International Patient Safety Goals

This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly�
Goal 2: Improve effective communication�
Goal 3: Improve the safety of high-alert medications�
Goal 4: Ensure safe surgery �
Goal 5: Reduce the risk of health care-associated infections�
Goal 6: Reduce the risk of patient harm resulting from falls

1. INTERNATIONAL PATIENT SAFETY GOALS

2. IPSG International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety .

3. OBJECTIVES To promote specific improvements in patient safety Highlight problematic areas in health care Describe evidence-and expert-based consensus solutions to these problems

4. IPSG GOAL Goal 1: Identify patients correctly Goal 2: Improve effective communication Goal 3: Improve the safety of high-alert medications Goal 4: Ensure safe surgery  Goal 5: Reduce the risk of health care-associated infections Goal 6: Reduce the risk of patient harm resulting from falls

5. Info graphic 2017

6. Goal 1: Identify patients correctly ECRI Institute Special report on Patient identification errors - June 2016 - Relevant studies published from January 2009 to January 2016 Overall identified 106 studies for inclusion: 39 studies described prevalence, 44 described problems contributing to patient ID errors and 40 assessed interventions .

7. continued……. About 9% of the events led to temporary or permanent harm or even death. ECRI Institute - PSO reviewed more than 7,600 wrong-patient events occurring over a 32-month period that were submitted by 181 healthcare organizations (News release - 09/26/2016 - Preventable, Potentially Fatal Patient Identification Errors Analysed )

8. How…….? UHID No. & Patient full name - Using two patient identifiers Additional identifiers – Age of patient and sex Check for ID band on patient – colour coding Blue – all patients Pink – vulnerable group DO NOT use Room No./Location for identification This is done to make sure that each patient gets the correct medicine and treatment . T he correct patient gets the correct blood when they get a blood transfusion (bar coding).

9. When…….? Before administering medications, blood or blood products Before taking blood and other specimens for clinical testing Before providing treatments and procedures Policies and procedures support consistent practice in all situations and locations

10. Goal 2: Improve effective Communication In a study of the 495 communication events observed in the ICUs, 123 ( 24.8%) involved a nurse communicating with another team member to clarify a patient’s orders or plan of care . A Health Care Quality Survey  conducted by the Commonwealth fund (2002) found that 25% of patients report they did not follow their clinician’s advice and provides the reasons cited in this survey :

11. continued……. 39%  disagreed with what the clinician wanted to do (in terms of recommended treatment) 27%  were concerned about cost 25%  found the instructions too difficult to follow 20%  felt it was against their personal beliefs And  7%  reported they did not understand what they were suppose to do

12. continued……. A large scale European Commission project has found that handover communication is responsible for 25% to 40% of adverse events (2015). The Joint Commission Guide to Improving Staff Communication, Second Edition, 2009, USA

13. Points to remember……. Verbal order – write down, read back and confirm (Read back of verbal orders with confirmation) Ensure proper handover and effective communication among all care givers(all shifts) Critical value/reports intimation immediately to the treating/duty doctor Critical value/reports to be documented in patient file on intimation by the doctor Get important test results to the right staff person on time.

14. Verbal orders in emergencies The complete verbal and telephone order or test result is written down by the receiver of the order or test result . The complete verbal and telephone order or test result is read back by the receiver of the order or test result . The order or test result is confirmed by the individual who gave the order or test result .

15. Clinical hand over Ineffective communication is now a well-recognised contributor to patient harm in hospitals. For some years, research has been suggesting that clinical handover is a critical site for communication problems. Nurses – 5 shifts – Daily Audit Register Doctors – 2 shifts - ICUs

16. SBAR Tool for Communication Use of SBAR tool for all patient related communications A structured communication technique designed to convey a great deal of information in a succinct and brief manner. This is important as we all have different styles of communicating , varying by profession, culture, and gender.

17. SBAR with scenario S Situation Concise statement of the problem What is going on now B Background Pertinent and brief information related to the situation What has happened A Assessment Analysis and considerations of options What you found/think is going on R Recommendation Request/recommend action What you want done

18. continued……. S - Situation One sentence description of needed Patient arrived for appointment on wrong day B - Background Details that give information to make an assessment (Can be from patient's view and from your clinical view as you inquire and research) Patient arrived for 11 am appointment today Appointment is at 11 am tomorrow Pt. comes from 40 kms away Pt. needed to have friend drive them to appointment Doctor has 1+ appointment available on schedule Doctor's assistant has some open times We don't know if the mistake was with the patient or the call centre A - Assessment Your position on the issue We should see the patient today R - Recommendation Your specific method for solving the problem I recommend that we use the 1+ time or have the assistant to see this patient

19. Goal 3: Improve the safety of high-alert medications High-Alert Medications (HAMs) are medications involved in a high percentage of errors and/or sentinel events Medications that carry a higher risk for adverse outcomes Look-Alike / Sound-Alike medications (LASA)

20. HAMs Performing an independent double-check (IDC) helps ensure safe administration of HAMs (High Alert Medications). According to ISMP, IDCs can prevent up to 95% of errors before they reach the patient .

21. Evidence based The most common anticoagulant errors are administration mistakes, including incorrect dosage calculation and infusion rates. Anticoagulants were linked to 59,316 errors reported to the United States Pharmacopeia MEDMARX registry from 2001 to 2006. Roughly 60% of these errors reached the patient and about 3% caused death or harm .

22. continued……. From January 1997 to December 2007, 446 medication-error sentinel events were reported to TJC’s (the Joint Commission) sentinel event database. About 7% were associated with anticoagulants; two-thirds of these involved heparin. Twenty-eight deaths occurred and six patients suffered loss of function. In 2005, enoxaparin was associated with four patient deaths and two cases of harm.

23. Things to do…….. Look alike & sound alike – separate storage and re-check drug name High risk – check and verification by a second staff before dispensing and double check before administration Concentrated electrolytes – strict control and check for dilution L abel medicines that are not labelled – loaded syringes to be labelled before loading the next drug – meet the labelling requirements including dilution E xtra care with patients who take medicines to thin their blood Medicine reconciliation at all transition points - up-to-date list of medicines patient currently on

24. continued…… Ensure concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken during inadvertent administration in those areas where permitted by policy. Concentrated electrolytes that are stored in patient care units are clearly labelled and stored in manner that restricted access.

25. continued……. Policies and / or procedures are developed to address the identification, location, labelling, and storage of high-alert medications. The policies and/or procedures are implemented.

26. Goal 4: Ensure safe surgery From 1995 to 2005, the Joint Commission (JC) sentinel event statistics database ranked wrong site surgery as the second most frequently reported event with 455 of 3548 sentinel events (12.8%)

27. Steps……… ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT PATIENT SURGERY Surgical site marking with active patient involvement throughout the hospital Time out for all invasive procedures throughout the hospital Inside OR- follow sign in, time out and sign out using surgical safety checklist Pause before the surgery to make sure that a mistake is not being made

28. How to ensure……..? Uses an instantly recognized mark for surgical-site identification and involves the patient in the marking process. Uses a checklist or other process to verify preoperatively the correct site, correct procedure and correct patient And that all documents and equipment needed are on hand, correct and functional.

29. continued…. The full surgical team conducts and documents a time-out procedure just before starting a surgical procedure . Policies and procedures are developed that support uniform process to ensure the correct site, correct procedure, and correct patient, including medical and dental procedures done in settings other than the operating theatre.

30. Goal 5: Reduce the risk of health care-associated infections FACT SHEET WHO - Health care-associated infections At any given time, the prevalence of health care-associated infection in developed countries varies between 3.5% and 12%. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection . At any given time, the prevalence of health care-associated infection varies between 5.7% and 19.1% in low- and middle-income countries.

31. HAIs SSI - Surgical Site Infection VAP - Ventilator Associated Pneumonia CAUTI - Catheter Associated Urinary Tract Infection CLABSI - Central Line Associated Blood Stream Infection

32. HAIs - Surgical Site Infection (SSI) A recent prevalence study found that SSIs were the most common healthcare-associated infection, accounting for 31% of all HAIs among hospitalized patients . The CDC healthcare-associated infection (HAI) prevalence survey found that there were an estimated 157,500 surgical site infections associated with inpatient surgeries in 2011 . NHSN data included 16,147 SSIs following 849,659 operative procedures in all groups reported, for an overall SSI rate of 1.9% between 2006-2008.

33. Ventilator Associated Pneumonia -VAP Research has shown that up to 15 percent of patients who get it may die from VAP ( Agency for Healthcare Research and Quality , CDC). The study, published in the  Journal of the American Medical Association , found that about 10 percent of critically ill patients placed on a ventilator develop ventilator-associated pneumonia (VAP). The finding is based on reviews of charts from hospitals across the country from 2005-2013.

34. VAP VAP rates  range from 1.2 to 8.5 per 1,000 ventilator days - Ventilator-associated pneumonia in the ICU - NCBI – NIH ( 2014)

35. Catheter Associated Urinary Tract Infection (CAUTI) UTIs additionally account for more than 12% of infections reported by acute care hospitals . Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract. Approximately 12%-16% of adult hospital inpatients will have an indwelling urinary catheter at some time during their hospitalization . Each day the indwelling urinary catheter remains, a patient has a 3%-7% increased risk of acquiring a catheter-associated urinary tract infection (CAUTI ) - CDC 2017 .

36. CAUTI Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay and increased cost and mortality . It has been estimated that each year, more than 13,000 deaths are associated with UTIs in USA alone.

37. Central Line Associated Blood Stream Infection (CLABSI) CLABSIs are serious infections typically causing a prolongation of hospital stay and increased cost and risk of mortality The pooled HAIs data from the ICUs of the 4 participating hospitals (NABH Accredited, India)during the 2-year period were: 57,807 ventilator days, 155,614 central line days and 376,585 urinary catheter days. Pooled mean HAI rates were highest for VAP; (6.74/1000 ventilator days ), the next was CLABSI (2.42/1000 central line days), followed by CAUTI (1.63/1000 urinary catheter days ).

38. continued……. Pooled Indian ICUs data revealed VAP rate of 6.74/1000 ventilator days, in contrast to CDC-NHSN of 1.43 and INICC of 19.5. Pooled Indian CLABSI rate was 2.40/1000 central line days in contrast to CDC-NHSN 1.02 and INICC 6.12, while pooled Indian CAUTI data was significantly better than the benchmark figure of CDC-NHSN at 2.09 and INICC at 6.5  Analysis of a multi-centric pooled healthcare associated infection data from India: New insights. J Nat Accred Board Hosp Healthcare Providers 2014;1:39-43.

39. Recommendations 5 moments of hand hygiene (WHO) Use hand rub (20 – 30 sec) or hand wash (40 – 60 sec) Appropriate PPE to be used Care bundles to prevent HAI (VAP, CAUTI, CLABSI, SSI) Use proven guidelines to prevent infections that are difficult to treat Surveillance and monitoring (key performance indicators and identifying unusual trends for RCA and CAPA)

40. continued……. The organization has adopted or adapted currently published and generally accepted hand-hygiene guidelines. The organization implements an effective hand-hygiene program. Policies and/or procedures are developed that support continued reduction of health care-associated infections.

41. Goal 6: Reduce the risk of patient harm resulting from falls Falls and recurrent falls are the leading cause of injury –related death. 1 of 3 people above 65 years fall every year. 1 of 5 falls causes a serious injury. 10 % of fatal falls for older adult occur in the hospital setting. Fall related hospitalizations in older adults increased 50 %.

42. Facts and figures Injuries are reported to occur in approximately 6 to 44 percent of acute inpatient falls Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient day The sequelae from falls are costly . Fall-related injuries account for up to 15 percent of re-hospitalizations in the first month after discharge from hospital

43. continued……. Fall-related injuries are the most common cause of accidental death in those over the age of 65, resulting in approximately 41 fall-related deaths per 100,000 people per year. In general, injury and mortality rates rise dramatically for both males and females across the races after the age of 85, but males older than 85 are more likely to die from a fall than females.

44. Evidence based A complimentary publication of The Joint Commission Issue 55, September 28, 2015 Preventing falls and fall-related injuries in health care facilities - Every year in the United States, hundreds of thousands of patients fall in hospitals, with 30-50 percent resulting in injury. Injured patients require additional treatment and sometimes prolonged hospital stays. In one study, a fall with injury added 6.3 days to the hospital stay.

45. continued…… The average cost for a fall with injury is about $ 14,000. Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event database, which has 465 reports of falls with injuries since 2009, with the majority of these falls occurring in hospitals . Approximately 63 percent of these falls resulted in death, while the remaining patients sustained injuries.

46. continued…… In addition, ECRI Institute reports a significant number of falls occurring in non-hospital settings such as long-term care facilities.

47. Fall risk management Daily fall risk assessment and re-assessment as and when required Side rails should always be up – always! Safety belt/side rails while transport Identify slip and trip areas and take necessary action

48. Roles and responsibilities Implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition or medications, among others. Measures are implemented to reduce fall risk for those assessed to be at risk. Measures are monitored for results, both successful fall injury reduction and any unintended related consequences.

49. Where are we……..? In some developed countries patients are 40 times more likely to die as a result of being admitted to an acute care hospital than in a traffic accident (IHI). Improved longevity and changing lifestyles are putting pressure on healthcare systems around the world. Hospitals must manage rapidly growing numbers of patients, who increasingly present with complex co-morbidities and chronic conditions . One indicator of these pressures is the high rate of avoidable patient harm in hospitals, which stands at 10% in developed countries and is significantly higher in developing nations.