INTERNATIONAL

PATIENT SAFETY
GOALS
OBJECTIVES:
At the end of the lecture the staff
nurse will be able to:
1. Identify and understand the
components of 6 International
Patient Safety Goals.
2. Strictly adhere to hospital
policy and procedure.
3. Implement measures to
maintain patient and staff
safety at all times.
OUTLINE:

-IPSG 1 Identify Patients Correctly

-IPSG 2 Improve effective communication
-IPSG 3 Improve the safety of High Alert Medications
-IPSG 4 Ensure Correct site, correct procedure, correct
patient surgery
-IPSG 5 Reduce the Risk of Health-Care Associated Infections
-IPSG 6 Reduce the Risk of Patient Harm Resulting from Falls
-Recommendations
-Reference
 1
Identify
Patients
6 Correctly
Reduce the
•Patients first 3
names
2
Risk of •Medical Record Improve
Patient Harm Number Effective
Resulting Communicati
from Falls on
• High Risk
Internation •Telephone
• Low/Moderate risk al Patient Order
•Verbal Order
5 Safety 3
Reduce the Goals Improve the
Risk of
Safety of
Health-Care 4
High Alert
Associated Ensure
Medications
Infections Correct-Site, •Proper Storage
• 5 Moments of Correct – •Proper Labeling
Hand Hygiene
Procedure, •Restrict Access
Correct
Patient-
Surgery
• Pre-op Checklist
IPSG 1:

IDENTIFY PATIENTS
CORRECTLY
What are the patient
identifiers ?
1. Patient’s first three names
2. Medical Record Number
3. Date of Birth

The ID band must include the following:

• Patient’s first 3 names (given name, father
name, grandfather name)

• Medical Record Number

• Date of birth in (Hijri date)

In the rare event of the patient being unknown, the
identification band should state:
- Emergency number (emergency1, emergency 2)
- Medical Record number
- Gender
- Approximate Age
- Ward or Location

As more information becomes available the ID band must

be updated. All information should be written in blue or
black pen and checked with the patient prior to
application of the identification band.

No procedure shall be conducted when the patient’s identity

cannot be verified because the ID band is illegible or missing.
Patient identification must be confirmed prior to conducting any
health care procedures.
IPSG 2:

IMPROVE EFFECTIVE
COMMUNICATION
Verbal Order
• Ordering physician gives her/his complete
medication order.
• The health care professional repeats back
the complete order.
• Ordering physician confirms the order.
• The complete verbal order must be
documented immediately on the doctor’s
order sheet by the nurse or recorder and
must be signed by the ordering physician
immediately after emergency situation is
resolved.
Telephone order are made by a physician
who is physically unable to be present to write
the order that requires immediate intervention.
The complete telephone order will only be
accepted in the following manner:
• an order given by a physician by telephone to
a receiver.
• the receiver who received the telephone order
writes the complete order in the physician
order sheet.
• the receiver reads back the physician
complete order.
• the physician confirms the order to the nurse.
• the receiver must document and sign the
telephone order (T.O.) in the following
 01/12/2018 at 2000H: T.O. by Dr. Ibrahim Bargash
Inj. Diclofenac Sodium 50 mg intramuscular once
daily

Ahlam Tayran/Dr. Ibrahim Bargash

•The receiver signs on the Doctor’s order

sheet.
•The telephone order must be countersigned
by the ordering physician at the earlier
possible time but not later than 24 hours.
Panic Result/ Critical Value Reporting
• Once critical value is confirmed, the
laboratory/ radiology technician, the result will
be communicated to the ordering physician/
designee or nurse immediately.
• The laboratory/ radiology technician identifies
himself/herself and verifies the patient
identification to the receiver.
• The receiver identifies herself/ himself to the
laboratory/ radiology technician. He/she will
document the panic result in the medical
record. The documentation should include the
date and time, name of the conveyor,
test/procedure, critical result.
• The patient identification, test/procedure,
critical value should be read back to the
IPSG 3:

IMPROVE SAFETY
OF HIGH ALERT
MEDICATIONS
High alert medications are those
medications involved in a high
percentage of errors and /or sentinel
events.
Look-Alike and Sound Alike
medications are medication names that
look similar or sound similar.
All HIGH ALERT medications must be
individually labeled with red warning
sticker “HIGH ALERT” and separated
from each other.
LOOK-ALIKE
 PRESCRIBING:
 Generic name instead of brand name is
mandatory.

 Telephone orders are not allowed.

 Verbal orders should only be allowed during

emergency situations.
IPSG 4:

ENSURE CORRECT
SITE, CORRECT-
PROCEDURE,
CORRECT-PATIENT
SURGERY
PRE PROCEDURE/PRE OPERATIVE VERIFICATION
-pre operative checklist must be filled up.
-SBAR form must be filled up.
-surgical consent properly filled up by surgeon.
-surgical site by surgeon

• The site mark is completed before

the patient enters the procedure or
operating room. A site mark will be
“SS” and must be visible.
SBAR
FORM
 Pre-
operative
Checklist
The pt enters the procedure room and the
nurse/radiographer/healthcare professional
will confirm: Identity of the patient,
procedure & site.
The physician performing the
procedure/surgery is responsible for reading
& interpreting the radiographic films to be
used during the procedure & confirming that
the films have been placed correctly for the
correct patient.
A verbal “time-out” or pause must be done in
the location where the procedure is to be
performed, immediately before the start of
the case by the entire procedure/surgical
team. Even when there is only one person
doing the procedure and site is appropriate.
It is not necessary to engage others in the
verification process if the would not
otherwise be involved in the procedure.
Site marking must be visible at the “time out”
or pause.
Time out requires the ff:
Correct patient
Correct side/site
Correct procedure
Correct patient position
Correct radiographs
Correct implants
Correct equipment
“Time out” will be documented in the
medical record. The documentation should
include:
Personnel present at the time out.
Verification of correct patient.
Verification of the correct side and
site.
Agreement on the procedure.
Verification of the correct position and
Available implants & equipment
IPSG 5:

REDUCE THE RISK

OF HEALTH CARE
ASSOCIATED
INFECTIONS
Routine Hand Washing- wash hands with soap
and water when visibly dirty or soiled with
blood or other body fluids, or after using the
toilet.

Alcohol-based hand rub- as the preferred

means for routine hand antiseptic in all other
clinical situation it applies, if hands are not
visibly soiled.
5 MOMENTS
OF HYGIENE
Hand wash for 40-60 seconds

Hand rub for 20-30 seconds

Remove excess jewelry before

doing hand washing
IPSG 6:

REDUCE THE RISK

OF PATIENT HARM
RESULTING FROM
FALLS
FALL- is defined as a sudden
unintentional event resulting in
person coming to rest on
floor/ground or lower level.
FALL ASSESSMENT
TOOLS
-MORSE FALL
-HUMPTY DUMPTY
-TIMED GET UP & GO
TEST
INITIAL ASSESSMENT:

Patients are assessed at the time of admission.

REASSESSMENT:

•Every 24 hours for Low and Moderate Risk

•Every shift if HIGH RISK
•Any Change in Patient Condition
•After surgical or procedural interventions
•Following a fall
In the event of fall:
1. Assess for injury and notify the physician.
2. Determine need for spinal immobilization before
moving the patient.
3. Ask patient if they have sensory loss on their
hands and feet, difficult to move fingers and toes.
If there is no risk of spinal injury, return patient to
bed.
4. Determine level of injury. Mild, moderate or
severe injuries. 5. Document in the form:
-Use the fall risk assessment tool to assess
-Initiate OVR and Fall Notification Form and
forward it to Nursing Supervisor, then to Patient
Safety Department for monitoring.
Notification
of Patient
Fall
MORSE FALL SCALE (FOR ADULT)
HUMPY DUMPTY (FOR
PEDIA)
RECOMMENDATIONS:
1. Do not be in a hurry. Identify patient before
performing any procedure.
2. Always maintain patients safety.
3. Complete SBAR form and pre-operative
checklist counterchecked by another staff
before shifting to OR.
4. Follow the 5 moments of hand hygiene to
prevent and minimize infection.
5. Strictly adhere to hospital and nursing Policy
and Procedures.
REFERENCES:
QPS 004 V04- PATIENT IDENTIFCATION
QPS 005 V04- CORRECT PATIENT,
SURGERY/PROCEDURE AND SITE POLICY
QPS 006 V04- VERBAL ORDERS, TELEPHONE
ORDERS, PANIC RESULT REPORT, HANDOVER
COMMUNICATION POLICY
QPS 007 V04- PREVENTION AND MANAGEMENT OF
FALL
MMU 001 V03
NR 033-V03 HAND-OFF COMMUNICATION (SBAR)
THANK YOU