IPSG -Hospital

INTERNATIONAL PATIENT SAFETY GOALS

Patient Identification

IPSG 4: Ensure Correct-Site, Correct-Procedure, Correct-Patients Surgery

Measurable Elements of IPSG 2

Standard IPSG 2:

1. The complete verbal order is documented and read back by the receiver and confirmed by the individual giving the order.

The hospital develops and implements a process to improve the effectiveness of verbal and/or telephone communication among caregivers.

2. The complete telephone order is documented and read back by the receiver and confirmed by the individual giving the order.

Major gaps identified:

• Use of unapproved abbreviations.
• TO / VO order not signed by another nurse.

3. The complete test result is documented and read back by the receiver and confirmed by the individual giving the result.

Measurable Elements of IPSG 2.1

Standard IPSG 2.1:

1. The hospital has defined critical values for each type of diagnostic test.

IPSG 1 : Identify Patients Correctly

The hospital develops and implements a process for reporting critical lab results of diagnostic tests.

2. The hospital has identified by whom and to whom critical results of diagnostic tests are reported.

Major gaps identified:

• Some critical laboratory result not relayed by the laboratory technicians by phone.
• No documentation on the received critical result by physicians.
• No documentation of the physicians on the initiated action plan on the acceptable time frame.

3. The hospital has identified what information is documented in the patient record.

Standard 1 :

Measurable Elements of IPSG 2.2

The hospital develops and implements a process to improve accuracy to patient identification

Standard IPSG 2.2:

1. Standardized critical content is communicated between health care providers during handovers of patient care

The hospital develops and implements a process for handover communication

2. Standardized forms, tools, and methods supports consistent and complete handover process.

3. Data from handover communications are tracked and used to improve approaches to safe handover communication.

Standard IPSG 4

Measurable Elements of IPSG 4

1. The hospital uses an instantly recognizable mark for surgical- and invasive procedure–site identification that is consistent throughout the hospital.

2. Surgical- and invasive procedure–site marking is done by the person performing the procedure and involves the patient in the marking process.

3. The hospital uses a checklist or other process to document, before the procedure, that the informed consent is appropriate to the procedure; that the correct site, correct procedure, and correct patient are identified; and that all documents and medical technology needed are on hand, correct, and functional.

The hospital develops and implements a process for ensuring correct-site, correct-procedure, correct-patient surgery.

IPSG 2 : Improve Effective Communication

Measurable Elements of IPSG 4.1

Standard IPSG 4.1

Effective communication, which is timely, accurate,complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety.

1. The full surgical team conducts and documents a time-out procedure in the area in which the surgery/invasive procedure will be performed, just before starting a surgical/invasive procedure.

2. The components of the time-out include correct patient identification, correct side and site, agreement of the procedure to be done, and confirmation that the verification process has been completed.

3. When surgery is performed, including medical and dental procedures done in settings other than the operating theatre, the hospital uses uniform processes to ensure the correct site, correct procedure, and correct patient.

The hospital develops and implements a process for the time-out that is performed in the operating theatre

immediately prior to the start of surgery to ensure correct-site, correct-procedure, and correct-patient surgery.

Measurable Elements of IPSG 1

3. Patients are identified before any diagnostic procedures.

Wristbands

Benefits:

• Portable.

• Cheap.

• Legible to all parties, medical and nursing staff, patients, and relatives.

• Generally easy and quick to attach.

• Widely accepted.

Limitations / Risks:

• Can be difficult to fit to newborns, obese patients, patients with an allergy to plastic.

• Wrong wristband can be attached to patient.

• Missing or incorrect information can lead to misidentification.

• Not all patients are given a wristband, e.g. emergency room, some outpatients.

1. Patients are identified using two

identifiers, not including the use of

the patient's room number or location.

Wristbands

While convenient and widely used in health care, errors involving wristbands play a role in patient misidentification.

In UK National Patient Safety Agency in 2006, more than one in 10 reported cases of patients “being mismatched to their care” were related to wristbands. Such mismatches occurred in more than 2900 of the total 24,382 reports of patients receiving the wrong care from February 2006 to January 2007.1

Aakre KT, Johnson CD (2006) Plain-radiographic image labeling: a process to improve clinical outcomes. J Am Coll Radiol. Dec;3(12):899-900.

Wristbands

six most common wristband errors

A. Wristband is not present

B. Wrong wristband, ie another patient’s wristband

C. Presence of more than one wristband, and conflicting information is written on both.

D. Partially missing information on the wristband

E. Erroneous information on the wristband

F. Written information on wristband is illegible

G. Patient’s name is written the same, written close to the same, and/or pronounced the same as another patient’s name

Wristbands

• accepted practice
• includes, at a minimum, full name, date of birth, and hospital number.
• sometimes colour-coded .

2. Patients are identified before providing treatments and procedures.

Times for verification of patient identity

Examples of acceptable patient identifiers include9:

A. Name

B. Assigned identification number

C. Telephone number

D. Date of birth

E. Social security number

F. Address

G. Photograph

Joint Commission, The. Protocol for preventing wrong site, wrong procedure, wrong person surgery. 2003. htt://www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8C- FEBA74A732EA/0/up_guidelines.pdf. Accessed October 10, 2006.

Major gaps identified:

• Incomplete ID band information
• Unclear print out / written information
• ID band not attached to the patient

Major gap identified:

• Some nurses are not confirming the identity of the patient from the mother / sitter.

Errors regarding the mismatching of patients

• A patient’s identity is not correctly documented. This will typically occur upon initial registration where the patient is linked to an incorrect medical record number or other identifier.

• A patient is moved from one location to another or from one practitioner or treatment team to another, (e.g. from ward to operating theatre).

• A procedure / medication / test / treatment is not tied to the correct patient. This can occur at the point of requesting a procedure / medication / test / treatment, at the point of applying the procedure / medication / test / treatment, or at the point of returning the procedure / medication / test results / treatment.

Standard IPSG 3

The hospital develops and implements a process to improve the safety of high-alert medications.

Standard IPSG 3.1

The hospital develops and implements a process to manage the safe use of concentrated electrolytes.

Measurable Elements of IPSG 3

1. The hospital has a list of all high-alert medications, including look-alike / sound-alike medications, that is developed from hospital-specific data.

2. The hospital implements strategies to improve safety of high-alert medications, which may include specific storage, prescribing, preparation, administration, or monitoring processes.

3. The location, labeling, and storage of high-alert medications, including look-alike / sound-alike medications, is uniform throughout the hospital.

Measurable Elements of IPSG 3.1

1. The hospital has a process that prevents inadvertent administration of concentrated electrolytes.

2. Concentrated electrolytes are present only in patient care units identified as clinically necessary.

3. Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that promotes safe use.

Major gaps identified:

• Some high alert medications stored in unlocked refrigerator.

IPSG 3 : Improve the Safety of High-Alert Medication

Measurable Elements of IPSG 6

1. The hospital implements a process for assessing all inpatients and those outpatients whose condition, diagnosis, situation, or location identifies them as at high risk for falls.

2. The hospital implements a process for the initial and ongoing assessment, reassessment, and intervention of inpatients and outpatients identified as at risk for falls based on documented criteria.

3. Measures are implemented to reduce fall risk for those identified patients, situations, and locations assessed to be at risk.

Standard IPSG.6

The hospital develops and implements a process to reduce the risk of patient harm resulting from falls.

Major gaps identified:

• No fall risk bed tag.
• No fall risk medical flagging.

Goal 6:

Reduce the Risk of Patient Harm Resulting from Falls

Measurable Elements of IPSG 5

Standard IPSG.5

1. The hospital has adopted currently published, evidence-based hand-hygiene guidelines.

2. The hospital implements an effective hand-hygiene program throughout the hospital.

3. Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital.

The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health

care–associated infections.

Major gaps identified:

• Non compliance on hand hygiene especially by medical staff before contact to patients.
• Wearing clean gloves by all staff members without performing hand hygiene first.

IPSG 5

Reduce the Risk of Health Care-Associated Infections

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

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