OBJECTIVE

 To promote specific improvement in patient safety

 Represent strategies to reduce the risk of medical errors
 Provide clear solutions for improving patient safety

Patient SAFETY GOALS

1. Identify patients correctly
2. Improve effective communication
3. Improve 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

1. Identify patients correctly

Wrong-patient errors occur in virtually all aspects of diagnosis and treatment
Do’s
 2 Identifiers- Patient Name & Avitis Number
 For unknown/ comatose patient brought in Emergency identify as
unknown 1 or 2.

Patients are Identified

 Giving medicines, blood or blood products.
 Taking blood samples and other specimens for clinical testing
 Before all surgical, invasive and diagnostic procedures

Don’t Use- Patient Room, location

2. Improve effective communication

Do’s
2.1. Verbal/Telephonic Order
 Use write and read back
2.2. Reporting critical results of diagnostic tests
 Use write and read back
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.

2.3. Handover Communication

 ISBAR

IDENTIFICATION: Patient Identification

SITUATION: What is happening at the moment?
BACKGROUND: What are the issues that led up to this situation?
ASSESSMENT: What do you believe the problem is?
RECOMMENDATION: What should be done to correct this situation.
EXAMPLE
I – Krishnan.M, Avitis No-01-25689 16M Male, Room No-506
S – presents with choking event post feed
B – previous well term baby, event preceded by 2-3 days fever, irritability and poor
sleep
A – thriving, examined well
R – reassure with likely discharge today if remains well
WHEN?
 Shift changes
 Inter-hospital transfers
 Intra-hospital transfers
 Time-critical situations such as medical emergencies or evacuations
 Procedure documents
ADVANTAGES:
 Ensures completeness of information and reduces likelihood of missing data
 Is an easy and focused way to set expectations for what will be communicated
 Ensures a recommendation is clear and professional
 Gives confidence in communication , focuses not on the people who are
communicating but on the problem itself.

3. Improve the Safety of High-alert medications

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
Do’s
HIghAlert Medications / Look Alike & Sound Alike Medications
 Double Checks
 HIgh Alert Medications ,Look alike and sound alike medications are stored with
proper labeling
 List of high-alert medications / Look alike and sound alike medications
 High-alert medications - Stored and kept in a locked cabinet
 High-alert medicationsSeparated from other medications and stored in boxes
with lids
 Labeled in Red with “High Alert Medication / Concentrated Electrolyte”
 Proper Orientation to Staff
4. Ensure correct Site, Correct Procedure, Correct Patient Surgery
Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common
occurrence in health care organizations.
Factors
 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.
 Inadequate patient assessment.
 Inadequate medical record review.
 Problems related to illegible handwriting.
 The use of abbreviations.
Preoperative verification
 Prior to the induction of Anesthesia
 The start of an invasive procedure
Ensure
 Patient’s identity (two identifiers)
 Procedure to be performed
 Correct procedure side/site
 Necessary imaging ,equipment , Implants or special requirements
are present
Timeout
 Prior to the start of the procedures
 Innvolves the entire operative team.

5. Reduce the Risk of Health Care Associated infections

 Infection Prevention and control
 Common Infections- Catheter-associated urinary tract infections,Bloodstream
infections, Ventilator Associated pneumonia (often associated with mechanical
ventilation
Do’s
Proper hand hygiene.
Comply with current published and generally accepted hand hygiene guidelines.
Implements an effective hand hygiene program.

6. Reduce the Risk of Patient Harm Resulting from falls

 Falls account for a significant portion of injuries
Do’s
 Evaluate its patients’ risk for falls and take action to reduce the risk of falling
 The evaluation includes
 fall history
 medications and alcohol consumption review
 gait and balance screening,
  walking aids used by the patient.
 Assess and periodically reassess each patients risk for falling, including the
potential risk associated with the patients medication regimen, and take action
to decrease or eliminate any identified risks.
 Fall RisK reduction program
Prevention of Patient Falls
 Educating patient and patient families on
Not to leave bed without any help
To wear non skid foot wear .
Nurses Call Bell
 Bed height to be fixed at the lowest lowel
 All side rails in the up postion
 Proper lighting