Patient Safety
2009 Hospitals' National Patient Safety Goals

Below are the Joint Commission's 2009 National Patient Safety Goals (NPSG) and related requirements that will apply specifically to accredited hospitals. Over the past six years in which the Joint Commission has issued the annual NPSG, Kuakini Medical Center has diligently taken steps to comply with these goals.

Goal: Improve the accuracy of patient identification.
Kuakini has implemented several methods of dual identification for patients. In the Chemotherapy department, patient information is placed behind a photo of the patient and later compared to the medical record. The Cardiac Catheterization Lab staff verbally asks patients their name and birth date and compare it to the patients’ driver’s license. Kuakini Medical Center will continue to use the patient’s name, medical record number and unique blood band identifier when administering blood products.

Prior to the start of any surgical or invasive procedure, a final verification process must be conducted to confirm the correct patient, procedure and treatment site. Kuakini caregivers follow a checklist to verify consent forms, the patient’s ID band, and if possible, verbally confirm the procedure with the patient. Immediately prior to the procedure, everyone involved observes a “time out” and re-confirms the patient’s identity and the procedure to be performed.

Physicians must actively participate in the "time out" before procedures and surgery that re-confirms the patient’s identity and the procedure to be performed. The performing physician should mark the patient’s surgical site.

Containers used for blood and other specimens are labeled in the presence of the patient.

Goal: Improve the effectiveness of communication among caregivers.
Clear and timely communication between caregivers is essential for safe, quality patient care.

Registered nurses at Kuakini who take physician orders over the telephone must write down the orders before confirming them with the physician. Simply listening to the physician order and then repeating it to the physician is no longer sufficient. This “read back” policy applies to all verbal or telephone orders, including medication orders.

The physician order sheet has been amended to include an area where nurses must initial to confirm that a “read back” took place.

Nurses also complete a shift report for each patient at the end of their shift. A standardized communication form ensures that patient care information is precisely relayed from one nursing shift to another to ensure that patient needs are addressed.

Kuakini already has a list of approved abbreviations, acronyms and symbols that can be used by physicians and staff. The Joint Commission recently issued an official list of abbreviations, etc. that health care facilities cannot use.

When patients are transferred from one health care professional to another (i.e. nursing shift changes) the caregivers must interact and allow for questioning about the patient's condition, care and treatment.

Kuakini departments, including the Laboratory, Imaging Services and Pathology departments, will immediately contact a patient’s caregivers when potentially life-threatening test results are discovered so that appropriate care can be quickly administered to the patient.

Goal:   Improve the safety of using medications.
Medications are clearly labeled prior to leaving Kuakini’s Pharmacy Department. Pharmaceuticals with similar looking and sounding names are stored away from one another in different areas of the pharmacy to prevent errors involving the interchange of these drugs.

Pharmacy compounds all Insulin and Heparin infusions in a sterile environment to ensure the cleanliness of the product. (The Pharmacy staff, in conjunction with the medical staff, provides an appropriate number of medications, strengths, and quantities to meet the needs of our patients.)

When available, Kuakini will try to order medications that are pre-labeled and dispensed to patients to minimize manipulations. In Kuakini’s Operating Rooms, however, medications are required to be transferred from a container to a syringe, or another container. In these cases, caregivers must clearly label all containers with any medication.

Anticoagulants are sometimes administered to patients to stop the inappropriate clotting of blood. Kuakini is in the process of developing an anticoagulant therapy program using standardized practices to reduce adverse drug events.

Goal:   Reduce the risk of health care-associated infections.
CDC hand hygiene guidelines note that using gloves in a health care setting reduces hand- and cross-contamination by 70 to 80 percent, so health care providers should also wash their hands regularly with soap and water and a fast-acting, alcohol-based hand rub.

The goal also directs health care providers to report all identified cases of unanticipated death or major permanent loss of function associated with a health care acquired infection as a sentinel event.

In April 2003, Kuakini revised its hand hygiene policy and procedures to fully comply with current CDC guidelines.

Goal:   Accurately and completely reconcile medications across the continuum of care.
At the time of admission, patients are asked to provide names, doses, and frequency of medication currently taken. This list is used to help providers order appropriate home medications for continuation in the hospital. Medications ordered for administration during hospitalization must be reordered after surgery and transferred between a medical/surgical unit and critical care unit. The patient's most current Medication Administration Record is referenced to ensure all necessary medications are re-ordered. When the patient is discharged to home or another care facility such as a long-term care facility, a complete list of the patient's medication is forwarded to the patient (or caregiver) and the next provider of care.

Goal:   Reduce the risk of patient harm resulting from falls.
Kuakini policies require that patients are assessed for falls upon admission, after every nursing shift (8 or 12 hours), and after the occurrence of any change in the patients’ condition. A patient’s potential risk for falls is also associated with the patient's medication regimen. Appropriate action is taken to address any identified risks. 

Goal: Encourage patients’ active involvement in their own care as a patient safety strategy.
The patient has the right to exercise his/her individual rights regarding patient care and to be involved in all aspects of his/her care including the development and implementation of his/her plan of care. The patient’s family or authorized representative has the right to participate in the decisions of patient care; however, the patient has the right to exclude family members from participating in the decision of patient care and to inform the Medical Center of this position.

This statement has been added to the “Patients’ Rights and Responsibilities” handout that every Kuakini patient receives upon admission. Kuakini will also launch an educational campaign to improve customer services and communication between Health Care Team members, patients and patients' family members.

Goal: Improve recognition and response to changes in a patient's condition.
A significant number of critical inpatient events are preceded by warning signs for an average of 6 to 8 hours. Critical events such as cardiopulmonary and respiratory arrests or changes in a patient’s vital signs are estimated to occur in 4% to 17% of inpatient admissions. Early response by a specially trained individual(s) to changes in a patient’s condition may reduce cardiopulmonary arrests and patient mortality.

Plans are currently being developed to create a rapid response team that will quickly address a patients’ condition if it worsens.

If you have any questions about Kuakini’s compliance with the National Patient Safety Goals, call Risk and Safety Manager Jan Pang at 547-9231.

Patient Safety