CQI-2 - Patient Safety Program

CQI– 2
APOLLO HOSPITALS,INDORE
Issue: B
Date: 01-03-2019
PATIENT SAFETY PROGRAMME
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PREPARED BY: APPROVED BY:
Assistant Medical Superintendent Unit Head

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CONTENT
Section Content Page no.
No.
Content 2
1 Introduction to the Patient safety 4
2 Objectives Of Patient Safety Programme 4
3 Key Responsibilities of Patient Safety Officer at XYZ 4
4 Patient safety goals 6
5 Patient age related hazards 8
6 Patient safety orientation 9
7 Patient transportation 9
8 Patient safety and hospital bed 9
9 Risk management 10
10 What is an incident 16
11 Electrical safety 15
12 Engineering & facility safety 16
13 Emergency protocol for lift outage 19
15 Transferring patients in the lift 19
16 High risk medicines 20
INTRODUCTION
1. WHAT IS PATIENT SAFETY?
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 Patient safety is simply defined as “the prevention of harm to patients”.

 Patient safety is an integral part of the delivery of quality of care and a fundamental right of all
patients.
 Although simple in definition, the road to ensuring patient safety in health care facilities is
complex and replete with obstacles.
 Our Organization has made patient safety a declared and serious aim by establishing
comprehensive patient safety programs with defined executive responsibility, operated by
trained personnel and in a culture of safety.
2. OBJECTIVES OF PATIENT SAFETY PROGRAMME

 To provide, clear and visible attention to safety
 To implement a system for analyzing and reporting any errors within the Organization
 To incorporate well-understood safety principles
 To establish multidisciplinary team training programs for providers
 To identify and analyze system failures
 To involve participation of patients and their families wherever required and be responsive to
their Inquires
 To communicate findings to the concerned department
 To provide education related to patient safety to all the health care workers.
 There is designated individual for coordinating and implementing the patient safety
programme.
Key Responsibilities of Patient Safety Officer:
1. Provides leadership and direction to the organizational patient safety strategy

2. Continuously evaluates and improves the patient safety program based on internal needs and
external requirements and NABH standards
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3. Collaborating with key organizational leadership (clinical, operational, legal), directs and is
accountable for the development and implementation of a comprehensive patient safety and risk
management plan and updates this plan at least annually.
4. Conducts an annual and on-going assessment of patient care risks by working closely with the
clinical leadership across with the team to develop International patient safety goals.
5. Develops and implements a company-wide patient safety measurement strategy
6. Develops and implements an adverse event reporting and patient complaint management system
that is easy to use and engages the frontline care providers, patients and families in patient safety
efforts
7. Supports/facilitates the implementation of innovation and systems that eliminate patient harm.
8. Works with clinical leaders and nursing personnel to coach/teach/train them in leading teams to
improve patient safety
9. Collaborates with the Quality improvement efforts to identify key improvement focus areas that
impact both patient care quality and safety.
10. Develops and implements initiatives to create a patient safety culture using transparency of
information as the foundation of this effort
11. Co-chairs the Quality and Patient Safety Steering Committee which will include clinicians from the
field and will have activities focused on data review, identification of trends, prioritization of risks
and actions to mitigate risks in an on-going way.
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12. Chairs the Patient Safety Peer Review Committee to consistently evaluate specific provider
performance during his/her employment. The chair will establish consistent processes for review
and feedback so that the focus is on on-going physician development and improvement whenever
possible.
13. Oversees individual case reviews and develops appropriate tools and training so that clinical
program leadership learns how to conduct these reviews and can partner effectively with the
patient safety efforts across HCO.
14. Works with clinical leadership to design, implement and assess the patient safety educational
modules for new employees. These educational modules will be on-going with a focus on teaching
specific skills such as conducting a root cause analysis and using patient safety tools such as the
learning from defect tool.
15. Participates as needed on clinical and operational calls to inform and educate the program teams
about the Patient Safety Program and also to get feedback and input into how this program grows
and is implemented.
16. Monitors literature and professional organizations for new or revised best practices related to
patient safety.
17. Assists individual providers as necessary in responding to inquiries from professional organizations
in collaboration with Quality department.
18. In collaboration with clinical leadership, develop a “second victim” support program to support
providers involved in adverse events.
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19. Attends patient safety and risk management educational conferences as reasonably requested
and/or approved by the Chief Operating Officer
20. Develops a standard way that safety programs partner with client patient safety efforts and
infrastructures.
21. Performs other duties as assigned
Skill set:
Nursing unit head, having the following:
 Minimum 3-5 years of experience working as Nursing head within a patient safety structure,
managing adverse event reporting and systems improvement
 Training in performance improvement (in-house training by Quality department)
 Proven track record in effectively working with teams
 Excellent verbal and writing skills and willingness to learn new skills
 Advanced interpersonal communication skills to provide effective consultation and

collaboration.
 Ability to organize and define problems, develop strategies, and carry out action plans
 Advanced analytical skills to trend and analyze data

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 Capable to exercising sound judgment and making independent decisions
 Ability to adapt to a complex and changing organizational and healthcare environment
 Ability to maintain and promote positive relationships across hospital and health system clients
we partner with.
 Open to feedback and coaching
Confidentiality
Maintains strict confidentiality with regard to protected health information and understands and
adheres to XYZ Multispecialty Hospital’s Privacy & Security policies and procedures.
The Patient safety programme is communicated and coordinated amongst all the staff through
proper training.
Patient safety programme to be reviewed at least once in four month and Patient safety programme
to be updated at least once in a year.
3. PATIENT SAFETY GOALS:

Patient Safety Goal 1: Identify Patients Correctly
 Use at least two patient identifiers when providing care, treatment or services. The intent
for this goal is to:
o To reliably identify the individual as the person for whom the service or treatment is
intended.
o To match the service or treatment with the person.
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 Patient identifiers used:

 UHID
 Patient NAME
 “The patient’s room number or physical location should not be used as an identifier”.
 Patients are identified before administering medications, blood or blood products.
 Patients are identified before taking blood and other specimens for clinical testing.
 Patients are identified before providing treatments and other procedures.
 Patients are identified before providing treatment by cross checking consultant name.
Patient Safety Goal 2: Improve the effective communication

 Ineffective communication is the most frequently cited category of root causes of sentinel
events.
 Effective communication, which is timely, accurate, complete, unambiguous, and
understood by the recipient, reduces error and results in improved patient safety.
 All the orders in the ward preferably are taken in written format, except in cases when it is
not possible to wait for the concerned doctor to arrive.
 Critical lab values and critical finding in the imaging are communicated to the concerned
unit verbally over the telephone. However this would follow with the report in the HIS/
printed report.
 The complete verbal and telephone order or test result is written down by the receiver of
the order or test result. Verbal orders are written in the “Verbal Order Form” and critical
test results are written in the case file.
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 The complete verbal and telephone order or test result is read back by the receiver of the
order or test result.
 The order or test result is confirmed by the individual who gave the order or the test result.
Patient Safety Goal 3: Improve the safety of High-Alert medications

 When medications are part of the patient treatment plan, appropriate management is
critical to ensuring patient safety.
 Every high-alert drug is been countersigned and checked by one another health care
workers
 There are policies & procedures developed and implemented to address the identification,
location, labeling and storage of high alert medications.
(Reference: Management of Medication Policy Manual)
Patient Safety Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

 The surgical site identification is done by using an instantly recognizable marking of the
site.
 Surgery time out checklist is used to verify pre-operatively the correct site, correct
procedure, and correct patient and that all documents and equipment needed are on hand,
correct and functional.
 The full surgical team conducts and documents a time-out procedure just before starting a
surgical procedure.
(Reference: OT Manual)
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Patient Safety Goal 5: Reduce the risk of health care-associated infections

 Compliance with the hand hygiene guidelines will reduce the transmission of Infectious
agents by staff to patients, thereby decreasing the incidence of healthcare associated
infections.
 Monitoring the hospital acquired infection rates and communicating them to the
concerned department also helps in reducing the risk of healthcare associated infections.
(Refer: Infection control manual)
Patient Safety Goal 6: Reduce the risk of patient harm resulting from falls
 A process for the initial assessment of patients for fall risk and reassessment of patients
when indicated by a change in condition or medications.
 Measures are implemented to reduce fall risk for those assessed to be at risk.
 Measures are monitored for results, both successful fall injury reduction and any
unintended related consequences.
 Ratio of patient and healthcare workers is followed in all the patient care area as approved.
 Medical and chemical restraints are used as and when required with the written order from
the physician.
4. PATIENT AGE RELATED HAZARDS:

 To ensure a safe environment for patients of all ages, the following guidelines have been
developed.
a. Pediatric Patients
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 Side rails should be utilized all the time, except when side rails were found to interfere with
the ease of nursing or clinical care and at these times child should not be left unattended.
 Light plastic wrappings are never permitted on sheets or pillows.
 Small candies, toys, etc., should not be accessible to a small child as he/she may choke or
insert them into a body orifice.
 Toys should be suitable for the age and condition of child
 All cleaning supplies will be kept in locked areas and never left where accessible to children.
 Medications will be kept locked at all times.
b. Elderly Patients
 Side rails should be utilized as and when found necessary. The decision shall be made by
the nurse.
 Patient rooms and corridors should be especially clear of furniture or equipment that may
lead to falls.
 Floors are to be kept clean and dry.
 Patients will be instructed on fall prevention measures.
 Be watchful for patient hypersensitivity to medications.
 Application of hot or cold compresses should be monitored closely.
 Nurse call button should be kept within reach.
5. PATIENT SAFETY ORIENTATION

 Patients with valuables should be informed of hospital policy on patient valuables.
 The location and use of call button, TV control, other switches, and side rails should be
explained to patients.
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 Patients should be informed of No Smoking Policy.

 Patients should be informed of policy concerning personal appliances.
 Hospital fire drills should be explained to prevent any panic or discomfort experienced by
the patient.
 Patient Handbooks will be provided to patient.
6. PATIENT TRANSPORT
a. Stretchers
 During transfer, bed clothes should be loosened to make for easier movement. Arrange bed
clothing so the patient will not be exposed or hampered.
 Communicate with the patient, work in unison with the patient, and do not permit patient
to overexert himself.
 During the transfer of the patient from his bed to a stretcher, brakes should be applied to
the bed and stretcher to prevent separation between bed and stretcher.
 Patients on a stretcher should be covered with a sheet or blanket and should be cautioned
to keep hands, feet and arms under the cover while on the stretcher.
 Patients being transferred on a stretcher should be transported feet forward.
 When using an elevator, always check to see that the corridor floor and the elevator floor
are at the same level before entering or exiting.
 Any defective stretcher should be removed from service, tagged and sent for repair.
 Side rails should be in upright position.
b. Wheelchairs
 Brakes will be locked when assisting patients in and out of a wheelchair.
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 Patients should always be supported when getting in/out of a wheelchair.

 Footrest should be raised when patient is getting in/out of a wheelchair.
 When using an elevator, always check to see that the corridor floor and the elevator floor
are level before entering or exiting.
 Any defective wheelchair should be removed from service and sent for repair.
7. PATIENT SAFETY AND HOSPITAL BEDS

 Side rails may be used as and when found necessary
 Upon admission to unit, patient shall be told the purpose and importance of bed rails being
in the up position. The fact should be stressed that this is for their own safety and welfare.
If a patient is not capable of understanding, a family member should be informed of the
need for side rails to be in the up position.
 Items such as water, telephones, call buttons, etc., should be in easy reach of patient so
he/she does not have to overreach and possibly fall from the bed.
 Beds should always be lowered before patients attempt to stand.
 When side rails are placed in the up position, Nursing Services should give it a tug to ensure
the latch is engaged.
 Brakes should always be locked when in position and especially during patient transfer.
Patients often use the bed for support when getting in and out of bed and could be injured
if the bed moves. When setting the brakes, push and pull bed to ensure stability.
 Any defective bed should be removed from service and repairs requested.
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8. RISK MANAGEMENT
RISK MANAGEMENT PROGRAMME:
 Risk Management Programme is developed by Quality and Patient Safety Steering
Committee with the active participation from the Top Management.
 Risk Management Programme involves the following steps:
- Identify the hazards/ risks in the hospital
- Evaluate and prioritize the risks
- Plan & implement the risk alleviation programme
- Review the programme
a. HAZARD/RISK IDENTIFICATION:
 The purpose of this programme is to ensure the level of safety compliance at the hospital
and to identify any situation that detracts from our goal of providing a safe and secure
environment for our patients, employees and visitors.
 Review of incident reports, employee accident reports, facility tours, grand rounds,
Infection Control and Security Reports.
 Facility Tour is carried out at least twice a year. This tour will be done by the members of
Quality and Patient Safety Steering Committee. Depending on the need other members
also participate in this activity.
 All the employees report any deviation from safety norms observed in their work areas. In
order to achieve this all the employees are trained to identify the deviations on a regular
basis.
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b. EVALUATE AND PRIORITIZE THE RISKS:

 The risks thus identified are evaluated to assess the potential harm and who might be
harmed.
 Depending on these 2 criteria the priorities are established, where the risk factors that may
cause the most danger are prioritized to be eliminated from the system.
c. PLAN & IMPLEMENT THE RISK ALLEVIATION PROGRAMME:

 The risks thus identified need to be eliminated or alleviated. Hence a plan is developed to
take corrective and preventive actions to alleviate the risks from the system.
 In this process concerned department/committee is involved to provide technical or clinical
inputs.
 The concerned staff are trained or instructed on the action plan thus devised and it is
executed with the regular monitoring.
 Monthly report on risk management is sent to Chief Operating Officer by the Safety Officer.
Analysis of the programme is done every month in Quality and Patient Safety Steering
Committee. If any need arises where immediate action to be taken for certain risks that is
identified or any changes to be made in the risk management programme, the committee
can meet even more frequently.
d. REVIEW THE RISK MANAGEMENT PROGRAMME:

 Risk management programme shall be reviewed at least once a year. However the short
term action plans and monitoring corrects deviations from the planned programme, if any.
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e. Policy on assessment, management & reduction of risk factors throughout the

Hospital
PURPOSE:
‘Apollo Hospital’ is committed to provide safe environment to all its patients, staff and visitors
by ensuring the risk factors are eliminated or reduced to prevent the adverse events.
DEFINITIONS:
 Risk assessment is a step in the risk management process. Risk assessment is the
determination of quantitative or qualitative value of risk related to a concrete situation and
a recognized threat in the hospital.
 Risk management involves clinical and administrative activities to identify, evaluate and
reduce the risk of injury. This also includes the implementation of systems for internal and
external reporting of system and process failures.
 Risk reduction is the decrease in the risk of a healthcare facility, given activity, and
treatment process with respect to patient, staff, visitors and community.
 Clinical Risk is involved with the patient care protocols, methodologies, competency of staff
including doctors, diagnostic techniques, care plan, medication administration and also
with patient’s condition.
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 Operational Risk is involved with the day to day operations of the hospital including
workload management, hospital policies & protocols, equipment management and patient
complaints.
 Physical Risk is concerned with the construction/ installation and maintenance of
infrastructure, physical facility and safety related issues including Fire and Non fire
emergencies.
 Hazard: Anything with the potential to cause harm
 Risk: The likelihood of that harm being realized
POLICY:
Apollo Hospital recognizes that the provision of healthcare and the activities associated with the
treatment and care of patients, employment of staff, maintenance of premises and equipments, by
their nature incur risks. The management accepts its corporate responsibility to provide the
highest standards of patient care and safety to all and as such the process of, Hazard Identification,
Risk Assessment and Management is viewed as an essential component in maintaining and
improving the standards at the organization.
RISK ASSESSMENT:
 Risks are assessed or identified using different methods.
 Facility tours are conducted at least once in 6 months to assess the risk factors associated with
the infrastructure i.e. building, electrical installations, fire safety devices, plumbing, and
medical gases.
 There is a checklist that covers all the aspects of “Safe Environment” with respect to
infrastructure and physical facility. The findings beyond the checklist are also recorded.
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 During internal audits the methods by which safety is ensured are evaluated i.e. preventive
maintenance of equipments, availability of safety devices, etc
 During the mock drills also the potential risks that may arise during activation of any
emergency codes.
 Infection Control and Drug & Therapeutic Committees evaluate the risks factors within the
scope of their functional authority.
• Quality and Patient Safety Steering Committee evaluates all the non-clinical risk factors
pointed out through different sources.
 All the staffs are trained to bring any risk factor that may cause harm to the people,
equipment’s or to the building to the notice of the safety officer.
 Incident reporting mechanism is also utilized to identify risks through reporting “Near Miss
Events”.
 The risks thus identified are rated as per the following categories:
(A) RISK CONTROL/ PREVENTION/ REDUCTION:

 Action plans are drawn up for significant or high level risks to ensure they are reduced to the
lowest practicable level.
 Apart from action plans, control measures are also established for all risks where these are
identified as necessary and must be brought to the attention of all staff affected by them.
 Monitoring is carried out at departmental levels to ensure control measures are being
implemented as required. Examples of controls could be: training, policies, procedures,
protective equipment, alarms, contingency plans, checklists etc.
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(B)REPORTING OF RISKS:
 Risks attracting a rating of ‘significant’ or ‘high’ are reported to and CEO
 All the categories of non-clinical risks identified are reported to Head-Operations
 All the categories of clinical risks are reported to Medical Administration & respective
committees.
(C) REPORTING OF SYSTEM AND PROCESS FAILURE:

 The system and process failures are reported internally to the Head-Operations, in his absence
to CEO on a regular basis.
 Such failures having major impact on the patient care services are reported also to CEO.
 The patients who are scheduled for treatment/ care that involves the system/ process that is
failed are also informed about the re-scheduling.
 Patients/ family who are in the waiting area or are in-patients will be informed in person by the
Guest Relation Officer or Coordinator for the service.
 Those who are yet to reach hospital are informed through a phone call.
 Apart from this there will also be a display closer to the failed system/ process that say, “For
your safety and deliverance of better/ accurate service ________________ equipment is
undergoing regular maintenance. We regret inconvenience caused. For re-scheduling your
appointment please call _____________, Telephone Number: ________________________”
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 Whenever there is up gradation/ change of system i.e. software, equipment, which may cause
delays the sign posting that says, “_____________ is under up gradation. Kindly excuse the
delays”
 Whenever the general services are out of order e.g. Lifts the display says, “Lift Maintenance
under progress. Inconvenience regretted”.
(D)REFERENCES:
 Facility tour reports,
 Minutes of meetings – Emergency Preparedness & Safety, Infection Control, Drugs &
Therapeutics Committees.
 Root Cause Analysis Reports
9. WHAT IS AN INCIDENT?
 An incident can be any anything, which can result in any harm or has the potential to cause
harm to a patient, staff or visitors. Or in other words “any event or circumstance that could
have or did lead to unintended or unexpected harm, loss or damage.” It can also be defined
as 'any event or circumstance arising during patient care that could have or did lead to
unintended or unexpected harm, loss or damage’.
o No harm
o Near miss
o Adverse Events
o Sentinel Events
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 “No Harm” –In no harm scenario, the error is not recognized and the deed is done but
fortunately for the healthcare professional the expected adverse event did not occur.
 “Near Miss Events” – any process variation which did not affect the outcome but for which
a recurrence carries a significant chance of a serious adverse outcome. These events are
those that were prevented just before its occurrence. This can be identification of risk
factors or potential hazards.
 “Adverse Events” are those events that have occurred and resulted in minor temporary
harm or damage.
 “Sentinel Event” is an unexpected incident, related to system or process deficiencies,
which leads to death or major and enduring loss of function for a recipient of health care
services.
 Major and enduring loss of function refers to sensory, motor, physiological, or psychological
impairment not present at the time services were sought or begun. The impairment lasts
for a minimum period of two weeks and is not relate to an underlying condition.
9.1 REPORTING AN INCIDENT:

 Online Portal is made available in all the departments, in which clinical incidents can be
reported with all the details. The types of incidents that can be reported in this form are
also listed on the second page of the form.
 Incident can also be reported over the telephone, in case the reporter finds it difficult to
comprehend. The extension number of Quality Improvement Team or the speed dial of the
team members and Safety Officer can be used for this purpose.
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10. ELECTRICAL SAFETY

GENERAL ELECTRICAL SAFETY MEASURES:
1) The following procedures shall be followed at all times when electrical devices are used:
 Electrical devices shall be protected from wet floors.

 Always switch to “OFF” position before plugging or unplugging an electrical device.
 Do not disconnect the device from the wall by grasping the cord. Only disconnect from wall
by grasping the plug.
 Electrical devices that malfunction should be removed from Service immediately and sent
for repair/replacement.
 Electrical cords that show evidence of fraying, extreme wear and tear cut in insulation or
evidence of burning shall be removed from service and sent for repair/replacement.
 If the ground pin is missing from the plug, remove device from service and send for repair
or replacement.
 Any device that has been dropped, abused, had liquid spill on it or has evidence of
overheating shall be removed from service and be checked for electrical integrity.
 Extension cords for patient care equipment must be approved by the Biomedical
Engineering Department.
 Maximum care should be taken to ensure that no medical equipment with a load greater
than 20 amp will be operated with an extension cord.
 If you find an open/ broken electrical socket or any open wire or any other electrical device
which may seem to be precarious when safety is concerned, inform the Safety Officer or
the Maintenance Department immediately.
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 In case of any sparks or burning smell, put off the main switch (if possible) and inform the
maintenance department immediately.
 Turn Off all the switches that are not in use.
 NAKED WIRES (WITHOUT PLUG) SHALL NOT BE INSERTED IN THE SOCKET
3) EMERGENCY PROTOCOL FOR ELECTRICITY OUTAGE:

 If you experience an electrical outage in your area for more than a minute immediately
notify Maintenance Department.
 The Maintenance Team looks into the problem and analyses the approximate time it takes
to repair and bring back the normal functioning. Depending on this the Safety Officer
decides whether the outage will be a long-term or a short-term one.
 Radiology – will be down – only available X-ray will be portable units – film processors
will be down.
 Clinical Laboratory – work load restricted to essential testing
 The Command Center instructs the following to all the departments:
 To keep the minimum lights on in the corridors, administrative offices, bathrooms not in
use, patient rooms.
 To keep the air conditioners on only if circulation of air is required.
 To put off all the computers, TV, printers, etc. Keep them on only for emergency work.
 If the refrigerators have only few items in it, same can be labeled appropriately and
stored in one refrigerator in the ward. And the others can be put off.
 To put off all the equipment’s which are not required.
 To pull off the plugs of all Microwave Ovens.
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 If the situation requires complete shutdown of the hospital relocation may be required.
Evacuation will be planned as per the Evacuation Procedure explained in this manual.
11. ENGINEERING & FACILITY SAFETY

1) PREVENTION PLAN
 Inspect all the floors in the hospital and check the facilities provided. Enter the
observations in a logbook.
 Any breakdowns/repairs to be performed must be entered in the logbook and attended at
the earliest. Attend to the major complaints after completing the inspection.
 In case the problem is major and needs to be attended immediately, inform the seniors in
the maintenance department. Make sure that these are attended immediately by the
concerned personnel.
 Attend to all the complaints given by the concerned department representative by
prioritizing the same.
 Carry out Preventive Maintenance of all critical areas, like CT- Scan room, Emergency Room,
Operating Rooms, ICU on non-working days like Sundays and Holidays
 When it comes to other critical area like ICU, concerned ICU Nursing in-charge will identify
the day and inform maintenance whenever the ICU wing or cubicle becomes free. Carry out
preventive maintenance during that time. The details of preventive maintenance activities
are as follows:
 Checking and rectifying loose connection of all electrical Power Outlets.
 Replacement of defective switch and sockets
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 Checking for any leakage in Oxygen Line and arresting the same by replacing the spares or
the entire outlet.
 Checking for any leakage in Vacuum Line and arresting the same by replacing the spares or
the entire outlet.
 Checking and cleaning the Supply and Return Air diffusers in the department
 Checking and arresting fresh and drain water leakage at all points.
 Painting of areas, which need painting.
 Maintenance of equipment.
Carry out the Preventive Maintenance periodically for that equipment’s that are not under AMC.
Record the activities carried out in the Maintenance Checklists.
And for those under AMC, make sure that PM visits are given on the assured dates. If in case you
find it is not been done, inform the same to the electrical or chief engineer immediately.
 Ensure elimination of Electromagnetic interference and prevent any damage or leakage to
ensure radio frequency interference proof environment.
 Make sure that the gas connections are not interchanged.
 Ensure smooth and proper working of circuit breaker mechanism.
2) AT THE TIME OF CONSTRUCTION

 Smoking is strictly prohibited in all Hospital facilities. This includes smoking in or adjacent
to all construction areas. An increased level of enforcement will be initiated for the prevention
of smoking in all construction areas.
 Combustible debris must be removed from the worksite at least daily. This is the
responsibility of the contracting company doing the job in our hospital.
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 Housekeeping inspections must be conducted at least daily in all construction areas. This is
responsibility of the Department of Operations.
 Proper storage practices must be adhered in order to ensure that flammable and
combustible liquids and solids are appropriately stored and safeguarded. Flammable liquid
containers, flammable liquid storage cabinets and rag cans will be used wherever required.
Flammable/combustible liquids shall be properly stored in approved flammable storage
cabinets anytime not in use- Department of Maintenance.
 Increased frequency and intensity of hazard surveillance inspections will be implemented
for all buildings, grounds and equipment during construction, demolition, repair or renovation
activities.
 Welding, cutting, brazing, soldering and other hot work inside the hospital requires a fire
watch sign must be posted at all areas other than those sites expressly designed for this
purpose.
 Electrical tools, extension cord lights, grinding wheels or any spark producing devices are
not to be used where flammable liquids are used or stored.
 Welding, cutting, burning, or other hot work equipment must be in good working
condition. Excess cylinders may not be stored in the facility. All cylinders must be capped and
secured, with fuel gases and oxidizers properly segregated and permission is sought from the
fire officer for the same.
 Temporary structures shall not be constructed inside buildings under construction/
renovation.
 Extinguishers, if not present in construction area shall be provided in rating and spacing
suitable to the construction activity.
CQI– 2
Issue: B
Date: 01-03-2019
Page 27 of 34
3) SUDDEN FAILURE OF SUPPLY OF GAS AND VACUUM:

Prevention plan
 Ensure the availability of medical gases like Oxygen, Nitrous Oxide, Carbon Dioxide;
Nitrogen & Helium and suction outlets are in working condition.
 Monitor the level of Oxygen, in the manifold room. Instruct the respective supplier to
replenish the same. The supplier will do so based on the requirement within 24 hours of
intimation.
 Periodically check the pressure level at different outlets to make sure there is no leakage
through the supply lines.
 Checking for leakage is done using soapy water, if it gives bubbles at certain points, it
indicates the leakage of gas/ minor cracks on the pipeline.
4) Action Plan
 Wherever central supply of Oxygen is not available, maintenance department will make
sure that cylinders are in adequate number and there is a backup.
 If in case there is a problem in the supply of Oxygen, maintenance department will make
sure that the supply is continuous through the standby cylinders.
12. EMERGENCY PROTOCOL FOR LIFT OUTAGE:

 This protocol is to see that the use of elevators on emergency power is appropriately managed
to best meet the needs of our patients during lift outage and restore service as soon as
possible.
 The Safety Instructions are displayed in the Lift along with the Emergency Contact numbers.
CQI– 2
Issue: B
Date: 01-03-2019
Page 28 of 34
 At the time of a normal power loss event and lifts are on emergency generator power. There
may be stopping of lift for few seconds. Once the power comes back the lift will automatically
start again.
 In cases where the lift breaks down in between the Emergency Button is pressed. The
Maintenance staff should respond to the trapped passengers and assist with evacuating them.
 The maintenance staff opens up the lift door with manual control.
 In cases of any disaster lifts are grounded and are shut down.
 Depending on the time and length of the outage, the Manager Operations may limit or stop
visitors from entering the hospital.
 In case of major breakdown estimated time for repair must be mentioned to the concerned
staff.
13. TRANSFERRING PATIENTS IN THE LIFT:

 If you are transferring a patient in wheelchair or stretcher call the lift or ask security or any
other staff present to call the lift before the patient could reach near the lift.
 In case you find the lift is not in working condition, do not move the patient to the corridor
unless and until you are sure that the lift has resumed functioning. Or if the patient can be
transferred in the wheelchair (when other lifts are functioning) or by walk facilitate the same. If
not speak to the relatives regretting the inconvenience and inform the approximate time that
would take to resume the normal functioning.
 When the lift outage is estimated to be more than 5 minutes and if the patient condition
requires emergency intervention, inform the doctor and move him/her to the close by room
with emergency facility such as oxygen line, suction, crash cart and continue the treatment.
CQI– 2
Issue: B
Date: 01-03-2019
Page 29 of 34
 For example if the patient who is in the stretcher and is in ground floor can be moved to the
next floor or to the Emergency Room.
 While shifting the corpse of expired patient, make sure the lift is in working condition before
moving out of the ward. If not call up maintenance and ask how long it would take to
recommence the functioning. If the time estimated is more than 10 minutes, MSW will
convince the relatives to move down to the Counseling Room in the ground floor and assure
them that the corpse will be brought to the ground floor by the staff safely.
14. PATIENT ASSESSMENT

 Functional Assessment (Activities of Daily Living)- Check for ability to perform ADL &apply Fall
risk assessment / Vulnerable Criteria
 Physiological status, nursing needs & risk of pressure ulcer has to be documented.
 Alcohol intake: Regular/occasional, if stopped, since when?
S0moking Habit: Smoker or not? If stopped, since when? When he was smoking how many
cigarettes per day? If any habits of tobacco chewing or drugs addiction is to be written.
 Systemic Assessment of the Patient: Carry out the systemic assessment of Eyes & ENT,
Respiratory, Cardiovascular, Breast, Gastrointestinal, Genitourinary, Neurological, Skin and
Extremities and put a tick mark in the appropriate box.
 If no abnormality detected put a tick mark in the box next to “No Abnormality Detected”
 If you are not able to assess a particular system indicate the reason.
 Ask if the patient wants to consult a Dietician, Counselor, Yoga therapist, Physiotherapist or
Pain Management Consultant.
CQI– 2
Issue: B
Date: 01-03-2019
Page 30 of 34
 For the subsequent admissions check the vitals and ask for the changes from the previous
assessment. Wherever abnormality was detected earlier ask specifically for the changes.
 For other systems ask all the questions as mentioned in the complete assessment form and
write only if there are any new findings.
 Any valuable and belongings to be handed over to the relatives & it should be documented.
 Write your name, time, date along with the signature& file it in the case file.
16. HIGH RISK MEDICINES:

High Risk Medications are drugs that have a heightened risk of causing significant patient harm
when they are used in error.
To minimize the risk include strategies such as:
 improving access to Information about these drugs;

 limiting access to High-Risk medications;
 standardizing the ordering, storage, preparation, administration and monitoring of these
products;
 Employing redundancies such as automated or independent double checks when
necessary.
 Eventual promotion of using Tallman lettering, using auxiliary labels & automated alerts.
 New formulary medications & additional relevant safety information will be reviewed for
inclusion on the High risk Medication list by the Pharmacy and Therapeutics committee.
 Medications that the Drug and Therapeutics Committee (P&T) has deemed to be High Risk or
High-Alert include the following category list :
CQI– 2
Issue: B
Date: 01-03-2019
Page 31 of 34
Drugs with Narrow therapeutic index

 Cytotoxic agents
 Heparin infusions
 Insulin – both continuous infusions and subcutaneous doses
 Narcotic drugs.
 Anticoagulants (anti-thrombotic drugs)
 Psychotropic substances
 Look Alike- Sound Alike Medication.
 Drugs used in acute conditions e.g. - Electrolytes, Plasma Expanders, Human Albumin etc.
 Drugs with greater drug-drug interaction potential
17. POLICY ON CONSENT
‘Apollo Hospital’ is committed to safeguard the interest of the patient and family in permitting or
not permitting the healthcare team member to perform any procedure or carry out any
investigations.
Informed consent is obtained through a process defined by the organization and carried out by
trained staff. An informed consent is a proof to the fact that the patient and the family are involved
in the care process. Before the commencement of any invasive procedure or any surgery the
patient or the family member is required to give his consent in writing. The patient consent is also
sought prior to a High-risk investigative procedure like CT scan with contrast, FNAC etc.
CQI– 2
Issue: B
Date: 01-03-2019
Page 32 of 34
1. TITLE OF THE POLICY & PROCEDURE:
Policy on taking Informed Consent from patients/ family members
1. PURPOSE:
Apollo Hospital’ is committed to safeguard the interest of the patient and family in permitting or
not permitting the healthcare team member to perform any procedure or carry out any
investigations.
An informed consent is obtained through a process defined by the organization and carried out by
trained staff .An informed consent is a proof to the fact that the patient and the family are involved
in the care process. Before the commencement of any invasive procedure or any surgery the
patient or the family member is required to give his consent in writing. The patient consent is also
sought prior to a High-risk investigative procedure like CT scan with contrast, FNAC etc.
2. POLICY & PROCEDURE:

3.1 The list of procedures for which consent is taken include
 On Registration
 On Admission
 HIV Testing
 Operating Room Procedures
 Anesthesia Administration
 High Risk Procedures
 Blood Transfusion
 Using Restraints
 Invasive Procedures – Therapeutic or Diagnostic
 CT procedures where Contrast is used
 Leaving Against Medical Advice
CQI– 2
Issue: B
Date: 01-03-2019
Page 33 of 34
 Transfer of patients from one facility to another
3.2 High Risk Procedures specific to the organization include;

 Surgery – age above 70 years, removal of organs such as esophagectomy, pancreatectomy,
cystectomy, cerebrovascular disease, co-existing serious morbidities effecting
cardiopulmonary, neuro, genitourinary, gastrointestinal systems.
3.3 At the time of Registration patient/ relative is oriented to the hospital policies and also the
general consent for OPD consultation and other routine investigation is taken. The details of
the individual who would be considered as the decision maker in cases where patient cannot
give consent is also collected.
3.4 The concerned healthcare team member shall explain the patient/ relative ‘sufficient
information so that he/she understands the nature of his/her condition, the nature and
purpose of the proposed treatment, the risks and consequences of the procedure or
treatment, the feasible alternative procedure or treatment and the consequences if the
procedure not performed nor any treatment given.’
3.5 An informed consent shall be obtained after the patient/ relative has understood the nature
and probable risks of the procedure or treatment are of such a common and ordinary in nature
so as to be within the patient’s understanding and knowledge.
3.6 Patient/ relative has to give his / her consent of willingness in writing in different formats
provided for different types of procedures.
3.7 An informed consent is also obtained when a clinician proposes to engage in or performs
human experimentation or other research/educational projects, and shall obtain a written
informed consent if the participation is agreed by the patient/ family and it also mention that
the patient has the right to withdraw/discontinue the participation any time.
CQI– 2
Issue: B
Date: 01-03-2019
Page 34 of 34
3.8 Consent is also taken from the patient and his family when they decide to discharge from the
hospital against medical advice. In such cases consent is taken only after explaining the risks of
such a decision.
3.9 The consent taken at the time of Registration is only limited to basic investigations and
treatment.
3.10 The doctor performing the procedure/ intervention, administering anesthesia, nursing staff
administering high risk medication, drawing sample for HIV testing, transfusing blood,
administering contrast and the admission & registration counter are responsible for explaining
the procedure and taking consent.
3.11 In case the patient is minor (below the age of 18yrs) or is in unconscious condition or not in a
stable mind or not in a position to take any decision the surrogate decision maker/
representative can give the consent. The priority order of surrogate decision maker is: Spouse,
adult children, parents, adult brothers or sisters, adult grandchildren. In case these relatives
are not available, a close friend or any other person who accompanied the patient can also give
consent.
3.12 In case the patient requires an emergency procedure or intervention, but is unconscious or not
in a state to give consent and is not accompanied by a legal representative, two of the senior
consultants shall give a written authorization stating that emergency procedure or intervention
is required in order to save the patient’s life.
3.13 All the entries in the consent form shall be filled compulsorily.

CQI-2 - Patient Safety Program

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CQI– 2

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

PATIENT SAFETY PROGRAMME

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

1 Introduction to the Patient safety 4

2 Objectives Of Patient Safety Programme 4

3 Key Responsibilities of Patient Safety Officer at XYZ 4

4 Patient safety goals 6

5 Patient age related hazards 8

6 Patient safety orientation 9

8 Patient safety and hospital bed 9

12 Engineering & facility safety 16

13 Emergency protocol for lift outage 19

15 Transferring patients in the lift 19

16 High risk medicines 20

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

 Patient safety is simply defined as “the prevention of harm to patients”.

2. OBJECTIVES OF PATIENT SAFETY PROGRAMME

Key Responsibilities of Patient Safety Officer:

1. Provides leadership and direction to the organizational patient safety strategy

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

5. Develops and implements a company-wide patient safety measurement strategy

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

21. Performs other duties as assigned

Nursing unit head, having the following:

 Proven track record in effectively working with teams

 Advanced interpersonal communication skills to provide effective consultation and

 Advanced analytical skills to trend and analyze data

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

 Capable to exercising sound judgment and making independent decisions

 Ability to adapt to a complex and changing organizational and healthcare environment

 Open to feedback and coaching

3. PATIENT SAFETY GOALS:

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

 Patient identifiers used:

Patient Safety Goal 2: Improve the effective communication

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

Patient Safety Goal 3: Improve the safety of High-Alert medications

Patient Safety Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

Patient Safety Goal 5: Reduce the risk of health care-associated infections

4. PATIENT AGE RELATED HAZARDS:

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

5. PATIENT SAFETY ORIENTATION

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

 Patients should be informed of No Smoking Policy.

PREPARED BY: APPROVED BY:

Assistant Medical Superintendent Unit Head

 Patients should always be supported when getting in/out of a wheelchair.

7. PATIENT SAFETY AND HOSPITAL BEDS