The document summarizes the presentation given by Ms. Eloisa E. Ramos on patient safety goals at Procare Riaya Hospital. It discusses the 6 International Patient Safety Goals including identifying patients correctly, improving communication, safety of high-alert medications, ensuring correct-site surgery, reducing healthcare-associated infections, and reducing falls. Key points from each goal are provided such as using two patient identifiers, implementing processes for verbal orders and reporting critical test results, and assessing and mitigating patient fall risks. The document aims to improve safety and quality of care through understanding and implementing the Joint Commission International's patient safety standards.

1. PRESENTED BY:
Ms. Eloisa E. Ramos
Training and Education Manager
Procare Riaya Hospital

2. To improve the safety and
quality of care in the
international community….

4. Patient Safety:
 Prevention of harm or injury to
patients
 Identification and control of things
that could cause harm to patients

6. GOAL:
 To be proactive-
- to report
- to fix
-to develop
-to implement systems and prevent
adverse events from occurring or re-
occurring

7. International Patient Safety Goals
JCIA standards 6th Edition
addresses the updated
International Patient Safety
Goals; of which they are six (6
IPSG’s).

8.  The purpose of the Joint Commission’s
International Patient Safety Goals (IPSGs)
is to promote specific
improvements in patient safety in
all international healthcare
institutions.

9.  IPSG# 1 :Identify Patients Correctly
 IPSG#2 :Improve Effective Communication
 IPSG#3 :Improve the Safety of High-Alert
Medications
 IPSG#4 :Ensure Correct-Site, Correct-
Procedure, Correct- Patient Surgery
 IPSG#5:Reduce the Risk of Health Care–
Associated infections (HCAI)
 IPSG#6:Reduce the Risk of Patient Harm
Resulting from Falls

12. 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.
The intent of this goal is twofold:
 First- to reliably identify the patient as the person
for whom the service or treatment is intended;
 Second - to match the service or treatment to that
individual patient.

13.  The hospital develops and implements a process
to improve accuracy of patients identification.
 Measureable Elements :
 1. Patient’s are identified using TWO identifiers ,
NOT Including use of the patient’s room number
or location.
 2. Patient’s are IDENTIFIED before providing
treatments and or procedures.
 3. Patient’s are IDENTIFIED before any diagnostic
procedures

14.  Purpose :
1.1. to provide guidelines for all health caregivers
to ensure positive and accurate identification of
patients……see complete policy IPSG
2.1 Patient Identification – is an ongoing
process to accurately identify patients using at
least two identifiers, none of which is the
patient’s room number .
Continue reading ……

15.  2 identifiers :
 3.3.1 Patient’s Medical Record Number
 ( mandatory )
 3.3.2 Patient’s Full name ( mandatory )
 3.3.3 Patient’s date of birth ( optional )
 UNKNOWN PATIENT :
 Maryam …please check this one …..

16. This Goal Applies to:
1. Ambulatory Care / Outpatient Dept. (Doctors,
Nurses)
2. Hospital Laboratory (Lab technicians)
3. Radiology
4. Physiotherapy
5. Patient Care Areas – Wards, ICU, NICU, L&D,
OR, etc.
6. Cardio-respiratory Care (RTs, etc.)

17. Activities where Accurate Patient Identification is
STRICTLY required:
1. Blood Extractions
2. IV insertion
3. Medication Administration
4. Routine Nursing Care (Vital signs, Tepid Sponge Bath,
Foley Cath insertion, etc.)
5. Surgical, Radiologic and other invasive procedures that
requires consent

19. Detailed….

26. Important Points:
• Ensure patients have ID bands placed on
wrist/legs.
• Simultaneously, patient recites name, while you
look into the information on the ID band then
checking with the medical record.
• Any discrepancies between the ID band and the
record must be reported to supervisor or to
admitting department ASAP.

27.  Identification of infant and mother
Baby Girl: Maria Delos Santos
MRN 001122

28. 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
under local laws or regulations.
> reporting back of critical test results, such as the
clinical laboratory telephoning the organization
to report the results of a critical lab value.

30.  Implement a process/procedure for taking verbal
or telephone orders
and relay of critical test
results.

31.  The hospital develops and implements a process
to improve the effectiveness of the VERBAL/ and
TELEPHONE communications among caregivers.
 MEASURABLE ELEMENTS
 1. The complete VERBAL ORDER is
documented and READ BACK by the receiver and
CONFIRMED by the individual giving the order.

32.  Purpose :
 Definitions :
 Open the intranet Policy IPSG # 2 and read
contents
 For the Orientee…

33. Improve Communication by:
1. Accurate taking of Verbal and Telephone orders
2. Implements a process for reporting of critical
results of diagnostic test.
3. Standardized approach to “handover
communication”

34. 1. Accurate taking of Verbal and Telephone
Orders
 The person receiving the information READ
BACK the order and verifies accuracy of
telephone and verbal orders.
 A 2nd person is ideally present to attest the relay of
information – both signs in chart.
 Physician signs ASAP – if resident available.
 Physician must sign the telephone order within 24
hours.

35.  Standard : The hospital develops and implements a
process for reporting critical results of diagnostic tests.
 Measurable Elements :
 1. The hospital has defined the critical values for each type
of diagnostic tests.
 2. The hospital has identified by whom and to whom the
critical results of diagnostic tests are reported.
 3. The hospital has identified what information is
documented in the patient record.
 Open intranet for Policy and Procedure..
 Read for the audience …..
 Examples of critical reports..

37.  Standard :
 The hospital develops and implements a process
for handover communication .
 Measurable Elements :
 1. Standardized clinical content is communicated
between health care providers during handovers
of patient care.
 2. standardized forms, tools and methods support
consistent and complete handover process.
 3. Data from handover communication are tracked
and used to improve approaches to safe handover
communication .

38.  Open APP IPSG2.2 Policy – Handover
Communication
 And read to Orientee ….
 Introduce the SBAR handover communication
process.
 S- Situation
 B – Background
 A – Assessment
 R – Recommendation

39. “hand-over” – transfer of
patients
Can occur between:
-Nurse to nurse
-Nurse to doctor
-doctor to doctor

44. **Standardizing a list of hospital-approved
abbreviations and symbols
- By principle, abbreviating and short-hand writing is
discouraged.
- Use of Hospital-approved abbreviations and
symbols ONLY.
- Administrative Policy and Procedure (APP)
- List available in Clinical Areas.

45.  When medications are part of the patient treatment plan, appropriate
management is critical to ensuring 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.
> 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], potassium phosphate [equal to or
greater than 3 mmol/mL], sodium chloride [greater than 0.9% concentrated],
and magnesium sulfate [equal to or greater than 50% 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.

46. Improve the safety of Medications
1. Label all medications, medication containers (for
example, syringes, medicine cups, basins), or
other solutions

47. Medication labels contain:
1. Name of drug (Brand and, preferably, with
Generic)
2. Dosage and route of administration
3. Frequency
4. Expiry date
* Drug information visible in all drug forms

48.  Standard :
The hospital develops and implements a process to
improve the safety of high alert medications .
 Measurable Elements :
1. The hospital has a lists of high alert medications,
including look alike, sound alike medications,
that is developed from hospital specific data.
2. The hospital implements strategies to improve
the safety of high alert medications, which may
include specific storage, prescribing, preparation,
administration and monitoring process.
3. The location , labeling and storage of high alert
medications, including look alike sound alike
medications is uniform throughout the hospital .

49.  Open policy and read to orientee..
 Policy integrated with ipsg3.1 and 3.2
 Show all high alert medication lists, LASA
meds…

50. • Multi-dose Vials and irrigation solutions:
- Must be labeled indicating the date and time
opened and expiry date.
Ex.
---discard after 28 days---
- Discard if empty or if suspected to be contaminated
(due to lack of label)
Drug/Solution: Sterile Water for Irrigation
Date/Time Opened: 20/12/2014
Expiry Date: 18/01/2015

51. Remove or
improve the
safety of high
alert medications
and look-alike-
sound-alike
(LASA) in all
patient care
areas.

53. 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, and
 lack of procedures for verifying the operative site.
 In addition, inadequate patient assessment,
 inadequate medical record review,
 a culture that does not support open communication
among surgical team members, problems related to
illegible handwriting, and
 the use of abbreviations are frequent contributing
factors.

58. Ensure Correct-site, Correct-procedure, Correct-
patient Surgery
 Identify patients correctly
 Use a checklist, including a “time-out,” before
surgery
 Verify that documents and equipment are correct
and functioning properly before surgery
 Mark precise site where surgery will be performed

59. Marking the surgical site involves the patient
and is done with an instantly recognizable mark.
 The mark should be consistent throughout the
organization, should be made by the person
performing the procedure,
 should take place with the patient awake and
aware,
 if possible, and must be visible after the patient
is prepped and draped.
 The surgical site is marked in all cases involving
laterality, multiple structures (fingers, toes,
lesions), or multiple levels (spine)

61. The purpose of the preoperative verification process is
to
 verify the correct site, procedure, and patient;
 ensure that all relevant documents, images, and
studies are available, properly labeled, and
displayed;
and
 verify any required special equipment and/or
implants
are present
 The time-out permits any unanswered questions or
confusion to be resolved.
The time-out is conducted in the location the
procedure will be done, just before starting the
procedure, and involves the entire operative team.
The organization determines how the time-out
process is to be documented.

62.  Standard:
 The hospital develops and implements a process
for ensuring correct site, correct procedure, and
correct patient surgery .
 Measurable Elements
1. The hospital uses an instantly
recognizable mark for invasive and
surgical procedure site identification that
is consistent throughout the hospital.
2. Surgical and invasive procedure site
marking is done by the person
performing the procedure and involves
the patient in marking the site process.

63. 3. The hospital uses a checklist or other process to
document , before the procedure, that the
informed consent is appropriate to the procedure,
that the correct site, correct procedure, and
correct patient are identified; and that all
documents and medical technology are on hand,
correct and functional .

65. Standard : JCI
The hospital adopts and implements evidence
based hand hygiene guidelines to reduce the
risks of healthcare associated infections.
Measurable Elements
 1. The hospital adopted currently published,
evidence based hygiene guidelines .
 2. The hospital implements an effective hand
hygiene program throughout the hospitals.
 3. Handwashing and hand disinfection
procedures are used in accordance with hand
hygiene guidelines throughout the hospital .

67. Infection prevention and control are challenging health
care–associated infections – a major concern for
patients and health care practitioners.
Infections common to many health care settings
include
1. CAUTI - 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.
2. SSI – Surgical Site infections
3. VAP – Ventilator Associated Pneumonia
4. CLABSI – Central Line Associated Bloodstream
Infection

68.  Open Hand hygiene policy / Inf control Nurse
Comply with current published and generally
accepted hand hygiene guidelines

69.  Do Hand Hygiene
• For visibly dirty, contaminated, or soiled
• Before
– eating, handling or cooking food.
– Patient contact
− Donning gloves when performing a sterile
procedures

70. –After:
 - Contact with a patient’s skin
 - Contact with body fluids or excretions, non
intact skin, wound dressings
 - Removing gloves
 - Using the toilet
 - changing a diaper, tending to someone who
is sick, or handling raw meat, fish, or poultry, or
any other situation leading to potential
contamination.

72. “I always make sure that I follow
the 5 moments of Handwashing”

75.  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 and to reduce the risk of
injury should a fall occur.
 The evaluation could include fall history,
medications , gait and balance screening, and
walking aids used by the patient.
 The organization establishes a fall-risk reduction
program based on appropriate policies and/or
procedures.
 The program monitors both the intended and
unintended consequences of measures taken to
reduce falls.

76. The hospital develops and implements a process to reduce
the risk of patient harm resulting from falls.
Measurable Elements
1. The hospital implements a process for assessing all
inpatients and those outpatients whose
conditions, diagnosis, situation, location identifies
them as high risk for falls.
2. The hospital implements a process for the initial an
ongoing assessment, re assessment, and
intervention of inpatients and outpatients as risks
for falls based on documented criteria.
3. Measures are implemented to reduce risk for fall
for those identified patients, situations, locations
assessed to be at risk.

77. Reduce the Risk of Patient Harm
Resulting from Falls
 Assess and periodically reassess
each patient’s risk for falling

80. 

81. Sources:
Joint Commission International 5th
edition
http://www.jcrinc.com/13798/
World Health Organization
PCRH APP