1、 Copyright, Joint Commission International1International Patient Safety Goals (IPSG) Client name/ Presentation Name/ 12pt - 2 Copyright, Joint Commission InternationalImproving Patient Safetymeans . . .Reducing Medical ErrorsReducing Patient HarmReducing Patient HarmClient name/ Presentation Name/ 1
2、2pt - 3 Copyright, Joint Commission InternationalChallenges for Patient Safety Leadership Move toward a more safety-oriented culture Practice proactive systems analysis & risk reduction Standardize processes and equipment Promote effective communication Ensure adequate and effective staffing Impleme
3、nt team training for all staff Encourage and support patient involvementClient name/ Presentation Name/ 12pt - 4 Copyright, Joint Commission InternationalSystems Analysis in Health CareA systematic evaluation of a health care organizations systems and processes: To identify vulnerabilities and hazar
4、dous conditions that could (and, over time, will) impact patient safety and quality of care. To focus the redesign of those systems and processes to improve patient safety and quality of care.Client name/ Presentation Name/ 12pt - 5 Copyright, Joint Commission InternationalImplementation of IPSG.Rep
5、resents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety expertsIncorporating these new tools into our accreditation requirements is a significant stepOrganizations taking responsibility for using the IPSG to foster an atmosphere of c
6、ontinuous improvement is even more importantClient name/ Presentation Name/ 12pt - 6 Copyright, Joint Commission InternationalJCI 4th Edition International Patient Safety GoalsPSG 1 Identify Patients CorrectlyPSG 2 Improve Effective CommunicationPSG 3 Improve the Safety of High-Alert MedicationsPSG
7、4 Ensure Correct-Site, Correct-Procedure, Correct-Patient SurgeryPSG 5 Reduce the Risk of Health Care Associated InfectionsPSG 6 Reduce the Risk of Patient Harm Resulting from Falls Client name/ Presentation Name/ 12pt - 7 Copyright, Joint Commission InternationalIPSG.1IPSG.1Identify Patients Correc
8、tlyIdentify Patients CorrectlyA collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification Use at least two (2) waystwo (2) ways to identify a patient: giving medications giving blood and blood products taking blood samples taking other sa
9、mples for clinical testing providing treatment or procedure The patients Room Number cannot be used as an identifier Client name/ Presentation Name/ 12pt - 8 Copyright, Joint Commission InternationalThe complete VO and TO or test result is written down by the receiver of the order or test result. Mu
10、st use a verification “read back” of complete order or test resultThe order or test result is confirmed by the individual who gave the order or test result Policies and procedures support consistent practice verifying the accuracy of verbal and telephone communicationsIPSG 2: Improve Effective IPSG
11、2: Improve Effective CommunicationCommunicationClient name/ Presentation Name/ 12pt - 9 Copyright, Joint Commission InternationalPolicies/procedures are developed to address identification, location, labeling and storage of high-alert medicationsPolicies/procedures are implementedConcentrated electr
12、olytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administrationConcentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts accessIPSG 3: Improve Safety of IPSG 3: Improv
13、e Safety of High Alert MedicationsHigh Alert MedicationsClient name/ Presentation Name/ 12pt - 10 Copyright, Joint Commission InternationalClinical Necessity Has to be supported by evidence Is the substance really needed very quickly? If it is used to dilute, is the diluted solution available?Client
14、 name/ Presentation Name/ 12pt - 11 Copyright, Joint Commission InternationalIPSG 4: Ensure Correct-site, IPSG 4: Ensure Correct-site, Correct-procedure, Correct-Correct-procedure, Correct-patient Surgerypatient SurgeryCollaboratively develop a policy/procedure that includes: Definition of surgery t
15、hat incorporates at least those procedures that investigate and/or treat diseases and disorders of the human body through cutting removing, altering, or insertion of diagnostic/therapeutic scopes. Client name/ Presentation Name/ 12pt - 12 Copyright, Joint Commission InternationalIPSG 4 Correct Site,
16、 Procedure and Patient Use an instantly recognizable mark for surgical site identification Involves the patient in the marking process Involves the full surgical team and is documented just before starting a surgical procedure Policies/procedures are developed to support uniform process to ensure co
17、rrect site, procedure, and patient (including medical and dental procedures done in settings other than the operating theater)Client name/ Presentation Name/ 12pt - 13 Copyright, Joint Commission InternationalChecklist or other Checklist or other process to verify:process to verify:CORRECTCORRECTSUR
18、GERYSURGERYSITESITEDOCUMENTSDOCUMENTSEQUIPMENTEQUIPMENTFunctional Functional & Correct& CorrectPROCEDUREPROCEDUREPATIENTPATIENTClient name/ Presentation Name/ 12pt - 14 Copyright, Joint Commission InternationalPSG 5: Reduce the Risk of PSG 5: Reduce the Risk of Health Care-Associated Health Care-Ass
19、ociated InfectionsInfectionsNeed data to demonstrate effectiveness The organization has adopted or adapted currently published and generally accepted hand-hygiene guidelines Implements an effective hand-hygiene program Policies/procedures are developed that support continued reduction of health care
20、 associated infections Client name/ Presentation Name/ 12pt - 15 Copyright, Joint Commission InternationalIPSG 6: Reduce the Risk IPSG 6: Reduce the Risk of Patient Harm resulting of Patient Harm resulting from Fallsfrom FallsImplements a process for the initial assessment of patient for fall risk a
21、nd reassessment of patients when indicated by a change in condition or medications, among othersMeasures are implemented to reduce falls risk for those at risk Client name/ Presentation Name/ 12pt - 16 Copyright, Joint Commission InternationalIPSG 6 Reducing Risk of Harm Resulting from Falls Measure
22、s are monitored for results, both successful fall injury reduction and any unintentional related consequences Policies/procedures support continued reduction of risk of patient harm resulting from falls in the organizationClient name/ Presentation Name/ 12pt - 17 Copyright, Joint Commission Internat
23、ionalNext Presentation Copyright, Joint Commission International18Access to Care andContinuity of Care (ACC)Client name/ Presentation Name/ 12pt - 19 Copyright, Joint Commission InternationalACC-Five Areas of FocusAdmission to the OrganizationContinuity of CareDischarge, Referral, and Follow-upTrans
24、fer of PatientsTransportationClient name/ Presentation Name/ 12pt - 20 Copyright, Joint Commission InternationalACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients Screening at point of first contact Determine if care can be provided Diagnostic test are available for decision making-st
25、andardized by policy Patients are informed if any wait or delay and reasons (waiting list)Client name/ Presentation Name/ 12pt - 21 Copyright, Joint Commission InternationalACC.1.1 Process of Admission or Registration Policies & Procedures (PP) standardize admission and registration for out-patients
26、 and in-patients PP Admitting emergency patients PP Holding patients for observation PP Managing patients when bed space not availableClient name/ Presentation Name/ 12pt - 22 Copyright, Joint Commission InternationalACC.1.1.1 Emergency Patients Evidence based triage process is used to prioritize pa
27、tients with immediate needs Staff are trained use of the triage process Staff prioritize patients based on urgency of needs Emergency patients are assessed and stabilized prior to transfer Client name/ Presentation Name/ 12pt - 23 Copyright, Joint Commission InternationalACC.1.1.2 Needs are Prioriti
28、zed for In-patients Screening assessment identifies patients needs Services or units are selected to meet needs based on the assessment: Preventative Palliative Curative RehabilitativeClient name/ Presentation Name/ 12pt - 24 Copyright, Joint Commission InternationalACC.1.1.3 Waiting Periods or Dela
29、ys In-patients and out-patients are informed of delays Reason for delay and available alternatives Documented in the patient medical record Written policies/proceduresClient name/ Presentation Name/ 12pt - 25 Copyright, Joint Commission InternationalACC.1.2 Information Provided Patient and Family re
30、ceive information during the admission process on: Proposed care Expected out comes of care Expected costs Sufficient information to make knowledgeable decisionsClient name/ Presentation Name/ 12pt - 26 Copyright, Joint Commission InternationalACC.1.3 Reduction of Barriers Leaders and staff identify
31、 most common barriers for patients Physical Language Cultural Other A process is identified and implemented to overcome or limit identified barriers to limit impact of barriers on delivery of servicesClient name/ Presentation Name/ 12pt - 27 Copyright, Joint Commission InternationalACC.1.4 Criteria
32、for Admission or Transfer to Intensive Care Admission/transfer criteria established for Intensive and Specialized Units Criteria are physiologic-based Appropriate individuals are involved in developing and implementing the criteria Patients meet the criteria (documented) Patients are discharged/tran
33、sferred when they no longer meet criteriaClient name/ Presentation Name/ 12pt - 28 Copyright, Joint Commission InternationalACC.2 Continuity of Patient Care Leaders design and support continuity (coordination & resources) Criteria or policies determine transfers within the organization Continuity an
34、d coordination is evident throughout all phases of patient care and to the patient Client name/ Presentation Name/ 12pt - 29 Copyright, Joint Commission InternationalACC.2.1 Individual Responsible There is an individual responsible for patients care who is a physician or other person qualified to as
35、sume responsibility for care identified to the hospital staff The individual documents the patient plan of care Transfer from one individual to another is described in policy Client name/ Presentation Name/ 12pt - 30 Copyright, Joint Commission InternationalACC.3 Referral and Discharge Policy Policy
36、 for the appropriate referral or discharge of patients Based on patients needs for continuing care The patients readiness for discharge Discharge planning begins early and includes the family as appropriate Policy guides patients “on pass” for a defined period of timeClient name/ Presentation Name/
37、12pt - 31 Copyright, Joint Commission InternationalACC.3.1 Cooperation with Community Practitioners Discharge planning for both supportive and continuing medical services Community providers, organizations and individuals are identified Appropriate referrals are made (in the patients home community
38、whenever possible)Client name/ Presentation Name/ 12pt - 32 Copyright, Joint Commission InternationalACC.3.2 Discharge Summary In-patient clinical records contain a discharge summary prepared by a qualified individual Follow up instructions Copies are: In the patients medical record Given to the pat
39、ient at discharge Provided to practitioner responsible for continued care Policy and procedure define discharge summaryClient name/ Presentation Name/ 12pt - 33 Copyright, Joint Commission InternationalACC.3.2.1 Discharge Summary Prepared at discharge, documented in the patients record and contains:
40、 Reason for admission Significant physical and other findings Significant diagnoses and co-morbidities Diagnostic and therapeutic procedures Significant medication and treatments Condition at discharge Discharge medications and all medications to be taken at home Follow up instructionsContinued on n
41、ext slide.Client name/ Presentation Name/ 12pt - 34 Copyright, Joint Commission InternationalACC.3.2 Discharge Summary Unless contrary to policy, laws, or culture, patients are given a copy A copy is provided to the practitioner responsible for patients continuing or follow-up careClient name/ Prese
42、ntation Name/ 12pt - 35 Copyright, Joint Commission InternationalACC.3.3 Out Patient Summary of Continuing Care Identify which continuing care patients require a summary Identify how the summary is maintained and who maintains it Identify format and content of summary Define what is considered curre
43、nt Policy for completed summaryClient name/ Presentation Name/ 12pt - 36 Copyright, Joint Commission InternationalACC.3.4 Understandable Follow Up Instructions Follow up instructions are understandable Return for follow up care When to obtain urgent care Care necessary to patients condition Client n
44、ame/ Presentation Name/ 12pt - 37 Copyright, Joint Commission InternationalACC.3.5 Against Medical Advice Process for management and follow up of in-patients and outpatients who leave AMA Known family physicians are notified Applicable with local laws and regualtionsClient name/ Presentation Name/ 1
45、2pt - 38 Copyright, Joint Commission InternationalACC.4 Transfer Policy Guiding process for transferring patients to include: Patients need for continuing care Transfer of responsibility to another provider or setting Who is responsible during transfer Situations where transfer is not possibleClient
46、 name/ Presentation Name/ 12pt - 39 Copyright, Joint Commission InternationalACC.4.1 Referring and Receiving Organizations Referring organization determines whether receiving organization can meet patients needs Arrangements (formal or informal) are in place when patients are frequently transferredC
47、lient name/ Presentation Name/ 12pt - 40 Copyright, Joint Commission InternationalACC.4.2 Written Summary Clinical summary is transferred with patient & includes: Patient status Procedures Other interventions provided Patients continuing care needsClient name/ Presentation Name/ 12pt - 41 Copyright,
48、 Joint Commission InternationalACC.4.3 Monitoring Patients During Transfer All patients are monitored during direct transfer Qualifications of the staff member doing the monitoring are appropriate for patients conditionClient name/ Presentation Name/ 12pt - 42 Copyright, Joint Commission Internation
49、alACC.4.4 Documentation of Transfer Documentation includes: Name of organization and individual agreeing to receive patient Reason for transfer Any special conditions related to transfer Any change of patients condition or status during transfer Any other notes require by the transferring organizati
50、onClient name/ Presentation Name/ 12pt - 43 Copyright, Joint Commission InternationalACC.5 Planning Transportation Needs Assessment of transportation needs when referring patients Transportation is arranged appropriate to patient needs Owned transport vehicles meet laws and regulations Contracted tr
