Quality, Patient Safety, Communication, Recordkeeping PDF

RT-108 BSRT - 2A Objectives De ne quality and patient safety Know the importance of quality and patient safety Know how to safely move patient Know the di erent hazards and what to do Know what is record keeping and its importance fi ff Quality and Patient Safety What is Qualit...

RT-108 BSRT - 2A Objectives De ne quality and patient safety Know the importance of quality and patient safety Know how to safely move patient Know the di erent hazards and what to do Know what is record keeping and its importance fi ff Quality and Patient Safety What is Quality? The quality of a service or product refers to the sum of its properties that serve to satisfy the need of its consumer. High quality services get high demand and also become a source of pride and nancial success for the producer. fi Safety Considerations Safety is a very important part of ensuring high-quality care. Patient safety must always be the rst consideration in respiratory care. The key areas of potential risk for patients, RT, and co-workers: Patient movement and ambulation, electrical hazards, re hazards, and general safety concerns. fi fi Patient Movement and Ambulation Basic Body Mechanics Posture involves the relationship of the body parts to each other. Poor posture may place inappropriate stress on joints and related muscles and tendons. The correct technique: straight spine and use of the leg muscles to lift the object.  Moving the patient in bed Conscious people assume positions that are the most comfortable. Bedridden patients often assume an upright position. In other cases, patients may have to assume certain positions for therapeutic reasons; postural drainage applied. Ambulation Helps maintain normal body function. Extended bed rest can cause numerous problems, including bed sores and atelectasis. Should begin as soon as the patient is physiologically stable and free of severe pain. RTs may assist to ambulate patients while they are on a O2 support. Safe Patient Movement Steps: 1. Place the bed in a low position and lock its wheels. 2. Place all equipment (e.g., intravenous (IV) equipment, NGT, surgical drainage tubes) close to the patients to prevent dislodgment during ambulation.  Safe Patient Movement Steps: 3. Assist the patient to sit up in bed (i.e., arm under nearest shoulder and one under farthest armpit). 4. Place one hand under the patient’s farthest knee, and gradually rotate the patient so that his or her legs are dangling o the bed. ff  Safe Patient Movement Steps: 5. Let the patient remain in this position until dizziness or light- headedness lessens (encouraging the patient to look forward rather that at the oor may help). fl Safe Patient Movement Steps: 6. Assist the patient to a standing position. 7. Encourage the patient to breathe easily and unhurriedly during this initial change to a standing posture. 8. Walk with the patient using no, minimal, or moderate support (moderate support requires the assistance of two practitioners, one on each side of the patient).  Safe Patient Movement Steps: 9. Limit walking to 5 to 10 minutes for the rst exercise. Monitor the patient during ambulation. Note the patient’s level of consciousness, color, breathing, strength or weakness, and complaints. fi Safe Patient Movement Steps: 10. Each session is documented in the patient chart The date and time of ambulation, length of ambulation, and degree of patient tolerance. Electrical Safety The potential for accidental shocks of patients or personnel in the hospital exists because of the frequent use of electrical equipment. The presence of invasive devices, such as internal catheters and pacemakers, may add to the risk for serious harm from electrical shock. RTs must understand the fundamental of electrical safety because respiratory care often involves the use of electrical devices. Fundamentals of Electricity The ability of humans to create and harness electricity is one of the most important developments in modern times. Despite the fact that electricity is one of the most popular sources of power, most people who use it have a poor understanding of it. Lack of knowledge is often a major factor in cases of electrocution. Preventing Shock Hazards Most shock hazards are caused by inappropriate or inadequate grounding. All equipment brought into the patient care area has been approved and checked on a regular basis by a quali ed expert. fi GROUND ELECTRICAL EQUIPMENT NEAR THE PATIENT All electrical should be connected to grounded outlets with three-wire cords. The third (ground) wire prevents the dangerous buildup of voltage that can occur on the metal frames of some electrical equipment.  Modern electrical devices used in hospitals are designed so their frames are grounded, but their connections to the patient are not. All electrical devices in reach of the patient are grounded, but the patient remains isolated from ground. Fire Hazards Signi cant reduction in health care facility res is primarily due to education and enforcement of strict re codes. 23% of res - hospitals or hospice 46% of res - nursing homes Most hospital res start in kitchen fi fi fi fi fi fi  3 conditions must exist for re to start: ✓ Flammable material must be present, ✓ O2 must be present, and ✓ The ammable material must be heated to or above its ignition temperature. fl fi  Fires in area where oxygen is being used are especially dangerous Fires in O2-enriched atmospheres (OEAs) are larger, more intense, faster burning, and more di cult to extinguish. O2 is non ammable, but: It greatly accelerates the rate of combustion Oxygen supports combustion fl ffi PASS - re extinguisher training P - pull pin A - aim nozzle S - squeeze handle S - sweep nozzle across base re If you identify a re in a patient care area, you must know what to do. Each hospital must have a core re plan that identi es the responsibilities of hospital personnel fi fi fi fi fi  RACE - core re plan Rescue patients in the immediate area of the re Alert other personnel about the re so they can assist in the rescue and can relay the location of the re to the o cials. Contain the re. Evacuate other patients and personnel in the areas around the re who may be in danger if the re spreads. fi fi fi ffi fi fi fi fi  RTs are frequently key participants in successful handling of hospital re. First, they know where the O2 zone valves are located and how to shut them o. Second, they have the knowledge and skills needed to evacuate patients receiving mechanical ventilation or supplemental O2 to sustain life. Third, they know how to treat and resuscitate victims of smoke inhalation. ff fi Question: 3 conditions must exist to start a re. What are those conditions? fi Question: How do you use the re extinguisher? fi Question: Most shock hazards are caused by? General Safety Concerns Direct Patient Environment Immediate environment around the patient can create risk for patient safety. To reduce the risk for patient falls and allow easy access to care, should be as free of impediments to care as possible. When care is completed, the RT should ensure that the patient has easy access to the patient call system.  Disaster Preparedness A key component involves learning to transport and transfer critically ill patients safely and preparation of loss of electricity. In these emergencies, hospitals have backup generators to power essential equipment. It is important for the RT to know the speci c hospital policy for power failures and other potential disasters. fi  Magnetic Resonance Imaging Safety MRI exposes the body to powerful magnetic elds and a small amount of radio-frequency. RTs need to become familiar with MRI-compatible ventilators, O2 supplies, and ancillary equipment. Each radiology department has speci c rules and safety precautions that need to be communicated to all patients, caregivers, and health care personnel. fi fi  Medical Gas Cylinders Use of compressed gas cylinders by RTs requires special handling. Improper storage or handling of cylinders include increased risk for re, explosive release of high- pressure cylinders, and the toxic e ect of some gases. It is important to store and transport cylinders in appropriate racks or chained containers Compressed gas cylinders should never be stored without support. fi ff Record-Keeping Recordkeeping The electronic medical record (EMR) is changing way healthcare practitioners document care. The overall content and concept of what we record remains the same. A medical records or chart presents a written picture of occurrences and situations pertaining to a patient throughout his or her stay in a health care institution. Property of institution and strictly con dential. Legal document For this reason, charting or record keeping must be done so that it is meaningful for days, months, or years. fi Components of a Traditional Medical Record Each health care facility has its own speci cation for the medical records it keeps. They vary among institutions, but most acute care medical records share common sections. Documentation sheets are designed to report data brie y and to decrease time spent in documentation. Entries can include any measurements, and review of a sequence of entries can reveal trends in patients’ status. fi fl Legal Aspects of Recordkeeping Legally, documentation of the care given to a patient means that care was given; no documentation means that it was not given. If the RT does not document care given, the practitioner and the hospital may be accused of patient neglect. Adequate documentation of care is valuable only in reference to standards and criteria of care. Documentation must re ect these standards. fl Practical Aspects of Recordkeeping Documentation is required for each medication, treatment, or procedure. Accounts of the patient’s condition and activities must be charted accurately and in clear terms. Brevity is essential, although a complete account of each patient encounter is needed. Documentation of consultations with the attending physician that include the date and time of the conversation is recommended. Assessments of data must be clearly within one’s professional domain. General Rules Entries on the patient’s chart should be printed or handwritten unless the institution is using an electronic medical record. Institutional policy may require that supervisory personnel countersign student entries in the hand-written record. Do not use ditto marks (“). Do not erase. Erasures provide reason for question if the chart is used later in a court of law. General Rules Record after completing each task for the patient, and sign your name correctly after each entry. Be exact in time, e ect, and results of all treatments and procedures. Chart patient complaints and general behavior. Leave no blank lines in the charting. Draw a line through the center of an empty line or part of a line. ff General Rules Use the present tense. Never use the future tense, as in “patient to receive treatment after lunch”. Spell correctly. Document conversations with the patient or other health care providers that you think are important (e.g., you informed the patient’s physician or nurse that the patient seems confused or more short of breath). Problem-Oriented Medical Record It is an alternative documentation format used by some health care institutions. POMR contains 4 parts: 1. Database 4. Progress notes - Contains routine information about the - Contain the ndings (subjective and patient. objective data), assessment, plans, and orders of the physicians, nurses, and other 2. Problem list practitioners involved in the care of the patient. - something that interferes with a patient’s physical or psychologic health or ability to - Whether electronic or written, the precise function. forms these records take vary among institutions but will share common 3. Plan information. fi POMR progress notes The format used is often referred to as SOAP S = subjective information O = objective information A = assessment P = plan of care Rule of Thumb Charting Progress Notes Using the SOAP Format Subjective information obtained from the patient, his or her family members, or a similar source Objective information based on caregivers’ observations of the patient, the physical examination, or diagnostic or laboratory tests such as arterial blood gases or pulmonary function tests Assessment which refers to the analysis of the patient’s problem Plan of action to be taken to resolve the problem