Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

FEB 1 1 2020

ADI	MINISTRATIVE ORDEF
No.	2020- 0007

SUBJECT: National Policy on Patient Safety in Health Facilities

I. RATIONALE

Patient safety is a fundamental element of health care and is regarded as an essential component for improving health outcomes. The provision of safe and quality health service that is responsive to the needs of the people is a vital pillar in helping achieve Universal Health Care.

In 2008, the Department of Health (DOH) issued AO No. 2008-0023 to institutionalize quality assurance where patient safety is regarded as one of the key dimensions of quality health care. Correspondingly, the Patient Safety Program was implemented to provide a framework for quality and safe health services in all DOH hospitals and other health facilities.

Anchored on the Universal Health Care Law and the recent call of the 72^nd World Health Assembly on Global Action on Patient Safety, the DOH is reaffirming its commitment to promote and integrate patient safety in health service delivery to improve health systems and health outcomes. The Patient Safety Program of the DOH reinforces the institutionalization of Patient Safety in health facilities to ensure its alignment to the overall strategy of FOURmula One Plus for Health, and hereby revises and enhances the National Patient Safety Policy to improve health care delivery in the country.

II. OBJECTIVE

This Order provides guidance on the effective implementation and institutionalization of the Patient Safety Program in health facilities to improve safety in health service delivery, including that of the vulnerable population.

III. SCOPE

This Order shall apply to all government and private health facilities providing preventive, promotive, curative, rehabilitative, and palliative care.

IV. DEFINITION OF TERMS

• A. Adverse Event- a preventable or accidental injury or illness caused by medical management, which requires additional monitoring, treatment, hospitalization, or that results in death. Medical management includes diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care (Agency for Healthcare Research and Quality).
• B. Sentinel Event most serious adverse events which cause permanent harm, severe or temporary serious injury, or death (WHO, 2009).

• C. Culture of Safety- an integrated pattern of individual and organizational behavior based on shared values, attitudes, perceptions, competencies, and patterns of behavior that strive to operationalize a culture: (1) where all health-care workers (including front-line staff, physicians, and administrators) accept responsibility for the safety of themselves, their co-workers, patients, and visitors; (2) that prioritizes safety above financial and operational goals; (3) that encourages and rewards the identification, communication, and resolution of safety issues; (4) that provides for organizational learning from accidents; (5) and that provides appropriate resources, structure, and accountability to maintain effective safety systems (WHO, 2010).
• D. Risk Management- clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself (The Joint Commission, 2007).
• E. No Blame Culture- a non-punitive culture encouraging voluntary reporting of events.

V. GENERAL GUIDELINES

• A. The Patient Safety Program shall be institutionalized in all health facilities at all levels of care. Key elements of the program include Leadership and Governance, Organizational Development, Risk Management, Teamwork and Communication, Human Resource Development, Documentation and Reporting, Health Worker Safety, and Patient-centered Care and Empowerment (ANNEX A).
• B. Engagement and alignment of various stakeholders shall be done for effective Patient Safety Program implementation and attainment of health system goals (ANNEX B).
• C. The Chief of Hospital/ Medical Center Chief and the Patient Safety Officer, as leaders of the Patient Safety Unit/ Committee, shall make a priority the establishment and maintenance of the Culture of Safety and No Blame Culture in the health facility.

VI. SPECIFIC GUIDELINES

A. Patient Safety Standards in the Health Facility

To ensure the institutionalization of the Patient Safety Program in the health facility, the following standards shall be implemented:

• 1. All health facilities shall have a Patient Safety Unit/ Committee with a designated Patient Safety Officer to oversee and manage the Patient Safety Program. This shall be composed of members from those with a permanent or regular appointment, auxiliary members as deemed necessary, and patient partners from patient groups. Duties and responsibilities are detailed in ANNEX C.
• 2. Each health facility shall formulate policies and guidelines aligned to the national strategies on Patient Safety to facilitate the implementation of the program.
• 3. Each health facility shall conduct a baseline assessment of Patient Safety status and

ANT IN

overall burden of unsafe care (adverse events, sentinel events, near misses). Annual assessmentand surveillance shall also be done thereafter.

• A proactive reporting and learning system shall be institutionalized in the health facility, requiring the leadership to encourage reporting of events in a protected, No Blame Culture environment.
• The reporting system shall ensure the confidentiality of individual cases. The events shall be documented and annual reports with summarized events and action taken will be made available to the managementofthe health facility.
• Proactive risk management strategies shall be employed to prevent adverse events through patient risk assessment, patient feedback surveys, health technology assessment, and the use of safety checklists.
• Targets and activities on key priority areas shall be met first. The health facility may opt to do activities on other patient safety areas depending on the need, capacity, and availability of resources.
• Safety checklists, such as Safe Surgery (ANNEX D) and Safe Childbirth (ANNEX E), shall be developed by DOH through the Health Facility Development Bureau (HFDB), which shall be used in patient care processes.
• All healthcare workers shall undergo training upon entry, and subsequently, augmented annually by continuing education, with focus on improving decisions and clinical judgments, and recognition and awareness on safety issues. Training and development activities shall be given budget allocation.
• 10. Annual World Patient Safety Day shall be celebrated in all health facilities every September 17th.

B. Strategies of the Patient Safety Program

All health facilities shall implement the following strategies. Specific activities for each strategy are detailed in ANNEX F.

• 1. Promotion of Culture of Safety through operational and managerial strategies that support quality and efficiency to reduce risks (ANNEX F,Letter A).
• Assessment of the nature and scale of adverse events through responsive and proactive mechanisms (ANNEX F,Letter B).
• Training and capacity building of health workforce sensitive to patient safety through staff professional development programs and training that increase professional competency, patient safety awareness, and capability of healthcare teams for effective program implementation (ANNEX F, Letter C).
• Prevention and control of Healthcare-Associated Infection through compliance with the Infection Prevention and Control standards set in A.O. 2016:0002 or the

National Policy on Infection Prevention and Control in Healthcare Facilities (ANNEX F, Letter D).

• 5. Implementation of key priority areas: Patient Identification Protocols, Effective Communication, Fall Prevention, Medication Safety, Safe Surgical Care, Blood Safety, Safe Childbirth, and Safe Injections (ANNEX F, Letter E).
• 6. Prioritization, promotion, and facilitation of patient safety research and the capacity to conduct it within the health facility (ANNEX F, Letter F).

C. Monitoring and Evaluation

The Program Implementation Review for Patient Safety Program shall be institutionalized and conducted by the Center for Health Development (CHD). Annual assessment shall also be done by each health facility to monitor the effectiveness of the activities of the Program and facilitate identification of priorities.

• 1. The findings of the assessment shall be reviewed and analyzed, and acted upon to identify opportunities for improvements.
• 2. Results of the annual assessment and the surveillance of adverse events shall be reported to the respective CHD.
• 3. The Health Facility Development Bureau shall monitor the implementation of the policy's provisions, and evaluation shall be done every three (3) years.

D. Phases of Implementation

The institutionalization of Patient Safety in Health Facilities shall be done by phase as follows:

1. Phase I:

• a. Formulate policies and guidelines in the health facilities
• b. Create a Patient Safety Committee with a designated Patient Safety Officer
• c. Baseline assessment of adverse events, sentinel events, and near misses

2. Phase II:

• a. Institutionalize a proactive reporting system
• b. Employ risk management strategies as directed by the Patient Safety Unit/Committee and led by the Patient Safety Officer.
• c. Training of health workforce and capacity building aligned with patient safety program strategies

3. Phase III:

• a. Annual assessment of program implementation and unsafe care surveillance
• b. Continued program implementation targeting the key priority areas

VII. ROLES AND RESPONSIBILITIES

1. Health Facility Development Bureau (HFDB) shall:

• a. Assist in the formulation of policies, guidelines, and standards for patient safety.
• b. Lead in the management of the patient safety program in health facilities.

• c. Provide appropriate and necessary technical assistance and capacity building to the HFDU and health facilities relative to the implementation of the program.
• d. Appropriate budget for effective and sustained implementation of the program.
• e. Conduct over-all monitoring and evaluation of the program.
• 2. Centers for Health Development (CHD), through the Health Facility Development Unit (HFDU), shall conduct the following activities in their respective regions:
  • a. Advocate for the adoption of the Patient Safety Program and assist in its roll-out in all health facilities
  • b. Facilitate the annual celebration of World Patient Safety Day
  • c. Provide technical assistance to health facilities related to the program implementation
  • d. Facilitate the reporting system through the collection, consolidation, validation and analysis of data, as well as preparation and dissemination of Quarterly and Annual Report generated by DOH-hospitals, LGU-managed hospitals (Province/Municipal/City), School-run hospitals, hospital under the Department of National Defense (DND) and other Health Facilities
  • e. Submit an annual report and evaluation to HFDB with recommendations for policy and program improvements as a feedback mechanism
  • f. Appropriate budget, provide facilities and other resources for the HFDU to carry out its activities and functions for the Patient Safety Program
• 3. Chiefs or Directors of DOH hospitals and LGU hospitals shall be responsible for:
  • a. Organize the multidisciplinary Patient Safety Unit/ Committee in their hospitals
  • b. Designate the most qualified Patient Safety Officer through a hospital order or memorandum, who will oversee the day-to-day activities related to patient safety
  • c. Authorize the use of official time, hospital facilities, and other resources for the Patient Safety Committee to carry out its functions
  • d. Allocate an adequate budget for the rational procurement of resources and materials necessary for the implementation of the Patient Safety Program
  • e. Coordinate with the DOH Center for Health Development on the status of Patient Safety program and submit data on adverse events and patient safety
  • f. Monitor and support the activities of the Patient Safety Committee
  • g. Report to FDA-Center for Device Regulation, Radiation Health and Research any incident that reasonably indicates that a medical device has caused or contributed to the death, serious illness or serious injury to a patient or any person in the hospital
• 4. Medical Directors, Hospital Administrators, or Head of private hospitals and health facilities shall be responsible for:
  • a. Organize the Patient Safety Committee which shall implement the Patient Safety program and standards in the health facility
  • b. Designate the most qualified Patient Safety Officer who will oversee the day-to-day activities related to patient safety
  • c. Monitor and support the activities of the Patient Safety Committee
  • d. Allocate an annual budget for the program activities in the hospital or facility
  • e. Report to FDA-Center for Device Regulation, Radiation Health and Research any incident that reasonably indicates that a medical device has caused or contributed to the death, serious illness or serious injury to a patient or any person in the hospital

profes tim

VIII. FUNDING MECHANISM

The health facilities shall allocate an annual budget for the activities of the Patient Safety Program in their respective facilities. HFDB shall endeavor to appropriate budget for the effective and sustained implementation of the program.

IX. REPEALING CLAUSE

Provisions under A.O. No. 2008-0023 "National Policy on Patient Safety" and all other related issuances inconsistent or contrary to the provisions of this Administrative Order are hereby revised, modified, repealed or rescinded accordingly.

X. EFFECTIVITY CLAUSE

This Order shall take effect immediately.

FRANCISCO T. DUQUE-III, MD, MSc

Secretary of Health

ANNEX A Patient Safety Program Framework

ANNEX B

Alignment of the Stakeholders to the Patient Safety Program

• 1. Health Facilities and Services Regulatory Bureau (HFSRB). In consultation with appropriate partners, HFSRB shall review and reinforce standard patient safety requirements in physical infrastructure, office and medical equipment management, pharmacy and laboratory operations, nursing care protocols, and other aspects of special and ancillary services. These standards shall be integrated in the orientation, training, and inspection checklists for the different levels of accreditation of health facilities upon the approval of appropriate regulatory authorities.
• 2. Pharmaceutical Division shall assist in the formulation of policies and development of programs to improve patient safety and build a strong safety culture by providing relevant information related to the appropriate use of therapeutic agents. Further, it shall ensure the promotion for the responsible and rational use of medicines through advocacy campaigns, in health facilities and regular updating of the Philippine National Formulary
• 3. Health Promotion and Communication Service shall provide technical assistance and leadership in the development of effective communication plans and health promotion including the development of messages and materials and promotion in various media platforms. Shall also co-lead in the advocacy and activities related to patient safety.
• 4. Food and Drug Administration shall provide leadership in the collection of national data on medication errors and related adverse events and shall be responsible for ensuring the safety, efficacy, and quality of medicines. Center for Device Regulation, Radiation Health, and Research shall assist in the formulation of policies and development of programs by providing relevant information related to the appropriate use of health devices and technologies and collection of national data on adverse events related to their use.
• 5. Bureau of Local Health System Development shall assist in the formulation of policies and development of programs to improve patient safety and build a strong safety culture involving the health facilities and institutions managed by local government agencies.
• 6. Knowledge Management and Information Technology (KMITS) shall lead in the management of information systems, resources, and technology pertinent to the enhancement of hospital operations that would promote safe practices.
• 7. Local Government Units shall provide administrative and financial support to health facilities under their administrative and technical supervision.
• 8. Development Partners (civic society/professional organizations, academe, multi/bilateral organizations) shall provide technical assistance, system development, funding support, and research and development for the implementation of the program.

ANNEX C

Duties and Responsibilities of Patient Safety Leadership

A. Patient Safety Unit/ Patient Safety Committee of each health facility

• a. Shall be composed of multidisciplinary members with representatives from administrative and medical staff, and patient partners from patient groups.
• b. Shall have the following functions:
  • 1. Formulate and implement policies, guidelines, and procedures aligned to the national strategies for patient safety;
  • 2. Coordinate with and disseminate information to all departments, sections, and services of the health facility for the implementation of the Patient Safety Program:
  • 3. Advocate and promote the No Blame Culture and Culture of Safety to all health personnel in the health facility;
  • 4. Formulate mechanisms for systematic adverse event reporting and surveillance;
  • 5. Organize and provide training and guidance to the health personnel related to patient safety and the implementation of standards and guidelines;
  • 6. Collaborate with partner agencies and other stakeholders in the health sector in pursuing program objectives;
  • 7. Conduct meetings at least once a month and whenever necessary in order to consolidate, analyze, and act on reports related to patient safety (adverse events. sentinel events, performance improvement activities, etc)
  • 8. Perform risk management activities to mitigate risks due to adverse events and to learn to prevent future recurrence

B. The Patient Safety Officer shall:

• a. Oversee the implementation of patient safety policies, guidelines, and initiatives in the $\gamma$ health facility;
• b. Conduct regular monitoring which includes, but are not limited to, the following:
  • 1. Clinical process and outcomes and system issues related to the quality of patient care in the related discipline/program/department
  • 2. Chart reviews and clinical audits for the relevant discipline/program
  • 3. Adverse events, sentinel events and near misses
• c. Identify and investigate performance improvement events, opportunities, and trends and lead in the conduct of performance improvement activities;
• d. Facilitate the surveillance and data collection of adverse events, near-misses, and sentinel events:
• e. Coordinate with the Patient Safety unit/committee to provide reports on patient safety issues and in the conduct of risk management activities.

Page 1 of 1

Surgical Safety Checklist

Patient Safety

Before induction of anaesthesia

(with at least nurse and anaesthetist)

Additional to a state of the second	tient confirmed his/her ie, procedure, and conser
Yes	s, processie, and conser	10.7
Is the site	marked?
Yes
No applica	ble
is the anac	sthesia machine and
September 1	check complete?
Yes
le the mile	e oximeter on the patient
and function
Yes
Does the P	ratient have a:
known alle	Barrier Committee Committee
No
Nes :
Difficult ali	rway or aspiration risk?
No
Yes, and e	quipment/assistance available
Risk of >5	00mi blood loss
CONTRACTOR OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE	chikiren)?
_ No
Yes, and b planned	wo IVs/central access and fluids

Before skin incision

(with nurse, anaesthetist and surgeon)

												hε
												a
		a

Confirm the patient's name, procedure, and where the incision will be made.

Has antibiotic prophylaxis been given within the last 60 minutes?

	Ų	Ye:
100	14

Not applicable

Anticipated Critical Events

To Surgeon:

What are the critical or non-routine steps? How long wil the case take? What is the anticipated blood loss?

To Anaesthetist:

Are there any patient-specific concerns?

To Nursing Team:

Has sterility (including Indicator resultd) been confirmed?

Are there equipment issues or any concerns?

Is essential imaging displayed?

Ves

Not applicable

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.

Before patient leaves operating room

(with nurse, anaesthetist and surgeon)

Nurse Verbally Confirms:

me name o	i rije brocedo	e
Completion	of instrument	, sponge and needle
counts

Specimen labelling (read speciment lable aloud, including patient name)

Whether there are any equipment problems to be addressed

To Surgeon, Anaesthetist and Nurse:

What are the key concerns for recovery and mangement of this patient?

Revised 1 / 2009

C-WHO, 2009

(https://www.who.int/patientsafety/safesurgery/checklist/en/)

SAFE SURGERY CHECKLIST

1.75600

ANNEX E SAFE CHILDBIRTH CHECKLIST

(https://www.who.int/patientsafety/implementation/checklists/childbirth/en/)

BEFORE BIRTH

WHO Safe Childbirth Checklist

Check your facility's criteria
Start plotting when cervix ≥4 cm, then cervix should dilate ≥1 cm/hr • Every 30 min: plot HR, contractions, fetal HR • Every 2 hrs: plot temperature • Every 4 hrs: plot BP
Ask for allergies before administration of any medication Give antibiotics to mother if any of: • Mother's temperature ≥38°C • History of foul-smelling vaginal discharge • Rupture of membranes >18 hrs
Give magnesium sulfate to mother if any of: • Diastolic BP ≥110 mmHg and 3+ proteinuria • Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain Give antihypertensive medication to mother if systolic BP >160 mmHg • Goal: keep BP <150/100 mmHg
Call for help if any of: Bleeding Severe abdominal pain Severe headache or visual disturbance Unable to urinate Urge to push

WHO Safe Childbirth Checklist

BEFORE BIRTH

WHO Safe Childbirth Checklist

Just Before Pushing (Or Before Caesarean)

manufacture and the shorts	Ask for allergies before administration of any medication
es mother need to start:	Give antibiotics to mother if any of:
tibiotics?	Mother's temperature ≥38 °C History of foul-smelling vaginal discharge
No	Rupture of membranes >18 hrs
Yes, given	Caesarean section
gnesium sulfate and	Give magnesium sulfate to mother if any of:
tihypertensive treatment?	Diastolic BP ≥110 mmHg and 3+ proteinuria
No	Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain
Yes, magnesium sulfate given	and try or are needed by the same paint
Yes, antihypertensive medication given	Give antihypertensive medication to mother if systolic BP >160 mmHg • Goal: keep BP <150/100 mmHg
nfirm essential supplies are at bedside and
epare for delivery:	Prepare to care for mother immediately after birth:
mother	Confirm single baby only (not multiple birth)
Gloves	1. Give oxytocin within 1 minute after birth
Alcohol-based handrub or soap	2. Deliver placenta 1-3 minutes after birth
and clean water	Massage uterus after placenta is delivered Confirm uterus is contracted
Oxytocin 10 units in syringe	1. Committed as a confidence
	Prepare to care for baby immediately after birth:
r baby	1. Dry baby, keep warm
Clean towel	2. If not breathing, stimulate and clear airway
Sterile blade to cut cord	3. If still not breathing:
Suction device	• clamp and cut cord
Bag-and-mask	clean airway if necessary ventilate with bag-and-mask
-ag and mass	shout for help
Assistant identified and ready to help at birt	th if needed.

WHO Safe Childbirth Checklist

Completed by ....

AFTER BIRTH

WHO Safe Childbirth Checklist

WHO Safe Childbirth Checklist

$\cup$
s mother bleeding abnormally?	If bleeding abnormally:
J No	Massage uterus
Yes, shout for help	Consider more uterotonic
•	Start IV and keep mother warm Treat cause: uterine atony, retained placenta/fragments, vaginal tear,
	uterine rupture
Does mother need to start:	Ask for allergies before administration of any medication
Antibiotics?	Give antibiotics to mother if placenta manually removed or if
□No	mother's temperature ≥38 °C and any of: • Chills
☐ Yes, given	Chills Foul-smelling vaginal discharge
er ener grant	~ i our-smening vaginar discriarge
	If the mother has a third or fourth degree of perineal tear give antibiotics to prevent infection
Magnesium sulfate and	Give magnesium sulfate to mother if any of:
antihypertensive treatment?	Diastolic BP ≥110 mmHg and 3+ proteinuria
J No	Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache,
J Yes, magnesium sulfate given	visual disturbance, epigastric pain
Yes, antihypertensive medication given	Give antihypertensive medication to mother if systolic BP >160 mmHg
- 103, onthrypertensive medication given	• Goal: keep BP <150/100 mmHg
Poes baby need: Referral?	Check your facility's criteria.
TYes, given
Antibiotics?	Give baby antibiotics if antibiotics given to mother for treatment of
J No	maternal infection during childbirth or if baby has any of:
☐ Yes, given	• Respiratory rate >60/min or <30/min
• • • • • • • • • • • • • • • • • •	Chest in-drawing, grunting, or convulsions
	Poor movement on stimulation
	Baby's temperature <35 °C (and not rising after warming) A shall temperature > 22 °C
Special care and monitoring?	or baby's temperature ≥38 °C
] No	Arrange special care/monitoring for baby if any:
☐ Yes, organized	More than 1 month early
	Birth weight <2500 grams
	Needs antibiotics Provised requesitation
	Required resuscitation
☐ Started breastfeeding and skin-to-skin conta	act (if mother and baby are well).
☐ Confirm mother / companion will call for hel	p if danger signs present.

Page 3 of 4

AFTER BIRTH

WHO Safe Childbirth Checklist

Before Discharge Confirm stay at facility for 24 hours after deliv	very.
Does mother need to start antibiotics? ☐ No ☐ Yes, given and delay discharge	Ask for allergies before administration of any medication Give antibiotics to mother if any of: • Mother's temperature ≥38 °C • Foul-smelling vaginal discharge
	Give magnesium culfate to methor if any af
Is mother's blood pressure normal?	Give magnesium sulfate to mother if any of: ■ Diastolic BP ≥110 mmHg and 3+ proteinuria
☐ No, treat and delay discharge☐ Yes	Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain
	Give antihypertensive medication to mother if systolic BP >160 mmHg • Goal; keep BP <150/100 mmHg
Is mother bleeding abnormally?	:
	If pulse >110 beats per minute and blood pressure <90 mmHg
□ No	Start IV and keep mother warm Treat cause (hypovolemic shock)
Yes, treat and delay discharge	· · · · · · · · · · · · · · · · · · ·
Does baby need to start antibiotics? ☐ No ☐ Yes, give antibiotics, delay discharge, give special care	Give antibiotics to baby if any of: Respiratory rate >60/min or <30/min Chest in-drawing, grunting, or convulsions Poor movement on stimulation Baby's temperature <35°C (and not rising after warming) or baby's temperature ≥38°C Stopped breastfeeding well Umbilicus redness extending to skin or draining pus
Is baby feeding well?
☐ No, establish good breastfeeding practices and ☐ Yes	d delay discharge
☐ Discuss and offer family planning options to m	nother.
☐ Arrange follow-up and confirm mother / comp	anion will seek help if danger signs appear after discharge.
Danger Signs
Mother has any of: Bleeding Severe abdominal pain	Baby has any of: Fast/difficult breathing Fever
Severe headache or visual disturbance	Unusually cold
Breathing difficulty	Stops feeding well
Fever or chills	Less activity than normal
Difficulty emptying bladder	Whole body becomes yellow
Epigastric pain	Title and a manifest of the title

Responsibility for the interpretation and use of the material in this checklist lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. For more information visit www.who.int/patientsafety.

WHO Safe Childbirth Checklist

Completed by

ANNEX F

Specific Activities and Strategies that Promote Patient Safety

A. Health facility operations and management systems that promote Culture of Safety

• 1. Leadership and Management commitment to patient safety
  • Patient safety as a strategic priority in health facility policies, organizational structure, plans and health programs
  • Promotion of the use of checklists in patient care processes
  • Establishment of a clinical audit system for system improvement
  • Conduct regular monthly morbidity and mortality meetings
  • Conduct regular patient safety executive walk-rounds to promote Culture of Safety
  • Ensure that hospital managers, clinicians, and all levels of health-care staff are responsible for patient safety at their levels and held accountable

2. Ensuring a safe environment in the health facility

• Compliance to environmental standards for health care
• Posting of warning signs marking unsafe areas and precautions on safety issues (fall, medication alert, radiation, etc)
• Ensure there is appropriate and safe supply of food and drinks for patients and staff
• Conform to guidelines on safe management of chemical and radiologic waste
• Establish a preventive maintenance programme for its physical environment
• Implement an emergency plan
• Establish systems to ensure standards of cleaning and sanitation

3. Health personnel safety is established

• Implementation of occupational health programme for all staff
• Ensure that clinical staffing levels reflect patient needs at all times
• Adherence to national labour laws
• Establish protocols for screening of personnel before employment and regularly afterwards for transmissible infections
• Provision of vaccination and providing mechanisms to protect from health-care associated infections

4. Medical records system is completed

• Usage of standardized codes for diseases, diagnosis, and procedures
• Establishment and maintenance of medical records archiving system
• Ensure that each patient has a single completed medical record with unique identifier
• Development of the infrastructure and capacity to introduce and strengthen information technology to minimize errors in patient care

5. Patient-centered care

• Obtain informed consent for treatments and procedures carrying risk to patients
• Communication and counselling of patients, their families and the staff involved when an adverse event occurs
• Involve participation from patients and their respective families in decisions regarding

their care

• Encourage and set up mechanisms for reporting of incidents by patients and their families
• Involve participation of patients and consumer advocates in patient safety committees and patient safety initiatives

B. Assessment of the nature and scale of adverse events

• 1. Implementation of a surveillance system for nature and scale of adverse events
  • Conduct a baseline assessment of the overall burden of unsafe care in the facility
  • Develop patient safety incident surveillance
  • Establish a system of analyzing all reported incidents to guide appropriate intervention at the institutional and health facility levels to prevent their recurrence
• 2. Usage of incident reporting system and risk mitigation strategies
  • Employ risk mitigation strategies to manage the effects of adverse events
  • Develop a system of reporting and disclosure for learning from all adverse events, sentinel events, and near misses
  • Conduct Patient Safety risk identification and management plan proactively (Root Cause Analysis and/or Failure Mode and Effects Analysis)

C. Training and capacity building of health workforce sensitive to patient safety

• 1. Strengthening education, training and professional performance inclusive of skills, competence and ethics of healthcare personnel
  • Develop standard treatment guidelines and standard operating procedures for healthcare practice and ensuring compliance
  • Establish accreditation of healthcare professional education and training for the improvement of standards
  • Identify knowledge, skills, attitude gaps of health professionals and providing learning and development avenues to address
• 2. Improving the understanding and application of patient safety and risk management
  • Address patient safety at the time of employment and induction and making it a component of performance reviews
  • Conduct periodic assessments of healthcare staff on their understanding and awareness of patient safety principles and practice
  • Encourage patient safety as part of bedside teaching, onsite learning and field work
  • Reinforce a Culture of Safety by advocacy, awareness, patient safety campaigns, and behavior modification methods for involvement by all healthcare personnel

D. Preventing and controlling Healthcare-Associated Infection (HAI)

• 1. Strengthen the Infection Prevention and Control (IPC) Program across all healthcare services
  • Establish evidence-based IPC policies, technical guidelines, standard operating procedures that are aligned with the national IPC policy
  • Create the IPC committee or team that will oversee the Infection Prevention and

Page 2 of 7 m

• Control program of the health facility in all services
• Build awareness on the principles of hygiene and sanitation for patients including visual reminders
• Strengthen microbiology laboratory support
• Implement policies and procedures for rational use of antibiotics
• Build the awareness and capacity of health-care workers, sanitary and supervisory staff in cleaning and sanitation and occupational safety

2. Employ a system to reduce HAI in the facility

• Improve hand hygiene practices using multimodal strategy for hand hygiene
• Undertake surveillance, identification and prevention of significant HAI
• Utilize effective barrier precautions and isolation procedures
• Provide appropriately cleaned, disinfected or sterilized equipment for patient care
• Provide appropriate design and ventilation of health facility for infection control, sinks and running water, supplies for hand hygiene and other IPC practices, isolation facility and sterile supplies

E. Implementation of Patient Safety key priority areas

• 1. Patient Identification Procedures and Protocols
  • Standardize patient identification procedures to have at least two identifiers, including full name and date of birth (room number is not one of them), for all patient care processes (procedures, transfer, or administration of medication and blood or blood components).
  • Provide clear protocols for maintaining patient sample identities throughout preanalytical, analytical, and post-analytical processes.
  • Use of biometric technologies or bar coding with check digits for patient identification
  • Provide clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name
  • Develop non-verbal approaches for identifying comatose or confused patients.
  • Develop and implement a process to improve the accuracy of patient identification and confirmation prior to procedures

2. Effective Communication¹

• Create policies against use of abbreviations in medical orders and in patient charts
• Develop and implement a process to improve the effectiveness of verbal and/or telephone communication among caregivers (i.e, reading back)
• Implement a process and protocol for reporting critical results of diagnostic tests.
• Use of standardized methods, forms or tools to facilitate consistent and complete handovers and referral of patient care (SBAR, IPASSthe BATON)

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^<sup>1 Joint Commission International, 2018. "Communicating Clearly and Effectively to Patients: How to Overcome Common Communication Challenges in Health Care" https://www.jointcommissioninternational.org/assets/3/7/JCI-WP-Communicating-Clearly-FINAL (1).PDF

a. SBAR- standardized technique to facilitate communication during transitions of care

• Ss Situation: Whatisthe situation?
  • e identifying self, the unit, and the patient (by using two patient identifiers- name and birthdate)
  • e briefly state the problem: what it is, when it started, and the severity
• B Background: Provide background information relevant to the situation (ie. admitting diagnosis, list of medications, allergies, most recent vital signs, other clinical information)
• A Assessment: What is your assessment of the situation?
• R Recommendation: What is your recommendation ofthe situation (ie. patient to be admitted, to be seen now,or an order to be changed)

b. TPASS THE BATON- an effective tool of a hand-off checklist of critical information

• Introduction of self and your role
• Patient- name, identifiers, age, gender, location
• Assessment- presenting chief complaint, vital signs, symptoms, diagnosis
• Situation- current status/ circumstance, level of uncertainty, recent changes, code status
• Safety Concerns- critical lab values/reports, socio-economic factors, allergies and alerts (falls, isolation, etc)

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• Background- comorbidities, previous episodes, current medications, family history
• Actions- what actions were taken or are required?
• Timing- level of urgency and explicit timing and prioritization of actions
• Ownership- who is responsible (nurse/doctor/team)? include patient/family responsibilities
• Next- what will happen next? anticipated changes? whatis the plan?

Page 4 of 7 "we + • Effectively discharge patients using standardized format "5 Ds of Discharge" and including the family when necessary.

c. "5 Ds of Discharge"- for effective discharge and successful continuity of care

Diagnosis Does the patient understand his or her diagnosis and why he or she

was in the hospital or receiving care from the doctor?

Drugs Does the patient know each medication he or she must take, the

reason for the medication, when to take the medication, and how to

administer it? Resources to obtain medications?

Diet Does the patient know and understand any dietary restrictions?

Does the patient need a nutrition consult?

Doctor follow- When should the patient see the doctor next? how and when to

make the necessary appointment and appropriate transportation?

Directions Are there other directions necessary to increase the patient's ability

to achieve optimal health? Does the patient understand when

urgent care should be obtained?

• Train staff members to recognize the behavior of patients with low health literacy skills, and accommodating patients' language and literacy needs

• Develop guidelines for requesting and receiving test results on an emergency or STAT basis, the identification and definition of critical tests and critical values, and the identification of to whom and by whom critical test results are reported.

3. Medication Safety

up

• Store and color label high-risk medications with control mechanisms for access. Sample high risk medications include high-dose heparin, narcotics, etc
• Utilize the national formulary of essential medicines for common health conditions
• Strengthen procurement of medicines to ensure quality and avoidance of sound alike, look-alike drugs
• Ensure availability of life-saving medications at all times
• Make information regarding appropriate use, side effects and drug interactions of all medicines including high-alert medications easily available
• Identify and designate qualified individuals permitted to administer medications (medication nurse)
• Ensure legible handwriting when prescribing or writing doctors' orders
• Ensure medicine reconciliation at admission and discharge
• Ensure patient (and/or carer) education about medication at discharge

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4. Safe Surgical Care

• Implement safe surgery checklist and guidelines for all surgical procedures (time-out to ensure correct site, correct procedure, and correct patient)
• Establish rational and appropriate antimicrobial prophylaxis in surgery
• Promote safe anesthesia and surgery

5. Blood Safety

• Implement guidelines on safe blood and blood products
• Establish 100% blood collection from regular voluntary, non-remunerated blood donors from low-risk population
• Ensure testing of all donated blood including screening for transfusion-transmitted infections, blood grouping, and compatibility testing and securely identified with two unique identifiers
• Utilize clinical practices that reduce unnecessary transfusions
• Create policy for post-blood transfusion incident management

6. Safe Childbirth

• Provide supplies, equipment, and medications that are required to safely and hygienically manage the process of labor and delivery
• Apply the WHO Safe Childbirth Checklist or an adaptation of it to support the delivery of essential maternal and perinatal practices
• Educate the mother or companion to call for help during labor if needed and during manifestation of danger signs upon discharge
• Ensure proper treatment while keeping confidentiality for mothers with HIV

7. Safe Injections

• Provide accessible quality injection equipment
• Educate all healthcare workers on safe and appropriate injection practices
• Establish regulations and guidelines on the management of sharps waste and disposal practices (e.g., no recapping, safety boxes)
• Put in place policies and systems that would prevent reuse of needles

8. Fall prevention

• Conduct fall risk screening/ assessment of patients, using standardized assessment tools, to identify those who are vulnerable
• Apply tailored/personalized fall prevention plan based on risk identified
• Utilize universal fall precautions and training on such topic all staff who interact with patients
• Conduct post-fall assessment to carefully assess patients for any injuries; documentation of findings; and reporting of the incident
• Employ strategies to assess fall risks in the outpatient setting

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F. Strengthening capacity in conducting patient safety research

• Facilitate the conduct of patient safety research as a priority topic in training and research health facilities
• Train the staff to use scientific research tools to address patient safety problems
• Facilitate access to scientific publications and articles
• Strengthen ethics committees to oversee patient safety research
• Ensure wide dissemination ofresearch results and translating successful interventions into a form that can be replicated
• Conductcross-sectional studies to assess the magnitude and nature of adverse events

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