INTERNATIONAL PATIENT SAFETY

RAHIMA M. SALENDAB, BSN, RN

PATIENTS SAFETY,,,,????

Prevent medical errors

Protect patient from harm

INTERNATIONAL PATIENT SAFETY GOALS

AUTHORED BY JCI (JOINT COMMISSION INTERNATIONAL)

STARTED AT JANUARY 1, 2007

INTERNATIONAL PATIENT SAFETY GOALS:

1. IDENTIFY PATIENT CORRECTLY2. IMPROVE EFFECTIVE COMMUNICATION3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATION4. ENSURE CORRECT – SITE, CORRECT – PROCEDURE,

CORRECT – PATIENT SURGERY5. REDUCE THE RISK OF HEALTH CARE ASSOSIATED

INFECTION6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM

FALLS

IPSG – 1 (IDENTIFY PATIENT CORRECTLY)

WHEN GIVING ANY TREATMENT

WHEN DOING ANY PROCEDURE

(PATIENT ROOM CANNOT BE USED AS AN IDENTIFIER)

FAILURES TO CORRECTLY IDENTIFY THE PATIENTS LEAD TO:

MEDICATION ERRORTRANSFUSION ERRORTESTING ERRORWRONG PERSON PROCEDURE

IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)

COMMUNICATION AMONG NURSEENDORSEMENT

NURSING DOCUMENTATIONCLEAR AND LEGIBLE HAND WRITINGDATE, TIME & SIGNATURE FOR EACH ENTRY

TELEPHONE ORDER

WRITE DOWN THE ENTIRE ORDER READ BACK WITNESS SIGN WITHIN 24 HOURS 

VERBAL ORDER

REPEAT BACK START THE ORDER SIGN AFTER SITUATION IS OVER

OR BEFORE PHYSICIAN LEAVE THE AREA

IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)

IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)

(DRUGS THAT BEAR A HIGHTENED RISK CAUSING SIGNIFICANT PATIENT HARM

WHEN USED IN ERROR)

TOP FIVE HIGH ALERT MEDICATIONS ARE:

1. INSULIN2. NARCOTICS3. INJECTABLE POTASSIUM CHLORIDE (PHOSPHATE)

CONCENTRATED4. INTRAVENOUS ANTICOAGULANTS5. SODIUM CHLORIDE SOLUTION ABOVE 0.9 %

IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)

LOOK ALIKE MEDICINE

Example of SOUND ALIKEFolinic Acid Folic AcidAmidaron Amlor

Zinnat ZantacFlumazenil Flamazine

Parlodel PanadolTazocin PrazocinFerrosac FerriproxKafocid KeflexLasix Losec

Aldactone AldometRanitidine Loratidinevoltarin ventolin

7 RIGHTS

1.RIGHT PATIENT2.RIGHT MEDICATION3.RIGHT TIME4.RIGHT ROUTE5.RIGHT DOSAGE6.RIGHT FREQUENCY7.RIGHT DOCUMENATION

IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)

IPSG – 4 (ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY)

UNIVERSAL PROTOCOL FOR WRONG SITE, PROCEDURE,

AND SURGERY PREVENTION

MARKING THE SURGICAL SITE A PRE – OPERATIVE VERIFICATION

PROCESS A TIME – OUT THAT IS HELD

IMMEDIATELY BEFORE THE START OF A PROCEDURE

(The pause before surgery begins is known as "time out" and is intended to make everyone

slow down for a few moments and double check what they are about to do.)

IPSG – 5 (REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION

EFFECTIVE HAND – HYGIENE COMPLY WITH THE CURRENT PUBLISHED & GENERAL

ACCEPTED HAND – HYGIENE GUIDELINES

IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS)

INITIAL ASSESSMENT OF PATIENT FALL RISK & REASSESSMENT OF PATIENT WHEN INDICATED BY A

CHANGE IN CONDITION OR MEDICATIONS

Document and report your observations and your interventions

THANK YOU

INTERNATIONAL PATIENT SAFETY GOALS

(USE CAPITAL LETTERS OF EACH WORD TO REMIND YOU OF THE GOAL)

IDENTIFY patients correctly (patient’s room cannot be used) when giving / doing any treatment or procedure.

COMMUNICATION – improved effective communication through implementation of a process or procedure for taking verbal or telephone orders or for reporting critical test results that require a verification “read back” of the complete order or test result by the person receiving the information. MEDICATION – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS. Remove concentrated electrolytes (including but not limited to Potassium chloride, Potassium Phosphate, Sodium Chloride ˃ 0.9% from patient care units. ELIMINATE – WRONG SITE, WRONG PATIENT, WRONG – PROCEDURE IN SURGERY INFECTION – reduce the risk of Health Care – Acquired Infections comply with the current published and generally accepted hand hygiene guidelines. FALL – reduce the risk of patient harm resulting from FALL. Take action to decrease or eliminate any identified risks.

I

CAN

MEMORIZE

EVERY THING I

FANCY