International Patient Safety GoalsPrepared By: Mr. Mouad M. Hourani. (Bcs, MPh) Prince Sultan Military Medical City (PSMMC)Continuous Quality Improvement & Patient Safety Coordinator
Why Patient safety Goals. List of Goals. Brief of each goal. Requirement of each goal. Summary. Scenario.
To promote specific improvements in patient safety. To highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to these problems. (JCIA – 4th Edition, 2011)
Goal 1: Identify Patients Correctly. Goal 2: Improve Effective Communication. Goal 3: Improve the Safety of High-Alert Medications. Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery. Goal 5: Reduce the Risk of Health Care–Associated Infections. Goal 6: Reduce the Risk of Patient Harm Resulting from Falls.
Wrong-patient errors occur in virtually all aspects of diagnosis and treatment. Patients may be sedated, disoriented, or not fully alert; may change beds, rooms, or locations within the organization; may have sensory disabilities; or may be subject to other situations that may lead to errors in identification. (JCIA – 4th Edition, 2011)
A policy to be collaboratively developed that address: › accuracy of patient identification Using at least two (2) ways to identify a patient. › The patients room number and location cannot be used to identify the patient. › Patients are identified when: 1. Giving medicines, blood or blood products. 2. Taking blood samples and other specimens for clinical testing. 3. Providing any other treatments or procedures.
Effective communication-which is timely, accurate, complete, unambiguous, and understood by the recipient— reduces errors and results in improved patient safety. Communication can be electronic, verbal, or written. The most error-prone communications are patient care orders given verbally and those given over the telephone, when permitted. Another error-prone communication is the reporting back of critical test results. (JCIA – 4th Edition, 2011)
A policy to be collaboratively developed that address: › the accuracy of verbal and telephone communications. › The complete verbal and telephone order or test result is written down – read back by the receiver of the order or test result those must be confirmed by the individual who gave the order or test result.NOTE: Not all countries permit verbal or telephone orders.
When medications are part of the patient treatment plan, appropriate management is critical to ensure patient safety. High-alert medications are those medications involved in a high percentage of errors and/or sentinel events, medications that carry a higher risk for adverse outcomes, as well as look-alike, sound-alike medications. Lists of high-alert medications are available from organizations such as the World Health Organization or the Institute for Safe Medication Practices. (JCIA – 4th Edition, 2011)
A frequently cited medication safety issue is the unintentional administration of concentrated electrolytes (for example, potassium chloride [equal to or greater than 2 mEq/mL concentrated). Errors can occur when staff are not properly oriented to the patient care unit, when contract nurses are used and not properly oriented, or during emergencies. The most effective means to reduce or eliminate these occurrences is to develop a process for managing high-alert medications that includes removing the concentrated electrolytes from the patient care unit to the pharmacy. (JCIA – 4th Edition, 2011)
The organization should identify the organization’s list of high-alert medications based on its own data. Concentrated electrolytes that are clinically necessary as determined by evidence and professional practice should be clearly labeled and stored in a manner that restricts access to prevent inadvertent administration.
A policy to be collaboratively developed that address: › The location, labeling, and storage of concentrated electrolytes. › The Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas.
Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common occurrence in health care organizations. These errors are the result of: › Ineffective or inadequate communication between members of the surgical team. › Lack of patient involvement in site marking. › Lack of procedures for verifying the operative site. frequent contributing factors: › Inadequate patient assessment. › Inadequate medical record review. › A culture that does not support open communication among surgical team members. › Problems related to illegible handwriting. › The use of abbreviations. (JCIA – 4th Edition, 2011)
Time out should be done for at least: procedures that investigate and/or treat diseases and disorders of the human body through cutting, removing, altering, or insertion of diagnostic/ therapeutic scopes. The time out applies to any location in the organization where these procedures are performed. And done just before starting the procedure which involves the entire operative team. The (US) Joint Commission’s Universal Protocol is: › Marking the surgical site; › A preoperative verification process; and › A time-out that is held immediately before the start of a procedure.
The surgical site Marking should: › Involve the patient. › Done with an instantly recognizable mark. › Be consistent throughout the organization. › Be made by the person performing the procedure. › Take place with the patient awake and aware, if possible. › Be visible after the patient is prepped and draped. › Marked in all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine). The purpose of the preoperative verification process is: › To verify the correct site, procedure, and patient. › To ensure that all relevant documents, images, and studies are available, properly labeled, and displayed; and › To verify any required special equipment and/or implants are present.
Use a checklist, including a ―Time-out" just before starting a surgical procedure, to ensure the correct patient, procedure, and body part. Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins. Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this.
Goal 5: Reduce the Risk of Health Care – Associated Infections
Infection prevention and control are challenging in most health care settings, and rising rates of health care–associated infections are a major concern for patients and health care practitioners. Infections common to many health care settings include catheter-associated urinary tract infections, bloodstream infections, and pneumonia (often associated with mechanical ventilation). Central to the elimination of these and other infections is proper hand hygiene. (JCIA – 4th Edition, 2011)
Internationally acceptable hand hygiene guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC), and various other national and international organizations. (JCIA – 4th Edition, 2011)
Comply with current published and generally accepted hand hygiene guidelines. Implements an effective hand hygiene program. Develop policies and/or procedures that address reducing the risk of health care– associated infections. NOTE: This should recognize that not all countries have a CDC (Centers for Disease Control and Prevention) or may not recognize the US CDC.
Reduce the Risk ofPatient Harm Resultingfrom Falls
Falls account for a significant portion of injuries in hospitalized patients. the organization should evaluate its patients’ risk for falls and take action to reduce the risk of falling using a fall-risk reduction program that based on appropriate policies and/or procedures. The evaluation could include fall history, medications and alcohol consumption review, gait and balance screening, and walking aids used by the patient. (JCIA – 4th Edition, 2011)
Assess and periodically reassess each patients risk for falling, including the potential risk associated with the patients medication regimen, and take action to decrease or eliminate any identified risks.
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Patient 60 years old admitted to ER complaining of sever chest pain. ECG ,Cardiac enzymes, CBC and KFT were done (IPSG 1: Identify patient correctly).The ECG shown massive MI and the cardiac enzymes were critically high (IPSG2: Improve Effective Communication). Patient transferred urgently to CardiacCatheterization Lab which indicated the need for open heart surgery as result ofleft main 95% occlusion. Therefore, after doing the success surgery (IPSG4:Ensure correct site, correct procedure and correct patient), patient wastransferred to CVICU Which was assessed by the registered nurse and found thatthe patient at high risk of fall (IPSG 6: Reduce the Risk of Patient Harm Resultingfrom Falls). In the next day the Lab technician called to notify low potassiumlevel (IPSG 2: Improve Effective Communication) and the consultant was notreachable. So, the nurse called him and he ordered her to give 20meq ofpotassium IV (IPSG 2: Improve Effective Communication). So that, the completeorder carried out using the medication that was stored in lucked key (secured)box, red labeled which given after double check (IPSG3: Improve safety of highalert medication). The patient was transferred to ward considering thedocumented risk of fall precaution by assisting him in ambulation, properteaching, raised side rails and low bed level (IPSG 6: reduce patient harmresulting from falls). Finally, patient was discharged with free of infectionbecause of physicians, nurses and other staff who dealt with patient were strictto follow hand Hygiene (IPSG5: reduce the risk of healthcare associatedinfections).