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1. Ahmad Thanin

2. International
Patient Safety
Goals (IPSGs)
Identify Patients Correctly.
Goal 1
Improve Effective Communication
Goal 2
Improve the Safety of High-Alert Medications
Goal 3
Ensure Safe Surgery
Goal 4
Reduce the Risk of Health Care-Associated Infections
Goal 5
Reduce the Risk of Patient Harm Resulting from Falls
Goal 6

3. Goal 1
Identify Patients
Correctly.

4. What is the patient Identification?
Patient identification is the
process of “correctly
matching a patient to
appropriately intended
interventions and
communicating information
about the patient's identity
accurately and reliably
throughout the continuum
of care

5. Identify the patient
Before giving Medications
Before giving blood and blood products
Before Specimen collection.
Before taking blood samples and other specimens for clinical testing.
Before providing any other Treatments / Procedures/ Surgery/ Investigation etc.
Before giving Food.
At the time of discharge (NICU and Nursery).

6. Patient Identification
All patients’: from admission to discharge : wrist band
In normal circumstances, a patient’s ID band must only be removed on discharge home.
Apply wristband to patient’s dominant wrist (i.e. the right wrist if the patient is right-handed).
For newborn:
• Immediately after delivery apply two bracelets: one on ankle and one on wrist, It should include
• Mother’s three names
• MRN
• Gender of the baby
• date and time of birth
• birth order for twins (Twin-1, Twin-2).

7. Wrist Band

8. Removal of ID
band: Only at time of discharge
Cut the ID band into small pieces
before discarding in the waste
If ID band is missing:
• Replace immediately; and
• Write incident report

9. Removal of ID
band in OR Wrist band may be intentionally and carefully removed
in the Operating Room (OR) during surgery if it obstructs
access to the patient’s operative sites, patients IV, etc.
Replacement band must be re-applied before removing
the existing one.
The person who removed the ID band must be
witnessed when re-applying and both individuals must
confirm the patient’s identification.
Nurses in Recovery Room (RR) shall not accept patients
for continued care if the correct wrist band is not
secured.

10. Incorrect Patient
Identification Can
lead to:
Medication errors
Incorrect surgery
Wrong-site surgery
Wrong treatment
Wrong baby discharged

11. Comatose /
Unconscious
Patient Without
Identity: Unknown
Health information system must
generate the temporary name as
Unknown Patient Number 1, Unknown
Patient Number 2 etc with the temporary
File/ Medical Record Number.
The person who removed the temporary
ID band must be witnessed when re-
applying the new ID and both individuals
must confirm the patient’s identification.

12. Disaster
Cases - ER
Patient Name as Disaster Number 1, Disaster
Number 2 etc, with File Number of the
patient, which should be modified upon
confirming the Identification of the Patient
The person who removed the temporary ID
band must be witnessed when re-applying
the new ID and both individuals must confirm
the patient’s identification
If it is not possible to secure or attach the ID
band on the patient’s wrist due to burns case
or severe RTA affecting the wrist-apply on
ankle.

13. How to identify patient correctly
according to IPSG 1?
Using two patient identification factors, but without including the room
or location of the patient in the complete Medical facility.
Complete patient name
MR Number
Preventative measures should be taken to ensure that the following
information is accurate before administering any medicines,
withdrawing blood, or collecting other samples for clinical purposes.

14. Remember
Always ask the
patient to tell his/her
name.
01
Never read the
patients details and
allow the patient to
passively agree.
02
Never assume that
the patient is in the
right bed, or has the
correct patient
record, always check
the wristband.
03

15. In case of more than one patient with the same name:
Highlight it at each
shift handover
01
Apply alert stickers
stating “Alert, Patient
with Similar Name”
on all relevant
documentation
02
Apply a card stating
“Alert, Patient with
Similar Name” to the
patients’ bed.
03
Use extra tools for
identification like
•National ID confirmation
•Birthdate
•Family members names.
04

16. Positive Patient Identification for Patient
Protection
Positive patient identification (PPID) is an approach to
avoiding patient misidentification for the prevention of
medical errors, which include errors in medication,
transfusion, and testing, as well as wrong-person procedures
and the discharge of infants to the wrong family.
PPID has been described as a combination of computer
systems, hardware devices, and printable products for the
purpose of identifying a patient by matching historical records
with current records.

17. Goal 2
Improve Effective
Communication

18. How to improve effective communications to meet the standards of
JCI Accreditation?
Telephone
order
Verbal
order
Reporting
of critical
results
ISBAR

19. Telephone order
When a physician is not present in the office, orders are taken over the phone to the nursing
station.
Telephone orders are only accepted at the nursing station if the patient care action is required
immediately or immediately after the call. The telephone is not an accepted option of placing
routine orders.
Orders for the following medicines cannot be made or received over the phone.
• Hazardous Medications
• TPN
• Narcotics or Controlled items

21. Important Rule

22. Verbal order
When a verbal order is received, the physician is on site but is preoccupied with emergency situations
such as Code Blue or is engaged in a sterile operation, the physician is considered unavailable.
Verbal instructions are only to be used in emergency circumstances.
Verbal instructions for narcotics or restricted medications from the treating physician are only acceptable
in emergency circumstances
verification should be done by “Repeat Back” of the entire order with the ordering physician by the
nurse/pharmacist receiving the order.

23. Important Rule

24. Documentation
shall include:
DATE AND TIME
ORDER RECEIVED
NAME OF CLINICIAN
RELAYING THE ORDER
ORDER AS DICTATED
BY THE CLINICIAN
ENDORSEMENT OF
THE ORDER AS
TELEPHONE/VERBAL
ORDER.
SIGNATURE AND ID
NUMBER OF BOTH
NURSES

25. Reporting of critical results
When a call from the lab for a critical result is received, the
nursing staff must record the critical result and promptly
validate the result in the Hospital Information System.
If the nursing staff is unable to reach the on-call physician,
the nursing staff must follow the escalation procedure.

27. Radiology /
Laboratory
critical result
If the Critical Result is confirmed, head of the department will sign the result,
and immediately contact the treating Physician by Phone (or the Ward
physician on Duty) to notify him/her about the patient Critical Result.
if the Head of department or the ( radiology / lab) doctor are not around then
the lab technician will call the Doctor and inform him about the initial result)
If we could not get the in-charge physician, then a call will be performed for
the head nurse in charge.
Radiology and laboratory departments will record & Sign in the Logbook of the
Critical Result the following Information:
• Patient name (three names),
• Patient ID,
• Critical Diagnostic result,
• Reporting time and Date,
• name of the Doctor informed.

28. ISBAR
The ISBAR framework
represents a
standardized approach to
communication which
can be used in any
situation. It stands for
Introduction, Situation,
Background, Assessment
and Recommendation

29. What are the advantages of ISBAR?
Ensures completeness of information and reduces likelihood of missed data
is an easy and focused way to set expectations for what will be communicated
Ensures a recommendation is clear and professional
Gives confidence in communication
focuses not on the people who are communicating but on the problem itself.

30. Why would healthcare providers use ISBAR?
It is portable, memorable and easy to use
Can be used to present information clearly in any situation
Helps you to organize what you’re going to say
Standardizes communication between everyone

31. Where can ISBAR be used?
The ISBAR framework may be used in any information
handover situation. For example:
• Shift changes
• Discharge to community services
• Inter-hospital transfers
• Intra-hospital transfers
• Time-critical situations such as medical emergencies or evacuations
• Procedure documents
• Reports, memorandums and briefings

35. What does this
say?

36. DO NOT USE USE
5.0 mg 5mg
.25 mg 0.25mg
MgSO4 Morphine Sulfate or Magnesium Sulfate
MSO4 Morphine Sulfate or Magnesium Sulfate
MS Morphine Sulfate or Magnesium Sulfate
DANGEROUS ABBREVIATIONS
DO NOT USE USE
Ug mcg
cc ml
U unit
QD daily
IU International Unit
SC or SQ SubQ

37. Goal 3
Improve the Safety
of High-Alert
Medications

38. Definition
• Medications that have a heightened risk of causing significant
patient harm when used in error.
High Alert Medication
• A category of medications in which all drugs included are
considered high alert although not listed individually in this
guideline
High Alert Medication Category

39. Definition
Look-Alike and Sound-Alike
Medications (LASA)
• Medications that can look alike (presentation,
strength, appearance and name) or sound like
(pronunciation) other medications leading to
avoidable mix-ups.
Tall Man Lettering
• a system in which part of a drug's name is
written in upper case letters to help distinguish
LASA medications from one another in order to
avoid medication errors e.g., on storage
shelves.

40. High-Alert
Medications
Medications involved in a high percentage of errors
and/or sentinel events.
Medications that carry a higher risk for adverse
outcomes.
Look-alike/sound-alike medications

41. Circumstances increasing risk errors in high-
risk medications
Poorly handwritten
medication orders
Verbal orders.
Similar product
packaging
Similar medication
name
Improper
packaging/labeling
to incorrect
administration
Oral liquid in IV
syringe
Topical products
stored in IV vials
Storage of products
with similar names
in the same
location
Similar
abbreviations
Improper storage
of concentrated
electrolytes

42. Double checking procedure
High alert medication
requires a double-
checking procedure
prior to administration.
The minimum
requirements for
double check will be
for:
With each dose/injection
For infusion
• At the time of initiation of therapy
• At the time of a concentration change
• At the change of each shift or any
transfer of care
• With any dose change

43. Double checking procedure
Compare the label with the product against
the prescription and label the product
content with the medication administration
recorded (MAR) for the subsequence dose.
The infusion pump setting will set also and
double checked for the correct rate of
infusion at initiation of the infusion.

44. Preventive strategy
Preventive strategy will be implemented to reduce the potential risk
associated with the use of High Alert Medication, use these will include:
• Not accepting the letter U instead of unit in Physician’s order for
Heparin and Insulin.
• Verbal and telephone order should be kept to the minimum when
prescribing high alert medications (verbal and telephone order for
Potassium Chloride Injection is PROHIBITED)
• Medication administered as intravenously will have a standard
concentration for adult patient.

45. IMPORTANT
High-Alert medications must
be properly labeled with Red
warning sticker “High-Alert”
for further dilution.

46. Storage and Dispensing:
High-Alert medications should NOT be stored in floors, only a limited quantity will be kept in a separate, locked cabinet
away from regular medication stocks in certain areas such as (Operating Room, Emergency Room, and Intensive Care Units).
Intravenous anesthetic and skeletal muscle relaxants agent should only be stocked in ICU, OR and ER.
Each drug should be stored in separate labeled plastic container.
Narcotic and controlled medications should be tightly controlled all over the hospital to prevent misuse or dangerous mix-
up, to be kept in separate steel cabinets with double locks.
Dispensing of such drugs (Narcotic & Controlled) only against treating consultant or specialist’s written order.

47. High-Alert
Medication
Categories
High-Risk Medication Category/Route Potential Error and Consequences
Concentrated electrolytes / I.V
• (Potassium Chloride, Calcium
Gluconate, Magnesium Sulphate,
Potassium Acetate, Sodium Chloride
14.6%, Sodium Phosphate)
Potentially Lethal Medications
Insulin / S.C / I.V ( only regular insulin can
be given I.V )
• Regular ( Humulin, Actrapid )
• NPH (Humulin N,Insulatard HM )
• 70/30 (Humulin , Mixtard )
• Lantus ( Glargine )
• Novomix 70/30 ( Penfill )
• Mixtard 30 HM ( Penfill )
• Levemir Penfill
• Inappropriate insulin given due to
Look-alike/Sound-alike errors
• Confusion of dose (units vs. ml )
• Drip rate errors causing bolus dose
infused into patient.
• Incorrect sliding scale
interpretations/order entry leading to
dosing errors.
• Insulin errors have the potential to
cause severe hypo/hypoglycemia.
These effects may require extra
monitoring, require treatment or in
severe cases may be fatal.

48. High-Alert
Medication
Categories
High-Risk
Medication
Category/Route
Potential Error and
Consequences
Nuromuscular
Blockers
• Cisatracurium
• Atracurium
• Mivacurium
• Succinylcholine
Potentially Lethal
Medications
(Restricted to critical
care and special care
areas. (ICU,ER,OR))

49. HIGH ALERT MEDICATIONS
Potassium
chloride (inj)
20meq
Magnesium
sulfate (inj)
10% (2gm)
Magnesium
Phosphate (inj)
Amidarone (inj)
200mg.
Epinephrine
(Adrenaline) inj
(1:1000)
Digoxin (inj)
(0.50mg)
Sodium
Bicarbonate
imj. 8.4%
Calcium
Chloride (inj)
10%
Calcium
Gluconate (inj)
Phenytoin (inj)
250 mg
Dopamine inj.
200 mg
Phenobarbiton
(inj) 250 mg.
Dobutamine
inj. 250 mg
Lidocain 1% for
arrhythmia (inj)
(IV)
Isoproterenol
inj 1:500mg
Warfarin (tab)
1,2,5 mg
Noradrenaline
inj-1-2mg/ml
Sodium
chloride IV 10%
Aminophylline
250 mg IV
Chemotherapy
drugs
Heparin Insulin inj

50. General Strategies for High Alert Medications
TALLman lettering
‘LASA’ on label, when applicable
“High Alert” on storage label
High Alert Medications must be stored in Red Bins using
Standardized Medication Labels
Medication which must be stored in Red Bins with Lids
•Concentrated Electrolytes
•Parenteral Skeletal Muscle Relaxants (Paralyzing agents)
Patient care areas: Stored in ADC locked Lidded
CPOE with clinical decision support, providing immediate warnings if unsafe orders are entered

51. General Strategies for High Alert Medications
Use of smart infusion pumps with dose checking software enabled
Order sets.
Independent Double-Check (IDC) Procedure in which two healthcare professionals separately check
(alone and apart from each other, then compare results) each component of prescribing,
transcribing, dispensing and verifying the medication before administering to the patient
• Dispensing
• Verifying at time of administration

53. OTHER LIST OF LOOK – ALIKE AND SOUND – ALIKE (LASA)
MEDICATION
DRUG NAME CONFUSED DRUG NAME SAFETY MEASURES
Amphotericin Liposomal Amphotericin Conventional TALLman letters, Store separately
AMILOride AMLOdipine TALLman letters, Store separately
BuPROPion BuSPIRone TALLman letters, Store separately
DiFLUcan DiPRIvan TALLman letters, Store separately
DoPAMine DoBUTamine TALLman letters, Store separately
EsMOLol EsMERon TALLman letters, Store separately
EpiNEPHrine EpheDrine TALLman letters, Store separately
FluOXETine FluPHENazine TALLman letters, Store separately
HydrOXYzine HydrALAZine TALLman letters, Store separately
HumaLOG HumuLIN TALLman letters, Store separately
PeniCILLIN PeniCILLAMINE TALLman letters, Store separately
ZanTAC ZyrTEC TALLman letters, Store separately

54. Concentrated
Electrolytes:
Magnesium Sulfate 50 % or more
concentration
Potassium Chloride 2 mmol/mL or
more concentration
Potassium Phosphate 3 mmol/ml
or more concentration
Sodium Chloride hypertonic
(greater than 0.9%)

56. Goal 4
Ensure Safe
Surgery

57. DIFFENTION
Time Out
is a final pause and final
verification process to
be done on a patient
before the performance
of a procedure/s in the
presence of all clinical
team members and in
the location where the
procedure is to be
conducted to assure
right patient, right site
and right procedure.

58. Time Out:
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.

59. Wrong site surgery and the Protocol
Check that the consent form or procedure request form is correct
Check
Mark the site with an indelible pen for the surgery or other invasive procedure
Mark
Confirm identification with the patient
Confirm
Take a “team time out” in the operating theatre, treatment or examination area for staff to verbally confirm that
all is correct
Take TIME OUT
Ensure appropriate and available diagnostic images.
Ensure

60. Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol
Days to hours before procedure
Step 1
Consent form or procedure request form, must include:
• Patient's full name.
• Procedure site.
• Name of procedure.
• Reason for procedure
Step 2
Mark site of invasive procedure:
• Must be marked by the person in charge of the procedure or another senior team member who has been
fully briefed about the procedure or operation

61. Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol
Just before entering the operation room or treatment room
Step 3
Patient Identification, staff must ask the patient to state:
• Their full name.
• Date of birth.
• Site for, or type of procedure
Remember to
Check the response against the marked site, ID Band, consent form and other documents

62. Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol
Immediately prior to procedure
Step 4
Team time out, within the operating theater or treatment room when the patient is present and prior to
beginning the procedure.
Staff must verbally confirm through “ team time out” when all other activities in the operation room stopped:
• Presence of correct patient
• The correct site has been marked.
• Procedure to be performed
• Availability of correct implant where required
Step 5
Imaging Data, if imaging data are used to confirm the site or procedure, two or more members of the team must
confirm the images are correct and properly labeled

63. The surgical site Marking should:
Involve the patient.
Be made by the person
performing the
procedure with a
permanent skin marker
Done with an instantly
recognizable mark.
Be consistent throughout
the organization.
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).

64. 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.

65. Mark site of invasive
procedure:

66. Surgical Time-Out
When a patient goes to surgery, their surgical team
takes great care to provide a safe experience. This
involves
Pre-
Procedure
Check-In
Sign-In Time-Out Sign-Out

67. Pre-
Procedure
Check-In
• Pre-op room
Where
• Patient and Pre-op Nurse
Who
• History and Physical
• Consent
• Nursing Assessment, including vital signs
• Operative site marked by surgeon
• Labs and images available
• Blood products, special equipment available if needed
What - Verification of:
• Before Patient is taken into OR
When

68. Sign-In
• Pre-Op room
Where
• Patient, OR nurse and Anesthesiologist or Certified
Registered Nurse Anesthetist (CRNA)
Who
• Patient, Procedure, Site and Consent
• Allergies, Airway Concerns and Aspiration Concerns
• Risk of blood loss
What – Verification of:
• Prior to giving anesthesia
When

69. Time-Out
•Operating Room
Where
•All members of the surgical team
Who
•Surgeon introduces all team members
•Verify patient, site and procedure
•Verify patient images
•Verify specific equipment available
•Assess Fire Risk
•Verify sterilization indicators for instruments
•Verify antibiotics have been given
•All members’ concerns addressed
What
•Prior to skin incision
When

70. Sign-Out
• Operating Room
Where
• All members of the surgical team
Who
• Procedure verified
• OR RN confirms sponge, sharps and instrument count
• Surgical specimens identified and labeled
• Identify equipment concerns
What
• Before Patient leaves OR
When

71. Example for X – HOSPITAL FORM TEMPLATE

72. Rule
• Anything that may require a consent
and/or is a “high risk” procedure requires
a TIME-OUT
• Don’t forget! The “TIME-OUT process
applies to procedures OUTSIDE the OR as
well!

73. Goal 5
Reduce the Risk of
Health Care-
Associated Infections

74. Introduction
• Healthcare Associated Infection
• is a localized or systemic condition resulting from an adverse reaction to the
presence of infectious agent(s) or its toxin(s) that was not present on admission to
the acute care facility.
• An infection is considered as health care associated in all elements as per Centers for
Disease Control and Prevention (CDC) site-specific infection criterion were first
present together on or after the 3rd hospital day (day of hospital admission is day 1)

75. Infection Control Program
Establishing an effective infrastructure for
the Infection Control Program by:
• Multidisciplinary team to oversee the Infection
Prevention Control Program.
• Program management.
• Policies and procedures.

76. Definitions
Hand Hygiene: A general term referring to any action of hand cleansing
Alcohol-Based
Hand Rub:
An alcohol-containing preparation designed for application to the hands
for reducing the number of viable microorganisms on the hands.
Antimicrobial
Soap:
Soap (i.e. detergent) containing an antiseptic agent.
Antiseptic
Agent:
Antimicrobial substances that are applied to the skin to reduce the
microbial flora.
Antiseptic Hand
Wash:
Washing hands with soap and water or other detergents containing an
antiseptic agent.
Detergents: Compounds that pose a cleaning action.
Hand Hygiene: A general term that applies to hand washing, antiseptic hand wash,
antiseptic hand rub, or surgical hand antisepsis.
Hand
Antisepsis:
Refers to either antiseptic hand wash or antiseptic hand rub.
Decontaminate
Hands:
To reduce bacterial counts on hands by performing antiseptic hand rub or
antiseptic hand washes.

78. Infection
Prevention
and Control
Program
consist of:
Standard Precautions
Hand Hygiene
Appropriate Use of Personal Protective Equipment
Cleaning, Disinfection and Sterilization
Correct Waste Disposal, Proper Sharp Disposal and Sharp Injury Management.
Linen Management.
Specimen Handling.
Environnemental Management and Spillage Management..
Aseptic Technique
Cough Etiquette.
Transmission-Based Precautions
Education .
Surveillance

79. Standard
Precautions
Standard precautions are based on the principle
that all blood, body fluids, excretions except sweat,
non intact skin and mucous membranes may
contain transmissible infectious agents.
Standard precautions are intended to be applied to
the care of all patients in all health care settings,
regardless of the suspected or confirmed presence
of an infectious agent.
Implementation of standard precautions constitutes
the primary strategy for the prevention of
healthcare associated transmission of infectious
agents among patients and healthcare personnel.

80. Hand
Hygiene
Healthcare associated infections are mainly spread through
the contaminated hands of health care workers.
Hand washing is the single most important way of
preventing the spread of infection.
Hand hygiene procedures include the use of alcohol-based
hand rubs and hand washing with soap and water.
Hand hygiene stations should be strategically placed to
ensure easy access.
Hand hygiene guidelines from WHO (5 moments of hand
hygiene) is used to observe and evaluate hand hygiene for
all categories of staff.

85. Hand Hygiene
should be done
in all the
following
instances
When hands are visibly dirty or contaminated with proteinaceous material or are
visibly soiled with blood or other body fluids, wash hands with either a
nonantimicrobial soap and water or an antimicrobial soap and water.
Wash
If hands are not visibly soiled, use an alcohol-based hand rub for routinely
decontaminating and in all other clinical situations.
Use
Decontaminate hands before and after having direct contact with patients.
Decontaminate
Decontaminate hands before clean/Aseptic procedure if moving from a contaminated
body site to another body site during care of the same patient.
Decontaminate

86. Hand Hygiene
should be done
in all the
following
instances
Decontaminate hands after contact with body fluids or
excretions, mucous membranes, non-intact skin, and
wound dressings. If moving from a contaminated body site
to another body site during care of the same patient. And
after removing sterile or non-sterile gloves.
Decontaminate hands before and after contact with a
patient's intact skin (e.g. when taking pulse or blood
pressure and lifting a patient).
Decontaminate hands after contact with inanimate
objects including medical equipment. After using a
restroom, wash hands with a non- antimicrobial soap and
water or with an antimicrobial soap and water.

87. Factors for poor adherence with hand
Hygiene:
Hand washing agents
may cause irritation
and dryness.
Sinks are
inconveniently
located/shortage of
sinks.
Lack of soap and
paper towels.
Insufficient time.
Lack of knowledge of
guidelines.
Beliefs that wearing
of gloves obviates the
need for hand
hygiene.

88. Appropriate Use of Personal Protective Equipment
Involves specialized equipment worn
by the staff for protection against
infectious materials.
The selection of personal
protective equipment is based
on the nature of the patient
interaction and potential for
exposure to blood, body fluids
or infectious agents. This
includes gloves, gowns, and
masks.
A review of available
personal protective
equipment should be
performed periodically due
to new product
developments and
improvements.

89. Cleaning, Disinfection and Sterilization
Reusable medical devices/equipment must be adequately reprocessed for
safe reuse.
Strict policy regarding single use items.
Spaulding’s classification of medical devices:
• Critical Item (contact with sterile areas of the body)
• Semi-Critical Item (contact with mucous membranes or non-intact skin)
• Non-Critical Item (contact with intact skin)

90. Correct
Waste
Disposal,
Proper Sharp
Disposal and
Sharp Injury
Management
Segregate general and infectious waste at the point
of generation.
Awareness of proper waste management should be
emphasized and strictly followed.
General Waste
• materials with no inherent hazard or infection potential e.g.
administrative, food waste etc. (Black / Blue plastic bag)
Biohazardous (Infectious Waste)
• these are wastes which has the potential for transmitting
infections/disease e.g. gloves, masks, blood-soaked dressings
etc. (yellow thick plastic bag with Biohazardous sign)

91. Correct Waste
Disposal,
Proper Sharp
Disposal and
Sharp Injury
Management
Human Waste Tissue
• as defined from fatwas 13290/13291 e.g. amputated
body parts, placenta etc. (red thick plastic bag with label).
Sharp Disposal
• sharps include any object that can penetrate the skin e.g.
needles, blades, broken ampoules etc. (puncture resistant
sharps container)
Safe Sharp Handling
• to be managed and disposed of in a manner as to prevent
injuries and transmission of disease e.g. no recapping of
needles, use of kidney dish for transportation.
Sharp Injury
• First aid, reporting, laboratory tests, forms.

92. Linen
Management
Proper handling of soiled linen (soiled
with blood or other body fluids) use of
personal protective equipment.
Transport from departments to
laundry in closed carts.
No mixing of clean and soiled linen.

93. Specimen
Handling
Contained in a sealed container/plastic bag
which is leak proof.
Contained specimen must be placed in a
secondary biohazard labeled plastic bag.
Ensure request form is not contaminated; place
in separate pocket of the biohazard plastic bag.
Sharps injury must be avoided on collecting,
containing and transporting of any specimen.

94. Environmental
Management
and Spillage
Management
Proper cleaning of patient’s rooms on daily
basis. Medical device surfaces and housekeeping
surfaces.
Terminal cleaning on discharge of patient.
Cleaning to be done with hospital prescribed
disinfectant.
Proper procedure to be followed indicated for
relevant spill e.g. blood spill, chemical spill.

95. Aseptic Technique
Are established to prevent or minimize the risk of
infection transmission to patients undergoing
invasive procedures or wound management.
Healthcare worker must observe and practice the
principles of aseptic technique as indicated by the
type of procedure to be done

96. Cough Etiquette
Educate healthcare personnel, patients and visitors on the
importance of source control measures to contain respiratory
secretions to prevent transmission of respiratory pathogens.
Especially during seasonal outbreaks of e.g. influenza.
Tissue to cover mouth when coughing or sneezing.
Correct way for tissue disposal and hand hygiene.
Avoidance of crowds.

97. Transmission-Based Precautions
Transmission-based precautions are used when the route of transmission is not completely interrupted using standard
precautions alone.
Use transmission-based precautions for patients with documented or suspected infection of colonization with highly
transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission.
Contact Precautions
• gowns, gloves (e.g. MRSA infected patients)
Droplet Precautions
• surgical mask, gowns, gloves, (e.g. German Measles, Meningitis, Mumps)
Airborne Precautions
• N95 mask, gowns, gloves, and negative pressure room (e.g. Pulmonary Tuberculosis, Measles, Chicken Pox).

98. Education
Monthly planned in-service education program for all departments.
On hand education and training whenever the need arises.
Comprehensive orientation program for new employees by infection control
nurses and demonstration of hand hygiene.
Competencies on various infection control practices.

99. Surveillance
Hand Hygiene
Waste Compliance
• Catheter Associated Urinary Tract Infection
• Central Line Associated Blood Stream
Infection
• Ventilator Associated Pneumonia.
• Surgical Site Infections
Health Care Associated Infections

100. Environmental hygiene
• Environmental hygiene is a fundamental principle of infection prevention in healthcare settings.
• Contaminated hospital surfaces play an important role in the transmission of micro-organisms,
including Clostridium difficile, and multidrug-resistant organisms such as methicillin-resistant
Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).
• Therefore, appropriate hygiene of surfaces and equipment which patients and healthcare personnel
touch is necessary to reduce exposure.
• Evidence supports the hypothesis that hospital can act as an important reservoir of many nosocomial
pathogens in several environments such as surfaces, medical equipment and water system.
• Healthcare settings are complex realities within which there are many critical points.
• Microbial contamination can result from the same inpatients, relatives and healthcare workers.
• The role of environmental hygiene is to reduce the number of infectious agents that may be present on
surfaces and minimize the risk of transfer of micro-organisms from one person/object to another,
thereby reducing the risk of cross-infection.

101. Screening and cohorting patients
• Early detection of multidrug-resistant organisms is an important component of any infection control
program.
• There is good evidence that active screening of preoperative patients for MRSA, with decolonization of
carriers, results in reductions in postoperative infections caused by MRSA.
• Isolation or cohorting of colonized/infected patients is a cornerstone of infection prevention and
control.
• Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to
other patients, hospital visitors, and healthcare workers, who may subsequently transmit them to
other patients or become infected or colonized themselves.
• Isolating a patient with highly resistant bacteria is beneficial in stopping patient-to-patient spread.
• Isolation measures should be an integral part of any infection prevention and control program,
however they are often not applied consistently and rigorously, because they are expensive, time-
consuming and often uncomfortable for patients.

102. Antibiotic stewardship
• Optimal infection control programs have been identified as important components of any
comprehensive strategy for the control of AMR, primarily through limiting transmission of
resistant organisms among patients.
• The successful containment of AMR in acute care facilities, however, also requires an appropriate
antibiotic use.
• Antibiotic stewardship programs (ASPs) can help reduce antibiotic exposure, lower rates of
Clostridium difficile infections and minimize healthcare costs.
• Most antibiotic stewardship activities effect multiple organisms simultaneously and have as a
primary goal the prevention of the emergence of antibiotic resistance.
• Thus, ASPs can largely be viewed in the context of horizontal infection prevention.
• Additionally, ASPs can contribute to the prevention of surgical site infections via the optimized
use of surgical antibiotic prophylaxis.

104. Goal 6
Reduce the Risk of
Patient Harm
Resulting from Falls

105. Definition
• A fall is an incident in which an adult or a child
unexpectedly falls down, unassisted or uncontrolled, from
a higher position to a lower position, with or without
injuries and which may or may not be related to physical
or mental pathology.
Fall
• sudden loss of balance that does not result in a fall or
other injury .
• This can include a person who slips, stumbles, or trips but
is able to regain control prior to falling.
Near Fall
• occurs when a patient is found on the floor and neither
the patient nor anyone else knows how he or she got
there .
un-witnessed fall

106. All in-patients will be
assessed for the risk of
fall upon admission.

107. Most Causing to Falls
• Loss of consciousness.
• Orthopedic disorders.
• Hypoglycemia.
• Anemia, Vision
• Hypotension.
• Drugs action.
• Post operative (sedation).
• Aging and sleeping habits
• Paralysis, TIA, CVA
Individual
• Unsafe higher position.
• Beds side rails.
• unlocked wheelchair.
• Water in the floor.
• Wire connections.
• Steps or stairs.
• Walker.
• Interfering Clothes
Environmental

108. Patient Fall Injury Levels
None:
• No injury.
Minor:
• minor injury
with abrasion
or bruise
treated by
dressing, limb
elevation,
topical
medication.
Moderate:
• injury lead to
Suturing or
limping treated
by bandage,
splinting,
muscle or joint
strain.
Major:
• which leads for
casting, skin
traction and
surgery, may
need
neurological
and vascular
attention.
Death:
• the patient died
as a result of
serious injury.
UTD:
• unable to
determine from
the
documentation
.

109. Fall assessment
All in-patients will be assessed for the risk of fall upon admission.
•post operative.
•following procedural sedation.
•after administer medication.
•after blood transfusion.
•transferring patients between 2 units.
•after recording incident of fall.
•any changing in ambulatory status or elimination status,
Reassessment is indicated for all of the following conditions:
•Hendrich 11 Fall risk for Adults.
•Humpty Dumpty Scale for Pediatrics.
•The Morse Fall Scale
Applying Risk Fall procedure for patients
Standard fall precaution shall be implemented for all patients.
Reporting and documenting any fall occurrence.
All Falls patients should be classified according to level of Injury

110. Post Fall Protocol of Care
First Aid.
Ensure that patient
is safe from further
danger .
ask for help.
don’t reposition the
patient until the
patient is ready to
do so.
move the patient
safely with
attention to moving
and handling.
complete the post
fall assessment
Form
Reporting.
Patient and Family
Education.

111. Standard Fall Precaution for Low-Risk Patients
1
Orient the
surrounding
environment.
2
Provide
Medication
Information.
3
Instruct patient
to call for
assistance.
4
Instruct to use
the rubber –
soled shoes or
non – slip
footwear to
prevent
slipping.
5
Secure call bell,
phone, bed
table.
6
Ensure the
clothes are not
interfere with
the patient
mobility.
7
Maintain the
bed in the
lowest position
and ensure bed
and
wheelchairs
are looked.
8
Put side rails.
9
Conduct
regular
environmental
rounds in all
areas
surrounding
the patients to
decrease the
risk of falls.
10
Keep
bathroom light
on and the
floor dry.

112. Standard Fall Precaution for Moderate Risk
Patients
Identify as falls risk on
medical record and
include in shift
endorsement.
Assist and supervise
ambulation, Reinforce
to always call for
assistance.
Conduct hourly safety
checks.
Perform regular pain
assessment
Offer assistance to the
bathroom or use
bedpan hourly while
awake.
Evaluate for reversible
causes
• Orthostatic B.P
• Monitor Blood Sugar .
• Adequate Hydration
Check the patients
after the visitors leave
always.
Don’t lower the bed
side rails if any nurse
rise it up.
Patient Education. Family Education.
Apply Fall Risk Hand
Band

114. Standard Fall Precaution
for High-Risk Patients
Apply all low and moderate interventions.
Place a high risk for fall sticker/ label on the patient charts and patient room.
Raise Both upper and lower side rails.
Place mattress on floor.
Review the medication.
Assess the need of physical therapy consultation.
Assess the need for 1:1 monitoring as needed.

115. Patient and Family Education
both about the risk of falling, Safety Issues, and their Mobility
Limitation.
Educate
patient to make position changes slowly.
Teach
how important the family to be involving tin the patient safety.
Emphasize
what patient can do to be healthy, active, and independent
Emphasize
on

116. Interventions based on the fall-risk
assessment
Monitoring gait and mobility.
Bladder/ Bowel Training Program.
Fall Alert Medication.
Maintaining a safe environment.
Assistive Devices Monitoring.

117. Monitoring gait and mobility.
Normal/Safe Gait &
Balance.
Balance Problem
while Standing
Balance Problem
while Walking
Change in Gait
Pattern while
Walking through
doorway
Jerking/ Unstable
when Making Turn
Requires an
Assistance

118. Bladder /Bowel Training Program
45% Falls Identified as Toileting related (Tzeng, 2010)
Is a training technique for bladder and bowel to decrease urgency and
incontinence based on behavioral modification treatment techniques that
involves placing patient on toileting schedule.
• > 60 Years Old
• On Laxative
• Bed Ridden
• Postoperative

119. MEDICATIONS FALL ALERT
Pharmacist are responsible for reviewing medication and supplements
to ensure that the risk of falls is reduced
Notify the for Drug that depress the central nervous system may cause
sedation, drowsiness, ataxia, as well as paradoxical effects like:
• Antihistamine
• Antiepileptic
• Antidepressant
• Anticonvulsant
• Cardiovascular drugs

120. Maintaining a Safe Environment
Environmental hazards or hazardous activities are described as primary causes for
approximately half of all falls, which includes:
• Walking on slippery/rough surfaces.
• Obstacles.
• Inadequate light.
• Loose carpets.
• Trip Hazard regarding to medical care ( IV Tubing, Urinary Catheter, ).
Such hazards are likely to cause trips or slips in any age group but pose a particular
risk for community- dwelling elderly persons who may already have multiple
intrinsic risk factors for falls.

121. Assistive
Devices
Monitoring
Nurse Call
Bell

122. Fall Alert” Sign