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::Assessment of Patient Safety in Hospital: a manual for evaluatours
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Assessment of Patient
Safety in Hospitals
a manual for evaluators
Supervised by:
Dr Seyed Hasan Emami Razavi
Dr Hamid Ravaghi
Dr Mahmood Reza Mohaghegh
Translators:
Dr Hamid Ravaghi, Dr Seyed Mohammad Sadat,
Farnaz Mostofian, Dr Sar Vazirian &
Dr Peygham Heydarpoor
Ministry of Health and Medical Education
Medical Affaires Deputy
Hospital Management and Clinical Excellence Office

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Forward
Provide, sustain and promote proper health care services impacts on all other aspects
of society including economic, politics and civic activities ,so it seems well worthed to
enhance quality of health care services in order to achive above mentioned objectives.
In our country the quality of health care services have been regarded and supported by
necessary and execu ves policies. Achieving to “Iranian 20 Years Visionary Strategic
Goals Statement” is one of the main key improvement in health care system. The
health care executives are upon applying and implementating “Clinical Governance” as
an proper framework for further improvement.
The “Risk Management and Patient Safety”is likely to be the most important pillare of
Clinical Governance as a new improvement tool, it is felt compiling educational
materials on patient safety to be used by managers and health care workers is a
compelling circumstances. Regarding this, the patient safety standards were
introduced in 4 levels in “Pa ent Safety Friendly Hospitals Initiatives: a manual for
assessors“ book which was translated and published by “Hospital Management and
Clinical Excellence Office”.
Due to importance and nessecity of implementing “critical standards “of PSFHI
standards in at least 10 percent of hospitals Iranwide by the end of  h cultural, civical
and economical developmental program and the moral, religious and legal
responsibility of every individual in health system and great opportunity facing, in
maintaining health and safety of patients on pain whom quarter to us from the
avoidable consequences of adverse events, I expect all managers and studious
personnel to assure monitoring patient safety program nationally, use this book
properly and prioritize the program nationally and do their best.
Dr.Hasan Emami Razavi
Deputy Minister for Medical Affaires

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Preface
Now a day, quality of care and hospitals performance improvement is a global issue
and a main agenda for health systems of states. In Islamic Republic of Iran, access of all
of the community members to highest level of health is one of the main goals of the
state. For this purpose continous quality improvement in hospitals and settlement of
“Clinical Governance” has been impressed in recent years. In this way “Hospital
Management and Clinical Excellence Office” was established in ”Medical Affaires”
realm aiming to enhance accountability and responsiveness of hospital care providers
against continous quality improvement. The office navigates related affairs in this
realm.
Patient Safety issue is one of the most important reasons for addressing quality of
care. Various studies and WHO reports have demonestrated that almost 10% of
hospitalized patients experience different events and harms. Imposing direct and
indirect expenses to individuals and health system and patient and staff dissatisfaction
are subsequences of these events whereas more than 50% of cases are preventable.
Thus in the “Clinical Governance” frame introduced in the state, patient safety
improvement is one of the most important topics located under risk management
pillar.
The translation for “Patient Safety Friendly Hospitals Initiattives“ Assessment Manual
is result of “Hospital Management and Clinical Excellence Office” efforts addressing
patient safety assessment in hospitals of state. Hope this manual is utilized by all
health care providers in our dear country and they share in improvement of this set by
their suggestions.
Finally I take it as duty to appreciate all of my colleagues who have participated in
preparation of this set, grantfully acknowledge dear Dr Sadat and Ms. Mostofian in a
special manner.
Dr Hamid Ravaghi
General Director for Hospital Management and Clinical Excellence Office

Special thanks to authors, compilers and editors of original text of this percious
manual and colleagues in WHO East Mediteranian Regional Office.

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Acknowledgments
We thank all of the contributors to this book, and appreciate the contributors'
expertise, effort, and commitment to Patient Safety Friendly Hospital Initiatives,
especially executive board, patient safety teams of Universities of Medical Sciences
and hospitals as below:
Shahid Doctor Chamran Hospital (Tehran University of Medical Science)
Taleghani Hospital (Shahid Beheshti University of Medical Science)
Shahid Motahary Hospital ( Shiraz University of Medical Science)
Baharloo Hospital ( Tehran University of Medical Science)
Firozgar Hospital ( Tehran University of Medical Science)
Alzahra Hospital (Isfehan University of Medical Science)
Ali ebn Abitaleb Hospital (Zahedan University of Medical Science)
Imam Hosein Hospital (Shahrood University of Medical Science)
Milad Hospital (Social Welfare Organization)
Sina Hospital (Tabriz University of Medical Science)
As our main contributors in first implementing phase of PSFHI program.
And efforts of our colleagues in Baghiyatolah Azam Hospital

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Thanks and appericiation to:
Thank to Dr Mohammad H. Niknam, Minister Cosultant & General Director for
International Cooperation for his close contribution on implementing patient
safety program.
Ms Nastarn Aslani as our main partner in International Relation Office for
implementing the patient safety program.

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Dr Ambrgio Manenti, WHO Representative in Iran for his efforts and supports
for the continuty of the program
Dr Samin Siddiqui, Health Policy Coordinator of EMRO for his interest and
supports to develop and implement the program
Dr Riham El Assady, Technical Officer of EMRO for her efforts and supports to
develop and implement the program and her role in compliling the PSFHI
Assessment Manual
Dr Sara Vazirian, National Professional Officer for Development of Health
Systems for her interest, support and cooperation in developing, continuity and
implementing of the program

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Dr Seyed Sajad Razavi, General Director for Supervision and Accreditation of
Clinical Affaires Office
Dr Mojdeh Ramezani Medical Care Institues Accreditation bureau
for their unsparing cooperation in integration of patient safety standards in national
accreditation framework.

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Dr Mohammad Sadegh Mahdavi Chief Executive of Baghiyatolah Azam Hospital
Dr Ali Akbari Sari faculty member of Tehran University of Medical Science ,
Dr Arash Rashidian faculty member of Tehran University of Medical Science &
President of National Health Researches Institute
for their percious comments and suggestions and contribution to Patient Safety and
PSFHI Manual training courses as lecturers and facilitators.

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Dear colleagues in Hospital Management and Clinical Excellence Office for their
unsparing cooperation.
Dr Mohammad Aghighi
Dr Roya Dastjerdi
Ms Sima Rafiee

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‫ارزیابان‬ ‫راهنمای‬
AERLS Adverse Event Reporting & Learning System
EMRO Eastern Mediteranian Regional Office
GCC (Persian) Gulf Cooperation Council
HAI Healthcare Aquired Infections
ISQua Internatinal Society for Quality in Health Care
NPSA National Patient Safety Agency
PS Patient Safety
PSFH Patient Safety Friendly Hospital
PSFHA Patient Safety Friendly Hospital Assessment
PSFHI Patient Safety Friendly Hospital Initiative
PSIB Patient Safety Internal Body
PSPI Patient Safety Performance Indicators
PSS Patient Safety Standards
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TOR Terms of References
WAPS World Alliance for Patient Safety
WHO World Health Organization
WHO HQ World Health Organization HeadQuarter

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. To Err Is Human: building a safe health system. Washington DC. Institue of Medicine, 2000.

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146
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1.1.1.A
.
1.1.2.A
.
1.1.3.A
.
2.1.1.A
.
2.1.2.A
.
4.1.1.A.
4.1.2.A
.
4.1.3.A
.
5.1.1.A
.
2.1.1.B
.
3.1.1.B
)
.(

179
1.1.1.C
.
1.1.2.C
.
2.1.1.C
.
2.1.2.C
.
3.1.1.C
.
3.1.2.C
HIVHBV.
5.1.1.C
.
2.1.1.D
.
2.1.2.D

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