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International patient safety rems lecture

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MEEQAT HOSPITAL
MEEQAT HOSPITAL

Lecture by sr.Rahima Salendab

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INTERNATIONAL PATIENT SAFETY RAHIMA M. SALENDAB, BSN, RN
PATIENTS SAFETY,,,,???? Prevent medical errors Protect patient from harm
INTERNATIONAL PATIENT SAFETY GOALS AUTHORED BY JCI (JOINT COMMISSION INTERNATIONAL) STARTED AT JANUARY 1, 2007
INTERNATIONAL PATIENT SAFETY GOALS: 1. IDENTIFY PATIENT CORRECTLY 2. IMPROVE EFFECTIVE COMMUNICATION 3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATION 4. ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY 5. REDUCE THE RISK OF HEALTH CARE ASSOSIATED INFECTION 6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS
IPSG – 1 (IDENTIFY PATIENT CORRECTLY)  WHEN GIVING ANY TREATMENT  WHEN DOING ANY PROCEDURE (PATIENT ROOM CANNOT BE USED AS AN IDENTIFIER)
FAILURES TO CORRECTLY IDENTIFY THE PATIENTS LEAD TO: MEDICATION ERROR TRANSFUSION ERROR TESTING ERROR WRONG PERSON PROCEDURE
IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)  COMMUNICATION AMONG NURSE ENDORSEMENT  NURSING DOCUMENTATION CLEAR AND LEGIBLE HAND WRITING DATE, TIME & SIGNATURE FOR EACH ENTRY
IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION) TELEPHONE ORDER VERBAL ORDER  WRITE DOWN THE ENTIRE  REPEAT BACK ORDER  START THE ORDER  READ BACK  SIGN AFTER SITUATION IS  WITNESS OVER OR BEFORE PHYSICIAN  SIGN WITHIN 24 HOURS LEAVE THE AREA
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) (DRUGS THAT BEAR A HIGHTENED RISK CAUSING SIGNIFICANT PATIENT HARM WHEN USED IN ERROR)
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) TOP FIVE HIGH ALERT MEDICATIONS ARE: 1. INSULIN 2. NARCOTICS 3. INJECTABLE POTASSIUM CHLORIDE (PHOSPHATE) CONCENTRATED 4. INTRAVENOUS ANTICOAGULANTS 5. SODIUM CHLORIDE SOLUTION ABOVE 0.9 %
LOOK ALIKE MEDICINE
Example of SOUND ALIKE Folinic Acid Folic Acid Amidaron Amlor Zinnat Zantac Flumazenil Flamazine Parlodel Panadol Tazocin Prazocin Ferrosac Ferriprox Kafocid Keflex Lasix Losec Aldactone Aldomet Ranitidine Loratidine voltarin ventolin
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) 7 RIGHTS 1.RIGHT PATIENT 2.RIGHT MEDICATION 3.RIGHT TIME 4.RIGHT ROUTE 5.RIGHT DOSAGE 6.RIGHT FREQUENCY 7.RIGHT DOCUMENATION
IPSG – 4 (ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY) UNIVERSAL PROTOCOL FOR WRONG SITE, PROCEDURE, AND SURGERY PREVENTION  MARKING THE SURGICAL SITE  A PRE – OPERATIVE VERIFICATION PROCESS  A TIME – OUT THAT IS HELD IMMEDIATELY BEFORE THE START OF A PROCEDURE (The pause before surgery begins is known as "time out" and is intended to make everyone slow down for a few moments and double check what they are about to do.)
IPSG – 5 (REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION  EFFECTIVE HAND – HYGIENE  COMPLY WITH THE CURRENT PUBLISHED & GENERAL ACCEPTED HAND – HYGIENE GUIDELINES
IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS)  INITIAL ASSESSMENT OF PATIENT FALL RISK & REASSESSMENT OF PATIENT WHEN INDICATED BY A CHANGE IN CONDITION OR MEDICATIONS  Document and report your observations and your interventions
INTERNATIONAL PATIENT SAFETY GOALS (USE CAPITAL LETTERS OF EACH WORD TO REMIND YOU OF THE GOAL) I I D E NT I F Y patients correctly (patient’s room cannot be used) when giving / doing any treatment or procedure. CAN COM M UNI CAT I ON – improved effective communication through implementation of a process or procedure for taking verbal or telephone orders or for reporting critical test results that require a verification “read back” of the complete order or test result by the person receiving the information. MEMORIZE M E D I CAT I ON – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS. Remove concentrated electrolytes (including but not limited to Potassium chloride, Potassium Phosphate, Sodium Chloride ˃0.9% from patient care units. EVERYTHING E LI M I NAT E – WRONG SITE, WRONG PATIENT, WRONG – PROCEDURE IN SURGERY I I NF E CT I ON – reduce the risk of Health Care – Acquired Infections comply with the current published and generally accepted hand hygiene guidelines. FANCY F ALL – reduce the risk of patient harm resulting from FALL. Take action to decrease or eliminate any identified risks.

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International patient safety rems lecture

  • 1. INTERNATIONAL PATIENT SAFETY RAHIMA M. SALENDAB, BSN, RN
  • 2. PATIENTS SAFETY,,,,???? Prevent medical errors Protect patient from harm
  • 3. INTERNATIONAL PATIENT SAFETY GOALS AUTHORED BY JCI (JOINT COMMISSION INTERNATIONAL) STARTED AT JANUARY 1, 2007
  • 4. INTERNATIONAL PATIENT SAFETY GOALS: 1. IDENTIFY PATIENT CORRECTLY 2. IMPROVE EFFECTIVE COMMUNICATION 3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATION 4. ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY 5. REDUCE THE RISK OF HEALTH CARE ASSOSIATED INFECTION 6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS
  • 5. IPSG – 1 (IDENTIFY PATIENT CORRECTLY)  WHEN GIVING ANY TREATMENT  WHEN DOING ANY PROCEDURE (PATIENT ROOM CANNOT BE USED AS AN IDENTIFIER)
  • 6. FAILURES TO CORRECTLY IDENTIFY THE PATIENTS LEAD TO: MEDICATION ERROR TRANSFUSION ERROR TESTING ERROR WRONG PERSON PROCEDURE
  • 7. IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)  COMMUNICATION AMONG NURSE ENDORSEMENT  NURSING DOCUMENTATION CLEAR AND LEGIBLE HAND WRITING DATE, TIME & SIGNATURE FOR EACH ENTRY
  • 8. IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION) TELEPHONE ORDER VERBAL ORDER  WRITE DOWN THE ENTIRE  REPEAT BACK ORDER  START THE ORDER  READ BACK  SIGN AFTER SITUATION IS  WITNESS OVER OR BEFORE PHYSICIAN  SIGN WITHIN 24 HOURS LEAVE THE AREA
  • 9. IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) (DRUGS THAT BEAR A HIGHTENED RISK CAUSING SIGNIFICANT PATIENT HARM WHEN USED IN ERROR)
  • 10. IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) TOP FIVE HIGH ALERT MEDICATIONS ARE: 1. INSULIN 2. NARCOTICS 3. INJECTABLE POTASSIUM CHLORIDE (PHOSPHATE) CONCENTRATED 4. INTRAVENOUS ANTICOAGULANTS 5. SODIUM CHLORIDE SOLUTION ABOVE 0.9 %
  • 11.
  • 13. Example of SOUND ALIKE Folinic Acid Folic Acid Amidaron Amlor Zinnat Zantac Flumazenil Flamazine Parlodel Panadol Tazocin Prazocin Ferrosac Ferriprox Kafocid Keflex Lasix Losec Aldactone Aldomet Ranitidine Loratidine voltarin ventolin
  • 14. IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) 7 RIGHTS 1.RIGHT PATIENT 2.RIGHT MEDICATION 3.RIGHT TIME 4.RIGHT ROUTE 5.RIGHT DOSAGE 6.RIGHT FREQUENCY 7.RIGHT DOCUMENATION
  • 15. IPSG – 4 (ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY) UNIVERSAL PROTOCOL FOR WRONG SITE, PROCEDURE, AND SURGERY PREVENTION  MARKING THE SURGICAL SITE  A PRE – OPERATIVE VERIFICATION PROCESS  A TIME – OUT THAT IS HELD IMMEDIATELY BEFORE THE START OF A PROCEDURE (The pause before surgery begins is known as "time out" and is intended to make everyone slow down for a few moments and double check what they are about to do.)
  • 16. IPSG – 5 (REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION  EFFECTIVE HAND – HYGIENE  COMPLY WITH THE CURRENT PUBLISHED & GENERAL ACCEPTED HAND – HYGIENE GUIDELINES
  • 17. IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS)  INITIAL ASSESSMENT OF PATIENT FALL RISK & REASSESSMENT OF PATIENT WHEN INDICATED BY A CHANGE IN CONDITION OR MEDICATIONS  Document and report your observations and your interventions
  • 18.
  • 19. INTERNATIONAL PATIENT SAFETY GOALS (USE CAPITAL LETTERS OF EACH WORD TO REMIND YOU OF THE GOAL) I I D E NT I F Y patients correctly (patient’s room cannot be used) when giving / doing any treatment or procedure. CAN COM M UNI CAT I ON – improved effective communication through implementation of a process or procedure for taking verbal or telephone orders or for reporting critical test results that require a verification “read back” of the complete order or test result by the person receiving the information. MEMORIZE M E D I CAT I ON – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS. Remove concentrated electrolytes (including but not limited to Potassium chloride, Potassium Phosphate, Sodium Chloride ˃0.9% from patient care units. EVERYTHING E LI M I NAT E – WRONG SITE, WRONG PATIENT, WRONG – PROCEDURE IN SURGERY I I NF E CT I ON – reduce the risk of Health Care – Acquired Infections comply with the current published and generally accepted hand hygiene guidelines. FANCY F ALL – reduce the risk of patient harm resulting from FALL. Take action to decrease or eliminate any identified risks.