Patient Safety Protocols and Infection Prevention
Universal Patient Safety Goals
National Patient Safety Goal 1: Patient Identification
Requirement: Use at least two patient identifiers when providing care.
Acceptable Identifiers
- Full legal name (as appears on ID band)
- Date of birth
- Medical record number (MRN)
NOT Acceptable as Identifiers
- Room number
- Bed location
- Physical appearance alone
Identification Required Before
- Medication administration
- Blood/blood product transfusion
- Specimen collection and labeling
- Procedures and treatments
SBAR Communication Framework
| Component | Description |
|---|---|
| S - Situation | What is happening now? |
| B - Background | Relevant clinical context |
| A - Assessment | What do you think the problem is? |
| R - Recommendation | What do you want to happen? |
Read-Back Verification (Required)
For verbal/telephone orders and critical test results:
- Write down the complete order or result
- Read back the information to the sender
- Receive confirmation that information is correct
High-Alert Medications
Definition: Medications that bear heightened risk of significant patient harm when used in error
| Category | Examples | Safety Measures |
|---|---|---|
| Anticoagulants | Heparin, Warfarin, DOACs | Independent double-check, standardized protocols |
| Insulin | All types | Independent double-check, glucose monitoring |
| Opioids | Morphine, Hydromorphone, Fentanyl | PCA protocols, sedation monitoring |
| Neuromuscular Blockers | Rocuronium, Succinylcholine | Auxiliary labels, OR/ICU only |
| Concentrated Electrolytes | KCl, Hypertonic saline | Remove from patient care areas |
| Chemotherapy | All agents | Independent double-check, dedicated area |
Infection Prevention and Control
Hand Hygiene Protocol (WHO Five Moments)
The Five Moments for Hand Hygiene
- Before patient contact
- Before aseptic procedure
- After body fluid exposure risk
- After patient contact
- After contact with patient surroundings
Hand Hygiene Technique
| Method | Duration | Indication |
|---|---|---|
| Alcohol-based hand rub | 20-30 seconds | Routine when hands not visibly soiled |
| Soap and water | 40-60 seconds | Visibly soiled, C. difficile, Norovirus |
| Surgical hand scrub | 2-5 minutes | Before surgical procedures |
Standard Precautions
- Hand hygiene - Per Five Moments
- PPE - Based on anticipated exposure
- Respiratory hygiene/cough etiquette
- Safe injection practices - One needle, one syringe, one patient
- Sharps safety - Use safety devices, do not recap
- Environmental cleaning
Transmission-Based Precautions
| Type | Conditions | PPE Requirements | Room |
|---|---|---|---|
| Contact | MRSA, VRE, C. difficile, Scabies | Gown and gloves for all room entry | Private or cohort |
| Droplet | Influenza, Pertussis, Meningococcal disease | Surgical mask within 6 feet | Private or cohort |
| Airborne | TB, Measles, Varicella, COVID-19 | N95 respirator (fit-tested) | Negative pressure AIIR |
CLABSI Prevention Bundle
Insertion Bundle (All Elements Required)
- Hand hygiene before procedure
- Maximal sterile barrier - Cap, mask, sterile gown, gloves, full-body drape
- Chlorhexidine skin antisepsis - Allow to dry 2-3 minutes
- Optimal catheter site - Subclavian preferred; avoid femoral
- Daily review of line necessity
Maintenance Bundle
- Hand hygiene before accessing
- Scrub the hub 15 seconds before each access
- Daily CHG bathing for ICU patients
- Dressing changes per protocol
- Daily assessment: Is this line still needed?
CAUTI Prevention
Appropriate Indications for Catheter
- Acute urinary retention or obstruction
- Accurate I/O in critically ill
- Perioperative for selected procedures
- Sacral wound healing in incontinent patients
CAUTI Prevention Bundle
- Insert only for appropriate indications
- Use aseptic technique
- Maintain closed drainage system
- Keep bag below bladder level
- Daily review: Can catheter be removed?
Fall Prevention Protocol
Morse Fall Scale
| Risk Factor | Scale | Points |
|---|---|---|
| History of falling | No/Yes | 0/25 |
| Secondary diagnosis | No/Yes | 0/15 |
| Ambulatory aid | None/Cane-Walker/Furniture | 0/15/30 |
| IV therapy | No/Yes | 0/20 |
| Gait | Normal/Weak/Impaired | 0/10/20 |
| Mental status | Oriented/Forgets limitations | 0/15 |
Scoring: 0-24 = Low Risk | 25-44 = Moderate Risk | 45+ = High Risk
Universal Fall Precautions (All Patients)
- Bed in lowest position, wheels locked
- Call light within reach
- Non-skid footwear
- Clear pathway, adequate lighting
- Hourly rounding
High-Risk Fall Precautions
- Fall risk signage and yellow armband
- Bed/chair alarm activated
- Room close to nursing station
- Toileting schedule every 2 hours
- Physical therapy evaluation