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INTERNATIONAL
PATIENT SAFETY
RAHIMA M. SALENDAB, BSN, RN
PATIENTS SAFETY,,,,????
Prevent medical errors
Protect patient from harm
INTERNATIONAL PATIENT
SAFETY GOALS
AUTHORED BY JCI (JOINT COMMISSION
INTERNATIONAL)
STARTED AT JANUARY 1, 2007
INTERNATIONAL PATIENT SAFETY
GOALS:
1. IDENTIFY PATIENT CORRECTLY
2. IMPROVE EFFECTIVE COMMUNICATION
3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATION
4. ENSURE CORRECT – SITE, CORRECT – PROCEDURE,
CORRECT – PATIENT SURGERY
5. REDUCE THE RISK OF HEALTH CARE ASSOSIATED
INFECTION
6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM
FALLS
IPSG – 1 (IDENTIFY PATIENT CORRECTLY)
WHEN GIVING ANY TREATMENT
 WHEN DOING ANY PROCEDURE
(PATIENT ROOM CANNOT BE USED AS AN
IDENTIFIER)
FAILURES TO CORRECTLY IDENTIFY THE
PATIENTS LEAD TO:
MEDICATION ERROR
TRANSFUSION ERROR
TESTING ERROR
WRONG PERSON PROCEDURE
IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)
 COMMUNICATION AMONG NURSE
ENDORSEMENT
 NURSING DOCUMENTATION
CLEAR AND LEGIBLE HAND WRITING
DATE, TIME & SIGNATURE FOR EACH ENTRY
TELEPHONE ORDER
 WRITE DOWN THE ENTIRE ORDER
 READ BACK
 WITNESS
 SIGN WITHIN 24 HOURS
VERBAL ORDER
 REPEAT BACK
 START THE ORDER
 SIGN AFTER SITUATION IS OVER
OR BEFORE PHYSICIAN LEAVE
THE AREA
IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)
(DRUGS THAT BEAR A HIGHTENED RISK
CAUSING SIGNIFICANT PATIENT HARM WHEN
USED IN ERROR)
TOP FIVE HIGH ALERT MEDICATIONS ARE:
1. INSULIN
2. NARCOTICS
3. INJECTABLE POTASSIUM CHLORIDE (PHOSPHATE)
CONCENTRATED
4. INTRAVENOUS ANTICOAGULANTS
5. SODIUM CHLORIDE SOLUTION ABOVE 0.9 %
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)
LOOK ALIKE MEDICINE
Example of SOUND ALIKE
Folinic Acid Folic Acid
Amidaron Amlor
Zinnat Zantac
Flumazenil Flamazine
Parlodel Panadol
Tazocin Prazocin
Ferrosac Ferriprox
Kafocid Keflex
Lasix Losec
Aldactone Aldomet
Ranitidine Loratidine
voltarin ventolin
7 RIGHTS
1.RIGHT PATIENT
2.RIGHT MEDICATION
3.RIGHT TIME
4.RIGHT ROUTE
5.RIGHT DOSAGE
6.RIGHT FREQUENCY
7.RIGHT DOCUMENATION
IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)
IPSG – 4 (ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT –
PATIENT SURGERY)
UNIVERSAL PROTOCOL FOR WRONG SITE,
PROCEDURE,
AND SURGERY PREVENTION
 MARKING THE SURGICAL SITE
 A PRE – OPERATIVE VERIFICATION
PROCESS
 A TIME – OUT THAT IS HELD
IMMEDIATELY BEFORE THE START
OF A PROCEDURE
(The pause before surgery begins is known as "time
out" and is intended to make everyone slow down
for a few moments and double check what they are
about to do.)
IPSG – 5 (REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION
 EFFECTIVE HAND – HYGIENE
 COMPLY WITH THE CURRENT PUBLISHED & GENERAL
ACCEPTED HAND – HYGIENE GUIDELINES
IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS)
 INITIAL ASSESSMENT OF PATIENT FALL RISK &
REASSESSMENT OF PATIENT WHEN INDICATED BY A
CHANGE IN CONDITION OR MEDICATIONS
 Document and report your observations and your
interventions
INTERNATIONAL PATIENT SAFETY GOALS
(USE CAPITAL LETTERS OF EACH WORD TO REMIND YOU OF THE GOAL)
I DENTI FY patients correctly (patient’s room cannot be used) when giving / doing
any treatment or procedure.
COMMUNI CATI ON – improved effective communication through
implementation of a process or procedure for taking verbal or telephone
orders or for reporting critical test results that require a verification
“read back” of the complete order or test result by the person receiving
the information.
MEDI CATI ON – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS.
Remove concentrated electrolytes (including but not limited to Potassium
chloride, Potassium Phosphate, Sodium Chloride ˃ 0.9% from patient
care units.
ELI MI NATE – WRONG SITE, WRONG PATIENT, WRONG –
PROCEDURE IN SURGERY
I NFECTI ON – reduce the risk of Health Care – Acquired Infections comply with
the current published and generally accepted hand hygiene guidelines.
FALL – reduce the risk of patient harm resulting from FALL. Take action to decrease
or eliminate any identified risks.
I
CAN
MEMORIZE
EVERYTHING
I
FANCY

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International patient safety rems lecture

  • 2. PATIENTS SAFETY,,,,???? Prevent medical errors Protect patient from harm
  • 3. INTERNATIONAL PATIENT SAFETY GOALS AUTHORED BY JCI (JOINT COMMISSION INTERNATIONAL) STARTED AT JANUARY 1, 2007
  • 4. INTERNATIONAL PATIENT SAFETY GOALS: 1. IDENTIFY PATIENT CORRECTLY 2. IMPROVE EFFECTIVE COMMUNICATION 3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATION 4. ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY 5. REDUCE THE RISK OF HEALTH CARE ASSOSIATED INFECTION 6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS
  • 5. IPSG – 1 (IDENTIFY PATIENT CORRECTLY) WHEN GIVING ANY TREATMENT  WHEN DOING ANY PROCEDURE (PATIENT ROOM CANNOT BE USED AS AN IDENTIFIER)
  • 6. FAILURES TO CORRECTLY IDENTIFY THE PATIENTS LEAD TO: MEDICATION ERROR TRANSFUSION ERROR TESTING ERROR WRONG PERSON PROCEDURE
  • 7. IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)  COMMUNICATION AMONG NURSE ENDORSEMENT  NURSING DOCUMENTATION CLEAR AND LEGIBLE HAND WRITING DATE, TIME & SIGNATURE FOR EACH ENTRY
  • 8. TELEPHONE ORDER  WRITE DOWN THE ENTIRE ORDER  READ BACK  WITNESS  SIGN WITHIN 24 HOURS VERBAL ORDER  REPEAT BACK  START THE ORDER  SIGN AFTER SITUATION IS OVER OR BEFORE PHYSICIAN LEAVE THE AREA IPSG – 2 (IMPROVE EFFECTIVE COMMUNICATION)
  • 9. IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS) (DRUGS THAT BEAR A HIGHTENED RISK CAUSING SIGNIFICANT PATIENT HARM WHEN USED IN ERROR)
  • 10. TOP FIVE HIGH ALERT MEDICATIONS ARE: 1. INSULIN 2. NARCOTICS 3. INJECTABLE POTASSIUM CHLORIDE (PHOSPHATE) CONCENTRATED 4. INTRAVENOUS ANTICOAGULANTS 5. SODIUM CHLORIDE SOLUTION ABOVE 0.9 % IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)
  • 11.
  • 13. Example of SOUND ALIKE Folinic Acid Folic Acid Amidaron Amlor Zinnat Zantac Flumazenil Flamazine Parlodel Panadol Tazocin Prazocin Ferrosac Ferriprox Kafocid Keflex Lasix Losec Aldactone Aldomet Ranitidine Loratidine voltarin ventolin
  • 14. 7 RIGHTS 1.RIGHT PATIENT 2.RIGHT MEDICATION 3.RIGHT TIME 4.RIGHT ROUTE 5.RIGHT DOSAGE 6.RIGHT FREQUENCY 7.RIGHT DOCUMENATION IPSG – 3 (IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS)
  • 15. IPSG – 4 (ENSURE CORRECT – SITE, CORRECT – PROCEDURE, CORRECT – PATIENT SURGERY) UNIVERSAL PROTOCOL FOR WRONG SITE, PROCEDURE, AND SURGERY PREVENTION  MARKING THE SURGICAL SITE  A PRE – OPERATIVE VERIFICATION PROCESS  A TIME – OUT THAT IS HELD IMMEDIATELY BEFORE THE START OF A PROCEDURE (The pause before surgery begins is known as "time out" and is intended to make everyone slow down for a few moments and double check what they are about to do.)
  • 16. IPSG – 5 (REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION  EFFECTIVE HAND – HYGIENE  COMPLY WITH THE CURRENT PUBLISHED & GENERAL ACCEPTED HAND – HYGIENE GUIDELINES
  • 17. IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS)  INITIAL ASSESSMENT OF PATIENT FALL RISK & REASSESSMENT OF PATIENT WHEN INDICATED BY A CHANGE IN CONDITION OR MEDICATIONS  Document and report your observations and your interventions
  • 18.
  • 19. INTERNATIONAL PATIENT SAFETY GOALS (USE CAPITAL LETTERS OF EACH WORD TO REMIND YOU OF THE GOAL) I DENTI FY patients correctly (patient’s room cannot be used) when giving / doing any treatment or procedure. COMMUNI CATI ON – improved effective communication through implementation of a process or procedure for taking verbal or telephone orders or for reporting critical test results that require a verification “read back” of the complete order or test result by the person receiving the information. MEDI CATI ON – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS. Remove concentrated electrolytes (including but not limited to Potassium chloride, Potassium Phosphate, Sodium Chloride ˃ 0.9% from patient care units. ELI MI NATE – WRONG SITE, WRONG PATIENT, WRONG – PROCEDURE IN SURGERY I NFECTI ON – reduce the risk of Health Care – Acquired Infections comply with the current published and generally accepted hand hygiene guidelines. FALL – reduce the risk of patient harm resulting from FALL. Take action to decrease or eliminate any identified risks. I CAN MEMORIZE EVERYTHING I FANCY