4. 1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High Alert
Medications
4. Ensure Correct-Site, Correct –
Procedure, Correct-Patient Surgery
5. Reduce the Risk of Health Care
Associated Infections
6. Reduce the Risk of Patient Harm
Resulting from Falls
7. No procedure shall be conducted when the
patient’s identity cannot be verified
because ID band is illegible or missing.
Patient should not be sent out of the unit
without some form of ID
Any clinician (doctor, nursing staff, health
care professional) who removes ID band is
responsible for ensuring another is applied.
If limb is not available bands must be
securely attached to the patient’s clothing
8. VERBAL ORDER
An oral order made by a physician during
emergency/ life threatening situation
TELEPHONE ORDER
Made by physician who is physically unable
to be present to write the order that requires
immediate intervention
*verbal and telephone orders should be limited
9. TELEPHONE ORDERS
Write & “READ BACK”
Example:
19-07-2015 @ 2000H: T.O. by Dr. A
Paracetamol 1gm Infusion IV stat
T.O. Dr. A/ SN B/ SN C
10. HIGH ALERT MEDICATIONS
Medications involved in high percentage
of errors and/or sentinel events,
medications that carry a higher risk for
adverse outcomes as well as look-
alike/sound alike medications
11. Telephone orders are not allowed when
prescribing HIGH ALERT MEDICATIONS
High Alert Medications are not allowed
as ward stock
All storage locations must be clearly
labeled with a red high alert sticker
An independent double check for high
alert medications is done by two nurses
before administering to the patient
14. SITE MARKING
When is site mark required?
Involves laterality (left, right)
Multiple structures (fingers, toes,
lesions)
Multiple levels (spine)
16. TIME OUT/PAUSE
A verification process before surgical
procedure
TIME OUT OF REQUIRES CONFIRMATION :
Correct patient
Correct site
Correct procedure
Correct patient position
Correct radiographs
Correct implants and equipment
17.
18. 5 MOMENTS OF HAND HYGIENE
1.Before touching the patient
2.Before aseptic procedure
3.After body fluid exposure risk
4.After patient contact
5.After contact with patient
environment
19.
20.
21. Timed Get Up and Go test (OP)
Humpty Dumpty (Peadia)
MORSE FALL SCALE (IP)
History of fall within 3 months
Secondary Diagnosis
Ambulatory Aid
IV Therapy
Gait
Mental Status
22. Patients are assessed at the time of admission
REASSESSMENT
• Every 24 hours for Low and Moderate Risk
• Every shift if HIGH RISK
• Any Change in Patient Condition
• Following a fall
23. PRECAUTIONS & PREVENTIVE MEASURES
LOW FALL RISK
•Educate patients
•Create patient safe environment
•Provide adequate lightning.
•Maintain bed in low position
•Lock movable transfer equipment
•Encourage the use of non-slip footwear.
•The re-assessment will be 24 hours and documented in the form.
24. MODERATE FALL RISK
•All standard precautions.
•Communicate patient's risk level to all members of the health care team
•Communicate family and inform about all precautions available in the
hospital.
•Supervise or assist elimination/ toileting. Provide bedside commode as
needed
•Encourage use of assistive devices and mobility aids.
•The re-assessment will be the same as low risk patients.
PRECAUTIONS & PREVENTIVE MEASURES
25. PRECAUTIONS & PREVENTIVE MEASURES
HIGH FALL RISK
•All standard and Moderate Fall measures
•A laminated sign of "Fall Alert“ will be hung
on the overboard.
•Remain with patient while toileting
•Shift the patient to a room with a
best visual access from nursing station.
•Provide patient observer (family or a Watcher)
•Re-assessment of patient with high risk is done every
shift (8 hours) and document in the re-assessment form.
•Fall alert stickers put on the medical file when sending
the patients to other departments for investigations or
procedures.
26. POST FALL MANAGEMENT
Assess for injury
Notify physician
Use fall risk assessment
Notify health care team & patient’s family
Initiate OVR
27. OCCURRENCE VARIANCE REPORT
(OVR)
Occurrence Variance Report (OVR)
are internal forms used to
document the details of
the incident and the
investigation of an occurrence
and the corrective actions taken.
30. When to useWhen to use
Any incident which is not consistent to routine patient care.
Injury to visitors or volunteers while on the hospital premises.
31. Miscommunication
Accidental needle prick
Absconded
Blood extraction
Problem in cleanliness
Medicines not transcribed
No response to call
What to reportWhat to report
32. Violation in standard precaution
Delays in:_______:
Non-availability of supplies/forms
Expired blood
Wrong patient identification
Other (specify:
What to reportWhat to report
33. TYPES OF EVENTS
SENTINEL EVENT
A “Sentinel Event” is an unexpected occurrence involving death or serious physical
or psychological injury, not related to the natural course of a patient’s illness or
underlying condition. Examples:
• Unanticipated death unrelated to the natural course of the patient’s: suicide
, homicide(
• Hemolytic Blood Transfusion.
• Wrong-site, wrong-procedure, wrong-patient surgery
• Infant abduction or infant who was sent home with the wrong parents.
NearMiss Events
A near miss is defined as any process variation which did not affect the
outcome but for which a recurrence carries a significant chance of a
serious adverse outcome
Adverse Events
Any change in health or side effects that occurs while the patient is
receiving the treatment
34. PolicyPolicy for OVRfor OVR
1. Report the details of any occurrence, which
has an impacts in the care of patient.
2. OVR Form will be initiated immediately after the
incident. And submit it to your immediate
supervisor within the current work shift.
35. 3. The report will NOT be used to CRITICIZE
OR BLAME the actions of the staff
involved.
4. Corrective actions shall be taken to
minimize risk of injury and adverse
outcomes. Corrective action(s) shall be
documented.
36. Root Cause Analysis
The purpose of the Root Cause Analysis is to
understand how and why a Event occurred and to
prevent the same or similar event from occurring in
the future by analyzing the course and causes behind
the event and working on defects.
37. QUALITY IMPROVEMENT
METHODOLOGY
(FOCUS – PDCA)
•Find - an opportunity for improvement
•Organize- a team
•Clarify- The current process
•Understand- the resources of the problem and the process variation
•Select- The improvement
•Plan - the improvement
•Do- the improvement
•Check- the results
•Act- To hold the gain
