1. KPJ HEALTHCARE BERHAD
INTERNATIONAL PATIENT SAFETY GOAL (IPSG) 1
IDENTIFY PATIENT CORRECTLY
Upon admission :
Print patient’s sticker for inpatient use, fasten
the ID band with patients information prior to
sending patient to the ward.
2. 1) Full Name
&
Blue –
Boy
IPSG 1 : Identifying Patient correctly
2 Identifiers ID Band
2) MRN/IC/Passport No. Pink – Girl
White –
Adult
3. IPSG 2 : Effective Communication
1)Verbal orders – listen, document & Read out
loud,
2) Timely reporting
3) Abbreviation that cannot be used.
4)
Situation,
Background.
Assessment &
Recommendation
Improve Effective Communication Among Caregivers
No Change Except Emphasis On Verbal order to be
evidence based - documentation
4. Goal 3: Improve the Safety of Using
Medications
Incorporated
Goal 4: Accurately and Completely Reconcile Medications
Across the Continuum of Care - adopted as continuous
improvement activities ie part of procedures but not as Patient
Safety Goal Initiative.
5. DEFINITION
1) Identification & handling of LASA
drugs
Risk of potentially harmful
medication errors may be
increased with LASA
drugs due to
i) misinterpretation of a written order
ii) misunderstanding of a verbal order
iii) inappropriate dispensing of LASA
drugs, especially when medication
or solutions are transferred to other
containers and labels are
incorrect/absent
are drugs which have the potential
for mix-up/confusion due to:
►look-alike packaging
► look-alike appearance
► sound-alike names (generic or
brand)
► prescribers’ ambiguous handwriting
LASA = Look-Alike, Sound-Alike
6. Incorporated :
Improve The Safety Of Using Medications;
Management Of High Alert Drug (And Concentrated
Electrolytes).
Management Of Anticoagulant
“All patients on anticoagulant therapy will have
continuous International Normalized Ratio (INR)
monitoring, with
documentation in the medical record”.
7. 2) Management Of High Alert Drug
Definition: medications that have an increased risk of
causing significant harm to a patient when used in error.
Hospital to establish a list of High Alert Medications
(approved by the Pharmacy and Therapeutic Committee
8. Medications are not kept as floor stock and must be
indent from the Pharmacy using a
“High Alert Medication - HAM Box”.
Additional label to be attached i.e. “High
Alert medication” to the medication.
In the ward, the medication must be stored in the
HAM storage box accordingly and all medication has
‘High Alert Item’ sticker.
10. 3)
Reconciliation
The Doctor ordering the medication reviews the list
of medications the patient has been taking - to
continue or discontinue each medication.
Reconciliation of medications will
include:
- Any omissions
- Any duplications
- Interactions
- Dosing errors
- Name/dose/route confusion
13. PLEASE DO NOT DISTURB
NURSE ON
MEDICATION ROUND
Remember we cannot change the workload,
but we can change the way we address it”
through measures like the apron;
Recommendation:
Apron – RED
For children printed ones
Words – as stated
both sides front (english)&
back ( bahasa)
a. Newly graduates are given the drug
calculation test and are mentored
throughout the 6 months period and
based on their competency allowed
to do medication independently.
b. if one staff is dedicated to the
medication round, then the rest of
the team need to support them and
be around to address other
patient needs
14. IPSG 4 :
Ensure Correct Site
Correct Procedure
Correct Patient Surgery
15. IPSG 4 : Ensure Correct Site Correct
Procedure Correct Patient Surgery
1. PatientID
2. Consent
3. Site
Marking
4. Imaging
Film
5. Time out
16. IPSG No 4 : Ensure Correct Site,
Correct Procedure Correct
Patient Surgery
Revisit Site Marking:
1. Policy has been reviewed emphasizing only 2 symbols allowed to
prevent ambiguity.
2. ONLY 2 Symbol of site marking - ‘circle’ and arrow.
3. For single eye surgery the arrow pointing as closed as to the incision
site shall be marked at the temple or between lateral canthus and the
ear.
4. Emphasized on use of “green band” for patients refusing site marking
- nature of procedure including side & site indicated on the wristband.
17. Revisit Site Marking:
5. Nose , throat surgeries & endoscope , skin prep done –
no site marking required.
6. Neonates or premature infants or patient where it is
anatomically and technically difficult to mark the
operative site includes areas such as perineum, is be
exempted from site marking.
IPSG No 4 : Ensure Correct Site
Correct Procedure Correct
Patient Surgery
18. IPSG 5 :Improved Hand Hygiene to
Prevent Associated Infection
Hand hygiene – hand rub
& hand wash.
5 Moments – hand
hygiene
19.
20. IPSG 6 : Reduce the Risk of Patient Harm
Resulting from Falls
Outpatient – brochures on fall prevention, yellow
label/sticker at A&E & other fall
prevention strategies.
Inpatients - Morse Fall Score, falling
Star & Orange ID band.
21. Pt safety Guideline
Content
Fall risk assessment for inpatients
-Adult –Morse Fall Scale
-Pediatric –Humpty Dumpty Scale
Pt classified as “High Risk” for fall –
LR,Nursery,HDU,ICU/CICU,OT,Cath-Lab and pt’s under
going SPD procedures.
NCP (Adult and Pediatric)
22. IPSG 5 :Improved Hand
Hygiene to Prevent
Associated Infection
Hand hygiene – hand rub &
hand wash.
5 Moments
IPSG 3 : 1)Improve the safety of Using
Medications
2) Management of High Alert Medication
1. LASA
IPSG 6 : Reduce the
Risk of Patient
Harm
Resulting
from Falls
Outpatient –
brochures on fall
prevention,
yellow
label/sticker at
A&E & other fall
prevention
strategies.
Inpatients –
MFS falling
Star & Orange
IPSG 1 : Identifying Patientcorrectly IPSG 2 : Effective Communication
Verbal orders – document & Read out loud,
Timely
reporting Abbreviation that
cannot be used.
Situation,
Background.
Assessment &
Recommendation
2 Identifier
Full Name &
MRN/IC/Passport
No.
ID Band
Blue – Boy
Pink – Girl
White -
Adult
IPSG 4 : Ensure Correct Site Correct
Procedure Correct Patient Surgery
Pt ID
Consent
Site Marking
Imaging Film
Time out
SUMMARY OF IPSG’S
Patient
Safety
Goals
