1. International Patient
Safety Goals
Prepared By: Mr. Mouad M. Hourani. (Bcs, MPh)
Prince Sultan Military Medical City (PSMMC)
Continuous Quality Improvement & Patient Safety
Coordinator
2. Why Patient safety Goals.
List of Goals.
Brief of each goal.
Requirement of each goal.
Summary.
Scenario.
3. To promote specific improvements in
patient safety.
To highlight problematic areas in
health care and describe evidence-
and expert-based consensus
solutions to these problems.
(JCIA – 4th Edition, 2011)
4. Goal 1: Identify Patients Correctly.
Goal 2: Improve Effective Communication.
Goal 3: Improve the Safety of High-Alert Medications.
Goal 4: Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery.
Goal 5: Reduce the Risk of Health Care–Associated
Infections.
Goal 6: Reduce the Risk of Patient Harm Resulting
from Falls.
6. Wrong-patient errors occur in virtually all
aspects of diagnosis and treatment.
Patients may be sedated, disoriented, or
not fully alert; may change beds, rooms,
or locations within the organization; may
have sensory disabilities; or may be
subject to other situations that may lead
to errors in identification.
(JCIA – 4th Edition, 2011)
7. A policy to be collaboratively developed
that address:
› accuracy of patient identification Using at
least two (2) ways to identify a patient.
› The patient's room number and location
cannot be used to identify the patient.
› Patients are identified when:
1. Giving medicines, blood or blood products.
2. Taking blood samples and other specimens for
clinical testing.
3. Providing any other treatments or procedures.
9. Effective communication-which is timely, accurate,
complete, unambiguous, and understood by the
recipient— reduces errors and results in improved
patient safety.
Communication can be electronic, verbal, or written.
The most error-prone communications are patient
care orders given verbally and those given over the
telephone, when permitted.
Another error-prone communication is the reporting
back of critical test results.
(JCIA – 4th Edition, 2011)
10. A policy to be collaboratively developed
that address:
› the accuracy of verbal and telephone
communications.
› The complete verbal and telephone order or
test result is written down – read back by the
receiver of the order or test result those must
be confirmed by the individual who gave the
order or test result.
NOTE: Not all countries permit verbal or
telephone orders.
12. When medications are part of the patient treatment
plan, appropriate management is critical to ensure
patient safety.
High-alert medications are those medications involved
in a 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.
Lists of high-alert medications are available from
organizations such as the World Health Organization or
the Institute for Safe Medication Practices.
(JCIA – 4th Edition, 2011)
13. A frequently cited medication safety issue is the
unintentional administration of concentrated
electrolytes (for example, potassium chloride
[equal to or greater than 2 mEq/mL concentrated).
Errors can occur when staff are not properly
oriented to the patient care unit, when contract
nurses are used and not properly oriented, or
during emergencies.
The most effective means to reduce or eliminate
these occurrences is to develop a process for
managing high-alert medications that includes
removing the concentrated electrolytes from the
patient care unit to the pharmacy.
(JCIA – 4th Edition, 2011)
14. The organization should identify the
organization’s list of high-alert
medications based on its own data.
Concentrated electrolytes that are
clinically necessary as determined by
evidence and professional practice
should be clearly labeled and stored in a
manner that restricts access to prevent
inadvertent administration.
15. A policy to be collaboratively
developed that address:
› The location, labeling, and storage of
concentrated electrolytes.
› The Concentrated electrolytes are not present
in patient care units unless clinically
necessary and actions are taken to prevent
inadvertent administration in those areas.
17. Wrong-site, wrong-procedure, wrong-patient
surgery is an alarmingly common occurrence in
health care organizations.
These errors are the result of:
› Ineffective or inadequate communication between
members of the surgical team.
› Lack of patient involvement in site marking.
› Lack of procedures for verifying the operative site.
frequent contributing factors:
› Inadequate patient assessment.
› Inadequate medical record review.
› A culture that does not support open communication
among surgical team members.
› Problems related to illegible handwriting.
› The use of abbreviations.
(JCIA – 4th Edition, 2011)
18. Time out should be done for at least:
procedures that investigate and/or treat
diseases and disorders of the human body
through cutting, removing, altering, or insertion
of diagnostic/ therapeutic scopes.
The time out applies to any location in the
organization where these procedures are
performed. And done just before starting the
procedure which involves the entire
operative team.
The (US) Joint Commission’s Universal Protocol
is:
› Marking the surgical site;
› A preoperative verification process; and
› A time-out that is held immediately before the start of
a procedure.
19. The surgical site Marking should:
› Involve the patient.
› Done with an instantly recognizable mark.
› Be consistent throughout the organization.
› Be made by the person performing the procedure.
› Take place with the patient awake and aware, if possible.
› Be visible after the patient is prepped and draped.
› Marked in all cases involving laterality, multiple structures
(fingers, toes, lesions), or multiple levels (spine).
The purpose of the preoperative verification process is:
› To verify the correct site, procedure, and patient.
› To ensure that all relevant documents, images, and studies
are available, properly labeled, and displayed; and
› To verify any required special equipment and/or implants
are present.
20. Use a checklist, including a ―Time-out" just
before starting a surgical procedure, to ensure
the correct patient, procedure, and body part.
Develop a process or checklist to verify that all
documents and equipment needed for surgery
are on hand and correct and functioning properly
before surgery begins.
Mark the precise site where the surgery will be
performed. Use a clearly understood mark and
involve the patient in doing this.
21. Goal 5:
Reduce the Risk of
Health Care –
Associated Infections
22. Infection prevention and control are
challenging in most health care settings, and
rising rates of health care–associated infections
are a major concern for patients and health
care practitioners.
Infections common to many health care
settings include catheter-associated urinary
tract infections, bloodstream infections, and
pneumonia (often associated with mechanical
ventilation). Central to the elimination of these
and other infections is proper hand hygiene.
(JCIA – 4th Edition, 2011)
23. Internationally acceptable hand
hygiene guidelines are available from
the World Health Organization (WHO),
the United States Centers for Disease
Control and Prevention (US CDC), and
various other national and
international organizations.
(JCIA – 4th Edition, 2011)
24. Comply with current published and generally
accepted hand hygiene guidelines.
Implements an effective hand hygiene
program.
Develop policies and/or procedures that
address reducing the risk of health care–
associated infections.
NOTE: This should recognize that not all countries have a
CDC (Centers for Disease Control and Prevention) or may
not recognize the US CDC.
26. Falls account for a significant portion of injuries in
hospitalized patients.
the organization should evaluate its patients’ risk
for falls and take action to reduce the risk of falling
using a fall-risk reduction program that based on
appropriate policies and/or procedures.
The evaluation could include fall history,
medications and alcohol consumption review, gait
and balance screening, and walking aids used by
the patient.
(JCIA – 4th Edition, 2011)
27. Assess and periodically reassess
each patient's risk for falling,
including the potential risk
associated with the patient's
medication regimen, and take
action to decrease or eliminate any
identified risks.
28. Improve Ensure Reduce the Reduce the
Improve the Safety Correct-Site, Risk of Risk of
Identify
Effective of High- Correct- Health Patient
Patients
Communi Alert Procedure, Care- Harm
Correctly Medicatio Correct-Patient Associated Resulting
cation Surgery
ns Infections from Falls
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,and correct- associated resulting from
identification on among medications
patient infections falls
caregivers
surgery
Comply with
Use of two identification, time-out
identifiers Write down location, labeling, Patient fall
process that Comply
before Verbal and and storage of assessment /
includes site
Administering telephone order high-alert marking, with hand reassessment
medications, or test result and medications and
read it back.
equipment hygiene and
blood, or blood the concentrated
Then confirmed electrolytes
readiness and and managemen
products and correct patient
Before taking by the person presence in precautions t as
and procedure
blood and other who gave the patient care units addressed in
order
prior to as in policy. policy
specimens for are addressed by procedure or
clinical testing policy operation.
29. Patient 60 years old admitted to ER complaining of sever chest pain. ECG ,
Cardiac enzymes, CBC and KFT were done (IPSG 1: Identify patient correctly).
The ECG shown massive MI and the cardiac enzymes were critically high (IPSG
2: Improve Effective Communication). Patient transferred urgently to Cardiac
Catheterization Lab which indicated the need for open heart surgery as result of
left main 95% occlusion. Therefore, after doing the success surgery (IPSG4:
Ensure correct site, correct procedure and correct patient), patient was
transferred to CVICU Which was assessed by the registered nurse and found that
the patient at high risk of fall (IPSG 6: Reduce the Risk of Patient Harm Resulting
from Falls). In the next day the Lab technician called to notify low potassium
level (IPSG 2: Improve Effective Communication) and the consultant was not
reachable. So, the nurse called him and he ordered her to give 20meq of
potassium IV (IPSG 2: Improve Effective Communication). So that, the complete
order carried out using the medication that was stored in lucked key (secured)
box, red labeled which given after double check (IPSG3: Improve safety of high
alert medication). The patient was transferred to ward considering the
documented risk of fall precaution by assisting him in ambulation, proper
teaching, raised side rails and low bed level (IPSG 6: reduce patient harm
resulting from falls). Finally, patient was discharged with free of infection
because of physicians, nurses and other staff who dealt with patient were strict
to follow hand Hygiene (IPSG5: reduce the risk of healthcare associated
infections).
