| Practice
#1 - Create a healthcare culture of safety |
A culture of safety
survey was given to our clinical staff and they are using it to develop
plans where needs were identified. We have a hospital safety committee
and we have Quality and Safety Committee of the Board of Trustees who
provide oversight and review of concerns. |
| Practice # 3 - Specify an
explicit protocol to be used to ensure an adequate level of nursing
care based on the institution's usual patient mix and the experience
and training of its nursing staff. |
Already completed. Interestingly, Leapfrog does not
hold Rural Hospitals accountable for this, but we do. |
| Practice
#5 - Pharmacists should actively participate in the medication-use
process, including, at a minimum, being available for consultation with
prescribers on medication ordering, interpretation and review of
medication orders, preparation of medications, dispensing of
medications, and administration and monitoring of medications. |
Our pharmacist is
available and very active with our medical and nursing staff. |
| Practice # 6 - Verbal
(including telephone orders) should be recorded whenever possible and
immediately read back to the prescriber, i.e., a healthcare provider
receiving a verbal order should read or repeat back the information the
prescriber conveys in order to verify the accuracy of what was heard.
This includes non-medicine orders as well. Read back should be
documented. |
MDI hospital has policies and procedures which address
verbal order read backs and even read back of our laboratory values
when given by phone. |
| Practice
#7 - Use only standardized abbreviations and dose designations |
Our hospital has a
formal list of abbreviations that can be used and the medical staff
identified a list of those that cannot. |
| Practice #8 - Patient care
summaries or other similar records should not be prepared from memory.
Information should be available and with the provider at the time of
dictation. |
Our patient information is available in the internal
computer system and for some things, in hard copy. We have provided
computer terminals at the sites where the physicians dictate their
summaries. |
| Practice
#9 - Ensure that care information, especially changes in orders and new
diagnostic information, is transmitted in a timely and clearly
understandable form to all of the patient’s healthcare
providers/professionals who need that information to provide care. |
On admission and
discharge, and during other changes of patient care unit our nurses
work with the patient or their families and compile a list of
medications the patient is currently taking. That list is provided to
the physician and a check is made looking at what lis ordered and
comparing them to what the patient might be taking. This is a check to
compile the most current listing for the patient and their physician to
work from. |
| Practice #10 - Ask each
patient or legal surrogate to recount what he or she has been told
during the informed consent discussion. |
Part of our process when patients are having surgery is
to review the procedure with the patient(or surrogate) to ensure they
indicate they understand what they have consented for. |
| Practice
#11 - Ensure that written documentation of the patient's preference for
life-sustaining treatments is prominently displayed in his or her chart. |
We have policies and procedures as
to where information will be kept in the patient's record so that the
patient's wishes will be honored. We also have special resuscitation
orders that physicians use if the patient does not want certain
treatments to sustain his/her life. |
| Practice #13 - Implement a
standardized protocol to prevent the mislabeling of radiographs. |
We have policies and procedure that addresses
preventing this from occurring. |
| Practice
#14 - Implement standardized protocols to prevent the occurrence of
wrong-site procedures or wrong-patient procedures. |
We have policies and procedures to
prevent wrong site surgery, part of this is taking a "time" with the
team as a whole to ensure all safety checks have been done. |
| Practice #15 - Evaluate each
patient undergoing elective surgery for risk of an acute ischemic
cardiac event during surgery, and provide prophylactic treatment of
high-risk patients with beta-blockers |
We have a policy for screening patients for the need
for betablocker therapy which has been developed by our Anesthesia
department and approved by the Surgical Services Committee |
| Practice
#16 - Evaluate each patient upon admission, and regularly thereafter,
for the risk of developing pressure ulcers. This evaluation should be
repeated at regular intervals during care. Clinically appropriate
preventive methods should be implemented consequent to the evaluation. |
We have assessment tools and
policies to address this as part of the initial nursing assessment and
ongoing evaluation. |
| Practice #17 - Evaluate each
patient upon admission, and regularly thereafter, for the risk of
developing DVT/VTE. Utilize clinically appropriate methods to prevent
DVT/VTE. |
The medical staff has approved an assessment tool and
standing orders are available for those who qualify. |
| Practice
#18 - Utilize dedicated anti-thrombotic (anticoagulation) services that
facilitate coordinated care management. |
Must be fully implemented by
November 31st with monthly metric reports to CQC and Ruth.
Accountability to job description |
| Practice #19 - Upon
admission, and regularly thereafter, evaluate each patient for the risk
of aspiration. |
Patients are evaluated on admission and with changes in
condition. We have an on call Speech Pathologist that can provide a
plan of care to address the concern. |
| Practice
#20 - Adhere to effective methods of preventing central venous
catheter-related blood stream infections. |
We have policies and procedures
that comply with national standards and we monitor to see if there are
infections and that the standards were carried out. |
| Practice #21 - Evaluate each
pre-operative patient in light of his or her planned surgical procedure
for the risk of surgical site infection (SSI), and implement
appropriate antibiotic prophylaxis and other preventive measures based
on that evaluation. |
We are part of a national study on this and are results
can be seen in the surgical infection prevention section of quality on
the website. |
| Practice
#22 - Utilize validated protocols to evaluate patients who are at risk
for contrast media-induced renal failure, and utilize a clinically
appropriate method for reducing risk of renal injury based on the
patient's kidney function evaluation. |
We follow this practice with our
protocols. |
| Practice #23 - Evaluate each
patient upon admission, and periodically thereafter, for risk of
malnutrition. Employ clinically appropriate strategies to prevent
malnutrition. |
Patients are evaluated and strategies/interventions
developed by our professional staff when needs are identified. |
| Practice
#24 - Whenever a pneumatic tourniquet is used, evaluate the patient for
risk of ischemic and/or thrombotic complication and utilize appropriate
prophylactic measures. |
Protocols are in place for the use
of pneumatic tourniquets. |
| Practice # 25 -
Decontaminate hands with either a hygienic hand rub or by washing with
a disinfectant soap prior to and after direct contact with the patient
or objects immediately around the patient. |
We have policies and procedures on handwashing and are
preparing for a campaign in the hospital to monitor compliance.
Handwashing is also "taught" and emphasized in orientation. |
| Practice
#26 - Vaccinate healthcare workers against influenza to protect both
them and patients from influenza. |
All of our staff were offered
vaccination this year and were asked to sign a form if they didn't wish
to receive it. |
| Practice #27 - Keep workspaces where medications are
prepared clean, orderly, well lit, and free of clutter, distraction and
noise. |
Our Nursing Care Committee does random reviews of areas
and looks at any information that flags this as a concern in providing
medications safely to patients. |
| Practice
#28 - Standardize the methods for labeling, packaging, and storing
medications |
Done |
| Practice # 29 - Identify all
high alert drugs and improve the safety of using high-alert medications
(e.g., identify and improve safety of using the following; intravenous
adrenergic agonists and antagonists, chemotherapy agents,
anticoagulants and anti-thrombotics, concentrated parenteral
electrolytes, general anesthetics, neuromuscular blockers, insulin and
oral hypoglycemics, narcotics and opiates). |
We have certain medications that have been identified
as given only by protocol and that have policy as to where they will be
stored. The Pharmacy and Therapeutics Committee is the group that
monitors high alert medications |
| Practice
#30 - Dispense medications in unit-dose or, when appropriate,
unit-of-use form, whenever possible. |
We not only do this, we also use
the bar codes on medications to assist in accurate "match up" of
patients with their medications. |