Category Archives: Quality

The Joint Commission Weekly Reminders

Check-List-Logo-360pxREMINDER #5: PROTECTED HEALTH INFORMATION (PHI)

Per Shore Regional Health Administrative Policy IM-08:

  • Only authorized personnel shall be permitted direct access to the electronic medical record or to storage and retrieval areas
  • When in use, records containing protected health information shall be kept in secure areas at all times. Hard copy medical records shall not be left unattended in areas accessible to unauthorized individuals. PC monitor screens are positioned to guarantee secure service. Computer access security and timeout functions help assure PMI is secure.

Be sure to lock computers or log out of Meditech when walking away from your computer! Patient care information left on/near workstations should be turned upside down so that PHI is not viewable by others.

The Joint Commission Weekly Reminders

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REMINDER #3: CLEAN AND DISINFECT PATIENT EQUIPMENT PROPERLY

 

Reminder #3


REMINDER #4: THERAPEUTIC DUPLICATION

  • Two or more medications that are prescribe “as needed” for the same indication MUST have clear direction for use
    • i.e., if Promethazine and Ondansetron are both ordered for nausea and/or vomiting, the prescriber must provide instruction on when to use each
    • IMPROPER ORDERs:
      • Ondansetron 4 mg IV Q4H PRN nausea/vomiting
      • Promethazine 12.5 mg IV Q4H PRN nausea/vomiting
    • MORE APPROPRIATE ORDERs:
      • Ondansetron 4 mg IV Q4H PRN nausea/vomiting
      • Promethazine 12.5 mg IV Q4H PRN nausea/vomiting unrelieved by Ondansetron
  • If clear instructions for use are NOT provided, the prescriber must be contacted for clarification
    • As a nurse, you cannot decide which medication to give when

THIS IS WORKING OUTSIDE YOUR SCOPE OF PRACTICE

The Joint Commission Weekly Reminders

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Reminder #1: MULTI-DOSE VIALS and POUR BOTTLES

Per Shore Regional Health Administrative Policy TX-22:

  • Multidose medication vials must be dated when opened with the DISCARD date – which is 28 days
  • Solutions in pour bottles used for non-sterile treatments are opened and must be dated for discard the following day

Reminder #2: Pain Assessment and Reassessment

  • The numeric Pain Intensity Scale (0-10) is the standardized scale that will be used at SRH
  • Mild Pain = 1-3 on the scale
  • Moderate Pain = 4-6 on the scale
  • Severe Pain = 7-10 on the scale
  • If the patient is unable to use the numeric scale an alternate scale is to be used
  • A reassessment of the presence and intensity of pain is to be documented following interventions intended to reduce the patient’s pain.
  • Medication administered for pain must be administered as ordered
    • If Tylenol 2 tabs is ordered for mild pain then it cannot be administered for moderate or severe pain – if the patient needs medication for moderate or severe and there is nothing other than the Tylenol order then the Practitioner MUST be contacted for an order.
    • If Tylenol 2 tablets ordered as a nurse you cannot decide to give only 1 tablet and see how that helps –THIS IS WORKING OUTSIDE YOUR SCOPE OF PRACTICE – You must administer the medication exactly as ordered.

Birthing Center Wins March of Dimes Honor

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March of Dimes’ Recognition Banner presented: Chris Parker, UM Shore Regional Health CNO and VP-Clinical Services, Ruth Ann Jones, director of Acute Care and Emergency Services, Wendy Jarrett community director, March of Dimes’ Eastern Shore Division,  Luanne Satchell, nurse manager, Women’s and Children’s Health Services, UM SRH; UM SRH; Jessica Hales, March of Dimes’ Eastern Shore Division; and Ken Kozel, president and CEO , UM SRH.

March of Dimes’ Recognition Banner presented: Chris Parker, UM Shore Regional Health CNO and VP-Clinical Services, Ruth Ann Jones, director of Acute Care and Emergency Services, Wendy Jarrett community director, March of Dimes’ Eastern Shore Division,  Luanne Satchell, nurse manager, Women’s and Children’s Health Services, UM SRH; Jessica Hales, March of Dimes’ Eastern Shore Division; and Ken Kozel, president and CEO , UM SRH.

University of Maryland Shore Regional Health was recognized in June 2015 with the presentation of a banner award, by the March of Dimes’ Maryland National Capitol Area Chapter and its partner entities, the Maryland Patient Safety Center, and the Maryland Department of Health and Mental Hygiene. The award recognizes UM Shore Regional Health’s commitment to improving the quality of care for moms and babies and the great strides made by the Birthing Center at UM Shore Medical Center at Easton in reducing the rate of non-medically indicated deliveries prior to 39 weeks gestation.

The banner program is a component of the March of Dimes “Healthy Babies are Worth the Wait” campaign, which urges women to wait for labor to begin on its own if their pregnancy is healthy, rather than scheduling delivery before 39 completed weeks of pregnancy.

Premature births cost the U.S. more than $26 billion a year and take a high toll on families. Babies born just a few weeks early are at risk of severe health problems and lifelong disabilities, and premature birth is the leading cause of death of children under five years old.  While the national rate of elective pre-term births has been declining since 2006, the current 11.4 percent rate remains higher than that of most developed nations. March of Dimes’ goal is to reduce it to 5.5 percent by 2030.

To qualify for March of Dimes Banner Recognition, hospitals completed an application and provided the following: data for at least two consecutive quarters showing rate of elective pre-term deliveries below 5% for each quarter; a written policy regarding non-medically indicated deliveries less than 39 weeks gestation; and a description of the process for monitoring the rate of non-medically indicated deliveries less than 39 weeks. State-wide, 30 hospitals earned March of Dimes Banner Recognition this year.

“We are proud that our expert team has worked  to address this issue in our community and to establish policies to avoid scheduling deliveries before 39 weeks of pregnancy, except when medically necessary,” said Ruth Ann Jones, EdD, MSN, RN, NEA-BC, director of Acute Care and Emergency Services. “The Birthing Center multidisciplinary team has done an exemplary job in reducing early elective deliveries in order to provide the best care to our mothers and babies — truly Creating Healthier Communities Together.”

Maryland Hospital Association Launches “KIDsafe” Campaign On Children’s Identity Theft

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child id theftChildren are the the #1 target of identity thieves — in fact, children’s identities are 35 times more likely to be stolen than adults. And the threat of identity theft against kids is growing fast — in 2014 alone, the Interstate Technology and Regulatory Council reported a 300 percent increase in calls related to child identity theft.

Why do you need to protect your child’s identity as soon as possible? Because beyond the immediate financial cost, it can take years to restore a stolen identity … and in the meantime, you child could be blocked from essential opportunities such as student loans, scholarships, credit cards and job offers.

To help parents protect their children from identity theft, the Maryland Hospital Association, in partnership with the Maryland Chapter of the American Academy of Pediatrics, the Maryland Office of the Attorney General and Maryland State Delegate Craig Zucker, has developed and will be launching the KIDsafe campaign. Scheduled for launch in early September, the campaign will encourage parents to request a credit freeze to protect their children and provide instructions on how to go about it.

If you would like to get started now to protect your child, submit a “credit freeze request” to the three credit agencies, as follows:

Experian — www. experian.com/freeze or 1-888-397-3742
Equifax — www.equifax.com or 1-888-298-0045
TransUnion — www.transunion.com/securityfreeze or 1-888-909-8872

Shore Medical Center at Chestertown Recognized for Achievements

University of Maryland Shore Medical Center at Chestertown recently participated in a Maryland Hospital Association event at Turf Valley, in Ellicott City, with 36 other Maryland hospitals involved in the CAUTI Project, an initiative that aims to reduce the number of catheter-associated urinary tract infections acquired by hospital patients. 

Three inpatient units at Shore Medical Center at Chestertown were recognized for their contributions to decreasing the number of CAUTIs, including the hospital’s Intensive Care (ICU), Intermediate Care (IMC) and Medical/Surgical units.  Additionally, the hospital staff submitted a presentation entitled, “CAUTI: Mission Possible” focusing on efforts being made to decrease inappropriate use of catheters and to eliminate such types of urinary tract infections.  This presentation tied for first place with one from Johns Hopkins Hospital awarding them a male and female catheterization simulator, a piece of equipment to be used by hospital staff. 

“Catheter-Associated Urinary Tract Infections are the second most common site of healthcare-associated infections,” comments Donna Saunders, infection prevention coordinator, Shore Medical Center at Chestertown. “CAUTIs not only increase patient discomfort, they also increase the patient’s hospital length of stay and costs. We joined the Maryland Hospital Association and Maryland Patient Safety Center’s worthwhile CAUTI project because of these issues.”

Saunders continues, “Many urinary tract infections can be prevented by following guidelines describing which patients are candidates for catheter placement. Educating physicians, nurses and patients on best practices to make sure catheters are used only when the patient’s condition requires the procedure, along with daily monitoring, are among the steps that have resulted in the reduced infection rate. Eliminating healthcare-associated infections such as CAUTIs improves patient outcomes and saves lives.”