International Patient

Safety Goals Prepared 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.

Identify Patients

Correctly

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 patient's 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.

Improve Effective

Communication.

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.

Improve the Safety of

High-Alert Medications

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.

Ensure Correct-Site,

Correct-Procedure,

Correct-Patient

Surgery

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 of

Patient Harm Resulting

from 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 patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to decrease or eliminate any identified risks.

Identify Patients

Correctly

The organization develops an approach to

improve accuracy of

patients’ identification

Use of two identifiers

before Administering medications,

blood, or blood products and Before taking

blood and other specimens for clinical testing

Improve Effective

Communication

The organization develops an approach to improve the effectiveness

of communicati

on among caregivers

Write down Verbal and

telephone order or test result and

read it back. Then confirmed by the person who gave the

order

Improve the Safety of High-

Alert Medicatio

ns

The organization develops an approach to improve the

safety of high-alert

medications

identification, location, labeling,

and storage of high-alert

medications and the concentrated

electrolytes presence in

patient care units are addressed by

policy

Ensure Correct-Site,

Correct-Procedure,

Correct-Patient Surgery

The organization develops an approach to

ensuring correct-site,

correct procedure

,and correct-patient surgery

Comply with time-out

process that includes site

marking, equipment

readiness and correct patient and procedure

prior to procedure or

operation.

Reduce the Risk of Health Care-

Associated Infections

The organization develops an approach to reduce the

risk of health care–

associated infections

Comply with hand hygiene

and precautions as in policy.

Reduce the Risk of Patient Harm

Resulting from Falls

The organization develops an approach to reduce the

risk of patient harm

resulting from falls

Patient fall assessment / reassessment

and managemen

t as addressed in

policy

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 (IPSG 2: Improve Effective Communication). Patient transferred urgently to Cardiac

Catheterization Lab which indicated the need for open heart surgery as result of left main 95% occlusion. Therefore, after doing the success surgery (IPSG4: Ensure correct site, correct procedure and correct patient), patient was transferred to CVICU Which was assessed by the registered nurse and found that the patient at high risk of fall (IPSG 6: Reduce the Risk of Patient Harm Resulting

from Falls). In the next day the Lab technician called to notify low potassium level (IPSG 2: Improve Effective Communication) and the consultant was not reachable. So, the nurse called him and he ordered her to give 20meq of potassium IV (IPSG 2: Improve Effective Communication). So that, the complete order carried out using the medication that was stored in lucked key (secured)

box, red labeled which given after double check (IPSG3: Improve safety of high alert medication). The patient was transferred to ward considering the documented risk of fall precaution by assisting him in ambulation, proper teaching, raised side rails and low bed level (IPSG 6: reduce patient harm resulting from falls). Finally, patient was discharged with free of infection

because of physicians, nurses and other staff who dealt with patient were strict to follow hand Hygiene (IPSG5: reduce the risk of healthcare associated infections).