patient guide

IMAM Reza Hospital Kermanshah
Nullam euismod commodo

patient safety


Patient safety is a global health concern, affecting patients in all health care settings, whether in developed or developing countries. WHO has recognized the importance of patient safety and prioritized it as a public health concern.

In response to the pressing need for the development of interventions that address lapses in patient safety, the WHO Regional Office for the Eastern Mediterranean launched the patient safety friendly hospital initiative. This initiative involves the implementation of a set of patient safety standards in hospitals. Compliance with the standards ensures that patient safety is accorded the necessary priority and that facilities and staff implement best practice.

Patient safety friendly hospital assessment

Patient safety standards are a set of requirements that are needed for the establishment of a patient safety program at the hospital level. They provide a framework that enables hospitals to assess patient care from a patient safety perspective, build a capacity of staff in patient safety and involve consumers in improving health care safety.

Patient safety friendly hospital assessment is a mechanism developed to assess patient safety in hospitals. It provides institutions with a means to determine the level of patient safety, whether for the purpose of initiating a patient safety program or as part of an ongoing program. The assessment is conducted through an external, measurement-based evaluation although it can also be conducted internally for self-assessment. It is voluntary. For the moment, the WHO Regional Advisory Group on Patient Safety is the primary assessment team. The group will assess hospitals to determine whether or not they comply with the WHO patient safety standards and patient safety performance indicators. Assessment has a number of benefits for hospitals. It demonstrates commitment and accountability regarding patient safety to the public. It offers a key benchmarking tool, delineates areas of weakness and encourages improvement to attain standard targets. Finally, it provides motivation for staff to participate in improving patient safety. The ultimate goal of the initiative is to improve the level of patient safety in hospitals by creating conditions that lead to safer care, thus protecting the community from avoidable harm and reducing adverse events in hospital settings.

Structure and organization of the manual

The manual is organized into two sections: 1) the patient safety standards, and 2) the patient safety friendly hospital assessment tools.

Section 1 comprises five domains divided into 24 subdomains. It also includes guidelines for the evaluator including documents to be reviewed for each standard, relevant interviews, an observation guide, and scoring guidelines.

Section 2 comprises a set of tools to facilitate the assessment process, including a suggested agenda for the assessment visit, interview questionnaires collated by an interviewee, a complete list of all documents required for the hospital and an observation checklist.

The five domains under which the standards are organized are A. Leadership and management; B. Patient and public involvement; C. Safe evidence-based clinical practice; D. Safe environment; and E. Lifelong learning. Each domain comprises a number of subdomains 24 in total. A set of critical (20 in total), core (90 in total) and developmental (30 in total) standards are distributed among the five domains.

Critical standards are compulsory standards with which a hospital has to comply to become enrolled in the patient safety friendly hospital initiative.

Core standards are an essential set of standards with which a hospital should comply to become safe for patients. It is not compulsory to meet 100% of the core standards in order for a hospital to be enrolled in the patient safety friendly hospital initiative. However, the percentage of standards complied with will determine the level the hospital attains.

Furthermore, the percentage of core standards fulfilled is important for internal benchmarking, to document improvement over time.

Developmental standards are the requirements that a hospital should attempt to comply with, based on its capacity and resources, to enhance safe care.

Levels of compliance with patient safety standards

Hospitals will be scored as patient safety friendly based on four levels of compliance, with level 4 representing the highest attainable level.

Level 1: Compliance with 100% of critical standards and any number of core and developmental standards.

Level 2: Compliance with 100% of critical standards and 60% to 89% of core standards, and any number of developmental standards.

Level 3: Compliance with 100% of critical standards and at least 90% of core standards, and any number of developmental standards.

Level 4: Compliance with 100% of critical standards and at least 90% of core standards, and at least 80% of developmental standards.

Patient Critical Standards

A: Leadership and management

1-The hospital has patient safety as a strategic priority. This strategy is being implemented through a detailed action plan.

2-The hospital has a designated senior staff member with responsibility, accountability and authority for patient safety.

3-The leadership conducts regular patient safety executive walk-rounds to promote the patient safety culture, learn about risks in the system, and act on patient safety improvement opportunities.

4-A designated person coordinates patient safety and risk management activities (middle management).

5-The hospital conducts regular monthly morbidity and mortality meetings.

6-The hospital ensures availability of essential equipment.

7-The hospital ensures that all reusable medical devices are properly decontaminated prior to use.

8-The hospital has sufficient supplies to ensure prompt decontamination and sterilization.

9-Qualified clinical staff, both permanent and temporary, are registered to precise with an

appropriate body.

B: Patient and public involvement standards

1- Before any invasive procedure, a consent is signed by the patient. He/she is informed of all risks, benefits and potential side effects of a procedure in advance. The physician explains, and the nurse oversees the signing.

2-All patients are identified and verified with at least two identifiers including full name and date of birth (and room number is not one of them) whenever the patient undergoes any procedure (e.g. laboratory, diagnostic or therapeutic procedures) or transfer or is administered any medication or blood components before care are administered, with special emphasis on high-risk groups e.g. newborn babies, patients in coma, senile patients.

C: Safe evidence-based clinical practices standards

1-The hospital maintains clear channels of communication for urgent critical results.

2-The hospital has systems in place to ensure safe communication of pending test results to patients and care providers after discharge.

3-The hospital has an infection prevention control program including an organization scheme, guidelines, plan, and a manual.

4-The hospital ensures proper cleaning, disinfection and sterilization of all equipment with a special emphasis on high-risk areas.

5-The hospital implements guidelines, including WHO guidelines, on safe blood and blood products.

6-The hospital has safe pre-transfusion procedures e.g. recruitment, selection and retention

of voluntary blood donors, blood screening (e.g. HIV, HBV).

7-The hospital ensures availability of life-saving medications at all times.

D: Safe environment standards

1- The hospital segregates waste according to hazard level and color codes it.

2-The hospital conforms to guidelines (including WHO guidelines) on the management of

sharps waste.

E: Lifelong learning standards


The nine patient safety guidelines by WHO

The nine solutions are now being made available in an accessible form for use and adaptation by the WHO Member States to re-design patient care processes and make them safer. They come under the headings of:

1.      Look-alike, sound-alike medication names;

2.      patient identification;

3.      communication during patient hand-overs;

4.      performance of correct procedure at correct body site;

5.      control of concentrated electrolyte solutions;

6.      assuring medication accuracy at transitions in care;

7.      avoiding catheter and tubing misconnections;

8.      single use of injection devices;

9.      improved hand hygiene to prevent health care-associated infection.




Dear Patient

1. In emergency conditions, you will be informed before any important decisions involve type of methods, advantages and disadvantages and you will be given consent forms for approval authority.

2. Identity bracelet which will be worn on your hand during the admission procedure indicates your identity. Our treatment team will check specifications on the bracelet before further proceeding for the accuracy of identification and maintain your security, therefore we would like to ask you to keep it safe in all treatment phases (from admission to discharge).

3. For keeping your security, three bins including yellow, blue and white were provided. You may put infected wastes in yellow bins, home wastes (food dishes, etc.) in blue bins and chemical wastes (drug wastes etc.) in white bins.

4. If the scan tests and graphics and pathologies results are not prepared when you are discharged, the receiving date will be informed via phone call or Email. Hence, please make sure the phone numbers and Email address you provide for us are available and not out of reach.

5. For more security, please keep bed guards (bed sides) up and avoid bringing them down without discretion of treatment team while you are resting.

6. It is necessary to keep operation wounds neat. To prevent infection, please wear neat and clean clothes, wash your hands and use Hand Rub.

7. If you observe medical faults, please let us know. Following ways are available for you:

1.      Ask nurses to give you related forms.

2.      Reporting boxes are available in all sections of the hospital.

3.      Our E-mail:

4.      Our website:

5.      Our Phone Number: +98-83-34276299

6.      Our security office which is located at level 3 of the hospital.

All Rights Resered for Imam Reza Hospital Kermanshah