IPSGs

1. INTERNATIONAL PATIENT
SAFETY GOALS
(IPSG)

2. Medical errors and deaths: Is the
problem getting worse?
• It was bad enough when the
Institute of Medicine figure that
98,000 deaths per year in the
US are caused by medical
errors, but now in the Journal
of Patient Safety, adverse
medical events result in
210,000 to 440,000 deaths per
year and 10 to 20 times those
numbers of serious harms.

3. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

4. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

5. IPSG1
PROCESS FOR IMPROVING ACCURATE
PATIENT IDENTIFICATION
• At least two (2) ways are used to identify patients
before they:
• Receive medications
• Blood and blood products
• Blood or other specimens are obtained
• Diagnostic imaging
• Receive treatment or procedure
• The patient’s room or bed number can’t be used as
an identifier

6. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

7. IPSG2
IMPROVE EFFECTIVENESS OF
COMMUNICATION
• Three standards:
• IPSG2: Verbal & telephone
communication
• IPSG2.1: Reporting results of critical
diagnostic tests
• IPSG2.2: Handover communications

8. IPSG2
PROCESS FOR IMPROVING EFFECTIVENESS OF
VERBAL & TELEPHONE COMMUNICATION
• The most error-prone communications
• Patient care orders given verbally and those
given over the phone
• Report back the critical test results
• Confirmation is given by the clinician issuing
the order (or reporting the critical test results)
after entire verbal or telephone order is
documented and read back by the receiver.

9. IPSG2.1
REPORTING RESULTS OF CRITICAL DIAGNOSTIC
TESTS
• The hospital has determined:
• What are considered critical
values for all diagnostic tests
• Who is authorized to report
and receive the critical results
• What is required as
documentation in the medical
record

10. IPSG2.2
HANDOVER COMMUNICATIONS
• Standardized handovers:
• Process included methods,
forms and tools
• Communications for critical
information
• Handovers communication
data is maintained and used to
improve quality

11. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

12. IPSG3
IMPROVE THE SAFETY OF HIGH-ALERT
MEDICATIONS
• IPSG3: High-alert medications
• IPSG3.1: Concentrated electrolytes
• High-alert medications are involved in a high percentage
of medication related errors and/or sentinel events
• Medications that carry an increased risk of adverse
events are frequently “Look-alike” or “Sound-alike”
• Identification, location, labeling and storage of high-alert
medications is the same in all hospital areas.
• ISMP list
https://www.ismp.org/tools/highalertmedicationLists.asp

13. IPSG3.1
IMPROVE THE SAFETY OF
CONCENTRATED ELECTROLYTES
• Remove concentrated electrolytes from patient
care units and store in the pharmacy e.g.,
• Potassium phosphate=/>3 mmol/ml
• Magnesium sulphate=/>50% or more concentrated
• Concentrated electrolytes aren’t stored on
patient care units except where permitted by
policy ( areas where clinically imperative)
• If any concentrated electrolytes aren’t stored on
patient care units unless they are clearly
labeled and stored in a way that supports safety

14. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

15. IPSG4
ENSURE CORRECT-SITE, CORRECT-
PROCEDURE, CORRECT-PATIENT SURGERY
• IPSG4: Process for correct-site, correct-procedure, correct- patient surgery
• IPSG4.1: Process for time-out
• Marking the surgical site:
• Instantly identifiable mark
• The same process throughout the organization
• Made by the individual performing the procedure
• When possible patient should be involved in the marking process
• Visible after the patient is prepped and draped
• Marked in all cases involving laterality, multiple structures (fingers, toes,
lesions) or multiple levels (spine)

16. IPSG4
ENSURE CORRECT-SITE, CORRECT-
PROCEDURE, CORRECT-PATIENT SURGERY
• There is a checklist or similar process to
complete a preoperative verification of:
• Correct site, procedure, and patient
• Correctly completed informed
consent, relevant documents, imaging
and other studies are available,
properly labeled and displayed
• Any required special equipment and/or
implants are working correctly

17. IPSG4.1
PROCESS FOR TIME-OUT
• “ Time-out” immediately before starting
• Involves the entire team
• Active communication
• Correct site, procedure, and patient is identified
• Confirm completion of verification process
• Resolve any confusion, answer any questions
• Patient participation not necessary
• Documented according to policy
• Consistent process applicable to all procedures in all areas

18. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

19. IPSG5
REDUCE RISK OF HEALTH CARE-ASSOCIATED
INFECTIONS
• In an effort to reduce HAI’s, the
organization utilizes up-to-date evidence
based published hand hygiene guidelines
• World Health Organization (WHO)
• Center For Disease Control And Prevention
( CDC)
• The guidelines of hand hygiene and
disinfection are completely implemented
in all hospital areas

20. WHEN TO WASH YOUR HANDS
WITH SOAP AND WATER
• Your hands are visibly soiled (dirty)
• Hands are visibly contaminated with
blood or body fluids
• Before eating
• After using the rest room
Wet hands first with
water (avoid HOT water)
Apply 3 to 5 ml of soap
to hands
Rub hands together for
at least 15 seconds
Cover all surfaces of
the hands and fingers
Rinse hands with water
and dry thoroughly
Use paper towel to turn
off water faucet

21. WHEN TO WASH YOUR HANDS
WITH AN ALCOHOL BASED
HAND RUB
• If hands aren’t
visibly soiled or
contaminated with
blood of body
fluids, use an
alcohol-based
hand rub for
routinely cleaning
your hands
Apply 1.5 to 3 ml of alcohol
gel to hands, and rub them
together
Cover all surfaces of the
hands and fingers including
areas around/under fingernails
Continue rubbing hands
together until alcohol dries
It should take at least 10-15
seconds of rubbing before
your hands feel dry

22. INTERNATIONAL PATIENT
SAFETY GOALS
IDENTIFY
PATIENT
CORRECTLY
IMPROVE
EFFECTIVE-
NESS OF
COMMUNIC-
ATION
IMPROVE
THE SAFETY
OF HIGH-
ALERT
MEDICATI-
ONS
ENSURE
CORRECT-
SITE,
CORRECT-
PROCEDURE,
CORRECT-
PATIENT
SURGERY
REDUCE
RISK OF
HEALTH
CARE-
ASSOCIATED
INFECTIONS
REDUCE
RISK OF
PATIENT
HARM FROM
FALLS

23. IPSG6
REDUCE RISK OF PATIENT HARM FROM FALLS
• There’s a risk reduction process to prevent or
decrease patient falls
• Written criteria for types of patient populations
(including outpatients)
• Initial and outgoing assessment for all fall risks
as indicated
• There’re implemented measures to reduce fall
risk for:
• Patient assessed to be at risk
• Risky situations
• Risky locations