International Patient

Safety Goals
Prepared By: Mr. Mouad M. Hourani. (Bcs, MPh)
Prince Sultan Military Medical City (PSMMC)
Continuous Quality Improvement & Patient Safety
Coordinator

Why Patient safety Goals.

List of Goals.
Brief of each goal.
Requirement of each goal.
Summary.
Scenario.

To promote specific improvements in

patient safety.

To highlight problematic areas in

health care and describe evidenceand
expert-based
consensus
solutions to these problems.
(JCIA 4th Edition, 2011)

Goal 1: Identify Patients Correctly.

Goal 2: Improve Effective Communication.

Goal 3: Improve the Safety of High-Alert Medications.

Goal 4: Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery.

Goal 5: Reduce the Risk of Health CareAssociated

Infections.

Goal 6: Reduce the Risk of Patient Harm Resulting

from Falls.

Identify Patients
Correctly

Wrong-patient errors occur in virtually all

aspects of diagnosis and treatment.

Patients may be sedated, disoriented, or

not fully alert; may change beds, rooms,
or locations within the organization; may
have sensory disabilities; or may be
subject to other situations that may lead
to errors in identification.
(JCIA 4th Edition, 2011)

A policy to be collaboratively developed

that address:
accuracy of patient identification Using at

least two (2) ways to identify a patient.

The patient's room number and location
cannot be used to identify the patient.
Patients are identified when:
1. Giving medicines, blood or blood products.
2. Taking blood samples and other specimens for
clinical testing.
3. Providing any other treatments or procedures.

Improve Effective
Communication.

Effective communication-which is timely, accurate,

complete, unambiguous, and understood by the
recipient reduces errors and results in improved
patient safety.

Communication can be electronic, verbal, or written.

The most error-prone communications are patient

care orders given verbally and those given over the
telephone, when permitted.

Another error-prone communication is the reporting

back of critical test results.
(JCIA 4th Edition, 2011)

A policy to be collaboratively developed

that address:

the accuracy of
communications.

verbal

and

telephone

The complete verbal and telephone order or

test result is written down read back by the

receiver of the order or test result those must
be confirmed by the individual who gave the
order or test result.

NOTE: Not all countries permit verbal or

telephone orders.

Improve the Safety of

High-Alert Medications

When medications are part of the patient treatment

plan, appropriate management is critical to ensure
patient safety.

High-alert medications are those medications involved

in a high percentage of errors and/or sentinel events,
medications that carry a higher risk for adverse
outcomes, as well as look-alike, sound-alike
medications.

Lists of high-alert medications are available from

organizations such as the World Health Organization or
the Institute for Safe Medication Practices.
(JCIA 4th Edition, 2011)

A frequently cited medication safety issue is the

unintentional administration of concentrated
electrolytes (for example, potassium chloride
[equal to or greater than 2 mEq/mL concentrated).

Errors can occur when staff are not properly

oriented to the patient care unit, when contract
nurses are used and not properly oriented, or
during emergencies.

The most effective means to reduce or eliminate

these occurrences is to develop a process for
managing high-alert medications that includes
removing the concentrated electrolytes from the
patient care unit to the pharmacy.
(JCIA 4th Edition, 2011)

The organization should identify the

organizations
list
of
high-alert
medications based on its own data.

Concentrated electrolytes that are

clinically necessary as determined by
evidence and professional practice
should be clearly labeled and stored in a
manner that restricts access to prevent
inadvertent administration.

policy to be collaboratively
developed that address:
The

location, labeling, and

concentrated electrolytes.

storage

of

The Concentrated electrolytes are not present

in patient care units unless clinically

necessary and actions are taken to prevent
inadvertent administration in those areas.

Ensure Correct-Site,
Correct-Procedure,
Correct-Patient
Surgery

Wrong-site,
wrong-procedure,
wrong-patient
surgery is an alarmingly common occurrence in
health care organizations.

These errors are the result of:

Ineffective or inadequate communication between

members of the surgical team.
Lack of patient involvement in site marking.
Lack of procedures for verifying the operative site.

frequent contributing factors:

Inadequate patient assessment.

Inadequate medical record review.
A culture that does not support open communication
among surgical team members.
Problems related to illegible handwriting.
The use of abbreviations.

(JCIA 4th Edition, 2011)

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.

The (US) Joint Commissions Universal Protocol

is:
Marking the surgical site;
A preoperative verification process; and
A time-out that is held immediately before the start of

a procedure.

The surgical site Marking should:

Involve the patient.
Done with an instantly recognizable mark.
Be consistent throughout the organization.
Be made by the person performing the procedure.
Take place with the patient awake and aware, if possible.
Be visible after the patient is prepped and draped.
Marked in all cases involving laterality, multiple structures
(fingers, toes, lesions), or multiple levels (spine).

The purpose of the preoperative verification process is:

To verify the correct site, procedure, and patient.
To ensure that all relevant documents, images, and studies
are available, properly labeled, and displayed; and
To verify any required special equipment and/or implants
are present.

Use a checklist, including a Time-out" just

before starting a surgical procedure, to ensure
the correct patient, procedure, and body part.

Develop a process or checklist to verify that all

documents and equipment needed for surgery
are on hand and correct and functioning properly
before surgery begins.

Mark the precise site where the surgery will be

performed. Use a clearly understood mark and
involve the patient in doing this.

 Goal

5:

Reduce the Risk of

Health Care
Associated Infections

Infection
prevention
and
control
are
challenging in most health care settings, and
rising rates of health careassociated infections
are a major concern for patients and health
care practitioners.
Infections common to many health care
settings include catheter-associated urinary
tract infections, bloodstream infections, and
pneumonia (often associated with mechanical
ventilation). Central to the elimination of these
and other infections is proper hand hygiene.
(JCIA 4th Edition, 2011)

 Internationally

acceptable
hand
hygiene guidelines are available from
the World Health Organization (WHO),
the United States Centers for Disease
Control and Prevention (US CDC), and
various
other
national
and
international organizations.
(JCIA 4th Edition, 2011)

Comply with current published and generally

accepted hand hygiene guidelines.

Implements
program.

Develop policies and/or procedures that

address reducing the risk of health care
associated infections.

an

effective

hand

hygiene

NOTE: This should recognize that not all countries have a

CDC (Centers for Disease Control and Prevention) or may

not recognize the US CDC.

Reduce the Risk of

Patient Harm Resulting
from Falls

Falls account for a significant portion of injuries in

hospitalized patients.

the organization should evaluate its patients risk

for falls and take action to reduce the risk of falling
using a fall-risk reduction program that based on
appropriate policies and/or procedures.

The evaluation could include fall history,

medications and alcohol consumption review, gait
and balance screening, and walking aids used by
the patient.
(JCIA 4th Edition, 2011)

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.

Improve
the Safety
of HighAlert
Medicatio
ns

Ensure
Correct-Site,
CorrectProcedure,
Correct-Patient
Surgery

Reduce the
Risk of
Health
CareAssociated
Infections

Reduce the
Risk of
Patient
Harm
Resulting
from Falls

The
organization
develops an
approach to
reduce the
risk of health
care
associated
infections

The
organization
develops an
approach to
reduce the
risk of patient
harm
resulting from
falls

Comply
with hand
hygiene
and
precautions
as in policy.

Patient fall
assessment /
reassessment
and
managemen
t as
addressed in
policy

Identify
Patients
Correctly

Improve
Effective
Communi
cation

The
organization
develops an
approach to
improve
accuracy of
patients
identification

The
organization
develops an
approach to
improve the
effectiveness
of
communicati
on among
caregivers

The
organization
develops an
approach to
improve the
safety of highalert
medications

The
organization
develops an
approach to
ensuring
correct-site,
correct
procedure
,and correctpatient
surgery

Write down
Verbal and
telephone order
or test result and
read it back.
Then confirmed
by the person
who gave the
order

identification,
location, labeling,
and storage of
high-alert
medications and
the concentrated
electrolytes
presence in
patient care units
are addressed by
policy

Comply with
time-out
process that
includes site
marking,
equipment
readiness and
correct patient
and procedure
prior to
procedure or
operation.

Use of two
identifiers
before
Administering
medications,
blood, or blood
products and
Before taking
blood and other
specimens for
clinical testing

Patient 60 years old admitted to ER complaining of sever chest pain. ECG ,

Cardiac enzymes, CBC and KFT were done (IPSG 1: Identify patient correctly).
The ECG shown massive MI and the cardiac enzymes were critically high (IPSG
2: Improve Effective Communication). Patient transferred urgently to Cardiac
Catheterization Lab which indicated the need for open heart surgery as result of
left main 95% occlusion. Therefore, after doing the success surgery (IPSG4:
Ensure correct site, correct procedure and correct patient), patient was
transferred to CVICU Which was assessed by the registered nurse and found that
the patient at high risk of fall (IPSG 6: Reduce the Risk of Patient Harm Resulting
from Falls). In the next day the Lab technician called to notify low potassium
level (IPSG 2: Improve Effective Communication) and the consultant was not
reachable. So, the nurse called him and he ordered her to give 20meq of
potassium IV (IPSG 2: Improve Effective Communication). So that, the complete
order carried out using the medication that was stored in lucked key (secured)
box, red labeled which given after double check (IPSG3: Improve safety of high
alert medication). The patient was transferred to ward considering the
documented risk of fall precaution by assisting him in ambulation, proper
teaching, raised side rails and low bed level (IPSG 6: reduce patient harm
resulting from falls). Finally, patient was discharged with free of infection
because of physicians, nurses and other staff who dealt with patient were strict
to follow hand Hygiene (IPSG5: reduce the risk of healthcare associated
infections).