Required Organizational Practices (ROP's)

The following information covers Sunnybrook's Required Organizational Practices (ROP's). These are common to all healthcare facilities in Canada.

ROP: Transfer of Accountability
What does the process look like when you accept a patient from another area (internal or external to the hospital) or from another service provider (shift-to-shift handover)?
Hint: mention and show the Transfer of Accountability Tool; read the TOA policy
· What kind of information is typically shared?
· Can you show me how and where you document this transfer process?
· What electronic systems are available to help transfer information?
Hint: if applicable to your area, mention and show the Patient Sign Out System or eDischarge System
· What happens when you can’t find the new caregiver assigned to your patient?


ROP: Reporting of Adverse Events and Near Misses
· Can you show me how you report a patient safety incident?
o Hint: Demonstrate the Safety Report system on Sunnynet
· Describe what happens with that report.
o Hint: Does your manager discuss them with you and your colleagues? How do you hear about them?
· What kinds of conversations do you have with your team about incidents that happen in your area?
· What learning has occurred as a result of staff/physicians reporting an incident(s)?
Hint: have you made any changes? Improvements? Implemented new policies or procedures?
· How would you define a near miss?
Hint: a near miss is an error or hazardous situation that was identified and resolved before any patient consequence or harm occurred.
· Does this hospital have a policy on reporting adverse events and near misses?
Hint: a formal policy is currently in the approval process and will be available with all other policies and standards on Sunnynet.
· How are you informed of common patient safety incidents that occur in your area?
Hint: managers or educators may discuss safety trends at staff meetings, or via email or communication boards.


ROP: Educating Patients and Families about their role in safety
· How and when do you involve patients and their families in discussions about safety?
Hint: the Patient Information Handbook has important information about patient safety and is available on all patient care units and from Communications & Stakeholder Relations. It is handed out in the PAC.
· How can patients or families report safety concerns?
Hint: patients and families can speak directly to their caregivers or managers on the unit, as well as representatives from Patient Relations if they have concerns
· What kind of information/resources do you have to share with patients and families about safety?
Hint: the Patient Information Handbook has important information about patient safety and is available on all patient care units and from Communications & Stakeholder Relations
Hint: Posters indicating the Top 5 Patient Safety Tips are available in many units and common patient/family areas

ROP: Adopt client safety as a written, strategic priority or goal
· Is patient safety made a priority in this hospital?
Hint: It is a Strategic Goal of this organization to lead in safety best practices.
Hint: Sunnybrook also has an ‘Accountability for Patient Safety’ Policy that lays the foundation for patient safety culture at Sunnybrook. An Incident Decision Tree has been developed to complement the policy and serves to emphasize the ‘just culture’.


· How does the hospital support patient safety?
Hint: The Department of Quality & Patient Safety provides leadership and expertise in patient safety to all levels of the organization. A Patient Safety Leadership Team is responsible for developing and facilitating the implementation of corporate patient safety initiatives. These include initiatives such as Patient Safety WalkArounds and Monthly Patient Safety Educational Rounds.
· Sunnybrook has a strategic goal to lead in safety best practices. Do you think there are any practices on your unit that directly contribute to that strategic goal?


ROP: Organizational client safety plan
· What kinds of initiatives or projects do you think are part of the organizations client safety plan?
Hints: Patient Safety WalkArounds
Disclosure Policy
Safety Reporting System
Surgical Site Infection Prevention
Venous Thromboembolism Prevention
Transfer of Accountability Tool


ROP: Disclosure of adverse events to patients and families
· What is your role in the disclosure of an adverse event, error or near miss to your patients and/or their family?
· How and when do you involve your patients in discussions about an adverse event?
Hint: Initial disclosure of the adverse event should take place as soon as practically possible after it has occurred or has been identified.
Hint: Disclosure to the patient should occur when the patient is able to comprehend the information. Disclosure to the patient’s substitute decision-maker may occur prior to this if appropriate.
Hint: Follow-up disclosure meetings may be required for thorough disclosure for any adverse event, especially for critical incidents.
· Does this organization have a policy on disclosing adverse events to patients and families?
Hint: Yes – the Sunnybrook Policy for the Disclosure of Adverse Medical Events and Unanticipated Outcomes of Care can be found on Sunnynet
· What kinds of supports are available to help you in a situation when you might have to disclose an error to a patient or their family?
Staff may access the Risk Manager/Shift Manager at pager 1400 for guidance and support.
Any time that a critical incident occurs, 24/7, physicians may contact their Department Chief for guidance and support. If the Department Chief is unavailable, a physician may contact the Medical Director on Call through Communications at ext. 4244.
The role of the Department Chief/Medical Director on Call/ Shift Manager/Risk Manager is to facilitate the staff’s/physician’s discussion about and investigations concerning the critical incident and to help plan the disclosure conversation with the patient and / authorized or substitute decision-maker.
· How would you document the process of disclosing an error to a patient or their family?
Hint: Notify the most responsible physician.
Complete an online e-safety report of the event.
Record in the patient’s chart the disclosure made to the patient and / or the patient’s SDM and who was involved in the disclosure.


ROP: Medication reconciliation at admission to the organization
· What is medication reconciliation?
Hints: A process to prevent medication errors and subsequent adverse events
Involves a systematic process to obtain a thorough medication history called a Best Possible Medication History (BPMH)
BPMH is then compared to medication orders at transitions in care (admission, transfer, discharge) in order to identify and resolve discrepancies
Partnership between health care professionals and patients/ families to ensure accurate and complete transfer of medication information at transitions in care
· Can you describe the process used in this area to reconcile the patients’ medications when they are admitted?
Hint: Will vary unit to unit, but consider who does it, when it is done and where it is documented in your area (some or all of the following may apply)
BPMH is documented on the Pre-Admission Medication List
The goal is to perform medication reconciliation for all patients however the pharmacist may give priority to select patients
When transcribing admission orders, the RN may compare the Pre-Admission Medication List to the admission orders to identify discrepancies
· What kinds of documentation or tools are available to help you conduct medication reconciliation?
Hints: Pre-Admission Medication List (PR 99630)
Medication Administration Record (MAR)
Patients and caregivers, personal medication lists, patients’ medication supply
Patients’ community pharmacy
Ontario Drug Benefit (ODB) Drug Profile Viewer (shows prescriptions filled for ODB patients [65 years of age and older, social assistance, Trillium]). This can be accessed in the Emergency Department and by pharmacists. When accessed, a copy is printed and placed in the chart.
e-Discharge (General Internal Medicine and Cardiology)
· How might you describe a Best Possible Medication History?
Hints: More comprehensive than a traditional primary medication history
Obtained through a systematic patient interview with verification of information from other sources (medication lists, community pharmacy, government medication databases, prescription vials)
Focuses on what the patient is actually taking as opposed to what was prescribed An accurate, up-to-date, complete medication list
· What kind of support/information is available to you to make sure medication reconciliation happens?
Hint: Unit pharmacist
Pharmacy Department
Clinical Nurse Educator or Advanced Practice Nurse
Patient Safety Pharmacists (patti.madorin@sunnybrook.ca, sandra.knowles@sunnybrook.ca)


ROP: Medication reconciliation at time of transfer or discharge
· Can you describe the process used in this area to reconcile the patients’ medications when they are transferred from another area?
Hint: Will vary unit to unit, but consider who does it, when it is done and where is it documented in your area (some or all of the following may apply)
Pharmacists review transfer orders and compare them to the Pre-Admission Medication List and existing medication profile (if applicable). Any discrepancies that are noted (other than discontinuation of certain ICU medications on transfer to the ward) are communicated to the team
When transcribing orders, RN may also use the Pre-Admission Medication List and previous MAR to verify changes and identify discrepancies in transfer orders
· Can you describe the process used in this area to reconcile the patients’ medications when they are discharged from your unit?
Hint: Will vary unit to unit, but consider who does it, when it is done, where it is documented and what is given to the patient, receiving service provider and receiving facility (if applicable) in your area (some or all of the following may apply)
Generally the physician is responsible for reviewing pre-admission medications and current medication orders to decide upon the discharge medication list and any required discharge prescriptions
The Discharge Prescription includes an area to document medications which have been stopped in hospital.
The physician completes a Discharge Notification Summary which is sent to the family doctor. This too has a section for recording medication changes.
For patients with significant medication changes, pharmacists are available to provide counselling before discharge. A detailed medication schedule is provided.
· What kinds of documentation or tools are available to help you conduct medication reconciliation?
See above section re: Med Rec at admission
· What kind of support/information is available to you to make sure medication reconciliation happens?
See above section re: Med Rec at admission
· What kind of information is given to the patient or their family to ensure they understand how to take their medications?


ROP: Use of at least 2 patient identifiers before providing service / care
· When do you typically verify your patient’s identity?
Hint: before providing any service or care, such as medication administration, obtaining lab specimens, administering treatment or beginning a procedure
· How do you double-check or verify the patient’s identification?
Hint: at least 2 identifiers must be used when checking the patient’s identification.
Hint: Room number or bed number are NOT appropriate identifiers
· Can you describe an event when a patient was not properly identified? How was that error prevented from recurring while that patient was under care here?
· What do you do when two patients in your area have similar names?
Hint: list any methods your unit uses to distinguish patients with similar names, including flagging charts, highlighting names on the board, assigning their care to different caregivers, etc.


ROP: Verification processes for high risk activities
· What would you consider a high risk activity conducted in your area?
Hint: examples include administering high risk medications, conducting procedures, receiving critical lab test results, etc.
· What does your team do to prevent adverse events associated with these high risk activities?
Examples: independent double checks for medications, checklists, surgical pause, verbal order read-back, standardized order sets, barcode scanning, MAR to MAR checking, blood transfusion policies, etc.
· What kinds of discussions occur with your team about patient safety in these situations?
Hint: do you discuss high risk activities or concerns at staff meetings? Do you have a safety committee who looks at preventing errors in high risk situations?
· Can you show me the process for administering high-risk medications?
· How do you receive and relay critical information to members of your team?

ROP: Abbreviations, symbols and dose designations NOT to be used
· Does the organization have a list of abbreviations that can’t be used?
Hint: Yes, the “Do Not Use Abbreviations” list is part of the Medication Order Writing Policy found on Sunnynet.
· Can you show me where I might find that “Do Not Use” list?
Hint: found with other policies and procedures on Sunnynet
· What information was provided to you at your orientation about the use of abbreviations in the organization?


ROP: Ongoing training on infusion pumps
· Can you show me how you use this piece of equipment?
· Describe the training you received on this piece of equipment.
· How often do you get to review your training on this piece of equipment?


ROP: Annual patient safety training for all staff
· What was the last patient safety topic you learned about?
Hint: this could include local patient safety topics (unique to your unit) or corporate topics such as: medication reconciliation, disclosure of adverse events, fall prevention, hand hygiene, transfer of accountability, patient safety culture survey, medication safety, pressure ulcer prevention, etc.
· How often you learn about new patient safety topics?
· Can you describe a patient safety initiative you know is important to this organization?
Hints: VTE Prophylaxis, Surgical Site Infection Prevention, Patient Safety Culture Survey, Safety Reporting, Disclosure, Systems Reviews, Patient Safety WalkArounds, Hand Hygiene, SMART pump training, Transfer of Accountability, Medication Reconciliation, Allergy policy, etc.
· What kinds of patient safety topics were discussed at your orientation?
Hint: Patient Safety presents at the bi-annual recertification.
· Are there any organization-wide educational forums where you can learn about patient safety topics?
Hint: Monthly Patient Safety Educational Rounds!


ROP: All staff have clearly defined roles and responsibilities for patient safety
· How would you describe your role in keeping patients safe at this hospital?
· What kinds of policies are in place to help you understand your role in patient safety?
Hint: Accountability for Patient Safety Policy
· Are there supports available to you in this organization to help you make better decisions about patient safety?
Hint: Managers can access patient safety reports and trend data. Representatives from Quality & Patient Safety, Risk Management, Patient Relations and Clinical Ethics are available for support with patient safety issues.
· Describe when/how patient safety is discussed in this area.
Hint: morning rounds, staff meetings, quality councils, departmental forums, etc.


ROP: Hand Hygiene
· Can you describe the hand hygiene protocol used in this area?
Hint: remember the 4 moments of hand hygiene!
· What kind of training have you received on this hand hygiene protocol?
Hint: hand hygiene education modules are available on the Infection Prevention & Control page of Sunnynet
· What kind of information have you received about how well you and your team follow this protocol?
Hint: have you ever seen the compliance for your unit? Did you ever speak about it at a staff meeting?
· What kinds of changes have you seen in this area related to hand hygiene?
· What do you think we could do better in meeting our hand hygiene targets?


ROP: Infection rates are tracked and shared
· If you wanted to know what the C. difficile rates were for your unit, who would you contact?
Hint: Infection Prevention & Control does the important work of tracking our hospital infection rates and can provide such data to units
· What kinds of discussions have occurred in this area about infection prevention?
· How do you communicate to others when an infection has occurred?
· Think about the last time your team/unit discussed infection rates – what were some of the concerns and improvements that were shared?


ROP: Falls Prevention
· Describe how your patients are assessed for their risk for falls.
Hint: mention and demonstrate any specific risk assessment tools used
· When a patient is identified as being at risk, what is the process for identifying and implementing the appropriate strategies?
Hint: Universal strategies such as appropriate lighting, keeping floors clean and dry, access to call bells, locking beds/stretchers when transferring patients.
Hint: Consider strategies for specific risk factors in individual patients, such as a regular toileting schedule, low bed and/or mat on the floor, hip guards to minimize injury from a fall, etc.

· What kind of information / data have you received to know how often falls occur in your area?
Hint: Managers can access patient safety reports and trend data related to falls.
· What patient safety strategies have been put in place here to prevent falls with your patients?
Hint: Mention any program-specific algorithms or guidelines and/or RNAO best practice guidelines on fall risk reduction
· How are staff educated and supported to implement best practices regarding fall risk reduction?
Hint: mention corporate and unit-specific orientation, in-services, decision tools (e.g. algorithms), inter-professional team consultations, etc.