Second part
- Patient security and safety policies
Correct patient identification policy
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Policy:
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.
· The nurse 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.
· The charge nurse will place a new bracelet if the original is lost or becomes illegible.
· The nurse makes sure the patient’s full name is as it is in the patient’s medical file and does not depend on another name (such as a nickname), and confirms the file number even if she is sure she knows the patient.
2- 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.
3- When taking any procedures, the nurse asks the patient about his name and introduces the patient herself and the procedure that will be performed, 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.
4- The nurse then matches the patient’s data on the bracelet with that in the medical file to confirm the patient’s identity before any procedure is taken.
5- When taking a sample, the laboratory technician or nurse places a label 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.
6- In the case of premature infant patients, a bracelet is placed on the child’s right leg.
7- 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 (anonymous/unknown - patient number - date and hour of admission)
· If it is an accident, a report is prepared to prove the accident.
8- For newborns, they are identified by a bracelet placed on the foot with the following recorded:
· Mother's name
· Male Female
· File No
9- Dialysis patients: They are identified by an enclosed badge with the patient’s name on it
10- Patients in the emergency room or recovery room with the patient’s triple name and reception ticket number
11- Outpatient patients have their test tubes and x-rays identified by the patient’s full name and outpatient ticket number
12- The radiology technician marks the x-rays with the patient’s quadrant name, file number, date, and time
13- None of the hospital employees remove the bracelet of any deceased patient until he leaves the hospital
14- 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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Policy:
The hospital’s medical team is committed to the process of handing over and receiving patients’ conditions in the various departments, including:
• Identify 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 between 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 delivery and receipt 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 transfer form).
• Between nursing staff members with each shift change (status 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.
• The nurse records the patient’s condition throughout the shift in the patient condition record.
• After the shift ends and the nurse attends the next shift, the nurse delivers to her 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 nurse prepares the patient for the operation according to the doctor’s instructions. The nurse hands over the patient and the patient’s pillow to the operating nurse and the patient’s treatment if requested by the doctor in accordance with the patient preparation form for operations and the patient receiving portion of the time-out form.
• After completing the operation, the operating nurse calls the nursing home nurse to come to receive the patient and the patient’s pillow.
• When there is a need to transfer the patient, the nurse transfers the patient and hands over the patient’s file after updating it to the nurse of the department to which the patient is transferred within the hospital.
• Resident doctors receive and receive the patient at the start of the work shift according to the patient handover form, which includes: (patient 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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Policy:
Specifies the necessary data that must be placed on catheters as well as those responsible for handling them to avoid connection or incorrect use of catheters.
The Purpose:
· Achieving patient safety by avoiding incorrect connections of catheters and tubes in all hospital departments.
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 Nurse.
Ø Supervisor.
Informing the patient of this is the responsibility of the nurse in charge of the patient's room.
· The department creates a policy for each type of tubes and catheters in the department, explaining:
o The person responsible for the installation.
o Installation and installation method.
o Ensure the integrity of the installation.
o Follow up and take care of 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 medication will be administered.
· The nurse must check all connections before giving any medication and before and after performing any procedure in accordance with the policy for each type.
Administrator:
• Nursing staff members.
• the doctors.
The Reviewer:
• International standards for patient safety.
• Egyptian accreditation standards.
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Policy to prevent patient falls and take the necessary measures to avoid falls
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Policy:
Each patient's potential fall risk is assessed upon admission to the hospital including the potential risk associated with the patient's treatment regimen on the form in the nursing assessment portion.
• Necessary measures must be taken to prevent falls.
Purpose:
Preventing patient falls by evaluating and re-evaluating cases regarding the possibility of falling and taking the necessary measures and precautions to prevent this.
The Definition:
Fall:
Any change in the patient's position from one level to a lower level, which leads to the patient touching the ground or any surface at a lower level.
Precautions that must be taken to protect patients from being exposed to the risk of falling:
• Environmental factors
• Identify patients at risk of falling.
• Educating patients at risk of falling and their families.
• Environmental factors:
The hospital/department takes into account the various environmental factors and influences that provide security and safety for the patient and prevent the possibility of him falling. Therefore, the department nurse or her representative periodically ensures that:
• The patient beds are safe and free from any breakage or malfunction.
• The sides of patient beds are safe and there are no defects.
• The patient bed brakes are safe and work efficiently.
• Safety of the trolley used to transport patients between departments.
• Do not move patients while department workers are performing the cleaning process to avoid patients falling during that time.
• Ensure the safety and quality of lighting.
• Ensure that there are no obstacles in the corridors.
• Ensure that the bell in the bathrooms works well.
• Ensure and keep the floors dry and clean so as not to increase the risk of slipping and falling.
1- Identifying patients at risk of falling
The nurse assesses the patient for fall risk according to the items on the nursing assessment form upon admission.
If there is a patient who may be at risk of falling, the nurse should do the following:
• Raise the sides of the bed
• Place the symbol (F) on the patient’s identification bracelet.
• Put the symbol (F) on the door of the patient’s room and/or bed if the room contains more than one patient.
• Repeatedly asking if you want to go to the bathroom.
2- Educating patients at risk of falling and their families through treating doctors and nurses
• Alert the patient to notify the nurse if he feels dizzy, sluggish, unbalanced, etc
• Warning the patient not to resort to sudden movements when changing position from sleeping to standing or sitting.
• Warning the patient not to bend down to pick up anything from the ground.
• Make sure to use comfortable shoes without heels that do not help with slipping.
• Be sure to keep the bell near the patient’s bed.
• The necessity of committing not to leave unwanted objects on the nightstand next to the bed or in the bathroom.
• Alert the patient to request assistance while walking and moving around.
• Do not place any sharp tools near the patient.
• Ease of movement of the medical team, patients and their families in the hospital rooms and rooms by not occupying them with any tools or equipment.
• Encourage the patient to use wall supports while walking to prevent falls, if any.
• Recording health education for patients and their families in the patient’s medical record.
3- If a patient suffers a fall, the following must be followed:
• The nurse measures vital signs before moving or assisting the patient to move or stand.
• When the patient may be injured or fractured, the patient should not be moved at all.
• The nurse notifies the doctor to examine the patient and determine how to lift him.
• The nurse helps the patient and places him in the wheelchair after ensuring that the brakes are lifted to prevent movement.
• The nurse records the falling incident on an incident report form.
• The responsible nurse re-evaluates the patient when there is any change in the condition of the patient who is at risk of falling, provided that she documents any change in condition as follows:
o The full name of the assessing nurse.
o Evaluation date.
o Evaluation hour.
o The new result of the assessment.
List of patients at risk of falling:
• A patient with a disorder in the level of consciousness of all types and causes
• A patient with all types and causes of convulsions.
• A patient with limb fractures.
• Diabetic coma patient.
• A patient with high or low blood pressure.
• Geriatric patient.
• The mentally ill patient, especially if he has suicidal tendencies.
• Patient with imbalance (stroke patient + hemiplegia).
• Pediatric patients.
• Patients treated with sedatives, diuretics and blood pressure lowerers.
Administrator:
• Nursing staff members.
• the doctors.
• Maintenance.
• Environmental safety officer.
References: - International standards for patient safety. - Egyptian Accreditation Standards 2013.
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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:
· A patient who suffers from psychological disorders that make him capable of harming himself or those around him.
· 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.
· The post-operative patient is agitated, leading to harm to himself and others.
· A liver patient who suffers from a state before hepatic coma and is agitated.
· The patient is conscious but has a history of harming 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 charge nurse determines the patient's need for restraint 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
⭕ Type of registration required
⭕ The time of giving the restriction order/the specific period of restriction
Restriction started:
Registration is performed using the fastest available method, whether pharmaceutical or physical, except after consulting a consultant. However, in some cases it is prohibited to use the pharmaceutical method.
Restriction method:
The nurse uses a leather belt, 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 charge nurse wraps the legs together and then ties them to the foot of the bed.
Male: The nurse in charge binds each patient's leg individually to 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 nurse takes care not to harm the patient psychologically or physically during the restraint.
The nurse 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 nurse records the patient's follow-up using the relevant form and includes the following data:
⭕ Patient behaviors - Vital signs - Blood circulation - Skin condition
The responsible nurse follows up on the patient under restraint for medical and surgical reasons at least every two hours, and this is documented in the patient’s medical file.
The nurse follows up on the patient who is under restraint for psychological reasons at least every half hour, and the 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 must be renewed by the treating physician at least every 24 hours based on continued need.
Restraining orders made for psychological reasons must be renewed by the treating physician at least every 6 hours based on continued need.
Fourth: Ending the restriction:
Specifications for ending the restriction: It is either the patient’s state of consciousness completely improves or it deteriorates and a coma occurs.
The trained nurse ends the patient's restraint in accordance with the doctor's orders, according to the patient's condition and according to medical evidence, provided that the time and date of ending the restraint are recorded.
Fifth: Training:
The patient care policy officer in the hospital 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 nurse introduces the patient and his family to the following:
⭕ The extent to which the patient needs to be restrained
⭕ Duration of restriction
⭕ Rating rate during restriction
Responsible: The treating physician
Forms: Restraint and Prosecution Order Form
References: Egyptian Quality Standards 2013 - Joint Commission International Standards 2014
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Policy to prevent bed sores while the patient is in the hospital
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Policy: Evaluate patients most at risk of developing bed sores and take measures to prevent them.
Purpose: To achieve patient safety in the hospital by preventing the occurrence of bed sores.
Working procedures:
• The nurse evaluates the skin condition of each patient upon admission to the hospital on the relevant form in the nursing assessment part.
• Patients who are confined to bed must be re-evaluated by the nurse in charge at the beginning of each shift. Only in the case of patients who are unable to move, the department nurse should do the following to prevent the occurrence of bed sores:
o Make a plan to turn the patient every two hours on the patient turn over form and attach the form to the medical record.
o The skin is massaged to stimulate the patient’s blood circulation, especially the areas with great prominence, to avoid bed sores, and this massage and its time are recorded in the medical record.
o Observing the patient’s skin to discover any area of the skin that shows redness and recording this in the medical record.
o Furnishing patients’ beds in the correct way and avoiding any folds in the bed sheets to avoid the occurrence of bed sores.
o Place an air mattress for the patient - if possible - to reduce and prevent the occurrence of bedsores.
o Pay attention to the degree of softness and dryness of the skin and use creams and moisturizers to avoid dryness.
o Taking care of the skin by giving the patient a full bath daily and when needed.
o Therapeutic nutrition that suits the patient according to his health condition, based on the doctor’s orders, to stimulate the body’s tissues and prevent the occurrence of bed sores.
• If the patient has bed sores, the following is done:
o All of the above is done to avoid increasing the area of bed sores.
o The treating physician makes sure to move the patient according to his condition.
Administrator:
• The doctors.
• Nursing staff members.
Models:
• Patient turning model.
• Degrees of bedsores.
The Reviewer:
• International standards for patient safety.
• Egyptian accreditation standards 2013.
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Critical outcomes policy
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The policy states the following:
· Definition of critically significant results.
· When to report critically significant results.
· How to report critically significant results.
· Who reports critically significant results.
Who receives the notification of critical 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/responsible nurse/laboratory or radiology technician) shall immediately inform the treating physician or the department nurse.
3- The informant must verify the full name of the person who was notified.
4- The recipient of the report (the treating physician) - (the nurse) shall do:
· Record the critical result immediately in the critical results log.
· The recipient of the report re-reads the patient’s data and the test result on the informant, with the aim of ensuring 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 proportionality 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 nurse in charge) documents the following data in the critical findings record 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 (doctor - nurse))
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
The number :........................
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