IPSG Updated As Per 7th Edition With Huddles

King Fahd Armed Forces Hospital, Jeddah
Continuous Quality Improvement & Patient Safety Department

Why?
Its all about Patient Safety!!!!!
How did we do so far?
JCI Standards
Health care Patient-

Organization Centered
Management Standards
Standards
IPSG’s
6 IPSGs
3-Improve the Safety

1-Identify Patients 2-Improve Effective of High-Alert
Correctly Communication Medications
6-Reduce the Risk of

4-Ensure Safe Surgery Patient Harm
5-Reduce the Risk of Health
Resulting from Falls
Care–Associated Infections
in and out patients
IPSG 1: patient Identification
• Patients must be identified using “ 2 unique

identifiers” :
1. FULL NAME : using all 3 names ( first, father, family
name)
2. Patient's MEDICAL RECORD NUMBER (MRN)

GOAL 1
IDENTIFY PATIENT CORRECTLY
The hospital develops and implements a process to improve accuracy of

IPSG.1 P patient identifications.
At least two patient identifiers, that do not include the use of the
ME 1 patient’s room number or location in the hospital, are used to identify
the patient and to label elements associated with the patient’s care and
treatment plan.
Patients are identified before performing diagnostic procedures,

ME 2 providing treatments, and performing other procedures.
The hospital ensures the correct identification of patients in special

ME 3 circumstances, such as the comatose patient or newborn who is not
immediately named.
IPSG 1King IDENTIFY PATIENT
Fahd Armed Forces Hospital, CORRECTLY
Jeddah
POLICY
The hospital develops and implements a process to improve accuracy of patient

identification
PRG11.504
No’s!!!!!
Bed number
Room Number
Location
IPSG 1 Patients are identified before
1. Performing diagnostic procedures ( taking

blood, cardiac catheterization)
2. Providing treatments
3. Performing procedures (insertion of an IV or

hemodialysis procedure)
2 Nurses
Continuous signed
Quality on the
Improvement blood
& Patient request
Safetyin form
Department
the specified area to confirm identification
Special Circumstances
Newborn
Footprint
 ID band for Baby and Mother
 Newborn Photo
New form: New born babies
Special Circumstances
• Unknown or unconscious patient :
i. Unknown male patient's ID band state :

“Adam 1, Adam 2”
ii. Unknown female patient's ID band state:

“Hawa 1, Hawa 2 ”
GOAL 2 IMPROVE EFFECTIVE
COMMUNICATION
The hospital develops and implements a process to improve

IPSG.2 P the effectiveness of verbal and/or telephone communication
among caregivers.
ME 1 Complete verbal orders are documented and read back by the

receiver and confirmed by the individual giving the order.
Complete telephone orders are documented and read back by

ME 2 the receiver and confirmed by the individual giving the order.
Complete test results are documented and read back by the

ME 3 receiver and confirmed by the individual giving the result
IPSGKing2 FahdIMPROVE EFFECTIVE
Armed Forces Hospital, Jeddah
COMMUNICATION POLICY
The hospital develops and implements a process to

improve the effectiveness of verbal and/or
telephone communication among caregivers.
PRG11.503 & PRG11.514& PRG11.532
Verbal/Telephone Order
• Only emergency and urgent situations

– Documented in the physician order sheet.
• Health care practitioner

– WRITE IT down,
– READ the order BACK
– physician shall CONFIRM .
• Verbal order authentication (physicians signature) as soon as the

emergency is over .
• All telephone order must be authenticated (physicians signature)

within 24 hrs of the order
IPSG.2.1 P The hospital develops and
implements a process for reporting critical
results of diagnostic tests.
The hospital defines critical results that may

ME 1 represent urgent or emergent life-threatening
values for diagnostic tests.
The hospital develops a formal reporting process,

used throughout the hospital that identifies how
ME 2 critical results of diagnostic tests are
reported/communicated to health care
practitioners.
ME 3 The hospital identifies what information is

documented in the medical record.
Critical Result Reporting
• Results that are significantly outside the normal range
• KFAFH defines critical values for each type of diagnostic test

and its accessible via electronic system
• Reported immediately
– 30 minutes for laboratory
– 60 minutes for imaging)
• It is the responsibility of the interpreting radiologist and

technician to notify the requesting physician.
Critical Result Reporting
• The receiver shall
– WRITE down the critical results
– READ BACK the information provided
• (patient’s name , MRN, reporter ‘s name, type of test , and
critical value of the result)
– CONFIRM the information to the person who is reporting

INPATIENT Reporting Process
As soon as results are available : shall call or page the

physician.
MRP Physician
5 minutes
On call Physician
Physician or on call physician

Charge nurse
15 minutes
Site manager
Clinical Director of the concerned service
Director of medical administration
Follow up with CQI & PS
Fill Incident Report

IPSG.2.2 P
The hospital develops and implements a
process for handover communication.
ME 1 Standardized critical content is communicated between

health care practitioners during handovers of patient care.
Standardized forms, tools, or methods that support a

ME 2 consistent and complete handover process are utilized.
Data from adverse events resulting from handover

ME 3 communications are tracked and used to identify ways in
which handovers can be improved, and improvements are
implemented.
Handover Process
Is the transfer of
professional
responsibility &
accountability
to another person
or professional group on
a temporary or
permanent basis
Trace the lines

Handover Process
• Handover tool (ISBAR) should be use during the following
situation:
During shift changes, break time (physician to physician, or physician to
nurse)
During transfer of Patient care to another unit ,diagnostic or other

Check the
treatment department within the hospital alarms
Discharge ( between staff and patients/families)
Trace the lines

Check the
alarms
Trace the lines

Electronic Nursing ISBAR form (Trial in ICU)
Trace the lines

MSD-H-1-GLD-013
Continuous Safety
Quality Improvement & Patient Huddles
Safety Department
Safety huddle during shift change Example of NICU – Page 1
Tra
ce
the
lin
es
Safety huddle during shift change Example of NICU – Page 2
Handover Process Failure

Breakdown communication during any handover can
result in
adverse events
and
loss of information
GOAL 3 IMPROVE THE SAFETY OF
HIGH-ALERT MEDICATIONS
IPSG.3 P The hospital develops and implements a process to improve
the safety of high-alert medications.
ME 1 The hospital identifies in writing its list of high-alert

medications.
The hospital develops and implements a process for reducing

ME 2 the risk and harm of high-alert medications that is uniform
throughout the hospital.
ME 3 The hospital annually reviews and, as necessary, revises its list

of high-alert medications.
IMPROVE THE
King Fahd Armed ForcesSAFETY
Hospital, Jeddah OF
HIGH-ALERT MEDICATIONS
The hospital develops and implements a process to

improve the safety of high-alert medications.
PRG11.511
High-Alert Medications
• HAM: are the medications that causing significant harm to the patient
when used in error.
• Handling HAM during
–Preparing
–Dispensing
–Administration
• must be done by 2 Independent health care staff (Double checking)

• Segregated from other medication.
• Stored in red colored bins
• Auxiliary label indicating the phrase
“HIGH ALERT , DOUBLE CHECK” and a
caution symbol.
Available in all areas and in the hospital formulary booklet

IPSG.3.1 P TheKing hospital
Fahd Armeddevelops
Forces Hospital,
andJeddah
implements a
process to improve the safety of look-alike/ sound-
New
alike medications.
ME 1 The hospital identifies in writing its list of look-

alike/sound-alike medications.
The hospital develops and implements a process for

ME 2 managing look-alike/sound-alike medications that is
uniform throughout the hospital.
ME 3 The hospital annually reviews and, as necessary,

revises its list of look-alike/sound-alike medications.
Look-alike/sound-alike medication
• Store LASA medication separately from their pair.
• Use Tall Man lettering to emphasize differences.
• Examples :metFORMIN and metOPROLOL
• Printed on a yellow label on the shelf.
• Auxiliary label indicating
the phrase “LASA”
42
LookKing
Alike Sound
Fahd ArmedAlike (LASA)
Forces medication
Hospital, Jeddah s
Look A Like: Sound A Like:

Different Drugs With The Similar Different Drugs With Similar
Packaging Phonetics
Amlodipine
Nifedipine
LASA lists
Available in all areas and in the hospital formulary booklet
IPSG.3.2 P The hospital develops and
implements a process to manage the
safe use of concentrated electrolytes
New
Only qualified and trained individuals have access to

concentrated electrolytes, and they are clearly labeled
ME 1 with appropriate warnings and segregated from other
medications.
The hospital only stores vials of concentrated
ME 2 electrolytes outside of the pharmacy in situations
identified in the intent.
Standard protocols are followed for adult, pediatric,
and/or neonatal electrolyte replacement therapy to
ME 3 treat hypokalemia, hyponatremia, and
hypophosphatemia 45
Concentrated Electrolytes
• Examples: Calcium (all salts), Magnesium sulfate, Potassium (all

salts), Sodium acetate.
• Stored in a secured area in the critical units, segregated from
other medications.
• Stored in red Bins.
• Use Auxiliary labels “CONCENTRATED ELECTROLYTE,

MUST BE DILUTED” in addition to the “HIGH ALERT.
DOUBLE CHECK”
46
Unapproved abbreviations
• The word «unit» must be spelled out in all orders for insulin
and heparin.
• Dosages written in «U» or «u» are not accepted.
• (No abbreviations on drug charts)
OD = Forbidden
GOAL 4 ENSURE SAFE SURGERY
IPSG.4 P The hospital develops and implements a process for the preoperative
verification and surgical/ invasive procedure site marking.
The hospital implements a preoperative verification process through the use

of a checklist or other mechanism to document, before the surgical/invasive
procedure, that the informed consent is appropriate to the procedure; that
ME 1 the correct patient, correct procedure, and correct site are verified; and that
all required documents, blood products, medical equipment, and implantable
medical devices are on hand, correct, and functional.
The hospital uses an instantly recognizable and unambiguous mark for

ME 2 identifying the surgical/invasive site that is consistent throughout the hospital.
ME 3 Surgical/invasive site marking is done by the person performing the procedure

and involves the patient in the marking process.
IPSG 4 ENSURE SAFE SURGERY
The hospital develops and implements a process for the

preoperative verification and surgical/invasive procedure site-
marking.
MSD-H-I-IPSG-004
Surgical or
Invasive Procedure
Surgical Verificatio Site

Time-out
checklist n Marking
Full details
Lab test & Implant or
Identity Consent of all
images prosthesis
procedure
The full team
Continuous actively
Quality participates
Improvement in a time-out
& Patient process, which includes a)
Safety Department
through c) in the intent, in the area in which the surgical/invasive procedure
will be performed, immediately before starting the procedure.
ME 1
a) Correct patient identity (Also see IPSG.1)
b) Correct procedure to be done
c) Correct surgical/invasive procedure site
d) Completion of the time-out is documented and includes date and time
Before the patient leaves the area in which the surgical/invasive procedure
was performed, a sign-out process is conducted, which includes at least d)
through g) in the intent.
ME 2 d) Name of the surgical/invasive procedure that was recorded/written
e) Completion of instrument, sponge, and needle counts (as applicable)
f) Labeling of specimens (when specimens are present during the sign-out
process, labels are read aloud, including patient name) (Also see IPSG.1 and AOP.5.7)
g) Any equipment problems to be addressed (as applicable)
When surgical/invasive procedures are performed, including medical and

ME 3 dental procedures done in settings other than the operating theatre, the
hospital uses uniform processes to ensure safe surgery.
Perform Time-Out immediately before staring

surgery/invasive procedure, the surgical team must
conduct and document a Time-Out procedure.
To confirm:
Correct patient identity
Correct procedure to be done
Correct surgical/invasive procedure site

Inside OR
Outside OR
Invasive procedure out side OR:
 Invasive lines: central line, PICC

CT guided biopsy
 Lumbar puncture
MRI guided biopsy
 Chest tube insertion
Dental extraction
 Thoracentesis
Dental surgery
 Joint aspiration/injection
Epidural catheter placement
 Bone marrow biopsy
Myelograms
 Bronchoscopy
Percutaneous interventional and pain
 Incision and drainage
management procedure
GOAL 5 REDUCE THE RISK OF HEALTH
CARE–ASSOCIATED INFECTIONS
The hospital adopts and implements evidence-based

IPSG. 5 P hand-hygiene guidelines to reduce the risk of health
care–associated infections.
ME 1 The hospital has adopted current evidence-based

hand-hygiene guidelines.
The hospital implements a hand-hygiene program
ME 2 throughout the hospital.
Hand-washing and hand-disinfection procedures are

ME 3 used in accordance with hand-hygiene guidelines
throughout the hospital.
IPSG 5
REDUCE THE RISK OF HEALTH CARE–
ASSOCIATED INFECTIONS
The hospital adopts and implements evidence-based hand-

hygiene guidelines to reduce the risk of healthcare–associated
infections.
PRG10.378
Hand Hygiene
The My 5 Moments for Hand Hygiene approach defines the key
moments when health-care workers should perform hand hygiene.
Contaminated Areas
All Hospital Staff
HAND RUB:
Hand Disinfection Procedure
Duration of the entire
procedure: 20-30 seconds
All Hospital Staff
Hand Washing Technique

Duration of the entire
procedure: 40-60 seconds
King Fahd
Hospital leaders Armed Forces
identify Hospital, Jeddah
care processes that need
Continuous Quality Improvement
improvement, adopt, and& implement
Patient Safety Department
evidence-based
IPSG. 5.1 P
interventions to improve patient outcomes and reduce the risk
of hospital-associated infections.
Hospital leaders identify priority areas for improvement of

ME 1 hospital-acquired infections.
Hospital leaders identify and implement evidence-based

ME 2 interventions (such as bundles) for all applicable patients.
Evidence-based interventions (such as bundles) used to reduce

ME 3 the risk of health care–associated infections are evaluated by
health care practitioners for compliance and improvement in
clinical outcomes.
IPSG 5.1 POLICIES
MSD-H-1-PCI-036 PREVENTION OF INTRAVASCULAR DEVICE

INFECTION
PRG11.526: Use of bundle for prevention of healthcare associated
PRG10.371 Surgical Site Infection
PRG10.304: CDC NHSN Surveillance Definition Infection
PRG10.372: Central Line Blood stream Infections CLABSI
PRG10.373: Ventilated Patient Care Guideline
PRG10.374: Catheter Associated Urinary Tract Infection CAUTI

Central Line
Surgical site Bundle Associated Blood
(SSI ) Stream Infection
(CLABSI)
Catheter
Ventilator
Associated Urinary
associated
Tract Infection
Pneumonia (VAP)
(CAUTI)
Prevention and
tracking of Hospital
acquired Infection
(HAI)
Goal 6 Reduce the Risk of Patient
Harm Resulting from Falls
The hospital develops and implements a process to reduce the risk of
IPSG.6 P patient harm resulting from falls for the inpatient population.
The hospital implements a process for assessing all inpatients for fall
ME 1 risk and uses assessment tools/ methods appropriate for the patients
being served.
The hospital implements a process for the reassessment of inpatients

ME 2 who may become at risk for falls due to a change in condition or are
already at risk for falls based on the documented assessment.
Measures and/or interventions to reduce fall risk are implemented for

ME 3 those identified inpatients, situations, and locations within the hospital
assessed to be at risk. Patient interventions are documented.
IPSG 6
REDUCE THE RISK OF PATIENT HARM
RESULTING FROM FALLS POLICY
The hospital develops and implements a

process to reduce the risk of patient harm
resulting from falls.
PRG11.525
Risk of FALL
Fall:
Loss of upright position that results in landing on the floor or
sudden, uncontrolled, unintentional, downward displacement of
the body to the floor or hitting another object.
Assess and reassess each inpatient who are at risk of fall .
Screen all outpatient who are at risk of fall .

Risk of FALL
• Fall risk assessment and re-assessment will done :
At the time of admission
Every shift
On transfer from one unit to another
Post-operatively
Any change in condition
Following a fall
Automatic at risk for fall
– Obstetric patients
– Oncology and hematology
– Dialysis
– Pregnant
– Polypharmacy
Risk of FALL
• IN-Patients considered high risk of fall :
– All inpatient must be assed for fall risk
– Children under 2 years of age is

Fall Assessment Tools
r i s k For
o
F ll R P
F a Fal aed
u l t lR s
d isk
A
The hospital
Continuous Qualitydevelops and
Improvement implements
& Patient a process to reduce
Safety Department the
IPSG.6.1 P risk of patient harm resulting from falls for the outpatient
population.
The hospital implements a process for screening outpatients

ME 1 whose condition, diagnosis, situation, or location may put
them at risk for falls and uses screening tools/methods
appropriate for the patients being served.
When fall risk is identified from the screening process,

measures and/or interventions are implemented to reduce fall
ME 2 risk for those outpatients identified to be at risk, and the
screening and interventions are documented.
Measures and/or interventions to reduce fall risk are

ME 3 implemented in situations and locations in the outpatient
department(s) assessed to be a risk for falls.
Risk of FALL
• Out-Patients considered high risk of fall :
– Diabetic
– Psychiatric
– Physiotherapy
– Ophthalmology
– Autism
– Pediatrics
– Preventive clinic
Actions to decrease /eliminate Fall

Risks
 Identify patients at risk by Yellow ID band .
 Evaluate fall history, medications review, gait and
balance screening and walking aids used by the
patient.
 Elevate the side rails of the bed
 Put the bed in the lowest level
 Put sign if the floor is wet for any reason
 Help the patient when he get up or moving out of
the bed
In Summary

IPSG Updated As Per 7th Edition With Huddles

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King Fahd Armed Forces Hospital, Jeddah

Continuous Quality Improvement & Patient Safety Department

Health care Patient-

3-Improve the Safety

6-Reduce the Risk of

• Patients must be identified using “ 2 unique

2. Patient's MEDICAL RECORD NUMBER (MRN)

The hospital develops and implements a process to improve accuracy of

Patients are identified before performing diagnostic procedures,

The hospital ensures the correct identification of patients in special

The hospital develops and implements a process to improve accuracy of patient

1. Performing diagnostic procedures ( taking

3. Performing procedures (insertion of an IV or

 ID band for Baby and Mother

• Unknown or unconscious patient :

i. Unknown male patient's ID band state :

ii. Unknown female patient's ID band state:

The hospital develops and implements a process to improve

ME 1 Complete verbal orders are documented and read back by the

Complete telephone orders are documented and read back by

Complete test results are documented and read back by the

The hospital develops and implements a process to

• Only emergency and urgent situations

• Health care practitioner

– READ the order BACK

– physician shall CONFIRM .

• Verbal order authentication (physicians signature) as soon as the

• All telephone order must be authenticated (physicians signature)

The hospital defines critical results that may

The hospital develops a formal reporting process,

ME 3 The hospital identifies what information is

• Results that are significantly outside the normal range

• KFAFH defines critical values for each type of diagnostic test

– 60 minutes for imaging)

• It is the responsibility of the interpreting radiologist and

• The receiver shall

– WRITE down the critical results

– READ BACK the information provided

• (patient’s name , MRN, reporter ‘s name, type of test , and

critical value of the result)

– CONFIRM the information to the person who is reporting

As soon as results are available : shall call or page the

Physician or on call physician

Clinical Director of the concerned service

Director of medical administration

Follow up with CQI & PS

Fill Incident Report

ME 1 Standardized critical content is communicated between

Standardized forms, tools, or methods that support a

Data from adverse events resulting from handover

Trace the lines

During shift changes, break time (physician to physician, or physician to

During transfer of Patient care to another unit ,diagnostic or other

Discharge ( between staff and patients/families)

Trace the lines

Trace the lines

Trace the lines

Handover Process Failure

ME 1 The hospital identifies in writing its list of high-alert

The hospital develops and implements a process for reducing

ME 3 The hospital annually reviews and, as necessary, revises its list

The hospital develops and implements a process to

when used in error.