Helen Newberry Joy Hospital and Healthcare Center Patient Safety

Critical Access Hospital and Hospital National Patient Safety Goals
Goal 1	Improve the accuracy of patient identification
a.	Use at least two patient identifiers when providing care, treatment, and services.
b.	Eliminate transfusion errors related to patient misidentification.
Goal 2	Improve the effectiveness of communication among caregivers
a.	Report critical results of tests and diagnostic procedures on a timely basis.
Goal 3	Improve the safety of using medications.
a.	Label all medication, medication containers or other solutions on and off the sterile field in preoperative and other procedural settings.
b.	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, arterial 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.
Goal 7	Reduce the risk of health care-associated infections
a.	Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the World Health Organization (WHO) hand hygiene guidelines.
b.	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), and multidrug-resistant gram-negative bacteria.
c.	Implement evidence-based practices to prevent central line-associated bloodstream infections. Note: This requirement covers short and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.
d.	Implement evidence-based practices for preventing surgical site infections.
Goal 8	Accurately and completely reconcile medications across the continuum of care.
a.	A process exists for comparing the patient's current medications with those ordered for the patient while under the care of the hospital. Note: This standard is in effect at this time.
b.	When a patient is referred to or transferred from one hospital to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented. Alternatively, when a patient leaves the hospital's directly to his or her home, the complete and reconciled list of medications is provided to the patient's known primary care provider, the original referring provider, or a known next provider of service. Note 1: When the next provider of service is unknown or when no known formal relationship is planned with the next provider, giving the patient and, as needed, the family the list of reconciled medications is sufficient. Note 2: This standard is not in effect at this time.
c.	When a patient leaves the hospital's care, a complete and reconciled list of the patient's medications is provided directly to the patient and, as needed, the family, and the list is explained to the patient and/or family. Note: This standard is not in effect at this time.
d.	In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Note 1: This requirement does not apply to hospitals that do not administer medications could affect the care, treatment, and services provided. Note 2: This standard is not in effect at this time.
Goal 15	The hospital identifies safety risks inherent in its patient population.
a.	Identify patients at risk for suicide. Note: The requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
Long Term Care National Patient Safety Goals
Goal 1	Improve the accuracy of resident identification.
a.	Use at least two resident identifiers when providing care, treatment, or services.
b.	Prior to the start of any surgical or invasive procedure, individuals involved int he procedure conduct a final verification process, such as a time-out, to confirm the correct resident, procedure, and using active, not passive, communication techniques.
Goal 2	Improve the effectiveness of communication among caregivers.
a.	For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order or tests result verifies the complete order or test result by having the person receiving the information record and "read back" the compete order or test result.
b.	There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
c.	The organization measures assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.
d.	The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.
Goal 3	Improve the safety of using medications.
a.	The organization identifies and, at a minimum, annually reviews a list of look alike/sound alike medications used in the organization and takes action to prevent errors involving the interchange of these medications.
b.	Reduce the likelihood of resident harm associated with the use of anticoagulant therapy.
Goal 7	Reduce the risk of health care associated infections.
a.	Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
b.	Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care associated infection.
c.	Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections.
Goal 8	Accurately and completely reconcile medications across the continuum of care.
a.	A process exists for comparing the resident's current medications with those ordered for the resident while under the care of the organization.
b.	When a resident is referred to or transferred from one organization to another, the complete and reconciled list of medication is communicated to the next provider of service and the communication is documented. Alternatively, when a resident leaves the organization's care directly to his or her home, the complete and reconciled list of medications is provided to the resident's known primary care provider, or the referring provider, or a known next provider of service.
c.	When a resident leaves the organization's care, a complete and reconciled list of the resident's medications is provided directly to the resident, and the resident's family as needed, and the list is explained to the resident and/or family.
d.	In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.
Goal 9	Reduce the risk of resident harm resulting from falls.
a.	The organization implements a fall reduction program that includes and evaluation of the effectiveness of the program.
Goal 10	Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.
a.	The organization develops and implements protocols for administration of the influenza vaccine.
b.	The organization develops and implements protocols for administration of the pneumococcus vaccine.
c.	The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks.
Goal 13	Encourage residents' active involvement in their own care as a resident safety strategy.
a.	Identify the ways in which the resident and his or her family can report concerns about safety and encourage them to do so.
Goal 14	Prevent health care associated pressure ulcers (decubitus ulcers).
a.	Assess and periodically reassess each resident's risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.