6 International Patient Safety Goals

6 International Patient

Safety Goals

References

By SN Michelle

Vetted by SSN Jingjing

• Oxford English Dictionary
• Shah, S. & Singhal, T. (2013). Hand hygiene and health care associated infections: What, why and how. Pediatric Infectious Disease. Jul 2013, 5(3); 130-134.
• Lan, Y. H., Wang, K. W. K., Yu, S., Chen, I. J., Wu, H. F., & Tang, F. I. (2014). Medication errors in pediatric nursing: Assessment of nurses' knowledge and analysis of the consequences of errors. Nurse Education Today. May 2014, 34(5); 821-828.
• Paparella, S. (2010). High-alert Medications: Shared Accountability for Risk Identification and Error Prevention. Journal of Emergency Nursing. Sep 2010, 36(5); 476-478.
• Allegranzi, B. (2009). Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection. Dec 2009, 73(4); 305-315.
• McGuckin, M. (2013). Patient empowerment and hand hygiene, 1997–2012. Journal of Hospital Infection, Jul 2103, 84(3); 191-199.

Improve Effective Communication

What?

SBAR, SBAR, SBAR

Reduce Risk of Patient Harm resulting from *FALLS*

• Conveying of critical information in a way that is timely, accurate, complete, unambiguous and easily understood by recipient
• Written, verbal and telephone order
• PS: Verbal and telephone order not acceptable in KKH
• Exception: E-situations - properly documented
• Complete verbal and telephone test results from lab must be read back by recipient and must be confirmed by the conveyor

• Have been used in major Singapore hospitals
• Recently reinforced in KKH
• Problems identified:
• Not everyone used to the format
• Jumbled up?
• Practice makes perfect!

WHat is Fall?

• Fall = move from a higher to a lower level, typically rapidly and without control (Oxford English Dictionary, 2014)
• From bed onto the floor?
• Musculoskeletal injuries
• Internal and external haemorrhage
• Pain
• Happens to both staff and patients, therefore be careful!

No Fall!!!

What measures?

• Cot rail up, up, up and stable
• Forget? Often forget? Look back before leaving.
• Make a habit of checking the rail lock.
• Parents/patient refused
• Reinforce the importance of cot rail up
• Caution!
• Phone charger, laptop charger, pump charger, whatever charger
• When cluttering inevitable, ensure proper organizing
• Puddles? Vomitus on floor? Wet?
• Cover with paper towel, call housekeeper
• Cytotoxic? Read PnP on spillage

• Safety/Security Measures
• Cot-side up
• Clutter-free
• Clean and dry floor
• Assess Patient’s Risk For Fall
• Patient and/or Caregiver Education

Improve the Safety of

hIGH-aLeRT mediCATIONS

Ensure Correct-site, Correct-procedure, Correct-Patient Surgery

What is it?

High Alert = Super Alert!

• Medications likely to be involved in high-percentage errors, medications carrying higher risk for adverse outcomes, look-alike sound-alike medications
• Proper labelling and storage of such medications e.g. concentrated electrolytes, OxyCODONE/OxyCONTINE (sound-alike).

Time-out, Time-out, Time-out

• We have them! Locked with The Blue in prep room!
• Counterchecking between incoming-outgoing shifts
• Proper documentations
• Order, paste sticker, take, 2 RNs, sign, use, 2RNs.

• Done both in OT

and in the wards

• Marking of surgical site
• Involve patient
• Instantly recognisable and visible
• Accurate marking for multiple structures (fingers, toe, hands, legs) or multiple levels (spine)
• Preoperative/pre-procedural verification processes

• Done before invasive/surgical procedures
• Ensure correct patient, site, procedure
• Ensure consent up
• Name tag has to be put on!
• Involve patient/parents
• Signed by the operating doctor and a witness (another Dr/RN)

Reduce *RISK* of healthCARE-associated Infections

Identify Patient Correctly

What are those?

• Nosocomial infections spread mainly through healthcare workers
• Catheter-related UTI, bloodstream infection, pneumonia are the most common
• Needlestick injury as well!

How to counter it?

• HAND HYGIENE!!!
• 7-steps
• 5 moments
• Handrub bottles
• Outside rooms
• Bedside
• In the pouch of all COWs, especially Injection COWs and CPOE COWs
• Handwash points
• Every room (and I mean EVERY room where hand hygiene is needed!)

Not applied in time!

What is it?

• Elective admission - patient’s data not admitted at the time of patient's arrival
• Procedure done without tag? NO!!
• To follow-up is important, important, important!

Extra precautions!

• Modes of transmission identified!
• Signage, again. Just slip in the slot on the outer door.
• Full PPE requisites available in the antechamber
• Regularly topped-up… (almost)

• Two identifications of reliable data (e.g. Full name, IC, date of birth, full address) against patient name tag.
• Name tag must be pasted on patient’s body parts that are easily accessible i.e. hands or legs. Name tag on bed rails or pyjamas is unacceptable.
• When to identify:
• During administration of medications, blood or blood products
• During time-out before a procedure
• Before taking and sending specimens for clinical testing
• Before handing newborns to moms and when taking them back
• Before and after safekeeping of patients' belongings, especially POM, EBM.

Spatula?

Problems?

Double name tags?

• Handwashing steps signage
• At hand-washing points
• Outside isolation room
• Double door
• Troublesome, huh?
• Bypass? Only when extremely, supremely necessary. Precaution taken.
• Pressure monitor
• Just call FM if out of range, we cannot play around with it anyway...

• Child keeps pulling out name tag on hands and legs
• Risk of being thrown out without replaced
• Advisable to put restraint e.g. splint? Depends.
• Involve parents to watch out.

• Not to disturb child at night
• One on the child, one on bedside/cot rail
• Risk: wrong patient
• Conclusion: Not allowed!

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