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International Patient Safety Goals (IPSG)*
The purpose of the IPSGs is to promote specific improvements in patient safety. The goals highlight
problematic areas in health care and describe evidence- and expert-based consensus solutions to theseproblems. Recognizing that a sound system design is needed in the delivery of safe, high-quality health
care, the goals encourage organizations to focus on solutions affecting the entire hospital system.
There are six IPSG standards with a combined total of 24 measurable elements (MEs). IPSG.1 has 5 MEs
while IPSG.5 has 3 MEs; the rest have 4 MEs each. Since there are only 24 MEs, a single Partially met
score of 5 shall easily bring down a standards aggregated score to 9.0 or less and the chapters
aggregated score to 9.78 or less. The goal is to score a 10 for each of the 24 measurable elements. As
with other standards, the IPSGs require that the organization has policies and procedures in place to
support the intent of each of these goals.
IPSG.1Identify patients correctly.This standard has a two-fold intent: to reliably identify the individual as the person for whom
the service or treatment is intended, and to match the service or treatment to that individual. Reliable
identification is ensured by using two patient identifiers full name and birthday. Matching the service
or treatment to the correct patient means the patients identification is verified before such treatment
or service is provided including administering medication, blood, or blood products, taking blood or
other specimens for testing, and other treatment or procedures in outpatient services.
What is challenging for TMC: incomplete patient identifiers or use of only 1, wrong patient verification
during initial patient encounter, sticking bar code labels on wrong order sheets.
IPSG.2Improve effective communication.
This standard ensures that communication between health care providers is timely, accurate, complete,
unambiguous and understood by the recipient. Error-prone communication includes patient care orders
or results of critical tests given verbally or through telephone. In such cases, the standards measurable
elements require that: a) the order or test result is written by the receiver, b) the written order or test
result is read back by the receiver to the giver, and c) the order or test result is confirmed by the
individual who gave it.
JCIA 2012Newsletter May 11, 2012
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What is challenging for TMC: documenting that read-back did occur.
IPSG.3 Improve the safety of high-alert medications.
High-alert medications are those with high risk for errors and/or sentinel events and adverse
outcomes. High-alert medications also include look-alike/sound-alike drugs. The organization should
collaboratively develop its policies and procedures wherein it identifies its own list of high-alert
medications based on its own data, and identifies how they will be labeled and stored in such a way thatinadvertent administration is prevented. In areas where storage of high-risk medications is allowed,
these should be labeled clearly and that they are stored in such a way that access is restricted.
Whats challenging for TMC: concentrated electrolytes can still be found in areas where they should not
be.
IPSG.4Ensure correct-sight, correct-procedure, correct-patient surgery.
Surgeries involving wrong patients, wrong body sites or wrong procedures do happen as a result
of ineffective or inadequate communication between members of the surgical team. This IPSG standard
ensures that the Universal Protocol s implemented in all applicable areas of the hospital. The standard
also calls for policies and procedures governing the implementation and monitoring of the Universal
Protocol in settings other than the OR where medical and dental procedures are done.
Whats challenging for TMC: documentation that time out do occur, Universal Protocol in applicable out-
patient areas.
IPSG.5 Reduce the risk of health care-associated infections
Proper hand hygiene is an intervention recommended by the World Health Organization and the
US Centers for Disease Control and Prevention to prevent common health care-associated infections
(HCAIs). The organization has to demonstrate that it has adapted the recommended guidelines and that
it effectively implements its hand hygiene program through 100% compliance. This standard also makes
sure that policies and procedures for continued reduction of HCAIs are in place and are being followed
by the entire organization.Whats challenging for TMC: non-compliance to moments 1 and/or 5, absence of hand-rub dispensers in
certain areas
IPSG.6 Reduce the risk of patient harm resulting from falls
This standard ensures that the organization should evaluate its patients risk for falls and take
action to reduce the risk of falling and to reduce the risk of injury should a fall occur. The organization
should establish a fall-risk reduction program based on appropriate policies and procedures.
Whats challenging for TMC: correct initial assessment and re-assessment, appropriate interventions
based on assessment.
*Taken from JCI Accreditation Standards for Hospitals, 4th
edition, pp.35-40
JCIA Newsletter
JCIA Newsletter 2012
Lead Editor: Dianne AchasContributors:
Jose M. Acuin, M.D.
Beth Vargas
James Cayabyab
Precious Aruelo
Michelle Casuga
Jen De Dios
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Ways to Ace the IPSG Standard
The JCI International Patient Safety Goals (IPSG) form
the bedrock of patient safety. Their achievement is
critical to full compliance with the JCI standards.
Because the 6 IPSGs form a separate standards
chapter, they greatly impact on the total survey score
of Medical City. In addition, the QPS standards requirethat a monitoring tool is used to track compliance to
each of the 6 IPSGs. This issue of the JCI Newsletter is
devoted to the JCI IPSGs and their intent statements.
The applicability grid that follows the text shows the
different areas in the hospital where the 6 IPSGs must
be achieved.
Goal 1: Identify Patients Correctly (IPSG.1)
The organization develops an approach to improve
accuracy of patient identifications.
Before giving medications, blood, or blood products;taking blood or other specimens for clinical testing; or
providing any other treatments or procedures, tell the
patient, Can you please tell me your full name and
birth date? I need to confirm it before I perform this
procedure on you.
Goal 2: Improve Effective Communication (IPSG.2)
The organization develops an approach to improve the
effectiveness of communication among caregivers.
Do not text criticalinformation such as assessment
findings and orders. You will never be sure you have
been completely understood or that the person you aretexting is going to act on the critical information
promptly and appropriately. If you must text critical
information, make a follow-up call to confirm
understanding and effective response to your concerns.
When transmitting critical information such as orders
or test results verbally OR over the phone, make sure
the recipient of your information writes it down
completely and legibly (or enters into a computer),
reads back the information to you and confirms with
you that what has been written down and read back is
accurate.
Remember: You have effectively communicated to
someone only after you are sure you have been
understood.
Goal 3: Improve the Safety of high-Alert Medications
(IPSG.3)
The organization develops an approach to improve the
safety of high-alert medications.
Check if your unit or department uses any of themedications included in the DrugWatch list.
Place warning labels such as Drug Watch List, Look-
Alike and Sound-Alike, etc. in the medicine bins. Use
Tallman labeling to prevent errors in look-alike and
sound-alike drugs. For drugs with sound-alike names,
the generic and brand names shall be written together
with the indication in order to verify drug identity.
Illegible, unclear or incomplete orders shall be verified
with the Prescribing Doctor prior to transcription.
Use standardized drip whenever possible
Use premixed solutions unless otherwise indicated(e.g., concentrated dopamine solutions for congestive
heart failure).
Telephone and verbal orders are strictly not allowed
except for IV follow-up, provided the physician will
write and/or countersign the order within 30 minutes.
The NIC must verify the illegible and unclear drug
orders through the read back process. Orders given by
the physician should be read back by the nurse-in-
charge to ensure proper understanding. In the absence
of the NIC, the physician should expect a call from the
unit regarding his/her order for clarification.
The staff pharmacist will not accept any verbal orders
to prepare incorporations of intravenous electrolytes.
The intravenous admixture of electrolytes and
chemotherapeutic agents will only be prepared by the
staff pharmacist upon receipt of the Physicians Order
Sheet (POS) and the corresponding charge slips for the
request. For incorporations of electrolytes to present
intravenous infusions, the staff pharmacist will prepare
the quantity of electrolytes to be added to the
intravenous infusion upon receipt of the POS and the
corresponding charge slip for the request.
Pharmacists compound and dispense sodium chloride
solutions above 9% (Therapeutics)
Dilution and infusion rates are prepared and set by
nurse-in-charge as ordered by the attending physician
and counter-checked by head nurse prior to
administration. (Therapeutics)
Use infusion pumps for infusion of chemotherapy and
other medication requiring accurate and timely
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regulation such as aminophyline, heparin, insulin,
inotropics and electrolytes and for critically-ill patients.
(NSD manual)
Goal 4: Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery (IPSG.4)
The organization develops an approach to ensuring
correct-site, correct-procedure, and correct-patient
surgery.
1. The correct operation and site of theoperation should be specified when the
procedure is scheduled, should be noted on
the record of the history and physical
examination and should be specified on the
informed consent. Anyone reviewing the
schedule, consent, history and physical
examination, or reports documenting the
diagnosis, should check for discrepancies
among all those parts of the patients record
and reconcile any discrepancies with the
surgeon when noted.2. All information that should be used tosupport the correct patient, operation, and
site, including the patients or familys verbal
understanding, should be verified by the
nurse and surgeon before the patient enters
the OR. Any discrepancies in the information
should be resolved by the surgeon, based on
primary sources of information, before the
patient enters the OR.
3. All verbal verification should be done usingquestions that require an active response of
specific information, rather than a passive
agreement.
4. The site should be marked by a healthcareprofessional familiar with the facilitys
marking policy, with the accuracy confirmed
both by all the relevant information and by an
alert patient or patient surrogate if the patient
is a minor or mentally incapacitated. The site
should be marked by the providers initials.
The site mark should be visible and referenced
in the prepped and draped field during the
time-out.
5. All information that should be used to supportthe correct patient, operation, and site,
including the patients or familys verbal
understanding, should be verified by the
circulating nurse upon taking the patient to
the OR.
6. Separate formal time-outs should be done forseparate procedures, including anesthetic
blocks, with the person performing that
procedure.
7. All noncritical activities should stop during thetime-out.
8. Verification of information during the time-out should require an active communication
of specific information, rather than a passive
agreement, and be verified against the
relevant documents. All members of the
operating team should verbally verify that
their understanding matches the information
in the relevant documents.
9. The surgeon should specifically encourageoperating team members to speak up if
concerned during the time-out. Operatingteam members who have concerns should not
agree to the information given in the time-out
if their concerns have not been addressed.
Any concerns should be resolved by the
surgeon, based on primary sources of
information, to the satisfaction of all members
of the operating team before proceeding.
Goal 5: Reduce the Risk of Health CareAssociated
Infections (IPSG.5)
The organization develops an approach to reduce the
risk of health careassociated infections.Habit Always wash in and wash out upon
entering/exiting a patient care area and before and
after patient care
Make washing hands a habit as automatic as
looking both ways when you cross the street or
fastening your seat belt when you get in your car
Active Feedback Coach and intervene to remind staff to wash
hands. Provide real time performance feedback
Clearly state expectations about when to sanitize
hands to all staff members
Communicate frequently provide visiblereminders and ongoing coaching to reinforce
effective hand hygiene expectations
Celebrate improved hand hygiene
No One Excused Protect the patient and the environment
everyone must wash in and wash out
Make it comfortable to wash hands with soap or
use waterless hand sanitizer
Hold everyone accountable and responsible
doctors, nurses, food service staff, housekeepers,
chaplains, technicians, therapists
Apply progressive discipline from the top
managers must hold everyone accountable forproper hand washing
Commit to achieve hand hygiene compliance of
90+ percent
Serve as a role model by practicing proper hand
hygiene Make it easy; examine work flow of
health care workers to ensure ease of washing
hands:
Provide easy access of hand hygiene equipment
and dispensers
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Create a place for everything: for example, a health care worker with full hands needs a dedicated space wherehe or she can place items while washing hands
Limit entries and exits from a patients room make supplies available in room and eliminate false alarms that
require staff to leave room to turn alarm off
Goal 6: Reduce the Risk of Patient Harm Resulting from Falls (IPSG.6)
The organization develops an approach to reduce the risk of patient harm resulting from falls.Review medications, especially high- risk medications, such as sedatives, antidepressants, antipsychotics and
centrally acting pain relief.
Assess and manage bone health in older people who have, or who are at risk of, low-trauma fractures. This
includes the use of vitamin D and calcium, as well as formal treatments for osteoporosis.
Check lying and standing blood pressure in older patients at risk of falls.
Ensure that acutely confused patients are investigated for the cause of the delirium, and contribute to the
clinical management plan for managing confused older patients.
Avoid using physical or chemical restraints, where possible.
If a patient falls while in hospital, examine them and investigate the fall as needed. Assess the patients risk of
falling in future, and provide individualized interventions to minimize this risk.
Ensure that older patients have their usual spectacles and visual aids in hand.
Organize routine screening urinalysis to identify urinary tract infection.
Organize routine physiotherapy review for patients with mobility difficulties:
Communicate to staff and the patient the limits of the patients mobility status using written, verbal and visual
communication
Put walking aids on the side of the bed that the patient prefers to get up from, and, where possible, assign a
bed that allows them to get up from their preferred side
Supervise or help the patient if required
Make sure that, while mobilizing, the patient wears fitted, nonslip footwear (discourage the patient from
moving about in socks, surgical stockings or slippers)
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TMC iNSTYLE
the Project JCi Wear T-shirt Design Competition and Fashion Show
Last May 3, 2012, the TMC community feasted their eyes on one of a kind fusion of fun, beauty, creativityand fashion as carefully selected models from various departments strut their way on the fashion ramp for
the first ever Project JCi Wear Fashion Show. The show is the first of the many events that the Medical
Quality Improvement Office and its partner departments have planned and organized this year in
preparation for the JCI re-accreditation in November.
As early as the day before, our Facilities and Housekeeping staff were seen constructing and decorating thespecially-designed catwalk at the Foyer where the event was held. Blue and yellow balloons, life-size
standees of the models, and multi-colored lights adorned the venue. Staff, patients and visitors alike felt the
excitement as soon as the upbeat music signaled the start of the show. The audience swelled shortly
thereafter upon seeing the events celebrity hosts, Maverick Only (of Totoo TV fame) and CRDs Ella
Lacson. Four departments gamely participated and expressed their support and commitment to JCIA by
designing artistically crafted T-shirts modeled by their own staff. These departments were Admissions,
Cathlab, Medical Information, and Systems and Quality. The Admitting Department bagged all the major
prizes including the Best T-shirt design (by Ms. Lourdes Zabala) and the Best Male and Female Models
(Vermont Ventura and Lou Angielyn Cruz). The winning design shall be used as inspiration for the 2012 TMC
Whats out for JCi Rock: TMCno sikat?!
Calling all TMC bands! Join our rock band contest at ipakitana kayo ang sikat!If your band has 5-7 members, you qualify.We will provide the lyrics, you provide the music. Submityour demo recording and be ready to perform your songduring the JCi Rock event in July. Amazing, amazing prizesare in store!
Interested parties may inquire at MQIO or CHI. Posters andannouncements will be released very, very soon.
JCi wear female models. L-R: Jean (MID), Lou(Admissions); Mich (Cathlab); & Cathy (SQD)
JCi Wear First Place Winners, Lourdes Zabala and
models Vermont Vergara & Lou Angielyn Cruz
receiving their award from Ms. Margaret
Bengzon and Dr. Jose Acuin,
JCi Wear Hosts:
Mr. Maverick Only
& Ms. Ella Lacson.
JCi wear male models. L-R: Jonathan (MID),
Vermont (Admissions); Ram (Cathlab); &
Chester (SQD)
Question No. 1
In what 2 stand
did TMC obtai
perfect 10 in 2
Survey?
Question No. 2
What are the
names of the 3 J
surveyors who
visited TMC las
2009?