Politics :

 Identify the patient using two means before giving him a treatment, blood or one of its derivatives, taking samples from the patient or any diagnostic or therapeutic procedure.

Purpose:

Achieve patient safety and reduce the risks that the patient may be exposed to during any procedure within the hospital.

Working procedures:

1-everyone who deals with the patient from the health team must include :

* Doctors .

* Nursing.

* Pharmacists.

* Laboratory technician.

* Radiology technician.

* Physiotherapist.

Use at least two means of identification for the patient to verify his identity, namely:

* The name is quaternary.

* File number.

* The nurse makes sure that the data of the identification bracelet is correct before placing it in the right arm by matching it with the patient's data and being legible and clear. If the bracelet cannot be placed in the right arm for any reason, such as the presence of a plaster cast, it is placed in the left arm.

* The responsible nurse will put a new bracelet if the original is lost or becomes illegible.

* The nurse verifies the patient's quadruple name as in the patient's medical file and does not rely on another name (such as a nickname) and verifies the file number even if she is sure of the patient's knowledge . 

2-the identity of the patient is confirmed before each treatment with him, such as:

◾ Give treatment.

◾ Blood transfusion or one of its derivatives.

◾ Taking a blood sample or any other samples necessary for medical analysis and laboratory examination.

◾ Transfer of the patient.

◾ Conduct diagnostic examinations.

◾ Or when taking any other actions.

Note: the identification label is not placed before the sample is taken or on the package, which is empty.

3-when taking any actions, the nursing staff should ask the patient for his name and introduce the patient to herself and the procedure that will be done taking into account ensuring the presence of the patient's bracelet and written on it two means of identification clearly, namely the patient's name and file number.

4 - then the nurse will compare the patient's data on the bracelet with those carried by the medical file to confirm the patient's identity before any procedure will be taken.

5-when taking a sample, the laboratory technician or nurse puts a sample identification sticker 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 identification procedures as the patient before withdrawing any sample.

6-in the case of patients for premature babies, a bracelet is placed on the right leg of the baby.

7 - in the case of patients who are confused in consciousness and have a coma and who There is no way to prove their identity, their identity is confirmed by the following ( Unknown / Unknown - Patient Number - Date and hour of admission )

· If it is an accident, an accident proof report is made.

8-for newborns, they are identified by a bracelet placed at the foot of their following registered:

* Mother's name

* Male / female

* File number

9-dialysis patients: they are identified by an envelope with the name of the quadruple patient

10-patients who are in the emergency room or recovery room with the patient's name and the number of the reception ticket 

11-outpatient patients their test tubes and radiographs are identified by the name of the triple patient and the outpatient ticket number

12-the radiology technician marks the radiology with the quadruple patient's name, File Number, Date and hour

13-none of the hospital staff will remove the bracelet of any deceased patient until he is discharged from the hospital

14-in case of an error in the patient identification process, the incident report requirements policy is referred to 

Responsible: medical team

References: - world standard standards for patient safety.

- Egyptian accreditation standards.

Critical outcomes policy

The policy: explains the following:

* Definition of critical significant results.

* When the results with critical significance are reported.

* How to report critical results.

* Who reports the results with critical significance.

* Who receives the communication of the results with critical significance.

* Documentation of reporting of critical significant results.

Purpose: to maintain the safety and security of the patient and take appropriate action when there are critically significant findings that require the intervention of the attending physician or any member of the medical team quickly.

Definition: critical values (Panic Values): are the results that may indicate a life-threatening situation that requires an urgent response or rapid intervention by the Attending Physician.

Working procedures:

1-each department shall draw up its own list of critical results, including the following:

* Results of critical laboratory tests (laboratory).

* Results of critical diagnostic examinations (radiology department).

* Critical medical examination results (inpatient departments / wards / dialysis ......).

2-in case of any critical result according to the previous lists, the official (laboratory doctor/ radiologist / resident doctor /nursing officer/laboratory technician or radiologist) will immediately inform the attending physician or nursing department.

3-the amount makes sure to confirm the Triple name of the one who was informed.

4-the recipient of the communication (the attending physician)- (nursing) will do:

* Record the critical score immediately in the critical score log.

* The recipient of the communication re-reads the patient's data and the result of the test on the amount in order to ensure that everything received and recorded in the patient's file is correct and accurate.

* The attending 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 of the amount.

5-document the reporting process through the following:

* The recipient ( attending physician ) – (responsible nursing) documents in the critical results register the following data immediately upon receipt of the communication

(Today's date - reporting time (hour, minute) - test result).

The action taken in terms of accepting the result, rejecting it or requesting a re-examination.

(The Triple name of the laboratory / radiology officer who made the report - the Triple name of the recipient of the communication (doctor-nursing))

In charge:

* Laboratory doctors and radiologists.

* Resident doctors.

* Nursing staff.

* The Attending Physician..

Models:

* List of critical results for each section.

* Critical results model. 

References:

* World standard standards for patient safety.

* Egyptian accreditation standards.

Patient name:............................................... .... the number : .......................

Date:    /    /     200                                    Section:........................