IPSG 1 – IDENTIFY PATIENTS CORRECTLY
- On registration, identification verification shall be done using EID / Passport / Driving License / Photo ID
- Use full name and MRN as two identifiers (Full Name, DOB & URN /MRN);
- For pediatrics and neonates, involve parents in identification
- Newborns – Use all identifiers - Baby’s Name (S/o or D/o...), URN /MRN, DOB and Gender
- Always follow active verification i.e., ask patients for their name
- Identify patients before performing diagnostic procedures, providing treatments, and performing other procedures and to include the process for comatose patients
- Room Number / Bed Number / Patient location must not be used for identification
- Know processes for patients with Same Name, Unconscious Patients and Unknown Patients
IPSG 2– IMPROVE EFFECTIVE COMMUNICATION
- Telephone orders and Critical Results communication - Write Down and Read Back (WDRB) & confirmation of the order / result.
- Critical results to be communicated within 15mins
- Document order / result in Bayanaty with Date, time & name of the person along with follow up action
- Hand-Off Communication – Follow ISBAR & Physicians handover form
IPSG 3 – IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS (HAM)
- High Alert Medication –identified with red High alert Medication Stickers, stored separately from other drugs
- LASA – Separated from other drugs and highlighted with yellow stickers Concentrated Electrolytes – stored in pharmacy & crash carts - separated from other drugs;
- Labeled with Red sticker “Concentrated Electrolytes” and diluted from pharmacy;
- For conc. Electrolytes and HAM - Two person verification for administration – includes all steps of preparation, patient identification and administration
IPSG 4 – ENSURE SAFE SURGERY
Applicable in all areas where invasive procedures are done (OT, Cath lab, Radiology, Intensive care units, Dialysis and OPDs - Dental, Orthopedics, Gastroenterology etc.)
Follow Universal Protocol.
- Pre-operative verification – Verify patient, surgery, consents, images, implants, blood etc.
- Site Marking – use an arrow sign pointing to the site of the operative procedure, to be done by the person performing the procedure; applicable for sites which involve laterality and/or paired organs, multiple structures
- Sign-in – Checks before induction (Correct patient, procedure, site, side, consent, site marking, imaging documents etc.)
- Timeout – immediately before incision / start of procedure; Verify Correct Patient, Surgery, Site & Side, antibiotic prophylaxis; Second timeout to be done if a second surgery is performed in the same sitting;
- Sign out – before patient leaves the operating room; verify recorded procedure, completion of instruments, sponge & needle count, labeling of specimens and any equipment Problems
IPSG 5 – REDUCE THE RISK OF HEALTHCARE-ASSOCIATED INFECTIONS
- Follow Hand Hygiene (HH)
- Hand Hygiene to be performed as per WHO 5 moments of Hand Hygiene;
- Before touching a patient,
- Before clean procedures
- After body fluid exposure risks
- After touching a patient, and
- After touching the patient's surroundings
- HH compliance is monitored by silent observers
- Provide “Just in Time” training for staff who are non-compliant
