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New 2006 Ambulatory Care and Office-Based Surgery National Patient Safety Goals

Goal 2E: Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Rationale: The primary objective of a “hand off” is to provide accurate information about a patient’s/client’s/resident’s care, treatment and services, current condition and any recent or anticipated changes. The information communicated during a hand off must be accurate in order to meet patient safety goals.

In health care there are numerous types of patient hand offs, including but not limited to nursing shift changes, physicians transferring complete responsibility for a patient, physicians transferring on-call responsibility, temporary responsibility for staff leaving the unit for a short time, anesthesiologist report to postanesthesia recovery room nurse, nursing and physician hand off from the emergency department to inpatient units, different hospitals, nursing homes and home health care, critical laboratory and radiology results sent to physician offices

Goal 3D: Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.

Rationale: This risk reduction activity is consistent with safe medication practices and addresses a recognized risk point in the safe administration of medications in perioperative settings. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. Medications or other solutions in unlabeled containers are unidentifiable. This unsafe practice neglects basic principles of medication management safety yet has been routine in many organizations with respect to medications transferred to the sterile field.

Implementation Expectations: Medications include any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; over-the-counter drugs; vaccines; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; intravenous solutions (plain, with electrolytes and/or drugs), and any product designated by the Food and Drug Administration (FDA) as a drug. Solutions include chemicals and reagents such as formaline, saline, sterile water, Lugol’s solution, radiopaque dyes, glutaraldehyde and chlorhexidine. Medications and solutions both on and off the sterile field should be labeled even if there is only one medication being used. Labeling occurs when any medication or solution is transferred from the original packaging to another container. Labels include the name and strength of the medication or solution, the date, and the initials of the person preparing the label. Labels can be developed by the facility or commercially available; sterile labels can be purchased.

All labels are verified both verbally and visually by two qualified individuals when the person preparing the medications is not the person administering the medication [Revised January 2006]. No more than one medication or solution is labeled at one time. Any medications or solutions found unlabeled are immediately discarded. All original containers from medications or solutions remain available for reference in the perioperative area until the conclusion of the procedure. All labeled containers on the sterile field are discarded at the conclusion of the procedure. At shift change or break relief, all medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting personnel.

Goal 3 (existing goal): Improve the safety of using medications.

Requirement 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Rationale for Requirement 3E: The medication process is one of the more complex processes involved in caring for a patient. Use of anticoagulants is one of the high risk treatments within the medication management process. Anticoagulants are commonly involved in adverse drug events due to the complexity of dosing and monitoring, patient compliance and numerous drug and dietary interactions which can effect drug levels. The use of standardized practices can reduce the risk of an adverse drug event from anticoagulants.

More Risk Management News and Updates

› Draft Candidate 2007 National Patient Safety Goals, Requirements and Implementation Expectations

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