Hospital Quality and Safety

International objectives for patient security

---

Objective #1: Correct identification of patients

The Clinica Bíblica Hospital has elaborated procedures to regulate good practice for the correct identification of its patients from admission to discharge from the institution. At his first encounter in Admissions, the patient assigned a bracelet with at least two data of information, which will identify him in an unequivocal manner throughout the institution, his complete name and identification number, and in the case of underage children, the name of the father, mother, or responsible adult is added.

During his stay, all documentation that is admitted to the clinical history of the patient, samples, and results that are generated by medical attention, will have a label, which explicitly links the patient with that information.

While he is receiving care, it is vital to establish the manner in which to proceed before any treatment, invasive procedure, application of medicines, collection of samples, transfusions or delivery of food to the patient: first, verify the two identifiers together with the patient, family member or responsible adult. The patient is asked his name and identification, and this is checked with the data on his bracelet; if they match, then proceed.

---

Objective #2: Improve effective communication

Rules have been established when it comes to receiving verbal instructions given by the doctor to the nurse or to the pharmacist, either verbally or by telephone, and to receive clinical examination results generated by diagnostic and laboratory professionals.

This practice obliges the professional who receives the instruction or the result to take note of it in the respective form of the patient´s file, read it again to confirm that what he heard was correct and confirm with his signature that he carried out this order. This is a living example to guarantee efficient communication in the most critical procedures in health care.

---

Objective #3: Improve security of high-risk medicines

The Clinica Bíblica Hospital has created different procedures and instructions to educate and help the personnel in the adequate use of medicines, especially high risk medicines, like, for example, psychotropic medications, narcotic drugs, those which sound or look the same as others. The practice reflects security in the process of selection, storage, prescription, dispensation, and administration, all with the objective to reduce errors in medications within the Hospital.

It is fundamental to monitor and control the correct use of medications, as it is for the treatment of the patient and must guarantee the patient´s security, avoiding different categories of harmfulness to the client and assuring compliance with the care plan of care prescribed by the physician.

---

Objective #4: Guarantee invasive procedures in the proper place with the right procedure and the correct patient.

To provide the patients in our Hospital with the security that complies with their expectations during their hospitalization or ambulatory visit, specifically invasive procedures, is a transcendent factor in the prevention of identification errors in this regard. Communication between the different members of the team that are involved with the care of the patients is of vital importance.

The Clinica Bíblica Hospital is committed to guarantee the correct surgery and/or invasive procedure of the right patient and in the proper place, working together by means of the implementation to:

Work as a team, conscious of the importance of verifying with the patient and/or his family members the procedure to take place (in case the patient is unable to confirm the information due to his state of health).

Fill out correctly the informed consent form in which the patient or his representative corroborates with the health personnel the procedure to be performed.

Mark the surgical and/or invasive site with the patient and /or his family before the start of any invasive procedure with the word: Yes.

Put into practice “Time Out”, the moment previous to performing the invasive procedure (when the supplies and necessary personnel are ready), to stop the activities in order to corroborate:

1. The correct patient
2. The surgical site and correct side marked with: Yes
3. Signed informed consent forms
4. Correct position
5. Complete surgical team

---

Objective #5: To reduce the risk of infections associated with health care

One of the main challenges in every health care institution is the reduction of infections associated with the attention given, whether because of the vulnerable condition of the users themselves or for the process of care that they receive in the health center; this represents one of the principle concerns of the patients and therefore of our institution.

For the sake of minimizing this risk, the Clinica Bíblica Hospital relies on a Committee for the Prevention of Hospital-acquired Infections that bases its work on continuous work plans which emphasize the importance of the control of hospital-acquired infections as part of the indicators that measure the quality of attention given to the users. Through ever improving processes and a focus directed to the prevention, the security of the patient and of the personnel.

Among these actions must be noted:

The washing of hands through diverse activities to promote this clean culture among the health personnel, patients, family members, and other visitors.

The promotion and continuous monitoring of the adequate segregation of solid and liquid waste of the Hospital.

Constant training of the health personnel to introduce them to new devices used in the Hospital, the new ones to come, talks by specialists, and reinforcement with campaigns aimed at ensuring good practices through the suppliers to our Hospital.

---

Objective #6: Reduce the risk of harm in patients caused by falls.

The falls of the patients within our Hospital represent a most important aspect, in the reinforcement of the process of attention to our patients and to attend to their new needs for care in a timely fashion with the least possible risk.

At the Clinica Bíblica Hospital evaluations are carried out of the patients at the time of admission and in key moments during their hospital stay with respect to their grade of mobility and/or dependence in order to perform activities of daily life; an important parameter to consider the risk of the patient to suffer a fall and thus the grade of attention and assistance necessary.

We rely on a Committee for the Prevention of Falls which organizes activities for updating and periodic monitoring with health care personnel related to the necessary measures to diminish the risk of falls and therefore the injuries suffered from these.

We count on characteristic identifiers that indicate to the personnel if a patient possesses a high risk of falling.