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.
The 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
Label medicines that are not labelled – loaded syringes to be
labelled before loading the next drug – meet the labelling
requirements including dilution
Extra 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: Reducetheriskof healthcare-associatedinfections
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. CatheterAssociatedUrinary TractInfection(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. CentralLine AssociatedBlood StreamInfection(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.