MEDICATION USE: Ensure the safe use of high‐risk medications.

The Medication Use ROPs are:

1. Concentrated electrolytes – Not applicable for Menno Home/Hospital.
2. Heparin safety – The availability of heparin products is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.
3. High‐alert medications – A documented and coordinated approach to safely manage high‐alert medications is implemented.
4. Narcotic safety – The availability of narcotic products is evaluated and limited to ensure that formats with the potential to cause patient safety incidents are not stocked in client service areas.

Surveyor Question: At Menno Place, how does the organization ensure that abbreviations, symbols, and dose designations are not used on any written, printed or electronic materials?

Evidence:

• “Do Not Use” Abbreviation List is on each unit and easily available.
• Every item on the “Do Not Use” Abbreviation List is no longer on any written, printed, or electronic document.
• Staff and physicians are made aware of the “Do Not Use” Abbreviation List and the policy.
• Preprinted orders are reviewed annually and are free of “Do Not Use” abbreviations. There are no “Do Not Use” Abbreviations present on any written, printed or electronic documents.
• Audits are completed regularly to ensure the “Do Not Use” Abbreviations are not used.

Heparin Safety and Medication Concentrations

Heparin is identified as a high alert medication that is an area of focus for safety.

Surveyor Question: How does your organization ensure that heparin concentrations are standardized and limited?

Evidence:

• Our organization uses manufactured products in pre-filled pharmacy unit doses.
• We do not store high-dose heparin products.
• Audits are completed annually, to ensure no high-dose heparin products are present on the units.

 Narcotic Safety

Narcotics are identified as high alert medications for safety reasons. Limiting different doses of narcotics, ensuring restricted access, as well as educating staff on their use reduces medication errors.

Surveyor Question: How does your team ensure that narcotics are stored and used safely?

Evidence:

• All narcotics are stored in a locked narcotic cupboard.
• Two nurses are required to count narcotics.
• A nurse is responsible for the keys to the narcotics cupboard.
• The Medical Medication Safety Advisory Committee (MMSAC) reviews medications stocked in contingency, ensuring no high dose narcotics are on-site.
• Audits are completed ensuring high dose narcotics are not stocked in med rooms.

Communication is one of our Accreditation 2018 Quality & Safety themes.  The goal is to communicate effectively at all levels within the organization and with external stakeholders (i.e. – Fraser Health). The communication theme includes the resident and families being involved with care.

Within this theme there are five Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation. They include:

1. Resident Identification –In partnership with residents and families, there must be at least two person-specific identifiers are used to confirm that clients receive the service or procedure intended for them (i.e. – medication administration).
2. The ‘Do Not Use’ List of Abbreviations – A list of abbreviations and symbols that are NOT to be used due to increased risk of error, have been identified and implemented.
3. Information Transfer at Care Transitions – Information relevant to the care of the resident is communicated effectively during resident transfer in and out of care.
4. Medication Reconciliation at Care Transitions – Medication reconciliation is a process whereby the most current medication history is obtained in partnership with the resident, family, and care team (pharmacist, nurse, and physician) to communicate accurate and complete information about medication lists across care transitions.
5. Medication Reconciliation as a Strategic Priority – A documented and coordinated medication reconciliation process is used to communicate complete and accurate information about medications taken when residents transfer in and out of the care home.

ROP 1  Resident Identification

Surveyor Question:  At Menno Place, how does the team ensure that resident identifiers are used prior to medication administration? How many resident identifiers are required?

Evidence:

At least two resident identifiers are used to confirm that the right resident receives the right medications, procedures or services (i.e. – lab).  Staff are required to verify resident identity before providing any service or care to a resident, often with the involvement of the resident or family.

Menno Home/Hospital uses the following identifiers:

1. Photographs of residents

Menno Home

• Electronic Medication Administration Record (eMAR)
• Resident room door
• Medication boxes
• Point of Care
• Resident Profile in Point Click Care
• Picture books

Menno Hospital

• Medication Administration Record (MAR)
• Medication boxes
• Point of Care
• Resident cork/Bulletin board
• Picture books
• ROF Binders

2. Second Verification

New staff or those unfamiliar with the resident for which treatment is to be performed, in addition to using photographs will verify the residents identification by consulting with another team member who is aware of the resident’s identification.

ROP 2  The “Do Not Use” List of Abbreviations

Surveyor Question: At Menno Place, how does the organization ensure that incorrect abbreviations and symbols which may cause errors are not used on any written, printed or electronic materials?

Evidence:

• “Do Not Use” List is on each unit and easily available.
• Every item on the “Do Not Use” List is no longer on any written, printed, or electronic document.
• Nurses and physicians are made aware of the list and the policy.
• Preprinted orders are reviewed annually by the Medical and Medication and Safety Advisory Committee and are free of ‘Do Not Use’ abbreviations; none are present on any written, printed or electronic medication documentation.
• Audits are completed regularly to ensure compliance with the DO NOT USE lists.

ROP 3  Information Transfer at Care Transitions (transfer in and out of care homes)

Surveyor Question: How does the team ensure that information is transferred in an accurate and timely manner at transition points?

Evidence:

At Menno Place we work to effectively communicate about the care of residents during care transitions amongst the care team (internal and external).

Effective communication is a critical element in improving resident safety, particularly with transition points such as handover of resident care from shift to shift or from service to service (i.e. from the care home to emergency departments).

Transition points include transfer between units, shift changes and breaks within a shift. Also included are external transfers to another care home or a transfer to an acute care site (ER). At each of these points, it is essential that information be transferred in an accurate and timely way.

Internal Transfers

Methods that ensure timely and accurate transfers between units include a combination of verbal and written information. Examples include: the electronic health record, the paper health record, verbal report nurse to nurse.

Shift Changes and Breaks

Verbal and written reports are used for shift changes and breaks. Written reports include electronic documentation and shift summary forms.

External Transfers

There are a number of practices for ensuring accurate and timely transfer of information when a resident is discharged or transferred including faxing, sending information on transfer sheets, using the telephone or giving verbal information face to face to emergency personnel. A standard transfer sheet is located in each resident record for easy completion. Physician discharge summaries are standardized.

Care Conference and Rounds

Face to face conversation with electronic and paper records are used to verify and plan actions and goals of care with the resident, family and care team. These meetings include input from physicians, nurses, health care assistants, OT, social workers, recreation staff, pastoral care staff and others as appropriate.

ROP 4  Medication Reconciliation at Care Transitions

Surveyor Question:  What process is in place to ensure that the best possible medication history is obtained and that the resident gets the right medication orders?

Evidence:

Medication reconciliation is conducted in partnership with the resident, family, or caregiver to communicate accurate and complete information about medications taken across care transitions. All new resident move-ins, re-admissions back to residential care home from an acute care facility or transfer out of a residential care home, have medication orders reconciled to ensure accuracy and continuity of medications.

The team reconciles the resident’s medications with the involvement of the resident, family or caregiver at the beginning of service when medication therapy is a significant component of care. Reconciliation is repeated periodically as appropriate including when transferred to another service or discharged.

ROP 5  Medication Reconciliation as a Strategic Priority

Surveyor Question:  How does Menno Place demonstrate its commitment to medication reconciliation?

Evidence:

At Menno Place, our organizational policy indicates our commitment to medication reconciliation.  Our policy indicates the roles, responsibilities and care transitions where medication reconciliation is required.  A medication reconciliation process is used to communicate complete and accurate information and medications across care transitions.

Nurses are educated in medication reconciliation through:

• Orientation checklists
• Education sessions (nurses meetings)
• Sign off sheets on policies and procedures when updates occur

The Medical and Medication Safety and Advisory Committee (MMSAC) is an interdisciplinary committee composed of pharmacists, nursing leaders and physicians. They review and approve the policy annually and with any changes.

EMERGENCY PREPAREDNESS THEME

Emergency Preparedness is one of our Accreditation 2018 Quality and Safety themes. It focuses on ensuring that Menno Place services and staff are prepared for emergencies and that an effective disaster response system in place. Although there are no Required Organizational Practices (ROPs) in this theme, it contains a number of high priority standards concerning staff and resident/patient safety. This theme covers four components of our organization’s emergency management processes, infrastructure and plans, including:

1. Emergency Colour Code Response Plans
2. Disaster Response Plans
3. Fire Safety Plans
4. Pandemic Plans (i.e. H1N1)

Quality and Safety Themes

In addition to Emergency Preparedness, the other Quality and Safety themes we have reviewed to date at Menno Place are:

• Infection Prevention and Control Theme – Reduce the risk of health care associated infections and their impact across the care continuum.
• Safety Culture Theme – Create a culture of safety.

Our remaining themes which we will review before our October 2018 survey include:

• Work life/Workforce Theme – Create a work life and physical environment that supports the safe delivery of care/service.
• Communication Theme – Improve the effectiveness and coordination of communication among care/service providers and among our recipients of care/service.
• Ethics Theme – Ensure processes are in place to support resident/patient safety efforts related to ethics, privacy and data management.
• Medication Use Theme – Ensure the safe use of high-risk medications.
• Risk Theme – Identify safety risks inherent in our resident/patient population.

Meeting Our Emergency Preparedness Priorities

The Emergency Preparedness theme covers emergency response plans, disaster plans, fire safety plans and pandemic outbreak plans. Ensuring everyone is familiar with these plans helps us adequately care for staff, residents and visitors in the event of an emergency.

Menno Place has detailed disaster response plans that provide guidance and instruction for identifying, activating and managing all levels of response situations.

1. EMERGENCY RESPONSE PLANS

Menno Place uses two main systems for identifying and responding to emergency situations: Emergency Colour Code Response Plans and the Emergency Command Centre.

 

Through our Emergency Colour Code Response Plans, we identify and respond to emergency situations using the resources at hand. For more complex emergencies, we activate our Emergency Command Centre to coordinate and manage response requirements.

Emergency Colour Code Response System

Menno Place uses a standardized colour code system to declare and respond to emergencies such as hazardous spills, evacuations, fires or missing residents. The colour codes allow people to convey essential information quickly and clearly, and to help prevent stress among residents and visitors. There are nine codes in total.

Our colour codes are:

• Code Blue: Medical Emergency (can include cardiac arrest)
• Code White: Aggressive/Violent Act
• Code Red: Fire
• Code Yellow: Missing Resident
• Code Brown: Hazardous Spill
• Code Black: Bomb Threat
• Code Green: Evacuation
• Code Orange: Disaster/Mass Casualty
• Code Grey: Air Exclusion

For each emergency colour code, Menno Place has response protocols. Together, the colour codes and their associated protocols form our Emergency Colour Code Response system that provides us with guidelines for responding to a variety of situations. The Emergency Colour Code Response procedures are available in a number of formats throughout our organization including:

• Binders – a manual book with the comprehensive colour code emergency response procedures that include step by step guidelines, as well as a one page quick reference sheet.
• Wallet size stickers – colour code stickers are available to be attached to the back of your security ID badge for quick reference.
• Flip chart – emergency response plan flip chart that provides a more detailed quick reference of managing emergencies.
• Sharepoint – an electronic repository of the emergency response procedures found in the binders.

Isolated or small internal emergencies can be managed with the resources on site and response protocols are outlined according to the colour code protocols. A colour code situation can quickly escalate and may require additional resources. In some cases, it may become so complex that it requires activation of the Emergency Command Centre. Menno Place has a system to practice responses to these colour codes.

Emergency Command Centre

If an event is beyond an employee and/or the work area’s ability to manage, a Command Centre may be activated. Through the Emergency Response structure, the Command Centre is established to manage large, complex events that may require additional resources and coordination. Specifically the Command Centre provides:

• Policy and management support and direction
• Information collection, evaluation and display
• Coordination of site services
• Priorities and objective setting
• Resource management
• Communications
• Information and warnings

Activating a Command Centre

The Chief Safety Officer or delegate has the authority to activate a Command Centre and to direct the use of staff for emergency response. The Chief Safety Officer on site works with external partners such as first responders, local authorities, utility companies and government as needed.

2. DISASTER RESPONSE PLANS

Menno Place has put a number of measures in place to support staff and residents through a disaster including disaster response plans, supplies, specialized resources and drills.

Preparing for a Disaster

Employees should be familiar is our Emergency Response Plan which includes planning for a disaster such as an earthquake.

To ensure you are prepared you should know:

• The location of your department’s emergency supplies
• The location of the site Command Centre
• Your department responsibilities in an event
• Any specific duties assigned to you or which may be assigned to you
• That your contact information in payroll is correct for fan-out
• Designated disaster routes to your workplace
• What your personal or family preparedness plan is

Employee Fan-Out Lists

Staff call back lists (Fan Outs) are in place in the event that we may require assistance when you are off duty or unscheduled. Fan Out lists are accessible for leaders to activate from outside the workplace.

Disaster Supplies

Disaster supplies are available in different locations on campus. Please ask your supervisor where they are at your site. Supplies include:

• Food and Water
• Search and Rescue items (hard hat, reflective vest, flashlights, candles, masks, etc.)
• First Aid
• Site Maps

Disaster Response Routes

Within the Lower Mainland, there is a network of pre-identified roads that will be used to move emergency supplies and services in the event of a major incident such as an earthquake. These routes are deemed priorities for clearing of debris so emergency vehicles and responders can gain access to impacted areas. Staff need to show their Menno Place picture ID security badge to access these routes.

Personal Preparedness

Just as every employee and department should know how to mitigate the consequences of a disaster and where to go for support, so should you and your family. Among other things you should:

• Ensure you have critical supplies that will last 72 hours
• Have an out of town contact
• Have a family meeting place
• Know your neighbours

3. FIRE SAFETY PLANS

Menno Place has a fire safety plan that is approved by the municipal fire department. Our fire safety plans include information about how to prevent, mitigate and respond to fires. They outline what to do in the event of a fire or fire alarm, how to use a fire extinguisher, general evacuation procedures and other fire safety information. We practice fire drills monthly.

Discovery of smoke or fire

In the unlikely event smoke or fire is discovered, staff should follow the ICE process. ICE stands for Investigate, Communicate, Evacuate.

• Investigate what is going on. What and where is the hazard?
• Activate the fire alarm and designate emergency call centre to call 911
• Move everyone away from hazard past fire doors or into another unit.

Responding to a fire alarm

If you hear the fire alarm or Code Red announcement the process is:

• Report to a nursing unit (use stairs not elevators)
• Check your work area for signs of smoke or flames
• Check fire panels for location of fire or listen for announcement
• Reassure residents and visitors
• Direct residents and visitors to stay in their rooms or a safe area
• Ensure hallways are unobstructed
• Prepare residents for evacuation
• Know where gas shut off (or oxygen shut offs) are located
• Provide direction to fire responders
• Know exit routes from work area

Evacuating or Relocating Due to Fire

All sites have an established Code Green procedure for evacuation. In the event of a Code Green due to fire staff should:

• Evacuate residents, staff and visitors from a danger area
• Move horizontally through a set of fire separation doors, moving from a danger area to a safe area
• If danger persists, move horizontally again
• Move vertically to a lower floor if there are no safe horizontal routes
• Move out of the building if necessary and gather at the pre-planned location for your site.

4. PANDEMIC PLANS

Pandemic Planning is part of our overall emergency preparedness plan. We follow pandemic protocols set by the health authority and the provincial government. We work with our partners in the health authority and other residential care homes on pandemic preparedness.

HOW WILL OUR EMERGENCY AND FIRE SAFETY PREPAREDNESS BE EVALUATED?

Surveyors will tour Menno Place and will gather information by:

• Reviewing documentation such as policies and fire drill records
• Talking and listening to leaders, staff, students, volunteers, residents and families
• Observing what takes place
• Recording what they read, see and hear

YOUR ROLE

During the on-site survey, surveyors will tour Menno Place and speak to staff, residents, students, volunteers, and family members. You may be interviewed and/or observed as surveyors gather information about how we plan for emergencies. Please ensure you take the time to review the location of emergency response supplies, location, binders and information. Prepare yourself by thinking through some of the questions that a Surveyor may ask you prior to the survey. Questions may include:

• Is there a plan for staff response in the event of an emergency or disaster?
• How are you trained?
• Have you participated in any drills or exercises?
• Are debriefings held following drills or exercises to identify areas to improve?
• When was the last fire drill you participated in?
• Are you aware of any exercises to test the Evacuation Plan?

 

If you have any questions, please ask your manager. If you are asked a question but you do not know the answer, please feel free to refer the surveyor to the appropriate person in your work area or to your supervisor.