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VA Nebraska-Western Iowa Health Care System

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* Patient Safety Goals/Unanticipated Adverse Events/Outcomes

The 2009 Patient Safety Goals and their provisions for implementation at VA Nebraska – Western Iowa Health Care System are:

  • Assure accuracy of patient identification when providing any type of treatment.  At this facility, we use the patient’s name and social security number. The patient should be actively involved and asked to verbalize their name and social security number. Use of the arm band is also acceptable for inpatients as it is bar-coded and contains the two identifiers.

  • Improve communication between clinical employees. When a clinical employee takes a verbal or telephone order or critical test result, the clinical employee is required to “write down & read back” the entire order or result to the physician. For more information, refer to Health Care System Policy COS-010, “Physician’s Verbal Orders.”

  • Do NOT use the following abbreviations, acronyms, and symbols:
“u” – spell out units
“IU” - spell out international units
“Q.D.” = spell out daily
“Q.O.D.” – spell out every other day
“MS” – spell out morphine sulfate
“MSO4” – spell out morphine sulfate
“MgSO4” – spell out magnesium sulfate
Trailing zero (1.0mg) – do not write 0 after decimal (1 mg)
Lack of leading zero (.5 mg) – write 0 before a decimal (0.5mg)
  • Take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver, of critical tests results and values. At this facility, reporting these results within one hour is considered timely. The diagnostic areas have identified which results are considered critical. For more information, refer to Health Care System Policy COS-045, Ordering and Reporting Emergent/Critical Patient Test Results.

  • Implement a standardized approach to “hand-off” communications among clinical staff, including an opportunity to ask and respond to questions regarding the patient.

  • Identify look-alike/sound-alike drugs and take measures to prevent errors involving them.

  • Label all medications, medication containers (such as syringes, medicine cups, basins) or other solutions on and off the sterile field in perioperative and procedural settings, including those utilized at the bedside.

  • Reduce the likelihood of patient harm associated with the use of anticoagulation therapy (applies only to organizations that provide anticoagulation therapy).

  • Decrease the risk of patients getting an infection in a health care setting. Follow the CDC hand hygiene guidelines. Alcohol-based hand rubs are the preferred method for hands not visibly soiled. Use a 15-second wash with antimicrobial soap and water for hands that are visibly soiled.

  • Identify cases of unexpected death or major, permanent loss of body function due to getting an infection in a health care setting. Such cases must be reported and investigated.

  • Document a complete list of the patient’s current medications, both prescribed and over-the-counter, upon entry into the organization. Communicate the medications to the next provider of services when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

  • Develop a process to assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medications, and take action.

  • Patients are screened and assessed in regard to their risk to commit suicide. This assessment is completed whenever a patient is admitted to Mental Health and annually on an outpatient basis.

  • The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

Both the Joint Commission and the VA has taken a proactive approach to dealing with potential or actual adverse events. The Medical Center has employed a Patient Safety Manager at X3134.

Adverse events are defined as untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided and may result from acts of commission or omission.

Sentinel events are defined as a type of adverse event such as unexpected death and serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function.

A close call is an event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention.

Each of these events – adverse, sentinel, and close call – require reporting and action.

Two Health Care System policies are available for reference:

  • QM-006 Report of Incidents Involving Injury or Risk to Patients
  • QM-007 Patient Safety Improvement Program


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