IPSG training Program

Introduction

•The International Patient Safety Goals

(IPSG) chapter focuses on promoting specific
improvements in patient safety within
healthcare organizations accredited by Joint
Commission International (JCI). By
addressing problematic areas and offering
evidence-based solutions, the IPSG aim to
enhance the delivery of safe, high-quality
healthcare. With an emphasis on systemwide
solutions, these goals play a crucial role in
driving global improvements in patient safety.
Program Overview

The Training Program associated

with the International Patient
Safety Goals (IPSG) aims to equip
healthcare professionals with the
knowledge and skills necessary to
effectively implement and comply
with the goals. This comprehensive
training program covers the
identified problematic areas in
healthcare and provides evidence-
and expert-based solutions.
Target Audience

 Physicians
 Nurses
 Pharmacist
 Quality team
 IPSG.1 Patient identification

Patient identification is a critical aspect of healthcare to ensure safe and accurate

care delivery. The International Patient Safety Goals (IPSG) emphasize the
importance of correctly identifying patients to prevent errors.

This involves using at least two unique identifiers, such as the patient's full name
and medical record number
number, andand implementing
implementing identification
identification bands.
bands.

Proper patient identification procedures help healthcare providers match services

and treatments to the correct individuals, enhancing patient safety and quality of
care by Appling the policy.
 IPSG.1 Patient identification

1. Using two patient identifiers which consists of patient name and medical record number in
all hospital.
2. The patient have wrist band all over his journey across all hospital departments contain
above two pt identifiers.
3. Using code(unknow 1.2.3, etc. ) and MRN for unknow patients.
4. if identification band is unable to be applied on patient’s wrist, so apply it on ankle.
5. Patient Identifications must be done in ( for example):
a. Before providing Treatments
b. Before performing Procedures
6. All health care providers shall identify patient by:
c. Asking him to tell his name
d. Verifying his stated name with the name on ID
7. Removal of ID bands:
e. With discharge from hospital
 IPSG.2 Improve Effective Communication

1. Improving effective communication is crucial in healthcare settings to enhance

patient safety and quality of care. Clear and accurate communication between
healthcare providers, patients, and their families is essential for conveying
information, understanding medical conditions, and making informed decisions.
2. By utilizing standardized communication tools, such as SBAR (Situation,
Background, Assessment, Recommendation), healthcare professionals can
effectively communicate critical information, leading to improved coordination,
timely interventions, and reduced errors.
3. Promoting active listening, empathy, and using plain language can further
enhance communication, fostering a therapeutic environment and better patient
outcomes.
 IPSG.2 effectiveness of
verbal and/or
telephone communication
1. Telephone orders:
a. Shall be accepted only in situation where the
doctor is not immediately available.
b. Are not accepted for:
I. Starting Narcotic or Scheduled Medications.
II. High-alert medications including look alike
sound alike.
III. Initiating TPN Therapy.
IV. Withdrawal of Life Support.
V. Chemotherapy Ordering.
VI.Blood transfusion.

c. The complete telephone order is documented and

read back by the receiver and confirmed by the
individual giving the order.
 IPSG.2 Improve Effective Communication
1. Verbal orders:
a. Are accepted only during situations of difficult or
impossible for hard-copy or electronic order
transmission, such as during resuscitation of
cardiac arrested patients, and during sterile
procedures.
b. In emergency situations, when the slight delay
associated with conducting the read-back
procedure might adversely impact the safe care
of the patient, e.g., during resuscitation of cardiac
arrested patients, a “Repeat Back" of the order
should still be done, then documentation of all
what happened occurs in the “Code Blue” form.

2. During verbal/ telephone orders, correct identification

of patients should be followed
 IPSG.2.1 Reporting critical results
1. Process of Reporting of Lab critical results:
1. Once the critical result is confirmed Laboratory doctor
/technician shall:
1. Track the patient on the hospital information system
by location to identify the patient position
2. Contact the nurse in ward to repot a critical result.
3. The nurse shall contact the patient's physician to tell
him/her the critical result within 10 min.
If patient physician is not available connect to ER
physician if cannot reach connect to ICU physician.
2. In case of radiology critical result, the radiology physician
contact patient physician.
 IPSG.2.1 Reporting
critical results
1. Documentation of critical results:
1. WRITE DOWN
2. READ BACK
3. CONFIRM.
1. For point of care testing:
1. Once the critical result is confirmed, the
nurse shall tell the result to Patient's
Physician at once.
2. Documentation: in patient medical record
will be in nursing notes and physician
progress notes.
IPSG.2.2 handover communication.
Handover between Health Care Providers such
as between physicians or between nursing
during shift changes :
1. Physician Handover between ingoing and
outgoing physician using (ISOBAR)
2. Nursing Handover between shifts using
(ISBAR)
3. Nursing Handover between different level of
care using (Individual endorsement)
All hand over document will be signed by
outgoing and ingoing staff.
All hand over document will keep in patient
medical record.
IPSG.3/3.1/3.2 improve the Safety of
High-Alert Medications.
1. This goal aims to identify medications that
have a higher risk of causing harm to patients
if used incorrectly.
2. By identifying these high-risk medications,
healthcare providers can implement specific
strategies to ensure their safe handling and
administration, thus preventing errors that
may lead to patient harm.
3. This goal emphasizes the importance of
comprehensive medication management
practices and promotes the use of evidence-
based guidelines to minimize risks associated
with high-risk medications.
 IPSG.3/3.1/3.2 improve the Safety of High-
Alert Medications.
1. The clinical pharmacy department identifies a list of all high-alert medications
which includes:
a. Concentrated electrolytes
b. Look-alike medications
c. Sound-alike medications
d. Other high-alert medications

2. High alert medications and concentrated electrolytes are stored, prescribed,

dispensed and administered in a way that reduces the likelihood of inadvertent
administration or ideally provides directions on the proper use of the medication.
 IPSG.3/3.1/3.2 improve the Safety of High-
Alert Medications.

3. Dilution and preparation of high alert medication and concentrated electrolyte

should follow the hospital IV chart manual.
4. Whenever possible, it is preferred that concentrated electrolyte solutions will be
purchased by the pharmacy department only in standardized and limited drug
concentrations.
5. For narcotics refer to Narcotic Policy.
 IPSG.4 Ensure Safe Surgery.

1. Patient safety is a top priority in healthcare, and preventing wrong-site, wrong-

procedure, and wrong-patient surgeries is crucial.
2. Effective communication, proper site marking, and a time-out process are
essential for achieving this goal. The preoperative verification process ensures
accurate patient, procedure, and site identification, as well as the availability of
necessary documents and equipment.
3. Site marking involves clear and consistent markings performed by the
responsible surgeon or physician. The time-out involves a team discussion to
confirm patient identity, procedure, and site. A sign-out process is conducted
before the patient leaves the procedure area, confirming important details and
addressing any issues.
4. These protocols contribute to safe surgical practices and patient well-being.
 IPSG.4/4.1 Ensure Safe Surgery.

The hospital develops and implements a process for ensuring correct-site, correct-
procedure, and correct-patient surgery by:
Marking the surgical site:
• Surgical site is marked in all cases (using arrow sign)
• site marking is done by the person performing the procedure
• involve the patient in the marking process.
Preoperative verification process:
• Verify the correct site, procedure, and patient
• Ensure that all relevant documents, images, and studies are available
• Ensure that informed consent is appropriate to the procedure
• Verify that any required special medical technology and/or implants are present on hand,
correct, and functional.
 IPSG.4/4.1 Ensure Safe Surgery.

time-out process:
• Done before starting a surgical/invasive procedure by full surgical team.
• correct patient identification, correct side and site
• Hospital identifies all areas where surgical and invasive procedures take place.
Sign-out process :
• Done before closure the membrane
• Name of the surgical/invasive procedure that was recorded/written.
• Completion of instrument, sponge, and needle counts.
• Labeling of specimens.
• Any equipment problems to be addressed.
IPSG.5/5.1 Reduce the Risk of
Patient Harm Resulting from Falls

Outpatient department:
Hospital implements a process for the initial and
ongoing assessment, reassessment, and
intervention of outpatients identified as at risk for
falls based form for outpatient department :
• Assess all outpatient for risk for fall
• Reassess if :
a. If any change in condition that may alter
the patient’s Consciousness.
b. If the patient receives any medication
affecting his/ her consciousness.
c. Post Procedural
 IPSG.5/5.1 Reduce the Risk of
Patient Harm Resulting from Falls

In patient departments:
Hospital implements a process for the initial and ongoing
assessment, reassessment, and intervention of inpatients
identified as at risk for falls based form for outpatient
department :
• All inpatients will be assessed for the risk of fall on
admission.
• Inpatients will be reassessed for the risk of fall:
a. If any change in condition that may alter patient
consciousness.
b. If patient receive any medication affecting
consciousness.
c. After surgery and/or anesthesia.
d. Transfer between different units.
e. Change in patient ambulation.
All patient that confirmed high risk for fall will be signed with
(F) sign throughout his stay in the hospital