Nursing jci 2017 recipe book version 1 (7th june) by ttsh nursing

2017/ Version 1 / Updated 5 th JUNE

IPSG 1 IPSG 2 IPSG 3 02 05 07

IPSG 5 IPSG 6 PCI 10 13 17

SQE QPS MPE 23 29 33

MMU PFR MOI

37 51 60

A Head to Toe Approach to Remember International Patient Safety Goals!

IPSG 1. Identify Patients Correctly - Important Points Correct Patient identification Process

If the first 2 identifiers are not available, staff can also use the following as identifiers to identify the patient: - Patient’s date of birth - Patient’s address - Patient’s hospital registration no.

2 Patient Identifiers should be used: • Allocating patient identification band • Giving medications or blood products • Taking blood and other specimens • Providing treatments or procedures

(including x-rays and scopes) • Before sending or fetching patient • Handing over a patient to another dept Never use patient’s room/bed number or locations as the identifiers!

When serving diet:

• Verify patient’s name • Check diet order by matching diet chit with headboard.

Hospital system enhancement for second identifier is in progress.

Where should we attach 2 Patient Identifiers other than wrist?

In situations where an ID band cannot be applied to the wrist or lower limb, staff should attach the ID label to patient’s deltoid area (upper arm) and cover/affix it with a waterproof transparent dressing. Where there is difficulty in the application of ID band/label, the issue should be brought to the attention of the supervisor and/or doctors for decision and relevant documentation should be made. 2

IPSG 1. Identify Patients Correctly - FAQs Questions Tell me how do you identify the correct patients? Or Tell me how do you know if the patient receives the correct treatment?

Answers Ask patient for 2 patient identifiers and check against relevant documents. • Patient’s name • NRIC No./ Passport No. / Work Permit No. Alternative identifiers if above not available: • Date of birth • Home address • Hospital registration number

Tell me how do you ensure the correct treatment is delivered to uncommunicative or unconscious patient?

Check wrist band against relevant documents.

How would you ensure the correct treatment is delivered to patient with unknown status?

For patient with unknown status, to use:

In outpatient – check with carer and verified against relevant documents • Patient’s name • NRIC No./ Passport No. / Work Permit No.

• Medical Record No. (MRN) • Hospital Registration No.

IPSG 1. Identify Patients Correctly - FAQs Questions Tell me what would you do if there is really no choice to attach patient’s wrist tag on any skin surface (i.e. severe skin excoriations)?

Answers We will clip the identifier tags on the patient’s clothes (shown in image below):

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IPSG 2. Improve Effective Communication

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- Important Points Effective HANDOVER of care of patient is required during: 1. Intrahospital Handover, e.g. shift change, breaks, transfer to another unit/level of care. 2. Interhospital Handover, e.g. transferring a patient to another acute care hospital, community hospital or nursing home.

Standardized critical content to communicate during handovers are:

Readback to communicate critical results verbally or via phone The test and the critical result with patient’s name & NRIC number must be - written down readback by the receiver - confirmed correct by the caller Critical results need to be communicated & acknowledged by the responsible clinician within: Laboratory & Radiology: - Inpatient/Ambulatory – 1 Hour - Outpatient – 2 Hour

IDRT Identification Diagnosis & condition Risks /referrals - Treatment SBAR

Standardized tool used during handovers of patient care in emergency/urgent clinical situation: Situation Background Assessment Recommendations

Verbal/Telephone Medication Orders NOT ALLOWED Except in clinical settings using the paper IMR and during an emergency situation where delay in administration of medication will result in unfavorable outcome. 5

IPSG 2. Improve Effective Communication - FAQs Questions Tell me what would you do if the doctor is not around to order treatment during an emergency?

Answers We do not accept verbal / telephone orders except in clinical settings using the paper IMR (ICL, Endo Centre and NHG 1 Health), and during an emergency situation where delay in administration of medication will result in unfavorable outcome. If verbal or telephone orders are needed, one should Readback. In situation in which a read-back is not possible, the RN receiving the verbal order is required to “call out” for the team’s awareness under the supervision of the Dr.

Tell me what is the process of receiving critical results?

Test and critical results with patient’s name and NRIC number will be • Written down • Read back to caller • Confirmed correct by caller • Notify clinician & Document

Tell me how do you communicate patient care?

Standardized critical content communicated between nurses during handovers of patient care are: • 2 patient identifiers • Diagnosis and Condition • Risks • Treatment

Lists of TTSH HAM & Lookalike Sound alike drugs can be found in Intranet

We don’t stock concentrated electrolytes!*

*Except in these locations: • ICUs & high-dependency wards (3A, 3B, 6A, 6B & 6C) • POTASSIUM CHLORIDE 7.45% INJ is available in Ward 9A Haemodialysis Unit, & is only allowed to be added to dialysis fluids. • Magnesium Sulfate 49.3% INJ is also available in OT/PACU, procedural suites, ED & E-kits for resuscitation purposes.

LookAlike SoundAlike Meds • Avoid placing LASA next to each other • Tall man letterings, bold & underline, and words on black background to distinguish LASA names • Pink bin labels to alert physical product look-alike

HAM Storage All HAM are to be labeled with “High-Alert” sticker on • Container where drugs are stored • Dispensed drugs from pharmacy and when using patient’s own medication from home

Lookalike Soundalike (LASA) & High Alert Medications (HAM) labels

IPSG 3. Improve the Safety of High Alert Medications (HAMs) - FAQs Questions

Answers

Do you have highalert medications in your hospital? What are they?

Yes.

Show me your list of highalert medications? Or Where can you find the list of high alert medications?

Intranet  Pharmacy Notice Board  High Alert Medications.

Tell me, do you take any measures to improve the safety of high alert medications?

All High-Alert Medications (HAM) are labelled with a “High Alert” sticker on • Container where drugs are stored • Dispensed drugs from pharmacy • Using patient’s own medication from home

Some of these medication includes heparin, warfarin, insulins, and cytotoxic drugs and concentrated KCl.

Other safety measures includes, • Use of Safety limits (Guardian Feature) on infusion pumps • Warfarin Initiation protocol –Phamacy Notice Board  High alert Medication Warfarin Initiation Guidelines • Administration policy as per QP-NUR-GEN-005 Tell me, do you keep concentrated electrolytes here?

No, we do not stock concentrated electrolytes (except for ICU, HD, OT, PACU, ward 9A-AHU) Note: magnesium sulfate inj is available in the E-kit (Etrolley), for resuscitation purposes.

isk tion R c e e h f T e ed In c u d ciat e R s . o t s 5 n s Poi G A S e t IP car n ta h r t l o a Hand hygiene audit data p e m H I • Talk about Infection Prevention Champions of Hand Hygiene

All healthcare workers must adhere to the 5 moments of hand hygiene by: • Using alcohol-based hand rub • Washing hands with an antiseptic agent It is one of TTSH’s priority indicator. The 5 moments for hand hygiene

(IPCs), shared governance and QAs. • Ward Dashboard indicators • Root causes of hand hygiene non-compliance were identified and appropriate interventions were implemented. • Reminders are placed at relevant locations to promote the practice of hand hygiene. • Hand hygiene audits are conducted at the institutional level and the local level. • Results from the institutional level audits are published on the intranet for access to information on the progress towards our target of 100%.

Where to find level audit data on Intranet?

TTSH Intranet  JCI Gold Seal JCI Documents PCI WINICINF003 Hand Hygiene

IPSG 5. Reduce The Risk of Healthcare Associated Infection - FAQs Questions Show me, how do you perform hand hygiene. (Auditor might stand and observe quietly)

Answers Handwash • Wet hands • Use 1 full pump (5mls) of antiseptic solution • Rub thoroughly using 7 steps (refer poster) • Rinse and dry hands. Recommended minimal duration for antispetic handwash is 30 seconds or as per manufacturer recommendation. Handrub Apply 1 – 2 pumps (3mls) of hand rub to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry or hand rub following the 7 steps of hand washing.

Tell me, how do you know that these steps are sufficient to reduce the risk of infection?

Our institution follows the World Health Organisation (WHO) guidelines on hand hygiene in healthcare.

Tell me, in which situation would you perform a handwash?

Do handwash when: • Hands are visibly contaminated with blood or body fluids. • Patient is tested positive with Bacillus anthracis or Clostridium difficile. • Patient with mites infection Do handrub when hand are not visibly soiled with blood & body fluids.

WI-NIC-INF-003

IPSG 5. Reduce The Risk of Healthcare Associated Infection - FAQs Questions Tell me the initiatives you have done in your department to improve the rates of hand hygiene?

Answers • Hand Hygiene pledge • Visual signage for hand rubs • Peer reminder and checks • Monthly audits • Infection Prevention Champions (IPC) • Annual Hand Hygiene Day in May. • Frequent audit by mystery auditor Share department initiatives if any.

Show me the Hand Hygiene audit data from your department.

Show unit dashboard and be prepared to share: • The poorest hand hygiene moment in the department • The healthcare provider whom are the weakest link. • The interventions done to improve it

IPSG 6. Reduce the risk of patient harm resulting from Falls - Important Points FALL RISK Inpatient Fall risk assessment and reassessment criteria Initial assessment done within 24 hours Reassessment: • Change in fall risk factors (Unsteadiness, Continence, Cognitive impairment) • Post-surgery • New complain of giddiness • Upon transfer • Post fall Patient at risk for falls are identified by: • Pink wrist tag • Pink column at headboard Post Fall Management • Assess injury, vital signs and mental status • Inform doctor to review patient • Initiating post fall management form Key measures to reduce falls All patients receive standard fall precautions e.g. position call bell within reach, assist patient accordingly to the functional assistance required etc. When high fall risk is identified, patient receives targeted interventions based on their risk factors. Interventions are planned and documented. (Refer to Whefra form-care planning section to show the specific measures that are planned and implemented for the patient)

Outpatient

(except designated high fall risk clinics) Fall screening and identification First Visit • Self Registration Kiosk- fail registration, patient to approach PSA. PSA initiate measures. Repeat Visit • Self Registration Kiosk • If patient has a history of fall in the last 6 months fail registration, patient to approach PSA. PSA initiate measures. *Situational risk are identified in each clinic, where appropriate. Interventions are implemented and documented. Key measures to reduce falls • Once identified as fall risk, a pink sticker will be applied on patient clothing. • Patient and/or carer receives falls education. Brochure will be given to all patient. • Offer direct help/assistance. • Advise carer to always accompany the patient and not to leave patient alone. • Observe patient for signs of weakness or giddiness after procedures and assist as appropriate. • Interventions are documented.

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions

Answers

Tell me, how do you ensure a safe environment for your patient?

We will perform hand hygiene and also reduce the risk of patient falls. • All patients who are admitted or transferred into the ward are assessed using the WHeFRA tool within the 24 hours of admission or transfer in. • High risk (>8), Low risk (<8). • Doctors orders on “fall precaution” supersedes WHeFRA score. • When high fall risk is identified, targeted measures are planned and implemented.

Show me the interventions performed to prevent falls for your patient.

Refer to the “Fall Risk Assessment (mWHeFRA) & Care Plan” form

Tell me, when do you know that your patient are at higher risk of falls?

Patients are reviewed every shift for change in condition/fall risk factors. (A review is done every shift, triggered during PCR documentation. A review is a brief process to quickly make a judgement if patient’s condition has changed since last WHeFRA assessment*). Patients are at higher risk of falls when: • A change in fall risk factors/condition (Unsteadiness, Continence, Cognitive impairment) • Post-surgery • New complain of giddiness • Upon transfer • Post fall

SD-NUR-GEN-019 Prevention and Management of Patient Falls

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions Tell me how do you reduce the risk of patient harm for patients on fall risk?

Answers We identify patients who are at risk of injury using the “ABCS” framework*. High fall risk patients with risk of injury will be flagged using the card “Fall: Injury Risk”. Measures include: • Adjusting the bed to the lowest level to reduce the impact of fall. • Cohorting the patient in the ‘High Fall Risk Cubicle’ (HFRC) for close observation if the patient is observed to be impulsive, confused, agitated and attempts to mobilize unsafely without calling for help. * ABCS Framework: • Age or frailty - Age ≥ 80 years and frail due to medical conditions. • Bones - Osteoporosis, met static bone cancer, previous fragility fracture , prolonged • Coagulation - Those with bleeding tendencies and anticoagulation usage. • Recent Surgery - Post operative patients especially those with amputation, abdominal or thoracic.

SD-NUR-GEN-019 Prevention and Management of Patient Falls

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions Tell me what would you do if you witness a patient fall?

Answers 1. 2. 3. 4. 5. 6. 7.

Assess injury, vital sign & mental status. Initiate “Post Fall Assessment Form” to guide the assessment. Inform doctor to review patient following fall. Monitor patient as per doctor‘s orders. Document the incident and report to Ward NM/NC. Raise incident report. Initiating other investigations and management options listed in the ‘Post Fall Management Guidelines’ as appropriate. If patient is discharged <24hours after incident, provide advice & education on abnormal signs to monitor for when patient is at home.

SD-NUR-GEN-019 Prevention and Management of Patient Falls

PCI Prevention and Control of Infections - Important Points Everyone is part of the PCI team! Standard Precautions

Purpose: To reduce the risk and transmission of microorganisms from both recognized or unrecognized sources of infection in the hospital.

Types of Isolation & PPE

Used in the care of specific patients known or suspected to be infected/colonised with pathogens spread by the following transmission routes: • Airborne • Droplets • Contact

Isolation Rooms

Call FCC if pressure gadget is not working. Use a tissue paper to test if the negative pressure is functioning.

Donning of PPE:

Isolation room without anteroom, to wear PPE outside isolation room

Special requirements for vulnerable patients: Immunocompromised patients, Perform hand hygiene & adhere to Standard Precaution. Switch off exhaust fan.

PCI Prevention and Control of Infections - Important Points Linen Management NonContaminated Linen Into canvas bag Contaminated Linen (blood/body fluids/scabies) Red biodegradeable bag  Disposbale plastic bag Canvas bag Waste Disposal General: Black/white/transparent bags Bio-hazard: Yellow bags Cytotoxic: Purple bags Radioactive: Red bags Glass bottles: Glass bottle bins Sharps & Needles Disposal Sharps, broken glass ampoules and vials: Sharp container Expired Products

• Practice Earliest-Expiry-First-Out (EEFO) for products with expiry dates • Adhere to First-In-First-Out (FIFO) for products with no expiry dates Check for expiry dates

• Drugs: Send to pharmacy for disposal • Consumables: Discard as general waste Single Use Item

• No reuse of single-use item • Single use items are not to be re-

prosses or re-sterilised even when they were opened and not used on patient.

Disinfection & Sterilization (WI-NIC-INF-005)

Critical items Items entering sterile tissues or vascular system • Must be sterile and comply with expiry dates Semicritical items Items in contact with mucous membranes, nonintact skin (e.g. Suction bottles, laryngoscope blades) • Require high level disinfection Noncritical items

Items in contact with intact skin (e.g. bedpan and BP cuff) • Require low level disinfection Food Label for Enteral Feeds/Food NAME NRIC Opened/ Stored On:

DATE

TIME

• Ensure patient’s food is labelled and dated • Advise patient to consume cooked food within 4

hours • Discard opened, half consumed or uncovered pack/ can of formula feeds or beverages stored at room temperature after 1 hour • Any opened or half-consumed food/drinks store in the fridge will be discarded after 24 hours. Note manufacturer’s recommendation for milk

PCI Prevention and Control of Infections - FAQs Questions

Answers

Tell me, what do you know about infection control?

Upon joining the institution, we have orientation programmes that includes: • 5 moments for hand hygiene • Standard & transmission based precautions • Other specific infection control polices

Tell me, how do you prevent the spread of diseases in your institution?

• 5 moments for hand hygiene • 1st tier: Practice of Standard Precautions for all patients • 2nd tier: Transmission based precautions (PCI Pg 1) • Appropriate use of PPE • Staff Vaccination • Patient & family education • Annual health screening

Tell me, what do you do when you are required to assist a procedure for an infectious patient?

We will practice the Standard Precaution. • 5 moment for hand hygiene • Gloves: Contact with blood and body fluid secretions, excretions, and contaminated items, mucous membranes and non-intact skin. • Surgical mask, Eye protection with Goggles/Visor: When performing procedures that are likely to generate aerosols and/or droplets/splashes of blood/body fluids e.g. suctioning, bronchoscopy, chest physiotherapy, etc. • Eye protection with Goggles/Visor must be worn when placing a catheter or injecting material in the spinal or epidural space. • Apron/Gown: When clothing is likely to be soiled with blood/body fluids. Reference: WI-NIC-INF-021 Standard Precautions WI-NIC-INF-022 Transmission-Based Precautions 19

PCI Prevention and Control of Infections - FAQs Questions

Answers

Tell me, how do you know that the negative pressure room is working?

• Ensure the exhaust fan switched on. • Check negative pressure gauge range (refer range indicated next to

What would you do If you were pricked by a used needle or had a blood/body fluid exposure?

• Do first aid by washing the puncture site or affected area with soap

gauge) • If it alarms or out of normal range, to call FCC at 8822. • Test with a piece of tissue paper: Place tissue paper at the gap at the base of the door. Tissue paper will be drawn into the room if it is working. under running water. • Inform supervisor, team doctors to do risk assessments, ensure source patient’s blood is taken (If source patient is known) • Seek medical attention (OHC/ED if after OHC operating hours) • Raise IRIS. Reference: WI-NIC-INF-020 Sharps and Needle Stick Injuries/Occupational Blood & Body Fluid Exposure

Tell me, what happens after the needle stick injury when the staff returns from OHC?

The doctor will follow up with the staff clinically and appropriate care will be given. The supervisor will be informed and will keep track of the progress of the staff while observing confidentiality. The Occupational Health Department will also be involved in caring for the staff. Reference: QP-NIC-INF-005 Employee Health, WI-NIC-INF-020 Sharps and Needle Stick Injuries/Occupational Blood & Body Fluid Exposure

PCI Prevention and Control of Infections - FAQs Questions Tell me, what happens if you witness a blood or body fluid spill?

Answers Spot/Small blood spills • Wear Gloves • Wipe area immediately with paper towel followed by disposable alcohol wipes. Large spills in a ‘Wet’ Area (e.g. Toilet) • Don PPE (Gloves, Apron, Eye protection) • Carefully hosed off the spill into the sewage system • Flush area with water and detergent • Disinfect area with NaDCC (10, 000ppm available chlorine) Large spills in ‘Dry’ Area • Blood and body fluid spill kit should be used • Don PPE (Gloves and Apron) • Contain and decontaminate the spill by pouring NaDCC granules. Ensure that the spill is fully covered by the granules. • Leave for at least 2 minutes or as per manufacturer’s recommendation • Using the disposable scoop, which is available in the “blood and body spill kit”, scoop the granules into a biohazard waste bag. If glass or other sharp materials is involved, scoop them into the sharps container. • Clean area of spill with mop, water and detergent • Disinfect area with NaDCC (10,000 ppm available chlorine) Reference: WI-NIC-INF-024 Management of Blood and Body Fluid Spills

PCI Prevention and Control of Infections - FAQs Questions Tell me, how do you know that the items are good to be used?

Answers • Check expiry dates & packaging integrity before use. • Do not use expired products/consumables • Expired pharmaceutical items are collated and returned to pharmacy as per policy Expired products/consumables are collected and returned to MMD as per policy • Earliest-Expiry-First-Out (EEFO) for items with expiry dates and First-In-First-Out (FIFO) is practiced for items with no expiry dates Reference: QP-PHA-INV-006 Disposal and Returns Of Expired/Deteriorated Goods, QP-MMD-MCS-001 Receiving And Storage, QP-MMD-MCS-003 Return To Store (RTS)- Return To Vendor (RTV) and WI-NIC-INF-021 Standard Precaution

Tell me, how do you clean your equipments?

We use 70% alcohol impregnated wipes for cleaning surfaces of machines and equipment.

SQE Staff Qualifications & Education - Important Points Organization commitment to training

Staff evaluation programme

Our hospital achieved its mission and meet our patients’ needs through:

Evaluation starts at the time you begin work. All staff are evaluated on their work performance, key job competencies, roles and responsibilities.

• A coordinated, uniformed and consistent

process in areas of recruitment, evaluation, appointment and orientation of staff • Education and learning opportunities offered to staff in advance personally and professionally • Staff health and safety programme provided to maintain health

Assessment of work performance is done: • During orientation and at the end of the probation period

Recruitment and appointment

• Documentation of evaluation and evidence of

• Continuous monitor, evaluation and feedback

through verbal and annual Total Performance Management (TPM) by supervisors staff competency through

• License, education and training of nurses are gathered and verified before appointment. • Every nurse must have a valid SNB license to practice in the hospital and it is to be renew yearly.

•

Nursing Competency Checklist for new Nurses (NCC). NCC will be submitted together with the staff’s confirmation report to HRM and will be retained in staff’s Personal file in HR

•

Competency assessment Checklist (CAC) will be used for specific competency assessment, for example haemodialysis and will be kept in the department

Staff orientation Programme Orientation programme is essential to induct staff to their new appointment and role in order for them to perform well. New nurses go through:

• Onboarding programme for new employees by

HR(P)D • Hospital and Unit-based orientation programme for new nurses

SQE Staff Qualifications & Education - Important Points Ongoing learning & development Hospital provides our staff opportunities to learn and advance personally and professionally through in- service education and other learning opportunities such as advanced diploma, bachelor and master degree and PHD. Learning needs are identified through: • Yearly learning need analysis exercise (LNA) • Adhoc requirement such as new services, equipment There must be records of these trainings and captured in the hospital training date base (SAP)

Competency in resuscitation technique Basic Cardiac Life Support (BCLS) • Compulsory for all medical, nursing and identified allied health staff • Recertification is every 2 years

Hospital’s staff health and safety programme All new staff undergo a pre-employment check-up by an appointed doctor. It includes physical medical examination, blood screening and chest Xray. All new staff need to complete a form to declare their medical conditions, if any. Applicant applying for position in departments that perform exposure prone procedures (EPP) must declare their Hepatitis B status and should be immunised if they are not immune. It is compulsory for all staff to be vaccinated with • Hep B • Varicella • MMR Hospital provides education, counselling and follow up for staff who may be second victims of adverse or sentinel events.

Heartsaver • HCAs Advanced Cardiac Life Support (ACLS) • Medical doctors 24

SQE Staff Qualifications and Education - FAQs Questions Tell me how do you know about your job scope or Do you have a job description (JD)?

Answers We have a JD and it is shard with us upon appointment or if revised . The JD is reviewed every 3 years. *Staff must be able to articulate own JD Staff to show JD in NOOG (Nursing Portal) -> Nursing Service -> Job Description

Tell me how the hospital prepares you to perform the work you are doing?

We will go through onboarding programme for new employees by HR(P)D, nursing hospital and unit-based orientation programme.

Tell me how soon you are enrolled for the onboarding programme / department induction Programme / nursing hospital orientation programme when you joined the organization?

• Department Induction: Within the 1st month (It covers the broad strategies and hospital-wide rules and guidelines in Infection Control, Fire Safety and Fire Evacuation, managing/ handling difficult or abusive situations, and IQEHS)

• Hospital Onboarding Programme: scheduled within 3 months

• New nurses will attend the nursing hospital orientation on their first day of work

SQE Staff Qualifications and Education - FAQs Questions Tell me the key competencies to work in this unit

Answers The Key competencies are: • BCLS

• Department Core competencies – Staff is assessed on the Department’s Core Competencies once he/she commence his work and on Annual basis Tell me who need to be BCLS certified and how frequent it is being done

All nurses, doctors, allied health professionals who have direct patient contact are required to have a valid BCLS certification. Recertification is required every 2 years.

Tell me how do you maintain or advance your skills and knowledge to meet patient needs and/or continuing education requirement? or How do you receive ongoing development for your skills and clinical knowledge?

Through: • Attend identified Courses after Learning Needs Analysis (LNA) exercise

How do you ensure that the staff clinical knowledge and skills are consistent with patient needs?

Staff work performance is evaluated during the probation period and annually during Total Performance Management (TPM) Exercise using the clinical core competencies

* For Supervisors

• Attend department / nursing in-services (CNE) and OJT sessions

SQE Staff Qualifications and Education - FAQs Questions

Answers

Tell me is there any staff health and safety programme for you as employee?

Yes, for example, • Annual flu vaccination / health screening for staff • Staff abuse talks to the departments • Safe manual handling programme during hospital orientation • Education and support for workplace violence • Education and support for staff who may be second victims of adverse or sentinel events

Tell me the measures hospital has put in place to reduce the risk of workplace violence

We have panic buttons, CCTV to monitor hospital premise and signages to discourage perpetrators.

Tell me the help a staff will receive after workplace violence or How can staff seek treatment or receive counselling and followup for injuries related to workplace violence

• Staff can seek treatment or medical assistance at OHC Service or ED • If the injury/trauma affected the staff’s mental and emotional state, the staff may be referred to the volunteers under the Staff Support Staff (3S) programme or to the relevant clinical departments for psychological treatment/followup. • Staff will be advised that they have a right to legal recourse

SQE Staff Qualifications and Education - FAQs Questions

Answers

Do you have counselling and followup treatment for staff who are second victims of adverse or sentinel events Or Tell me the safety programme available for staff who may be second victims of adverse or sentinel events

Yes, we do. For Nursing, the respective supervisor will provide emotional support if staff display signs/symptoms of distress and will review alternate work arrangements/environment if necessary. At Hospital level, there is a tiered model and available resources to help our staff if professional help is required. StaffSupportStaff (3S) Helpline: 9720 8515 (Mon – Fri 8am – 6pm) Psychiatric Medicine: 6889 4343 Care & Counselling: 6357 8222

Does nursing staff participate in the hospital’s quality improvement (QI) activities?

Yes. Individual staff participation in QI is evaluated in TPM.

Do you receive education or training about your roles in providing a safe and effective patient care facility?

Yes, we received training on our roles in the hospital programmes for

• Fire safety • Security • Hazardous materials • Emergency • Medical equipment • Utility system

QPS Quality and Patient Safety Important Points

TTSH Quality Principles • Patients are our top priority • Quality is achieved through people • All work is part of a process • Decision making by facts • Quality requires continuous learning and improvement Promotion of Safety Culture • Patient Safety Leadership Walkabouts • Patient Safety Workshops • Open Communications Workshops • Non-punitive Incident Reporting • Patient Safety Climate Survey TTSH Quality Improvement & Patient Safety Framework 1. Detection • Voluntary Incident Reporting System • Patient Feedback System • Morbidity & Mortality Review • Nursing Audits • Clinical Indicators Tracking • Enterprise Risk Management 2. Analysis Analysis of patient safety incidents or trends from indicators is done through Quality Assurance Committees (e.g. Falls Prevention Committee, Medication Safety Team), department Supervisors, Quality Review Officers (QROs). Methodologies for analysis • Root Cause Analysis (within nursing, a local RCA is initiated for all falls with major injuries, wrong patient medication administration errors and medication administration errors involving high alert medications)

3. Methodologies for Improvement TTSH adopts the PDSA (Plan, Do, Study, Act) Cycle, Lean Methodologies and Apple Philosophy for improvement and are incorporated into our Clinical Practice Improvement Programme (CPIP) and ‘MyCare’ Program. Skills and knowledge of improvement methodologies are taught to improvement teams through a network of improvement facilitators and faculty. Quality Improvement Tools Some tools include: • PDSA (Plan, Do, Study, Act) cycles • Root Cause Analysis (RCA) • 6S • Job Breakdown Sheet (JBS) • Standard Work (SW) Communication Channels • Various communication channels where quality issues are discussed & communicated include: • CEO townhall meetings • Management Review • Unit Council Meetings/UBQIC • Ward meetings • Roll call e.g. when a fall has happened during the shift • Hospital Conference • Safer Practice Alerts • Regular features on quality improvement are disseminated via the TTSH Tribune for general communications. Organisational Learning and Training • Quality & Patient Safety trainings include: • Patient Safety & Quality in orientation programme • Root Cause Analysis (RCA) & Failure Mode Effect Analysis (FMEA) workshops • CPIP, MyCare & Service with Excellence workshops • Risk Management For Nurses courses • IRIS café for supervisors 29

QPS Quality and Patient Safety - FAQs Questions

Answers

Who is responsible for Quality and Patient Safety in the hospital?

The Chairman, Medical Board (CMB) [A/Prof Thomas Lew] oversees the implementation of the hospital’s Quality Improvement and Patient Safety Programme and chairs the Quality Council (QC) QC assumes overall authority for the direction and drives all the quality programmes in the hospital. He is assisted by Assistant Chairman, Medical Board (Clinical Quality & Audit)[Dr Tan Hui Ling]. The Assistant Director of Nursing (Quality) [Hoi Shu Yin] is a member in the Quality Council and provides leadership in nursing quality matters.

What are your hospital’s quality principles?

TTSH quality principles include: • Patients are our top priority • Quality is achieved through people • All work is part of a process • Decision making by facts • Quality requires continuous learning and improvement

How do you translate and apply them in your daily work?

Articulate how the principles are applied in your daily work. E.g. [Decision making by facts] Hand hygiene data is used to identify gaps in practice. ‘Before patient contact’ is the worst performing moment and we are initiating improvements to improve that.

What are your department’s quality improvement projects?

Articulate your priority indicators. Demonstrate how you are trending data (use of run chart/column graphs), analyzing data (use of RCA to identify root cause), and improving including key actions based on your analysis (use of PDSA, 6S, CPIP).

QPS Quality and Patient Safety - FAQs Questions

Answers

Where can you get the data? Do you know where to find it?

Quality indicators including falls, medication errors, pressure ulcers are provided from the Quality department. Other Quality Data e.g. Hand Hygiene data can be found in the intranet- QMIS. (Nursing supervisor- refer to the Measures Tool)

What do you do when your department has not met the target set?

If data did not show improvement, explain why and what is being done to address the issues identified. We perform analysis (if RCA is used, can show), implement targeted interventions to address the issues using the PDSA cycle (annotate your chart with the identified issues (analysis) and action plans. Improvements can be articulated as: “ We reduce variation by ….” / “We have achieved target or improvement shift…”/”We are no longer seeing the issues we have previously identified”

What aspect of patient care has your unit improved in the last 6/12 months? What do you intend to improve in the next 6/12 months?

Share your priority indicators/department specific indicator/ground-up initiatives - Show your charts and explain the trends by referring to the annotations and actions on the charts.

How do you manage the adverse incident that happens in your area? What is root cause?

• We performed a huddle after an incident. During the

huddle, we will discuss the key issues/gaps and identify key actions to prevent the incident from happening again. • We also reviewed the events that occurred in our area to identify gaps in practice and opportunities for improvement. [Be prepared to show the documented RCA (if used), articulate the identified root cause and the resulting action plans].

QPS Quality and Patient Safety - FAQs Questions

Answers

How are staff involve in quality decisions & the resulting quality activities?

Articulate how staff participates in QI initiatives in the department. Show any posters of projects/6S/DIBs, innovations. Share the platforms where improvement suggestions/ideas can be submitted. Examples: • Daily Improvement Board (DIB) • Research /Innovation fund

What is a culture of safety?

A culture of safety is a culture that is open and fair. Being open and fair means that staff can share information openly and freely, and are given fair treatment when an incident happens.

How do you promote such a culture?

Acceptance that safety is a priority and responsibility at all levels Understanding that human make errors and that the system should be made robust in preventing and mitigating errors, while upholding the principle of accountability- Use Just Culture tool to guide management of staff post event. • Non-punitive approach to adverse events/incidents • Encouragement and recognition for error reporting • Learning from errors and sharing in a transparent and open manner • Open conversations among peers about errors and near-misses

MPE Medical Professional Education - Important Points Job description of medical students in TTSH Job descriptions on roles & responsibilities of medical students can be found in the TTSH intranet under PPEO Portal.

Hospital orientation programme for trainees* All medical students undergo a hospital orientation including the following programmes on quality care and patient safety:

• Hospital quality & patient safety programme • Infection control programme • Medication safety programme • The international Patient Safety Goals • All other required hospital orientation, including at the department and unit level

• Any ongoing required education

Supervision required for medical trainees • All medical students are under direct

supervision of the assigned clinical teacher / faculty members.

• Residents are under direct or indirect

supervision according to their demonstrated competency. It is defined in JD as well.

• All residents are only allowed to perform

procedures and prescribed medications that they are taught and are familiar with. All medications that are new or unfamiliar will be raised to supervisors for advice.

* Trainees refer to medical students and residents

Supervisors will ensure that students participate in and have familiarised themselves with the programmes. All residents undergo residency orientations, department orientations and patient safety workshops. 33

MPE Medical Professional Education - FAQs Questions How are the residents and medical students orientated in the clinical units?

Answers Medical students All medical students undergo a hospital orientation including the following programmes on quality care and patient safety: i. Hospital quality and patient safety programme ii. Infection control programme iii. Medication safety programme iv. The International Patient Safety Goals v. All other required hospital orientation, including at the department and unit level vi. Any ongoing required education.

• The medical students will be supervised by their clinical supervisor and oriented to the layout of the clinical units. • They are also encouraged to approach nursing staff if they are in doubt during the attachment to the clinical unit.

Residents • All residents undergo residency orientations, department orientations and patient safety workshops. • The residents are given an orientation checklist which has to be completed within the first week of their commencement to work period in the hospital. • The residents will need to approach the nursing staff in the clinical unit to complete their checklist requirement.

MPE Medical Professional Education - FAQs Questions How do you identify the trainees and medical students from the doctors?

Answers • All medical students will wear their white coat and school nametag for identification at clinical areas.

• All residents wear white name tags while senior

residents wear black name tags. Their responsibility in the clinical areas are defined in the roster.

How do you know what are the procedures that the residents are allowed to do?

What are the procedures that the medical students are allowed to do?

• List of doctors privileged to perform procedures can be found in intranet.

• The residents are allowed to performed

procedures and it is noted that they are to perform any complex procedure within their scope of practice. • It is their professional duty to seek supervision from a senior if they are unsure or unfamiliar with the procedure. • Medical students are not allowed to perform any procedure independently but they can if they are under direct supervision of the assigned clinical teacher or faculty member.

MPE Medical Professional Education - FAQs Questions Are you allowed to act on the trainees’ instructions? Are trainees allowed to write in patient records (paper or electronically)?

Answers No from medical students. Yes for residents. Medical students are not allowed to write in the patient’s electronic records Residents are authorised to write in patient record as defined below.

MMU Medication Management and Use - Important Points Who provides oversight to medication management & use? The oversight is provided by the MMU Chapter and the Drugs & Therapeutics Committee.

Medication Storage

Medication Preparation

For information on storage of high-risk medications and Look-alike Sound-alike medications, please refer to IPSG 3 (pg 7).

- Medication must be prepared in a safe and

Medications shall be stored using EEFO (Earliest expiryfirstout) principle.

- IV (Sterile) medications are prepared and administered using aseptic technique.

clean environment

Medication trolleys should be locked when unattended!

- After preparation, medications should be

- Weekly checks for drugs topped up by pharmacy.

• Medications not administered

- Monthly checks by the department staff (using the “Drug Storage Checklist”) and quarterly audit by pharmacy staff

- Dispose drugs expiring within 1 month to prevent inadvertent administration of expired drugs.

Patient’s home medication brought into the hospital are: - Identified by the Dr. or pharmacist - Clearly labeled with patient’s name & NRIC number, HAM label as appropriate - Cable tied - Placed at patient’s bedside locker For high risk patients e.g. patients with Psychiatric conditions, suicidal, confusion/cognitive impairment, home medications are kept at medication trolley.

administered immediately.

immediately must be labeled with name of medication, dosage/ concentration, date prepared and patient’s name. - Multi dose vials once opened, “opened date” and “discard date” must be indicated.

Medication Administration The 5 rights must be adhered to when administrating medication. Stat Dose

To be served within 1 hour

Once Dose

To be served within 3 hours

Regular Dose (e.g. TDS, QDS)

To be served within 2 hours before and after the standard timing 37

MMU Medication Management and Use - Important Points Medication Administration

Controlled Drug (CD) Disposal

Where only a portion of a CD is withdrawn from an ampoule and given to the patient, the remaining volume shall be discarded by a SN in the presence of a witness (a SN or NM/NC). All ampoules should be discarded into the sharps box. The contents of all syringes and infusion bags should be emptied into a biohazardous sharps boxes. For location* with large volume liquid disposals, the sharps boxes should be lined with an absorbent gel pad (photo above). Empty syringes or bags can be disposed of as general waste.

*High volume CD disposal area:

Monitoring & Reporting Adverse Drug Reactions (ADRs) should be reported via CPSS/CMIS and/or using the HSA Suspected Adverse Drug Reactions Report Form. Medication errors are reported via IRIS

- PACU - ICU (include HD) - Procedural rooms – OT, Endo Centre, NHG 1-Health, DIR, ICL, 2B Endo. - Wards @ L11 & L12 - Wards 83 & 85 - Ward SA 9 For low volume areas with rare usage, to dispose CD content into sharps boxes. Reference: WI-ENV-HSK-007 Disposal Of Pharmaceutical Waste 38

MMU Medication Management and Use - FAQs Questions Tell me who ensures and checks the medication storage area?

Answers For areas where pharmacy performs topping up once or twice weekly, e.g. wards • Top up personal will check for proper storage conditions each time he tops up. For medications in Omnicell • Pharmacy will perform cycle count and storage check every 3 months. For other locations, the nurse will conduct monthly storage check. Reference: WI-PHA-INV-003 Storage and Transportation of Medications

Do you lock up your medications?

All medication storage area including the medication trolleys are locked.

Tell me what are your High Alert Medications?

HAMs are medications involved in a high percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomese.g. insulins, heparins and concentrated electrolytes. They are stored separately and prescribed with extra caution. HAMs list is available on the intranet TTSH Intranet  Pharmacy Notice board  High Alert Medications.

MMU Medication Management and Use - FAQs Questions What are look alike sound alike medications?

Answers There is a list of medication sound alike medications e.g. ADREnaline & NORadrenaline; gliCLAzide & gliPIzide • Action for Name look and sound alike: convert description to Tall man lettering on dispensing labels and shelf labels, different strengths are highlighted using bold and underline. There is a list of look alike medication e.g. Haloperidol inj & Bromhexine Inj • Action for Product Look alike: Place drugs apart, where possible and highlight look-alike drugs using pink labels. The list is found on the intranet.TTSH Intranet  Pharmacy Notice Board  Drugs Storage  Sound Alike and Look Alike Drugs

How are medications requiring temperatures of ≤ 25°C stored?

Medications requiring ≤ 8°C are stored in the fridge. Other medications are in air-conditioned areas with temperature of ≤ 25°C. • FCC performs monthly Preventive Maintenance for air-con unit • Staff will report to FCC when air-con malfunctions

Why are some emergency kits and trolleys kept in nonairconditioned locations?

This is to facilitate quick and timely access for emergencies. The integrity of the medications will be checked prior to administration (e.g. if there are any signs of instability such as precipitates). Once expired (or damaged), the emergency kit or the request for drugs in emergency trolleys will be promptly sent to pharmacy for replacement. 40

MMU Medication Management and Use - FAQs Questions

Answers

How do you ensure that the drug fridge temperature is within range?

There is a temperature gauge that continuously monitor the fridge temperature (range is 2-8°C). • The alarm will sound if the temperature falls out of range. As the medication prep rooms in the wards have high traffic flow 24hrs a day, any activation of the fridge alarm will definitely be detected and attended to, as the alarm does not go off automatically until someone sees to it. • The door will be checked if it had been closed properly.

What happens if the temperature for the medication goes out of range?

If the problem persists; • FCC will be informed • Medications will be transferred to another fridge, if necessary. • Pharmacy (Drug information services @ 2016) will also be consulted on the need to transfer drugs and if the drugs can still be used. For outpatient areas / Areas that does not operate 24/7 After Office Hours • Alarm monitoring system will send out an SMS notification to Building Energy Management System Team and on-call Pharmacist/Nurse. • FCC will arrange with a security officer immediately to enter the department immediately to investigate and to rectify the problem. • FCC will contact the on-call pharmacist or the on-call nurse, If the temperature cannot be restored to normal range quickly. • The pharmacy staff or nurse will transfer the medications to another refrigerator. • Pharmacy (Drug information services @ 2016) will also be consulted on the need to transfer drugs and if the drugs can still be used.

MMU Medication Management and Use - FAQs Questions Can sample medications be used in TTSH?

Answers Yes. - Sample medications are stored centrally and dispensed at Pharmacy for SOC. - Sample medications are stored and dispensed from Inpatient Pharmacy for some subsidy programs.

Who is responsible for Trial drugs? Or What are you required to do if there are trial drugs kept in your area?

How do you document wastage of CD?

Trial drugs are usually managed by Clinical Research Unit with Pharmacy oversight. Pharmacy will conduct a drug storage check for trial drugs once every 3 months. Trial drugs in the ward (in use for patient) must be labeled with patient’s name and store in locked med cart (or medication fridge, if required) Workflow depends on type of wastage e.g. single use ampoules, tablets, patch etc. Please refer to 1. Pharmacy Notice Board, TTSH Intranet  Control Drugs (CDs)  CD Procedures (Omnicell departments) or CD Procedures (Non-Omnicell departments) 2. WI-PHA-NUR-001 Handling of Controlled Drugs in The Ward, OT, Clinic and other Departments

MMU Medication Management and Use - FAQs Questions What do you do if there is a broken CD?

Answers CD in Omnicell – found in Omnicell bin 1. Remove broken CD from Omnicell 2. Perform “cycle count” to reduce the quantity. 3. Indicate “Broken CD” during discrepancy resolution 4. RN reporting breakage fills up the “Report on Breakage/Wastage/Loss of Controlled Drug(s) in the Wards/Theatres/Clinics” form 5. 3 signatures are required; a. RN who discovered and report the incident b. Witness (RN or Doctor) c. Ward/OT/Clinic manager 6. Return broken/expired drug and form to pharmacy (to bring along CD administration book) *Keep the broken drug in CD cupboard if return cannot be done immediately. CD in Omnicell – After issued to patient 1. Perform “Return to Patient” in omnicell. (DO NOT place broken / expired drugs back in omnicell) 2. During count back, count physical quantity balance/ without broken CD 3. Repeat steps 3-6 as above For Nonomnicell areas 1. Retain physical CD with drug name 2. Call for another RN or Doctor to witness 3. Repeat steps 4-6 as above (Continued on the next page) 43

MMU Medication Management and Use - FAQs Questions

Answers

What do you do if there is a expired CD?

Please refer to: 1.Pharmacy Notice Board, TTSH Intranet  Control Drugs (CDs)  CD Procedures (Omnicell departments) or CD Procedures (Non-Omnicell departments)

2.WI-PHA-NUR-001 Handling of Controlled Drugs in The Ward, OT, Clinic and other Departments Do you have a process for finding out what current medications a newly admitted patient is taking?

Medication Reconciliation is carried out by the pharmacist upon admission.

Do you allow patients to use their own medications?

Yes, if medication is not available in the hospital. The medication must be identifiable by: • Proper labelling • Not expired • In good condition

Reference: JCI-MMU-HAP-001 Medication Management and Use WI-PHAIPT-008 Medication History Taking and Reconciliation

Pharmacist should check that the drug and dose are correct. The Doctor/ Nurse should indicate in the e-IMR “patient’s own medication”.

MMU Medication Management and Use - FAQs Questions Do you allow patients to self administer medications?

Answers Self-administration of medication is not allowed.

• All medications are administered in the presence of the nurse • Patients are instructed to inform the nurse if medication is required. What is your process for getting medication during the night or when the pharmacy is closed?

Obtain from other wards. or Send request to Emergency pharmacy.

How do you obtain Parenteral Nutrition? (clinical nutrition team changed term from TPN)

The order is sent to pharmacy

• Pre-mixed bag with no alterations/additives can be obtained anytime from the pharmacy.

• Orders for customized formulation or premixed with alterations/additives has to be sent to pharmacy before 11am. How is Parenteral Nutrition Stored?

• Parenteral nutrition must be stored refrigerated (2-8°C) when not due for administration to the patient Reference: JCI-MMU-HAP-001 Medication Management and Use TTSH Intranet Pharmacy Notice Board Premixed Parenteral Nutrition

MMU Medication Management and Use - FAQs Questions What constitutes a complete medication order?

Answers 1. Two Patient Identifiers • Name, NRIC 2. Drug name (generic name preferred) • Dose or strength/concentration • Dose form • Frequency of administration • Route 3. Doctor’s name, MCR number, signature (only in paper IMR, not required in eIMR) 4. Date and Time of order Any cancellation or alteration is initialed against outpatient medication records (OMR).

Who reviews a medication order? Or What is reviewed? How is an appropriateness review conducted? Or What is the process for an appropriateness review?

Doctors & Pharmacists review an order before administration of the first dose for: • allergies • lethal drug/drug interactions • weight-based dosaging • potential organ toxicity (for example, administration of potassium sparing diuretics in patients with renal failure) * Exception: Formal Medication review is not required in an emergency or when ordering doctor is present for ordering, administrating and monitoring of the patient e.g. in the OT or ED, or with oral, rectal, or injectable contrast in interventional radiology or diagnostic imaging where the medication is part of the procedure. Reference: JCI-MMU-HAP-001 Medication Use and Administration 46

MMU Medication Management and Use - FAQs Questions

Answers

Do you accept verbal orders / Telephone orders?

Verbal / telephone medications orders are not accepted except in clinical settings using the paper IMR and during an emergency situation where delay in administration of medication will result in unfavorable outcome.

What do you do if you are unsure about the medication to be administered to the patient?

• Refer to pharmacy notice board • Refer e-MIMs • Call Drug information service @ ext 2016 • Consult ward pharmacist or contact on call pharmacist

Are pharmacists available 24hrs?

Yes, on call pharmacist can be contacted through operator or HMS after office hours.

(through operator) after office hours

Or Are pharmacists available after office hours? Do you prepare chemotherapy here?

No, cytotoxic drugs are reconstituted at the pharmacy. Cytotoxic drugs dispensed by the pharmacy will be labeled with the word “CYTOTOXIC”.

Do you clean the medication trolley?

Yes, the medication trolleys are cleaned before and after each medication round. (ensure medication trolleys is kept clean, neat and tidy, there will be checks on cleanliness)

MMU Medication Management and Use - FAQs Questions Do you prepare IV medications in this unit? Where do you prepare it? Show me.

Answers IV medications are prepared on the IV injection trolley in the preparation room using aseptic technique.  Remove any items not required from preparation area  Disinfect preparation area with alcohol wipes  Perform hand hygiene  Reconstitute IV medications using aseptic technique  Perform hand hygiene before patient contact *After preparation, medications should be administered immediately.  Medications not administered immediately must be labeled with name of medication, dosage/concentration, date prepared and patient’s name References: JCI-MMU-HAP-001 Medication Use and Administration, WI-PHA-INV-003 Storage and Transportation of Medications

Do you keep Multidose medication? What is your policy on Multidose medication?

Multi-dose medication, e.g. Insulin Multi-dose vials once opened need to be dated with “open date” and “discard date”. E.g. Insulin, discard period is 4 weeks once opened. Reference: Pharmacy notice board  Drug Storage Discard Date for Medications and Disinfectants: 1.List of Items, Discard Dates and References 2.Recommended Usage on Multi-Dose Vials

What precaution do you observe when administrating medications?

5 Rights Right Patient, Right Drug, Right Dose, Right Route, Right Time. Reference: JCI-MMU-HAP-001 Medication Use and Administration

MMU Medication Management and Use - FAQs Questions For areas using Guardian feature Do you set limits to your infusion pumps? What do you do if the pump alerts that the dose is out of range?

Answers Dose limit is preset when the Guardian Feature mode is selected *The doctor (registrar or above) should inform the nurse if dose prescribed falls outside the preset dosing limits, and document in the medical notes. If the pump alerts on dosing entry, the nurse will recheck if dose entered correctly. Pump “Override” is done after confirmation with Registrar. Nurse is to document the name of doctor who agrees to override and prescribed dose, in patients notes.

What do you do when a medication is recalled?

Recalls are made through pharmacy • Pharmacy will inform of product recall with details including product’s name, strength, batch number etc. Patient care areas will retrieve products from storage areas (including medication trolley) and set aside the recalled product 1. for collection by pharmacy, or 2. returned to pharmacy, together with the “Goods Return” form.

What is a medication error?

A medication error is; A preventable event that may occur at any step of the medication use process (ordering, transcribing, dispensing, administrating and monitoring). It may lead to inappropriate use or jeopardize patient safety.

What is a near miss?

A ‘near miss’ is an event or a situation that could have resulted in harm but did not, either by chance or through timely intervention. It must be monitored, documented and reported within 24hours via IRIS. Staff who are accountable for taking action on the reports are notified.

MMU Medication Management and Use - FAQs Questions What do you do when there is an medication error?

Answers When a medication error occurs; • Patient’s vital signs will be monitored • The doctor will be informed immediately. • The nursing officer will be informed and the event will be reported in the Hospital occurrence reporting system (IRIS) within 24hrs. Reference: JCI-MMU-HAP-001 Medication Use and Administration

what do you do If a patient has an Adverse Drug Reaction (ADR)?

If an ADR is observed, patient will be assessed (closely observed) and the doctor informed immediately.

How are drug allergies / ADR reported?

Clinically important or serious adverse drug reactions are reported within 24 hours to: • IRIS • CMIS (Critical Medical Information System)

Attending doctor documents details of: • Allergies • Expected or unexpected adverse effects • Description of the reaction • Action taken • Outcome

Attending doctor submits HSA Adverse Drug Reaction Form to Pharmacy or online and this will be forwarded to the Health Sciences Authority.

PFR Patient Family Rights - Important Points Patient’s right confidentiality

Our patients receive information on available care and services and how to access these services. They are also informed about their rights and responsibilities. These information are made available in the Patient’s Charter. Patient’s Charter is • given to all patients in the financial counselling pack • displayed in all wards • available in 4 languages (English, Mandarin, Malay, Tamil) on the TTSH Intranet  JCI Gold Seal  PFR Chapter Materials  Patient’s Charter  English/Mandarin/Malay/Tamil

privacy

and

We respect patient’s right to privacy and confidentiality in our daily care activities: • NOT holding patient-related discussion in public areas. • NOT posting confidential information on patient’s headboard. • Patient is interviewed, examined and undergo treatment in surrounding designed to give reasonable visual and hearing privacy. • Do not leave patient’s medical record unattended. • Log off any EMR when not in use. Religious and spiritual needs • All patients are screened for religious / spiritual concerns on admission (Nursing Assessment Record, NAR).

* Refer FAQs for details Translation Service Likelihood of students and trainees participating in care process

• Resource for translation services are available in Intranet Translation Services

• This information is provided to patients in

Patient’s Charter. • Patient’s permission is sought when students and trainees are involved.

PFR Patient Family Rights - FAQs Questions Tell me how the hospital address inpatient’s religious / spiritual needs

Answers Religious/spiritual needs are assessed and support is provided if required. If a patient or family member expresses spiritual/religious needs, the doctor / nurses can:

• Refer the patient/ family to his or her regular place of worship.

• Refer the patient to appropriate religious organisation found in Annex A of JCI-PFR-HAP-008.

• Refer the patient to an appropriate counsellor. Tell me how do you address the patient or family’s request to perform religious/spiritual ritual in the ward/unit What about patient in isolation room? Tell me how the hospital safeguard patient’s belonging

Religious service or worship can be carried out in Patient Care Rooms.

If the patient is isolated and required religious support, we will educate the religious leader on isolation precaution.

• Patient/family are advised to bring home valuables or have the valuables be sent for safe keeping. • Each property bag should be sealed with signed legal seals and passed to the receiving officer • Patient’s NRIC, work permit, driving license and passport shall be placed separately in a clear plastic bag and transfer to Security office • All staff must wear ID • Registration is required for all visitors entering the wards. Suspicious visitor will be approached. 52

PFR Patient Family Rights - FAQs Questions

Answers

Tell me how are patients protect from physical assault?

• When a patient/visitor or staff exhibits aggressive behaviour that results in substantial risk of harm to self and or others, ward staff will call security officer and or press Panic Button to call for assistance.

• If the violence person is a patient, the primary doctor will be called to consider administering medication to sedate or calm the patient.

• If the violence person is a visitor or member of public, police assistance will be sought when pacifying him or her is futile. Tell me how is patient informed of any unanticipated outcome of care?

The attending doctor and team will inform the patient of his/her progress during daily round including any unanticipated outcomes of care post intervention. For severe unanticipated outcome requiring immediate measures, they would be informed by the attending doctor soonest possible.

Tell me the process when a patient/family requests for a second opinion?

• The attending specialist doctor will first offer a choice from the List of TTSH specialist doctors.

• If patient/family does not wish to choose from the list, the attending specialist will offer a list of visiting consultants appointed by TTSH.

• If patient/family insists on seeking second opinion from his/her preferred Specialist doctor who is not accredited by TTSH, the attending TTSH Specialist doctor will seek approval first from the HOD and CMB. 53

PFR Patient Family Rights - FAQs Questions Tell me how is a DNR order issued?

Answers • Attending doctor will discuss with patient and or family.

• Doctor will document the agreed extend of care Tell me what do you do when faced with ethical dilemmas when caring for patients?

• Consult direct supervisor or HOD • Hospital Clinical Ethics Committee is available for consultation

– –

Put up blue letter referral and call extension 8350/8342/8362 Email case details to clinicalethicscommitte@ttsh.com.sg

Tell me the process should a patient / family have any complaints or conflict?

• Staff will escalate to Nurse Manager/Senior Nurse

Tell me the procedures that require written consent?

Written consent is required for • Surgery • Anaesthesia • Use of blood and blood products • Other high risk procedures and treatments e.g. chemotherapy, radiotherapy, biopsy, sedation

(Refer to JCI-PFR-HAP-003 Consent taking for procedures and Treatments for details)

Manager (Unit) if unable to handle • Doctors are consulted of there is any clinical issue • Patient’s Charter is available with information on the contact number to PRS

PFR Patient Family Rights - FAQs – Questions Tell me the process for taking consent for operation/procedure/treatment?

Answers The following should be explained to the patient/ legal guardian during consent taking for operation/procedure/treatment: • Patient’s medical condition • Nature of treatment • Site of operation • Potential benefits of the proposed operation/procedure/treatment • Main risks and complications • Consequences of declining • Alternatives treatments • Transfusion of blood/blood products (if necessary) • Photography for medical treatment or related purposes The attending doctor must document in the case notes that the above have been explained.

What do you do if the patient does not speak English?

• Check if any staff in the ward/nearby speak the patient’s language

• If not, refer to Intranet for internal resource of translation service Do you use family members as interpreters for consent?

• Family members, are used as last resort

PFR Patient Family Rights - FAQs – Questions Tell me the process of consent taking when a patient is incapable of giving consent

Answers Patient’s Legal Guardian Or Emergency • 1 Associate Consultant (AC) and above can authorise the treatment Elective situation • 2 ACs and above can concur and authorise medically-indicated procedures, which are in the best interests of the patient If the treatment is significantly complex and patient is at high risk of morbidity & mortality, the 2nd AC should be skilled in the specialty or independent of the care of the patient. After Office Hours • Registrars can sign on behalf of the AC after getting authorisation • Consultant must sign on the consent form the next working day Decisions are discussed and communicated with relatives, and made in the best interest of the patient

PFR Patient Family Rights - FAQs – Questions Tell me the validity of the consent Or How long is this consent valid for?

Answers Operations/Procedures • 6 months. If there is any material change in the nature, purpose or risks of the operation/ procedure within the 6-month validity period, and/or if an alternative or additional operation/procedure is proposed, a fresh consent is required. Chemotherapy • 12 months*, if it is a continuation of the original treatment and there is no significant change in the treatment objectives and risks. *Blood transfusions consent when taken within the context of chemotherapy is valid for a series of blood transfusions if the indications and risk-benefit considerations remain the same. If there is any material change in the patient’s disease or nature and purpose of the treatment, then a new consent has to be taken. Acupuncture • One treatment cycle Consent must be reaffirmed verbally and documented at each treatment episode. The consent should be reobtained with a new consent form should there be any change in the clinical condition of the patient that would alter the risk-benefit considerations

PFR Patient Family Rights - FAQs Questions

Answers

Tell me about the care you provided to your vulnerable groups of patients

• The vulnerable elderly –limit transfer to reduce disorientation;

(Refer to JCI-PFR-HAP-011 Care for the Vulnerable Groups of Patients for Details )

assessment and management should include maintaining fluid balance; pain management; pressure ulcer risk management; falls and immobility; continence risk; depression; polypharmacy; end of life/palliative care.

• Elderly with dementia or cognitive impairment – appropriate

referral to be made to diagnose, treat and manage the condition and behaviour; facilitate career support and respite care.

• Children – involve family/guardian in the care; assess family’s

ability to cope and needs for support; confirm identify of career before discharge home; Where there are concerns regarding child protection, the hospital should ensure that the children are not discharged until there is a plan in place to ensure his/her safety.

• Individual with development disability - be sensitive and

responsive to the needs of these patients, and render appropriate assistance; referral to relevant healthcare professionals to provide a more comprehensive evaluation for patients.

• Disabled patient - communicate with them, assist in feeding and familiarise with specialised aids and equipment.

• Comatose patients - Refer to JCI-COP-HAP-004 • Elder mistreatment –if a case is suspected, doctor in-charge

will engage other health care professionals to assess the need for care/protection. Patient is encouraged to lodge police report if warranted.

• Child abuse and neglect – referral to arrange for professional assistance.

PFR Patient Family Rights - FAQs Questions Tell me how the hospital safeguard patient’s belonging?

Answers * Refer to following documents for details:

•WI- NUR-GEN-008 Collecting Patient’s Property in the Ward

(Itemised and Non-itemised Process) •WI-ADS-ADM-001 Safekeeping of Patient’s property •WI-EMD-DOC-006 Collecting Patient’s Property in the Emergency Department •WI-EMD-DOC-009 Safekeeping of Patient’s Valuable Property from Ward/Emergency Department •WI-NUR-1Health-007 Safekeeping of Patient’s Property at Endoscopy Centre •WI-NUR-DSC-007 Safekeeping of Patient’s Property at Day Surgery Centre •SN-NUR-PAC-004 Safekeeping of Patient’s Property in Post Anaesthesia Care unit

•Patient/family are advised to bring home valuables or have the valuables be sent for safe keeping. •Each property bag should be sealed •Patient’s NRIC, work permit, driving license and passport shall be placed separately in a clear plastic bag and transfer to Security office •All staff must wear ID •Registration is required for all visitors entering the wards. Suspicious visitor will be approached.

Management of Information(MOI) - Important Points -

Maintain privacy and confidentiality of information • • •

• •

Protect medical records from loss, destruction, tampering and unauthorized access. No records should be left unattended. Access to electronic clinical information systems is via unique user IDs. Sharing of individual user IDs and passwords is prohibited. Clinical system should be logged out when not in use to ensure the security and confidentiality of patient information. Only authorised personnel can make entries in patient record.

Abbreviation

(Intranet JCI icon TTSH abbreviation list) • • •

Use only abbreviations and symbols from the approved “Master” list Do not use abbreviations in the “Do Not Use” list. Abbreviations are not allowed in consent forms and documents that patients and families receive from the hospital about patient’s care, e.g. discharge summary and education material.

Reference: JCI-MOI-HAP- 002 Clinical Documentation & Information Management

Good documentation practice • • •

•

• •

Medical records should be up-to-date, legible, complete and accurate at all times. All the entries shall be documented legibly with date, time, name (use name stamp on hardcopy form) and signature. Any alteration to the medical record should be indicated with a single line drawn through the incorrect entry and initialled. The original entry should readable. Any additional notes may be added as part of the medical record with explanation for the addition. The additional notes should be dated, timed, with the author’s name and signature. It must not be written in between existing entries. All sections of the medical record should be filled. Fill in with “NA (Non Applicable)” for section not required to complete. Entries by students should be countersigned. 60

Management of Information(MOI) - Important Points -

To Do: • Verify information belongs to the correct patient using 2 patient identifiers • Ensure the information accurately reflects the patient’s current status. Content should be verified to avoid incorrect or unnecessarily long entries • Attribute to the appropriate provider or record for any materials copied. (E.g. State date, time, original author and note location if this information is essential for continuity of care).

“Copy and Paste” guidelines (NEW!) • •

• • • • •

Involves selection of data from an original or previous source to reproduce it in another location. Associated with risks of inaccurate information leading to potential harm when the information pasted was not reviewed and updated to reflect the correct patient and current status of the patient. Healthcare providers documenting in the electronic medical record are responsible for verifying the accuracy of the information. Do not copy and paste freely If inaccuracies are discovered, the original author, care team or consultant in charge of the patient is to be notified. If the electronic record is locked, a new record is to be created to state the mistake in the original record. If the electronic record is not locked, the content should be rectified with date, time and author clearly stated to reflect the authorship of the correction.

Not To Do: • Copy the signature block of a completed note into a new note. • Copy data or information in such a way as to imply that a healthcare provider is involved in the care of the patient when the healthcare provider is not. • Copy entire laboratory, pathology, radiology or other information in the health record verbatim into progress notes when it is not specifically addressed or clearly pertinent to the specific current patient problem. Reference: JCI-MOI-HAP- 002 Clinicat Documentation & Information Management

Management of Information(MOI) - Important Points -

Health Information Technology System Downtime (NEW!) • • •

System downtime can occur as planned/scheduled or unplanned/unscheduled. It is a part of staff orientation program and is conducted for every new nurses. Downtime procedure will be included in the training for any new clinical system deployed.

Downtime communication Workflow a)

Planned/scheduled downtime ITD will circulate announcement w via internal email 7 days before downtime. Supervisors to disseminate the information to the ground staff during roll call. Unplanned/unscheduled downtime Department key users and Point of Contact (POC) will be notified through HMS who will in turn inform the ground staff to start downtime workflow.

Level of downtime contingencies process for key clinical systems a)

Staff can refer to treatment/medication orders via local backup laptop for CCOE/eIMR, and C-doc direct login App for Read access only.

If documentation is required, • Print the eIMR-iMAR and CCOE eOrders downtime report from local backup laptop and document any changes on the printed report. • Print relevant hardcopy forms from DES (Xerox photocopier) for documentation. • Refer to data recovery process of individual system on workflow of filing hardcopy report or transcribing to clinical systems.

In the event Document Efficiency System (Xerox photocopier) is also not available, retrieve the hardcopy forms from the Downtime Kit.

a)Reference: WI-NUR-GEN-027 Downtime Procedure for Inpatient Health Information Technology Systems

Management of Information(MOI) - Important Points -

Document Retention Period

Reference: QP-HIS-RET-001 Medical Records Retention Guidelines

Management of Information(MOI) - FAQs Questions

Answers

Tell me what happens when a patient request for their medical records?

• Patients can request for their medical records through HIS. Copies

How do you ensure only authorized person enters the patient’s record?

• Only authorized persons (identify by badge) are allowed in the

of Lab and X-ray reports may be released upon patient's request.

• It is not the usual practice of the hospital to release entire medical records to patients. • Patient's medical records are provided to the Court/Police/other government registries/agencies under the Law.

• • • •

Are you able to access all the files of the patient?

wards. Anyone without badge ID will be questioned & identity will be verified. Access to electronic clinical information systems is via unique user IDs. Sharing of individual user IDs and passwords is prohibited. Unattended computers are logged off. All staff should use their name stamps when making entries on hardcopy forms. Regular medical records audit is conducted .

• Individuals are authorized to gain access to patient’s clinical

records based on need and defined by job title and function.

• Read-only access for staff not involving in patient care but require access to the systems.

Management of Information(MOI) - FAQs Questions Tell me, how do you protect patient’s confidential information?

Answers • Do not disclose, whether directly or indirectly, patient’s information to any unauthorised persons.

• Do not leave records unattended in open areas. • Unattended computers are logged off. • Where possible, computer screens are displayed such that they are not readily viewed by passers-by.

How is the use of abbreviations being monitored?

• The hospital has a list of approved abbreviation which is available on TTSH Intranet.

• The use of non-approved abbreviations will be picked up during medical record audits.

Tell me, how are you notified in an event of system downtime?

• Staff will be informed of system downtime by department supervisor.

• For scheduled downtime, ITD will circulate announcement via

internal email 7 days before downtime. For unscheduled downtime, key users will be notified via HMS. • Document on hardcopy forms printed from DES or local backup laptop (for treatment and medication orders). If DES is also down, retrieve the hardcopy forms from Downtime Kit.