PATIENT SAFETY INDICATORS

INTRODUCTION
The Patient Safety Indicators (PSIs) are a set of 26 indicators (including 18 provider-
level indicators) developed by Agency for Healthcare Research and Quality (AHRQ) to
have information on safety-related adverse events occurring in hospitals following
operations, procedures, and childbirth.

LEVELS OF PSIs
PSI indicators are at two levels- area level PSIs and provider level PSIs as tabulated
here

Provider-level patient safety indicators Area-level patient safety indicators

• Accidental puncture or laceration • Foreign body left in during
during procedure procedure
• Complications of anesthesia • latrogenic pneumothorax
Death in low mortality DRGS • Infection due to medical care
• Decubitus ulcer Failure to rescue • Technical difficulty with medical
• Foreign body left in during care
procedure iatrogenic • Transfusion reaction
pneumothorax • Postoperative wound dehiscence
• Selected infection due to medical in abdominopelvic surgical
care Postoperative hemorrhage or patients
hematoma
• Postoperative hip fracture
Postoperative physiologic and
metabolic derangements
• Obstetric trauma- vaginal delivery
with instrument
• Obstetric trauma- vaginal delivery
without instrument
• Obstetric trauma- cesarean
section delivery
• Postoperative pulmonary
embolism or deep vein
thrombasis
• Postoperative respiratory failure
• Postoperative sepsis
• Transfusion reaction
• Postoperative wound dehiscence
in abdominopelvic surgical
patients
• Birth trauma injury to neonate

Prevention Quality Indicators (PQIs)

These are defined using area population as denominator. For many conditions,
hospitalizations or ambulatory care can be avoided. To examine the health care
system as a whole, and to access the quality outpatient care these prevention quality
indicators are used. Prevention quality indicators are related to the following as
shown
• Bacterial pneumonia
• Dehydration
• Pediatric gastroenteritis
• Urinary tract infection
• Perforated appendix
• Low birth weight
• Angina without procedure
• Congestive heart failure Hypertension
• Adult asthma Pediatric asthma Chronic obstructive pulmonary disease
• Diabetes short-term complication
• Diabetes long-term complication
• Uncontrolled diabetes Lower-extremity amputation among patients with diabetes

In-patient Quality Indicators (IQIs)

These are defined using both hospital admissions and area population as
denominator. Most indicators are defined using hospital level admissions as the
denominator. These are based on existing, validated indicators and have potential to
improve internal quality.

MORTALITY RATES → Acute myocardial infarction (2 versions)

FOR CONDITIONS → Congestive heart failure
→ Gastrointestinal hemorrhage
→ Hip fracture
→ Pneumonia
→ Stroke
MORTALITY RATE FOR → Abdominal aortic aneurysm repair
PROCEDURES → Coronary artery bypass graft
→ Craniotomy
→ Esophageal resection
→ Hip replacement
→ Pancreatic resection
→ Pediatric heart surgery
HOSPITAL-LEVEL → Cesarean section delivery (primary and
PROCEDURE total) Incidental appendectomy in the
UTILIZATION RATES elderly
→ Bi-lateral cardiac catheterization
→ Vaginal birth after Cesarean section (2
versions) Laparoscopic cholecystectomy
AREA-LEVEL → Coronary artery bypass graft
UTILIZATION RATES → Hysterectomy
→ Laminectomy or spinal fusion
→ PTCA
VOLUME OF → Abdominal aortic aneurysm repair
PROCEDURES → Carotid endarterectomy
→ Coronary artery bypass graft
→ Esophageal resection
→ Pancreatic resection
→ Pediatric heart surgery
→ PTCA
CARE OF VULNERABLE PATIENTS

Definition:
A vulnerable patient is unable to protect and take care of him or herself, against
significant harm or exploitation.

The following types of patients are considered vulnerable:

• Below 12 years and above 65 years
• Terminally ill patients
• Patient with intense and chronic pain (pain more than 6)
• Women experiencing terminations and pregnancy
• Patients with emotional psychiatric disorders
• Patients receiving chemotherapy
• Patient whose immune system is compromised
• Patient suspected of drug and alcohol dependency

CARE AND POLICY FOR VULNERABLE PATIENTS

 In a hospital, all vulnerable patients will be given all-necessary care needed

with consideration.
 The first step is to identify the vulnerable patient who may require special
attention. Vulnerable patients so identified can be given a patient ID band of
orange color.
 If the patient's condition demands further care that is not available in
hospital, patient will be transferred to the other hospitals/facilities.
 During transfer, the patient's staff nurse will accompany the patient along
with the caregiver.
 If the patient's condition is critical, he will be escorted by a doctor and a nurse
while transferring from one hospital to another.
 Staff taking care of high-risk patients must have adequate training and skills.
 All healthcare providers will maintain a safe environment, related to: bed
rails, equipment, wheelchairs, fall precautions and mobility needs.
 All healthcare providers will encourage family involvement and support in
care delivery, decisions and education as appropriate.
 Special consent considerations will be taken when needed for each individual
case following the hospital-approved consent policies.
 Once the patient is stabilized with the disease process, they will be fit for the
discharge.
 The patient will be discharged with follow-up advice.
 All documentation required for the team to work and communicate
effectively in the care of high risk patients must be maintained as per hospital
documentation policy.

PREVENTION OF FALL
In order to assess the fall risk, tools used are discussed ahead. Morse fall risk
assessment is tabulated as follows:


Humpty dumpty scale for paediatrics (HDFS), is a seven- item assessment
scale developed to assess which is used to document gender, age, diagnosis,
 environmental factors, response to surgery/sedation, cognitive impairments,
and medication usage.
Obstetric fall risk assessment tool uses a scoring system that determines the
female vulnerable patient's risk for a fall and provides a structured systematic
approach for RNs to use.
Care for prevention of fall: The following measures are taken in this regard:
 Fall leaf is displayed on patient cot.
Restraints may be used to prevent fall of unconscious or mentally unstable
patients. Hospitals must have disabled-friendly environment as many
patients categorized as vulnerable may be disabled.
Such patients should be monitored more frequently for ensuring that they
are safe. They shall be accompanied by an attendant while going to
washroom or any other area.
The washroom must have grab bars, anti-skid mats and call alarm system.
While they are on bed, safety railings should be put up in place to prevent
fall from bed.
While being transported on wheelchairs or stretchers, safety belt shall be put
up
PREVENTION OF IATROGENIC INJURY
Up to 50% of adverse events that occur in hospitals are preventable, latrogenic
illnesses are most commonly associated with medications, diagnostic and
therapeutic procedures, nosocomial infections, and environmental hazards.
Healthcare practitioners ensure that the required services are provided, and
duplication of these services is also avoided too.

CARE FOR PREVENTION OF IATROGENIC INJURIES

Responsibility of healthcare team:

Interdisciplinary team, pharmacist consultation (physicians can become more aware
of adverse drug events), and acute care for all including the elderly, and advance
directives, avoidance of surgery, use of local analgesia, post-operative care of patient,
minimization of medication.

Responsibility of patient and family:

• Patient should try to understand treatments and ask questions to satisfy

doubts.  Take a note of any potential adverse effects after any procedure,
and contact a healthcare provider immediately.
• It is always good to provide medical history, list of medications and allergies.
• Communicate clearly and respectfully with your health care team. Studies
show that those who communicate nicely, tend to get better care.
PREVENTION OF IV COMPLICATION
Air embolism occurs most frequently with the use of central venous access devices
or when IV lines associated with the catheter are disconnected. Catheter-related
thrombosis arises as a result of injury to the endothelial cells of the venous wall. It
causes injury to endothelial cells of vein wall, allowing platelets to adhere and
thrombosis formed. Common medications that can cause phlebitis are diazepam,
erythromycin and tetracycline. Thrombophlebitis slows and eventually stops the flow
of infusion.
 INTERVENTIONS FOR PREVENTION OF IV COMPLICATIONS

❖ Use proper venipuncture techniques to reduce injury to the vein

❖ Use veins in the upper extremities
❖ Select veins with adequate blood volume for solution characteristics
❖ Avoid placing catheters over joint flexions
❖ Avoid multiple venipuncture
❖ Anchor cannulas securely, remove the needle
❖ Application of warm compress
❖ Continuously monitor the patient's vital signs

Interventions to take care of catheter embolism are:

✓ Discontinue the infusion
✓ Place the patient in Trendelenburg position on his left side to allow air to
enter the right atrium and disperse through the pulmonary artery
✓ Administer oxygen
✓ Notify the doctor Document the patient's condition and your intervention

Interventions to take care of hematoma are:

Inappropriate use of tourniquet, unsuccessful insertion attempts can lead to
hematoma and it can be taken care of by:
Frequent assessment of the site
Upon insertion, slowly advance the needle to prevent puncturing both vein walls
Discontinue therapy when there is edema and apply pressure for at least 5 minutes
upon removal

Interventions to take care of septicemia are:

Septicemia may be due to infection at the site of insertion of catheter because of

failure to maintain aseptic technique, poor taping, immuno compromised condition,
prolonged indwelling time of device. These can be prevented by:
▪ Culture the site and the device, monitor the patient's vital signs, administer
medications as prescribed
▪ Use scrupulous aseptic technique, secure all connections, change IV
solutions, tubing and venous access device at recommended times, use IV
filters
▪ Accurately document visual inspection and palpation data,notify the
physician Practice good hand hygiene before and after palpating. inserting,
replacing, or dressing any intravascular device
▪ Replace site, tubings and bags per policy such as change set after 72 hours,
TPN and single use of antibiotics

Interventions to take care of septicemia are:

Shock may be due to rapid introduction of a foreign substance, usually a medication,
into the circulation.
→ Stop the infusion, careful monitoring of IV flow rate and patient response,
maintain prescribed rate, know the actions and side effects of the drug being
administered, use of IV pumps when indicated and begin infusion of 5%
dextrose at keep vein open (KVO) rate in emergency cases, evaluate
circulatory and neurologic status, notify the physician.
 → Edema observed in patients is prevented by raising the head of the bed,
slow the infusion rate, administer oxygen as needed, notify the doctor and
administer medications as ordered.
→ To take care of allergic reactions, stop the infusion immediately and infuse
normal saline solution, maintain a patent airway, notify the doctor,
administer antihistaminic steroid, anti-inflammatory, and antipyretic drugs,
as ordered, give 0.2-0.5 ml, of aqueous epinephrine subcutaneously and
repeat at 3-minute intervals and as needed, as ordered
CARE OF LINES, DRAINS AND TUBING

• Infusion lines are taken care by following measures:

• Disinfect the infusion lines with sterile gauze and 70% alcohol daily.
• Handle with gloved hands.
• After collection of blood samples, flush the lines with heparinized saline to
keep these patent and free from blocking or (use 0.9% normal saline
solution).
• Clean the cap with 70% alcohol before connecting the three ways valve.
• Use aseptic techniques during all procedures.

Drain is a tube used to remove pus, blood or other fluids from a wound. The drain is
fixed by a suture at the end of the wound and a safety pin must be placed through
the end to prevent the drain slipping inwards.

The care of drains is made with the help of the following:

Connect drain to suction source.
Ensure that the drain is secured and the system is intact to prevent
dislodgement and infection or irritation of surrounding skin.
Accurately measure and record drainage output.
Monitor changes in character or volume of fluid; identify any complications
resulting in leaking fluid (e.g. bile or pancreatic secretions) or bleeding.

 Replace fluid loss through drain by additional IVFs. Drains should be removed
once the drainage has stopped or becomes less than 25 mL/day. Drains can
be 'shortened by withdrawing approximately 2 cm per day, allowing the site
to heal gradually.
 Drains that protect post-operative sites from leakage form a tract and are
usually kept in place for one week.
 Emptied every 8 hours or as needed, mark and date the output every 8 hours.
Change when full or not working, record drainage in ostomy bag or number
of dressing changes if no bag is used.

? Hickman Catheter

Wash and disinfect your hands with 70% alcohol, wear PPE before entering
the patient's room (Isolation Room), disinfect your hands again.
Record chest tube output of past 24-hourperiod every morning, ensure that
clamp is open for drainage, consider removing chest tube once output is less
than 200 ml. in 24- hour-period.
Remove sutures around chest tube while holding chest tube steadily in place
Instruct patient to perform valsalva maneuver. Withdraw chest tube quickly
while simultaneously covering entrance site with Vaseline gauze.
 Tightly tape 4 x 4 gauze over entire entrance site ensuring that no air is able
to leak into the chest tube wound.
Document chest tube removal.

RESTRAINT POLICY AND CARE-PHYSICAL AND CHEMICAL

(Ministry of Health and Family Welfare)

Physical restraints are:

Applied when behavioral expressions of distress and/or a change in medical status
occur. It should be an intervention focused at managing the concerned behavior for
a given point of time. This policy applies to all health workers engaged in patient
safety processes in a hospital.
This helps:
→ To prevent interference/obstruction with medical treatment (such as self
extubation and intubation).
→ To protect medical devices (such as intravenous lines, in dwelling urinary
catheters, and feeding tubes).
→ To prevent falls and injury of any kind.
→ To control disruptive behavior (such as agitation, wandering, and
combativeness). To preclude the possibility of harming self, staff and other
patients.

Policy
Restraint may only be used to ensure the immediate physical safety of the patient,
staff or others and must be discontinued at the earliest possible time. Alternative and
nonphysical interventions are attempted prior to use of restraints. Patient's dignity
should be maintained during restraint.

Physician orders
✓ Restraints shall be applied with only a physician's order that defines the
reason for restraint, less restrictive alternatives attempted/considered, type
of restraint to be used, and duration for which the restraint may be applied.
✓ The time limit shall not exceed one calendar day, after which new orders are
required if restraints must be continued.
✓ In emergency situations, (ie., self-extubation), if the physician is not available
to issue the restraint order,
✓ restraint is initiated by a registered nurse based on an appropriate
assessment of the patient.
✓ In that case, the physician is notified within 12 hours of the initiation of
restraint and a written order is obtained from that physician and entered into
the patient's medical record.

Ongoing care and monitoring:

Patients shall be monitored at least every 2 hours to determine the following and
make adjustments as necessary:
➢ Position, circulation, and skin integrity of restrained area
➢ Maintenance of privacy and comfortable body and room temperature.
➢ Appropriate application of the device(s).
➢ Toileting and fluid needs.
➢ Nutrition.
 ➢ Range of motion
➢ Restraint reduction or removal

Documentation in the medical record shall reflect the required monitoring.

✓ Patients shall be positioned for safety and comfort. Patients shall have active
or passive range of motion to the affected joint(s) as medically necessary.
✓ The patient and/or family, whenever possible, shall be educated regarding:
Reason for restraint
✓ How the patient/family can avoid restraint
✓ Criteria necessary for release from restraint.

Reassessment of use:
The Consultant, in collaboration with the health care team, shall evaluate the patient
at
 The end of the prescribed duration of restraint to determine the need for
continued use
 Of the device(s). If restraint remains necessary, the order must be renewed.
 In the absence of order renewal, restraints shall be removed by the responsible
Nursing staff.
 Reapplication of Restraint
 The patient is continually assessed to ascertain his or her condition and to
determine if restraint can be discontinued.
 If a patient, who was recently restrained, must be placed back into restraints, new
physician order is required.
 A temporary release that occurs for the purpose of caring for a patient's needs
(e.g., toileting, feeding, and range of motion) is not considered a discontinuation of
the Intervention.

Assessment, care, and monitoring:

Each aspect of patient assessment and care is considered complete

Position: Proper alignment of the restrained limb(s) is maintained.

Circulation: The affected limb(s) has been checked and device application has been
determined not to impair circulation to the extremity:
• Nail bed blanched in less than 3 seconds
• Pulse is present above and below restraint.

Skin integrity: Skin integrity has been checked under and around the device(s), and
at all bony prominences and no pressure or reddened areas have developed.
• The patient is covered either by gown, sheet, or curtain and is protected from public
view.
• Device application: The device is applied according to the manufacturer's guidelines
and in a manner that is secure but not tight. Straps are secured to bed or chair frame
(never to side rails or other moveable parts); and quick release is possible.
• Fluid needs: Fluids are administered as ordered by the physician. If the patient is
not on fluid restriction, oral fluids are offered at least every two hours. If the patient
is nothing by-mouth (NPO), oral care is provided at least daily to maintain integrity of
oral mucosa.
• Toileting needs: Elimination needs are attended to, either by foley catheter (only if
ordered for other medical necessity) or by offering the patient the bed pan or
assistance to bathroom or bedside commode chair.
• Nutrition offered: Nutritional needs are met as ordered by the physician. If oral
intake is allowed, the patient is offered and assisted with meals and snacks.
• Range of motion: Active or passive range of motion in the affected limb(s) is
completed either by the patient or the caregiver. For patients requiring limb
restraints, ROM is recommended at least every 2 hours.
• Evaluation for restraint reduction or removal: Need for the use of restraint(s) is
evaluated frequently (at least every two hours) and restraints are discontinued at the
earliest possible time

BLOOD AND BLOOD TRANSFUSION POLICY

Confirm the diagnosis of thalassemia and appropriate clinical and laboratory for
transfusion.
Use careful donor selection and screening, favouring voluntary, regular, non-
remunerated blood donors.
Before first transfusion, perform extended red cell antigen typing of patients at
least for C, E, and Kell.
At each transfusion, give ABO, Rh(D) compatible blood. Matching for C, E and Kell
antigen is highly recommended.
Before each transfusion, perform a full cross-match and screen for new antibodies,
or in centres that meet regulatory requirements, perform an electronic cross-match.
Use leucoreduced packed red cells. Pre-storage filtration is strongly recommended,
but blood bank pre-transfusion filtration is acceptable. Bedside filtration is only
acceptable if there is no capacity for pre-storage filtration or blood bank
pretransfusion filtration.
Use washed red cells for patients who have severe allergic reactions.
Transfuse red cells stored in CPD-A within one week of collection and red cells
stored in additive solutions within two weeks of collection.
Transfuse every 2-5 weeks, maintaining pre-transfusion haemoglobin above 9-10.5
g/dL. or higher levels (11-12 g/ dl.) for patients with cardiac complications.
Keep a record of red cell antibodies, transfusion reactions and annual transfusion
requirements for each patient.
Keep the post-transfusion hemoglobin below 14-15 g/dl.

PREVENTION OF DEEP VEIN THROMBOSIS

✓ General measures to help lower the risk of developing a DVT are to take
regular exercise and maintain a healthy body weight.
✓ When certain medical conditions or inherited disorders are present, long-
term anticoagulant treatment to minimize the risk of DVT may be
recommended.
✓ Patient is advised to use graduated compression stockings or the use of a
pneumatic compression device, and administration of the correct dose of
anticoagulation agent (heparin or LMWH).
✓ Drinking plenty of non-alcoholic fluids to avoid dehydration.
✓ Leg and ankle exercises along breathing exercises encourage blood flow in
the legs.
 ✓ People at high risk of DVT may be prescribed aspirin or anticoagulant tablets
or injections whilst travelling

SHIFTING AND TRANSPORTING OF PATIENTS

General instructions in moving and lifting patients are as follows:

✓ Seek assistance when lifting or moving patients. Maintain a good anatomical
position of the body and use longest and strongest muscles of extremities for
vigorous activities.
✓ Keep the object or patient close to the body to prevent unnecessary strain
on the muscle.
✓ Place the feet apart to provide a wide base of support and flex the knees to
come closer to patient/object.
✓ Slide, roll, push or pull an object rather than lift it in order to reduce the
energy needed to lift the weight against pull of gravity.
✓ Avoid disturbances/interruptions in path of the movement of patient.
✓ Move obese patients by sliding them rather than lifting them.
✓ The height of the bed should be adjusted to a height that allows the nurse to
keep her back as erect possible while moving patient to avoid back injury.
✓ The patient is moved to the edge of the bed before he is lifted from bed. This
helps the nurse to keep her trunk more erect.
✓ When moving a patient by more than one nurse, each nurse assumes the
responsibility for supporting one of the patient's body sections. In order to
coordinate the movements of the nurses and to maintain the patient's body
in correct alignment, the nurse gives signal by counting 1...2...3 with each
activity of procedure.
✓ Unless contraindicated, encourage the patient to use his abilities as much as
possible.
✓ Observe the patient for the symptoms of orthostatic hypotension. E.g.
fainting, dizziness, sweating, etc.
✓ Always lock the wheels of the bed, stretcher or wheel chair while transferring
the patients so as to increase the maximum static friction between the
wheels and the floor.

TRANSPORTING THE INJURED PERSON

❖ The position of the casualty should not be changed unnecessarily.
❖ If the casualty is to be removed to the hospital, arrange for an ambulance.
❖ Never move a severely injured person unless there is immediate danger to
life, it is better to leave the casualty undisturbed, send for help, and provide
first aid on the spot.
❖ Never attempt to move a seriously injured casualty by your own if help is not
available.
❖ Watch the general conditions of the person during transportation (Any
haemorrhage/ deterioration in the general condition). The casualty's airway
should stay open.
❖ If there is bleeding, should be controlled. The casualty most maintain an
accurate position. There should be regular monitoring of the condition of the
casualty.
❖ The supporting bandages and dressing should stay in place and remain
effectively applied.
❖ The chosen transfer method must be secure, comfortable and prompt.
 ❖ The body of the patient is transferred as one unit and the head side of the
casualty is carried by taller first aider.

METHODS OF TRANSFER

o For a single person (One first aiders) are - Drag method. ankle pull/leg pull
method, shoulder pull/collar pull method, blanket pull method, cradle
method, fireman’s carry, pick-a-back carry and human crunch method.
o For two persons (Two first aiders): Twohanded seat, double human crutch,
fourhanded seat, wheel chair method, chair method and stretchers

SURGICAL SAFETY
CARE COORDINATION EVENT RELATED TO MEDICATION
RECONCILIATION AND ADMINISTRATION

✓ Understand how three particular key drug classes correspond with many
ADEs: Anticoagulants (bleeding) opioids (accidental overdoses, sedation, and
respiratory depression) and diabetes agents (Hypoglycemia), Due as the high
risks of inaccurate or missing information, provides must have point of-care
 access to comprehensive, real-time actionable pharmacy data to help ensure
more complete documentation and reduce ADEs in the process.
✓ Commit extra resources toward keeping certain high-risk populations, such
as the elderly and paediatric patients, safe.

Identifying the appropriate medication, dose, and frequency. Mistakes can often
occur in this point to the reconciliation process, often attributable to gaps in
information.

✓ Capture all medications and their details: While documenting the details of
a patient's prescription, medications is critical, also ask for information about
all other medications, such as vitamins, herbals, health supplements,
nutraceuticals, respiratory therapy-related medications (e.g.. inhalers),
vaccines, and intravenous solutions. Be sure to capture the medication name,
strength, dose, route, formulations, frequency, and most recent dose taken.
✓ Help patient recollect the memory: Patients who take multiple medications
can struggle to remember all of them. Probing questions can help with
memory recollection. Types of probing questions include open-ended
questions, close ended questions, and questions about specific conditions.

Providers must take health literacy into consideration when working on developing
an accurate medication list and educating patients on their regimen and potential
risks. Specifically, it can be helpful to target efforts on improving communication.

✓ Focus on high-risk situations: One high-risk situation for medication

reconciliation errors occur when patients are transferred from one
organization to another, meaning that their information must be shared
between separate organizations.
✓ Avoid data entry inaccuracies, Start the process before the patient arrives:
Prior to scheduled visits or surgeries, remind patients to bring a current list
of their medications to the appointment.
✓ Put pharmacists or registered nurses in charge: At each transition, ask a
pharmacist or registered nurse (RN) with managing medication
reconciliation. Pharmacists and RNs are uniquely qualified to lead
interdisciplinary efforts to maintain an effective medication reconciliation
process.
✓ Separate medication reconciliation from rooming tasks to lessen the
burden.
✓ Educate and involve patients: Make sure patients understand the
importance of an accurate medication list. Ways to provide this information
include using posters, handouts, and verbal prompts at check-in.
✓ Be consistent: It is vital to proper medication reconciliation

To avoid communication errors, follow these guidelines

Don't assume without confirming: When it comes to provider-to-provider

communication failures, don't assume other members of the team have all the
significant patient information they need. Speak and discuss the patient's
information.
Clarify: Whether you are the giver of the receiver of information, failing to clarify an
order, a statement made verbally, a piece of medical documentation, or a non- verbal
gesture can lead to medical errors. Before giving information, work to proactively
promote understanding by asking questions in kind way.

Listen: Put your thoughts on hold before responding and take time to understand the
perceptions of others.

Give what you would hope to receive: At work, as in life, we want to be

communicated within a way that is respectful, timely, clear, complete, and kind. In
the healthcare setting, ensure giving and receiving such communication respectfully,
timely, clearly and completely.

Ensure that your entries in the EMR are accurate and complete: Prior to finalizing
your medical record entries. review them as diligently as you would an important
article or letter you might write.

Focus first on areas where risk is highest: The top two areas of vulnerability are
surgery and emergency departments. These two areas must be focused.

Be conscious of "fault lines": A brief communication about potentially life-altering

moment in case of critical patient must be communicated accurately, timely, and
clearly. Poor communication can affect a patient's healthcare outcomes.

Build infrastructure: Consider implementing communications training. Meaningful

and lasting culture change takes time so keep patience.