International Patient Safety Goals

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Ms.Nikethana R Nair, M.Sc (OBG), MBA (HA), M.?c
(Psy)M.Phil (HHSM), Nursing Superintendent, Meenak
shi Mission Hospital Research Center - Madurai
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Goal 1

• Identify the Patient Correctly

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/UHID
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Goal 2

• Improve Effective Communication

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Other Documents....

• Adverse event data are tracked and used to
  identify improvements for hand over
  communications.
• Handover between patients and families

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Goal 3
Improve the Safety of High-Alert Medication
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• High alert medications are those medications
  involved in a high percentage of errors/sentinel
  events, medications that carry a higher risk for
  adverse outcomes as well as look- alike / sound
  alike medications.
• Chemotherapeutics
• All Narcotic Drugs Fentanyl patches
  Injections, Inj. Pethidine, Morphine injections
  Tablets, Pentazocine injection
• Concentrated electrolytes I.V. KCL 2mEq/ml or
  more concentrated, I.V. Potassium Phosphate, I.V.
  Nacl (more than 0.9), I.V. Mg Sulphate (50 or
  more concentrated)
• Mg sulfate is stored in 3 to 10 ampules for
  managing pre eclampsia
• Look Alike/ Sound Alike drugs Staff should know
  all drugs in LASA
• Narrow Therapeutic Index drugs I.V. Phenytoin,
  I.V. Aminophylline, Inj. Tacrolimus, Inj.
  Digoxin, Tab. Lithium carbonate
• Anticoagulants I.V. Heparin, Tab. Acenocoumarol
  (Acitrom), Tab. Warfarin
• Insulins
• Antipsychotics Inj. Haloperidol
• Anesthetic Inj. Ketamine Hydrochloride (All
  CCU) kept under double lock

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Cont....

• High alert sticker for all high alert medications
• Double lock for Narcotics and high concentrated
  electrolytes
• Key custodian
• Tall Man lettering for LASA labels
• Store LASA drugs in separate racks - Segregation
• Color coding for insulin storage
• Concentrated electrolytes are stored only in the
  specific areas
• Independent Double check and double sign
• Replace the empty ampoules of narcotics
• Wastage of narcotics should be discarded in the
  presence of doctor and obtain doctors signature
• HAM monitoring
• Adverse events to be reported

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Goal 4

• Eliminate Wrong site,
• Wrong patient,
• Wrong procedure/Surgery

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Goal 5

• Reduce the risk of Healthcare Acquired
• Infections

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Goal 6

• Reduce the Risk Of Patient Harm
• Resulting from Falls

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CARE OF PATIENT

• Patient safety is a new healthcare discipline
  that emphasizes the reporting, analysis, and
  prevention of medical error that often lead to
  adverse healthcare events.

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Who When

• For safety of the patient vulnerability
  assessment should be done for all the patients at
  the time of admission

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When to be Used.....

• It is done at the time of admission for all the
  patients
• Fall Risk reassessment is done when the patient
  condition changes eg.when the patient shifted
  from ICU to ward, after surgery when the patient
  shifted to ICU or ward
• Moarse Fall Risk Assessment safety first policy
  is used to meet the standards

• If the AFRAT score is more than or equal to 45
  then the Reassessment is done every 48 hrs
• If it is less than 45 then re- assessment is done
  every 7th day
• It is done except for HDU and ICU patients
  because they are already considered to be
  vulnerable

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• CRITERIA FOR REASSESSMENT
• There is a change of disposition in the clinical
  condition of the patient (eg.post code orange
  ,code blue)
• When the patient undergoes a surgery for any
  reason
• Patients is placed on restraint
• Patient ,during his course of stay in the
  hospital has /develops hearing/vision impairment
  even with the use of aids
• Patient uses assistive devices to aid in mobility
  (eg.crutches,cane,walkers)
• Patient is disoriented- with impaired cognition,
  altered sensorium

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SAFETY MEASURES

• Patient should not be left unattended
• Any untoward incident to be reported immediately
• To use Safety belts while transporting patient
•  Bed to be locked always
• Vitals have to be recorded
• Safety brochure and fall prevention education to
  be given.
• In case of falls, incident reports have to be
  documented.
• Record the above in PFE form.
• IDTR should be filled after 72 hours of admission

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Cont....

• Safety first sticker is placed at the head end of
  the patient
• Side rails should be always up wheels should be
  locked when the patient is in the bed
• Patient should not be left unattended
• Avoid slippery floors
• Accompany the patient to the wash room
• Safety belt should be on when the patient is
  transported in the wheel chair or stretcher
• Call bell should be at the reach of patient
• Any untoward incident should be reported
  immediately in AIRS
• All vulnerable patients elimination needs are to
  be met at the bedside. A bedside commode or
  bedpan should be provided

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