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Copy of SIX INTERNATIONAL PATIENT SAFETY GOALS (IPSG)
Transcript of Copy of SIX INTERNATIONAL PATIENT SAFETY GOALS (IPSG)
What is it ?
Identify Patients Correctly
1. To reliably identify the patient correctly, for whom the service or treatment is intended.
2. To match the service or treatment to that individual.
Acceptable identifiers – ( two identifiers )
Patient complete name
Patient medical records number on ID wrist band and/or Medical File
Not Acceptable identifier
Patients room number
Location or posting the patient's name above the bed or on the door
Patients are identified
providing treatments and procedures/diagnostic.
What are the identifiers?
When do you identify your patient?
Blood, or blood products.
Serving restricted diet.
Providing radiation therapy.
During time out - before a procedure.
Before taking and sending specimens for clinical testing.
And any interaction with the patient.
Improve Effective Communication
What is it ?
Conveying of critical information in a way that is timely, accurate, complete, clear and understood by recipient.
Complete verbal and telephone test results from lab (or Medication Order from Doctor) must be
by recipients ( Nurse 1, confirmed by Nurse 2) and must be re-confirmed by the conveyor.
Standardize abbreviations, acronyms, and symbols used throughout NGHA-PMBAH, including a list of those not to be used.
Improve the Safety of High-Alert Medications
What are high alert medications ?
These medications are involved in a high percentage of errors and/or sentinel events, medications that carry higher risk for adverse outcomes, as well as look-alike, sound-alike medications.
In which area the concentrated electrolytes are available? How are they stored?
Concentrate electrolytes are available in ICU, ER, NICU, L&D and it is kept in separate, secured cabinet and labeled by Special warning label.
IPSG.2.2 – The hospital develops and implements a process for handover communication
Standardized auxiliary labels will be used for high alert medications.
An independent double check procedure will be performed for all High Alert and Paediatric/Neonatal Medication administration.
Always use the 6 Rights before administration: Right Patient, Right Medication, Right Time, Right Dose, Right Route and Right Documentation.
Segregate them to reduce the risk of error.
Store the High Alert medications in RED BOXES that are labelled as “High Alert Medication”.
High Alert Medications are medications that pose an increased risk of causing significant harm to patients if used in error
Look-Alike and Sound-Alike Medications are medications whose names/packages sound/look similar to other drug names/packages.
Healthcare providers will adhere to the following:
Use Tallman lettering labels for Look-Alike, Sound-Alike Medications.
Look-Alike, Sound-Alike medications without approved TALL Man Lettering will be labelled as “Name Alert”.
Utilize medication segregation for Look-Alike, Sound-Alike Medications.
IPSG.3.1 The hospital develops and implements a process to manage the safe use of concentrated electrolytes
Concentrated Electrolytes are High Alert Medications that must first be diluted prior to parenteral administration, to ensure patient safety.
Concentrated electrolytes will be:
Stored and kept in a locked cabinet, with a similar sign in/out procedure used for Narcotics and Controlled Substances.
Separated from other medications and stored in red boxes with lids
Labeled with “High Alert Medication/Concentrated Electrolyte”
Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
The hospital develops and implements a process for ensuring correct-site, correct-procedure, and correct-patient surgery.
This process starts in the ward/department before sending the patient for any procedure.
Ensure that documents, imaging and test results, vital signs and paperwork are properly labeled and readily available.
Informed consents are completed and signed by the Physician, Patient/Guardian or Parent and the witness.
Proper handover is done in the Holding bay and all discrepancies should be corrected before sending the patient into the procedural Room.
Reduce the Risk of Health
Care –Associated Infections
What is it ?
Comply with current published and generally accepted hand hygiene guidelines.
Implement an effective hand hygiene program.
Develop policies and/or procedures that address reducing the risk of health care –associated infections.
Reduce the Risk of Patient Harm Resulting from Falls
When do you re-assess the patient for fall risk?
We reassess the patient for fall risk following;
Medication effects, such as those
Anticipated with sedation or diuretics
Immediately postoperative (within 48 hours post surgery),
Change in ambulation
Change in level of consciousness or mental status
After a fall
Transfer between units
When do you initiate the fall assessment (time frame)?
We initiate the fall risk assessment upon admission.
What is it ?
Develop and Implement a process to reduce the risk of patient harm resulting from fall.
How can we reduce the risk patient harm resulting from falls in hospital settings?
By assessing and reassessing all inpatients and those out patients whose condition, diagnosis, situation, or location identifies them as at high risk for fall.
Why Patient Safety Goals
To promote specific improvements in patients safety.
To highlight problematic areas in health care and describe evidence - and expert-based consensus solutions to these problems.
List of Goals
Identify Patients Correctly.
Improve Effective Communication.
Improve the Safety of High-Alert Medications.
Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery.
Reduce the Risk of Healthcare Associated Infections.
Reduce the Risk of Patient Harm Resulting from Falls.
IPSG.2.1 – The hospital develops and implements a process for reporting critical results of diagnostic test
Read back procedure for the receipt of laboratory or radiology results:
The technologist/reporter will provide the report to Nurse A.
Nurse A will WRITE the critical results on the patient clinical record.
Nurse B will READ BACK the information provided, including the patient’s medical record number and name to the reporter.
The technologists/reporter will verify the information is correct to Nurse B.
Both Nurse A and Nurse B must document the date and time the report was received, badge number of the person providing the report and their own names, job titles and badge numbers and both must sign the result sheet.
TIME OUT : This is the full verification that is performed
immediately prior to the induction of Anesthesia
or the start of an invasive procedure when the
entire care team actively and verbally confirms:
APP 1429-02 Look-Alike, Sound-Alike and High Alert Medications
APP 1433-36 . Medication storage and security
APP 1430-16. Patient Identification
APP 1426-08 Surgical / procedural site verification
APP 1430-05 Fall prevention