Developed by
Patient name : unidentified patient
Dr. Mohamed Shaban
MRN : Generated form EPR
Prescription Identification of unidentified patient
Verbal order is only allowed during emergency situation HAM
Telephone orders are not alllowed Before patient reach OR
Patient 4 names
Correct site , procedure & patient
Storage 2 identifiers
Secured +Red Labeled + Separation Covers
List should be available in all areas Patient MRN Consent completed
Pre operative verification
Administration Available assessments , images
List updated annually
Independent double checking Before providing treatment
Situations Documented in EPR Available implantable devises & Medical equipment ( if needed)
Before any procedure
Prescription LASA KKESH strategies
Verbal and telephone orders are limited
Before diagnostic procedures
MRP utilize both Generic & Band names
Indication should be added The Ophthalmologist who will do the procedure, before sending the patient to OR
Tall man lettering will appear in EPR Patient Identification
Storage Site Marking Shape : Small circle 5 cm in diameter, immediately outside the
Secured +Green Labeled + Segregated lateral end of the eye brown of the targeted eye
Improve Medication safety
Administration
Independent double checking Concentrated Electrolytes Time out process
The whole team shall share actively , Immediately before the skin incision Scope
Prescription Sign out correct patient identity , correct site , correct procedure
Only by internal physician consultant
Verbal orders allowed only during emergency situations Scope
5 moments Before the patient leave the procedure area
1. Name of the procedure
Storage Hand hygiene practices and guidelines Covering 2. Completion of instruments , sponge and needles counts
Crash cards & HDU Hand hygiene technique WHO & CDC Guidelines 3. Labeling of specimens
Labeled with Yellow + Red labels Reduce the risk of infection 4. Any equipment problems
Safe Surgery
Segregated KKESH defined critical results should be reported immediately
Evidence based interventions
IPSGs
“ Bundles” Laboratory Results
Administration
Independent double checking Reporting critical results of diagnostic tests Radiological Results
Reporting process
Outpatients ECG results
(Excluding high risk locations)
Effective Communication
1. Reporter should communicate results immediately with the ordering physician
Risk Of Fall 2. The receiver should read back the results from Trackcare
Visual Screening 3. Reporter should confirm the results
If positive
Patient Fall Risk Assessment A. If the Oredring physician could not be reached, communicate the
Minimum content results to charge nurse and she should follow step 1&2
Inpatient handover communication.
Patient Fall implemented
B. If the physician is away from the hospital , the MRP should write
All inpatients should be assessed during admission down and readback
Outpatient Patient fall implemented
( high risk locations) Occasions
Test type + results Name of reporter + name of healthcare worker Date + time
Patient reassessment should be tailored Telephone and Verbal Order
All critical Outpatients should be based on the assessment score 1. Between level of services
assessed during admission 2. Between healthcare providers Tool : physician notes
Physician handover
Situations
Patient intervention Tools and Scope Scope : Required investigation & Required interventions
Telephone order : Urgent patient need
Nursing handover
Verbal order : life threatening & during sterile procedure
Limited to medication in critical situations
The ordered should be given by privileged physician
Other practitioner handover
1. Written down
2. Read back Tool : Related forms
3. Confirmation
Scope : Required assessment & Required interventions
