1.

0 POLICY: It is the policy of the hospitals is too aimed at ensuring the health and
safety of patients throughout their care journey. To protect patients from harm during
the delivery of healthcare services. Patient safety is a constant domain in any
framework for quality healthcare. All organizations should ensure the safety of our
patients through the adaptation of safe practices this includes:
1.1 Improve the accuracy of patient identification by using at least 2 identifiers
when providing care, treatment, and services. Two identifiers are used when
administering medications, blood/blood products, collecting any type of specimen for
testing, providing treatments or performing procedures.
1.2 Report critical results of tests and diagnostic procedures on a timely basis.
1.3 Label all medications, medication containers, and other solutions on and off
the sterile field in perioperative and other procedural settings.
1.4 Comply with current WHO hand hygiene guidelines.
1.5 Conduct a Safe Surgery Checklist on all patient undergoing operation.
1.6 All sentinel events, adverse events and near misses should be reported using
the SBAR Method.
1.6.1. S = Situation – what happened
1.6.2. B= Background – patient information
1.6.3. A= Assessment – what you found
1.6.4. R=Recommendation – what needs to be done

2.0 OBJECTIVES:
2.1 To encourage and promote a culture of patient safety at all levels across the
organization. Fostering an environment where staff feels comfortable reporting errors or
near misses without fear of retribution. This encourages open communication and
continuous improvement.
2.1 To promote organizational commitment and accountability for safety through
the selection of priority initiatives that is aligned with the organization’s quality and
safety goals and objectives.
2.3 To develop and implement standardized protocols for clinical practices,
medication administration, infection control and other critical areas to minimize
variability and reduce errors.
2.4 To articulate the organization’s safety and quality and objectives to all staff
and physicians.
 2.5 To provide patients and their families with information about their conditions,
treatment plans and safety measures to enhance their understanding and involvement
in care.
2.5 To implement systems for monitoring patient safety incidents, analyzing data
and reporting finding to identify trends and areas for improvement.

3.0 SCOPE:
3.1 Patient safety encompasses a wide range of activities, practices and policies
aimed at protecting patients from harm during their healthcare experience. This includes
ensuring the best practices to minimize the risk of errors in diagnosis and treatment to
patient, implementing measures to prevent medication errors, falls prevention, blood
transfusion safety, establishing protocols to prevent healthcare-associated infections,
utilizing robust patient identification, adopting protocols such as Surgical Safety
Checklist, implementing system of reporting and analyzing sentinel events, adverse
events, near misses and unsafe conditions to facilitate learning and prevent recurrence.

4.0 DEFINITION:
4.1 Patient Safety –is the absence of preventable harm to a patient during the
process of health care.
4.2 Culture of Safety – is where safety is embedded in all activity, where staff
have constant and active awareness of potential harm.
4.3 Error – an unintended act, either omission or commission, or an act that that
does not achieve its outcome such as medication errors and adverse drug reactions.
4.4 Sentinel Event – a patient safety event (not primarily related to the natural
course of the patient’s illness or underlying condition) that reaches a patient and results
in any of the following:
4.4.1 Death
4.4.2 Permanent Harm
4.4.3 Severe temporary harm
4.5 Patient Safety Event – is an event, incident, or condition that could have
resulted or did result in harm to a patient.
4.6 Adverse Event – a patient safety event that resulted in harm to a patient
4.7 No-harm Event – a patient safety event that reaches the patient but does not
cause harm.
4.8 Near Miss (or Close Call) – patient safety event that did not reach the
patient.This includes but not limited to the following:
4.8.1 Mistaken identity
4.8.2 Wrong labelling of specimen, ancillary procedures and laboratory
results
4.8.3 Or any process variation which did not affect the outcome due to
screening by chance.
4.8.4 Hazardous Condition/s (or “Unsafe”) – a circumstance (other than
a patient’s own disease process or condition) that increases the probability of an
adverse event
4.9 Adverse Drug Reaction - any response to a drug which is noxious,
unintended and occurs at doses used for prophylaxis, diagnosis or therapy.
4.10 Medication Error – any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the
control of health professional.
4.11 Risk Management – clinical and administrative activities undertaken to
identify, evaluate and reduce the risk of injury to patients and significant others.
4.12 Root Cause Analysis – a process of identifying the basic or casual factor/s
that underlie the variation in performance, including the occurrence and possible
occurrence of a sentinel event.

5.0 RESPONSIBILITIES:
5.1. Nurse Manager/Head Nurse – responsible for monitoring compliance
to all provision stipulated in this document and reporting sentinel, adverse and
critical events to the Patient Safety Coordinator, Director of Nursing and
Customer Relation Officer.
5.1. Patient Safety Coordinator – In charge in monitoring of compliance
process for patient safety events and making sure it is confidential and
responsible for collecting and analyzing data related to the event to identify
trends, root causes and areas of improvement.
5.1 Staff Nurse/ Nurse on Duty/Nursing Aide – has the duty to report all
sentinel, adverse, critical events and near misses to her/his head nurse related to
patient safety events.
 5.1.4 Attending Physician – responsible for ensuring immediate patient
safety in case of a sentinel events and collaborates with the healthcare team to
address the error immediately.

6.0 PROCEDURES:
6.1 Upon identify patient safety risks in the area the staff should notify first
the head nurse make an incident report including time, date, location, individuals
involved and detailed description of the event and actions taken. Assess the
situation and quickly evaluate the incident to determine the severity and
immediate risks to the patient and others.
6.2 Initial investigation shall be done by the Head Nurse in collaboration
with the Nurse Manager, once reported was verified the physician shall be
notified for appropriate interventions.
6.3 All events regardless of severity shall be reported immediately to the
Physician, Nurse Manager, Head Nurse, Director of Nursing and Patient Safety
Coordinator within 24 hours.
6.4 The uneventful occurrence of error will be reported to the Patient
Safety Coordinator and accomplish appropriate reports.
6.5 The Department unit and Patient Safety Coordinator in collaboration
with the Head Nurse shall review and validate the incident. And shall submit a
written report using the Incident Report form to the Patients Safety Coordinator
and HRD.
6.6 The Root Cause Analysis must be performed to initiate a thorough
investigation of the incident, including gathering data, interviewing involved staff
and reviewing relevant documentation and protocols.
6.7 Then identify the contributing factors to analyze the root causes of the
incident to determine the underlying issues.
6.8 For the Nursing Service the Director of Nursing agrees to implement
corrective actions based on Code of Discipline (MTCMC-HRD-PR-003) and RCA
to create action plans to address identified issues.
6.9 The Director of Nursing involve the training officer if offer additional
training or education to staff involved in the incident to reinforce best practices
and enhance skills related to patient safety.
6.10 Submit fully accomplish incident report with corrective action to
Patient Safety Chairman/QA and HRD for review and present during
Management meetings.
 6.11 Provide follow care to ensure that the patient receives appropriate
follow-up care and support including necessary medical or psychological
interventions.
6.12 Sentinel Event/Near Misses/Adverse Events Reporting and
Evaluation
6.12.1 All sentinel events are reported. These include the following
incidents:
6.12.1.1. Suicide of any patient receiving care, treatment,
and services in a staffed around-the-clock care setting or within 72
hours of discharge, including from the hospital’s emergency
department (ED)
6.12.1.2. Unanticipated death of a full-term infant
6.12.1.3. Discharge of an infant to the wrong family
6.12.1.4. Abduction of any patient receiving care, treatment,
and services
6.12.1.5. Any elopement (that is, unauthorized departure) of
a patient from a staffed around-the-clock care setting (including the
Emergency Department), leading to death, permanent harm, or
severe temporary harm to the patient.
6.12.1.6 Hemolytic transfusion reaction involving
administration of blood or blood products having major blood group
incompatibilities (ABO, Rh, other blood groups)
6.12.1.7 Rape, assault (leading to death, permanent harm,
or severe temporary harm), or homicide of any patient receiving
care, treatment, and services while on site at the hospital
6.12.1.8 Rape, assault (leading to death, permanent harm,
or severe temporary harm), or homicide of a staff member, licensed
independent practitioner, visitor, or vendor while on site at the
hospital
6.12.1.9 Invasive procedure, including surgery, on the wrong
patient, at the wrong site, or that is the wrong (unintended)
procedure
6.12.1.10 Unintended retention of a foreign object in a
patient after an invasive procedure, including surgery
6.12.1.11 Severe neonatal hyperbilirubinemia (bilirubin > 30
milligrams/deciliter)
 6.12.1.12 Prolonged fluoroscopy with cumulative dose >
1,500 rads to a single field or
any delivery of radiotherapy to the wrong body region or >
25% above the planned radiotherapy dose
6.12.1.13 Fire, flame, or unanticipated smoke, heat, or
flashes occurring during an episode of patient care
6.12.1.14 Any intrapartum (related to the birth process)
maternal death
6.12.1.15 Severe maternal morbidity (not primarily related to
the natural course of the patient’s illness or underlying condition)
when it reaches a patient and results in permanent harm or severe
temporary harm.
6.12.2 All near misses are also reported. These include but not
limited to the following:
6.12.2.1 Mistaken identity
6.12.2.2 Wrong labelling of specimen, ancillary procedures
and laboratory results
6.12.2.3 Or any process variation which did not affect the
outcome due to screening by chance.
6.12.3 Errors, critical incidents and other adverse events that may
bring adverse outcome to the patients are also reported like medication errors, adverse
drug reactions equipment malfunction during usage, nosocomial infection, needle stick
injury, surgical site infection or the like.
6.12.4 Patients who had near misses and adverse events should
be observed and monitored for at least 24 hours.
6.12.5 Critical patient should be observed, monitored and treated in
the ICU.
6.12.6 The nurse on duty reports the incident to the nurse
supervisor for recording and inclusion in the Sentinel events,
adverse events, and corrective action report form. The nurse
supervisor informs the PSC about the incident.
6.12.7 If the staffs witness the incident, after management of the
patient, it is his/her duty to inform the Nurse Supervisor.
 6.12.8 The Senior House Officer reports the incident in the Sentinel
events, adverse events, and critical events report form using the
SBAR Method. He then submits the report to the PSC.
6.12.9 The form is then submitted to the Patient Safety Coordinator
for investigation, evaluation and recommendation.
6.12.10 The report is included in the agenda of the meeting of the
Patient Safety Committee and involved personnel/staff are invited.
Minutes of the meeting are taken.
6.12.11 A copy of the final report with recommendation is submitted
to the PSC
6.13 Fall Prevention
6.13.1 All patients should have Falls Screening on admission.
6.13.2 The patient at risk is identified and risk factors are assessed.
One or more of the listed risk factors will categorize the patient as Fall
High Risk:
6.13.2.1. fluctuating changes in behavior/delirium symptoms
6.13.2.2. patients on blood thinning medications
6.13.2.3. patient with mobility aid (cane or walker)
6.13.2.4. older age > 75 years old
6.13.2.5. absence of relative
6.13.2.6. previous fall
6.13.2.7 acute illness
6.13.2.8 chronic conditions (muscle problems)
6.13.2.9 Medications, especially the use of four or more
prescription drugs
6.13.2.10 Cognitive impairment
6.13.2.11 Reduced vision, including age related changes
6.12.2.12 Difficulty rising from a chair
6.13.2.13 Neurologic changes
6.13.2.14 Decreased hearing including age related changes
6.13.2.15 Risky behaviors
 6.13.3 All patients who underwent general or regional anesthesia
are considered fall high risk for at least 24 hours.
6.13.4 All patients identified as high risk will have a comprehensive
risk reduction plan developed with the patient and family.
6.13.5 These interventions to reduce falls are initiated:
6.13.5.1 Suitable, sturdy locked equipment at all times
(bedside, head and foot rails)
6.13.5.2 Occupied beds in low position with wheels locked
6.13.5.3 Rooms and hallways are cleared of obstacles
6.13.5.4 Floor is clean, dry and clear of personal items, spills
and clutter
6.13.5.5 With at least one accompanying person at all times
including bathroom privileges.
6.13.6 Witnessed and Unwitnessed Fall –Post Falls Management
6.13.6.1 Do not move, call for assistance –REASSURE
patient
6.13.6.2 Baseline vital signs, initial GCS
6.13.6.3 Clean wounds if any
6.13.6.4 Observe for change in behaviour
6.13.6.5 Call Medical Officer for review and treatment
6.13.6.6 Liaise for appropriate test and notify consultant
6.13.6.7 Monitor vital signs hourly for 24 hours including
neurological exam
6.13.6.8 Notify family
6.13.6.9 Flag as high risk
6.13.6.10 Include in the Sentinel Event Report

6.14 WHO Surgical Safety Checklist (MTCMC-ND-F-095)

6.15 Medication Safety
6.15.1 Medication orders should be written legibly in ink and should
include:
6.15.1.1 Medication generic name
 6.15.1.2 Dosage, frequency and route of administration
6.15.1.3 Signature of the physician over name with license
number
6.15.1.4 Date and hour the order was written
6.15.2 “Do Not Abbreviate” practice is implemented except for the
units.
6.15.3 Telephone orders and verbal orders except in extreme
emergency situation is not accepted. After the emergency situation, all drugs given to
the patient should be written and signed by the attending physician/resident in the chart.
6.15.4 A sterile technique in drug preparation in a quiet
environment free from any distraction is implemented. All syringes should be labelled
with patient name, medication name and time of preparation unless the medication is
prepared in front of the patient.
6.15.5 Blood Transfusion Reaction Guidelines (ANCI-GL-035)
6.15.6 Infection Control Prevention Manual (MTCMC-CLIN-MN-
004)

7.0 REFERENCES:
7.1 The Joint Commission and National Patient Safety Goals
7.2 Code of Discipline
7.3 Falls Prevention and Management
7.4 Policy of Medication Error
7.5 Prevention and Management of Pressure of Injury