IPSG.ppt

International Patient Safety Goals

1. Ms.Nikethana R Nair, M.Sc (OBG), MBA (HA), M.Ṣc (Psy)M.Phil (HHSM),
Nursing Superintendent,
Meenakshi Mission Hospital & Research Center -Madurai

3. Goal 1
Identify the Patient Correctly

6. Goal 2
Improve Effective Communication

10. Other Documents....
•Adverse event data are tracked and used to
identify improvements for hand over
communications.
•Handover between patients and families

11. Goal 3
Improve
the Safety of
High-Alert Medication

12. High alert medications are those medications involved in a high percentage of
errors/sentinel events, medications that carry a higher risk for adverse outcomes
as well as look-alike / sound alike medications.
•Chemotherapeutics
•All Narcotic Drugs–Fentanyl patches & Injections, Inj. Pethidine, Morphine
injections & Tablets, Pentazocine injection
•Concentrated electrolytes–I.V. KCL 2mEq/ml or more concentrated, I.V. Potassium
Phosphate, I.V. Nacl (more than 0.9%), I.V. Mg Sulphate (50% or more concentrated)
•Mg sulfate is stored in 3 to 10 ampules for managing pre eclampsia
•Look Alike/ Sound Alike drugs–Staff should know all drugs in LASA
•Narrow Therapeutic Index drugs –I.V. Phenytoin, I.V. Aminophylline, Inj.
Tacrolimus, Inj. Digoxin, Tab. Lithium carbonate
•Anticoagulants–I.V. Heparin, Tab. Acenocoumarol (Acitrom), Tab. Warfarin
•Insulins
•Antipsychotics–Inj. Haloperidol
•Anesthetic–Inj. Ketamine Hydrochloride (All CCU) kept under double lock

13. Cont....
•High alert sticker for all high alert medications
•Double lock for Narcotics and high concentrated electrolytes
•Key custodian
•Tall Man lettering for LASA labels
•Store LASA drugs in separate racks -Segregation
•Color coding for insulin storage
•Concentrated electrolytes are stored only in the specific areas
•Independent Double check and double sign
•Replace the empty ampoules of narcotics
•Wastage of narcotics should be discarded in the presence of doctor
and obtain doctor’s signature
•HAM monitoring
•Adverse events to be reported

15. Goal 4
Eliminate Wrong site,
Wrong patient,
Wrong procedure/Surgery

19. Goal 5
Reduce the risk of Healthcare
Acquired
Infections

21. Goal 6
Reduce the Risk Of Patient Harm
Resulting from Falls

22. CARE OF PATIENT
Patient safetyis a new
healthcare discipline that
emphasizes the reporting,
analysis, and prevention of
medical error that often lead to
adverse healthcare events.

23. Who & When
Forsafetyofthepatientvulnerability
assessmentshouldbedoneforallthe
patientsatthetimeofadmission

24. When to be Used.....
•If the AFRATscore is more than or
equal to 45 then the Reassessment is
done every 48 hrs
•If it is less than 45 then re-
assessment is done every 7
th
day
•It is done except for HDU and ICU
patients because they are already
considered to be vulnerable
•It is done at the time of admission
for all the patients
•Fall Risk reassessment is done
when the patient condition changes
eg.when the patient shifted from
ICU to ward, after surgery when
the patient shifted to ICU or ward
•Moarse Fall Risk Assessment &
safety first policy is used to meet
the standards

26. CRITERIA FOR REASSESSMENT
There is a change of disposition in the clinical condition of the
patient (eg.post code orange ,code blue)
When the patient undergoes a surgery for any reason
Patients is placed on restraint
Patient ,during his course of stay in the hospital has /develops
hearing/vision impairment even with the use of aids
Patient uses assistive devices to aid in mobility
(eg.crutches,cane,walkers)
Patient is disoriented-with impaired cognition, altered sensorium

27. SAFETY MEASURES
•Patient should not be left unattended
•Any untoward incident to be reported immediately
•To use Safety belts while transporting patient
•Bed to be locked always
•Vitals have to be recorded
•Safety brochure and fall prevention education to be given.
•In case of falls, incident reports have to be documented.
•Record the above in PFE form.
•IDTR should be filled after 72 hours of admission

28. Cont....•Safetyfirststickerisplacedattheheadendofthepatient
•Siderailsshouldbealwaysup&wheelsshouldbelockedwhenthepatientisin
thebed
•Patientshouldnotbeleftunattended
•Avoidslipperyfloors
•Accompanythepatienttothewashroom
•Safetybeltshouldbeonwhenthepatientistransportedinthewheelchairor
stretcher
•Callbellshouldbeatthereachofpatient
•AnyuntowardincidentshouldbereportedimmediatelyinAIRS
•Allvulnerablepatient’seliminationneedsaretobemetatthebedside.A
bedsidecommodeorbedpanshouldbeprovided