Part Two
- Patient safety and security policy
Correct patient identification policy
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Politics :
Identifying the patient using two means before giving him treatment: blood or one of its derivatives, taking samples from the patient, or any diagnostic or therapeutic procedure.
The Purpose:
Achieving patient safety and reducing the risks that the patient may be exposed to during any procedure within the hospital.
Working procedures:
1- Everyone from the health team who deals with the patient must include:
· Doctors.
· Nursing.
· Pharmacists.
· Lab. Technician.
· Ray technician.
· Physiotherapist.
Use at least two means of identification for the patient to verify his identity:
· The name is fourfold.
· File No.
2- The nursing staff ensures that the identification bracelet data is correct before placing it on the right arm by matching it with the patient’s data and ensuring that it is legible and clear. If it is not possible to place the bracelet on the right arm for any reason, such as the presence of a cast, it is placed on the left arm.
3- The responsible nursing staff will place a new bracelet if the original is lost or becomes illegible.
4- The nursing staff confirms the patient’s full name as in the patient’s medical file and does not depend on another name (such as a nickname) and confirms the file number even if they are sure they know the patient.
5- The patient’s identity is verified before every interaction with him, such as:
Ø Giving treatment.
Ø Transfusion of blood or one of its derivatives.
Ø Taking a blood sample or any other samples necessary for medical analysis and laboratory examination.
Ø Transfer of the patient.
Ø Conducting diagnostic tests.
Ø Or when taking any other actions.
Note: Do not apply an identification label before taking the sample or on the package when it is empty.
6- When taking any measures, the nursing staff asks the patient about his name and introduces the patient herself and the procedure that will be taken, taking into account the presence of the patient’s bracelet and the two means of identification clearly written on it, which are the patient’s name and the file number.
7- Then the nursing staff matches the patient’s data on the bracelet with that in the medical file to confirm the patient’s identity before any action will be taken.
8- When taking a sample, the laboratory technician or nursing staff places a sticker identifying the sample that includes the patient’s name and file number immediately after taking the sample and before leaving the place.
Note: The laboratory technician performs the same patient identification procedures before withdrawing any sample.
9- In the case of premature infants, a bracelet is placed on the child’s right leg.
10- In the case of patients who have disturbed consciousness or are in a coma and for whom there is no way to prove their identity, their identity is proven by the following (unknown/unknown - patient number - date and hour of admission)
· If it is an accident, a report is prepared to prove the accident.
11- For newborns, they are identified by a bracelet placed on the foot with the following recorded:
· Mother's name
· Male Female
· File No
12- Dialysis patients: They are identified by an enclosed badge with the patient’s name on it
13- Patients in the emergency room or recovery room with the patient’s name in three and the reception ticket number
14- Outpatient patients have their test tubes and x-rays identified by the patient’s full name and outpatient ticket number
15- The radiology technician marks the x-rays with the patient’s quadrant name, file number, date, and time
16- None of the hospital employees remove the bracelet of any deceased patient until he leaves the hospital
17- In the event of an error in the patient identification process, reference is made to the incident report requirements policy
Responsible:
Medical team
References:
- International standards for patient safety.
- Egyptian Accreditation Standards 2013.
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Patient delivery and receipt policy
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Politics:
The hospital's medical team is committed to the process of handing over and receiving patients' conditions in the various departments, including:
• Determine the necessary duties that must be handled during the delivery and receipt process.
• Determine who is responsible for delivery and receipt.
• Determine how to document the delivery and receipt process.
The Purpose:
• The delivery and receipt process is a vital process in order to maintain the safety and security of patients by codifying the exchange of patient information among the medical team while he is in the hospital for the continuity of providing medical care to patients.
Responsible for delivery and receipt:
• Between doctors of the same specialty by using the hand-over model.
• Between doctors with different specialties for patients whose condition requires consultation with doctors from more than one specialty, using the medical consultation form.
• Emergency doctors when transporting the patient to and from hospital departments (Patient Transport Form).
• Between nursing staff members with each shift change (situation book).
• Nursing staff members when transporting a patient to and from operations, care, or to another department (time out form)
Working procedures:
• When a new patient is admitted, the head nurse or her representative receives the patient from the paramedic and the admission or reception office worker, and records all the patient’s data and what the treating physician requested in the patient’s condition record.
• Nursing staff members record the patient’s conditions throughout the shift in the patient conditions record.
• After the shift ends and the nursing staff attends the next shift, the nursing staff delivers the conditions of all patients in terms of the development of their medical condition, especially critical cases, surgical cases, treatment given to the patient, any change that has occurred, and any requests such as bringing test results or rumors related to the patient, and preparing the patient for operations, if any. ............etc., with the delivery and receipt documented with the signature of the two nurses in the notebook.
• In cases of operations, the nursing staff prepares the patient for the operation according to the doctor’s instructions. The nursing staff hands over the patient and the patient’s pillow to the nursing staff for the operations and treatment for the patient if requested by the doctor in accordance with the patient preparation form for operations and the patient receipt portion of the time-out form.
• After completing the operation, the surgical nursing staff contacts the department nursing staff to come to receive the patient and the patient’s footbed.
• When there is a need to transfer the patient, the nursing staff transfers the patient and delivers the patient’s file after updating it to the nursing staff in the department to which the patient is transferred within the hospital.
• Resident doctors receive and pick up the patient at the start of the work shift according to the patient handover form that includes: ) Patient’s name - File number - Diagnosis - Positive medical examination results - Positive test results - Follow-up and notes).
• When the patient needs to be referred for consultation, the consultation form is used and the required data is recorded according to the form
Administrator:
• Nursing staff members.
• the doctors.
Models:
• Medical file.
• Record patients’ conditions.
• Consultation form.
• Delivery and receipt form for doctors.
• Operations time-out model.
The Reviewer:
• International standards for patient safety.
• Egyptian accreditation standards.
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Policy to avoid incorrect connection of catheters and tubes
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Politics:
· Specifies the necessary data that must be placed on the catheters, as well as those responsible for handling them, to avoid the connection or incorrect use of the catheters.
The Purpose:
· Achieving patient safety by avoiding incorrect connection of catheters and tubes in the artificial kidney unit.
Working procedures:
· Patients, their families, or hospital employees do not have the right to disconnect, install, or reinstall any type of tube or catheter, except:
Ø The doctor.
Ø Nursing staff members.
Ø Supervisor.
Informing the patient of this is the responsibility of the nursing staff responsible for the patient’s room.
· The department creates a policy for each type of tubes and catheters in the department, explaining:
o Responsible for installation.
o Installation and installation method.
o Ensure the integrity of the installation.
o Follow up and care for the connection.
· The following information is required to be shown on each catheter: the name of the installer, date and hour.
· Installation and verification of the correct installation of each type is carried out according to its policy.
· The doctor must specify the name and type of tube through which the medicine will be administered.
· Nursing staff must verify all connections before giving any medication and before and after performing any procedure in accordance with the policy for each type.
Administrator:
• Members of the nursing staff.
• the doctors.
The Reviewer:
• International standards for patient safety.
• Egyptian accreditation standards.
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Safe use of restraint and seclusion policy
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Politics :
· The patient’s safety and security are maintained and his right not to be restricted unless there is harm to the patient or those around him
· The patient is restrained for the shortest possible time after evaluating the patient and ensuring the necessity of restraint using the least means
· The patient is restricted based on the order of the qualified treating physician
Purpose: To preserve the patient’s rights and dignity and prevent him from harming himself or others.
Restraint: is a means that reduces or prevents the patient's movement. There are two types:
Either physical: This is a method of restraining the patient by the hands, feet, and torso of the body.
Or medicinal: It is a medication given with the aim of reducing the patient’s movement and calming his behavior.
Isolation: This is the restriction of the patient’s residence in a special room or area in cases of violence and aggressive behavior by the patient towards himself or those around him, including workers, patients, and others.
Reasons for restriction:
1. A patient who suffers from psychological disorders that make him capable of harming himself or those around him.
2. A neurological patient who suffers from a cerebral shock and in the event of agitation makes him unable to move unconsciously and capable of harming himself and others.
3. The post-operative patient is agitated, leading to harm to himself and others.
4. A liver patient who suffers from a state before hepatic coma and is in a state of agitation.
5. The patient is conscious but has a history of hurting himself before or removing the devices installed on him, such as the monitor - the central vein - or injection and pumping devices.
Reasons for isolation: The patient with behavioral diseases is isolated in a room alone until he is transferred to another hospital and the patient’s family is informed.
Procedures :
First: Patient evaluation:
· The responsible nursing staff determines the patient’s need for registration based on his behavior
The treating physician records the restriction order in the patient’s medical file, explaining the following:
The reason for the restriction
The type of restriction required
The time the restraining order was given/the specific duration of the restriction
Restriction started:
· Registration is performed using the fastest available method, whether pharmaceutical or physical, except after consulting a consultant, but in some cases it is prohibited to use the pharmaceutical method.
Restriction method:
· Nursing personnel use leather belts, gauze and cotton ties, or other means to restrain parts of the body. The four limbs are often used for restraint, except in cases such as meal times and personal hygiene.
· Female: The responsible nursing staff wraps the legs together and then ties them to the foot of the bed.
· Male: The responsible nursing staff restrains each leg of the patient individually at the foot of the bed.
· The treating physician shall sign the verbal registration order within 24 hours from the time he is notified of the case.
· The nursing staff takes care not to harm the patient psychologically or physically during the restraint.
· The nursing staff takes care to maintain the patient’s privacy.
· Patients whose freedom is legally restricted. The doctor is prohibited from participating in restricting them except when there is a strict medical necessity (Article 35 of Professional Ethics - Resolution 238 of 2003)
Second: Patient follow-up:
· The nursing staff records the patient’s follow-up using the relevant form, which includes the following data:
- Patient’s behaviour
- Vital Signs
- Blood division
- Skin condition
· Responsible nursing staff members follow up on the patient under restraint and for medical and surgical reasons at least every two hours, and this is documented in the patient’s medical file.
· Nursing staff members follow up on the patient under restraint for psychological reasons at least every half hour, and observations are recorded in the patient’s medical file on the patient restraint form.
Third: Renewal of the restriction order:
· Restraining orders made for medical and surgical reasons, the treating physician must renew the order at least every 24 hours based on continued need.
· Restraining orders made for psychological reasons, the treating physician must renew the order at least every 6 hours based on continued need.
Fourth: Ending the restriction:
· Specifications for ending the restraint: It either completely improves the patient’s state of consciousness or deteriorates and leads to a coma.
· Trained nursing personnel terminate the patient’s restraint in accordance with the doctor’s orders, according to the patient’s condition and in accordance with medical evidence, provided that the time and date of ending the restraint are recorded.
Fifth: Training:
· The person responsible for the hospital's patient care policies provides practical training to the doctors and nurses in the internal care department on how to implement the policy.
Sixth: Health education for the patient and his family:
The doctor/responsible nursing staff informs the patient and his family of the following:
- The extent of the need to restrain the patient
- Restriction period
- Rating rate during restriction
Responsible:
Nursing staff members
· Physician
Forms:
Restraint and follow-up order form
The Reviewer:
· Egyptian Quality Standards 2013
· JCI Standards 2014
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Critical outcomes policy
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The policy explains the following:
· Definition of critically significant results.
· When to report critically significant results.
· How to report critically significant results.
· Who reports critically significant findings.
· Who receives the communication of critically significant findings.
· Document reporting of critically significant findings.
Purpose:
To maintain the safety and security of the patient and take appropriate action when there are critically significant results that require rapid intervention by the treating physician or any member of the medical team.
Definition:
Panic Values: These are results that may indicate the presence of a life-threatening situation for the patient that requires an urgent response or rapid intervention by the treating physician.
Working procedures:
1- Each department develops a list of its critical results, which includes the following:
· Results of critical laboratory tests (laboratory).
· Results of critical diagnostic examinations (Radiology Department).
· Critical medical examination results (internal departments / care / dialysis......).
2- In the event of any result of critical significance according to the previous lists, the person in charge (laboratory physician/radiologist/resident physician/department nursing staff members/laboratory or radiology technician) shall immediately inform the treating physician or department nursing staff members.
3- The informant must verify the full name of the person who was notified.
4- The recipient of the report (the treating physician) - (the nursing staff) shall do the following:
· Record the critical result immediately in the critical results log.
· The recipient of the report re-reads the patient’s data and test results to the informant in order to ensure that everything that was received and recorded in the patient’s file is correct and accurate.
· The treating physician has the right to accept or reject the result in light of its suitability to the patient’s condition, which may require a re-examination or procedure from the informant.
5- Document the reporting process through the following:
· The recipient (the treating physician) – (the responsible nursing staff members) shall document in the critical findings record the following data immediately upon receiving the report:
(Today's date - Reporting time (hour and minute) - Test result).
The action taken in terms of accepting or rejecting the result or requesting a re-examination.
(The full name of the laboratory/radiology official who reported - the full name of the recipient of the report (the doctor - the nursing staff))
Administrator:
• Laboratory and radiology doctors.
• Resident doctors.
• Nursing staff.
• Physician..
Models:
• List of critical results for each section.
• Critical Results Model.
The Reviewer:
• International standards for patient safety.
• Egyptian accreditation standards.
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Model of findings with serious clinical implications
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