PATIENT CENTERED STANDARDS:

INTERNATIONAL PATIENT SAFETY GOALS:

IPSG 1: Identify Patients Correctly

IPSG 2: Improve Effective Communication
IPSG 3: Improve the Safety of High Alert Medications
IPSG 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
IPSG 5: Reduce the Risk of Health Care-Associated Infections
IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls

1: IDENTIFY PATIENTS CORRECTLY we use at least two (2) ways to identify a patient when: • Giving
medications • Taking blood samples • Taking other samples for clinical testing • Providing treatment or
procedure

Q: How do you identify a patient in your Hospital? • Full name of the patient. • Medical Record Number.
Q: What do you do in case you have two patients with the same name? • The staff registering the
patient shall report the presence of patients with similar names to their head of departments, who shall
circulate it to all concerned departments.

Q: What is the recommended time for hand washing and Hand Rub? • Washing hands with plain soap
and water is 40-60 seconds • Hand Rub: 20-30 seconds

Q: What are the 5 Moments for Hand Hygiene? • Before patient contact • Before clean/aseptic
procedure • After body fluid exposure risk • After touching a patient • After touching patient
surroundings Note: When alcohol-based hand rub is already used, do not use antimicrobial soap
concomitantly

Q: What are the other opportunities/indications for hand Hygiene: • Before starting and leaving work •
Before and after contact with patients • Before leaving an isolation room • Before and after performing
invasive I non-invasive procedures • Before and after handling an invasive device (regardless of whether
or not gloves are used) for patient care • Before donning gloves and after removing gloves. Before and
after donning /removal of other personal protective equipment • Before and after preparing/ handling
or eating food • Before and after bed making • Before and after preparing/handling medication • Before
and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the
patient • If moving from a contaminated body site to a clean body site during patient care • After
contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings • After
using toilet facilities. • After handling contaminated laundry/waste • After contact with other potentially
hazardous material such as chemicals or disinfectants.

PATIENT & FAMILY RIGHTS (PFR)

Areas of Focus for PFR: • Identify, Protect, and Promote Patient Rights to care and treatment and to be
involved in their care and decisions • Patients’ rights to privacy and confidentiality of care and
information • Informed Consent • General Consent • Protecting patients’ possessions from theft or loss
• Complaints To be compliant to the standards in PFR, please • Educate the Patient about the
Informed and General Consent • Abbreviations must not be used in Consent Forms (refer to CLS 2.13
Policy) • Do not leave patient files or documents unattended, open or exposed • Cover patients during
transport • Knock before entering a room • Keep doors closed during treatments and times of care •
Discuss care only in the presence of the patient or in the presence of others with permission from the
patient

Q: How will you administer High Alert Medications and narcotics? • Preparation and administration is
witnessed by 2 RN’s

Incident - Any occurrence which is not consistent with the routine clinical or non-clinical operations
which might happen.

Near Miss - is serious error or mishap that has the potential to cause an adverse event but fails to do so
because of mere chance or because it is intercepted.

Sentinel Event - an unexpected occurrence involving death or serious physical or psychological injury or
the risk thereof, not related to the patient’s natural course of illness. Examples are: • Homicide •
Surgery on the wrong patient or wrong site • Child abduction • Child discharge to a wrong family •
Hemolytic blood transfusion reaction

REMEMBER: A near-miss can be just as important to investigate! DO NOT hesitate to report an error
that almost was a sentinel event.

Q: What are the Standard Precaution?

1. The basic requirements for infection prevention and control strategies such as strict hand washing to
reduce the spread of microorganisms.

2. Adherence to aseptic techniques and appropriate use of Personal Protective Equipment (PPE).

3. A method of infection prevention and control in which all human blood and body substances (blood,
body fluids, secretions, excretions, non-intact skin and mucous membranes) are considered potentially
infectious.

4. Standard precautions are used for all patients regardless of their diagnosis.

Q: What do you do if you get a needle stick injury? • We initially bleed the body part by pressing and
holding under running water. Wash area with soap and apply anti-septic, cover with a sterile dressing,
report to Infection Control.

QQ: How will you discard broken glass? • Discard in a safe sharp container box

Q: How often is are the curtains cleaned in clinical area? • Once monthly, when visibly soiled or dealing
with infectious cases

Q: When are the sharp boxes and laundry bags changed? • When 2/3 full or after one month (sharps)

Q: What do you do in case there is a fire

P - ull the pin

A - im at the base of the fire

S - queeze the handle

S - weep side to sid

R – escu

A – larm

C – ontain

E – xtinguish

QUESTIONS??? 1. How many patient identifiers need to check as per AZHD policy? a. 1 b. 2 c. 3 d.
none 2. The following are correct identifiers EXCEPT: a. Patient 2 names b. Patient 3 names c. Patient
UAE ID number d. Patient Medical Record Number 3. When is correct patient identification NOT
required? a. Before general anesthesia b. Before drawing blood sample c. Before IV cannulation d.
Before patient leaving against medical advise 4. What is NOT applicable for critical results reporting? a.
Should be reported within the same shift b. Should read back c. Should confirm d. Should
write down 5. State true or False, Telephone order is allowed in AZHD only if the doctor is outside of the
clinic. a. True b. False

6. Critical results shall be reported primarily to: a. Patient’s family member b. Requesting physician b.
Patient d. Medical Director 7. The following are high alert medications except: a. Epinephrine b.
Morphine c. Naproxen d. Insulin IV 8. What color is used as indicator for high alert medications at
AZHD? a. Red b. Blue c. Yellow d. Orange 9. What is the protocol for LASA (look alike, sound alike)
medications at AZHD? a. LASA medications are considered as any other over the counter medications. b.
LASA medications shall be labeled and segregated. c. LASA medications are not used in AZHD. d. LASA
medications are managed by Narcotic Surgeon. 10. What is the primary measure adopted by AZHD to
reduce healthcare associated infections (HAI)? a. AZHD accept only non-infected patients b. Emergency
patients are transferred to the nearest hospital immediately c. We do hand wash/rub before/after every
procedure/patient contact. d. All of the above 11. Hand washing is done for the duration of ____
seconds. a. 30 seconds b. 15 seconds c. 60 seconds d. 45 seconds 12. What do you call that
program from WHO that was adopted by AZHD? a. 5 Memories of Hand Hygiene b. Five Moments of
Hand Hygiene b. 5 Moments of Hand Washing d. All of the above 13. Fall risk assessment is applied to
surgical patients only. a. True b. False 14. Fall risk assessment shall be performed before and after
surgery. a. True b. False 15. Fall risk assessment is not performed to those patients who drink alcohol.
a. True b. False