International

Patient
Safety
Goals
Dr. Fathi Mohamed Ali
TQM-AUC
 By Studying this Lecture, you
will be able to:

Know the 6
International Patient
Safety Goals
 Improving Patient Safety
means . . .

Reducing Medical Errors

Reducing Patient Harm

For patient safety solutions to save lives and
prevent medical errors, the solutions must not
only be developed and disseminated, they
must also be implemented.
Through the WHO Action on Patient Safety
Initiative, known also as the High 5s project,
the Collaborating Centre is supporting a
program that will take five patient safety
solutions into hospitals in seven countries
 High 5s Project
The 5 solution areas include:
1. Prevention of patient care hand-over errors
2. Prevention of wrong site/wrong procedure/wrong
person surgical errors
3. Prevention of continuity of medication errors
4. Prevention of high concentration drug errors
5. Promotion of effective hand hygiene practices
 2008 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
 Evolution of the International
Patient Safety Goals

2005 Announcement of the JCI International

Patient Safety Goals (IPSG)
2006 Pilot testing of the JCI IPSG
– Results did not impact accreditation decision
2007 Implementation of IPSG as requirements for
International accreditation of hospitals

2008 IPSG as part of published 3rd Edition of JCI

Standards for hospitals, effective January 2008
T
Intrenational Patient Safety Goals
 Identification
Identify Patients Correctly

• Use at least two (2) ways to identify a patient

 IPSG.1
Identify Patients Correctly

 A collaborative process is used to develop policies and/or procedures

that address the accuracy of patient identification
 Use at least two (2) ways to identify a patient:
• giving medications
• giving blood and blood products
• taking blood samples
• taking other samples for clinical testing
• providing treatment or procedure
 The patient’s Room Number cannot be used as an identifier
Verification Process

Correct Patient (Identification)

Scope: All radiology procedures
 Ask the patient
“What is your FULL NAME?”
“What is the name of the PROCEDURE you are having
today?”. Also ask SITE/SIDE if required
 Never state patient’s Name
“Do not tell the patient… the patient tells you”
E.g. Call “Mr. Abdullah”, then ask the above questions
including additional questions related to clinical history as
outlined on Request Form
Correct Patient (Identification) Cont.
 Inpatients
1. Ask patient to state Full Name/ Procedure
2. Check responses against Referral Form & Patient ID Band
(wrist/ankle) including MRN– MANDATORY
Do Not Proceed if :
 Patient ID Band is absent. Call Ward Nurse to personally ID
patient and complete Time Out Verification sticker (all personnel
sign).
 Patient can not verbalise identity. Nurse Escort must verify
patient identity. Complete Time Out Verification sticker (all
personnel sign).
Verification Process - Cont.
 Outpatients
1.Ask patient to state Full Name/ Procedure
2.Check responses against Referral Form
Do Not Proceed if :
 Patient can not verbalise identity.
Proceed only after :
 Identity is verified by accompanying relative, family
member, friend or healthcare interpreter.
 Reinforcing the Message

Displayed at all
imaging consoles
Have you checked the
Patient ID ?
- Prior to the Procedure -

Asked patient their:

• Name
• (Procedure)
Checked response &
MRN against ID Band &
Are you Request Form

sure !
ESR Preparation tools
 8. Scope of risk (Patient Identification) Checklist
LEGEND: PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I = Observation/Interview
DR=Document Review
NM =Not met (Score 0 less than 49%) PM = Partially met (Score 2 If 50% to 79%) FM = Fully met( Score 3 If 80% or more) NA =
Not applicable(Cancelled Score )
RESULT COMMENTS
Points of measurement PT FM PM NM NA
 Each Patient has a unique identifier number registered by
DR+OBS
medical records
 Patients are identified by 2 identifiers which are the unique
medical records number and the patient's full name (at least DR+O/I
triple name)
 At least the two patient identifiers are used before collecting
DR+O/I
blood samples and other specimens for clinical testing.
 At least the two patient identifiers are used before
DR+O/I
administering blood, or blood components.
 At least the two patient identifiers are used when
DR+O/I
administering medications.
 At least the two patient identifiers are used before providing
DR+O/I
treatments or procedures.
 Two nurses or one nurse and a physician verify the patient’s
DR+O/I
identity prior to blood drawing for cross match.
 Two nurses or one nurse and a physician verify the patient’s
DR+O/I
identity prior to blood drawing for cross match.
 Two nurses or one nurse and a physician verify the patient’s
DR+O/I
identity prior to blood drawing for cross match.
 Communication
Improve Effective Communication

• Implement a process/procedure for taking

verbal or telephone orders
Intrenational Patient Safety Goals
 IPSG 2: Improve Effective
Communication

 A collaborative process is used to develop policies and/or procedures

that address the accuracy of verbal and telephone communications

 Person receiving the following:

• Verbal order
• Telephone order
• Reporting of critical test results
Must use a verification “read back” of complete order or test
result
 The order or test result is confirmed by the individual who gave
the order or test result
 Critical Test Results
• Ensure that there is collaborative process to
determine what they are
– Clinical Laboratories
• Bedside testing
– Imaging Studies
– Electrocardiogram
– Pulmonary Function Testing
– other
Official “Do Not Use” list:
• u
• IU
• qd
• qod
• Leading decimal point
(always use a Leading zero)
• Trailing zero
 SBAR Guidelines: Step 1
Have all the patient’s information available before you
contact the physician.
 Name
 Medical record number
 Age
 Diagnosis
 Medication list
 Allergies
 Vital signs
 Lab results
 Advance Directive
 SBAR Guidelines: Step 2

A physical assessment has been conducted

 Have I seen and assessed the patient myself
before calling?
 Review the chart for appropriate physician to call.
 SBAR Guidelines: Step 3

(S) Situation: What is the situation you are calling

about?
 Identify self, agency, and patient name
 What is going on with the patient that is a cause
for concern. A concise statement of the problem
 SBAR Guidelines: Step 3 (cont.)
(B) Background: What is the clinical background information
that is pertinent to the situation?
 Admitting diagnosis and date of admission
 List of current medications, allergies, IV fluids, etc.
 Most recent vital signs
 Lab results: provide the date and time test was done
and results of previous tests for comparison
 Medical history
 Recent clinical findings
 Advance Directive/code status
 SBAR Guidelines: Step 3 (cont.)

(A) Assessment: Share the results

of your clinical assessment
 What are the clinician’s findings?
 What is the analysis and
consideration of options?
 Is this problem severe or life
threatening?
 SBAR Guidelines: Step 3 (cont.)

(R) Recommendation: What do you want to happen

and by when?
 What action/recommendation is needed to correct the problem?
 What solution can you offer the physician?
 What do you need from the physician to improve the patient’s
condition?
 In what time frame do you expect this action to take place?
 Scenario – Home Care Aide
• S = Hi Tammy (nurse) this is Helen Adams the home health
aide. I am at Mrs. Elmer’s house and she is experiencing more
shortness of breath (SOB) when walking today.

• B = When I walked Mrs. Elmer to the bathroom for her bath she
had SOB than she didn’t have on Monday (today is
Wednesday). Mrs. Elmer also verbalized that she weighs 2 lbs
more than yesterday. I also noticed that her ankles are swollen.
If I press on the swollen area and remove my finger you can
see the indentation.

• A = I think that it is her Congestive Heart Failure (CHF) again

• R = I think that you need to see Mrs. Elmer.

 5. Scope of risk (Telephone and Verbal Orders) Checklist
LEGEND: PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I = Observation/Interview
DR=Document Review
NM =Not met (Score 0 less than 49%) PM = Partially met (Score 2 If 50% to 79%) FM = Fully met( Score 3 If 80% or more)
NA = Not applicable(Cancelled Score )
RESULT COMMENTS
Points of measurement
PT FM PM NM NA

 Telephone orders can only be initiated by a physician that is not

physically available in the unit because of another clinical DR+INT
involvement.
 Telephone orders are covered by a policy that identifies the
restricted orders and medications that cannot be initiated by a DR
phone call.
 Telephone orders follow a write down (in the physician order
situated in patient record), read back and confirm process. DR+INT

 Telephone orders are signed by the ordering physician within a

DR+INT
maximum period of 24 hours
 Verbal orders from a physician are allowed only in emergency
INT
situations
 Verbal orders should follow a write down; read back; and
confirm process with the exception of extreme emergencies, DR+INT
such as in code blue situations
 Verbal orders are signed by the ordering physician as soon as
DR+INT
the emergency situation is over
 Medication Safety
Improve the Safety of High-alert Medications

• Remove concentrated electrolytes from

patient care units
Intrenational Patient Safety Goals
 IPSG 3: Improve Safety of
High Alert Medications
 A collaborative process is used to develop policies and/or procedures
that address the location, labeling and storage of
concentrated electrolytes
 Concentrated electrolytes are not present in patient care units unless
clinically necessary and actions are taken to prevent inadvertent
administration in those areas where permitted by policy
 Remove concentrated electrolytes from patient care
units, including, but not limited to, the following:

• Potassium Chloride
• Potassium Phosphate
• Sodium Chloride > 0.9%
 High-alert medications (cont.)
)‫األدوية عالية الخطورة (تابع‬

High-alert medication

Insulin
 High-alert medications (cont.)
)‫األدوية عالية الخطورة (تابع‬

High-alert medication

Insulin
 High-alert medications (cont.)
)‫األدوية عالية الخطورة (تابع‬

High-alert medication

Antithrombotic agents
(anticoagulants)
 High-alert medications (cont.)
)‫األدوية عالية الخطورة (تابع‬

High-alert medication

Potassium chloride
 ESR Preparation tools
MM.5 The hospital has a system for the safety of high-alert medications.
MM.5.1 - There is a written multidisciplinary plan for managing high-alert medications and
hazardous pharmaceutical chemicals. It includes identification, location, labeling, storage,
dispensing, and administration of high-alert medications.
Activity: Document Review

Review the multidisciplinary plan for managing high-alert medications and hazardous
pharmaceutical chemicals.
Required Documents...
There is a written multidisciplinary plan for managing high-alert
High-alert Medications and
medications and hazardous pharmaceutical chemicals. It
Hazardous Chemicals
includes identification, location, labeling, storage, dispensing,
Multidisciplinary Plan
and administration of high-alert medications.
 ESR Preparation tools
MM.5.2 - The hospital identifies an annually updated list of high-alert medications and
hazardous pharmaceutical chemicals based on its own data and national and international
recognized organizations (e.g., Institute of Safe Medication Practice, World Health
Organization). The list contains, but is not limited to, the following:
MM.5.2.1 Controlled and narcotics medications.
MM.5.2.2 Neuromuscular blockers.
MM.5.2.3 Chemotherapeutic agents.
MM.5.2.4 Concentrated electrolytes (e.g., hypertonic sodium chloride, concentrated potassium salts).
MM.5.2.5 Antithrombotic medications (e.g., heparin, warfarin).
MM.5.2.6 Insulins.
MM.5.2.7 Anesthetic medications (e.g., propofol, ketamine).
MM.5.2.8 Investigational (research) drugs, as applicable.
MM.5.2.9 Other medications as identified by the hospital.
Activity: Document Review

Review the updated list of high-alert medications and hazardous pharmaceutical chemicals
(MM.5.2.1 - MM.5.2.9).

Required Documents...
The hospital identifies an annually updated list of high-alert medications
and hazardous pharmaceutical chemicals based on its own data and
national and international recognized organizations (e.g., Institute of
Safe Medication Practice, World Health Organization). The list contains,
High-Alert but is not limited to, the following: MM.5.2.1 Controlled and narcotics
Medications and medications. MM.5.2.2 Neuromuscular blockers. MM.5.2.3
Hazardous Chemotherapeutic agents. MM.5.2.4 Concentrated electrolytes (e.g.,
Chemicals List hypertonic sodium chloride, concentrated potassium salts). MM.5.2.5
Antithrombotic medications (e.g., heparin, warfarin). MM.5.2.6 Insulins.
MM.5.2.7 Anesthetic medications (e.g., propofol, ketamine). MM.5.2.8
Investigational (research) drugs, as applicable. MM.5.2.9 Other
medications as identified by the hospital.
 ESR Preparation tools
MM.5.3 - The hospital plan for managing high-alert medications and hazardous pharmaceutical
chemicals is implemented. This includes, but is not limited to, the following:
MM.5.3.1 Improving access to information about high-alert medications.
MM.5.3.2 Limiting access to high-alert medications.
MM.5.3.3 Using auxiliary labels or computerized alerts if available.
MM.5.3.4 Standardizing the ordering, transcribing, preparation, dispensing, administration, and
monitoring of high-alert medications.
MM.5.3.5 Employing independent double checks.
Activity: Observation
Observe for evidence of implementation of high alert plan (MM.5.3.1 - MM.5.3.5).

Activity: Staff Interview

Staff interview to look for evidence of implementation of high alert plan (MM.5.3.1 - MM.5.3.5).
 ESR Preparation tools
MM.5.4 - The hospital develops and implements standard concentrations for all medications
administered by intravenous infusion.
Activity: Document Evidence

Review the hospital approved standard concentration for all medications administered by
intravenous infusion.
Required Documents...
Evidence of Implementation of The hospital develops and implements standard
Standard Concentrations of IV concentrations for all medications administered by
Infusions intravenous infusion.
 ESR Preparation tools
MM.6 The hospital has a system for the safety of look-alike and sound-alike (LASA)
medications.
MM.6.1 - There is a multidisciplinary policy and procedure on handling look- alike/sound-alike
(LASA) medications.
Activity: Document Review

Review the multidisciplinary policy and procedures on handling LASA medications.

Required Documents...
Policy for Handling Look- There is a multidisciplinary policy and procedure on
alike/Sound-alike Medications handling look- alike/sound-alike (LASA) medications.

MM.6.2 - The hospital reviews and revises annually its list of confusing drug names, which
include LASA medication name pairs that the hospital stores, dispenses, and administers.
Activity: Document Review

Review the updated list of confusing drug names including LASA medications.
 ESR Preparation tools
MM.6.3 - The hospital takes actions to prevent errors involving LASA medications
including the following, as applicable:
MM.6.3.1 Providing education on LASA medications to healthcare professionals at orientation and
as part
of continuing education.
MM.6.3.2 Using both the brand and generic names for prescribing LASA
medications. MM.6.3.3 Writing the diagnosis/ indication of the LASA
medication on the prescription. MM.6.3.4 Changing the appearance of look-
alike product package.
MM.6.3.5 Reading carefully the label each time a medication is accessed, and/or prior to
administration.
MM.6.3.6 Minimizing the use of verbal and telephone orders.
MM.6.3.7 Checking the purpose/indication of the medication on the prescription prior to
dispensing and administering.
MM.6.3.8 Placing LASA medications in locations separate from each other or in non-alphabetical
order.
Activity: Observation
Observe for evidence of error prevention due to LASA medications (from MM.6.3.2 to MM.6.3.8)

Activity: Document Evidence

Staff education material and attendance record for LASA

medications. Required Documents...

Staff education material and attendance record for LASA medications

Activity: Staff Interview

Staff interview for evidence of error prevention due to LASA medications (from MM.6.3.1 to
MM.6.3.8)
 39. Scope of risk (High Alert Medication-
Concentrated Electrolytes) Checklist
LEGEND: PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I = 
Observation/Interview DR=Document Review NM =Not met (Score 0 less than 49%) PM = Partially met (Score 2 If
50% to 79%) FM = Fully met( Score 3 If 80% or more) NA = Not applicable(Cancelled Score)
RESULT COMMENTS
 Points of measurement
PT FM PM NM NA
 Availability of Written policy for the inventory, handling, DR
storage, dispensing and administration of high alert
medications (including the definition of high alert medication
and a defined global list and unit lists)
 Only privileged physicians may order intravenous medications DR+
(Midazolam, ketamine) in doses intended to provide
anesthesia.
 High alert medications are present in patient care units OBS
according to approved list and in minimal quantities.
 High alert medications are secured when stored in patient care OBS
units
 High alert medications dispensing is double checked and DR
documented +OBS

 High alert medications administration is double checked and DR +

documented OBS
 40-2. Scope of risk (Medication Errors Prevention: Look alike,
Sound Alike Medicines) Checklist
LEGEND:PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I =
Observation/Interview DR=Document Review NM =Not met (Score 0 less than 49% ) PM = Partially met
(Score 2 If 50% to 79%) FM = Fully met( Score 3 If 80% or more) NA = Not applicable(Cancelled Score )

RESULT COMMENTS
Points of measurement PT
FM PM NM NA

 There is a standardized list of look-alike/sound-alike DR+

medications used in storing, dispensing and OBS
administering medicines.

 The hospital annually review and revise when necessary DR

its list of look-alike/sound-alike

 Do not store the products in immediate proximity to one DR

another and/or use shelf flags to alert staff.

 Limit the brands of comparable products that are stocked OBS

in the pharmacy and the patient care areas
 Eliminate
Eliminate Wrong-site, Wrong-patient, Wrong-
procedure Surgery
• Use a checklist, including a “time-out,” before
surgery
• Verify that documents and equipment are
correct and functioning properly before
surgery
• Mark precise site where surgery will be
performed
Intrenational Patient Safety Goals
 IPSG 4: Ensure Correct-site,
Correct-procedure, Correct-
patient Surgery

 Collaborative process used to develop P&P

 Mark the precise site in clearly understood way

and involve patient in doing this
 Develop process or checklist to verify correct
documents and functioning equipment

 Use a Checklist including “Time-Out” just before

surgical procedure
Team Time Out –
Interventional (invasive) Radiology
(All invasive procedures covering CT / Ultrasound / Angiography / Mammography
and selective Screening procedures)
In procedure room, with patient present.
Confirm patient ID, request/consent forms, image data all correct.
Site marked by interventional doctor.
Team Leader calls Time Out immediately prior to procedure
commencement (patient draped) to confirm:
 Verification of patient identity (Full Name/MRN/ID Band)
 Agreement on the intended procedure
 Verification of correct position i.e level & side
 Verification of the visible marked site
 Availability of correct implants/equipment/medication
– DO NOT proceed until resolve discrepancies (document)
PATIENT’S NAME:--------------------------AGE:-------------------------------
FILE:------------------------- DEPT:----------------------------- ATTENDING
PHYSICIAN:----------------------------------------------------------------------------
DIAGNOSIS:--------------------------------------------------------------------------------
PLANNED
PROCEDURE:-------------------------------------- ---------------------------------
 ESR Preparation tools
QM.18 The hospital has a process to prevent wrong patient, wrong site, and wrong
surgery/procedure.
QM.18.1 - There is a process implemented to prevent wrong patient, wrong site, and wrong
surgery/procedure during all invasive interventions performed in operating rooms or other
locations.
Activity: Staff Interview
Interview staff to verify adherence to surgical/procedural safety protocol in the operating room,
endoscopy unit and surgical ward.
QM.18.2 - The process consists of three phases: verification, site marking, and
time out. Activity: Closed Medical Record Review
Review medical record to confirm compliance with the process to prevent wrong patient
wrong site wrong procedure that has 3 phases.

QM.18.3 - A pre-procedure verification of the patient information is carried out

including the patient’s identity, consent, full details of the procedure, laboratory tests
and images, and any implant or prosthesis.
Activity: Closed Medical Record Review
Review the medical record of a patient went for any invasive procedure to make sure that
the pre- procedure verification, site marking, and time out are noted in the chart.
 ESR Preparation tools
QM.18.4 - The surgical/procedural site is marked before conducting the
surgery/procedure.
QM.18.4.1 The site is marked especially in bilateral organs and multiple structures (e.g. fingers,
toes, and spine).
QM.18.4.2 The site is marked by the individual who will perform the procedure.
QM.18.4.3 The patient is involved in the marking process.
QM.18.4.4 The marking method is consistent throughout the hospital.
QM.18.4.5 The mark is visible after the patient is prepped and draped.
Activity: Closed Medical Record Review
Review the medical record of a patient went for any invasive procedure to make sure that
the pre- procedure verification, site marking, and time out are noted in the chart.

QM.18.5 - A final check (time-out) is conducted before the procedure is initiated.

QM.18.5.1 The time-out is conducted in the location where the procedure will be done, just
before starting.
QM.18.5.2 The time-out is initiated by a designated member of the team and involves the
members of the team, including the individual performing the procedure, the anesthesia
providers, and the nurse(s) involved.
QM.18.5.3 The entire procedure team uses active communication during the time out.
QM.18.5.4 During the time-out, the team members agree on the correct patient identity, the
correct procedure to be performed, the correct site, and when applicable, the availability of the
correct implant or equipment.
Activity: Observation
Observe the time-out process.

Activity: Staff Interview

Interview staff to assess knowledge regarding time-out process.

QM.18.6 - The hospital documents its processes for preventing wrong patient, wrong
site, and wrong surgery/procedure.
Activity: Open Medical Record Review
Review the medical record of a patient went for any invasive procedure to make sure that the pre-
procedure verification, site marking, and time out are noted in the chart.
 18. Scope of risk (Verification Process/Time
Out) Checklist
LEGEND: PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I = Observation/Interview
DR=Document Review
NM =Not met (Score 0 less than 49%) PM = Partially met (Score 2 If 50% to 79%) FM = Fully met( Score 3 If 80% or more) NA = Not
applicable(Cancelled Score )

RESULT COMMENTS
Points of measurement PT
FM PM NM NA
 Time- Out is done before skin incision and after starting anesthesia, and is OBS
read out loud
 Time- Out is done with nurse, anesthetist and surgeon or his/ her designee OBS

 The surgeon or his/ her designee, anesthetist and nurse verbally confirm the OBS
patient’s name.
 The surgeon, anesthetist and nurse verbally confirm the procedure. OBS
 The surgeon provides information regarding the critical or non-routine OBS
steps, if any.
 The surgeon provides information regarding how long will the case take. OBS
 The surgeon provides information regarding how much blood loss is OBS
anticipated
 The anesthetist provides information regarding any patient-specific OBS
concerns.
 The nurse has confirmed the sterility of the instrumentation (including OBS
indicator results).
 The nurse has confirmed whether there are equipment issues or concerns. OBS

 The team ensures essential radiology imaging is displayed. OBS

 IPSG 5: Reduce the Risk of
Health Care-Associated
Infections

 A collaborative process is used to develop P&P that

address reducing the risk of health care–associated
infections

 The hospital has adopted hand hygiene guidelines

 The hospital implements an effective hand

hygiene program
 Infections
Reduce the Risk of Health Care-acquired
Infections

• Comply with current published and generally

accepted hand hygiene guidelines
 ‫‪Intrenational Patient Safety Goals‬‬
‫‪GOAL 5‬‬
‫‪Reduce the risk of health care–associated infections.‬‬
‫‪5.1. Meeting Hand Hygiene Guidelines.‬‬
‫)‪5.2. Preventing ventilator-associated pneumonia (VAP‬‬
‫‪5.3. Preventing Blood Stream Infections.‬‬
‫‪5.4. Preventing catheter-associated urinary tract infections (CA-UTI),‬‬
‫الهدف الخامس ــ تقليل مخاطر العدوى المرتبطة‬
‫‪ :‬بالرعاية الصحية‬
‫‪ .‬بتنفيذ برنامج وإرشادات فعالة لنظافة اليدين ‪5.1.‬‬
‫اجراءات تدعم الخفض المستمر لعدوي الرئتين المرتبطة ‪5.2‬‬
‫‪.‬بجهازالتهوية الميكانيكية‬
‫‪ ..‬اجراءات تدعم الخفض المستمر لعدوى مجرى الدم ‪5.3.‬‬
‫اجراءات تدعم الخفض المستمر لعدوي الجهاز البولي ‪5.4.‬‬
‫‪ .‬المرتبطة بالقسطرة‬
Contact Precautions

N95
Airborne Precautions

Droplet Precautions PAPR

 Clinical staff wear gloves when contact with blood or
11 OBS 100%
other potentially infectious materials is possible
Clinical staff removes gloves after caring for a
12 OBS 100%
patient
Clinical staff do not wear the same pair of gloves for
13 OBS 100%
the care of more than one patient

14 Clinical staff do not wash gloves OBS 100%

Clinical staff keeps natural nail tips less than 0.5 cm

15 OBS 100%
in length

Artificial nails are not worn when having direct

16 OBS 100%
contact with patients

Healthcare workers are provided feedback about

17 INT 100%
their adherence to hand hygiene

Patients and their families are encouraged to

18 INT 100%
remind healthcare workers to practice hand hygiene
 Falls
Reduce the Risk of Patient Harm Resulting from
Falls
• Assess and periodically reassess each patient’s
risk for falling
 KFH. PATIENT SAFETY GOALS
GOAL 6
Reduce the risk of patient harm resulting from falls
6.1 initial assessment of patients for fall risk and reassessment of patients when
indicated by a change in condition or medications, among others.
6.2. Measures are implemented to reduce fall risk for those assessed to be at risk.
6.3. Measures are monitored for results, both successful fall injury reduction and any
unintended related consequences

‫الهدف السادس ــ تقليل خطر الحاق الضرر بالمريض نتيجة‬

‫ السقوط‬.
6.1 ‫تنفيذ عملية تقييم خطر سقوط المرضي اوليا واعادة التقييم‬
‫ عند اللزوم‬.
6.2 ‫تنفيذ برنامج خفض سقوط المرضي المعرضون للخطر‬.
6.3 ‫مراقبة تنفيذبرنامج تقليل خطر السقوط‬.
 Falls Prevention Program
 Falls happen because of a complex interaction of
intrinsic and/or extrinsic factors.
 Interventions require a multi-faceted approach.
 A comprehensive falls prevention program will
include an assessment of many factors, by a team of
professionals, with interventions that address a variety
of approaches that will help most patients, as well as
be tailored for individual patient needs. A falls
prevention program should be oriented to both
reducing falls and reducing injuries.
Falls Prevention Program

1. Assessing/screening for risk factors for falls

2. Using triggers to implement falls prevention
protocol
3. Implementing protocol according to patient needs
4. Assessing and reassessing patient
5. Reporting falls (internal and external)
6. Measuring/monitoring fall rates
7. Improving falls prevention program
 IPSG 6: Reduce the Risk of
Patient Harm resulting from
Falls

 Develop PP using collaborative process

 Assess and periodically Reassess each
patient’s risk for falling, including the
potential risk associated with the
patient’s medication regime,
 Take action to decrease or eliminate
any identified risks.
 FALLS
• Falls are a common cause of morbidity and
the leading cause of nonfatal injuries and
trauma-related hospitalizations in the
United States.
• Falls occur in all types of healthcare
institutions and to all patient populations.
• In hospitals, falls consistently make up the
largest single category of reported
incidents.
Patient Falls: A Complex Syndrome
Background:
A detailed analysis of patient falls over the past 6 months
demonstrates that 133 patient falls occurred:
• 98 of these patients screened positive for Fall Risk on admission
• 43 of these patients were trying to get out of bed
• 24 of these patients were trying to go to the bathroom
• 29 of these patients were confused (delirium/dementia)
• 15 of these patients suffered injury
• 3 of these patients suffered serious injury
Patient Falls: A Complex Syndrome

As Nursing, Physicians, Pharmacists,

Therapists and others have partnered to
ascertain the root cause for patient falls, it
is recognized that:

patient falls represents a complex

medical/surgical/nursing syndrome…
 Patient Falls: A Complex Syndrome
• A fall is not an isolated event/incident.
• A fall (like acute coronary syndrome) has the potential to be a
serious clinical event with major morbidity and mortality.
• A patient’s first fall is often the harbinger to a subsequent serious
fall.
• However, the first fall may be the serious fall.
• A fall can be caused by a patient’s dementia (chronic confusion).
• A fall can be caused by a patient’s delirium (acute confusion).
• The Patient’s medications (e.g., meperidine) may be the cause of
the delirium (acute confusion).
• Upon admission we (ED, Admitting Physician, Nursing) don’t notice
the patient has lost ability to ambulate (possible neurological
deficit). “I didn’t know I couldn’t walk!”.
Patient Falls: A Complex Syndrome
• A fall may be caused by nosocomial toileting
requirements (e.g., cathartics)
• A fall may be caused by vision, hearing, sensory
and motor impairment.
• A fall may be caused by environmental hazards
(e.g., wet floors).
• A fall may be caused by poor judgment (e.g., “I
thought I could get to the bathroom without
help”).
• A fall can be prevented by thoughtful strategies
designed for the individual patient (e.g., a low
bed).
 33. Scope of risk (Prevention of Patient Fall) Checklist
LEGEND:PT = Preparation Tool INT = Interview OBS = Observation MR = Medical Record O/I = Observation/Interview DR=Document Review NM
=Not met (Score 0 less than 49% ) PM = Partially met (Score 2 If 50% to 79%) FM = Fully met( Score 3 If 80% or more) NA = Not applicable(Cancelled
Score )
RESULT
Points of measurement PT COMMENTS
FM PM NM NA
 Patients are assessed for fall risk on admission, and further reassessed by an evidence- DR-O/I
based scale
 No excess equipment, supplies and furniture in patient rooms O/I
 Excess electrical and telephone wires are secured OBS
 Spills are cleaned immediately and “Danger - Wet Floor” signs are placed promptly OBS

 Patient is given orientation to surroundings O/I

 Bed is kept in lowest position during use unless impractical O/I
 Bed side rails are kept up O/I
 Locks on beds, stretchers and wheelchairs are secured O/I
 Absence of raised edges on the floor O/I
 Place call light and frequently needed objects within patient reach O/I
 Encourage patients/their families to call for assistance when needed O/I
 Assure adequate lighting O/I
 Walkers/Canes are stable and have rubber tips in good condition OBS
 Wheelchairs brakes are secure O/I
 Foot pedals of the wheelchair fold easily so that patient may stand safely O/I
 Properly positioned and secure handrails next to the toilet/shower O/I
 Raised toilet seats available which are well fitting and secure O/I
 Receptacles for soap and shampoo which are easy to reach and do not require the O/I
patient to bend over
 Room for a seat in and near the shower O/I
 Call buttons accessible from sitting position either on toilet seat or in shower area OBS
 Patient Safety Requires a Team Effort

• Consider your actions and how

they may affect patient safety
• Stay alert for things that don’t
seem right
• Take appropriate steps to
address a problem