patient safety checklist in a hospital
I. Patient Identification
- Ask the patient to state their full name.
- Request the patient’s date of birth.
- Cross-check the provided information with the patient's wristband.
- Ensure both identifiers match the medical records.
- Ask the patient about any known allergies.
- Document allergies in the patient's medical record.
- Check for allergies to medications, foods, and environmental factors.
- Consult with the pharmacy if any doubt arises.
- Request the patient to provide their medical record number.
- Verify the number against the hospital's system.
- Ensure that the number corresponds to the correct patient’s file.
- Update any discrepancies immediately.
II. Medication Safety
- Compare current medications with the patient's medical history.
- Identify any missing, incorrect, or outdated medications.
- Consult with the prescribing physician for clarifications.
- Document any discrepancies and resolutions in the patient's chart.
- Check that all medication labels are legible and accurate.
- Store medications in designated areas based on type and usage.
- Verify expiration dates and remove expired medications.
- Follow safety protocols for high-alert medications.
- Cross-reference prescribed dosages with standard guidelines.
- Ensure correct administration route is specified (oral, IV, etc.).
- Assess patient-specific factors affecting dosage and route.
- Double-check with a second healthcare professional if unsure.
III. Infection Control
- Wash hands with soap and water for at least 20 seconds.
- Use alcohol-based hand sanitizer if soap and water are unavailable.
- Ensure all areas of hands, including between fingers and under nails, are cleaned.
- Dry hands thoroughly with a clean towel or air dryer.
- Assess the risk of exposure to blood or bodily fluids.
- Select gloves, masks, gowns, and eye protection based on the task.
- Ensure PPE is properly fitted and free of defects.
- Dispose of used PPE in designated biohazard containers.
- Use an autoclave for steam sterilization of heat-resistant items.
- Follow manufacturer's instructions for chemical sterilants.
- Inspect instruments for cleanliness before and after sterilization.
- Document sterilization processes for accountability and compliance.
IV. Fall Prevention
- Use a standardized fall risk assessment tool.
- Evaluate patient history, medications, and mobility.
- Document findings in the patient's medical record.
- Communicate risk level to the healthcare team.
- Reassess regularly, especially after changes in condition.
- Provide non-slip footwear to the patient.
- Install bed alarms to alert staff if the patient attempts to get up.
- Ensure the patient’s environment is clutter-free.
- Keep necessary items within reach of the patient.
- Use bed rails as appropriate, ensuring they are safe.
- Explain the importance of calling for assistance.
- Demonstrate how to use walking aids properly.
- Discuss potential hazards in their environment.
- Encourage wearing non-slip footwear at all times.
- Review the fall prevention plan regularly.
V. Surgical Safety
- Ask the patient to confirm their name and procedure.
- Show the patient the marked surgical site.
- Ensure patient understands the procedure being performed.
- Document patient's confirmation in their medical record.
- Gather all surgical team members in the operating room.
- Review the patient's identity, procedure, and surgical site.
- Confirm presence of necessary equipment and instruments.
- Document the completion of the time-out process.
- Conduct a pre-procedure count of all instruments.
- Verify instruments with the surgical team before incision.
- Perform a post-procedure count to ensure none are missing.
- Document counts in the surgical record.
VI. Emergency Preparedness
- Provide comprehensive training sessions for all staff.
- Include simulations of emergency situations.
- Review protocols regularly to ensure understanding.
- Assess staff knowledge through quizzes or practical tests.
- Update training materials as protocols evolve.
- Create a schedule for regular inspections of equipment.
- Ensure all items in crash carts are present and functional.
- Replace expired or damaged supplies immediately.
- Document maintenance and inspection results.
- Train staff on proper equipment use and location.
- Plan drills for fire, medical emergencies, and evacuations.
- Schedule drills at least twice a year.
- Evaluate staff response and identify areas for improvement.
- Provide feedback to staff post-drill to enhance performance.
- Incorporate lessons learned into future training.
VII. Patient Education
- List all medications with dosages and timings.
- Explain purpose of each medication clearly.
- Discuss potential side effects and interactions.
- Provide written instructions for easy reference.
- Encourage patient to ask questions for clarity.
- Identify critical signs such as fever or pain.
- Explain when to seek immediate medical attention.
- Discuss less urgent but important symptoms to monitor.
- Provide a written list of symptoms to watch for.
- Encourage patient to contact healthcare provider if unsure.
- Confirm date, time, and location of follow-up appointments.
- Explain the purpose of each follow-up visit.
- Discuss any tests or procedures to be expected.
- Provide written reminders for appointments.
- Encourage questions about care and follow-up.
VIII. Documentation
- Record the date, time, and nature of interaction.
- Include patient responses and any relevant observations.
- Use clear, concise language for easy understanding.
- Ensure entries are made in real-time or as soon as possible.
- Sign and date each entry for accountability.
- Verify all sections of the checklist are filled out.
- File completed checklists in the designated location.
- Use electronic systems if available for efficiency.
- Ensure checklists are easily accessible for future reference.
- Review for compliance with hospital policies.
- Assess documentation for changes in patient status.
- Collaborate with the healthcare team for input.
- Update care plans to reflect current patient needs.
- Communicate changes to all relevant staff members.
- Document all updates in the patient's record.
IX. Communication
- Foster an environment where team members feel safe to share ideas.
- Implement regular check-ins to discuss patient care and concerns.
- Utilize communication tools like huddles or digital platforms.
- Recognize and reward effective communication practices.
- Establish anonymous reporting systems for safety issues.
- Provide training on the importance of reporting.
- Ensure leadership supports and values safety reports.
- Communicate that all reports are taken seriously and acted upon.
- Set a consistent schedule for safety meetings.
- Include updates on safety incidents and lessons learned.
- Encourage staff participation and input during briefings.
- Distribute meeting notes to reinforce key messages.
X. Continuous Monitoring and Improvement
- Schedule audits quarterly.
- Utilize standardized audit tools.
- Involve a multidisciplinary team.
- Review compliance with safety protocols.
- Document findings and recommendations.
- Develop patient surveys focusing on safety.
- Distribute surveys during discharge.
- Conduct focus groups for in-depth insights.
- Ensure anonymity to encourage honesty.
- Analyze feedback for actionable trends.
- Prioritize changes based on impact.
- Develop an action plan with timelines.
- Communicate changes to all staff.
- Monitor implementation of changes.
- Reassess effectiveness in subsequent audits.
Use in Manifestly