While treating the patients in a hospital, safety of the patients is the first and foremost consideration. It means, the treatment process and all the procedures should be safe and hazard free.
Any incidence of safety violation, whether due to negligence or not, has multiple adverse effects. The patient suffers in terms of prolonged morbidity, mortality and extra financial burden.
The hospital, too, suffers in terms of negative publicity, loss of reputation, litigation and the consequences thereof.
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High standards of safety require an organization-wide work culture of safety, where each and every hazard prone activity is carried out in full cognizance of the attendant hazards and, taking all possible measures to prevent the hazards from happening.
It requires development of standardized protocols /procedures on the basis of the best practices in respect of every important activity after a careful process analysis and identification of weak links in the chain.
These protocols and procedures, if strictly implemented after adequate continuous training and education of staff, can go a long way in minimizing the incidence of safety violations in the hospitals. Some of the other important precautions to be taken are:
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i. Don’t change the staff at the last minute, unless absolutely inescapable
ii. Remember Murphy’s Law “Anything that can go wrong will go wrong”. So be prepared for it
iii. Don’t undertake the procedure if it is too hazardous unless the risks of not doing it are greater
iv. Be ready with the trained staff, fully operational equipment and the instruments/drugs necessary to handle effectively the unexpected/untoward developments
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v. Take a written informed consent of the patient/next of kin.
1. Personal Hygiene of Staff:
Personal hygiene of the staff attending to the patient is a very important factor. It is, specially, important in case of those in direct contact with patients such as the doctors, nurses, housekeeping staff and the dietary staff involved in distribution of food. A neat, clean and hygieneconscious staff not only inspires confidence among the patients, but is also a key factor in promotion of infection free practices. It includes:
a. Personal hygiene
b. Hygienic dress
c. Hand Hygiene
d. Staff with cough, common cold or other such infections to avoid contact
e. General measures
a. Personal Hygiene:
Orderly maintenance of one’s person such as neat, clean uniform/attire, hair neatly tied or tucked in, clipped and clean nails, proper shave or a well maintained beard, odor free breath and hygienic habits such as proper hand wash after visiting the toilet.
b. Hygienic Dress:
Use of apron, gown, mask and gloves where indicated,
c. Hand Hygiene:
Hand hygiene is the most important factor in infection control. Hand hygiene is essential before and after touching the patient, before touching an invasive device used for patient care, after contact with blood/body fluids, non-intact skin or wound dressings, after touching a contaminated body site and before touching another body site on the same patient, after touching inanimate surfaces or objects in the immediate vicinity and after removing the gloves. It is needed even before handling medication or preparing/serving the food.
For most of the routine treatment and care activities/procedures such as giving injections, catheterization, contact with blood/body fluids, dressing of the wounds, taking a blood sample, contact with immunocompromized patients, the hands need to be hygienic and free from infections.
The World Health Organization (WHO) has issued Guidelines on Hand Hygiene in Health Care to improve hand hygiene and reduce the transmission of pathogenic microorganisms to patients and healthcare workers (HCWs). Some of the measures recommended for infection free hand hygiene are discussed below:
i. Hands should be washed with soap and water when visibly dirty, soiled with blood/ other body fluids, after using toilet and when exposure to potential spore forming pathogens, such as Clostridium difficult, is suspected. A good hygienic wash involves wash of hands using a good disinfectant for about 20 to 30 seconds at least to remove the entire transient bacterial flora.
ii. For routine hand antisepsis in all other clinical situations, use of an alcohol-based hand rub would be an effective measure. Soap and alcohol-based hand rub should not be used together.
iii. A health care worker with cuts or skin disease on the hands or forearms should avoid touching the patient or performing any surgical/other procedure.
Techniques of Hand Hygiene:
i. Rub a palmful of alcohol based hand rub over all hand surfaces until dry
ii. When washing hands wet the hands with water and apply enough soap to cover all surfaces, rinse hands with water and dry thoroughly with a single use towel or blower
iii. Turn off the tap with the elbow or the towel and do not reuse the towel.
Hand Hygiene for Surgical Procedures:
For surgical/other invasive procedures, however, a simple hygienic hand wash is not enough. To eliminate the chances of any surgical infections, it requires a proper surgical scrub of the hands so that the entire transient as well as resident bacterial flora are eliminated. Following procedure is recommended:
i. Remove your watch, jewelry, artificial nails, etc.
ii. Wash hands with soap and use nail cleaner (brushes are not recommended) to remove debris from underneath the nails preferably under running water
iii. Surgical hand antisepsis by scrubbing the hands and forearms up to elbows with an antimicrobial soap (2% chlorhexidine) up to five minutes by watch. Alternately alcohol based hand rub can also be used but only on dry hands
iv. Put on the sterile gloves by the correct technique.
It may be noted that use of gloves is not a substitute for hand hygiene. Gloves are recommended in situations where contact with blood/body fluids/other infectious materials are likely. They should be removed/changed before touching another patient/another site on the same patient.
d. Infections among Staff:
Any staff suffering from any infections transmissible through touch or aerial route such as cough cold, running nose, conjunctivitis, should be excused from contact with the patients and certainly disallowed to perform any procedure.
e. General Measures:
Other measures needing attention for promotion of high level of personal hygiene are:
i. Education of staff about hygienic personal habits and measures for improvement of hygienic practices
ii. Screening of staff suffering from any infectious conditions
iii. Provision of facilities for implementation of hygienic practices such as:
a. Periodic medical examination of staff,
b. Provision of adequate hand wash facilities at convenient locations. Adequate number of wash hand basins with liquid soap, elbow operated/foot operated taps, blower hand dryers/tissue roles, are essential requirement. Conventional clothe towels are rather unhygienic and should never be allowed at common facilities for staff or public.
c. In the wards, for quick disinfection of hands, before and after examining a patient, antiseptic hand rub/spray containers fixed on the walls in the corridors can be quite convenient and effective.
d. Availability of adequate quantity of clean/disposable gowns, caps, masks and gloves.
2. Patient Identification Procedure (For Consent, Medication Investigations, Invasive/Non Invasive Procedures, and Therapeutic Diets:
Instances of medication error, wrong surgical/non surgical procedure or wrong diet due to mistaken identity of the patient are not unheard of, especially in busy hospitals with fast turnover of patients.
The consequences of such mistakes can sometimes be as serious as amputation of wrong limb or of wrong patient or wrong medication leading to even death of patient.
These mistakes and their consequences are completely and absolutely preventable. Any good hospital alive to the dangers of incorrect identification will have a fool proof SOP for patient identification which will be used by all the doctors, nurses and technicians for identification of correct patient before examining the patient, drawing samples for investigations, administration of medicines, obtaining consent for any procedure, conducting any procedure surgical/nonsurgical or even issue of diet.
Patient identification can be carried out by the Central Registration number (CR No.) name, age, sex, residential address, father/mother’s name, the disease/diagnosis or the bed/room number of the patient.
However, it is felt that no single parameter can be relied upon. The identification must be by use of multiple identifiers as discussed below:
i. At least two different identifiers must be used such as the name, the CR number, the residential address other than the bed/room number. Use of bed/room number is not a reliable identifier
ii. The identification must be based on active communication (in spoken words) between the care provider and the patient rather than the passive communication (by nodding the head or gesturing)
iii. The information must be tallied with the case records to be doubly sure
iv. The identification must be immediately prior to commencing the procedure without any interruption in between. If the care provider has to leave the place in between then on return the identification must be redone to be doubly sure that it is the correct patient
v. The identification procedure (even if it appears to be unnecessary/time consuming formality) must be repeated before every procedure.
Identification of patients in the wards: It is very important. Even at the cost of looking fussy or silly, it is worth its while to be sure of the patient’s correct identity. Somebody, other than the patient lying in the patient’s bed is not an uncommon situation.
Imagine the nurse poking the needle into his/her arm or handing over the capsules to him/her without even being sure that he/she is the actual patient for whom the medication is meant for. The nurse may follow the steps given below:
1. Check the patient’s particulars and the physician’s instructions from the patient’s case file.
2. Go to the patient’s room/bed and check the room/bed number.
3. Ask from the patient his full name, father’s name, age and cross check from the case file.
Identification of babies:
In case of babies in NICU/nursery, the chances of mix up are very high. Wrong identification can not only lead to the catastrophic effects of wrong treatment, but can also lead to baby swapping which has happened at many places.
In view of the above, it is recommended that the following procedure is adopted for identification of babies.
Immediately after birth and identification of the baby, an identity band (in quadruplicate) should be prepared. One band each should be secured around the left ankle and left wrist (as per the hospital policy) of the baby, one band should be tied around the left ankle of the mother and the fourth should be preserved in the hospital records.
The bands should be made of water proof material which does not get spoiled during cleaning and washing. The band once secured can be removed only by cutting and hence, would be temper proof. All the four Identity bands are exactly identical and have the following information:
a. Name of the mother and the father
b. Sex of the baby
c. Date of Birth
d. Time of birth
e. Mother’s CR number
f. Mother’s bed number
In psychiatric cases, the following procedure is recommended for patient identification:
Every patient on admission (until discharge/death) should be identified by unique water proof, temper proof ID disks (in duplicate) secured above the left ankle and the left wrist (as per the hospital policy).
The ID disks should be such as can be removed only by cutting and should be prepared in triplicate (third one for the hospital record). Each disk should have the following information:
a. Name of the Patient
b. Age and sex of the patient
c. Father’s name
d. Central registration number
e. Date of admission
f. Bed number
g. Name of the hospital and contact number
3. Disclosure of Past Medical History and Consumption of Medicines other than those Prescribed by the Physician in Charge:
Often, a patient admitted in the hospital for a particular disease may have long standing other past illnesses for which he/she may be on treatment under advice from some other doctor/hospital.
If the patient continues those medicines, there may be chances of their interfering/interaction with the other medicines prescribed by the treating physician for the current illness resulting into some complications.
It is, therefore, advisable that the patient informs the physician in-charge of all the past ailments and the medicines (along with dosage) the patient is taking.
The physician, too, must make a deliberate effort and insist on finding the details so that if those medicines are required to be continued, they are included in the treatment regime prescribed or are discontinued for the time being, if he deems it fit.
While admitted in a hospital, the patient should not be taking any medication other than those prescribed by the physician in-charge case. Otherwise, the outcome of treatment may not be the desirable one and the patient may be held responsible for the consequences.
4. Essentiality of Patient’s Consent:
Consent of a patient for treatment by the doctor is a prerequisite of paramount significance.
In legal parlance (Section 13 of the Indian Contract Act) two or more persons are said to consent when they agree upon the same thing in the same sense”.
In medical practice consent means permission or expression of willingness to undergo a particular course of action (procedure), such as willingness to be subjected to medical examination, a surgical operation or blood transfusion.
It is essential that the medical examination or any investigation or treatment procedure is carried out by the doctor only after due consent of the patient.
It is a legal requirement because interfering with the body of another person without his/her due consent amounts to violation of the privacy and trespass to the body of the person.
Secondly, in the eventuality of any harm visiting the patient as a consequence of the treatment process, it may be actionable as a criminal offence, if it had not been carried out after full knowledge and consent of the patient.
Instances have happened, where the doctor proceeded with a medical procedure without prior informed consent of the patient and was later dragged to the courts of law where he was held guilty.
Further, the consent has to be specific for the procedure. It signifies permission only for the specific procedure mentioned and not for any other procedure.
Depending upon the course of action considered necessary, its consequences and the risks involved, there are different types of consents such as implied, expressed or informed consent.
Implied Consent:
Implied Consent is not an expressed consent but assumed by the demeanor of the patient and is the commonest form of consent.
The fact that the patient presents himself at the doctor’s chamber for the purpose of advice/treatment (even though verbally not expressed) implies that he agrees to medical examination in a general sense.
This, however, would not include examination of the private parts which would require express consent of the patient.
Express Consent:
Express Consent is for non routine actions and is required to be sought for a specific procedure such as giving injection, blood sample collection, the rectal or vaginal examination or examination of breasts which is not covered under the implied consent.
When a patient presents himself/herself before the doctor, he/she does not anticipate anything more than a routine examination. If any act is required that is beyond the routine examination, the doctor must take prior expressed (generally verbal) consent of the patient.
Informed Consent:
Informed Consent is about certain special procedures required for diagnosis, treatment, or research and involving a certain amount of risk to the patient such as a surgical operation to be performed, blood transfusion to be done, chemotherapy/radiotherapy to be started.
For performing these procedures, a prior written consent (format as per annexure 8 attached) from the patient/guardian is required after full information about the procedure such as its necessity, the risks involved, the alternate options available to the patient, if any, the risks/ benefits of the options available, the chances of recovery and the cost involved.
In addition to English, the consent form should also be available in the local language that the patient understands.
Qualified Consent:
It is a written informed consent by the patient or his/her guardian where the patient or the guardian prohibits a specified additional or alternate procedure or technique that might become necessary during the course of the procedure permitted by the patient or the guardian. For instance:
i. A badly crushed limb where the doctor foresees the necessity of amputation which the patient disallows.
ii. A patient with multiple fibroids where the doctor recommends hysterectomy, but the patient expressly forbids hysterectomy and allows only the removal of fibroids.
iii. The case, where the patient agrees to hysterectomy but expressly forbids oophorectomy.
These are unusual situations restricting the professional discretion of the doctor and may involve certain unforeseen risks.
In such situations, the doctor is advised to obtain a written bond or release from the patient, his/her guardian or the next of kin, stating that he/she understands the implications and undertakes the responsibility for the entire risks incidental to the refusal. In such situations the doctor has two options:
a. Refuse to treat the patient on grounds that proper care cannot be provided because of patient’s refusal to allow the procedure felt necessary by the treating doctor.
b. Perform only the procedure and up to the extent allowed by the patient.
Legality of Consent
i. The consenting parties must be competent to consent in terms of Section 10 of the Indian Contract Act. They should be above 18 years of age, mentally sound and not disqualified by any law.
ii. The consent must be of free will and understanding (Section 14), otherwise it becomes voidable under Section 19.
The consent would not be valid if obtained under the following circumstances:
i. If the patient is a minor (below 18 years of age)
ii. If the patient is mentally ill/not in a mentally sound condition at that time (due to the disease condition, effect of drugs/intoxicants or emotional disturbance)
iii. If obtained under duress
iv. If obtained by coercion (Section 15)
v. If obtained through undue influence (Section 16)
vi. If obtained fraudulently (Section 17)
vii. If obtained by misrepresentation of facts (Section 18)
viii.If given by mistake subject to the provisions of Section 20, 21 and 22 of the Act
ix. If obtained for illegal/unethical purpose.
Examples:
A doctor influencing a patient critically sick/not in a position to make sound judgment, to pay to the doctor an unreasonable amount for his services in this case, the consent would be voidable on grounds of incompetence to consent as well as undue influence.
Refusal of Consent/Informed Refusal:
Patient or his legal guardian has the right to refuse to give consent for a particular procedure or a course of treatment.
In such situations, the right course for the doctor is to explain in detail again to the patient, the necessity of the procedure advised.
If still, the patient refuses the consent then the doctor should take the refusal in writing (see annexure 9), countersigned by some neutral witnesses.
The refusal must include a mention that the risks and consequences of refusal of consent have been fully explained to the patient and the patient undertakes full responsibility of all the risks and consequences of his/her decision.
After that the doctor may continue the treatment to the extent consented by the patient or may, if he thinks it is too risky to continue, advise the patient in writing to arrange for some other doctor for treatment without delay. He may discontinue after another doctor has taken charge of the patient.
In the case of Dr T.T. Thomas Vs Elissar, It was held by the Kerala High Court that failure to perform an emergency operation to save the life of a patient amounts to negligence.
The doctor’s plea that the patient had not given consent for operation could not be proved and was rejected.
The case highlights the necessity of taking the refusal of consent in writing so as to have a written proof in defense of the doctor’s innocence.
Situations Where Consent is Not Applicable:
a. For medical examination:
i. Of immigrants for detection of diseases.
ii. For detection of notifiable diseases—under orders of the magistrate.
iii. Psychiatric examination under court orders.
iv. Of food handlers mandated by the service rules.
v. Of members of armed forces mandated by the service rules.
vi. Of the accused under arrest, on requisition from the police authorities.
b. In life threatening emergencies (IPC section 92):
Besides the above, there are common situations that the doctors come across such as unidentified/unconscious victims of road side accidents brought to the emergency by some passersby.
Such life threatening situations, especially when the patient is unconscious and has no relative around to give the consent for procedures urgently required, are a real dilemma for the doctors.
The right course of action in such situations would be to inform the police and go ahead with the life saving procedure after informing the Medical Superintendent.
In such critical situations where life is at stake, waiting for the consent or for the police to arrive may mean the loss of life and defeat the very purpose of consent.
The doctors, in such situations, must act in good faith and carry on with whatever life saving procedures are indicated.
Any decision/action in good faith and in the absolute interest of the patient will always have the support of law (Section 92 IPC) and gratitude of the patient/relatives.
5. Procedures Justified by the Clinical Condition:
Since a doctor-patient relationship is based on implicit faith, the doctor must ensure that the investigations and treatment procedures that he advises are fully justified and not guided by any considerations other than the patient’s interests.
Unwarranted investigation/ procedure not only add to the cost, but may also cause harm to the patient.
For instance, take the case of CT scanning. Not only it may cost additional few thousand rupees, but may also cause unnecessary and harmful exposure of the patient to heavy radiation.
Similarly, angiography, angioplasty or surgical procedures have their own risks. An unwarranted procedure may mean waste of money as well as unjustified risk to life.
The doctor must remember that his job is to inform the patient fully and honestly and let him make informed decisions. And in keeping with that he should never fail to take appropriate form of consent, where ever indicated.
Whatever procedure, investigative, surgical or non surgical is contemplated, must be in the best interests of the patient. Once decided, the procedure must be carried out without any undue delay so that the patient can derive maximum benefit. Of particular importance are the investigative procedures.
The reports must be made available without any undue delay. In case, the reports are found to be critically abnormal requiring immediate/urgent intervention (see annexure 10) the same must be communicated to the patient/physician in-charge case forthwith.
6. Technical Correctness of Procedure:
Medical ethics require a doctor to take professional decisions in the best interests of the patient and as per the best current practices by the medical fraternity, all over the world.
Further, he must have the knowledge and experience to conduct the procedure correctly. Sometimes doctor’s decisions may be guided by monetary gains or professional image or ego.
That is highly unethical. For instance, resorting to Cesarean section where normal delivery is possible would be an unethical practice. Resorting to angioplasty where CABG may be the option of choice, would not be technically correct.
Holding on to a patient and giving inappropriate treatment, knowing full well the inadequacy of one’s competence would be wrong when others better qualified and more competent to treat the patient, are available. These situations can compromise the safety of patient very seriously.
The doctors must guard against such tendencies and the administrators must monitor and prevent such practices.
7. Safety of Procedure:
The procedure being conducted on the patient must be safe and without any undue hazards/complications, as per the current medical knowledge. It must be an acceptable course of action for the specific clinical condition and under the specific circumstances.
If the procedure has any attendant hazards, as mentioned in the literature and known to the doctor, the same must be explained to the patient and his attendants without causing any undue alarm.
In case of a procedure with serious risks to the safety of patient such as possibility of loss of life, limb or organ, the same may be undertaken only if the procedure is unavoidable and the risks of not doing the procedure outweigh the possible risks involved in doing the procedure.
In all such situations, the patient and the relatives must be taken into full confidence and the risks and consequences associated with various options available must be explained to them in detail. In any case the final decision about the procedure must be taken by the patient and his/her relatives.
Doctor should never take decision on behalf of the patient, or force a decision by the patient or prompt a decision by misrepresentation of facts. Doctor’s job is to explain the facts, merits/demerits of the options available and offer his professional advice in the best interests of the patient.
Safeguards against Negligence by Staff:
(a) Right Man for the Right Job (Credentialling and Privileging)
It is the responsibility of the hospital management to ensure that they recruit the staff with right qualifications (specific to every job slot) and experience. A square peg in a round hole can be dangerous in the medical set up.
It is important that the credentials and antecedents of prospective employees be properly verified before appointment of the individual to rule out the possibility of fake degrees/diplomas/experience certificates as well as criminal activities in the past.
Having established the credentials of the prospective staff, it is important to fix the job responsibilities in accordance with the qualifications, experience and competence of the individual.
Doctors/technicians have a tendency to take on patients/procedures which may be outside the range of their known competence. This is a dangerous tendency as it can seriously affect the life and safety of their patients.
As a normal practice:
i. Any new employee with right qualifications but without experience should not be given independent charge of any job. He/she should be made to work as an understudy under the supervision of a senior person for 3 to 6 months
ii. A new employee with right qualifications and experience should be first observed by the seniors and then allowed to perform independently the jobs observed to be within his competence level.
(b) Standardized Protocol for History taking/Examination/Evaluation and Periodic Reassessment:
Eliciting the essential details of patient’s history of illness, past illness and family history, the detailed physical examination as per the standardized protocol as well as the diagnostic investigations, as applicable, are crucial to correct diagnosis of the disease and evaluation of the patient’s condition.
This must be done in an unhurried manner, to the full satisfaction of the doctor, missing no findings and leaving no room for doubts.
The same applies to reassessment also, which must be done at the prescribed periodicity and as required, depending upon the patient’s clinical condition.
Any important finding missed may lead to wrong diagnosis, wrong treatment and incalculable harm to the patient in terms of complications, adverse effects, delayed recovery or even death of the patient.
Instances are not unknown where hurriedly carried out incomplete examination of an unconscious (live) patient (who could, perhaps, have been saved) lead to the wrong declaration of death, suspension of all resuscitative treatment and patient dying actually due to lack of treatment.
In view of the likelihood of such disastrous effects of negligence, all the positive as well as important negative findings must be given due weight age.
In case, the findings are contradictory, the examination must be repeated all over until all the findings are reconciled and understood in the right perspective.
(c) Planned Schedule-Standardized Timings:
For safety of patients, all patient care activities, especially the risky procedures, should be conducted as per a planned schedule.
This allows the staff sufficient time to plan every aspect, including the availability of adequate trained staff, equipment and stores as well as mental and physical preparation of the patient.
Any procedure (especially the risky one) should never be allowed in a hurry except in a critical life-threatening situation where non performance or delayed performance would definitely do more harm than the possible risks of performing the procedure in emergency.
Often, it is seen that the patients requiring day care surgery/procedure are rushed to the OT without any pre-procedure fitness check or preparation, not because it is an emergency requirement but because of doctor’s reluctance to delay the procedure until next day.
For fear that the patient may change his/her mind or may go to some other doctor, he may not be willing to let the patient go. Or, the patient posted for day care surgery may reach the OT just in the nick of the time without giving any time for evaluation, preparation and settling the patient before surgery.
An unplanned/unscheduled procedure squeezed in the busy planned schedule has another disadvantage in that it forces the staff to adjust the timings of planned procedures, also.
Due to non availability of standard time for the procedure, the staffs are forced to take short cuts by omitting some of the steps/activities.
These rushed procedures can end up with serious safety violations and complications, and should always be avoided.
It is, therefore, prudent that the procedures be carried out as per a planned schedule and allowing standard timings for every procedure.
(d) Standardized Protocols-No Short Cuts:
The main advantage of standard protocols is that they are prepared after wide consultation, careful consideration and on the basis of the best practices that are followed, all over the world.
A standard protocol, therefore, is expected to be the safest and the most effective way of doing a particular job.
However, they need to be implemented fully. Often due to individual fads or due to rush of work or non availability of protocols, doctors tend to take the shortcuts and do the things in their own individual way. That is not safe or prudent.
For example, instances of wrong surgical procedure or procedure on a wrong patient or at the wrong site have happened in many hospitals, all over the world, because of undue haste and hurry or failure in correct identification of patient, or the correct site or the procedure to be performed.
To avoid such catastrophic surgical errors, the protocol for “Prevention of wrong surgery on wrong site or wrong patient” has been worked out and is in practice in all good hospitals. Any surgeon not following the protocols would be indulging in unsafe practices prone to serious surgical errors such as amputation of wrong limb, removal of the wrong kidney, testis or eye or opening up the wrong side of chest.
It is incumbent on management of all hospitals to ensure that standardized protocols are made available and implemented in r/o all activities that are important, problematic or prone to mistakes.
(e) Preparedness for Handling the Complications-Expected and Unexpected:
In every procedure, surgical or nonsurgical, there is some element of uncertainty and probability of expected or unexpected complications because the mysteries inside the human body can never be exactly foreseen. An experienced physician would never take chances.
He would carefully rim through all the complications, possible and probable, before the procedure, and think of what needs to be done in anticipation of every complication one by one.
This prior planning is very crucial and would stand the physician in good stead, should any of the complications, occur. Often when a complication occurs unexpectedly, one is not ready to handle it.
The thought process and the resultant actions, no matter how quick, may consume all the precious moments that are available, leaving little time to react and respond.
However, if the doctor had already planned his response to every possible/ probable complication and had even prearranged the standby instruments, equipment or specialists, his reaction to the complication would be immediate and he would be able to swing around all the resources and handle the complication, without any loss of time.
To ensure safe procedures, therefore, it is a must that the doctor foreseer’s and pre-plans for every possible/probable contingency/complication.
(f) Check List to Check for Complications:
The protocol must include a check list for checking back at the end of the procedure, if anything has been missed.
That would include every significant step such as checking for bleeders if any or counting of forceps/other instruments/OT towels, etc. before closing the operation site.
Only if everything has been checked to be in order as per the check list, and nothing has been missed, should the surgeon proceed with the closure.
(g) Correct Identification of the Patient:
One of the most disturbing and unpardonable form of negligence is the failure to identify the correct patient before performing any procedure.
Drawing blood sample from the wrong patient, administration of medication to the wrong patient, performing surgical/other interventional procedure on the wrong patient, issue of wrong diet to the wrong patient, are the instances that have been happening in the hospitals, leading often to serious consequences, sometimes as serious as even the death of the patient.
It is in view of the magnitude as well as the serious consequences of these mistakes that JCAHO had adopted “Correct Identification of Patient” as its first goal in 2003, when it started the program of reduction of medical errors by setting National Patient Safety Goals.
The goals are being reviewed every year with additions/deletions. However, Correct Identification of Patient remains still the first and foremost among the patient safety goals.
8. Safe Nursing Care/Procedures:
Nurses have a responsibility towards safety of patients admitted under their charge. Nursing care and procedures constitute a major component of patient’s care and its quality or disqualify has a tremendous influence on the outcome, i.e., recovery of patient.
It involves getting the investigations done, medication administration, nursing care procedures, monitoring of the patients vital parameters, provision of infection-free fresh linen and food and taking care of the personal hygiene of patients.
Any mistakes in any of these activities such as sampling errors, medication errors, hot water bottle burns, infections or bed sores or fall of the patient from bed, can have serious implications for the health and safety of the patient.
Instances have happened where patients admitted with minor curable ailments ended up with permanent disability or death due to negligence on the part of nurses.
The case of a nurse in a West Bengal hospital giving acid in place of water by mistake to a patient or faulty administration of an intravenous drug to a child by an unqualified nurse leading to permanent brain damage, in a Delhi hospital, are incidents that keep happening because of negligent performances by nurses.
These adverse/sentinel events are all preventable if the nursing care and procedures are carried out as per standard protocols giving due attention to the safety of patients. Following are some of the important measures which, if implemented, can go a long way in making the nursing care safer for the patients:
1. Credentialing and privileging of all nursing staff at the time of appointment.
2. Provision of nurses in every shift in every nursing care unit as per the staffing norms, depending upon the work load and bed compliment.
3. Availability of documented standard protocols covering all nursing activities that may have a bearing on the safety of patients.
4. Continuous training of nurses in implementing the nursing protocols especially, those aimed at ensuring safety of patients and implementation of the protocols religiously by every nurse.
5. A fool proof system of correct identification of patient.
6. Ensuring continuity of nursing care of every patient by the same nurses in every shift from admission till discharge.
7. Detailing the newly recruited nurses on independent duty only after their knowledge about the protocols and skills have been tested and found satisfactory.
8. A system of double check/monitoring by the supervisor, of all activities prone to mistakes.
9. A documented policy making it mandatory that all orders/instructions by the doctors to nurses are in writing, especially about the high risk medicines.
10. A documented policy and procedure for verification of all high risk medication orders by nurses from the physicians prescribing the same.
11. A documented policy about the procedures that nurses can or cannot perform. For instance:
i. Blood transfusion may be started only in the presence of a doctor
ii. Nurses not trained in a particular specialty will not be posted to those areas such as NICU, ICU, CCU, OT, Labor room, etc. Similarly, emergency department will have nurses skilled and competent in life saving procedures such as CPR.
12. A system of reporting of every incident of nursing negligence on the Event Reporting Form.
13. A system of investigation, identification of cause and mode of failure and implementation of remedial measures in r/o every incident. A record of the same should be maintained for review and analysis.
14. Training in specialized nursing such as OT, Maternity, Neonatal intensive care, Coronary care, etc. to be conducted to ensure availability of a large pool of well trained nurses.
15. Meticulous implementation of the infection control measures.
16. High quality nursing care records as per the standard format and conduct of regular nursing audit.
9. Patients’ Safety during Lean Hours of Night:
Night hours are the hours when the level of activity is much lower and the staff posted as well as supervision of their work is lesser than during the morning or evening shift. The patients are mostly asleep and staffs, too, are relaxing.
However, these are also the hours when safety of the patients may be at a higher risk of theft of property, sexual assault, or deterioration of condition.
Taking advantage of the subdued/switched off lights and the staff dosing off, anti social elements can sneak in.
Hospital management is required to make sure that staff on duty at night remains fully alert. Availability of hot tea or coffee for the staff on duty, and surprise visits by the administrators at odd hours can enhance the alertness of the staff on duty.
Adequate strength of well trained security staff posted at all strategic locations and CCTV cameras can be very useful. Similarly, having only one entry/exit gate open after sunset/evening visiting hours, can further improve the situation.
10. Instructions for Compliance by OPD Patients/Discharged Patients:
Patient’s need to be properly advised about certain DO’s and DON’Ts, especially when they have to continue treatment at home, on their own so that they take the treatment as prescribed, avoid any harmful activities/substances and have a smooth early recovery from disease they must be advised about all important aspects (as applicable), such as:
1. Information about the patient’s disease, its causes, and precautionary measures for prevention of recurrence and after effects/side effects of medication.
2. Precautions to be taken at home to prevent any complications or for secondary prevention such as complete discontinuation of smoking in heart patients.
3. Instructions about usage of medication, dosage, timings, especially in relation to food, other drugs, whom to contact in an emergency, follow up consultation, etc.
4. Life style changes, if any, indicated such as activities to be done or to be avoided (driving/ swimming, etc. and avoidance of any food/beverages/alcoholic drinks.