG.07.
According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback.
--Rationale for NPSG.07.01--
Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04, EP 1)
1.
Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01, EP 1)
2.
- Improve compliance with hand hygiene guidelines based on established goals.
Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin- resistant Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), carbapenem-resistant enterobacteriaceae (CRE), and other multidrug-resistant gram-negative bacteria.
NPSG.07.
Elements of Performance for NPSG.07.
Patients continue to acquire health care–associated infections at an alarming rate. Risks and patient populations, however, differ between hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment. The elements of performance for this requirement are designed to help reduce or prevent health care–associated infections from epidemiologically important multidrug- resistant organisms (MDROs).
Note: Hand hygiene, contact precautions, as well as cleaning and disinfecting patient care equipment and the patient’s environment are essential strategies for preventing the spread of health care–associated infections. Hand hygiene is addressed in NPSG.07.01. Contact precautions for patients with epidemiologically significant multidrug-resistant organisms (MDROs) are covered in IC.02.01, EP 3. Cleaning and disinfecting patient care equipment are addressed in IC.02.02.
--Rationale for NPSG.07.03--
Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug- resistant organism acquisition and transmission. (See also IC.01.03, EPs 1–3)
1.
Educate staff and licensed independent practitioners about multidrug-resistant organisms and prevention strategies. Education occurs upon hire or granting of initial privileges and periodically thereafter as determined by the organization. Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the organization.
2.
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Provide central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.
5.
- Use a catheter checklist and a standardized protocol for central venous catheter insertion.
Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters.
7.
Perform hand hygiene prior to catheter insertion or manipulation.
Use maximum sterile barrier precautions during central venous catheter insertion.
For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.
10.
Use an alcoholic chlorhexidine antiseptic for skin preparation during central venous catheter insertion unless contraindicated.
11.
Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.
12.
- Evaluate all central venous catheters routinely and remove nonessential catheters.
Implement evidence-based practices for preventing surgical site infections.
NPSG.07.
Elements of Performance for NPSG.07.
Educate staff and licensed independent practitioners involved in surgical procedures about surgical site infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities.
1.
Educate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.
2.
Implement policies and practices aimed at reducing the risk of surgical site infections. These policies and practices meet regulatory requirements and are aligned with evidence-based guidelines (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).
3.
As part of the effort to reduce surgical site infections:
- Conduct periodic risk assessments for surgical site infections in a time frame determined by the hospital.
- Select surgical site infection measures using best practices or evidence-based guidelines.
- Monitor compliance with best practices or evidence-based guidelines.
- Evaluate the effectiveness of prevention efforts. Note: Surveillance may be targeted to certain procedures based on the hospital’s risk assessment.
4.
Measure surgical site infection rates for the first 30 or 90 days following surgical procedures based on National Healthcare Safety Network (NHSN) procedural codes. The hospital’s measurement strategies follow evidence-based guidelines. Note 1: Surveillance may be targeted to certain procedures based on the hospital's risk assessment. Note 2: The NHSN is the Centers for Disease Control and Prevention’s health care–associated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate health care–associated infections. For more information on NHSN procedural codes, see cdc/nhsn/CPTcodes/ssi-cpt.html.
5.
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Provide process and outcome (for example, surgical site infection rate) measure results to key stakeholders.
6.
Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations. * Footnote *: A limited number of National Patient Safety Goals contain requirements for practices that reflect current science and medical knowledge. In these cases, the element of performance refers to a practice that is cited in scientific literature or endorsed by professional organizations. This means that the practice used by the hospital must be validated by an authoritative source. The authoritative source may be a study published in a peer-reviewed journal that clearly demonstrates the efficacy of that practice or endorsement of the practice by a professional organization(s) and/or a government agency(ies). It is not acceptable to follow a practice that is not supported by evidence or widespread consensus. During the on-site survey, surveyors will explore the source of the practices the hospital follows.
7.
When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations. * Footnote *: A limited number of National Patient Safety Goals contain requirements for practices that reflect current science and medical knowledge. In these cases, the element of performance refers to a practice that is cited in scientific literature or endorsed by professional organizations. This means that the practice used by the hospital must be validated by an authoritative source. The authoritative source may be a study published in a peer-reviewed journal that clearly demonstrates the efficacy of that practice or endorsement of the practice by a professional organization(s) and/or a government agency(ies). It is not acceptable to follow a practice that is not supported by evidence or widespread consensus. During the on-site survey, surveyors will explore the source of the practices the hospital follows.
8.
Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Note: Evidence-based guidelines for CAUTI are located at:
- Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, 2014 at journals.cambridge/action/displayAbstract?fromPage=online&aid=10312260&fulltextType=RA&fileId=S 9823X
- APIC Implementation Guide: Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014 at apic/Resource_/EliminationGuideForm/0ff6ae59-0a3a-4640-97b5-eee38b8bed5b/File/CAUTI_06.pdf
- Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009 at cdc/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf
NPSG.07.
Elements of Performance for NPSG.07.
Educate staff and licensed independent practitioners involved in the use of indwelling urinary catheters about CAUTI and the importance of infection prevention. Education occurs upon hire or granting of initial privileges and when involvement in indwelling catheter care is added to an individual’s job responsibilities. Ongoing education and competence assessment occur at intervals established by the organization.
1.
Educate patients who will have an indwelling catheter, and their families as needed, on CAUTI prevention and the symptoms of a urinary tract infection. Note: See FAQs about “Catheter-associated Urinary Tract Infection" at shea- online.org/images/patients/NNL_CA-UTI
2.
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Goal 15
The hospital identifies safety risks inherent in its patient population.
Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
NPSG.15.
Elements of Performance for NPSG.15.
Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals.
--Rationale for NPSG.15.01--
Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
1.
- Address the patient’s immediate safety needs and most appropriate setting for treatment.
When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
3.
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Introduction to the Universal Protocol for Preventing Wrong Site, Wrong
Procedure, and Wrong Person Surgery™
The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure.
The Universal Protocol is based on the following principles:
- Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.
- A robust approach using multiple, complementary strategies is necessary to achieve the goal of always conducting the correct procedure on the correct person, at the correct site.
- Active involvement and use of effective methods to improve communication among all members of the procedure team are important for success.
- To the extent possible, the patient and, as needed, the family are involved in the process.
- Consistent implementation of a standardized protocol is most effective in achieving safety.
The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. A hospital should consider its culture when designing processes to meet the Universal Protocol. In some hospitals, it may be necessary to be more prescriptive on certain elements of the Universal Protocol or to create processes that are not specifically addressed within these requirements.
Hospitals should identify the timing and location of the preprocedure verification and site marking based on what works best for their own unique circumstances. The frequency and scope of the preprocedure verification will depend on the type and complexity of the procedure. The three components of the Universal Protocol are not necessarily presented in chronological order (although the preprocedure verification and site marking precede the final verification in the time-out). Preprocedure verification, site marking, and the time-out procedures should be as consistent as possible throughout the hospital.
Note: Site marking is not required when the individual doing the procedure is continuously with the patient from the time of the decision to do the procedure through to the performance of the procedure.
Conduct a preprocedure verification process.
UP.01.
Hospitals should always make sure that any procedure is what the patient needs and is performed on the right person. The frequency and scope of the verification process will depend on the type and complexity of the procedure.
The preprocedure verification is an ongoing process of information gathering and confirmation. The purpose of the preprocedure verification process is to make sure that all relevant documents and related information or equipment are:
- Available prior to the start of the procedure
- Correctly identified, labeled, and matched to the patient’s identifiers
- Reviewed and are consistent with the patient’s expectations and with the team’s understanding of the intended patient, procedure, and site
Preprocedure verification may occur at more than one time and place before the procedure. It is up to the hospital to decide when this information is collected and by which team member, but it is best to do it when the patient can be involved. Possibilities include the following:
- When the procedure is scheduled
- At the time of preadmission testing and assessment
- At the time of admission or entry into the facility for a procedure
- Before the patient leaves the preprocedure area or enters the procedure room
Missing information or discrepancies are addressed before starting the procedure.
--Rationale for UP.01.01--
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Mark the procedure site before the procedure is performed and, if possible, with the patient involved.
2.
The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:
- An individual in a medical postgraduate education program who is being supervised by the licensed independent practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed
- A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure (that is, an advanced practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who will be present when the procedure is performed. Note: The hospital's leaders define the limited circumstances (if any) in which site marking may be delegated to an individual meeting these qualifications.
3.
The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital. Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site.
4.
A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum). Note: Examples of other situations that involve alternative processes include:
- Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
- Teeth
- Premature infants, for whom the mark may cause a permanent tattoo
5.
A time-out is performed before the procedure.
UP.01.
Elements of Performance for UP.01.
The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are identified. This requirement focuses on those minimum features of the time-out. Some believe that it is important to conduct the time-out before anesthesia for several reasons, including involvement of the patient. A hospital may conduct the time-out before anesthesia or may add another time-out at that time. During a time-out, activities are suspended to the extent possible so that team members can focus on active confirmation of the patient, site, and procedure.
A designated member of the team initiates the time-out and it includes active communication among all relevant members of the procedure team. The procedure is not started until all questions or concerns are resolved. The time- out is most effective when it is conducted consistently across the hospital.
--Rationale for UP.01.03--
- Conduct a time-out immediately before starting the invasive procedure or making the incision.
The time-out has the following characteristics:
- It is standardized, as defined by the hospital.
- It is initiated by a designated member of the team.
- It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.
2.
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When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.
3.
During the time-out, the team members agree, at a minimum, on the following:
- Correct patient identity
- The correct site
- The procedure to be done
4.
Document the completion of the time-out. Note: The hospital determines the amount and type of documentation.
5.
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National Patient Safety Goals Jan2019
Course: Health & Well Across Lifespan (NUR 1020)
University: Florida SouthWestern State College
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