Patient Safety Goals

1. Identify patients correctly

2. Improve Patient Communication
3. Improve the 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
7. Improve recognition & response to changes in patient condition.
8. Accurately & completely reconcile medications across the continuum of care.
9. Encourage patients active involvement in their own care as a patient safety strategy
10. Reduce the risk of hospital fires.

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 Goal-1 Identify Patients Correctly

All patients’ will have standard an identity band placed on their wrist at
the time of admission which will remain on during the entire period of
hospitalization

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 When do you identify patients
• 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
• The patient room number is NOT to be used as a patient identifier.
• Label specimens in the presence of the patient immediately after collection
• Check two patient identifiers when reporting critical test results
Outpatient department:
Patient’s full name
Date of birth
To be verified using a legal Photo identity

Inpatient/emergency department:
Patient’s full name
LLH Number
To be verified using ID Band

Newborns

For newborn we apply infant ID bracelet, one on ankle and one on wrist, with the following information.
- Baby of (mother’s full name)
- Baby Date of birth
- Birth Order if multiple birth (Baby-1, Baby-2)

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 Special circumstances

Confused/disoriented patients, identification is made by the emergency staff until

the patient’s identity is established and an identification band attached

(Unknown1 male/female, LLA number). Identification of the patient to be

confirmed against ID band before any procedure or medication administration.

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DO YOU EVER USE ROOM NUMBER OR BED NUMBER TO IDENTIFY YOUR PATIENTS?

As per our hospital policy, we are NOT supposed to use patient room
number or bed number to identify them.

Friday, July 21, 2023 7

 When do you remove the wrist bands from patients and who does it?

• The nurse shall remove the wrist band prior to the patient leaving his/ her rooms after the
discharge procedure are completed.

• Note: ID bands must not be removed if a patient is transferred to another hospital.

Friday, July 21, 2023 8

 How do you discharge newborn in your hospital?

The staff nurse shall discharges the baby to the parents after verifying the following that includes but
is not limited to:

­ Matching baby's name bracelet with mother's name, bracelet and the Medical Record/ File
Number.
­ Reviewing education provided to mother about the baby's care.

­ Documenting in the medical record with the signature of the qualified Nurse and Doctor.

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How do you verify the identity of patient’s prior to administration of blood?

­ Two (2) licensed staff should verify the patient’s identity and blood bag, prior to the administration of
blood at the bed side.

Friday, July 21, 2023 10

 What do you do if a patient refuses to wear an ID band?

­ Patients must be informed of the importance of wearing an ID band and the risks involved if they do not comply

so that they can make an informed decision. The decision of a patient not to wear a name band must be clearly

documented in the healthcare records.

­ Other staff shall be made aware of this by writing in the case notes and extra care taken when administering

treatments or medications.

­ Photo identification of the patients who refuse to wear an ID band shall be done prior to any procedure,

treatment, or service and when obtaining consent. 11

 GOAL 2 : IMPROVE EFFECTIVE COMMUNICATION

Who can give telephone/verbal order?

­ As per our hospital policy, Only Doctors may give a Telephone Order

­ Verbal orders are accepted only on emergencies

12
Who can receive Telephone orders and what is the process of receiving and documenting it?

­ Registered Nurse/Pharmacist can receive a telephone order.

­ The receiver of the information will write down (or enter into the computer) the complete order, then the order is
confirmed by the individual who gave the order. The rule: WRITE DOWN, READ BACK, and CONFIRM

­ The telephone order shall be countersigned and stamped by the ordering physician within 24 hours of giving
one order.

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 How do you accept verbal orders?

­ Verbal Orders should be given and accepted only during emergency.

­ Use the REPEAT-BACK verification process (verbal order repeated and the person giving the
order verbally confirms)

What is the timeline for physicians to acknowledge the verbal orders given

­ The verbal order should be immediately signed by the ordering physician after the emergency is
over and before the physician leaves the unit.

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 To whom should critical results of diagnostic tests be reported to?

• Any investigation result with critical results received from the laboratory or radiology shall be
reported immediately to the attending physician.

• When receiving such critical test results, the same methodology should be followed: WRITE
DOWN, READ BACK, and CONFIRM

• Receiving Physician should document the critical values in the patient medical records
• In case physician is not reachable, inform to ER physician.

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What are the importance of Read Back?
• Different pronunciation, accents or dilects

• Background noise

• Muffled speech caused by the presence of surgical mask

• Unfamiliar terminology

• Sound-Alike medications

• Interruptions and distractions

 How do we define critical test results?

­ Results that are significantly outside the normal range that may indicate a high-risk or life-threatening
condition

­ Reference for critical values and handling critical test results can be found in below policy in Lab and
Radiology which is available in INTRANET

- IPSG.2.1 LLH-LAB-GEN-P&P-002 Critical Values and Intimation Procedures

- IPSG.2.1 LLH-RAD-SOP-017 Critical Result & Test Notification

Friday, July 21, 2023 17

 SBAR

What is the standard communication tool we use especially during handover of

patient care within the hospital (ex: shift endorsements, patient transfers, sending
patients to diagnostic or treatment departments like radiology or physical therapy)?

SBAR
(Situation, Background, Assessment, Recommendation)

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 GOAL 3: IMPROVE THE SAFETY OF HIGH ALERT MEDICATION

What are high-alert medications?

• Medications that have a heightened risk of

causing significant patient harm when used in
error. Examples: insulin, heparin, concentrated
electrolytes (pls. see High Alert, Look-Alike and
Sound-Alike Medication List posters)

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 What are the hospital’s strategies to improve the safety of high alert medications?

­ Labeled with high alert Red stickers as “High-Alert Medication”

­ Kept in locked cabinets/trolleys
­ Stored separately from regular medications and look-alike medications
­ Concentrated electrolytes are not stocked up in the wards, only in critical areas as needed.
­ Independent double check should be done prior to administration.

Note: High alerts - RED Label as “High-Alert Medication”

Concentrated electrolytes - Green Color Label

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 High Alert Medication List
­ High Alert Medication List has been made available in
INTRANET

­ High Alert Medication list has been reviewed on annual basis

and approved by Pharmacy & Therapeutic Committee

­ High Alert Medication List are reviewed annualy

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Friday, July 21, 2023
 How to reduce the risk of High Alert Medications?

­ High alert Medication and Concentrate Electrolytes should be stored in locked

cabinets, should be stored separately from the normal medications

­ Stored only in critical care areas and crash carts

­ Independent Double check

­ Using color code labels

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 How is independent double check being done?

• A medication double check or second provider verification will be

required prior to administration of High Alert medication and at time
of shift report or any transfer of care.

• Documentation of double check will be recorded on the patient file.

• All high alert medications will be double checked by two RNs.

• A physician or pharmacist will perform a double check in the event

that the second RN is unavailable

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Key Points on Concentrated electrolytes:
Areas to place concentrated electrolytes to be identified by pharmacist. List to be approved by P&T
committee and annually re reviewed & in-between if required.

­ Concentrated electrolytes shall not be stored in the patient care areas other than in patient care units
identified as clinically necessary OT, ICU, SCBU, LDR and ER.
­ Concentrated electrolytes must be double checked before they are prepared, dispensed and
administered.
­ One health care provider prepares the drug and another counterchecks.
­ Preparation of Concentrated Electrolytes will be done by competent Pharmacists and competent
registered nurses.
­ Electrolyte will be prepared in ip pharmacy by competent staff and during emergency two competent
nurses will prepare
­ double check upon administration shall be done to prevents inadvertent administration of
concentrated electrolytes
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• The patient’s nurse should verify the medication being administered matches the
physician’s order or patient’s Medication order sheet. The second provider will
independently verify the following SEVEN Rights are correct:

• Right patient
• Right medication
• Right dose
• Right route
• Right indication
• Right time/frequency
• Right documentation
 GOAL 4: Ensure Safe Surgery

How does the hospital ensure the correct site, correct procedure, and correct
patient surgery?

We adhere to our policy:

• Ensure correct patient – by using the 2 patient identifiers

• Ensure correct site - the surgeon marks the site with an ARROW mark using a surgical marker; we
involve the patient during marking (as much as possible); the surgical site is marked in all cases
involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine).

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 GOAL 4: Ensure Safe Surgery

What are the essential components to ensure correct-site, correct-

procedure, correct-patient surgery?
• Site-marking
• Preoperative verification process and
• Time-out

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Ensure correct procedure – Check the signed informed consent; imaging studies are reviewed A
preoperative verification process is performed and for inpatients, it is done at the following times:

­ In the ward/clinic by the operating surgeon

­ Just before sending the patient to OR, by the ward nurse · In the receiving area, by the receiving OR
nurse.

Components of the verification process:

­ Verify the correct patient, procedure and site
­ Ensure that all relevant documents, images, and studies are available, properly labeled, and displayed
­ Verify that any required blood products, special medical technology and/or implants are present

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What is time-out?
• Time out is called out by the circulating nurse in the presence of entire team (Inclusive of Surgeon
and anesthetist (in OT)) prior to the incision.

• At the time of time-out the circulating nurse verifies the patient identification against the ID band,
Procedure, Consent, Incision site and Correct position.

• During time out everyone should stop what they are doing and participate (to say “agreed”) in the
time-out.

• The surgical team should not leave the OT after time-out

Friday, July 21, 2023 29

 SAFE SURGERY
Safe Surgery Includes:

Pre Operative Checklist

• Verification by Physician
• Verification by Ward / unit nurse
• Verification by OR Receiving Nurse

Surgical Safety Checklist

• Sign In
• Time Out
• Sign Out

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 SURGICAL SAFETY CHECKLIST

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 SURGICAL SAFETY CHECKLIST

­ Surgical Safety Checklist is a tool for the relevant clinical teams to improve the Safety of surgery by
reducing deaths and complications

­ Surgical safety Checklist was developed by incorporate World Health Organization (WHO) and
Association of peri Operative Registered Nurses (AORN) Guidelines

Friday, July 21, 2023 32

 SIGN IN

­ Sign-in is to verify the correct site, procedure, and patient just before the induction of
anesthesia and to ensure that all relevant documents, images, and studies are available and
displayed and any special equipment and/or implants are present

Friday, July 21, 2023 33

 TIMEOUT
• It 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.

• Time out should before the start of the procedure (after

induction or anesthesia) in Operating Rooms and
Invasive Procedure rooms or when anesthesia / sedation
is administered
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 What is checked during the timeout process?

 NOTE: The procedure should not start until the final time out
is completed and any questions or concerns are resolved.

 Time of time-out must be documented in the timeout form.

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 SIGN OUT
 Sign Out: is the last phase of an operation in which
the surgical team confirms the procedure done,
sponge, instruments and needle are correctly
counted, specimen labelled with correct patient
identification, if there is any equipment problem to
be addressed and reviewing the key concerns for
recovery before the patient leaves the operating
room

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 TIME OUT OUTSIDE OR

­ Ensuring right patient, right procedure, right side, right site out side operating room

Friday, July 21, 2023 37

 GOAL 5: REDUCE THE RISK OF HEALTH CARE -ASSOCIATED INFECTIONS

What are the common infections associated to health care?

As mentioned in our hospital policy, following are the infections commonly associated with
healthcare:

1. Catheter Associated Urinary Tract Infection

2. Central Line Associated Blood Stream Infection
3. Ventilator Associated Pneumonia
4. Surgical Site Infections

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How do you prevent your patient from getting an infection during hospitalization?

­ We adhere to our standard precautions `hand hygiene guidelines and PCI (Prevention and
Control of Infection) Program

Friday, July 21, 2023 39

What are 5 moments of Hand hygiene ?
 What are the different types of hand hygiene?
Methods Agent Purpose Area Duration
(minimum)
Routine Hand Water and non- Remove soil and All surfaces of 40-60 Seconds
wash antimicrobial transient the hands and
soap (i.e., plain microorganisms fingers
soap)
Antiseptic hand Alcohol-based Remove or All surfaces of 20-30 Seconds
rub handrub destroy transient the hands and
microorganisms fingers
and reduce
resident flora
(persistent
activity)
Surgical Water and Remove or Hands and 2–6 minutes
Antisepsis antimicrobial destroy transient forearms
soap (e.g., microorganisms
chlorhexidine, and reduce
iodine and resident flora
iodophors, (persistent
chloroxylenol, activity)
triclosan)

Friday, July 21, 2023 41

Which guidelines are following for hand hygiene?
• WHO and CDC

How is the hand hygiene monitored?

• Hand hygiene compliance is monitored by the following process
using Hand hygiene tool
• ICN selects silent observer every month
• Silent observer does the monitoring with the help of the hand
hygiene monitoring tool
• Silent observer forwards the forms at the end of month to ICN
• ICN compiles data
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What is the rate of hand hygiene compliance in your unit?

XX. XX %

Friday, July 21, 2023 43

 How do you dispose different types of waste (color coding)?

­ General Waste
e.g. administrative, food Waste etc. - (Black plastic bag)

­ Bio hazardous (Infectious Waste)

e.g. gloves, masks, dressings etc.
(Yellow thick plastic bag with Bio hazardous sign)

­ Human Tissue & Highly infected Waste -(Red thick plastic bag with label).

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 GOAL 6 : Reduce the Risk of Patient Harm Resulting from
Falls
Policy regarding fall risk assessment
How is fall assessment done in OP?
• Using Morse fall risk assessment criteria and documented in EMR during
every visit. This practice is followed for every review.

How often is fall risk assessed and reassessed in IP?

• Fall risk assessment is done on admission and once every shift.
• If the patients risk status changes (as after medications; post operative status;
transfer of unit of care; post fall), reassessment is done immediately and then
every shift

Friday, July 21, 2023 45

 How do you protect your patient from falls?

• We perform risk assessment and reassessment (Risk assessment tools used are: Morse
Fall Scale for adult and Humpty Dumpty Scale for children)

• We apply standard fall prevention precautions and extra precautions for high risk
patients

• We conduct patient and family education on fall prevention

• We have a FALL PREVENTION PROGRAM

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 What are the measures taken to reduce fall?
• Fall Risk Screening, Assessment
• Identify vulnerable patients
• Wheel chairs/stretchers are provided with safety straps and brakes.
• Personnel accompany the patient at all times.
• Assisted toilet” for the vulnerable patients.
• Education to the patient/attendant imparted.
• LAMP (Look At Me Please) signage outside their IP room
• Patients are not left unattended
• Beds are positioned low, railings put up, calling bells within reach of the patient at
the bedside, toilet alarms, Adequate lighting
• Patients and attendants are orientated & Educate
• Post Fall Protocol of Care
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 Within what time do you report the incident of falls to quality office?

• When a fall occurs, inform physician and Head Nurse/Charge Nurse Immediately.

• Report all near fall and identification of hazards by submitting the Fall Hazard / Near Fall Report
Form to the Quality Department before the shift ends or within 24 hours.

• Complete the Post Fall Assessment Form and attach in the patient’s medical record.

Note: Post fall assessment shall be done immediately after stabilizing the patient and continuous
monitoring of the patient

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 In which conditions/situations do we reassess our patients for the fall risk?
­ Following a change in the patient’s condition .
­ After a fall.
­ Immediate post-operative period.
­ Following procedural sedation.
­ After administration of medication , procedure or change in condition that may alter patient’s
level of consciousness or mental status 6. Changes in ambulatory status and/or elimination status
­ Transfer between nursing units/clinics.
­ When in locations that poses a high risk for falls (physiotherapy department)
­ When in situations that poses a high risk for falls (patients arriving by ambulance, patient
transfers from wheelchairs or carts, or the use of patient-lifting devices)

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 Is the incidence of falls monitored in your unit/hospital?

Yes. It is one of our clinical indicators and also considered a nursing sensitive
care measure.

Friday, July 21, 2023 50

 What is the falls rate in your unit?

XX. XX %

Friday, July 21, 2023 51

 Goal 7: Accurate & completely reconcile medications across the
continuum of care

Medication reconciliation is an interdisciplinary process between Pharmacist, physician and

nurses that compares the patient’s most current list of home medications against the physician’s
orders upon admission, and discharge, addressing discrepancies, thereby decreasing potential
Adverse Drug Events (ADEs) and omissions of medication therapy.
 Goal 8: Improve recognition & response to changes in
patient condition
The licensed nurse assigned to the patient or supervising the care of the patient is responsible for notification of
and communication to the medical staff regarding significant changes or significant deterioration in the patient’s
condition and for assuring that there is physician response.

PROCEDURE:

Changes in the condition of the patient are determined by assessments utilizing parameters defined in physician
orders, the patient’s previous condition, and/or by patient safety factors (EARLY WARNING SCORE)

Based on the score – Rapid Reponse Team (RRT) or Code Blue or other interventions are implemented as per the
policy
 Goal 9: Encourage the patients active involvement in their own care as a
patient safety strategy

PROCEDURE:

1. The hospital respects and supports patients’ and families’ rights to participate in the care process.

2. Patients and families shall be asked to participate in the care process by making decisions about care,
asking questions about care, and even refusing diagnostic procedures and treatment.

3. Patient’s education needs are assessed and appropriate education is provided to assure that patients
understand and effectively participate in their care needed.

4. Education will be provided in an interactive way to assure patient participation in care.

 Goal 10: Reduce the risk of hospital fires

Whenever a fire occurs the following procedures will be

taken. (RACE)
R – Rescue
A – Alarm
C – Confine/Contain
E – Extinguish/Evacuate
 Goal 10: Reduce the risk of hospital fires

Every member of staff has a responsibility to ensure that they know:

• Where the fire alarm boxes are and

how to operate them?
• Where telephones are? What number to call
and what information to give?
• Where the fire equipment is located and
how to use it correctly?
• The fire evacuation map location, routes and exits for the area.
• Fire assembly point.
 DEFINE BENCHMARKING?

A continuous process of measuring products, services, and/or practices

against the competition in order to find and implement best practices

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 DEFINE INDICATOR?

Performance measurement tool which is used as a guide to monitor,

evaluate and improve the quality of patient care and service.

Friday, July 21, 2023 58

 DEFINE STANDARD?

Statement of structure and process expectations necessary to enhance quality

care.

Friday, July 21, 2023 59

 DEFINE TRENDING?

The evaluation of data collected over a period of time for the purpose of identifying
patterns or changes

Friday, July 21, 2023 60

 What Quality Improvement Methodology you adopted for improvement?

­ We have adopted the FOCUS-PDSA Quality Improvement Methodology

Performance Improvement Project on “Online feedback Survey”

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 FOCUS?
• Find - An improvement opportunity.
• Organize - A team who understands the process.
• Clarify – Current knowledge of the process.
• Understand – The causes of variation in the
process.
• Select – The improvement that needs to take place

Friday, July 21, 2023 62

 How you prioritize quality improvement?

­ Quality Council is responsible to establish priority areas for quality improvement.

­ Quality Improvement priorities are based on the following:

 Customers’ Feedback
 Variations in Operation
 Strategic Plan (Strategic Priorities)

63
 What is the selection Criteria for process improvement or
Quality Indicator?

• High Risk

• High Cost

• High Volume

• Problem Prone

• JCI, JAWDA / DOH requirements

64
 Define Risk Assessment?

­ A systematic process of evaluating the potential risks that may be involved in a projected
activity or undertaking

­ A Risk Assessment is a calculation of the likely impact of a hazard should it come to fruition

65
 Proactive Risk Assessment

• An important element of risk management is risk analysis, such as a

process to evaluate near misses and other high-risk processes for
which a failure would result in a sentinel event. One tool that provides
such a proactive analysis of the consequences of an event that could
occur in a critical, high-risk process is Failure Mode and Effects
Analysis (FMEA) and Hazard Vulnerability Analysis (HVA).

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 Define Data?
• Factual information (as measurements or statistics) used as a basis for
reasoning, discussion, research, or calculation. — H. A. Gleason.

67
 Define Data Validation?
• Data Validation is a process that is used to compare a body of data to the requirements
in a set of documented acceptance criteria. It checks that the data is sensible before it
is processed.

Or

• The comparison of data against a set of documented acceptable criteria is known as

data validation. It determines to what extent analytical and other forms of data are
reliable, accurate and usable in various contexts. Validation is done to ensure that
programs and processes operate on correct and accurate data and is used by various
organizations and government agencies

Friday, July 21, 2023 68

 When you do Data Validation?

• Data Validation would be done during the following:

• Implementation of a new measure, especially the clinical measures that intend to help a hospital in
evaluating and improving the clinical process or outcome;
• When data will be made public on the hospital’s website or in other ways;
• Whenever changes have been made to an existing measure; such as the data collection tools have changed
or the data abstraction process or abstractor has changed;
• Whenever the data resulting from an existing measure has changed in an unexplainable way;
• The data source has changed, such as when part of the patient record has been turned into an electronic
format and thus the data source is now both electronic and paper; or
• The subject of the data collection has changed, such as changes in average age of patients, comorbidities,
new practice guidelines implemented, or new technologies and treatment methodologies introduced.

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 Define Sample?

In statistics and quantitative research methodology, a sample is a set of data

collected and/or selected from a statistical population by a defined procedure

Friday, July 21, 2023 70

 How you determine your sample size for Data Validation?

Required Sample Size for

Sample Size (Actual Collected Data)
“Data Validation”
<180 data source/records At least 9 data source/records, or if <9 data
source/records 100%

180 data source/records or greater At least 5% or maximum of 50 data

source/records

Valid data shall have an accuracy more than or equal to 90%

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 Proactive Risk Assessment

• An important element of risk management is risk analysis, such as a

process to evaluate near misses and other high-risk processes for
which a failure would result in a sentinel event. One tool that provides
such a proactive analysis of the consequences of an event that could
occur in a critical, high-risk process is Failure Mode and Effects
Analysis (FMEA) and Hazard Vulnerability Analysis (HVA).

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 What is FEMA?
Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a
process to identify where and how it might fail and to assess the relative impact of different failures,
in order to identify the parts of the process that are most in need of change. FMEA includes review
of the following:
Steps in the process
• Failure modes (What could go wrong?)
• Failure causes (Why would the failure happen?)
• Failure effects (What would be the consequences of each failure?)

FMEA Project on “CLINICAL ALARM SYSTEM”

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 Define an Event?

Something that happens or is regarded as happening; an

occurrence, especially one of some importance

Friday, July 21, 2023 74

 Occurrence Variance Report (OVR)
or
Incident Report (IR)

• Incident/Events that are unusual, unexpected, may have an element of risk, or

that may have a negative effect on patients, staff, or the hospital.

• Near Miss

• Sentinel Events
 Near Miss

A near miss is an unintentional incident that could have caused

damage, injury or death but was narrowly avoided.

or

Any process variation that did not affect an outcome, but for which a
recurrence carries a significant chance of a serious adverse outcome.

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 Sentinel Events

A sentinel event is a patient safety event (not primarily related to the natural
course of the patient’s illness or underlying condition) that reaches a patient and
results in any of the following:
• Death

• Permanent harm

• Severe temporary harm

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Severe temporary harm is defined as critical, potentially life-threatening harm lasting for a limited time with no permanent residual
but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-
threatening condition, or additional major surgery, procedure, or treatment to resolve the condition. An event is also considered
sentinel if it is one of the following:

­ Death that is unrelated to the natural course of the patient’s illness or underlying condition (for example, death from a
postoperative infection or a hospital-acquired pulmonary embolism);

­ Unanticipated death of a full-term infant; and

­ Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of
discharge, including from the hospital’s emergency department (ED)

­ Major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition;

­ Transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or transplanting contaminated
organs or tissues
­ Hemolytic transfusion reaction involving administration of blood or blood products having major blood group
incompatibilities (ABO, Rh, other blood groups)

­ Infant abduction or an infant sent home with the wrong parents; and

­ Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care,
treatment, and services while on site at the hospital

­ Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed
independent practitioner, visitor, or vendor while on site at the hospital

­ A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall

­ Any intra-partum (related to the birth process) maternal death

­ Any peri-natal death unrelated to a congenital condition in an infant having a birth weight greater than 2,000 grams
­ Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the
planned radiotherapy dose

­ Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)

­ Invasive Procedure / Surgery on the wrong patient, wrong body part / side, wrong procedure (all events of surgery on the wrong patient or wrong
body part are reviewable under the policy, regardless of the magnitude of the procedure or the outcome.)

­ Unintended retention of a foreign object in a patient after an invasive procedure or surgery or other procedure

­ Abduction of any patient receiving care, treatment, and services

­ Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED), leading to death,
permanent harm, or severe temporary harm to the patient

­ Severe maternal morbidity (not primarily related to the natural course of the patient’s illness or underlying condition) when it reaches a patient and
results in permanent harm or severe temporary harm

­ Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care
 Report All Incidents

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 OVR FORM
Staff should be aware the location of
the incident reporting form

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 Which kind of Incidents and Events should be reported?

A. A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that

reaches a patient and results in any of the following:

- Death
- Permanent harm
- Severe temporary harm

B. Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge,

including from the hospital’s emergency department (ED)

C. Unanticipated death of a full-term infant

D. Discharge of an infant to the wrong family

E. Abduction of any patient receiving care, treatment, and services

F. Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the

ED), leading to death, permanent harm, or severe temporary harm to the patient

G. Hemolytic transfusion reaction involving administration of blood or blood products having major blood group

incompatibilities (ABO, Rh, other blood groups)

H. Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care,

treatment, and services while on site at the hospital

I. [

J. Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure

K. Unintended retention of a foreign object in a patient after an invasive procedure, including surgery

L. Severe neonatal hyperbilirubinemia (bilirubin > 30 milligrams/deciliter)

G. Prolonged fluoroscopy with cumulative dose > 1,500 rads to a single field or any delivery of radiotherapy to the wrong
body region or > 25% above the planned radiotherapy dose

H. Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care

I. Any intrapartum (related to the birth process) maternal death

J. Severe maternal morbidity (not primarily related to the natural course of the patient’s illness or underlying condition)
when it reaches a patient and results in permanent harm or severe temporary harm
 When and whom one should report Sentinel Events?

All the Sentinel Events should be reported immediately to the Quality

Department and Top Management

Friday, July 21, 2023 86

 How Sentinel Events are investigated?

• All sentinel events require immediate investigation and appropriate response. All events shall
have an Incident Report or Occurrence Variance Report (OVR) generated and the team/
committee will complete the RCA Square; as per the directives of the Department of Health
(DOH), all sentinel events have to be reported within 48 hours and submit an initial report within
7 days ; when the report is accepted by DOH, Hospital shall submit the final report within 45 days
with details of the investigation, root cause analysis and action plan to minimize risk of recurrence

87
 Root Cause Analysis (RCA)

A process for identifying the basic or causal factor(s) that underlies variation in
performance, including the occurrence or possible occurrence of a sentinel event.
(JCI)

In how many hours an incidents/accident must be acted upon of its occurrence?

All incidents/accidents must be acted upon within 24 hours of its occurrence.

 THINGS TO REMEMBER
­ Incident reported in your unit

­ Hospital QIPS Plan

­ Indicators hospital wide and your department / unit

­ Performance Improvement Projects for your department and hospital wide

­ Clinical Guidelines, Pathways, Protocols

­ IPSG Implementation