Ahmad Thanin

Goal 1 Identify Patients Correctly.

Goal 2 Improve Effective Communication

International Goal 3 Improve the Safety of High-Alert Medications

Patient Safety
Goals (IPSGs) Goal 4 Ensure Safe Surgery

Goal 5 Reduce the Risk of Health Care-Associated Infections

Goal 6 Reduce the Risk of Patient Harm Resulting from Falls

Goal 1
Identify Patients
Correctly.
What is the patient Identification?

Patient identification is the

process of “correctly
matching a patient to
appropriately intended
interventions and
communicating information
about the patient's identity
accurately and reliably
throughout the continuum
of care
Identify the patient
Before giving Medications

Before giving blood and blood products

Before Specimen collection.

Before taking blood samples and other specimens for clinical testing.

Before providing any other Treatments / Procedures/ Surgery/ Investigation etc.

Before giving Food.

At the time of discharge (NICU and Nursery).

Patient Identification
All patients’: from admission to discharge : wrist band

In normal circumstances, a patient’s ID band must only be removed on discharge home.

Apply wristband to patient’s dominant wrist (i.e. the right wrist if the patient is right-handed).

For newborn:
• Immediately after delivery apply two bracelets: one on ankle and one on wrist, It should include
• Mother’s three names
• MRN
• Gender of the baby
• date and time of birth
• birth order for twins (Twin-1, Twin-2).
Wrist Band
Removal of ID
band: Only at time of discharge

Cut the ID band into small pieces

before discarding in the waste

If ID band is missing:
• Replace immediately; and
• Write incident report
Removal of ID Wrist band may be intentionally and carefully removed
band in OR in the Operating Room (OR) during surgery if it
obstructs access to the patient’s operative sites,
patients IV, etc.

Replacement band must be re-applied before removing

the existing one.

The person who removed the ID band must be

witnessed when re-applying and both individuals must
confirm the patient’s identification.

Nurses in Recovery Room (RR) shall not accept patients

for continued care if the correct wrist band is not
secured.
Incorrect Patient Medication errors
Identification Can
lead to: Incorrect surgery

Wrong-site surgery

Wrong treatment

Wrong baby discharged

 Health information system must
generate the temporary name as
Comatose / Unknown Patient Number 1, Unknown
Unconscious Patient Number 2 etc with the
temporary File/ Medical Record
Patient Without Number.
Identity:
Unknown The person who removed the temporary
ID band must be witnessed when re-
applying the new ID and both
individuals must confirm the patient’s
identification.
 Patient Name as Disaster Number 1, Disaster
Number 2 etc, with File Number of the
patient, which should be modified upon
confirming the Identification of the Patient

Disaster The person who removed the temporary ID

band must be witnessed when re-applying

Cases - ER
the new ID and both individuals must
confirm the patient’s identification

If it is not possible to secure or attach the ID

band on the patient’s wrist due to burns case
or severe RTA affecting the wrist-apply on
ankle.
How to identify patient correctly
according to IPSG 1?

Using two patient identification factors, but without including the

room or location of the patient in the complete Medical facility.

Complete patient name

MR Number

Preventative measures should be taken to ensure that the following

information is accurate before administering any medicines,
withdrawing blood, or collecting other samples for clinical purposes.
Remember

01 02 03
Always ask the Never read the Never assume that
patient to tell his/her patients details and the patient is in the
name. allow the patient to right bed, or has the
passively agree. correct patient
record, always check
the wristband.
 In case of more than one patient with the same name:

01 02 03 04
Highlight it at each Apply alert stickers Apply a card stating Use extra tools for
shift handover stating “Alert, Patient “Alert, Patient with identification like
with Similar Name” Similar Name” to the • National ID confirmation
on all relevant patients’ bed. • Birthdate
documentation • Family members names.
Positive Patient Identification for Patient
Protection

Positive patient identification (PPID) is an approach to

avoiding patient misidentification for the prevention of
medical errors, which include errors in medication,
transfusion, and testing, as well as wrong-person procedures
and the discharge of infants to the wrong family.

PPID has been described as a combination of computer

systems, hardware devices, and printable products for the
purpose of identifying a patient by matching historical
records with current records.
Goal 2
Improve Effective
Communication
 How to improve effective communications to meet the standards of
JCI Accreditation?

ISBAR
Reporting
Verbal of critical
order results
Telephone
order
Telephone order

When a physician is not present in the office, orders are taken over the phone to the nursing
station.

Telephone orders are only accepted at the nursing station if the patient care action is required
immediately or immediately after the call. The telephone is not an accepted option of placing
routine orders.

Orders for the following medicines cannot be made or received over the phone.

• Hazardous Medications
• TPN
• Narcotics or Controlled items
Important Rule

All telephone orders must be

signed, timed, and dated by all
nurses and physicians who are
involved in the procedure within
24 hrs
Verbal order

When a verbal order is received, the physician is on site but is preoccupied with emergency situations
such as Code Blue or is engaged in a sterile operation, the physician is considered unavailable.

Verbal instructions are only to be used in emergency circumstances.

Verbal instructions for narcotics or restricted medications from the treating physician are only acceptable
in emergency circumstances

verification should be done by “Repeat Back” of the entire order with the ordering physician by the
nurse/pharmacist receiving the order.
Important Rule

The verbal order shall be

IMMEDIATELY signed by the
physician after the emergency is
over and before the physician
leaves the unit.
 DATE AND TIME NAME OF CLINICIAN
ORDER RECEIVED RELAYING THE ORDER

Documentation ORDER AS DICTATED

ENDORSEMENT OF
THE ORDER AS

shall include: BY THE CLINICIAN TELEPHONE/VERBAL

ORDER.

SIGNATURE AND ID
NUMBER OF BOTH
NURSES
Reporting of critical results

When a call from the lab for a critical result is received, the
nursing staff must record the critical result and promptly
validate the result in the Hospital Information System.

If the nursing staff is unable to reach the on-call physician,

the nursing staff must follow the escalation procedure.
 If the Critical Result is confirmed, head of the department will sign the result,
and immediately contact the treating Physician by Phone (or the Ward
physician on Duty) to notify him/her about the patient Critical Result.

Radiology /
if the Head of department or the ( radiology / lab) doctor are not around then
the lab technician will call the Doctor and inform him about the initial result)

Laboratory If we could not get the in-charge physician, then a call will be performed for

critical result
the head nurse in charge.

Radiology and laboratory departments will record & Sign in the Logbook of the
Critical Result the following Information:
• Patient name (three names),
• Patient ID,
• Critical Diagnostic result,
• Reporting time and Date,
• name of the Doctor informed.
ISBAR

The ISBAR framework

represents a
standardized approach to
communication which
can be used in any
situation. It stands for
Introduction, Situation,
Background, Assessment
and Recommendation
What are the advantages of ISBAR?

Ensures completeness of information and reduces likelihood of missed data

is an easy and focused way to set expectations for what will be communicated

Ensures a recommendation is clear and professional

Gives confidence in communication

focuses not on the people who are communicating but on the problem itself.
Why would healthcare providers use ISBAR?

It is portable, memorable and easy to use

Can be used to present information clearly in any situation

Helps you to organize what you’re going to say

Standardizes communication between everyone

Where can ISBAR be used?

The ISBAR framework may be used in any information

handover situation. For example:
• Shift changes
• Discharge to community services
• Inter-hospital transfers
• Intra-hospital transfers
• Time-critical situations such as medical emergencies or evacuations
• Procedure documents
• Reports, memorandums and briefings
What does this
say?
 DANGEROUS ABBREVIATIONS
DO NOT USE USE DO NOT USE USE

Ug mcg
5.0 mg 5mg
cc ml
.25 mg 0.25mg
U unit

MgSO4 Morphine Sulfate or Magnesium Sulfate

QD daily

MSO4 Morphine Sulfate or Magnesium Sulfate

IU International Unit

SC or SQ SubQ MS Morphine Sulfate or Magnesium Sulfate

Goal 3
Improve the Safety
of High-Alert
Medications
Definition

High Alert Medication

• Medications that have a heightened risk of causing significant

patient harm when used in error.

High Alert Medication Category

• A category of medications in which all drugs included are

considered high alert although not listed individually in this
guideline
 Look-Alike and Sound-Alike
Medications (LASA)
• Medications that can look alike (presentation,
strength, appearance and name) or sound like
(pronunciation) other medications leading to
avoidable mix-ups.
Definition
Tall Man Lettering
• a system in which part of a drug's name is
written in upper case letters to help distinguish
LASA medications from one another in order to
avoid medication errors e.g., on storage
shelves.
 Medications involved in a high percentage of errors and/or
sentinel events.

High-Alert Medications that carry a higher risk for adverse outcomes.

Medications
Look-alike/sound-alike medications
Circumstances increasing risk errors in high-
risk medications
Poorly handwritten Similar product Similar medication
Verbal orders.
medication orders packaging name

Improper Storage of
packaging/labeling Oral liquid in IV Topical products products with
to incorrect syringe stored in IV vials similar names in
administration the same location

Improper storage
Similar
of concentrated
abbreviations
electrolytes
Double checking procedure

High alert medication With each dose/injection

requires a double-
checking procedure
prior to administration.
The minimum For infusion
requirements for • At the time of initiation of therapy
double check will be • At the time of a concentration change
for: • At the change of each shift or any
transfer of care
• With any dose change
Double checking procedure
Compare the label with the product against
the prescription and label the product
content with the medication administration
recorded (MAR) for the subsequence dose.

The infusion pump setting will set also and

double checked for the correct rate of
infusion at initiation of the infusion.
Preventive strategy

Preventive strategy will be implemented to reduce the potential risk

associated with the use of High Alert Medication, use these will include:

• Not accepting the letter U instead of unit in Physician’s order for

Heparin and Insulin.
• Verbal and telephone order should be kept to the minimum when
prescribing high alert medications (verbal and telephone order for
Potassium Chloride Injection is PROHIBITED)
• Medication administered as intravenously will have a standard
concentration for adult patient.
IMPORTANT

High-Alert medications must

be properly labeled with Red
warning sticker “High-Alert”
for further dilution.
Storage and Dispensing:

High-Alert medications should NOT be stored in floors, only a limited quantity will be kept in a separate, locked cabinet
away from regular medication stocks in certain areas such as (Operating Room, Emergency Room, and Intensive Care Units).

Intravenous anesthetic and skeletal muscle relaxants agent should only be stocked in ICU, OR and ER.

Each drug should be stored in separate labeled plastic container.

Narcotic and controlled medications should be tightly controlled all over the hospital to prevent misuse or dangerous mix-
up, to be kept in separate steel cabinets with double locks.

Dispensing of such drugs (Narcotic & Controlled) only against treating consultant or specialist’s written order.
High-Alert High-Risk Medication Category/Route Potential Error and Consequences

Medication Concentrated electrolytes / I.V

• (Potassium Chloride, Calcium
Potentially Lethal Medications

Categories Gluconate, Magnesium Sulphate,

Potassium Acetate, Sodium Chloride
14.6%, Sodium Phosphate)

Insulin / S.C / I.V ( only regular insulin can • Inappropriate insulin given due to
be given I.V ) Look-alike/Sound-alike errors
• Regular ( Humulin, Actrapid ) • Confusion of dose (units vs. ml )
• NPH (Humulin N,Insulatard HM ) • Drip rate errors causing bolus dose
• 70/30 (Humulin , Mixtard ) infused into patient.
• Lantus ( Glargine ) • Incorrect sliding scale
• Novomix 70/30 ( Penfill ) interpretations/order entry leading to
• Mixtard 30 HM ( Penfill ) dosing errors.
• Levemir Penfill • Insulin errors have the potential to
cause severe hypo/hypoglycemia.
These effects may require extra
monitoring, require treatment or in
severe cases may be fatal.
High-Alert
Medication High-Risk Potential Error and
Categories Medication Consequences
Category/Route

Nuromuscular Potentially Lethal

Blockers Medications
• Cisatracurium (Restricted to critical
• Atracurium care and special care
• Mivacurium areas. (ICU,ER,OR))
• Succinylcholine
HIGH ALERT MEDICATIONS
Potassium Magnesium Epinephrine
Magnesium Amidarone (inj) Digoxin (inj)
chloride (inj) sulfate (inj) (Adrenaline) inj
Phosphate (inj) 200mg. (0.50mg)
20meq 10% (2gm) (1:1000)

Sodium Calcium
Calcium Phenytoin (inj) Dopamine inj. Phenobarbiton
Bicarbonate Chloride (inj)
Gluconate (inj) 250 mg 200 mg (inj) 250 mg.
imj. 8.4% 10%

Lidocain 1% for
Dobutamine Isoproterenol Warfarin (tab) Noradrenaline Sodium
arrhythmia (inj)
inj. 250 mg inj 1:500mg 1,2,5 mg inj-1-2mg/ml chloride IV 10%
(IV)

Aminophylline Chemotherapy
Heparin Insulin inj
250 mg IV drugs
General Strategies for High Alert
Medications
TALLman lettering

‘LASA’ on label, when applicable

“High Alert” on storage label

High Alert Medications must be stored in Red Bins using

Standardized Medication Labels

Medication which must be stored in Red Bins with Lids

• Concentrated Electrolytes
• Parenteral Skeletal Muscle Relaxants (Paralyzing agents)

Patient care areas: Stored in ADC locked Lidded

CPOE with clinical decision support, providing immediate warnings if unsafe orders are entered
General Strategies for High Alert
Medications

Use of smart infusion pumps with dose checking software enabled

Order sets.

Independent Double-Check (IDC) Procedure in which two healthcare professionals separately

check (alone and apart from each other, then compare results) each component of prescribing,
transcribing, dispensing and verifying the medication before administering to the patient
• Dispensing
• Verifying at time of administration
 OTHER LIST OF LOOK – ALIKE AND SOUND – ALIKE (LASA)
MEDICATION

DRUG NAME CONFUSED DRUG NAME SAFETY MEASURES

Amphotericin Liposomal Amphotericin Conventional TALLman letters, Store separately
AMILOride AMLOdipine TALLman letters, Store separately
BuPROPion BuSPIRone TALLman letters, Store separately
DiFLUcan DiPRIvan TALLman letters, Store separately
DoPAMine DoBUTamine TALLman letters, Store separately
EsMOLol EsMERon TALLman letters, Store separately
EpiNEPHrine EpheDrine TALLman letters, Store separately
FluOXETine FluPHENazine TALLman letters, Store separately
HydrOXYzine HydrALAZine TALLman letters, Store separately
HumaLOG HumuLIN TALLman letters, Store separately
PeniCILLIN PeniCILLAMINE TALLman letters, Store separately
ZanTAC ZyrTEC TALLman letters, Store separately
 Magnesium Sulfate 50 % or more
concentration

Potassium Chloride 2 mmol/mL or

Concentrated more concentration

Electrolytes: Potassium Phosphate 3 mmol/ml

or more concentration

Sodium Chloride hypertonic

(greater than 0.9%)
Goal 4
Ensure Safe
Surgery
DIFFENTION

is a final pause and final

verification process to
be done on a patient
before the performance
of a procedure/s in the
presence of all clinical
team members and in
the location where the
procedure is to be
conducted to assure
right patient, right site
Time Out and right procedure.
Time Out:

Time out should be done for at least: procedures that investigate and/or treat
diseases and disorders of the human body through cutting, removing, altering, or
insertion of diagnostic/ therapeutic scopes.

The time out applies to any location in the organization where these procedures
are performed.

And done just before starting the procedure which involves the entire operative
team.
Wrong site surgery and the Protocol

Check Check that the consent form or procedure request form is correct

Mark Mark the site with an indelible pen for the surgery or other invasive procedure

Confirm Confirm identification with the patient

Take a “team time out” in the operating theatre, treatment or examination area for staff to verbally confirm that
Take TIME OUT all is correct

Ensure Ensure appropriate and available diagnostic images.

 Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol

Days to hours before procedure

Step 1
Consent form or procedure request form, must include:
• Patient's full name.
• Procedure site.
• Name of procedure.
• Reason for procedure

Step 2
Mark site of invasive procedure:
• Must be marked by the person in charge of the procedure or another senior team member who has been
fully briefed about the procedure or operation
 Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol

Just before entering the operation room or treatment room

Step 3
Patient Identification, staff must ask the patient to state:
• Their full name.
• Date of birth.
• Site for, or type of procedure

Remember to
Check the response against the marked site, ID Band, consent form and other documents
 Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol

Immediately prior to procedure

Step 4
Team time out, within the operating theater or treatment room when the patient is present and prior to
beginning the procedure.
Staff must verbally confirm through “ team time out” when all other activities in the operation room stopped:
• Presence of correct patient
• The correct site has been marked.
• Procedure to be performed
• Availability of correct implant where required

Step 5
Imaging Data, if imaging data are used to confirm the site or procedure, two or more members of the team
must confirm the images are correct and properly labeled
The surgical site Marking should:
Marked in all cases
Be visible after the involving laterality,
Involve the patient. patient is prepped and multiple structures
draped. (fingers, toes, lesions), or
multiple levels (spine).

Be made by the person

Take place with the
performing the
patient awake and
procedure with a
aware, if possible.
permanent skin marker

Done with an instantly Be consistent throughout

recognizable mark. the organization.
 The purpose of the preoperative verification
process is:

To ensure that all relevant

documents, images, and To verify any required
To verify the correct site,
studies are available, special equipment and/or
procedure, and patient.
properly labeled, and implants are present.
displayed; and
Mark site of
invasive
procedure:
Surgical Time-Out

When a patient goes to surgery, their surgical team

takes great care to provide a safe experience. This
involves

Pre-
Procedur
Sign-In Time-Out Sign-Out
e Check-
In
 Where

• Pre-op room

Who

Pre- • Patient and Pre-op Nurse

What - Verification of:

Procedure •
•
History and Physical
Consent

Check-In
• Nursing Assessment, including vital signs
• Operative site marked by surgeon
• Labs and images available
• Blood products, special equipment available if needed

When

• Before Patient is taken into OR

 Where

• Pre-Op room

Who

• Patient, OR nurse and Anesthesiologist or Certified

Registered Nurse Anesthetist (CRNA)

Sign-In What – Verification of:

• Patient, Procedure, Site and Consent

• Allergies, Airway Concerns and Aspiration Concerns
• Risk of blood loss

When

• Prior to giving anesthesia

 Where

• Operating Room

Who

• All members of the surgical team

What

Time-Out
• Surgeon introduces all team members
• Verify patient, site and procedure
• Verify patient images
• Verify specific equipment available
• Assess Fire Risk
• Verify sterilization indicators for instruments
• Verify antibiotics have been given
• All members’ concerns addressed

When

• Prior to skin incision

 Where

• Operating Room

Who

• All members of the surgical team

Sign-Out What

• Procedure verified
• OR RN confirms sponge, sharps and instrument count
• Surgical specimens identified and labeled
• Identify equipment concerns

When

• Before Patient leaves OR

Example for X – HOSPITAL FORM TEMPLATE
Rule

• Anything that may require a consent

and/or is a “high risk” procedure requires
a TIME-OUT
• Don’t forget! The “TIME-OUT process
applies to procedures OUTSIDE the OR as
well!
Goal 5
Reduce the Risk of
Health Care-
Associated Infections
Introduction

• Healthcare Associated Infection

• is a localized or systemic condition resulting from an adverse reaction to the
presence of infectious agent(s) or its toxin(s) that was not present on admission to
the acute care facility.
• An infection is considered as health care associated in all elements as per Centers for
Disease Control and Prevention (CDC) site-specific infection criterion were first
present together on or after the 3rd hospital day (day of hospital admission is day 1)
Infection Control Program

Establishing an effective infrastructure for

the Infection Control Program by:
• Multidisciplinary team to oversee the Infection
Prevention Control Program.
• Program management.
• Policies and procedures.
 Hand Hygiene: A general term referring to any action of hand cleansing

Alcohol-Based An alcohol-containing preparation designed for application to the hands

Hand Rub: for reducing the number of viable microorganisms on the hands.

Antimicrobial Soap (i.e. detergent) containing an antiseptic agent.

Soap:

Antiseptic Antimicrobial substances that are applied to the skin to reduce the
Agent: microbial flora.

Definitions Antiseptic Hand

Wash:

Detergents:
Washing hands with soap and water or other detergents containing an
antiseptic agent.

Compounds that pose a cleaning action.

Hand Hygiene: A general term that applies to hand washing, antiseptic hand wash,
antiseptic hand rub, or surgical hand antisepsis.

Hand Refers to either antiseptic hand wash or antiseptic hand rub.

Antisepsis:

Decontaminate To reduce bacterial counts on hands by performing antiseptic hand rub or

Hands: antiseptic hand washes.
 Standard Precautions

Hand Hygiene

Infection Appropriate Use of Personal Protective Equipment

Prevention
Cleaning, Disinfection and Sterilization

Correct Waste Disposal, Proper Sharp Disposal and Sharp Injury Management.

and Linen Management.

Specimen Handling.

Control Environnemental Management and Spillage Management..

Aseptic Technique

Program Cough Etiquette.

consist of:
Transmission-Based Precautions

Education .

Surveillance
 Standard precautions are based on the principle
that all blood, body fluids, excretions except sweat,
non intact skin and mucous membranes may
contain transmissible infectious agents.

Standard precautions are intended to be applied to

Standard the care of all patients in all health care settings,
regardless of the suspected or confirmed presence
Precautions of an infectious agent.

Implementation of standard precautions constitutes

the primary strategy for the prevention of
healthcare associated transmission of infectious
agents among patients and healthcare personnel.
 Healthcare associated infections are mainly spread through
the contaminated hands of health care workers.

Hand washing is the single most important way of

preventing the spread of infection.

Hand Hand hygiene procedures include the use of alcohol-based

hand rubs and hand washing with soap and water.
Hygiene Hand hygiene stations should be strategically placed to
ensure easy access.

Hand hygiene guidelines from WHO (5 moments of hand

hygiene) is used to observe and evaluate hand hygiene for
all categories of staff.
 When hands are visibly dirty or contaminated with proteinaceous material or are
Wash visibly soiled with blood or other body fluids, wash hands with either a
nonantimicrobial soap and water or an antimicrobial soap and water.

Hand Hygiene If hands are not visibly soiled, use an alcohol-based hand rub for routinely

should be done
Use decontaminating and in all other clinical situations.

in all the
following Decontaminate Decontaminate hands before and after having direct contact with patients.

instances
Decontaminate hands before clean/Aseptic procedure if moving from a contaminated
Decontaminate body site to another body site during care of the same patient.
 Decontaminate hands after contact with body fluids or
excretions, mucous membranes, non-intact skin, and
wound dressings. If moving from a contaminated body
site to another body site during care of the same patient.
Hand Hygiene And after removing sterile or non-sterile gloves.

should be done Decontaminate hands before and after contact with a

in all the patient's intact skin (e.g. when taking pulse or blood
pressure and lifting a patient).
following
instances Decontaminate hands after contact with inanimate
objects including medical equipment. After using a
restroom, wash hands with a non- antimicrobial soap and
water or with an antimicrobial soap and water.
Factors for poor adherence with hand Hygiene:

Sinks are
Hand washing agents
inconveniently Lack of soap and
may cause irritation
located/shortage of paper towels.
and dryness.
sinks.

Beliefs that wearing

Lack of knowledge of of gloves obviates the
Insufficient time.
guidelines. need for hand
hygiene.
Appropriate Use of Personal Protective Equipment
A review of available
personal protective
equipment should be
performed periodically due
Involves specialized equipment worn to new product
by the staff for protection against developments and
infectious materials. improvements.

The selection of personal

protective equipment is based
on the nature of the patient
interaction and potential for
exposure to blood, body fluids
or infectious agents. This
includes gloves, gowns, and
masks.
Cleaning, Disinfection and Sterilization
Reusable medical devices/equipment must be adequately reprocessed for
safe reuse.

Strict policy regarding single use items.

Spaulding’s classification of medical devices:

• Critical Item (contact with sterile areas of the body)
• Semi-Critical Item (contact with mucous membranes or non-intact skin)
• Non-Critical Item (contact with intact skin)
 Segregate general and infectious waste at the point
of generation.
Correct
Waste Awareness of proper waste management should be
emphasized and strictly followed.
Disposal,
General Waste
Proper Sharp
Disposal and
• materials with no inherent hazard or infection potential e.g.
administrative, food waste etc. (Black / Blue plastic bag)

Sharp Injury Biohazardous (Infectious Waste)

Management • these are wastes which has the potential for transmitting
infections/disease e.g. gloves, masks, blood-soaked dressings
etc. (yellow thick plastic bag with Biohazardous sign)
 Human Waste Tissue

Correct Waste
• as defined from fatwas 13290/13291 e.g. amputated
body parts, placenta etc. (red thick plastic bag with label).

Disposal, Sharp Disposal

• sharps include any object that can penetrate the skin e.g.
Proper Sharp needles, blades, broken ampoules etc. (puncture resistant
sharps container)

Disposal and Safe Sharp Handling

Sharp Injury • to be managed and disposed of in a manner as to prevent

injuries and transmission of disease e.g. no recapping of

Management
needles, use of kidney dish for transportation.

Sharp Injury
• First aid, reporting, laboratory tests, forms.
 Proper handling of soiled linen (soiled
with blood or other body fluids) use
of personal protective equipment.

Linen Transport from departments to

Management laundry in closed carts.

No mixing of clean and soiled linen.

 Contained in a sealed container/plastic bag
which is leak proof.

Contained specimen must be placed in a

Specimen secondary biohazard labeled plastic bag.

Handling Ensure request form is not contaminated; place

in separate pocket of the biohazard plastic bag.

Sharps injury must be avoided on collecting,

containing and transporting of any specimen.
 Proper cleaning of patient’s rooms on daily
basis. Medical device surfaces and
housekeeping surfaces.

Environmental Terminal cleaning on discharge of patient.

Management
and Spillage Cleaning to be done with hospital prescribed
Management disinfectant.

Proper procedure to be followed indicated for

relevant spill e.g. blood spill, chemical spill.
Aseptic Technique

Are established to prevent or minimize the risk of

infection transmission to patients undergoing
invasive procedures or wound management.

Healthcare worker must observe and practice the

principles of aseptic technique as indicated by the
type of procedure to be done
 Educate healthcare personnel, patients and visitors on the
importance of source control measures to contain respiratory
secretions to prevent transmission of respiratory pathogens.
Especially during seasonal outbreaks of e.g. influenza.

Tissue to cover mouth when coughing or sneezing.

Cough Etiquette
Correct way for tissue disposal and hand hygiene.

Avoidance of crowds.
Transmission-Based Precautions
Transmission-based precautions are used when the route of transmission is not completely interrupted using standard
precautions alone.
Use transmission-based precautions for patients with documented or suspected infection of colonization with highly
transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent
transmission.

Contact Precautions
• gowns, gloves (e.g. MRSA infected patients)

Droplet Precautions
• surgical mask, gowns, gloves, (e.g. German Measles, Meningitis, Mumps)

Airborne Precautions
• N95 mask, gowns, gloves, and negative pressure room (e.g. Pulmonary Tuberculosis, Measles, Chicken Pox).
Education

Monthly planned in-service education program for all departments.

On hand education and training whenever the need arises.

Comprehensive orientation program for new employees by infection control

nurses and demonstration of hand hygiene.

Competencies on various infection control practices.

 Hand Hygiene

Waste Compliance

Surveillance Health Care Associated Infections

• Catheter Associated Urinary Tract Infection

• Central Line Associated Blood Stream
Infection
• Ventilator Associated Pneumonia.
• Surgical Site Infections
Environmental hygiene
• Environmental hygiene is a fundamental principle of infection prevention in healthcare settings.
• Contaminated hospital surfaces play an important role in the transmission of micro-organisms,
including Clostridium difficile, and multidrug-resistant organisms such as methicillin-resistant
Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).
• Therefore, appropriate hygiene of surfaces and equipment which patients and healthcare personnel
touch is necessary to reduce exposure.
• Evidence supports the hypothesis that hospital can act as an important reservoir of many nosocomial
pathogens in several environments such as surfaces, medical equipment and water system.
• Healthcare settings are complex realities within which there are many critical points.
• Microbial contamination can result from the same inpatients, relatives and healthcare workers.
• The role of environmental hygiene is to reduce the number of infectious agents that may be present on
surfaces and minimize the risk of transfer of micro-organisms from one person/object to another,
thereby reducing the risk of cross-infection.
Screening and cohorting patients
• Early detection of multidrug-resistant organisms is an important component of any infection control
program.
• There is good evidence that active screening of preoperative patients for MRSA, with decolonization of
carriers, results in reductions in postoperative infections caused by MRSA.
• Isolation or cohorting of colonized/infected patients is a cornerstone of infection prevention and
control.
• Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to
other patients, hospital visitors, and healthcare workers, who may subsequently transmit them to
other patients or become infected or colonized themselves.
• Isolating a patient with highly resistant bacteria is beneficial in stopping patient-to-patient spread.
• Isolation measures should be an integral part of any infection prevention and control program,
however they are often not applied consistently and rigorously, because they are expensive, time-
consuming and often uncomfortable for patients.
Antibiotic stewardship
• Optimal infection control programs have been identified as important components of any
comprehensive strategy for the control of AMR, primarily through limiting transmission of
resistant organisms among patients.
• The successful containment of AMR in acute care facilities, however, also requires an appropriate
antibiotic use.
• Antibiotic stewardship programs (ASPs) can help reduce antibiotic exposure, lower rates of
Clostridium difficile infections and minimize healthcare costs.
• Most antibiotic stewardship activities effect multiple organisms simultaneously and have as a
primary goal the prevention of the emergence of antibiotic resistance.
• Thus, ASPs can largely be viewed in the context of horizontal infection prevention.
• Additionally, ASPs can contribute to the prevention of surgical site infections via the optimized use
of surgical antibiotic prophylaxis.
Goal 6
Reduce the Risk of
Patient Harm Resulting
from Falls
 Fall

• A fall is an incident in which an adult or a child

unexpectedly falls down, unassisted or uncontrolled, from
a higher position to a lower position, with or without
injuries and which may or may not be related to physical
or mental pathology.

Near Fall

Definition • sudden loss of balance that does not result in a fall or

other injury .
• This can include a person who slips, stumbles, or trips but
is able to regain control prior to falling.

un-witnessed fall

• occurs when a patient is found on the floor and neither

the patient nor anyone else knows how he or she got
there .
All in-patients will be
assessed for the risk of
fall upon admission.
Most Causing to Falls

• Loss of consciousness. • Unsafe higher position.

• Orthopedic disorders. • Beds side rails.
• Hypoglycemia. • unlocked wheelchair.
• Anemia, Vision
Individua Environment • Water in the floor.
• Hypotension.
l •
al • Wire connections.
Drugs action.
• Post operative (sedation). • Steps or stairs.
• Aging and sleeping habits • Walker.
• Paralysis, TIA, CVA • Interfering Clothes
 Patient Fall Injury Levels

None: Minor: Moderate: Major: Death: UTD:

• No injury. • minor injury • injury lead to • which leads for • the patient died • unable to
with abrasion Suturing or casting, skin as a result of determine from
or bruise limping treated traction and serious injury. the
treated by by bandage, surgery, may documentation
dressing, limb splinting, need .
elevation, muscle or joint neurological
topical strain. and vascular
medication. attention.
Fall assessment
All in-patients will be assessed for the risk of fall upon admission.

Reassessment is indicated for all of the following conditions:

• post operative.
• following procedural sedation.
• after administer medication.
• after blood transfusion.
• transferring patients between 2 units.
• after recording incident of fall.
• any changing in ambulatory status or elimination status,

Applying Risk Fall procedure for patients

• Hendrich 11 Fall risk for Adults.

• Humpty Dumpty Scale for Pediatrics.
• The Morse Fall Scale

Standard fall precaution shall be implemented for all patients.

Reporting and documenting any fall occurrence.

All Falls patients should be classified according to level of Injury

Post Fall Protocol of Care
complete the post
First Aid. fall assessment Reporting.
Form

move the patient

Ensure that patient safely with
Patient and Family
is safe from further attention to
Education.
danger . moving and
handling.

don’t reposition
the patient until
ask for help.
the patient is ready
to do so.
 Standard Fall Precaution for Low-Risk
Patients

1 2 3 4 5 6 7 8 9 10

Orient the Provide Instruct patient Instruct to use Secure call bell, Ensure the Maintain the Put side rails. Conduct Keep bathroom
surrounding Medication to call for the rubber – phone, bed clothes are not bed in the regular light on and
environment. Information. assistance. soled shoes or table. interfere with lowest position environmental the floor dry.
non – slip the patient and ensure bed rounds in all
footwear to mobility. and areas
prevent wheelchairs surrounding
slipping. are looked. the patients to
decrease the
risk of falls.
Standard Fall Precaution for Moderate Risk
Patients
Identify as falls risk on Assist and supervise
medical record and ambulation, Reinforce Conduct hourly safety Perform regular pain
include in shift to always call for checks. assessment
endorsement. assistance.

Evaluate for reversible

Offer assistance to the
causes Check the patients Don’t lower the bed
bathroom or use
• Orthostatic B.P after the visitors leave side rails if any nurse
bedpan hourly while • Monitor Blood Sugar . always. rise it up.
awake. • Adequate Hydration

Apply Fall Risk Hand

Patient Education. Family Education.
Band
Standard Fall Precaution
for High-Risk Patients

Apply all low and moderate interventions.

Place a high risk for fall sticker/ label on the patient charts and patient room.

Raise Both upper and lower side rails.

Place mattress on floor.

Review the medication.

Assess the need of physical therapy consultation.

Assess the need for 1:1 monitoring as needed.

Patient and Family Education

both about the risk of falling, Safety Issues, and their Mobility
Educate Limitation.

Teach patient to make position changes slowly.

Emphasize how important the family to be involving tin the patient safety.

Emphasize what patient can do to be healthy, active, and independent

on
Interventions based on the fall-risk
assessment
Monitoring gait and mobility.

Bladder/ Bowel Training Program.

Fall Alert Medication.

Maintaining a safe environment.

Assistive Devices Monitoring.

Monitoring gait and mobility.

Normal/Safe Gait & Balance Problem Balance Problem

Balance. while Standing while Walking

Change in Gait
Pattern while Jerking/ Unstable Requires an
Walking through when Making Turn Assistance
doorway
Bladder /Bowel Training Program

45% Falls Identified as Toileting related (Tzeng, 2010)

Is a training technique for bladder and bowel to decrease urgency and

incontinence based on behavioral modification treatment techniques that
involves placing patient on toileting schedule.
• > 60 Years Old
• On Laxative
• Bed Ridden
• Postoperative
MEDICATIONS FALL ALERT

Pharmacist are responsible for reviewing medication and supplements

to ensure that the risk of falls is reduced

Notify the for Drug that depress the central nervous system may cause
sedation, drowsiness, ataxia, as well as paradoxical effects like:
• Antihistamine
• Antiepileptic
• Antidepressant
• Anticonvulsant
• Cardiovascular drugs
Maintaining a Safe Environment

Environmental hazards or hazardous activities are described as primary causes for

approximately half of all falls, which includes:

• Walking on slippery/rough surfaces.

• Obstacles.
• Inadequate light.
• Loose carpets.
• Trip Hazard regarding to medical care ( IV Tubing, Urinary Catheter, ).

Such hazards are likely to cause trips or slips in any age group but pose a
particular risk for community- dwelling elderly persons who may already have
multiple intrinsic risk factors for falls.
Assistive Devices
Monitoring Nurse
Call Bell
Fall Alert” Sign