Medication Management (Safe Practices 14-18)

Medication Management (Safe Practices 14-18) David Bates, MD Hayley Burgess, PharmD Charles Denham, MD November 8, 2007 This Webinar focuses upon the following NQF-EndorsedTM Safe Practices: Safe Practice 14. The healthcare organization must develop, reconcile, and communicate an accurate medication list throughout the continuum of care. Safe Practice 15. Pharmacists should actively participate in medication management systems by, at a minimum, working with other health professionals to select and maintain a formulary of medications chosen for safety and effectiveness, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, assurance of the safe storage and availability of medications, dispensing of medications, and administration and monitoring of medications. Safe Practice 16. Standardize methods for the labeling and packaging of medications. Safe Practice 17. Identify all high-alert drugs, and establish policies and processes to minimize the risks associated with the use of these drugs. At a minimum, such drugs should include intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, and opiates. Safe Practice 18. Healthcare organizations should dispense medications, including parenterals, in unit-dose, or, when appropriate, in unit-of-use form, whenever possible. 2007 TMIT 1

NQF Safe Practices for Better Healthcare: A Consensus Report 30 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness 2007 TMIT 2

NQF Safe Practices Maintenance Committee Safe Practice 2006 Update Process SWOT analysis of each practice Comprehensive literature search Expert technical advisory support from more than 250 experts Participation by The Joint Commission, CMS, and AHRQ Input from hospitals and facility involved in 100,000 Lives Campaign Feedback from the Field - Hospitals that reported publicly through The Leapfrog Group and TMIT National Research Test Bed 2007 TMIT 3

Harmonization The Quality Choir 2007 TMIT 4

The Patient Our Conductor 2007 TMIT 5

2007 TMIT 6

7 7

Click Here To Register 8 8

Click Here To Access Resources From Prior Workshops or Webinars 9 9

Click Here To Access Resources From Prior Workshops or Webinars 10 10

Click Here To Access Slide Sets, Summary Table of Practices, and Peer Reviewed Papers 11 11

30 Safe Practices Organized into Functional Chapters Creating and Sustaining a Culture of Safety (Chapter 2) Informed Consent, Honoring Patient Wishes, and Disclosure (Chapter 3) Matching Healthcare Needs with Service Delivery Capacity (Chapter 4) Information Management and Continuity of Care (Chapter 5) Medication Management (Chapter 6) of Healthcare-Associated Infections (Chapter 7) Condition- and Site-Specific Practices (Chapter 8) 2007 TMIT 12

Expansion Implementation Approaches New Horizons and Areas for Research Outcomes, Structure, Process, and Patient-Centered Measures Setting-specific applicability - Rural Hospitals - Children s Hospitals - Specialty Hospitals Relation of each Safe Practice to other relevant Practices 2007 TMIT 13

27 Safe Practices required modification 23 Safe Practices included changes deemed material and will require vote 3 Safe Practices embedded into other related practices Risk of Malnutrition Use of Pneumatic Tourniquets Medication Workspaces 3 New Safe Practices Medication Reconciliation Direct Caregivers Disclosure 2007 TMIT 14

Culture SP 1 2007 NQF Report Culture Consent & Disclosure Consent & Disclosure Workforce Information Management & Continuity of Care Medication Management Healthcare-Assoc. Infections Condition- & Site-Specific Practices 2007 TMIT All Rights Reserved 15

2007 NQF Report CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 16 DVT/VTE Sx Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture Culture SP 1 CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Structures Culture Meas, Team Training ID Mitigation & Systems F.B, & Interv. & Team Interv. Risk & Hazards Culture Measurement, Feedback and Interventions CHAPTER 2: Creating and Sustaining a Culture of Teamwork Patient Training and Team Safety Interventions Identification and Mitigation of Risks and Hazards CHAPTER 1: Background Summary, and Set of Safe Practices Leadership Structures & Systems Consent & Disclosure Culture Measurement, Feedback and Interventions Informed Life Sustaining Disclosure Consent Treatment Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTERS 2-8 : Practices By Subject Nursing Workforce Work Force Direct Caregivers ICU Care CHAPTER 3: Informed Consent & Disclosure Informed Consent Life Sustaining Treatment Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 17 DVT/VTE Sx Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices CHAPTERS 2-8 : Practices By Subject Structures & Systems Consent & Disclosure Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Culture Meas., F.B., & Interv. Discharge System Medication Management High-Alert Meds Culture CPOE Med. Recon. Team Training & Team Interv. Order Read-back Std. Med. Labeling & Pkg. ID Mitigation Risk & Hazards ICU Care Abbreviations Unit-Dose Medications CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Life Sustaining Informed Consent Consent Treatment Disclosure Life-Sustaining Treatment CHAPTER 3: Informed Consent & Disclosure Disclosure Informed Consent Work Force Life-Sustaining Treatment Nursing Direct Workforce Caregivers Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 18 DVT/VTE Sx Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas, F.B, & Interv. Life Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Force CHAPTER 4: Workforce Direct Nursing Workforce Workforce Caregivers Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg ICU Care Abbreviations Unit-Dose Medications CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 19 DVT/VTE Sx Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Consent & Disclosure Informed Consent Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Hand Hygiene Hospital-Associated Infections Influenza Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers Nursing Direct Workforce Caregivers ICU Care ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Information Management & Continuity of Care Labeling Studies Critical Order Care Info. Read-back Discharge Systems Labeling Discharge CPOE Abbreviations Studies System Safe Adoption of Integrated Clinical Systems including Medication Management CPOE Med Recon. Order Read-back Pharmacist High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications Abbreviations Asp. + VAP Central V. Cath BSI Sx Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 20 DVT/VTE Contrast Media Use CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Hand Hygiene Critical Care Info. Influenza Asp. + VAP Central V. Cath BSI Order Read-back CHAPTER 6: Medication Labeling Discharge Management CPOE Abbreviations Studies System Pharmacist Role Medication Management Medication Reconciliation Med Recon. High-Alert Medications Pharmacist High Alert Std. Med Unit Dose Central Role Meds & Pkg Medications Standardized Medication Labeling & Packaging Unit-Dose Medications Hospital Acquired Infections Sx Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 21 DVT/VTE Contrast Media Use CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Consent & Disclosure Informed Consent Culture Meas., F.B, & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Hospital-Acquired Infections Hospital Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Asp +VAP Central Venous Catheter-Related Blood Stream Infection Central Venous Catheter-Related Blood Stream Surgical Site Infection Influenza Central V. Cath Sx Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Condition & Site Specific Practices Press. Ulcer Critical Care Info. Evidence- Based Ref. Discharge System Wrong-site Sx Anticoag. Therapy CPOE Periop. MI 22 Order Read-back Abbreviations CHAPTER 7: Healthcare-Associated Infections Medication Management of Aspiration and Med Recon. Ventilator- Associated Pneumonia, Pharmacist High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications Hand Hygiene Influenza Infection Surgical Site Infection DVT/VTE Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Team Training & Team Interv. Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Hospital-Acquired Infections Hospital Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Asp +VAP Central Venous Catheter-Related Blood Stream Infection Wrong-Site, Wrong Procedure, Wrong Person Surgical Site Infection Influenza Central V. Cath Sx Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Press. Ulcer Critical Care Info. Discharge System Wrong site Sx CPOE Peri-Op MI 23 Order Read-back Abbreviations CHAPTER 8: Condition- Medication or Management Site-Specific Practices Evidence-Based Referrals Med Recon. Anticoagulation Pharmacist Therapy High Alert Std. Med Unit Dose Central Role Meds Labeling & Pkg Medications DVT/VTE Pressure Ulcer Surgery Perioperative Condition Myocardial & Site Specific Infarct/Ischemia Practices Evidence Anticoag DVT/VTE Based Ref. Therapy Contrast Media-Induced Renal Failure Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

2006 Proposed NQF Report Culture Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Hospital-Acquired Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath BSI Anticoag. Therapy Periop. MI 24 DVT/VTE Sx Site Inf. Contrast Media Use CHAPTER 7: Hospital-Acquired Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions 263 (Prior SP 1)* 300 SME 120 20 40 1000 Points Spread Over 30 Practices 3 New & 3 Redefined Practice Element 4: Identification & Mitigation of Risks and Hazards 120 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) 9 12 4 4 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight Safe Practice 4: Disclosure NA 25 CHAPTER 7: of Healthcare-Associated Infections CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) 119 Safe Practice 6: Direct Caregivers NA New Safe Practice 7: ICU Care Leap 2 100 20 Safe Practice 19: of Aspiration and VAP (Prior SP 19) Safe Practice 20: CVC BSI (Prior SP 20) Safe Practice 21: Surgical Site (Prior SP 21) 24 33 37 20 30 30 CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 22: Hand Hygiene (Prior SP 25 ) 33 30 Safe Practice 8: Critical Care Information ( Prior SP 9) 84 84 Safe Practice 23: Influenza (Prior SP 26) 11 10 Safe Practice 9: Order Read-Back (Prior SP 6) 36 25 Chapter 8: Condition- and Site-Specific Practices Safe Practice 10: Labeling Studies (Prior SP 13) 16 15 Safe Practice 24: Evidence-Based Referrals Leap 3 Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE 17 Leap 1 25 Safe Practice 25: Wrong-Site, Wrong Procedure, Wrong Person Surgery (Prior SP 14) 30 20 Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management 17 15 Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15) 23 20 Safe Practice 14: Medication Reconciliation NA New 35 Safe Practice 27: Pressure Ulcer (Prior SP 16) 28 25 Safe Practice 15: Pharmacist Role (Prior SP 5) 32 32 Safe Practice 28: DVT/VTE (Prior SP 17) 27 25 Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) 22 20 Safe Practice 29: Anticoagulation Therapy (Prior SP 18) 39 35 Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) 21 29 20 25 Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 2 ) 12 10 25 2006 CareLeaders Corp.

EXECUTIVE SUMMARY OVERVIEW CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions Practice Element 4: Identification & Mitigation of Risks and Hazards 2004 Weight 263 (Prior SP 1)* 300 SME 2007 Weight 120 20 40 120 What went up or is new? Culture 263 to 300 Disclosure 25 Direct Care Giver - 20 Medication Reconciliation - 35 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) 9 4 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) 12 4 CHAPTER 7: of Healthcare-Associated Infections Safe Practice 4: Disclosure NA CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) 119 Safe Practice 6: Direct Caregivers NA New 25 100 20 Safe Practice 19: of Aspiration and VAP (Prior SP 19 ) Safe Practice 20: CVC BSI (Prior SP 20 ) Safe Practice 21: Surgical Site (Prior SP 21 ) 24 33 37 20 30 30 Safe Practice 7: ICU Care Leap 2 Safe Practice 22: Hand Hygiene (Prior SP 25 ) 33 30 CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 8: Critical Care Information ( Prior SP 9) 84 Safe Practice 9: Order Read-Back (Prior SP 6) 36 84 25 Safe Practice 23: Influenza (Prior SP 26 ) Chapter 8: Condition- and Site-Specific Practices 11 10 Safe Practice 10: Labeling Studies (Prior SP 13) 16 15 Safe Practice 24: Evidence-Based Referrals Leap 3 Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE 17 Leap 1 25 Safe Practice 25: Wrong-Site, Wrong Procedure, Wrong Person Surgery (Prior SP 14 ) 30 20 Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management 17 15 Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15 ) 23 20 Safe Practice 14: Medication Reconciliation NA New 35 Safe Practice 27: Pressure Ulcer (Prior SP 16 ) 28 25 Safe Practice 15: Pharmacist Role (Prior SP 5) Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) 32 22 32 20 Safe Practice 28: DVT/VTE (Prior SP 17) Safe Practice 29: Anticoagulation Therapy (Prior SP 18 ) 27 39 25 35 Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) 21 29 20 25 Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 22 ) 12 26 10 2006 CareLeaders Corp.

NQF Report 2006 Update Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Pharmacist Central Role Medication Management High Alert Meds Med Recon. Std. Med Labeling & Pkg Unit Dose Medications CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications CHAPTER 6: Improving Patient Safety Through Medication Management Safe Objective 14: To prevent adverse drug events (ADEs) by accurately and completely reconciling across the continuum of care. New Safe Practice Alignment and harmonization with JCAHO NPSG and IHI 100,000 Lives Safe Practice 14: The facility must develop, reconcile, and communicate an accurate medication list throughout the continuum of care. HARMONIZATION: Safe Practice 14: JCAHO CAMH 2006 Standards MM.1.10(2); NPSG 8A; 8B IHI 100,000 Lives Campaign Standardizing a Measure of Patient Perspectives of Hospital Care: A Consensus Report (NQF 2005) - HCAHPS 27 New Practice

SP 14: Medication Reconciliation PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Medication Reconciliation: The healthcare facility must develop, reconcile, and communicate an accurate medication list throughout the continuum of care. A standardized process must be in place to obtain and document a complete list of each patient s current medications upon admission to the facility, with the active involvement of the patient and, as appropriate, family or caregiver. The list includes those medications prescribed by the organization s first provider of service and comparison of all medications the organization provides to those on the list. The complete list of the patient s medications must be communicated to the next provider of service, the patient and, as appropriate, family/caregiver when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the facility. Providers receiving the patient in a transition of care should check the medication reconciliation list to make sure it is accurate and in concert with any new medications to be ordered/prescribed. The list should include the full range of medications as defined by accrediting organizations such as JCAHO. At a minimum the list should include: Prescription medications, Sample medications, Vitamins, Nutriceuticals, Over-the-counter drugs, Complementary and alternative medications, Radioactive medications, Respiratory therapy-related medications, Parenteral nutrition, Blood derivatives, Intravenous Solutions (plain or with additives), and Any product designated by the FDA as a drug. At a minimum, reconciliation must occur any time the organization requires that orders be rewritten: Any time the patient changes service, setting, provider, or level of care AND Anytime new medication orders are written. For transitions not involving new medications or rewriting of orders, the organization should determine whether reconciliation must occur. 28 28

NQF Report 2006 Update Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices CHAPTER 6: Improving Patient Safety Through Medication Management Safe Objective 15: Ensure that medications are used in safe and effective ways by taking a systems approach and leveraging the knowledge of pharmacists through a multi-disciplinary focus. Pharmacist Central Role Medication Management High Alert Meds Med Recon. Std. Med Labeling & Pkg Formerly Safe Practice 5 Former Safe Practice 27 incorporated in alignment with JCAHO MM standards Harmonized with JCAHO MM standards and NPSG including medication storage Unit Dose Medications CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications HARMONIZATION: Safe Practice 15: JCAHO CAMH 2006 Standards MM.2.10; MM.2.20; MM.2.30(8); MM.4.10; MM.4.10(11); MM.4.20; MM.4.20(15); NPSG 3C. Standardizing a Measure of Patient Perspectives of Hospital Care: A Consensus Report (NQF 2005) HCAHPS Safe Practice 15: Pharmacists should actively participate in medication management systems, including, at a minimum, working with other health professionals to select and maintain a formulary of medications chosen for safety and effectiveness, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, assuring safe storage and availability of medications, dispensing of medications, and administration and monitoring of medications. 29 Material Changes

SP 15: Pharmacist s Role PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Pharmacist s Role: Pharmacists should actively participate in medication management systems, including, at a minimum, working with other health professionals to select and maintain a formulary of medications chosen for safety and effectiveness, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, assuring safe storage and availability of medications, dispensing of mediations, and administration and monitoring of medications. Pharmacists should: Provide medication safety recommendations and promote medication error prevention strategies throughout the organization; Review all medication orders and the patient medication profile for appropriateness and completeness document the review in the patient s record before medications are dispensed or made available for except in those instances when review would cause a medically unacceptable delay; Oversee the preparation of mediations, including sterile products, and assure they are safely prepared; Work with others to identify and at a minimum, annually review a list of look-alike/sound alike drugs used in the organization, and take action to prevent errors involving interchange of these drugs; Work with others to assure that concentrated electrolytes are removed from care units unless patient safety is at risk if concentrated electrolyte is not immediately on a specific care unit or area or if concentrated electrolytes must stay in the care area, then special precautions must be taken to prevent inadvertent administration; NOTE: Potassium concentrates should never be stored in patient care areas except for areas where patients are undergoing open heart procedures. Work with others to provide a work environment that facilitates attention to detail, reduces distractions and interruptions and promotes the accurate prescribing, dispensing and administration of medication orders; and Ensure that all medication storage areas are periodically inspected according to the institution s policy to make sure mediations are stored properly and in a manner that precludes confusion between systemic internal medications and other substances. When a fulltime pharmacist is not available onsite, a pharmacist is available by telephone or accessible at another location that has 24 hour pharmacy services. 30 30

NQF Report Culture 2006 SP 1 Update CHAPTER 1: Background Summary, and Set of Safe Practices Pharmacist Central Role Medication Management High Alert Meds Med Recon. Std. Med Labeling & Pkg Unit Dose Medications CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications CHAPTER 6: Improving Patient Safety Through Medication Management Safe Objective 16: Ensure that systems are in place to optimize proper labeling and packaging of medications in order to reduce adverse events resulting in improper labeling and packaging. Formerly Safe Practice 28 Expansion of practice to include labeling and packaging outside the pharmacy Aligned and harmonized with JCAHO MM standards and NPSG Medication storage now addressed in revised Safe Practice 15. HARMONIZATION: Safe Practice 16: JCAHO CAMH 2006 Standards MM.4.30;MM.4.30(4); NPSG 3B; 3D Standardizing a Measure of Patient Perspectives of Hospital Care: A Consensus Report (NQF 2005) HCAHPS. Safe Practice 16: Standardize methods for labeling and packaging of medications. 31 Material Changes

SP 16: Standardized Medication Labeling and Packaging PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Standardized Medication Labeling and Packaging: Standardize methods for labeling and packaging of medications. Medications should be labeled in a standardized manner according to: hospital policy applicable law and regulation and standards of practice. At a minimum all medications should be labeled with: Drug name, strength, and amount; Expiration date ( beyond use date or the last date that the product should be used) when not used in 24 hours); Expiration time if expiration occurs in less than 24 hours; and Date prepared and diluent for all IV admixtures. All medications, including medications and solutions both on and off the sterile field, should be labeled when transferred from the original package to another container even if there is only one medication being used. To aid staff and standardize labeling, pharmacists should provide appropriate labels for sterile procedure areas when the process of labeling containers is performed. Limit and standardize parenteral drug concentrations and utilize ready-touse products, to the extent possible. Ensure compliance with the policies and procedures for medication labeling and packaging. 32 32

Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Safe Objective 17: To ensure safe use of high alert drugs by taking a systematic multidisciplinary approach and leveraging human factors principles... NQF Report 2006 Update CHAPTER 6: Improving Patient Safety Through Medication Management Pharmacist Central Role Medication Management High Alert Meds Med Recon. Std. Med Labeling & Pkg Unit Dose Medications Former Safe Practice 29 Alignment and harmonization with JCAHO MM standards including, at a minimum, which medications should be included in high alert medication list. Includes medications that can pose risk to healthcare workers as well as patients. Multidisciplinary team approach to identification, protocol/guideline development, monitoring and information exchange, as well as performance improvement. Critical importance of human factors principles in safe use design CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications HARMONIZATION: Safe Practice 17: JCAHO CAMH 2006 Standards MM.7.10(2) Safe Practice 17: Identify all high alert drugs and establish policies and procedures to minimize the risks associated with use of these drugs. At a minimum, such drugs should include intravenous adrenergic drugs, agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, and opiates Material Changes 33

SP 17: High-Alert Medications PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST High-Alert Medications: Identify all high alert drugs and establish policies and procedures to minimize the risks associated with the use of these drugs. At a minimum, such drugs should include intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, and opiates. Explicit organizational policies and procedures (such as procuring, ordering, transcribing, preparing, dispensing, administering, and/or monitoring) should be in place for the management of high-alert drugs. Such policies include assuring that staff has appropriate qualifications or certifications to handle certain drugs such as anesthesia and chemotherapy medications. A multidisciplinary team should be formed and utilized to identify and regularly review safeguards for all high-alert drugs. Designate, communicate and make available to relevant caregivers a list of high-alert drugs with protocols, guidelines, dosing scales, and/or checklists for each high-alert drug (e.g. nomograms for heparin, standardized order forms for antineoplastic drugs). Implement a process to identify new medications for addition to the highalert drug list. Implement a process to audit compliance with high-alert protocols and guidelines. Centralize or externalize (e.g. outsource) as appropriate, error prone processes (e.g. IV admixture programs). Evaluate and improve access to drug information regarding high alert mediations at the point of care and other areas where such medications pose a risk to patients or staff, as indicated. 34 34

NQF Report 2006 Update Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Pharmacist Central Role Medication Management High Alert Meds Med Recon. Std. Med Labeling & Pkg Unit Dose Medications CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit Dose Medications CHAPTER 6: Improving Patient Safety Through Medication Management Safe Objective 18: Reduce adverse events resulting from bulk packaging of medications. Former Safe Practice 30 Explicit inclusion of parenterals Education to staff accountable for preparation of unit dose medications on how to use each single dose packaging systems provided by the organization. Alignment and harmonization with JCAHO MM standards HARMONIZATION: Safe Practice 18: JCAHO CAMH 2006 Standards MM.4.40 (4)(5) General Tests and Assays Chapter 797. Pharmaceutical Compounding Sterile Preparations (USP) Safe Practice 18: Healthcare organizations should dispense medications, including parenterals, in unit-dose, or when appropriate unit-of-use form, whenever possible. 35 Material Changes

SP 18: Unit Dose Medications PRACTICE ADDITIONAL SPECIFICATIONS CHECKLIST Unit Dose Medications: Healthcare organizations should dispense medications, including parenterals, in unitdose, or when appropriate unit-ofuse form, whenever possible. Medications, including parenterals, should be contained in unit-dose (single-unit) packages and maintained in this form until time for administration. Medication in patient care areas, including parenterals, should be maintained in the most ready-to-administer forms available from the manufacturer or, if feasible, in unit-doses that have been repackaged by the pharmacy or a licensed repackager. Every unit-dose package label should contain a machine-readable code identifying the product name, strength, and manufacturer. For most medications, not more than 24 hour supply of doses should be delivered to, or be available at, the patient care area at any time. There should be an established ongoing organizational process to monitor the use of unit-dose medications. The organization consistently uses one dose packaging system or if more than one system is used, the organization provides education about the use of all dose packaging system(s) in use to those using them. 36 36

2007 TMIT 37