2020 Report of Patient Safety Committee

_b:., Quality care close to home. ~PRING VALLEY HOSPITAL,. MEDICAL CENTER 771eValley ~·Health System'" June 25, 2020 Brenda Erdoes Director of the Legislative Counsel Bureau 401 S. Carson Street Carson City, NV 89701-4747 Re: Annual Patient Safety Report per NRS 439.877 Spring Valley Hospital Medical Center Dea r Director Erdoes: Pursuant to NRS 439.877 Spring Valley Hospital Medical Ce nter, is required to annually submit a summary of its Patient Safety Committee Activities to your office, including information relating to the development, revision and usage of patient safety checklists and pa tient safety policies and a summary of the annual review conducted for the prior 12 month period. The following information is being provided in conformity with this requirement. Establishment of Patient Safety Checkli sts: Pursuant to t he provisions of NRS 439.877 the Patient Safety Committee adopted Patient Safety Checklists. These checklists are reviewed and modified as necessary based upon outcome and performance data on a yearly basis. Currently, Spring Valley Hospital Medical Cent er utilizes and monitors compliance with checklist s covering numerous patient areas. These include Hand Hygiene, Patient Ident ifica tion, Code Blue Cart Inspection, Central Line Insertion, (etc.) Checklist. Adoption of Pol icies, Procedures and Protocols: In conjunction with the checklists, Spring Valley Hospital Medical Center has developed and implemented policies, procedures and protocols to ensure compliance with the letter and intent of t he checkl ists. Patient Safety Compliance: During the ca lendar year 2019- 2020 the hospital Patient Safety Officer in conjunction with the hospital Qua lity Management and Risk Management Departments and Nursing leadership conducted reviews of staff and physician compliance with estab lished patient safety po Ii c i es and checklists. These reviews included direct surveillance, clinical process reviews and root cause analysis. 5400 South Rainbow Boulevard • Las Vegas, Nevada 8911 8 Telephone (702) 853-3000• Facsimile (702) 853-3340 Patient Safety Committee: This committee is comprised of the following members: CEO, COO, CNO, Risk Director, Quality Director, Pharmacy Director, Infection Prevention Director, Nursing Leadership, Procedural Area Leadership, and three Physician Charis. The committee discusses primary safety related topics affecting or having the potential to affect the facility, using a 4-step methodology to identify the issue, best practice, recommendations and implementation of safety measures, as well as monitoring for success or need for the application of additional measures. If you have any questions regarding the hospital's patient safety checklists or its quality programs, please feel free to contact me at your earliest opportunity. Paula Carlisle, RN, MSJ, CPHRM Patient Safety Officer Spring Valley Hospital Medical Center REPORT TO THE DIRECTOR OF THE LEGISLATIVE COUNSEL BUREAU PURSUANT TO NRS 439.877(4)(D)- SUBMITTED BY: July 1, 2020 Spring Valley Hospital Medical Center Paula Carlisle, Patient Safety Officer 5400 South Rainbow Boulevard, Las Vegas, NV 89118 Contact Number: 702-853-3342 July 1, 2019 - July 1, 2020 Patient Safety Checklists and Patient Safety Policies Developed Include: Usage** New Revisions* Review*** Fire Safety, Equipment Testing Plant Services, Security X Informed Consent Housewide X Womens Services, Case Adoption, Infant X Management Advanced Directives Housewide X Alarm Safety Nursing Ambulation or Gait Training Therapy Services X Amniocentesis/Amniotic Fluid reduction L+D X Amputation Therapy Services Therapy Services X Amputee Training Therapy Services X Anesthesia Workplace Surgical Services, Special Procedures, L+D X Animal Assisted Therapy Housewide X Antepartum Testing L+D X Anticoagulation Safety and Monitoring Housewide X Aseptic Technique Therapy Services X Assessment of Patients Therapy Services X Anesthesia Workplace Surgical Services, Special Procedures, L+D X Animal Assisted Therapy Housewide X Antepartum Testing L+D X Anticoagulation Safety and Monitoring Housewide X Aseptic Technique Therapy Services X Assessment of Patients Therapy Services X Assessment of Pediatric Patients Therapy Services X Assistance- Code Lift Housewide X Back Surgery Therapy Services X Education, All staff with Basic Life Support Education X patient interaction Behavior- Code Grey Housewide X Behaviors Which Undermine A Culture of Safety Medical Staff X Bladder Scanning (checklist) Rehab X Blood Administration (checklist) Lab, Nursing X Cancer Therapy Services X Care and Identification of the neonate at Birth (checklist) L+D X Care of the Perinatal HIV Exposed Newborn L+D, Postpartum, Nursery X Central Line Associated Blood Stream Infection (CLABSI) Prevention Infection Control, Nursing X Cerebral Vascular Accident Therapy Services X Chronic Obstructive Pulmonary Disease Therapy Services X Circulating RN Duties (checklist) Surgical Services X Clinical information for transfer (checklist) Rehab X Code Blue, Neonatal NICU, Nursery, Maternity, ER, Medical Staff X Code Lockdown (Secure Facility from External Threats) Housewide X Code Silver Housewide X Code Stemi Housewide X Contrast Administration in Radiology (checklist) X Radiology Controlled Substance Discrepancy Resolution X Medical Staff, Nursing Construction Risk Assessment (checklist) Housewide X Controlled Drugs: Automatid Dispensing, Inventory Housewide X Coordination of Services Rehab X CPM Rental Therapy Services X Crash Cart Daily Checklist Nursing X Critical Test Reporting Nursing, Medical Staff X Cryotherapy Therapy Services X Death in the Surgical Area (checklist) Surgical Services X Debridement Therapy Services X Decontamination of Endoscopes and High Level Disinfection Surgical Services X Decorations and Heating Devices Housewide X Diabetic Stop Orders (checklist) Pharmacy X Direct Admit and Inpatient Transfer (checklist) Housewide X Nursing, Case Discharge Planning (checklist) X Management, Medical Staff Discharge Planning (checklist) NICU X Discharge Planning (checklist) Therapy Services X Disclosure of Unanticipated Outcomes (checklist) Nursing, Medical Staff X Documentation Standards Therapy Services X Domestic Violence (checklist) Housewide X Draping the Surgical Field Surgical Services X Pharmacy, Nursing, Medical Drug Recalls (checklist) Staff X Dysphagia/ Swallowing Dysfunction Program Nursing, Speech Therapy X Education Policy Rehab X Electrical Safety Engineering X Electrical Stimulation Therapy Services X Elopement Prevention Code Walk (checklist) Nursing, Security X Emergency Cases Normal Hours (checklist) Surgical Services X Emergency Drugs Nursing, Pharmacy X EMG Biofeedback Therapy Services X EMTALA Emergency, Maternity X Environmental Assessment Rounds (checklist) Housewide X Environmental Services Duty List Environmental Services X EOC Policy, Grounds Plant Services X Epidermolysis Bullosa Care NICU, X Equipment Inventory Management (checklist) Biomed X Ethics Consultation Mechanism Housewide, Medical Staff X Ethyl Chloride and Flourimethane spray and stretch Therapy Services X Evaluation and management of severe pre-eclampsia before 34 L+D weeks gestation X Evaluation of Contracted Services Housewide, Administration X Event Reporting Housewide X Exclusive Breastmilk Feeding of the Newborn Postpartum Expiration and Post Mortem Care Nursing, Medical Staff X Falls Prevention Policy (checklist) Housewide X Federal agency compliance- Information data management Rehab X Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Speech Therapy, Nursing X Fire Safety Management Plan Housewide X Fire Watch Plant Services X First Assistant (non-MD) Surgical Services X Forensic Staff Orientation and Education Security X Formulary Development and Maintenance Pharmacy, Medical Staff X Functional Independent Measure Therapy Services X Generating Communications When the Phones are Out Housewide X Generator Testing (checklist) Housewide X Guideline for Alternative Birthing (checklist) L+D X Guideline for Anesthesia Services (checklist) L+D, Medical Staff X Guideline for Operative Procedures (checklist) L+D X Guideline for Perinatal Loss (checklist) Womens Services, Case Management X Guidelines for Fetal Monitoring (checklist) L+D X Guidelines for the Care and Management of PICC for the Neonate ( checklist) NICU X Handling of Tissue Specimens in Surgery (checklist) Surgical Services X Pharmacy, Medical Staff, Hard Stop Antibiotics After 24 Hours (checklist) Nursing X Hazard Report Housewide X Hazardous Materials Housewide X Hazmat, General Waste Environmental Services X Healthcare Associated Infections Housewide X Hearing Screen (checklist) Nursery, NICU, Therapy X Plant Services, Security, Helipad Safety and Orientation (checklist) X Emergency Department High Alert Medications Pharmacy, Nursing X Home Visit Rehab X Hospital Security Security X Hypoglycemia Protocol (checklist) Pharmacy Identification of Staff-Visitors-Parents Housewide X Identification of the Pediatrician L+D X Infant Driven Feedings (checklist) NICU, Nursery, Maternity X Infection Control (checklist) NICU X Infection Prevention Bundle Checklist Housewide X Infection Prevention and Control Program Housewide X Therapy Services, Infection Prevention Guidelines (checklist) Environmental Services X Initial assessment of L+D/antepartum/Triage patients (checklist) L+D X In-service and Technician Training Biomed X Biomed, Receiving, Plant Inspection of incoming Electrical Equipment (checklist) Services X Integration of Services Rehab X IV Contrast Media-

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