The

Top

30 Patient Safety
Policies and
Procedures
Edited by Diana Arendt, RN, MSN, CCRN
and Hilde Hithe, RN, BSN
Foreword by Robert Marder, MD
 Contents

About the editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

About the reviewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

The patient safety climate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Evidence of increased interest in patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Reasons for increased interest in patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Creating a culture of safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
The role of policies and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
How this book is organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
About the policies and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
How to use the policies and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
The next phase of patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi

Chapter 1: Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Policy 1. General Safety Guidelines Summary Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Policy 2. Safety Management Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Policy 3. Sentinel Event Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Policy 4. Immediate Safety Interventions and Chain of Command Reporting . . . . . . . . . . . . . . . 29

Chapter 2: Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Policy 5. Infant or Child Abduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Policy 6. Employee, Physician, Visitor, or Vendor Identification . . . . . . . . . . . . . . . . . . . . . . . . . 45
Policy 7. Bar Code Medication Processing and Administration . . . . . . . . . . . . . . . . . . . . . . . . . 49

T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures 
C o n t e n ts

Chapter 3: Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Policy 8. Unusual Occurrence Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Policy 9. Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Policy 10. “Do Not Use” Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Policy 11. Patient Rights Education––Okay to Ask . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Policy 12. Critical Test Result Verbal Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Policy 13. Legibility of Written Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Policy 14. Nonpunitive Reporting Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Chapter 4: Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Policy 15. Fall Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Policy 16. Restraint Use––Medical Surgical and Behavioral Health . . . . . . . . . . . . . . . . . . . . . 115
Policy 17. Patient Initial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Policy 18. Patient, Procedure, and Site Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Policy 19. Preoperative Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Chapter 5: Equipment/Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Policy 20. Clinical Alarm Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Policy 21. Medical Device Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Policy 22. Hospital Bed Fire Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Policy 23. Universal Precautions for Handling Potentially Infectious Substances . . . . . . . . . . . 163

Policy 24. Latex Allergy Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Policy 25. General Fire Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Chapter 6: Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Policy 26. Patient Controlled Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Policy 27. Medication Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Policy 28. Pharmacist Review of Medication Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Policy 29. Medication Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

 T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures
 Management
Identification
Communication
Chapter One Risk Assessment
Equipment/Environment
Medication
Management
Identification
Communication
Risk Assessment
Equipment/Environment
Medication
Management
Identification
Communication
Risk Assessment
Equipment/Environment
Medication
Management
 Management

SSample
ample G eneral S
General afety G
Safety uidelines S
Guidelines ummary C
Summary Checklist
hecklist

Department: Policy number: 1 of 3

Policy 1

Section: Management Effective date: Page: 1 of 4

Title: General Safety Guidelines Summary Checklist q Non

m N on--clinical
clinical
am Clinical
q C
Approved by: Medical
Medical Executive
Executive Committee, Patient Care
Committee Patient Care,and
andSafety
SafetyCommittee
Committee Review date:
Revision date:

PURPOSE

To establish guidelines and general codes of safe work practices. To ensure a safe occupational and
patient care environment by establishing standards for safety awareness and work practices for staff
and physicians.

SCOPE

This is an organizationwide policy and applies to all services and care settings in the organization.

POLICY

1. All employees, licensed independent practitioners, and allied health professionals will complete an
annual safety educational program.

2. General safety:

a. Be familiar with machinery and equipment used.

b. Know what to do in case of an emergency.

c. Fatigue may be a causal factor of accidents. Use break times appropriately and know your
limitations.

d. Be knowledgeable about the infection control program.

T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures 
Chapter One

Policy
Sample General Safety Guidelines Summary Checklist (cont.)
1
e. Report any injury to your supervisor.

f. Wear appropriate clothing and closed-toe shoes.

g. Report unsafe conditions, including defective or broken equipment.

h. Do not run in the facility.

i. Share your ideas about safe practices.

3. Prevent accidents when moving equipment or patients:

a. Lifting––

(1) if it appears to be too much to handle alone, ask for help

(2) look over and above the object to be lifted; make sure it is not too awkward to lift

(3) stand close to the object with feet apart for balance

(4) bend knees and keep back as straight as possible

(5) get a good grip and keep weight close to your body

(6) lift gradually, straighten knees, and stand up; use leg muscles

b. Pushing and pulling––

(1) avoid twisting your body; change direction by moving your feet

(2) do not change grip while carrying the load

(3) face the spot on which the load will rest

4. Prevent falls:

a. Report slip/trip hazards to the environmental health and safety or engineering depart-
ments or use the hospital hot line

b. Push wheeled vehicles

 T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures
 Management

Policy
Sample General Safety Guidelines Summary Checklist (cont.)
1
c. Use a stepladder or nonwheeled step stool for out-of-reach items

d. Watch your step while walking

e. Use handrails for support when going up or down stairs

f. Keep hallways clear of clutter (items must be moveable and to one side of the hallway)

g. Walk at a safe speed

h. Wear nonskid-soled shoes

i. Never leave articles on stairs

5. Know how to prevent fires:

a. Adhere to nonsmoking rules and remind others to do the same

b. Inspect your work area frequently; report faulty wiring

c. Use extra caution around gas, flammable, and oxygen equipment

6. Know the various types of fire extinguishers and how to operate them:

a. Class A for wood, paper, and textile

b. Class B for flammable liquids and gas

c. Class C for electrical fires

d. ABC for all types of fires

e. To operate a fire extinguisher, use “PASS”––pull, aim, squeeze, and sweep

7. Know what to do in case of a fire:

a. In case of a fire, use “RACE”––relocate, alarm, confine, and extinguish

b. Know your evacuation plan

c. Know where to report

T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures 
Chapter One

Policy
Sample General Safety Guidelines Summary Checklist (cont.)
1
d. Know where the pull alarm boxes are located

e. Know where the fire extinguishers are located

8. Know how to prevent electrical accidents:

a. Inspect cords and plugs; ensure that they are intact

b. Keep cords away from rough, sharp, hot, or greasy surfaces

c. Make sure that equipment with three-prong plugs is grounded

d. If a machine overheats, smokes, or sparks, unplug it and call the engineering department

e. Do not touch electrical equipment if you are in or near a wet spot or if your hands are wet

9. Know how to prevent equipment accidents:

a. Know how to correctly operate any machine that you use

b. Turn equipment off and use lock-out features, when possible, whenever equipment is not
being used

c. Watch clothing; loose sleeves, hair, belts, ties, jewelry, and identification badge chains
are dangerous around machines with moving parts

d. Be sure that mechanical guards are in place when operating machines

e. Wear personal protective equipment if the job requires it (e.g., safety glasses, ear plugs,
gloves, etc.)

f. Unplug and remove malfunctioning equipment used on patients; tag it with a red repair
sign and move it to the dirty utility area

10. Storage of equipment:

a. Large bulk items should be stored on bottom shelves

b. All containers in the department must be labeled, showing the manufacturer’s instructions
for use and disposal, as applicable

 T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures
 Management

Policy
Sample General Safety Guidelines Summary Checklist (cont.)
1
c. Store items at least 18 inches from sprinkler heads

d. Do not store boxes or patient care equipment directly on the floor

11. Liquid spills:

a. Wipe up spills immediately; when handling hazardous materials, handle per the appropri-
ate material safety data sheet information.

b. Spills on clothes or on the body should be flushed with water immediately. If a spill
involves a caustic agent, healthcare attention should be sought from the employee health
or emergency department.

12. Glassware:

a. All used glassware and pieces with evidence of cracks or chips will be discarded in punc-
ture-proof sharps containers

13. Drugs, chemicals, and reagents:

a. Toxic chemicals will be maintained in small quantities. All containers must be permanently
labeled to display the name of the chemical and storage directions.

b. All personnel in departments where biohazardous materials are stored must be able to
identify the chemicals, be knowledgeable regarding the preparation and handling of the
chemicals, and know how to protect themselves in the event of spillage or exposure to
the chemicals.

14. Office safety:

a. Keep desk and file drawers closed when unattended

b. Be prepared for a natural disaster:

(1) Remove plants and heavy items from overhead

(2) Secure electronic items

T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures 
Chapter One

Policy
Sample General Safety Guidelines Summary Checklist (cont.)
1
(3) Keep a flashlight and batteries readily available

(4) Keep tennis shoes and a change of casual clothes available in case they are
needed

(5) Know escape routes from the work area

c. Keep floors clear

d. Use a safety ladder for reaching high places––do not stand on chairs or boxes

e. Use caution when handling knives, scissors, letter openers, staples, or other sharp
instruments

f. Secure filing cabinets and shelving to the wall

g. Report broken or sharp furniture to the manager

h. Practice ergonomically correct use of chairs, keyboards, phones, and other office equip-
ment; contact the physical medicine department for an ergonomic review of workspaces

REFERENCES

The Joint Commission on Accreditation of Healthcare Organizations, State Health Department,

Occupational Safety and Health Administration

 T h e T o p 30 P a t i e n t S a f e t y P o l i c i e s and Procedures
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