The Institute for Healthcare Improvement (IHI) spearheads National Patient Safety Week each year, seeking to encourage everyone to learn more about health care safety and the steps we can take to protect ourselves and our patients from harm.
March 13-19, 2022 is National Patient Safety Week, a week to honor the important work of protecting patients and health care staff from harm. This year’s theme is, “Together, we are Better, Stronger, and Safer!”
The Institute for Healthcare Improvement (IHI) spearheads National Patient Safety Week each year, seeking to encourage everyone to learn more about health care safety and the steps we can take to protect ourselves and our patients from harm. This harm is not only found in hospital settings; the World Health Organization estimates that approximately 40% of patients cared for in ambulatory and primary care settings experience harm. In the United States, there are as many as 400,000 deaths each year resulting from preventable harm in a health care setting.
Preventing harm requires working together
Is this scenario a familiar one for you as a staff member, patient, or family member?
It was an icy February evening when Kim noticed her mom was not responding when she tried to wake her up. Kim knew the hospice nurse would not be able to get to her home due to the icy roads. She called 911, and the EMS team transported her mom to the local emergency department (ED).
Kim’s mom was evaluated in the ED and was found to have a urinary tract infection. While her mom was getting a CT scan, the nurse reviewed the patient’s medications with Kim. Kim didn’t bring her mom’s medication list with her, so she described the medications as best she could before remembering she could call the hospice nurse for help with the medications. The hospice nurse called back and read the medication list to the ED nurse, but she was working from an old set of data, as her laptop was having connectivity issues.
The old data did not include two recent medication changes that impacted the patient’s absorption of her warfarin. The hospital decreased the warfarin dose based on the lab results, but without the two new medications that were omitted from the list, she was no longer adequately anticoagulated. She suffered a stroke two days after returning home from the ED.
In this scenario, the ED nurse, the daughter, and the hospice nurse all tried to provide safe, effective care. Unfortunately, the patient was harmed after an incomplete medication handoff. Preventing harm means we must work together, committing to patient safety. This video from the World Health Organization video clip beautifully illustrates how “Together, we are Better, Stronger, and Safer.”
How does this challenge impact your hospice or home health agency?
The scenario above involved coordination between a hospice organization and the ED. While no agency wants to harm their patients, how much energy and resources should you focus on this issue? 400,000 deaths a year from preventable harm is a lot, but most of that is in the hospital, right?
You may be familiar with the use of checklists to ensure no key steps are missed in the operating room. If you have had surgery, you are familiar with the requirement for the surgeon to autograph the appropriate knee or hip. Dr. Atul Gawande, the force behind the operative check list, describes its value in this video. Unfortunately, patient harm is prevalent in the post-acute setting as well. Patients receiving care in their home are at risk of harm and your agency must identify and address these risks. Luckily, there are tools you can use to minimize harm and mitigate risks that can be used in the home setting.
If operating room risks are not something you need to focus on, where should you focus your resources? One tool to incorporate into your agency’s policies and practice is the Joint Commission National Patient Safety Goals (NPSG). Even if you are not Joint Commission-accredited, the information is valuable and will help you focus on areas where your agency is most at risk.
The National Patient Safety Goals for the Home Care Program applies to care provided wherever the patient calls home. Home care, home health, and hospice agencies can use these goals to better understand their risks and ensure they are doing their best to minimize them.
These are the National Patient Safety Goals for the Home Care Program – 2022.
NPSG #1: Improve the accuracy of patient identification.
NPSG #3: Improve the safety of using medications.
NPSG #7: Reduce the risk of health care-associated infections.
NPSG #9: Reduce the risk of patient harm resulting from falls.
NPSG #15: The organization identifies safety risks inherent in its patient population (risks associated with home oxygen therapy).
Applying National Patient Safety Goals to improve your quality of care
Using these safety goals, you can set your organization up for success:
Ensure that staff identify patients, especially those living in a communal setting, prior to providing treatments, administering medications, and obtaining specimens. Make sure your staff label all specimens in the patient’s presence. Patients with cognitive impairment can answer to the wrong name!
Ensure that your agency has a robust medication reconciliation process in place. Make sure medication handoffs are complete and medication error reduction strategies are incorporated into your quality program.
Evaluate your hand hygiene program annually and adjust goals as needed. Hand hygiene assessments should be done at every joint visit, not just annually.
Educate your staff annually on your fall assessment and prevention program and policies. Incorporate your fall data into your quality improvement program.
Work with your oxygen provider to follow up with patients and families regarding oxygen safety. Ensure everyone who makes patient visits is able to spot oxygen safety risks and knows how to correct risks and communicate them to the correct person.
Remember, patient safety is everyone’s job
As healthcare providers, it is everyone’s responsibility to speak up when they see a risk. Sometimes that means speaking up when it may feel uncomfortable to do so. But speaking up can mean the difference between harm and keeping patients and coworkers safe. For tips on how to do this, watch this video on speaking up for patient safety.
If you want more information on the National Patient Safety Goals for the Home Care Program – 2022, check out our 30-minute course coming in April! Remember, even if your agency is not affiliated with The Joint Commission, these goals will still be useful for your staff and your organization.
If you want more information on medication safety, look for two medication safety courses, one focused on the home setting and one specific to hospice, which will be out this summer.
For more resources you can use to learn about National Patient Safety Week and how other organizations celebrate and share your activities, take a look at:
Remember, “Together, we are Better, Stronger, and Safer!”