10. TEAM WORK IN HOSPITALS
When caregivers work together- benefits for the
employees, the patients and the health-care facility
Patients receive thorough care when providers
Providers can concentrate on their areas of
expertise, knowing they are part of a team looking
after the whole patient- shared responsibility
Quality of care improves
Hospitals save money with effective team care
14. PREVENTING ERRORS- IPSG
International Patient Safety Goals (IPSG) help hospitals address
specific areas of concern in some of the most problematic areas of
The goals describe evidence and expert based consensus
solutions to these problems
16. Goal 1: Identify patients correctly
ECRI Institute- PSO reviewed 7,600 wrong-patient events
occurring over 32-months- voluntarily submitted by 181 hospitals.
Deep dive report on patient identification errors (News release -
26/Sep/2016 - Preventable, Potentially Fatal Patient Identification
Errors Analysed )
About 9% of the patient identification events led to temporary or
permanent harm or even death.
17. IDENTIFY PATIENTS
Primary responsibility of healthcare workers- check identity
and match the correct patients with correct care.
Using two identifiers
• UHID No. and Patient full name.
• Additional identifiers- Age of patient and sex
• DO NOT use Room No./Location for identification
Standardize patient identification (ID band colour, Marker)
Incorporate training on identifying patients
Educate and involve the patients on correct identification.
18. When to identify patients
Before any surgery, minor procedure and treatment
Before administering medications, blood or blood
Before taking blood and other specimens for clinical
Before investigations and imaging
19. Goal 2: Improve effective Communication
Communication failures- major factor in 30 % malpractice cases
examined by CRICO Strategies- research and analysis offshoot of
the company that insures Harvard-affiliated hospitals.
Communication failures linked to 1,744 deaths in five years- US
malpractice study- 1.7 billion dollars as malpractice costs- Feb 2016
A large scale European Commission project has found that handover
communication is responsible for 25% to 40% of adverse events
20. Effective communication situations
Can be verbal, electronic or written
Effective communication is timely, accurate, unambiguous,
complete and understood by the recipient
Patient care orders given verbally are most error prone.
Critical test result reporting is found to be another error prone
21. Effective Communication in critical
Verbal and telephone order or test result is written down and
read back by the receiver.
Critical value/reports intimation immediately to the treating
team member and documented. Read back to be followed.
Standardized approach to hand-over communication between
staff, change of shift and between different patient care units in
the course of a patient transfer. Suggested elements of this
Use of the SBAR (Situation, Background, Assessment, and
22. SBAR Tool for Communication
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.
Concise statement of the
What is going
Pertinent and brief
related to the situation
What you want
24. Goal 3: Improve the safety of high-alert
From January 1997 to December 2007, 446 medication-error
sentinel events were reported to TJC’s (the Joint Commission)
sentinel event database.
High-Alert Medications (HAMs) are
Medications involved in a high percentage of errors and/or
Medications that carry a higher risk for adverse outcomes
Look-Alike/Sound-Alike medications (LASA)
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.
26. PREVENTING MEDICATION ERRORS
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
Avoid storing concentrated electrolytes in patient care areas, unless
Concentrated electrolytes that are stored in patient care units are
clearly labelled and stored in manner that restricted access.
Loaded syringes to be labelled before loading the next drug – meet the
labelling requirements including dilution
Medicine reconciliation at all transition points - up-to-date list of
medicines patient currently on
27. 15 hospitalised after wrong drug
injected before sterilization
12 Jan 2017, Kamalapur, Ballari district
15 women admitted for tubectomy, for
Hospitalised after being injected wrong
medicine before the surgery.
Adrenaline administered instead of
Atropine sulfate injection
Women felt giddy, began to vomit and felt
their hearts race and rushed to Taluk
Root Cause: LOOK ALIKE MEDICINES
28. Goal 4: Ensure safe surgery
From 1995 to 2005, the Joint Commission (TJC) sentinel event
statistics database ranked wrong site surgery as the second most
frequently reported event with 455 of 3548 sentinel events (12.8%)
ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT
Surgical site marking with active patient involvement throughout
Time out for all invasive procedures throughout the hospital
Inside OR- follow sign in, time out and sign out using surgical
Pause before the surgery to make sure that a mistake is not being
30. Doctors operate on wrong leg of 24-
• June 22, Fortis
• Fractured right foot due
to fall in the stair case
• Operated on the
healthy left ankle of a
24 year old
• Multiple screws placed
on the left ankle
• Temporary cast placed
on the fractured foot
31. Goal 5: Reduce the risk of health care-associated
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
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
32. Reduce the risk of HAI
SSIs -31% of all HAIs among hospitalized patients (CDC
15% of patients who get it may die from VAP and 10% critically
ill on ventilator develop VAP(Agency for Healthcare Research
and Quality, CDC)
Approximately 12 – 16 % hospitalized adults will have an
indwelling urinary catheter and each day, patient has a 3%-7%
increased risk of acquiring CAUTI
CLABSIs - prolongation of hospital stay and increased cost and
risk of mortality ( 7 – 21 days)
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
Surveillance and monitoring
The organization has adopted or adapted currently published
and generally accepted hand-hygiene guidelines.
The organization implements an effective hand-hygiene
Policies and/or procedures are developed that support
continued reduction of health care-associated infections.
35. Goal 6: Reduce the risk of patient harm
resulting from falls
Falls and recurrent falls are the leading cause of injury –related
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%
Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient
36. 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
37. 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.
38. BUILDING A SAFETY CULTURE
Top management commitment- Conduct Patient Safety Leadership Rounds
Encourage reporting- Create a Reporting System
Create openness- do not blame or shame
Designate a Patient Safety Officer
Active patient safety committee
Appoint safety champions/ advisors in units
Involve Patients in Safety Initiatives
Re-enact Real Adverse Events from Your Hospital
Simulate Possible Adverse Events
Safety training and awareness
Priority to safety and take safety issues seriously
39. The patient……
THE SOLE BREAD WINNER OF THE FAMILY,
HE IS THE FATHER OF A SMALL KID,
SON OF AN OLD FATHER,
HUSBAND OF A YOUNG LADY,
AND IS NOW YOUR RESPONSIBILITY
TO TREAT HIM AND SEND HIM SAFE TO HIS
IMAGINE YOUR OWN THERE
TAKE CARE OF HIM LIKE YOUR BROTHER
By…..Dr. Lallu Joseph
Memorial Sloan-Kettering Cancer Center in Manhattan
May 26, Rajeswari Ayyappan, the 59-year-old mother of the Indian actress Sridevi, underwent surgery for a malignant tumor on the left side of her brain.
The tumor was left intact because her neurosurgeon took another patient's X-rays into the operating room and operated on the wrong side.