INTERNATIONAL PATIENT SAFETY GOALS

CERTIFICATE PROGRAM IN HEALTHCARE QUALITY MANAGEMENT

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATION

© CAHO 2020-21. All rights reserved

 IPSG - History

§ Developed by JCI in 2006.

§ Version 3 released in 2017.
§ Adapted from JCAHO’s National
Patient Safety Goals (2003).
§ Has six stated goals.

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 About IPSG

International Patient Safety Goals

(IPSG) help accredited organisations
address specific areas of concern in
some of the most problematic areas
of patient safety.

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 Goal 1: Identify Patients Correctly

§ Two identifiers (Ex: full name and UHID).

§ Verify patient identification before all invasive and diagnostic
procedures.
§ Identification wristbands for In-patients.
§ “Time out” before starting all surgical and invasive procedures.
§ Do not use patient room numbers and location for identification.

https://www.jointcommissioninternational.org/-/media/jci/jci-documents/contact-us/submit-a-jci-standards-interpretation-
question/jci_standards_interpretation_faqs.pdf

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 Discussion

§ Patient K.Sudha ,Diagnosis - Primary Infertility - posted for Dignostic

laparoscopy
§ Patient M.Sudha ,Diagnosis – P2L2 - posted for Sterilisation surgery.
§ Due to the proximity of the two OTs, a mix-up occurred, and the
wrong patient shifted to OT.
§ Luckily, due to alert doctors and staff members, this near miss
incident was identified in time.
§ Discuss this and similar incidents from your experience
§ Actions you would take to avoid them.

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Goal 2: Improve Effective Communication

Handover and effective communication among all care givers (all shifts).

Critical value/reports intimation immediately to the treating/duty doctor.

Critical value/reports to be documented in patient file on intimation by the

doctor.

Get important test results to the right staff person on time.

Handling verbal orders.

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 Other Aspects of Effective Communication in
Healthcare Settings

Verbal order – write down, read back and confirm

§ The complete verbal and telephone order or test result is written down by the
receiver of the order or test result.
§ The complete verbal and telephone order or test result is read back by the
receiver of the order or test result.
§ The order or test result is confirmed by the individual who gave the order or
test result.

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 Tools

SBAR

Call-Out

Check-Back

Hand-Off

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 SBAR

§ Format to transmit critical

information in a predictable format.
§ Ideal for use in a variety of
settings:
Ø Change of shift hand-offs
Ø Telephone calls
Ø Orienting new team members
Ø Periodic summaries

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 Discuss Situation - Roleplay

Mrs. Roseline is 24 years, who is 4 h post-op from a

caesarean is in the ICU.
A: Assessment
BP is 90/50 mm of Hg, she's tachycardic, pulse
110/mt, and her abdomen is becoming quite
distended.
You are worried.
As a healthcare professional, how will you
communicate it to the Consultant?

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 SBAR - Example

S: Situation
I am nurse Stella from ICU.I am calling about a patient Mrs .Roseline ,whose BP is
low.

B: Background
Mrs.Roseline is 24 years,who is 4 h post-op from a caesarean ,done for placental
abruption and admitted to the ICU in haemorrhagic shock due to DIC. She has
received 10 units of packed red blood cells and 2 units of fresh frozen plasma so
far.

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 SBAR – Example

A: Assessment
I am worried that she is bleeding because her pressures are dropping, BP is
90/50 mm of Hg, she's tachycardic, pulse 110/mt, and her abdomen is
becoming quite distended.

R: Request/Recommendation
I would like you to come and evaluate her right away.

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 Call-Out

A strategy used to communicate important or critical

information.
§ It informs all team members simultaneously during
emergency situations.
§ It helps team members anticipate next steps.

One important aspect of a call-out is directing the information to a specific individual.

Credit: www.ahrq.gov

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 Check-Back

Credit: www.ahrq.gov

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 Hand-Off

The transfer of information

during transitions in care across
the continuum.
§ Includes an opportunity to ask
questions, clarify and confirm.

Credit: www.ahrq.gov

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 Hand-Off

Hand-off consist of:

§ Transfer of responsibility and
accountability.
§ Clarity of information.
§ Verbal communication of
information.
§ Acknowledgment by receiver.
§ Opportunity to review.

Credit: www.ahrq.gov

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Goal 3: Improve the Safety of High-alert Medications

§ Drugs that bear a heightened risk of causing significant patient

harm when they are used in error.
§ Medications that carry a higher risk for adverse outcomes.
§ Identification, location, labelling and storage of high-alert
medications.
§ Independent double-check (IDC) - prevents up to 95% of errors.
§ Look-Alike/Sound-Alike medications (LASA).
§ Loaded syringes to be labelled (including dilution).
§ Restricted access.
§ Reconciliation at transition points. Credit: ISMP

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 Q&A

What points should be mentioned on a medication label

(like on an Infusion pump or Syringe pump)?

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Label on IV Infusion Pump

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Label on Syringe Pump

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3 timepoints in WHO Surgical Safety Checklist

Sign In Time Out Sign Out

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Goal 5: Reduce the Risk of Health Care-associated
Infections (HAIs)

§ SSI - Surgical Site Infection

§ VAP - Ventilator Associated Pneumonia
§ CAUTI - Catheter Associated Urinary Tract Infection
Ø Each day the indwelling urinary catheter remains, a patient has a 3%-7%
increased risk of acquiring a catheter-associated urinary tract infection
(CAUTI) - CDC 2017.
§ CLABSI - Central Line Associated Blood Stream Infection
§ 5 moments of hand hygiene (WHO)
§ Appropriate PPE
§ Care bundles to prevent HAI
§ Surveillance and monitoring, RCA and CAPA

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Five moments of hand hygiene

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Five moments of hand hygiene

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Five moments of hand hygiene

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Five moments of hand hygiene

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Five moments of hand hygiene

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Five moments of hand hygiene

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Goal 6: Reduce the Risk of Patient Harm Resulting
from Falls

§ Initial assessment for fall risk.

§ Reassessment when indicated by a change in
condition or medications, among others.
§ Implement measures to reduce fall risk.
Ø Side rails should always be up – always!
Ø Safety belt/side rails while transport.
Ø Identify slip and trip areas and take
necessary action.
§ Monitor for results.

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 Summary

Goal 1: Identify patients correctly

§ Two identifiers, wrist bands, Time out
§ DO NOT use Room numbers, location

Goal 2: Improve effective communication

§ Read Back, SBAR

Goal 3: Improve the safety of high-alert medications

§ LASA, labeling of loaded syringes, IDC, Medication reconciliation

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 Summary

Goal 4: Ensure safe surgery

§ Sign-in, Time-out, Sign-out

Goal 5: Reduce the risk of health care-associated infections

§ Hand hygiene, Care bundles, Surveillance

Goal 6: Reduce the risk of patient harm resulting from falls

§ Initial assessment, re-assessment, side rails and safety belts

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 Q&A

1. Name the Checklist Which of the following is

used to assess Patient NOT one among the 5
falls. Rights of medication?

a) Morse Score a) Right Patient

b) Braden Scale b) Right Drug

c) Wells Score c) Right Bed

d) Visual Analog Scale d) Right Route

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 Q&A

Which of the following is

1. Name the Checklist used NOT one among the 5
to assess Patient falls. Rights of medication?
a) Morse Score(Fall) a) Right Patient

b) Braden Scale (Bed sore) b) Right Drug

c) Wells Score(DVT) c) Right Bed

d) Visual Analog Scale(Pain) d) Right Route

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 Services in a Hospital

§ Clinical Services

§ Managerial Services

§ Clinical Support Services

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 QA in Clinical Services

§ Emergency Department
§ Laboratory
§ Radiology
§ Patient care (OPD, IPD, Critical care)
§ Operation Theatre
§ Labour Room
§ Blood transfusion
§ Dialysis
§ Ophthalmology

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 Lab Departments

§ Biochemistry
§ Clinical Pathology
§ Microbiology
§ Serology
§ Haematology

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 Complexity of a Laboratory System

Reporting Patient/Client Prep

Sample Collection
Personnel Competency
Test Evaluations
•Data & Laboratory
Management
•Safety
•Customer Service
Sample Receipt and
Accessioning

Record Keeping

Sample Transport
Quality Control
Testing

Introduction Laboratory Quality Management System-Module 1 42

 NABL - ISO 15189:2012

Medical laboratories – Requirements for quality and

competence

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 Radiology Departments

AERB GUIDELINES
§ X-Ray
§ CT
§ MRI
§ Mammography
§ PET
§ Radiotherapy
§ Nuclear medicine

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Intensive Care Unit

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Operation Theatre
QA in Clinical Support Services

Pharmacy

CSSD

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Pharmacy

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Functions of CSSD

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Quality Assurance in Managerial Indicators

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Quality Assurance In Managerial Departments

HR,

Kitchen, Laundry, Mortuary

Bio-medical equipment

Utility

MRD

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 What is Quality Indicator?

§ Represent an instrument for bringing quality,

efficiency and efficacy.
The Quality Indicators (QIs) § Key performance indicators – monitors, evaluates,
are measures of health care and improves performance.
quality that make use of § Multi dimensional in nature.
readily available hospital § Directs to achieve goals and objectives.
inpatient administrative data. § Set performance standards.
§ Benchmarks.
§ Captures data both in clinical and support services.

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 Clinical - Indicators Related to Patient Care

§ Related to – clinical structure, process and outcomes.

§ Could be monitored related to patient assessment, safety and quality control

programmes of all diagnostic services medication management, use of blood and
blood components, surgical anaesthesia services mortality and morbidity indicators.

§ Indictors have formular, multiplier and sample size.

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 Clinical Indicators

§ Clinical quality indicators have been in use by health services since the 1980s.
§ Increased awareness of quality and safety issues coupled with accreditation has
seen the expansion and development of clinical indicators for specific disease and
procedure/therapy types.
§ Clinical indicators are measures of the process, structure and/or outcomes of
patient care.
§ They allow clinical care to be monitored over time and to be benchmarked against
established care standards.

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 Clinical Indicators

Clinical indicators have multiple purposes including:

§ Benchmark care (To make comparisons over time and between services.).
§ Make judgments about services.
§ Set service or system priorities.
§ Organise care.
§ Document the quality of care.
§ Support accountability, regulation and accreditation.
§ Support quality improvement.

Clinical indicators may point to system level issues, however they are rarely specific
enough to provide an insight into an individual doctor’s clinical performance.

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 Clinical Indicators

An ideal clinical quality indicator should be:

§ Evidence based, valid and reliable.
§ Able to permit useful comparisons.
§ Relevant to the important aspects of quality of care.
§ Relevant to important aspects (effectiveness, safety and efficiency) and dimensions
(professional, organisational and patient oriented) of quality of care.
§ Feasible (that is, be appropriate, measurable and improvable) as well as valid and
reliable.

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 Managerial Indicators

§ Related to medication procurement, utilisation rates ICU, OT, Dialysis, equipment’s.

§ Waiting times - OPD, Diagnostics.
§ TAT of services.
§ Statistics.
§ Patient satisfaction rate.
§ MRD documentation.

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Any Questions

? 58
Thank You!

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 Things to Do

§ Time out for all invasive procedures.

§ Follow sign in, time out and sign out using surgical safety checklist.
§ Pre-operative verification of correct site, correct procedure and correct
patient – Checklists.
§ Ensure that all documents and equipment needed are on hand, correct and
functional.

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 Goal 4: Ensure Safe Surgery

§ Correct-site, correct-procedure, correct patient

surgery.
Ø Including medical and dental
procedures done in settings other than
the operating theatre.
§ Instantly recognized mark for surgical-site
identification.
§ Surgical site marking with active patient
involvement.

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