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Online Version is available on the SHCC website. Click on "Current Pearls" in sidebar or goto: www.shccPearls.com
••ALERTS: 2010 NPSG, 2010 Univ Proto, ESC Tool, 2010 PC Chapter, Fld Rvw: Staff Effec ••REFS: SEA#43, Newest Deemed Stndrds, Med Mgt Tracers, RM Tracers, H1N1 Pregnancy, H1N1 Podcast ••PEARLS: CDC H1N1 Preg Guide, ••DWNLDS: 2010 Standards (Pre-Pub), NASMHPD Wrkfrc Devel, H1N1 Podcas/FAQ
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Alerts
Perspectives v29 #10, Pg03- Approved: Revised Universal Protocol for 2010 [ALERT: JCSC and MD] Note that the protocol now applies to “all surgical and non-surgical invasive procedures.” Although an update of the relevant FAQ has not yet been posted, SIG told us that minor procedures such as venipuncture would still be excluded. There are also changes in the site-marking process.
Perspectives v29 #10, Pg14- Revision to the ESC Tool on Secure Extranet [ALERT: JCSC] The 'Who' sections of the electronic ESC now require more specificity. Titles are to be entered for the person responsible for implementing corrective actions and/or approving newly developed or revised policies, procedures or processes.
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Reference Articles
Perspectives v29 #10, Pg01- Approved: 2010 National Patient Safety Goals [••REF••] The 2010 NPSG were released on 9/25/09. While there are no new goals, there are language refinements and a significant number of deletions (6) and movement of requirements into standards (18). Much of the content is retained somewhere in the standards, but only five Goals (1-3 and 7-8) remain for hospitals/BHC. [ALERT: JCSC] "Effective immediately, during the on-site survey, surveyors will not evaluate compliance with requirements that have been deleted." It should also be noted that NPSG 8, which is still being evaluated/refined, is not included in these changes and is not being scored during survey (refer to March RTP for more details). The other changes will to into effect on January 1, 2010. The article includes a useful table of changes and a full description of the goals themselves. The pre-publication version of the 2010 NPSG chapter and outline are now available online at TJC.
Perspectives v29 #10, Pg10- Sentinel Event Alert: Leadership Committed to Safety [••REF••] TJC revised this SEA (#43) on 9/8/09 after we published our September review of the announcement in JC Online. It now provides a clarification of staff acts requiring discipline based in part on the work of James Reason. The article provides a summary of the SEA's 14 recommendations. However, the actual SEA#43 is the reference we would encourage LDR to read. See also Assessing Unsafe Acts (A table Developed by the Missouri Baptist Medical Center based on Managing the Risks of Organizational Accidents by James Reason)
Perspectives v29 #10, Pg16- Accepted: New and Revised Hospital Elements of Performance Related to CMS Application Process [ALERT: LDR, JCSC, MDx, HR, PI] & [••REF••] In response to the need for more specificity to meet DMS deemed status application requirements, TJC has now released a third revision of EP for TJC/CMS-DS hospitals. The article says "the majority of revisions are minor editorial changes…" A box is provided with descriptions of "More substantive changes…" made to 10 EP. This includes 7 new EP for 1/1/2010 implementation (EC.02.04.03, EP 14 - HR.01.01.01, EP 28 - LD.04.01.05, EP 9 MS.03.01.01, EP 16/17 - PC.03.01.01, EP 10 - RI.01.07.01, EP 18), 2 revised EP for 1/1/2010 implementation, (LD.04.04.05, EP 13 - PI.01.01.01, EP 2) and 1 New EP for 7/15/2010 implementation (LD.01.05.01, EP 8). There are also 3 revised EP related to telemedicine (LD.04.03.09, EP 4/9 - MS.13.01.01, EP 1), but TJC is still hoping to achieve allowance for credentialing and privileging by proxy that is currently not permitted by CMS. Their implementation is delayed until 7/15/2010. [Color code: relates to Nuclear Medicine, Anesthesia] See also full details in the 2010 Pre-Publication Standards [Info] {PDF}
The Source v7 #10, Pg08- Medication Management System Tracer: [••REF••] The article provides a list of 11 sample tracer questions for staff and another 5 for patients. JCSC and staff conducting medication management tracers should consider incorporating these questions into their practice tracers and PI processes.
Pt Safety v9 #10, Pg01- Without a Trace(r)… Your Organization May be at Increased Risk for a 'Never Event' [••REF••] This article generally encourages the use of tracer methodology as a pro-active improvement and prevention strategy. The particular focus is on the identification and avoidance of preventable serious incidents. NCQF calls these Never Events and CMS developed a similar list that it calls Hospital Acquired Conditions )HAC). The article includes tables listing each. You will recall from our review of a February Patient Safety article on 'Never Events' that CMS discontinued reimbursement for care related to such incidents in October 2008. If not currently doing so, JCSC and LDR should consider a more deliberate use and incorporation of tracers into their overall hospital performance improvement and risk management processes. This article provides useful suggestions, strategies and a sample tracer form. Take note of the use of tracer teams with recorders vs. the less formal, undocumented process conducted by one or two individuals. See also Tracer Methodology 101: Staff Training for Tracers, Source, April 2009, Vol 7, Issue 4
Pt Safety v9 #10, Pg02- Patient Safety Pulse: Your Patient Safety News: Pregnant Women Vulnerable to H1N1 Virus FYI: JCSC. [••REF••] There have been six deaths of pregnant women (April 15 - June 16, 2009) and a recent Lancet study[H1N1 2009 influenza virus infection during pregnancy in the USA, Lancet, Vol 374, Issue 9688] that suggests pregnant women may be more severely affected by HIN1. IC should be aware of the recommendation that pregnant women with suspected or confirmed influenza infection receive prompt treatment with antiviral medication as published in CDC clinical guidance for treatment and prophylaxis in pregnant women.
JCO 10/14/09:
- Free Podcast [••REF••] : IC Beginning 10/15/09 TJC and CDC are offering a free educational 30-minute podcast (with accompanying 47-slide PowerPoint) to help organizations prepare for … the 2009-2010 influenza season. After listening, you can also e-mail questions about H1N1 or seasonal influenza. The most frequently asked will be answered/included in an H1N1 FAQ
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