PATIENT SAFETY MANUAL FOR ICU

Table of content-

Important Phone Number…………………………………….1

Staffing pattern................................................................…...2

Safety protocols......................................................................3

Levels of incidents and protocols to be followed…………….4

Knowledge based information on safety issues…………...4, 5, 6

List of documentation………………………………………...6

Communication protocols…………………………………..7, 8

References…………………………………………………….8

Reception-1000

Medical director-1001

Head of department-1021

Infection control committee-1022

Hospital Safety Officer-1030

Fire Protection Engineer-1111

Bio-Medical Officer- 1031

Page | 1
 PATIENT SAFETY MANUAL FOR ICU

STAFFING OF THE ICU

1. Consultant Medical Staff

Director
Deputy Director
Director of Research
Supervisor of Training
Consultants
2. Senior Nursing Staff
Nursing Director
Clinical Services Coordinators
Nurse Managers
3. Administrative Staff
Administrative Manager
Team Leader / Roster Manager
Unit Secretary
Ward Clerks

PURPOSE:

 Setting up of standards and ensuring their implementation at

ground level.
 To prepare safety guidelines for achieving utmost patient safety.
 To ensure Patient and employee awareness towards safety
measures.
 To develop and implement ICU risk management and quality
improvement plans that include patient safety as a core value

SCOPE:

 Ensuring compliance of all the set rules and regulations in

conformance of state standards.
 Ensuring safety of patients as well as employees.

Page | 2
 PATIENT SAFETY MANUAL FOR ICU

 Ensuring documentation of all the standards for implementation

and review.
 Avoiding all incidences which might result in injury.

SAFETY PROTOCOL TO BE FOLLOWED IN THE ICU

• Clearly label patient beds; consider having a removable sign at the

foot of the bed with the patient's name and bed number.
• Verify patient identification by verbally communicating with the
patient and/or check patient's identification band.
• Institute a standard change of shift policy, where nurses handing
off patients personally review orders during their shift with
oncoming nurses to clarify complete and incomplete orders.
• Open communication among all staff is a key element for
successful teamwork.
• Ask questions and avoid making assumptions.
• Perform a medication audit on each patient once during each shift,
which could be performed at change of shift.
• Create a mentoring culture for medical students, residents, nurses
and other ICU staff where every question is welcomed and proper
supervision is exercised.
• Check the Pyxis machines daily to ensure medications and doses
are stored in appropriate bins.
• Incorporate "check backs" during provider team and patient
interactions, where providers repeat an order during a handoff to
help verify information transfer.
• Incorporate independent redundancies into patient care. An
independent redundancy is when more than one person checks to
make sure a clinical process is executed properly. For example,
when a physician orders a medication, a nurse checks the
medication order (first redundancy) for patient allergies and other
Page | 3
 PATIENT SAFETY MANUAL FOR ICU

drug interactions. This action is followed by a pharmacist who also

checks the medication order (second redundancy) for patient
allergies and multiple drug interactions.
• Reconcile drugs at the time a patient is discharged. Specifically, a
nurse should complete a standardized form and confirm allergies
and home medications, and resolve discrepancies before the patient
is discharged.
• Use a rolling line cart to keep all sterile supplies needed for
insertion and maintenance of central line catheters.
VARIOUS LEVELS OF INCIDENTS AND THE PROTOCOL TO BE
FOLLOWED IF AN INCIDENT OCCURS

✔ All incidents must be reported by the employees concerned to their

supervisor immediately and without unreasonable delay at the end
of each shift.
✔ Patients who are more prone to a specific risk must be closely
monitored.
✔ Nursing staff should ensure that patients and family member are
well oriented with the layout of the unit.
✔ An incident report should be completed at the end of the shift
within 24 hours.
✔ A detailed documentation will be entered into the patient records.
✔ Ensure incident is well communicated to all shifts.

KNOWLEDGE BASED INFORMATION ON SAFETY ISSUES AS

WELL AS STEPS TO BE TAKEN IF STAFF FEELS THAT SAFETY
OF THE PATIENT CAN BE COMPROMISED.

• PRONE POSITIONING
Prone positioning may be used in the Intensive Care Unit in an attempt to
improve arterial oxygenation and pulmonary mechanics in patients with
acute lung injury or acute respiratory distress syndrome (ARDS).

Page | 4
 PATIENT SAFETY MANUAL FOR ICU

Relative contraindications to prone positioning:

1. Increased intracranial pressure

2. Hemodynamic instability
3. Spinal instability
4. Unstable bone fractures
5. Abdominal surgery
6. Abdominal compartment syndrome
7. Active intra-abdominal process
8. Pregnancy

• BED SIDE ITEMS

1. The following items are kept at each bedside:
6 - Size 14 suction catheters
6 - Sterile gloves (3 size 7 ½, 3 size 8)
1 – Full suction set-up & canister
1 - Sphygmomanometer with cuff
1 – Oxygen flow meter
1 – IV pole, pump & module
1 – Motor device for foot/leg pumps (kept in pt. closet)
2. A container with supplies on bedside table, with minimally:
2 - 6’ suction tubing
2 –Suction catheters
2 - Pulse oximetry probes
6 - Electrode patches
6 - 2 x 2 gauze
6 - 4 x 4 gauze
6 – Needleless IV access ports
6 – IV caps
1 - 1" waterproof tape
1 – Transpore tape
1 - Tourniquets

Page | 5
 PATIENT SAFETY MANUAL FOR ICU

6 - Sterile Q-Tips
6 - Sterile tongue depressors
6 - Tegaderm, small & large
6 - Surgilube
6 - Chlorhexidine preps or swabs
10 - Alcohol swabs
3. Nightstand containing:
Bedpan
Urinal
Roll of toilet paper
4. Additional items pertinent to patient care (i.e. dressing supplies) may be
stocked at the bedside as needed.

• CONTINUOUS MOVEMENT OF THE PATIENT

Continuous movement of the patient is necessary to avoid painful bed
sores, which occur due to lack of movements in ICU patients.

LIST OF DOCUMENTATION

 ICU Admission Register-

a. This is to ensure that clinics are aware when a patient has been
admitted under their bed card.
b. The admission note should incorporate all relevant aspects of the
patient’s medical history, clinical examination and results of
appropriate investigations.
 Fumigation Book-
a. Details about fumigation carried out in department.
 Daily case-note entries-
a. Notes are most efficiently recorded so that current results and
management plans are recorded
b. Significant changes in physical condition necessitating changes in
management, e.g. renal failure requiring dialysis.

Page | 6
 PATIENT SAFETY MANUAL FOR ICU

c. Invasive procedures, e.g. laparotomy, tracheostomy, PAC/CVC

insertion.
d. Results of specific investigations or tests, e.g. CT scans, endocrine
tests
e. Changes in policy, e.g. non-escalation of treatment, advance
directives.
 Handover summary
a. Due to the large number of complex patients, an ongoing handover
summary should be established for each patient
b. This facilitates ease of handover between day and night resident
staff and for the duty consultant staff.
 Transfer Register-
a. Details about transferred patient from ICU
 Bio-medical equipment check book-
a. Book about bio-medical eqpt. function and working.
 CSSD book-Book about sterile pack record etc.
 Breakdown Book-Details of break down record.
 Discharge Register-
a. Details of patient discharge data.
b. This is a single page document outlining all relevant transfer
information.

HOSPITAL SPECIFIC INFORMATION ON THE

COMMUNICATION PROTOCOLS

Hospital medical emergency code is “123#”.

Upon dialling 123#, switchboard automatically pages the following people:
♦ ICU registrar
♦ ICU equipment nurse
♦ Medical registrar

In case of Code Blue *all calls must be attended immediately

♦ Cardiac or respiratory arrest.
Page | 7
 PATIENT SAFETY MANUAL FOR ICU

♦ Threatened airway.
♦ Major haemorrhage

In case of Fire
a) A copy of the hospital emergency procedures (fire, smoke, bomb-threat)
is kept in the nursing stations.
b) The chief fire and emergency officer is the overall controller during a
fire or smoke emergency (code red).
c) Become familiar with the location of fire exits, extinguishers and
blankets in the Unit.
i. Unless a fire is small and easily contained do not attempt to fight
the fire yourself.
ii. Remove yourself from the immediate vicinity of the fire, alerting
other staff members as indicated, and position yourself behind the
automatic fire doors.
iii. Wait for the arrival of the Fire Chief and assist in any patient
movement/evacuation only as indicated by the Fire Chief.
d) Role of medical staff:
i. There is no place for “heroic” action. Ensure your own safety first.
ii. Wait for the arrival of the fire fighting officials.
iii. Assist in patient assessment/management under the coordination of
the Fire Chief.
iv. In the event of a significant fire / smoke hazard, staff will only re-
enter the danger zone in the immediate company of a fire-fighter,
with appropriate breathing apparatus.

REFERENCES:
 http://www.icuadelaide.com.au/files/manual_icu.pdf
 http://www.innovations.ahrq.gov/content.aspx?id=1848
 http://nursing.uchc.edu/unit_manuals/intensive_care/docs
 http://www.mihealthandsafety.org/icu/9.htm
 http://patientsafety.esicm.org/press.asp

Page | 8