SVIMS
S
S N VER EEVEN
NEV NTS
Firs
st introducced in 2001 1, the termm ‘Never Evvents’ refers to shock king, egreggious, unammbiguous and
meeasurable e events tha at should never oc ccur in heealthcare. During thee last 15 years,
y a lisst of
succh highly sserious advverse even nts have beeen catalog gued in maany countrries. Thesee events re esult
in death
d or siignificant disability
d an
nd are prevventable. SVIMS
S hass started m
measuring each of th hese
‘Neever Eventts’ and ha as put in place
p safetty parame eters to mitigate anyy harm witth the goa al to
elim
minate them. Thus, SVIMS
S beccome the F First Healtth Care Syystem in Inndia, to voluntarily report
saffety record, towards continuous
c s quality im
mprovemen nt. Never Events
E indi cate funda
amental sa afety
pro
oblems with hin an orgaanization oro system. They are grouped
g into 7 categoories SVIMMS will chooose
onee from ea ach of thesse groupin ngs as ou utlined abo
ove & will methodicaally put in n place sa afety
meeasures to eliminate them:
t
Indiccator
Neverr Event Ca
ategory
Desscription Benchma
ark
i. Care Managemen
M nt Events Stage
S 3 & 4 Decubituss ulcer 0
durin
ng hospital
ii. A
Administrattion of drug
g or biologiical Mis
smatched Blood Trannsfusion 0
with seerious harm
m.
iii. Rad
diological Events
E Metallic
M object in MRRI suite 0
caussing injury
iv. Envirronmental Events Fa
alls in hosppital premisses with 1
serio
ous injury
v. Pro
ocedure Ev
vents Wrong site e/wrong paatient 0
pro
ocedure
vi. D
Device Eve
ents Fooreign objeect unintenntionally 0
lefft inside bo
ody during surgery
vii. Patientt Protection Events Misidentific
M cation or m
missing 0
baby
On 12-07-20 016, Hon’ble Health Minister, D
Dr. Kamineni Sriniva
as garu unnveiled SV
VIMS Webbsite
porting of one such
rep h never evvent, nammely stagee 3 / 4 Deecubitus UUlcer.On 9-12-2016
6, to
coincide with
h “World Patient Safety
S Daay’ , Direc
ctor-cum-V
Vc of SVIM MS Dr.T.SS.Ravi Kumar
veiled (‘go
unv o live’) th
he full sp
pectrum o of Seven Never Events listeed, underr the ban nner
‘Se
erious Sevven’
NEVER EVENTS
i. Decubitus Ulcer - stage 3 / 4
Decubitus Ulcer is also known as Pressure sore/bed sore. Since the monitoring
started in September 2015 after the arrival of the new Director and during the
period Sep 2015 to Jan’ 2018, no stage 3 / 4 Decubitus Ulcer has developed in
any patient as a result of stay at SVIMS.
Even though only stage 3 and 4 Decubitus Ulcer are considered as never events, at
SVIMS nursing section has started following all patients for the identification and
corrective measures for stage 1 and stage 2 Decubitus Ulcer in order to prevent
them progressing to stage 3 or 4. It is to be noted that stage 2 ulcers are observed
only in patients who are transferred in with decubitus ulcers and no patients at
SVIMS developed any stage 2 ulcers.
DECUBITUS ULCERS REPORT STAGE 1 (Sept’15 to Jan’18)
Ulcers Developed at Inpatients
Month Hospital
SVIMS Outside Total ICU Total
Total
Sept,15 5 13 18 388 2002
Oct,15 5 2 7 495 2539
Nov,15 1 0 1 397 1937
Dec,15 4 7 11 408 1999
Jan,16 9 9 18 521 2496
Feb,16 5 8 13 425 2085
Mar,16 3 3 6 451 2102
Apr,16 9 5 14 430 2100
May,16 2 7 9 410 2126
June ,16 1 6 7 431 2010
July,16 6 8 14 493 2860
Aug,16 2 4 6 466 2271
Sept,16 6 8 14 623 3121
Oct, 16 1 5 6 485 2484
Nov,16 4 8 12 464 2329
Dec,16 3 11 14 601 2973
Jan,17 6 14 20 499 2288
Feb,17 5 8 13 529 2573
Mar,17 6 8 14 634 3215
April,17 3 6 9 535 2594
May,17 5 6 11 525 2528
June,17 9 10 19 629 3142
Ulcers Developed at Inpatients
Month Hospital
SVIMS Outside Total ICU Total
Total
July,17 4 7 11 520 2608
Aug,17 2 4 6 554 2539
Sep,17 4 6 10 690 3069
Oct,17 4 7 11 531 2581
Nov,17 2 2 4 558 2557
Dec, 17 2 7 9 545 2547
Jan’18 6 8 14 523 2325
Total 124 197 321 14760 72000
ii. Mismatched Blood Transfusions causing serious harm
Protocol for Prevention of Mismatched Blood Transfusion
1. SCOPE & APPLICATION
Never events are serious medical errors or adverse events that should never happen
to a patient. Consequences include both patient harm and increased cost to the
institution. Technicians and nurses provide a critical role in preventing never events
through risk anticipation and adoption of evidence-based practice. Mismatched blood
transfusion is one of the never events which should never happen in a hospital
2. RESPONSIBILITY
• Staff nurse in donor section to correctly label the blood bag.
• The technician on duty in Red Cell Laboratory to correctly receive the blood sample and to
issue the blood for which requisition is received.
• The staff concerned in the ward/OT to correctly label the sample and to transfuse the blood
unit.
3. REFERENCE
• Technical Manual, Directorate General for Health Services-2nd edition
• Model standard operating procedures for blood transfusion services, WHO
• NACO guidelines 2015
4. PROTOCOL
Checks at the donor blood collection section
• Each donor will be given a unique number and once his blood is collected, it is identified
by that number only.
• Verify the donor's identity by tallying with the name on the donor card and the donor
number.
• Write the segment number of the blood bag on to the donor card as a second check.
• Cross check the numbers on the bag, pilot tubes and donor card to ensure identity.
Record the entry in the donor registers using the same number.
Checks while doing blood grouping and typing:
• One technician should do forward grouping from the segment of the blood bag by
correlating the segment number and unique donor number with that entered in the donor
card. Enter the results in the donor unit and in the donor cell grouping register.
• Another technician should do reverse grouping from the pilot tubes collected, by
identifying the unique donor number. Enter the result in the serum grouping register. Both
the forward and reverse grouping result should correlate each other
Checks at the component storage section
• All untested units should be kept in the unscreened Refrigerator/agitator.
• After testing is over, release the fully tested. Write clearly the unit number, date of
collection and expiry and the volume on each colour coded label as per the grouping
register records.
• After the bags are labelled, ask a second technician to double check the number and
group on the bags tallying them with the records.
Checks in the cross matching section:
• Receive the requisition form along with the patient’s blood sample. Check for patient’s
identity. Name of the patient, UHID number, age and sex should correlate with the blood
sample and requisition form. Check the blood group with that of the blood group entered in
the request. If there is any discrepancy, check the blood group of the received blood
sample. If it correlates with the hospital information system, then ask the concerned ward
staff to change in the request before proceeding with the crossmatching.
• If there is no discrepancy between the HIS and the blood group in the request, proceed
with the blood grouping of the patient with the currently received sample
• If there is no discrepancy then proceed with the crossmatching. If still discrepancy
persists, then the old blood sample might be a wrong sample. Trace back the old details
and investigate where the fault is.
• Carry out compatibility testing using departmental SOP. In order to avoid outdating,
implement FIFO policy
• The technician who is issuing blood should make entries in the crosmatching form with
counter sign from the medical officer.
• Make entries in the issue register and in the request.
• The receiving person should check the blood unit and the crossmatching report from for
any discrepancy
Checks at the ward/OT:
• Before administering blood component, FINAL IDENTITY -check of the patient, blood unit
compatibility tag and the complete documentation should be done.
• Ask the patient, if conscious, to identify himself/ herself by name, spouse name, age or
any other identification.
• If unconscious, ask relatives or any other staff to verify the patient’s identity.
• Check that details on the compatibility tag exactly match with the documentation.
• Check the blood unit for any leakage and for any visible discoloration & expiry date
• Two different persons should do the check for patient’s identity and the same should be
documented.
5. DOCUMENTATION
• Make necessary entries in donor register, grouping register, cross matching register, issue
register, incident report register, critical value reporting register, cross matching form, case
file.
STATISTICS OF WHOLE BLOOD/BLOOD COMPONENTS ISSUES AND NEVER
EVENTS
S.No. Year Total No. of Whole Blood/ Never events
Blood Components Record
Issued
1. 2014 18,062 Nil
2. 2015 17,109 Nil
3. 2016 17,807 Nil
4. 2017 23,548 1
(upto 15/12/2017)
iii. Me
etallic Ob
bject in MRI
M Suite
e causin
ng injury
MRI SA
AFETY REP
PORT
1 th January
The lasst unexpectted event in MRI occcurred on 10 y 2015 at 2.30 PM where
w in
Oxygenn cylinder was
w pulled in the ma
agnet. How
wever no paatient / peersonnel in
njury or
hardwaare loss wass suffered. No
N adversee MRI events during 2016
2 & 20177.
To totallly avoid succh situation ollowing steps are being followed :-
n in future fo
1. Oxygen line
es are made available in preparattion area
2. Screening at
a inlet for oxygen
o nders is being done
cylin
3. Maintenancce of routinee duly signeed MRI safe st for all thee patients is being
ety check lis
done Sincee from that time
t h occurred in our deppartment.
no succh incident has
sample cchecklist
iv. FALLS IN HOSPITAL PREMISES CAUSING SERIOUS INJURY
FALL HUDDLE REPORT ON (9/11/15 to 311/1/18)
S/No Name of Injury after Diagnosis Date of Time Root Cause of fall Treatment & status at
the fall fall discharge
Resident
1 Patient Patella Not Applicable Nov 19, 7.30PM - Rain water stagnation T.Dolo 650, Ranctac,
transverse # 2015 &pt not taken diet more Physiotheraphy &
attender
than 10 hrs shifted to BIRRD OT
2 Staff Patella N.A Dec10 1.15PM Due to water stagnation Strict bedrest 14 days,
Nurse swelling and 2015 Volini gel, myospase
back pain
3 Fessy Fracture ulnar N.A Jan 19, 5.30PM Slip from trolley while POP applied,
worker bone 2016 cleaning Roof Immobilisation of
hand,voveran, Rantac,
myospase
4 Patient Head injury N.A Jan 17, 12.30AM Giddiness due to not Inj –Rantac, Inj-
Attender 2016 taken diet Diclofenac- 1 Taxim
given
5 Patient Injury over N.A Mar 8, 3.45PM Phobia regarding Suturings done, minor
Attender chin 3x2 2016 hospital instruments dressing,voveron,
cms antacids
6 Patient Left humerus HTN Mar 22, 7 AM Hypertension sudden POP applied & shifted to
# 2016 giddiness BIRRD
7 Patient Injury over Metabolic Apr 26, 11.45AM Hypertension sudden Suturings done, minor
Rt.eyebrow Encepahalopa 2016 giddiness dressing,voveron,
thy antacids
8 Patient Rt.parietal Meningoma May 4, 5.30PM Giddiness,reoccurence Suturings done, minor
region 2016 history of fall dressing,voveron,
injury antacids
9 Patient Fracture Dcmp with May 28, 10.30pm Giddiness, vomitings Skin traction, bird
Rt.femur AFwith FVR 2016 consultation sent plan
for sub trachetic
extension
10 Patient Mild back pain CKD,HTNon May 29, 12;45pm Dizziness Tab;ultracet;local
MHD 2016 application of diclo gel
11 Patient Injury over Right occipital Jun 9, 4.am Sudden loss of muscle Suturings done, minor
Lt.fore head infract in 2016 control,parathesia dressing,voveron,
parietal region antacids
12 Patient Fracture Left Rt.Lung July 7.30am Obstructed dhothi of Skin traction with 3 kgs
femur consolidation 10,2016 patient leeds fall of
weight
13 Patient OP-Endo RVD with Jul 12.00pm Sitting on chair 1 point DNS IV Fluid
Giddiness thyroid 1,2016 given, Foot elevation.
nodule& dysp
14 Patient Fracture at - Aug 20, 12.30pm Slip while walk Pop applied on left
Attender Lt.elbow ulnar 2016 elbow, Tab. Aceclopara,
region Tab.Rantac,
Tab.Chymoralforte
15 Patient Injury Aug 29, 10.30am Slip Tab. Cefixime 200mg
Occipital 2016 Tab. Aceclopara
region
16 Student Fracture - Sep 19, 2.30pm Slipped leg Pop applied Tab. Dolpal
medical 2016 Tab. Chymoral forte
condyle of
Lt.humerus
17 Staff Fractured - Sep 9.30am Slip Plan for LCLCP plate
Rt.prosthetic 26,2016 fixation.
femur
18 Patient Lt.Distal radial - Nov 5, 6:20 Am Power earthling Inj . Taxim 1g Tab .calpol
attender and ulna 2016 BD
fracture Tab. Chymoral forte BD
Tab. Ecosprin 75 mg
S/No Name of Injury after Diagnosis Date of Time Root Cause of fall Treatment & status at
the fall fall discharge
Resident
19 Patient Bilateral Post of MVR Nov 9, 8.30pm Disoriented, Anxiety Pop slab applied in both
fracture 2016 feet, suturing done at
calcaneum parietal region.
D2-L2 Psychiatric consultation
spondylosis of done.
both
posterior
calcaneum
20 In December month there is no falls reported.
21 In January, 2017 month there is no falls reported.
22 In February, 2017 month there is no falls reported.
23 Patient Rt. CKD with Mar 11, 6.30am Wet floor. 1.Inj.Pan.40mg IV given.
temporal diabetic 2017 2.Tab.Chymoral forte BD.
bone nephropathy, 3.Tab.Ultracet SOS.
fracture & HTN, Hbs 4.Tab.Augmentin 625mg BD.
laceration Ag+ve 5.Neurosurgery consultation
over lower done and advised dressing.
lip.
24 In April, 2017 month there is no falls reported.
25 In May to August, 2017 months there were no falls reported.
26 In Oct 2017 Patient Right femur fracture
27 No falls reported in Jan’18
Fall Huddle Report
Nov, 2015 to Jan 2018 : Monthly Statistics
Month Patients Patient Hospital Staff Total
relatives / Student
Nov, 15 - 1 - 1
Dec,15 - - 1 1
Jan, 16 1 1 2
Feb, 16 - - - -
Mar,16 1 1 - 2
Apr,16 1 - - 1
May,16 3 - - 3
June,16 1 - - 1
July,16 2 - - 2
Aug, 16 1 1 - 2
Sep, 16 - - 2 2
Nov, 16 1 1 - 2
Dec, 16 - - - -
Jan,17 - - - -
Feb,17 - - - -
Mar,17 1 - - 1
Apr,17 - - - -
May,17 1 - - 1
Month Patients Patient Hospital Staff Total
relatives / Student
June17 Falls not reported in this month.
July,17 2 - - 2
Aug,17 Falls not reported in this month. -
Sep,17 Falls not reported in this month. -
Oct17 1 - - 1
Nov,17 - - - 1
Dec’17 1 - - 1
Jan’18 - - - -
TOTAL 16 5 4 25
Fall Huddle Report from Nov 2015 to Jan 2018
18
16
14
12
10 Patients
Patient Relatives
8
Staff/Students
6
0
Patients Patient Relatives Staff/Students
Corrective Action :
1. Side rails fixed to all trolleys in EMD and decided to be procured side rails Trolleys in future.
2. Fixed support handles in all toilets
3. Fixed support handles to Ramps.
4. For construction of new bathrooms/toilets anti-skid tiles arranged.
5. Arranged caution boards while mopping the floors.
6. Planning to Education programmes regarding prevention of falls to nursing, physicians, allied
health & administrative staff.
v. Procedure Events & vi) Device Events
In order to prevent wrong site/wrong patient procedure , SVIMS has begun implementation of
WHO surgical checklist in all procedure areas. Members of SVIMS quality council (SQC) group
assigned this task, will monitor & report data monthly.
Department of Anaesthesiology and Critical care
WHO SURGICAL SAFETY CHECK
Sri Venkateswara Institute of Medical Sciences
LIST
University
Hand over S/N Take over S/N Hand over S/N/Anaesth Tech.
Ward----------- Date----- Time---- OT----------- Date-------- Time ------ RR----------------- Date---------------Time------------
----
BEFORE INDUCTION OF ANAESTHESIA (SIGN IN)
Patient has confirmed Yes No Relevant Lab Yes No Anaesthesia safety check list Yes No
result
Identity ECG/ECHO/An Known allergy
gio
Site marked/Not applicable CXR/CT/MRI Airway/Aspiration risk
Consent obtained Biochemistry If, yes assistance/equipment available
Procedure Haematology Risk of > 0.5L(>7mL/kg in children)
blood loss
Part preparation done Microbiology If, yes IV access and fluid planned
Denture/Jewellery/contact lenses Xylocaine/Antibiotic test dose given and encircled
removed
Double hair bun prepared for DVT Prophylaxis
females
NPO status( write no of hours) Patient warming system/Need for active warming
Blood group and cross matching Blood and blood product availability
done
BEFORE SKIN INCISION (TIME OUT)
Entire surgical team confirms Yes No Surgeon shares Nursing /Anaesthesia technician reviews
Patient’s name Critical/Unexpected step Sterility, including indicator results
Surgical procedure to be Expected duration Equipment Issues
performed
Surgical site Expected blood loss Working suction
Essential imaging available Anaesthesiologist shares Baby tray/Crash cart
Antibiotic prophylaxis within the Anaesthesia plan Catheter/Tube/Lines
last 60 minutes
Antibiotic re-dosing plan Patient specific concerns Other concerns
BEFORE PATIENT LEAVES OPERATING ROOM (SIGN OUT)
Nurse reviews with Team Yes No Equipment problems that need to be addressed.
Instrument, sponge and needle Entire team discusses concerns for patient recovery and management
counts are correct
Specimen labelling
Name of the procedure recorded
vi. Patient Protection Events
Measures taken in SPMC Hospital to prevent baby abduction
• Standard Operating Procedures have been developed for security& ward staff in order to prevent
baby abduction .
• ID tags tied to the wrist of the mother and baby Immediately after delivery.
• Foot prints of the baby taken in the Case sheet/File immediately after delivery in the case sheet
along with signature of responsible patient attender.
• Transfer out/discharge forms developed to transfer the baby with in hospital (Intra hospital) and
outside hospital (Inter hospital), also for normal discharge.
• Baby will not be allowed to move outside of the ward without proper transfer out/discharge form and
also without responsible attendant along with hospital staff.
• At the time of transfer out/discharge of the baby from the post natal ward/NICU the duty nurse along
with doctor on duty and baby mother will sign on the transfer out/discharge slip which will be
checked by security at Post natal ward & main entrance along with baby ID tag.
• Security guards at the Post natal ward and main entrance will record the details of the baby along
with attendant details at the time of transfer out/discharge.
• CC Camera’s were fixed at the entrance of the Post natal ward and at main entrance.
Quality and Patient Safety http://svimstpt.ap.nic.in/new/quality.pdf
Code Blue http://svimstpt.ap.nic.in/new/codeblue.pdf
Never Event http://svimstpt.ap.nic.in/new/neverevents.pdf
Health Associated Infections http://svimstpt.ap.nic.in/new/HAI.pdf
Biomedical Equipment http://svimstpt.ap.nic.in/new/hai-biomedical.pdf
Performance List
Mortality http://svimstpt.ap.nic.in/new/mortality.pdf
