IPSG 1 – Identify the patient correctly

1. Two identifiers – Name & UHID No

2. Order of placing the ID band (Adult ) – Right hand – Left hand – Right leg – Left Leg
3. Order of placing the ID band ( Neonates ) - Right ankle – Left ankle
4. Two identifiers for unconscious/comatose patients without any identity – Unknown 1 & ID No, Unknown
2 & ID No
5. Two identifiers for MTP patients - Gynae/serial number in roman letter/ year (For eg.
Gynae I 2019) – It replaces for name of the patient ( First identifier ) and UHID No (Second identifier)
6. For children < 3 years of age - Guardian should have ID band
IPSG 2 – Improve effective communication
[Link] back policy – while receiving critical values and while receiving orders from the doctor while
informing the sugar value
Write – Read it back – Confirm – put tick as read it back
[Link] hand off – In between shifts, In house transfer (shifting from one unit to another), Transferring
for any diagnostic purpose, Shifting to OT/ shifting from OT, If assigned Nurse is leaving the unit for any
reason – Explain where it is to be documented. 1
IPSG 3 – Improve the safety of high alert medications - 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 and Injections, Inj. Pethidine, Morphine injections and Tablets,
Pentazocine injection
• Concentrated electrolytes – I.V. Potassium Chloride 2mEq/ml or more concentrated, I.V. Potassium
Phosphate, I.V. Sodium Chloride( more than 0.9%), I.V. Magnesium Sulphate(50% or more
concentrated)
• 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
UPDATED LIST OF HIGH ALERT MEDICATIONS

3
 IPSG-3 SAFETYMEASURES WHILE USING HIGH ALERT MED

 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

4
IPSG -4 – Ensure correct site, correct patient, correct procedure/surgery
 TIME OUT
 [Link] to the start of any invasive procedure, conduct a final verification process “ time out” to confirm the
correct patient, procedure and site using active communication techniques.
 2. Sugical and invasive procedure site marking is required for the following
 n all cases involving laterality
 multiple structures (fingers, toes, lesions)
 multiple levels (spine)
 For dental procedures, site marking must be done on the radiograph.
 3. Surgical/procedure site marking shall be done by the Surgeon performing the procedure and shall involve
the patient to indicate the site.
 4. Only an arrow mark shall be used, using a skin marking pen for site marking.
 5. Incase the patient is on ventilator or otherwise cannot be involved in the site marking process, the
responsible surgeon or his designee shall conduct the site marking in the presence of another doctor.
 6. Nurse should mention the correct site on pre-operative check list in case of OT procedures.
5
 IPSG -4 – Ensure correct site, correct patient, correct
procedure/surgery
 Time out is not applicable for following procedures
 Nasogastric tube insertion
 Intravenous cannulation / IV or IM injection
 Urinary catheter insertion
 Emergency intubation
 SIGN IN
 Sign in shall be performed before induction of anesthesia by anesthetist to verify correct patient, as per safe surgery checklist
 TIME OUT
 The surgeon shall call a time out in OT. Outside the OT person performing the procedure/ providing sedation shall call for time out just before
the procedure.
 Nurse, Surgeon, and Anesthetist shall verify the correct patient by using 2 identifier, correct procedure, correct side and site, consent for the
procedure, agreement to procedure, availability of all documents, equipment’s, implants and investigations or images.
 Surgeon shall call out the surgery or procedure to be done and the site, it shall be confirmed with site marking and consent.
 If any verification process fails to identify the correct site, all activities shall be halted until verification is accurate. Document the same.
 Same time out procedure is applicable incase where two or three surgical sites are being operated sequentially in one setting, when a member
of the surgical team responsible for the second/ third surgical site attends the initial time out. If not present during initial time out, a separate
time out needs to be done for the second and third surgery.
 SIGN OUT
 Done by the Nurses before patient leaves the area in which the surgical or invasive procedure was performed. It includes name of the
surgery/invasive procedures, completion of instrument, sponges and needle counts, labelling the specimens(if present),any equipment
problems to be addressed ( if applicable
 IPSG -5- Reducing risk of health care associated infections
 Types of Hand hygiene – antiseptic hand wash, antiseptic hand rub, surgical hand antisepsis
 Hand washing – washing hand with soap and water
 Visibly soiled hands – Hands showing visible dirt or visibly contaminated with blood or other body fluids.
 Indications for Hand hygiene during Healthcare delivery
 Before touching patient
 Before clean aseptic procedure
 After touching patient
 After body fluid exposure risk
 After touching patient surrounding.


 Steps of hand hygiene – For both soap and water and alcohol gel
 Technique – Take liquid soap or alcohol hand rub or gel onto hands
 Rub palm to palm
 Rub right palm over left dorsum followed by left palm over right dorsum (back to back)

IPSG -5- Reducing risk of health care associated infections

 Rub palm to palm and interlock fingers.(between fingers)

 Rub back of fingers to opposing palm with fingers interlocked concentrating on finger tips.
 Rotational rubbing of right thumb and right wrist clasped in left palm and vice versa (thumb and
wrist)
 Rotational rubbing with clasped fingers of right hand in left palm and vice versa( nails in the palm of
hand)
 If washing hands with soap and water – Dry hands with good quality disposable towel
 Duration of medical hand washing – 20 seconds
 Duration of Alcohol rub – Till hands are dry
 Measuring compliance for hand hygiene
 Compliance on hand hygiene is monitored by direct observation and by other methodologies like
ATP based checks.
 Compliance rates are discussed in the infection control committee meetings as well as the strategies
undertaken to ensure compliance on hand hygiene.
 Goal 6:Reduce the Risk of Patient Harm resulting from fall

 "Assess and periodically reassess each patient's risk for falling, including the potential risk associated with
the patient's medication regimen, and take action to decrease or eliminate any identified risks.”
 We use the AFRAT (Apollo Fall Risk Assessment Tool) score in both inpatients and ambulatory care
settings(separate tools have been identified and used) and Safety First Policy to meet the standards
 Monitor intended and unintended consequences of measures taken to reduce falls
 Exceptions: ICUs, HDU, Emergency, Pediatric and Neonatology units
 IPSG-6 (VULNERABLE PATIENT’S CRITERIA)

VULNERABLE PATIENTS
➢ Child and adolescents (below 15 years)
➢ Elderly (above 65 years)
➢ Physically/Mentally challenged
➢ Terminally ill
➢ Women in labor or experiencing termination of pregnancy
➢ Patients with emotional or psychiatric disorders
➢ Any patient Who cannot perform ADLs
➢ Patients with intense or chronic pain
➢ Patients suspected of drug and / or alcohol dependency
➢ Victims of abuse and neglect
➢ Patients with infectious or communicable diseases
➢ Patients receiving chemo or radiation therapy
➢ Immunocompromised patients
 IPSG-6 (AFRAT Reassessment)

PROCESS
➢All patients are assessed for fall within 24hours of admission except ICUs, HDUs, Emergency, Pediatrics and
Neonatology (Vulnerable zones)
➢If AFRAT Score ≥45, reassessment & documentation is done every 48 hours
➢If AFRAT Score <45, reassess & document every 7th day.
➢AFRAT reassessment is also done whenever patient’s condition changes. Such patients shall be reassessed as
soon as possible and then after 48 hours after which the regular pattern of AFRAT scoring shall be followed
➢ CRITERIA FOR REASSESSMENT
➢There is a change of disposition in the clinical condition of the patient ([Link] 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 ([Link],cane,walkers)
➢Patient is disoriented- with impaired cognition, altered sensorium
 IPSG-6(awareness on fall risk medications)

Patient is on anesthetics agents and or sedative medications

➢Amitryptaline
➢Prochlorparazene
➢Nitrazipam
➢Levodopa
➢Digoxin
➢Chlorpheneramine
➢Morphine
➢Pheneytoin
➢Proponolol
➢Oxybutynine
➢Hydrochlorthyzide
➢Diuretics
➢Laxatives
 Plan of care for falls prevention

PLAN OF CARE
➢ ‘Safety First’ Program
➢ Safety-first sticker is pasted at the head end of the patient (as applicable)
➢ Frequent assessments and documentation in care plan
➢ Violet colored ID Bands to identify the patients except for Pediatric and Neonates
➢ Side rails are kept raised
➢ Safety brochure is given to the patient
➢ Call bells are kept within reach of the patient
➢ Rooms are kept well lightened
➢ Patient are not left unattended
➢ Bed is kept locked
➢ Patient and family education on Fall prevention
➢ Safety rounds
➢ Safety belts are used while transporting patient
➢ Inter disciplinary team rounds
➢ Any untoward incident are reported immediately