INTERNATIONAL PATIENT SAFETY GOALS
OBJECTIVE
To promote specific improvement in patient safety
Represent strategies to reduce the risk of medical errors
Provide clear solutions for improving patient safety
Patient SAFETY GOALS
1. Identify patients correctly
2. Improve effective communication
3. Improve safety of high alert medications
4. Ensure correct Site, Correct Procedure, Correct Patient Surgery
5. Reduce the risk of health care associated infections
6. Reduce the risk of patient harm resulting from falls
1. Identify patients correctly
Wrong-patient errors occur in virtually all aspects of diagnosis and treatment
Do’s
2 Identifiers- Patient Name & Avitis Number
For unknown/ comatose patient brought in Emergency identify as
unknown 1 or 2.
Patients are Identified
Giving medicines, blood or blood products.
Taking blood samples and other specimens for clinical testing
Before all surgical, invasive and diagnostic procedures
Don’t Use- Patient Room, location
2. Improve effective communication
Do’s
2.1. Verbal/Telephonic Order
Use write and read back
2.2. Reporting critical results of diagnostic tests
Use write and read back
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.
2.3. Handover Communication
ISBAR
IDENTIFICATION: Patient Identification
SITUATION: What is happening at the moment?
BACKGROUND: What are the issues that led up to this situation?
ASSESSMENT: What do you believe the problem is?
RECOMMENDATION: What should be done to correct this situation.
EXAMPLE
I – Krishnan.M, Avitis No-01-25689 16M Male, Room No-506
S – presents with choking event post feed
B – previous well term baby, event preceded by 2-3 days fever, irritability and poor
sleep
A – thriving, examined well
R – reassure with likely discharge today if remains well
WHEN?
Shift changes
Inter-hospital transfers
Intra-hospital transfers
Time-critical situations such as medical emergencies or evacuations
Procedure documents
ADVANTAGES:
Ensures completeness of information and reduces likelihood of missing 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.
3. Improve the Safety of High-alert medications
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
Do’s
HIghAlert Medications / Look Alike & Sound Alike Medications
Double Checks
HIgh Alert Medications ,Look alike and sound alike medications are stored with
proper labeling
List of high-alert medications / Look alike and sound alike medications
High-alert medications - Stored and kept in a locked cabinet
High-alert medicationsSeparated from other medications and stored in boxes
with lids
Labeled in Red with “High Alert Medication / Concentrated Electrolyte”
Proper Orientation to Staff
4. Ensure correct Site, Correct Procedure, Correct Patient Surgery
Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common
occurrence in health care organizations.
Factors
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.
Inadequate patient assessment.
Inadequate medical record review.
Problems related to illegible handwriting.
The use of abbreviations.
Preoperative verification
Prior to the induction of Anesthesia
The start of an invasive procedure
Ensure
Patient’s identity (two identifiers)
Procedure to be performed
Correct procedure side/site
Necessary imaging ,equipment , Implants or special requirements
are present
Timeout
Prior to the start of the procedures
Innvolves the entire operative team.
5. Reduce the Risk of Health Care Associated infections
Infection Prevention and control
Common Infections- Catheter-associated urinary tract infections,Bloodstream
infections, Ventilator Associated pneumonia (often associated with mechanical
ventilation
Do’s
Proper hand hygiene.
Comply with current published and generally accepted hand hygiene guidelines.
Implements an effective hand hygiene program.
6. Reduce the Risk of Patient Harm Resulting from falls
Falls account for a significant portion of injuries
Do’s
Evaluate its patients’ risk for falls and take action to reduce the risk of falling
The evaluation includes
fall history
medications and alcohol consumption review
gait and balance screening,
walking aids used by the patient.
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.
Fall RisK reduction program
Prevention of Patient Falls
Educating patient and patient families on
Not to leave bed without any help
To wear non skid foot wear .
Nurses Call Bell
Bed height to be fixed at the lowest lowel
All side rails in the up postion
Proper lighting
