GOAL THREE C
Identify and review a list of look-alike/sound-alike drugs.

How do we meet this goal at UTHCPC?
There are a lot of injectables but we do have liquids. We require physicians to rewrite their orders as MG, rather than CC or ML. P&T reviews sound-alike/look-alike drug annually. We also have a list posted in all medication rooms..

GOAL SEVEN
Reduce the risk of healthcare-associated infections.

a) Comply with current CDC hand hygiene guidelines.

b) Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection.

How do we meet this goal at UTHCPC?
We meet goal number seven with the implementation of the CDC hand hygiene guidelines that limits the length of nails in direct care providers and prohibits the wearing of artificial nails or tips. Furthermore, we have provided an alcohol based hand sanitizer in direct care areas for staff. This goal also requires that hospital acquired infections that result in serious harm or death be reported as sentinel events. The infection control nurse monitors infection data and reports the findings to the IC committee. Our most serious reported infection is pneumonia. All cases of pneumonia are monitored to determine how long after the patient arrived here did the pneumonia occur.

GOAL EIGHT
Accurately and completely reconcile medications across the continuum of care.

Goal Eight A
Implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to UTHCPC and with the involvement of the patient.

Goal Eight B
A complete list of patient's medication is communicated to the next provider of service when it refers or transfers a patient.

How do we meet this goal at UTHCPC?
During admission, the nurse documents/enters a complete list of the patient's medication taken prior to admission into the Prescription Wrier. This information is made available to the nurse and physician responsible for the admission assessment/IPE. The list of medications will appear in the assessment document for review.
The physician will use this information to reconcile the admitting medications to home medication under the Medication Reconciliation section of the IPE.

Upon discharge, the pharmacy staff reconciles the current medications to the discharge medications (discharge script) and calls the physician for clarification if there is a discrepancy. The current list of meds are then forwarded to the next provider of care.

GOAL NINE
Reduce the risk of patient/resident/client harm resulting from falls.

Goal Nine A
Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identification risks.

How do we meet this goal at UTHCPC?
1. Screen all patients upon admission and reassess q shift for fall risk.
2. Place patients on precautions to prevent falls if they are identified at risk.
3. Analyze falls considering what meds patients are taking and are revising fall forms to better capture data related to med use and falls.
4. We have developed an education module, which covers medication use, and fall risk.
5. We will be initiating fall prevention unit based groups pending approval of Nurse Management meeting.