International Patient

Safety Goals
Lecturer: Ms. Rosalyn Noche
IPSG Officer

King Fahad Hospital of the University General Hospital Orientation

 Definitions
• JCI : Joint Commission International
– works to improve patient safety and quality of health care in
the International community by offering education,
publications, advisory services and international
accreditation and certification.
• IPSG: International Patient Safety Goals:
– To promote specific improvements in patient safety
– Highlight problematic areas in health care
– Describe evidence- and expert-based consensus solutions to
these problems

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 JCI International
Patient Safety Goals
IPSG 1: Identify patient correctly
IPSG 2: Improve effective communication
IPSG 3: Improve the safety of high-alert medications
IPSG 4: Ensure correct-site, correct-patient, correct-procedure surgery
IPSG 5: Reduce the risk of health care-associated infections
IPSG 6: Reduce the risk of patient harm from falls

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 1: Identify Patient Correctly
ADM-Gen 01-035: Patient Identification

 Patient identification is an independent

function. Must be performed by each and every
healthcare provider who shall provide direct care.

• Patient identifiers used in KFHU

 Patient's name ( Last, First, Middle)
 Medical Record Number
* Date of Birth

NEVER USE: PATIENT ROOM NUMBER OR

LOCATION (Bed Number) AS AN IDENTIFIER.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 • White band: All Patients
• Red Band: Allergy
• Blue Band: Newborn Boy
• Pink Band: Newborn Girl
• Green Band: For Surgical Intervention
• Yellow band: Risk of Fall

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 When to Identify patients?
 Blood Transfusion
 Medication Administration
 Collection of blood & body fluid samples
 Confirmation of death
 Surgical intervention and any invasive procedure
 Transport or transfer of patients
 During room-in of the baby to the mother (HUGS & KISSES)
 Treatments, Dietary services, diagnostics and imaging
procedures

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 2: Improve Effective
Communication
• Effective Verbal and/or Telephone Order
(ADM-Gen 01-029)
• Critical Results Reporting (ADM-Gen 01-034)
• Handover Communication (SBAR)
(ADM-Gen 01-153)

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Verbal and/or Telephone Orders
ADM-Gen 01-029
Policies:
 Verbal orders shall be received ONLY during emergencies
 The nurse must REPEAT BACK the order loudly for doctor to hear.
Physician must enter the order immediately in the Quadra-Med after the
emergency is over.

 Complete Telephone Order is documented and READ BACK by the receiver

and confirmed by the individual giving order

 Ensure all orders was entered in the system.

• Consultants, Specialists & Residents– authorized to give

• Nurses – authorized to accept

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation
 Critical Results
• Critical Result:
– Any Result or finding that may be considered life
threatening or that could result in severe morbidity
and require urgent or emergent clinical attention.
• Significantly abnormal test result:
– Non emergent , non-life threatening result that need
attention and follow up action as soon as possible, but
for which timing is not as crucial as critical results.
• Critical test:
– STAT test that require rapid communication of results.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Critical Result Reporting
ADM-Gen 01-034
Policies:
• Reported Critical results require “Read Back”
by the person receiving the information
• Notification TAT: >30 mins. - OVR

Notification TAT (Turn Around Time):

The interval of time that the result is ready
to be reported until the time that the
appropriate physician was notified of the
result is within 30 minutes unless the
critical value is improved from a previous
value and the concerned health care
provider is aware of the previous value

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Critical Result Reporting
ADM-Gen 01-034

Critical test results includes:

 Laboratory
 Radiology or Imaging
 ECG and other cardio
diagnostics

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Policy
• All critical tests will be completed immediately.
• All critical results will be reported and READ BACK
and documented
• All Radiological critical tests results to be
reported to the ordering physicians and
documented.
• Any Significantly abnormal Test Result ,a
mandatory notification should be generated in
KFHU QUADRA-MED.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 3: Improve the Safety of
High-Alert Medications
• Definition: Drugs that have a heightened risk of causing significant
harm when used in error (Insulin, Anesthetics, Electrolytes,
Narcotics, etc.)
• Procedure:
• Standardization of the dosing, units of measure and
terminology
• High alert sticker (Red)
• Omnicell machine is now available in the hospital. High alert
medications are stored already in the Omnicell .
• Lists of High Alert Medications and Look-alike Sound-alike drugs
must be visible to all staff in every unit.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

Look-alike, Sound-alike Medication
(LASA)

Using protocols to reduce

risks
Ensuring prescription
legibility
Use electronic prescribing

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 4: Ensure Correct-Site, Correct-
Procedure, Correct-Patient Surgery
 Pre-operative verification process
 Marking of the operative site should
be done by the physician who will do
the procedure
 Having the team involved in the
procedure take a TIME OUT before
starting the procedure.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 A time out form, as per WHO guidelines,
is being used in KFHU
Correct patient identity
Correct side and site
Agreement on the procedure to be
done (consent)
Correct procedure
Availability of correct implants and
any special equipment
• Only use clearly understandable marking at the
surgical site and involve the patient in the marking
process.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Procedure
• Pre operative scheduling of procedure involving
laterality (or digit or spine) ; Right, left, bilateral,
• Physician should document in the medical record
the planned procedure with the site and
laterality.
• Surgical Consent form
• Site marking form
• Verification of the site and laterality with the
patient prior to sedation or anesthesia.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 • Marking arrow should be visible in the
operative field.
• Not required in clear evident scenarios.
• Premature infants, tattoo
• Tapes for eyes and face.
• Dental are exempted.
• Marking not required for procedures which do
not relate to laterality e. g laparotomy, CS,
laparoscopy
• Mark the site with an arrow, not X

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 • In OR circulating nurse should:
– Review the planned procedure on the
schedule
– Review the Consent
– Identify the patient
– View the site marking
– Review all reports related to the procedure,
XR …

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 5: Reduce the Risk of
Healthcare Acquired Infections
Adhere to Infection Control Policies

1.Remember: decontaminate hands with a hygienic hand

rub and wash with disinfectant soap before and after direct
contact with a patient or with objects immediately around a
patient
 Hand Sanitizers: to be rubbed in until hand is dry
 Hand wash with soap & water for 15- 20 secs

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation
 IPSG 6: Reduce the Risk
of Patient Falls
Fall – a sudden, uncontrolled, unintentional, downward
displacement of the body to the ground or other object.
Excluding falls resulting from violent blows or other purposeful
actions.

Universal fall precaution MUST be applied

to all patients.

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation
 Reassessments must be performed after
every shift and/or in the following
situations:
• Post procedure or surgery
• Post specific medications (Narcotics, Sedative,
Diuretics)
• Change in mental status
• Change in ambulatory status
• Transfer between units
• After fall occurrence

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 For Ambulatory Patients:
– Fall Risk Assessment Scale for Ambulatory
patients must be documented.
– On call Physician must be notified for any falls
– OVR completed and submitted to Risk
Management

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 Implement
Universal Fall Precautions
• Orient patient to • Adequate lighting
surroundings • Keep nurse call system,
• Adequate footwear telephone accessible, within
• Bed in low position reach
• Lock wheels; wheelchairs, • Reduce room clutters
beds, commodes, • Toileting rounds every 2
stretchers.. hours
• Wipe up spill • Ensure Patient and Family
Education

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 1:
• Identify patients correctly

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 2:
•Improve effective
communication

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 3:
• Improve the safety of high-
alert medications

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 4:
• Ensure correct-site,
correct-patient, correct-
procedure surgery

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 5:
• Reduce the risk of health
care-associated infections

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 IPSG 6:
• Reduce the risk of patient
harm from falls

KING FAHAD HOSPITAL OF THE UNIVERSITY General Hospital Orientation

 End of lecture.
Thank you for listening.
For inquiries / questions about this lecture,
please email RNoche@uod.edu.sa

King Fahad Hospital of the University

General Hospital Orientation