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NAVAN strategic plan
GOAL I Improve the accuracy of identification: This patient safety goal is imponant in the proper identification of patients receiving blood or blood products. Here are suggestions for proper identification
of patients receiving blood producl"
Do's and Don'ts for PatientBlood Product Identification: • Do match the patient's name and account/medical record number (0 the blood product documentation. • Do consider using a blood bankspecific identification system that assigns unique identification num-
bers to patients, requisitions, specimens, and blood products. This will help ensure that the compatibility specimen is tmceable to the blood product being administered. • Do have at least two individuals check the information on the blood product against the documentation
to be written in its entirety and then read back verbatim. Consideration should be given to not accepting chemotherapy medications as a verbal order. It may be pmdent to have a second person listen
What to Do Write the purpose of the medication (that is the diagnosis or the indication for use) on the prescription on
the same patient Develop a policy for taking
when accepting telephone orders for medications. JCAHO makes the following suggestions to lower the risk of errors resulting from misinterpreted verbal orders for medication:
Rationale • Minimizes the risk of confusion resulting from
look alike medications e.g., Losec and Lasix • Pharmacist can screen the medication for the proper dose. duration. and appropriateness to diagnosis and will minimize duplicate orders
verbal or telephone orders
Provide generic and brand
• Allows for safe and appropriate labeling of all
name on all medication labels medications, and minimizes opportUnity for error • Ensures consistency between the documents and helps to prevent misinterpretation of orders. Provide patients with written • Providing written information allows the indiinformation about their vidual printed material for other healthcare providers to check and verify. drugs, including the brand • Always discuss the medication and use with and generic names
the individual. JCAHO also will be looking for a hard copy of verbal orders for laboratory testing, per state and federal guidelines.
to ensure accurdCY.
• Don't use the patient'S room number or bed number as an identifier. • Don't ask a colleague to verify that it is Patient Z's blood. • Do ask the colleague to match the blood with Patient Z's name and unique identifier.
GOAL 3 Improve the safety of using high-alert medications Since the first Sentinel Event Alert, one death resulting from accidental
Common Risk Factors and Proaetive Planning Tips for High-Alert Medications Proactive Planning Common Risk Factors
GOAL 2 Effective communication and the importance of a "read back" of telephone or verbal orders for medications: In facilities ulat allow verbal orders or
telephone orders, although discoumged as much as possible, there should be a system of checks and balances to ensure ulat verbal orders for medications are confirmed and correct. JCAHO states that consistency of practice should be ensured through policy and procedure. TI,e process should allow for the order
injection of Potassium Chloride (KCL) has been reponed. Medications are included in a High-Alen Medication List with risk factors and planning discussed,
• No dose-check systems • Mix.ups due to insulin and
heparin vials being kept in
I. Insulin
• Establish a check system in which one nurse prepares the dose and another nurse reviews
it
close proximity to each other on nursing units • "U" used as an abbreviation for "units" in orders (can be confused with "0," leading to a
abbreviate it.
IQ-fold overdose)
• Establish an independent
• Incorrect rates programmed into an infusion pump
check system for infusion pump rates and concentration settings.
Spr
ng
• Do not store insulin and heparin near each other.
• Spell out "units" rather than
2003
.JVAD
47
.'
of patients receiving blood producl"
Do's and Don'ts for PatientBlood Product Identification: • Do match the patient's name and account/medical record number (0 the blood product documentation. • Do consider using a blood bankspecific identification system that assigns unique identification num-
bers to patients, requisitions, specimens, and blood products. This will help ensure that the compatibility specimen is tmceable to the blood product being administered. • Do have at least two individuals check the information on the blood product against the documentation
to be written in its entirety and then read back verbatim. Consideration should be given to not accepting chemotherapy medications as a verbal order. It may be pmdent to have a second person listen
What to Do Write the purpose of the medication (that is the diagnosis or the indication for use) on the prescription on
the same patient Develop a policy for taking
when accepting telephone orders for medications. JCAHO makes the following suggestions to lower the risk of errors resulting from misinterpreted verbal orders for medication:
Rationale • Minimizes the risk of confusion resulting from
look alike medications e.g., Losec and Lasix • Pharmacist can screen the medication for the proper dose. duration. and appropriateness to diagnosis and will minimize duplicate orders
verbal or telephone orders
Provide generic and brand
• Allows for safe and appropriate labeling of all
name on all medication labels medications, and minimizes opportUnity for error • Ensures consistency between the documents and helps to prevent misinterpretation of orders. Provide patients with written • Providing written information allows the indiinformation about their vidual printed material for other healthcare providers to check and verify. drugs, including the brand • Always discuss the medication and use with and generic names
the individual. JCAHO also will be looking for a hard copy of verbal orders for laboratory testing, per state and federal guidelines.
to ensure accurdCY.
• Don't use the patient'S room number or bed number as an identifier. • Don't ask a colleague to verify that it is Patient Z's blood. • Do ask the colleague to match the blood with Patient Z's name and unique identifier.
GOAL 3 Improve the safety of using high-alert medications Since the first Sentinel Event Alert, one death resulting from accidental
Common Risk Factors and Proaetive Planning Tips for High-Alert Medications Proactive Planning Common Risk Factors
GOAL 2 Effective communication and the importance of a "read back" of telephone or verbal orders for medications: In facilities ulat allow verbal orders or
telephone orders, although discoumged as much as possible, there should be a system of checks and balances to ensure ulat verbal orders for medications are confirmed and correct. JCAHO states that consistency of practice should be ensured through policy and procedure. TI,e process should allow for the order
injection of Potassium Chloride (KCL) has been reponed. Medications are included in a High-Alen Medication List with risk factors and planning discussed,
• No dose-check systems • Mix.ups due to insulin and
heparin vials being kept in
I. Insulin
• Establish a check system in which one nurse prepares the dose and another nurse reviews
it
close proximity to each other on nursing units • "U" used as an abbreviation for "units" in orders (can be confused with "0," leading to a
abbreviate it.
IQ-fold overdose)
• Establish an independent
• Incorrect rates programmed into an infusion pump
check system for infusion pump rates and concentration settings.
Spr
ng
• Do not store insulin and heparin near each other.
• Spell out "units" rather than
2003
.JVAD
47
.'