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What is Patient Safety?In its simplest form,

patient safety is “prevention of harm to

patients.”

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• Infection control (IC) is a quality standard that is essential for the well being and safety of patients.• It affects most departments of the hospital and involves issues of quality, risk management, clinical governance and health and safety.

Infection Control

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Identification Communication Medication Eliminate Infection Falls

International Patient SafetyGoals

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Identification

Identify Patients Correctly

Use at least two (2) ways to identify a patient

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IPSG.1Identify Patients Correctly

A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification

Use at least two (2) ways to identify a patient:

• giving medications• giving blood and blood products• taking blood samples• taking other samples for clinical testing• providing treatment or procedure

The patient’s Room Number cannot be used as an identifier

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Verification Process

Correct Patient (Identification)Scope: All radiology procedures

Ask the patient

“What is your FULL NAME?”

“What is the name of the PROCEDURE you are having today?”. Also ask SITE/SIDE if required

Never state patient’s Name

“Do not tell the patient… the patient tells you”

E.g. Call “Mr. Abdullah”, then ask the above questionsincluding additional questions related to clinical history as outlined on Request Form

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Correct Patient (Identification) Cont.

Inpatients1. Ask patient to state Full Name/ Procedure

2. Check responses against Referral Form & Patient ID Band (wrist/ankle) including MRN– MANDATORY

Do Not Proceed if : Patient ID Band is absent. Call Ward Nurse to personally ID

patient and complete Time Out Verification sticker (all personnel sign).

Patient can not verbalise identity. Nurse Escort must verify patient identity. Complete Time Out Verification sticker (all personnel sign).

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Verification Process - Cont.

Outpatients1.Ask patient to state Full Name/ Procedure

2.Check responses against Referral Form

Do Not Proceed if :

Patient can not verbalise identity.

Proceed only after :

Identity is verified by accompanying relative, family member, friend or healthcare interpreter.

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Reinforcing the Message

Displayed at all imaging consoles

Have you checked the Patient ID ?

- Prior to the Procedure -

Are you sure !

Asked patient their:• Name• (Procedure)Checked response & MRN against ID Band & Request Form

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Communication

Improve Effective Communication

Implement a process/procedure for taking verbal or telephone orders

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A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications

IPSG 2: Improve Effective Communication

Person receiving the following:

• Verbal order• Telephone order• Reporting of critical test results

Must use a verification “read back” of complete 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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Critical Test Results

Ensure that there is collaborative process to determine what they are Clinical Laboratories

Bedside testing Imaging Studies Electrocardiogram Pulmonary Function Testing other

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“Do Not Use” list:

u IU qd qod Leading decimal point

(always use a Leading zero)

Trailing zero

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Medication Safety

Improve the Safety of High-alert Medications

Remove concentrated electrolytes from patient care units

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A collaborative process is used to develop policies and/or procedures that address the location, labeling and storage of concentrated electrolytes

Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy

IPSG 3: Improve Safety of High Alert Medications

Remove concentrated electrolytes from patient care units

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Eliminate

Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery

Use a checklist, including a “time-out,” before surgery

Verify that documents and equipment are correct and functioning properly before surgery

Mark precise site where surgery will be performed

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IPSG 4: Ensure Correct-site, Correct-procedure, Correct-patient Surgery

Collaborative process used to develop P&P

Mark the precise site in clearly understood way and involve patient in doing this

Develop process or checklist to verify correct documents and functioning equipment

Use a Checklist including “Time-Out” just before surgical procedure

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Team Time Out –Interventional (invasive) Radiology(All invasive procedures covering CT / Ultrasound / Angiography / Mammography and selective Screening procedures)In procedure room, with patient present.Confirm patient ID, request/consent forms, image data all correct.Site marked by interventional doctor.

Team Leader calls Time Out immediately prior to procedure commencement (patient draped) to confirm: Verification of patient identity (Full Name/MRN/ID Band)

Agreement on the intended procedure Verification of correct position i.e level & side Verification of the visible marked site Availability of correct implants/equipment/medication

– DO NOT proceed until resolve discrepancies (document)٢٠

Universal Protocol

SURGERYSITE

DOCUMENTS

EQUIPMENT

BODY PARTPROCEDURE

PATIENT

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Reduce the Risk of Health Care-acquired Infections

Comply with current published and distributed hand hygiene guidelines

IPSG 5: Reduce the Risk of Health Care-Associated Infections.

A collaborative process is used to develop P&P that address reducing the risk of health care–associated infections

Infections

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Contact Precautions

Airborne Precautions

Droplet Precautions

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Falls

Reduce the Risk of Patient Harm Resulting from Falls

Assess and periodically reassess each patient’s risk for falling

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Falls are a common cause of morbidity and the leading cause of nonfatal injuries and trauma-related hospitalizations.

Falls occur in all types of healthcare institutions and to all patient populations.

In hospitals, falls consistently make up the largest single category of reported incidents.

FALLS

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IPSG 6: Reduce the Risk of Patient Harm resulting from Falls

Develop P&P using collaborative process Assess and periodically Reassess each

patient’s risk for falling, including the potential risk associated with the patient’s medication regime,

Take action to decrease or eliminate any identified risks.

A fall can be prevented by thoughtful strategies designed for the individual patient (e.g., a low bed).

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Improving Patient Safetymeans . . .

Reducing Medical Errors

Reducing HAIs

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WHO Patient Safety WHO Patient Safety was launched in October

2004 with the mandate to reduce the adverse health and social consequences of unsafe health care

An essential element of WHO Patient Safety is the formulation of a Global Patient Safety Challenge: a topic that covers a significant aspect of risk to patients receiving health care, relevant to every WHO Member State

The First Global Patient Safety Challenge was launched in 2005

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Through the promotion of best practices in hand hygiene, the First Global Patient Safety Challenge aims to reduce health care-associated infection (HCAI) worldwide

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HCAI rates reported from developing countries

Type of survey Prevalence

(%)

Incidence

(%)

Incidence (per 1000

patient-days)

Incidence (per 1000

device-days)

Hospital-wide 4.6–19.1 2.5–5.1 9.7–41.0

Adult ICU 18.4–77.2 4.1–38.9 18.2–90.0

Neonatal ICU 2.9–57.7 2.6–62.0

SSI 1.2–38.7

VAP 2.9–23.0

CR*-BSI 1.7–44.6

CR*-UTI 3.2–51.0

WHO Guidelines on Hand Hygiene in Health Care (2009)٣٠

Device-associated infection rates in ICUs in developing countries compared with NHSN rates

Surveillance network,study period, country Setting

N°patients CLA-BSI* VAP* CR-UTI*

INICC, 2002–2007,18 developing countries†1 PICU 1,808 6.9 7.8 4.0

NHSN, 2006–2007, USA2 PICU / 2.9 2.1 5.0

INICC, 2002–2007, 18 developing countries†1

AdultICU # 26,155 8.9 20.0 6.6

NHSN, 2006–2007, USA2 AdultICU# / 1.5 2.3 3.1

* Overall (pooled mean) infection rates/1000 device-daysINICC = International Nosocomial Infection Control Consortium; NHSN = National Healthcare Safety Network; PICU = paediatric intensive care unit; CLA-BSI = central line-associated bloodstream infection; VAP = ventilator-associated pneumonia; CR-UTI = catheter-related urinary tract infection.

1Rosenthal V et al. Am J Infect Control 20082NHSN report. Am J Infect Control 2008† rgentina, Brazil, Chile, Colombia, Costa Rica, Cuba, El Salvador,

India, Kosova, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, Turkey, Uruguay#Medical/surgical ICUs

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Most frequent sites of infection and their risk factors

LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency

13%

BLOOD INFECTIONSVascular catheterNeonatal ageCritical careSevere underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologiesLack of training and supervision

14%

SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxisIncorrect surgical skin preparationInappropriate wound careSurgical intervention durationType of woundPoor surgical asepsisDiabetesNutritional stateImmunodeficiencyLack of training and supervision 17%

URINARY TRACT INFECTIONSUrinary catheterUrinary invasive proceduresAdvanced ageSevere underlying diseaseUrolitiasisPregnancyDiabetes

34%

Most common sites of health care-associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

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HOSPITAL ENVIRONMENT

HIV

TB ٣٣

How are infections transmitted?How are infections transmitted?

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How to Break the Chain of Infection????

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Hand hygiene is the simplest, most effective measure for preventing

Healthcare -Associated Infections.

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30%-40% of all HAIs are Attributed to Cross Transmission:

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What is the KKH Multimodal Hand What is the KKH Multimodal Hand Hygiene Improvement Strategy?Hygiene Improvement Strategy?

Based on the evidence and recommendations from the WHO Guidelines on Hand Hygiene in Health Care (2010), a number of components make up an effective multimodal strategy for hand hygiene

ONE System changeAccess to a safe, continuous water supply as well as to soap and towels; readily accessible alcohol-based handrub at the point of care

TWOTraining / Education Providing regular training to all health-care workers

THREE Evaluation and feedback Monitoring hand hygiene practices, infrastructure, perceptions and knowledge, while providing results feedback to health-care workers

FOUR Reminders in the workplacePrompting and reminding health-care workers

FIVE Institutional safety climateCreating an environment and the perceptions that facilitate awareness-raising about patient safety issues

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Most common mode of transmission of pathogens is via hands!

Infections acquired in healthcare Spread of antimicrobial

resistance

So Why All the Fuss About Hand Hygiene?

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All health care’s works involve the hands

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Handsspreadgerms

Hands are contaminated

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The health care environment is contaminated

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The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2007, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

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The inanimate environment is a reservoir of pathogens

Recovery of MRSA , VRE & ACINITOBACTER.

Devine et al. Journal of Hospital Infection. 2007;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2006

Walther et al. Biol Review, 2007:849-869٤٧

The Iceberg EffectInfected

Colonized

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Colonized or Infected:What is the Difference?

People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized

If an infection develops, it is usually from bacteria that colonize patients

Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers

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Patients are vulnerable to infection

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Types of Hand HygieneNormal hand washingAntiseptic hand washingAlcohol-based hand rubCan be used instead of hand washing , if hands are not visibly soiled with blood or any other patient body fluids

Surgical hand wash

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Routine Hand Washing

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Antiseptic Hand Washing

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Waterless Hand Rub “alcohol-based hand rub

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Efficacy of Hand Hygiene Preparations in Killing Bacteria

Good Better Best

Plain soap Antimicrobialsoap

Alcohol-basedhand rub

Guideline for Hand Hygiene in Health-Care Settings MMWR,2010. vol. 51, no. RR-16.

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Hand Hygiene Options

~ Use soap and water for visibly soiled hands ~~ Do not wash off alcohol handrub ~

Apply to palm; rub hands until dry

Wet hands, apply soap and rub for

>10 seconds. Rinse, dry & turn

off faucet with paper towel.

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Surgical Hand Wash

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Areas Most Frequently Missed

HAHS © 1999٦١

Hand Hygiene

Hand Hygiene Comment

Typical Compliance

Observational studies of hand hygiene report compliance rates of 5-81%

Common Reported Barriers To Compliance

Insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants and lack of hand hygiene promotion by the institution

Compliance

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With hand hygiene they’re dead ٦٣

Skin irritation Inaccessible hand washing

facilitiesWearing glovesToo busy Lack of appropriate staffBeing a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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Why Not?Working in high-risk areas Lack of hand hygiene

promotion Lack of role model Lack of institutional priority Lack of sanction of non-

compliers

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Successful Promotion

Education Routine observation & feedback Engineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs

available Patient education

(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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Successful Promotion

Reminders in the workplacePromote and facilitate skin careAvoid understaffing and

excessive workload; Nursing shortages have caused

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SAVE LIVES: Clean Your Hands5 May 2009–2020

Through an annual day focused on hand hygiene improvement in health care, this initiative promotes continual, sustainable best practice in hand hygiene at the point of care in all health-care settings around the world

Clean Care is Safer CareThe First Global Patient Safety Challenge

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Hand CareNailsRingsHand creamsCuts & abrasions“Chapping”Skin Problems

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Fingernails & Artificial Nails Keep fingernails short

Allows thorough cleaning and prevents glove tears

Long nails make glove placement more difficult and may result in glove perforation

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Fingernails & Artificial Nails

Follow MCH policy regarding artificial fingernails; use of artificial fingernails is not allowed.

USAF Guidelines for Infection Control in Dentistry, 2004.٧٢

What is the Story on Moisturizers and Lotions?

ONLY USE facility-approved and supplied lotions

Because: Some lotions may make medicated

soaps less effective Some lotions cause breakdown of latex

gloves Lotions can become contaminated with

bacteria if dispensers are refilled

~ Do not refill lotion bottles ~ ٧٣

Gloves are not a substitute for handwashing!

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Gloves are not a substitute for handwashing!

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Wearing gloves does not replace the need for hand hygiene

Small, inapparent defects

Frequently torn during use

Hands frequently become contaminated during removal

DeGroot-Kosolcharoen 2004, Korniewicz 1999, Kotilainen 2001, Olsen 1998, Larson 2005, Murray 2001, Burke 2005, Burke 1990, Nikawa 1994, Nikawa 2006, Otis 2007 ٧٥

What is the single most important reason for healthcare workers to practice good

hand hygiene?

1. To remove visible soiling from hands2. To prevent transfer of bacteria from

the home to the hospital3. To prevent transfer of bacteria from

the hospital to the home 4. To prevent infections that patients

acquire in the hospital

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How often do you clean your hands How often do you clean your hands S INTACT S INTACT ’’PATIENTPATIENTafter touching a after touching a

(for example, when measuring (for example, when measuring SKINSKINa pulse or blood pressurea pulse or blood pressure)?)?

1.1. AlwaysAlways

2.2. OftenOften

3.3. SometimesSometimes

4.4. NeverNever

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clean your YOUEstimate how often hands after touching a patient or a contaminated surface in the hospital?

1. 25%2. 50%3. 75%4. 90%5. 100%

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1. Plain soap and water2. Antimicrobial soap and

water3. Alcohol-based hand rub

Which hand hygiene method is best at killing bacteria?

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Which of the following hand hygiene agents is LEAST drying to your skin?

1. Plain soap and water2. Antimicrobial soap and

water3. Alcohol-based hand rub

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It is acceptable for healthcare workers to supply their own lotions to relieve dryness of hands in

the hospital.

1. Strongly agree2. Agree3. Don’t know4. Disagree5. Strongly disagree

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Healthcare-associated organisms are commonly resistant to alcohol.

1. Strongly agree2. Agree3. Don’t know4. Disagree5. Strongly disagree

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When a healthcare worker touches a patient who is COLONIZED, but not infected with resistant

organisms (e.g., MRSA or VRE) the HCW’s hands are a source for spreading resistant organisms to

other patients.

1. Strongly agree2. Agree3. Don’t know4. Disagree5. Strongly disagree

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A co-worker who examines a patient with VRE, then borrows my pen without cleaning his/her

hands is likely to contaminate my pen with VRE.

1. Strongly agree2. Agree3. Don’t know4. Disagree5. Strongly disagree

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How often do you clean your hands after touching an ENVIRONMENTAL SURFACE near a patient (for

example, a countertop or bedrail)?

1. Always2. Often3. Sometimes4. Never

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Use of artificial nails by healthcare workers poses no risk to patients.

1. Strongly agree2. Agree3. Don’t know4. Disagree5. Strongly disagree

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Glove use for all patient care contacts is a useful strategy for reducing risk of

transmission of organisms.

3. Don’t know4. Disagree5. Strongly

disagree٨٨

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Infection Control is Everyone’s Responsibility!

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Each Healthcare Provider is like a piece of a jigsaw puzzle: each piece needs to fit together to form a best

Infection Control Practices!

PhysiciansNurses

Non ClinicalStaff

Phlebotomists

Patient/Family

Pharmacists

RespiratoryTherapists

Paramedics

AdministrativeStaff

Patient CareAssistant

Dieticians٩٢

Teamwork and Effective Communication For Patient Safety

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HAND HYGIENE AWARENACE

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