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‘Patient Safety is Everyone’s Responsibility’

Guidance Document

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Table of Contents

1. Background and Need ---------------------------------------------------------------------------- 4

2. Purpose and scope ---------------------------------------------------------------------------------5

3. Introduction------------------------------------------------------------------------------------------6

4. Patient safety fundamental concept-----------------------------------------------------------7

5. 10 facts about patient safety---------------------------------------------------------------------8

6. Cost of Poor-Quality Health Services-----------------------------------------------------------9-10

7. Vulnerable Patients--------------------------------------------------------------------------------11

8. Cause of Healthcare errors-----------------------------------------------------------------------12

9. Risk factor affective patient safety and key facts-------------------------------------------13-14

10. Adverse event---------------------------------------------------------------------------------------16-20

11. Suggestive solutions to reduce medication error-------------------------------------------21-23

12. Safe Surgery------------------------------------------------------------------------------------------24-25

13. Problems related to Patient Identification----------------------------------------------------26-27

14. Communicating Clearly and Effective to Patients-------------------------------------------27-28

15. Hospital Acquired Infection-----------------------------------------------------------------------29

16. Achieving total system safety--------------------------------------------------------------------30

17. Reference---------------------------------------------------------------------------------------------31-32

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Abbreviations: -

1. AB-PMJAY – Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

2. OT – Operation Theatre

3. ICU- Intensive Care Unit

4. SNCU- Sick Newborn Care Unit

5. NICU – Neonatal Intensive Care Unit

6. PICU- Pediatric Intensive Care Unit

7. HBsAG- Hepatitis B Surface Antigen

8. HCV- Hepatitis C Virus

9. BHT- Bed Head Ticket

10. IPHS – Indian Public Health Standards

11. NABL –National Accreditation Board for Testing and Calibration Laboratories

12. NABH- National Accreditation Board for Hospitals and Healthcare Providers

13. NQAS- National Quality Assurance Standards

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Background

Ayushman Bharat, a flagship scheme of the Government of India, was launched as recommended by the

National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has

been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which

is to "leave no one behind." The major focus of AB PM-JAY is to cover secondary and tertiary care for

beneficiaries near their locations. Till date around 24000 hospitals are empaneled in PMJAY. Ensuring

quality and patient safety is very important during care.

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Purpose and scope

Every point in the process of care can contain an inherent risk. Its nature and scale vary greatly based on the context of health care provision and its availability, infrastructure and resourcing within and across countries. The challenge for all health systems, and all organizations providing health care, is to maintain a heightened awareness to detect and ameliorate safety risks as well as address all sources of potential harm. This document will give brief idea about patient safety, adverse event, medication error etc.

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Introduction

atient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centered. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient. It encompasses different aspects that are crucial to delivering quality health services. It is about safe surgical care, safe childbirth, injection safety, blood safety, medication safety, medical device safety, safe organ, tissue and cell transplant, bio-medical waste management, prevention of healthcare associated infections and much more. Failure to deliver safe care is attributed to unsafe clinical practices, unsafe processes and poor systems and processes.

Patient safety has been increasingly recognized as an issue of global importance and in 2002, WHO Member States agreed on a World Health Assembly resolution on patient safety. In recent years, there is growing recognition that patient safety and quality of care are critical dimensions of Universal Health Coverage (UHC).

P Despite progress in the past 15

years, patient safety remains an

important public health issue.

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Patient Safety - a fundamental component for Universal Health Coverage

Safety of patients during the provision of health services that are safe and of high quality is a prerequisite for strengthening health care systems and making progress towards effective universal health coverage (UHC) under Sustainable Development Goal 3 (Ensure healthy lives and promote health and well-being for all at all ages).

Target 3.8 of the SDGs is focused on achieving UHC “including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” In working towards the target, WHO pursues the concept of effective coverage: seeing UHC as an approach to achieving better health and ensuring that quality services are delivered to patients safely.

It is also important to recognize the impact of patient safety in reducing costs related to patient harm and improving efficiency in health care systems. The provision of safe services will also help to reassure and restore communities’ trust in their health care systems.

“To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed”.

Important

Definitions in

Patient Safety (Based

on AHRQ PSNet Glossary [nd],

Runciman et al. 2009, and

others as noted)

Error: An act of

commission (doing

something wrong) or

omission (failing to do the

right thing) that leads to an

undesirable outcome or

significant potential for

such an outcome. For

instance, ordering a

medication for a patient

with a documented allergy

to that medication would

be an act of commission.

Failing to prescribe a

proven medication with

major benefits for an

eligible patient (e.g., low-

dose unfractionated

heparin as venous

thromboembolism

prophylaxis for a patient

after hip replacement

surgery) would represent

an error of omission.

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Facts on patient safety (Source -WHO)

Fact 1: One in every 10 patients is harmed while receiving hospital care

Fact 2: The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability across the world

Fact 3: At least 1 out of every 7 Canadian dollars is spent treating the effects of patient harm in hospital care

Fact 4: Investment in patient safety can lead to significant financial savings

Fact 5: Unsafe medication practices and medication errors harm millions of patients and costs billions of US dollars every year

Fact 6: Inaccurate or delayed diagnosis is one of the most common causes of patient harm and affects millions of patients

Fact 7: Hospital infections affect up to 10 out of every 100 hospitalized patients

Fact 8: More than 1 million patients die annually from complications due to surgery

Fact 9: Medical exposure to radiation is a public health and patient safety concern

Harm: An impairment of

structure or function of the

body and/or any deleterious

effect arising there from,

including disease, injury,

suffering, disability and

death, and may be physical,

social, or psychological.

Just culture: A culture

that recognizes that

individual practitioners

should not be held

accountable for system

failings over which they

have no control. A just

culture also recognizes

many individual or “active”

errors represent predictable

interactions between

human operators and the

systems in which they work.

However, in contrast to a

culture that touts “no

blame” as its governing

principle, a just culture does

not tolerate conscious

disregard of clear risks to

patients or gross

misconduct (e.g., falsifying a

record, performing

professional duties while

intoxicated).

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Cost of Poor-Quality Health Services

According to The Lancet Global Health commission on High Quality Health Systems, whose report has been published on September 6, 2018.(Source: The Lancet)

• 2.4 million Indians die of treatable conditions every year, the worst situation among 136 nations . Poor care quality leads to more deaths (1.6 Million) than non-utilization or access to healthcare (0.838 Million)

• According to an estimate by Deccan Herald, basis on the same report 4,300 Indians die daily due to poor hospital care

• The over eight million excess deaths globally due to poor quality health systems led to economic welfare losses of $6 trillion in 2015 alone.

0 5 10 15 20

Avertable deaths

Deaths preventable by…

Deaths amenable to…

Deaths due to use of poor…

Deaths due to non…

Avertabledeaths

Deathspreventable by public

healthinterventio

ns

Deathsamenable

tohealthcare

Deaths dueto use of

poorquality

services

Deaths dueto non

utilizationof healthservices

South asia 4.92 1.9 3.02 1.94 1.07

World 15.6 7 8.64 5.05 3.6

Amenable deaths to healthcare (In Millions)

Safety culture: The safety culture

of an organization is

the product of

individual and

group values,

attitudes,

perceptions,

competencies, and

patterns of

behavior that

determine the

commitment to,

and the style and

proficiency of, an

organization’s

health and safety

management.

Organizations with

a positive safety

culture are

characterized by

communications

founded on mutual

trust, by shared

perceptions of the

importance of

safety, and by

confidence in the

efficacy of

preventive

measures (Health

and Safety

Commission 1993).

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(Source – The lancet)

Can you imagine?

• Baby in Hospital Allegedly Bitten by Rats-- 2015

• Child theft in Delhi's DDU hospital caught on camera– 2013

• 90 killed in hospital fire (AMRI) Calcutta – 2011

• Baby burnt to death in incubator while nurse sleeps -- 2010

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Vulnerable patients:

Old age persons New born/neonates Differently abled persons

Special Child Intensive Care Unit Patients

• Patients without attendants

• Patients under sedation or other medication affecting CNS

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Causes of Healthcare errors

Human Factors • Variations in healthcare provider training & experience, fatigue,

depression and burnout • Diverse patients, unfamiliar settings, time pressures • Failure to acknowledge the prevalence and seriousness of medical errors • Increasing working hours of nurses

Medical Complexity • Complicated technologies, powerful drugs • Intensive care, prolonged hospital stays

System Failures • Poor communication, unclear lines of authority of physicians, nurses, and other care providers • Complications increase as patient to nurse staffing ratio increases • Disconnected reporting systems within a hospital: fragmented systems in which numerous hand-offs

of patients results in lack of coordination and errors • Drug names that look alike or sound alike • The impression that action is being taken by other groups within the institution • Reliance on automated systems to prevent error • Inadequate systems to share information about errors hamper analysis of contributory causes and

improvement strategies • Cost-cutting measures by hospitals in response to reimbursement cutback • Environment and design factors. In emergencies, patient care may be rendered in areas poorly suited

for safe monitoring • Infrastructure failure: According to the WHO, 50% of medical equipment in developing countries is

only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.

“The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training”.

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Risks / Factors affecting the safety of patients in the hospital (but not limited to this):

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Key facts

• The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world.

• In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable.

• Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths.

• Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs.

• Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

• In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events.

• Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes.

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Adverse Events

The most commonly used definition of harm in patient safety is the ‘adverse event’. This concept has originally described by the authors of the Harvard Medical Practice Study. They defined an adverse event as:

“An unintended injury caused by medical management rather than by the disease process and which is sufficiently serious to lead to prolongation of hospitalization or to temporary or permanent impairment or disability to the patient at time of discharge or both”.

Types of Adverse Events:

The most frequent adverse events are-

• Surgical Complication: A surgical complication is any undesirable, unintended and direct

result of an operation affecting the patient that would not have occurred had the operation gone well as could reasonably be hoped

• Healthcare/hospital acquired Infection: A hospital-acquired infection or nosocomial

infections or healthcare-associated infections (HAI), are infection(s) acquired during the process of receiving health care that was not present during the time of admission Adverse drug events.

• Medication related errors/events: o Adverse drug events: An adverse drug event is “an injury resulting from the use of a drug.

This includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug (including dose reductions and discontinuations of drug therapy).”1 Adverse Drug Events may result from medication errors but most do not.

o Medication error: Medication errors are mishaps that occur during prescribing, transcribing, dispensing, administering, adherence, or monitoring a drug. Examples of medication errors include misreading or miswriting a prescription.

*Source –World Health Organization, Patient Safety- Making health care safer

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Medication errors leading to the death or serious disability of patient due to:

o Omission error o Dosage error/dose preparation error o Wrong time /wrong rate of administration /wrong administrative technique/route

error/wrong patient o Monitoring/Compliance error

Problem in management of medication:

• Prescription/orders not clearly written

• No prescribed format for writing orders

• Medication is administered based on memory

• Records not kept for medication management

• Dosages and time of admiration not recorded

• High Patient load

Incidents and errors:

Near miss - An event or situation that could have

resulted in an accident, injury, or illness, but did not, either by chance or timely intervention. It is a serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted.

Sentinel event - Unexpected incident involving death or serious physical or psychological injury, or

the risk thereof. The fundamental objective of sentinel event reporting is corrective in nature and the identification of appropriate actions to prevent recurrence.

Hand

writing not

readable

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Where do errors occur:

*Source - Goulding. Arch Intern Med. 2004;164:305-312

High alert medicines:

• Medication that has a higher likelihood of causing injury if they are misused

• Errors with these medications are not necessarily more frequent – just that their consequences may be more devastating

High-risk medications: High risk

medications are drugs that have a heightened risk of causing significant patient harm when they are used in error

• Drugs with narrow therapeutic range –Antiepileptic drugs, lithium

• Controlled substances - Morphine, diazepam, psychotropic medicines, - Look-alike & sound-alike (LASA)medicines

Some high alert medicines:

- Concentrated electrolytes

-Insulin

-Anticoagulants

-Chemotherapy

-IV digoxin

-Opiates

Some Sound Alike

medicines:

- Lante Vs. Lantus

- Pam Vs. Pan

- Daonil Vs. Diavol

- Glynase Vs. Zinase

_ Isoprin Vs. isoptin

- Lasix Vs. Lorax

- Arkamin Vs. Artamin

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Phenytoin – dose 300

mg ‘or’ 100 mg??

High alert drugs –

Always cross out and

re write (if any

changes)

Poor storage- Mixing of drugs

One of the potential causes of

medication error

Example of Look A like drugs

(Thousands more)

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Uniqueness about the ICU and medication error –

*Source – WHO

Complex environment:

• High-risk patients

• Difficult working conditions/High stress

• Emergency admissions

• Multiple care providers – Challenges the integration of different care plans

• Reliance on sophisticated technologies & equipment

Types of medications:

• Twice as many medicines compared to other areas.

• Frequent use of boluses and infusions

• IV Programming errors of infusion pumps

• Wight- based infusions, need mathematical calculations

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Suggestive Solutions to reduce medication error (But not limited to this):

For LASA drugs

• Identify high alert drugs in the hospital and circulate a list in all clinical areas

• Annually review a list of look-alike/sound-alike drugs

• Keep high alert drugs separately with limited access

• Recommended dosages and concentration calculations should be displayed at the nursing station

• Double verification before administration

• Develop policy for verbal orders

• A separate space should ideally be earmarked for the preparation of injections / drips

For High alert/risk medicines –

• Make a list drugs and display prominently at all clinical care locations

• Doubly verify these before dispensing/ administration

• No verbal orders for high alert drugs except in emergency

• Store in different locations in pharmacies and patient care units

• Control of concentrated electrolyte solutions & the use of anticoagulation therapy

• Label high alert medicines

• Make a note of all Drug Allergies & Write in Bold

K

5S- Sort/Set in Order/Shine/Standardize/Sustain – A system for organizing work spaces so work can be performed efficiently, effectively, and safely

Labeling/Marking of high alert drugs

Every things is on the place

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Develop a list of Error prone abbreviations, symbols and dose designations:

• The symbols “>” and “<” -<10 - mistaken as ‘40’

• Give space between drug and strength - Tegretol300 mg misread as Tagretol 1300 mg, Inderal40 mg misread as inderal 140 mg

• Mix-ups: between "l" and the number "1; "O“ &"0,“; "Z“ & "2,“; "1"& "7.“

Documentation:

• Legible Real time record – properly maintain

• Do not alter notes. Do not temper/obliterate the original note

• If mistake discovered later (inaccurate, misleading or incomplete), insert an additional note as a correction with date

• For altering cross original words/ statements by a single stroke of pen, so that crossed text is still legible & re-write new one – date & sign both

“An unsigned medical record

has no legal validity” –

National commission

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*Source - WHO

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*Source - Toft B. External inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham. London: Department of Health, 2001.

Safe surgery

Why safe surgery is important

Surgery is often the only therapy that can alleviate disabilities and reduce the risk of death from common conditions. Every year, many millions of people undergo surgical treatment, and surgical interventions account for an estimated 13% of the world’s total disability-adjusted life years (DALYs). While surgical procedures are intended to save lives, unsafe surgical care can cause substantial harm. Given the ubiquity of surgery, this has significant implications:

• the reported crude mortality rate after major surgery is 0.5-5%;

How things go wrong?

‘Mr. David James…was prepared for an intrathecal (spinal) administration of chemotherapy as part

of his medical maintenance program following successful treatment of leukemia. After carrying out

a lumbar puncture and administering the correct cytotoxic therapy (Cytosine) under the supervision

of the Specialist Registrar Dr Mitchell, Dr North, a Senior House Officer, was passed a second drug

by Dr Mitchell to administer to Mr. James, which he subsequently did. However, the second drug,

Vincristine, should never be administered by the intrathecal route because it is almost always fatal.

Unfortunately, whilst emergency treatment was provided very quickly in an effort to rectify the

error, Mr. James died some days later’

Professor Brian Toft was commissioned by the Chief Medical Officer of England to conduct an

inquiry into this death and to advise on the areas of vulnerability in the process of intrathecal

injection of these drugs and ways in which fail-safes might be built in. The orientation of the

inquiry was therefore, from the outset, one of learning and change. We will use this sad story,

and Brian Toft’s thoughtful report, to introduce the subject of analyzing cases. Although the

names of those involved were made public, I have changed them in the narrative as identifying

the people again at this distance serves no useful purpose. This case acts as an excellent, though

tragic, illustration of models of organizational accidents and systems thinking.

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• complications after inpatient operations occur in up to 25% of patients; • in industrialized countries, nearly half of all adverse events in hospitalized patients are

related to surgical care; • at least half of the cases in which surgery led to harm are considered preventable; • mortality from general anesthesia alone is reported to be as high as one in 150 in some parts

of sub-Saharan Africa. For the purpose of introducing the concept surgical safety WHO has undertaken a number of global and regional initiatives to address surgical safety. Below is the surgical safety checklist developed by WHO that can be used:

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Problems related to Patient Identification:

Throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. Between November 2003 and July 2005, the United Kingdom National Patient Safety Agency reported 236 incidents and near misses related to missing wristbands or wristbands with incorrect information. Patient misidentification was cited in more than 100 individual root cause analyses by the United States Department of Veterans Affairs (VA) National Center for Patient Safety from January 2000 to March 2003.

The major areas where patient misidentification can occur include drug administration, phlebotomy, blood transfusions, and surgical interventions. The trend towards limiting working hours for clinical team members leads to an increased number of team members caring for each patient, thereby increasing the likelihood of hand-over and other communication problems.

Suggested Actions:

The following strategies should be considered:

1. Ensure that health-care organizations have systems in place that: a) Emphasize the primary responsibility of health-care workers to check the identity of patients

and match the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care is administered.

b) Encourage the use of at least two identifiers (e.g. name and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care. Neither of these identifiers should be the patient’s room number.

c) Standardize the approaches to patient identification among different facilities within a health-care system. For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g. name and date of birth) could be written, or implementation of biometric technologies.

d) Provide clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name. Non-verbal approaches for identifying comatose or confused patients should be developed and used.

e) Encourage patients to participate in all stages of the process. f) Encourage the labeling of containers used for blood and other specimens in the presence of the

patient. g) Provide clear protocols for maintaining patient sample identities throughout pre-analytical,

analytical, and post-analytical processes. h) Provide clear protocols for questioning laboratory results or other test findings when they are

not consistent with the patient’s clinical history. i) Provide for repeated checking and review in order to prevent automated multiplication of a

computer entry error. 2. Incorporate training on procedures for checking/ verifying a patient’s identity into the orientation

and continuing professional development for health-care workers.

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3. Educate patients on the importance and relevance of correct patient identification in a positive fashion that also respects concerns for privacy.

Communicating Clearly and Effectively to Patients

Hospitalized patients may encounter two to three different shifts of staff each day, as well as various physicians, nurses, and teams making rounds and other staff administering tests or providing treatment. In ambulatory settings in various locations, a patient may see a primary care provider as well as different specialists, along with staff associated with each of them.

As a result, a patient often must piece together communications of varying quality to assemble a picture of his or her health status—a picture that still likely lacks the proper context, completeness, and accuracy. In some cases, this unclear picture can result in serious problems. Inadequate communication can lead to malpractice claims, patient harm, and/or death.

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Common communication shortcomings or challenges

The factors highlighted below are common contributors to communication lapses that can lead to suboptimal patient health outcomes:

1. Inadequate handovers: Inadequate handover communication, also referred to as handoff communications or transitions of care, is a major factor contributing to adverse events, including sentinel events causing significant harm or death to patients. These handovers occur between health care practitioners (for example, physician to physician, physician to nurse, nurse to nurse, and so on); between different levels or locations of care in the same hospital (for example, emergency department to surgery); between providers at two different organizations (for example, hospital to home care); and between health care practitioners and the patient and family (for example, at discharge).

2. Inadequate discharge planning or instructions: Discharging a patient without a well-considered plan can lead to readmission, lack of adherence to the plan, and difficulty with managing medications and follow-up treatments. A common mistake by providers is giving patients information including complex and unfamiliar terminology shortly before discharge, without taking the time to explain it and make sure the patient understands it. Providers working in understaffed organizations can find themselves under pressure to discharge patients “quicker and sicker” without a detailed discharge plan.

3. Cultural barriers: Providing efficient and effective care requires having conversations in which the provider and patient both understand the meaning of words, concepts, and metaphors. Establishing this kind of effective communication often requires a provider to share cultural knowledge with a patient. Bridging the cultural gap often requires extra effort or resources. Cultural differences also affect the working relationships between providers, as physicians and nurses, for example, sometimes have different value systems relating to how patients are cared for and treated.

4. Age-related challenges: In the healthcare setting a healthcare worker has to deal with both children and elderly. Both fall at opposite ends of the spectrum. There are particularly unique challenges associated with communicating with adolescents. For example, adolescents may not readily disclose information for fear of being judged. On the other hand, some elderly patients may have cognitive deficits or hearing disabilities, which make communication more challenging. Multiple comorbidities also contribute to miscommunication between caregivers and elderly patients. Effective communication with patients and families is particularly important at the end of life, especially when communicating with families about withdrawing of life-sustaining treatment.

5. Errors in medical orders and test results: Verbal orders or test results, given both in person and over the telephone to patients and fellow providers, are another type of error-prone communication. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order or result.

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Hospital-Acquired Infections:

Types of Hospital acquired infections:

• Central Line-Associated Blood Stream Infections

• Catheter-Associated Urinary Tract Infections

• Ventilator-Associated Pneumonia

• Surgical Site Infections

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References

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http://www.iarmm.org/IESRE2012May/Vincent_Essentials.pdf

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Report of an Expert Panel Convened by The National Patient Safety

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Patient-Safety-Improvement.aspx

14. Safe Surgery - https://www.who.int/patientsafety/topics/safe-surgery/en/

15. Problems related to patient identification - https://www.who.int/docs/default-

source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution2-patient-

identification.pdf?sfvrsn=ff81d7f9_2#:~:text=STATEMENT%20OF%20PROBLEM%20AND%20IMP

ACT,infants%20to%20the%20wrong%20families.

16. Communicating Clearly and Effectively to Patients -

https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-

final_(1).pdf

17. Hospital-acquired infections -

https://www.who.int/csr/resources/publications/whocdscsreph200212.pdf