King Saud University – King Khalid University Hospital

NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
PATIENT FALL 2013
Numerator: Number of PATIENT FALL x 1000
FORMULA
Denominator: Number of Patient Care Days

Number of Number of Patient Fall Rate per 1000

MONTH/2013 Patient Care Total Patient Care Benchmark
Days Moderate Days
No Harm Low Harm Death
Harm
January 20137 6 1 0 0 7 0.35
February 18049 6 3 0 0 9 0.50
March 19881 4 0 2 0 6 0.30
April 19565 6 2 0 0 8 0.41
May 20365 4 2 0 0 6 0.29
June 19653 2 0 0 0 2 0.10 KKUH 2012
Patient Fall rate
July 18876 0 0 0 0 0 0.00
was 0.31 per
August 17422 3 3 0 0 6 0.34
1000 patient care
September 19975 5 3 0 0 8 0.40
day
October 20583 6 1 0 0 7 0.34
November 19773 6 0 0 0 6 0.30
December 20930 5 1 2 0 8 0.38
53 16 4 0
Total 235209 73 0.31
73
NUMERATOR
EXCLUSION
INCLUSION CRITERIA
CRITERIA

Inpatient areas falls:

1. Falls, trips, and slips with or without
All patient falls in
physical injury.
Bronchoscopy,
2. Persons found on the floor or requiring
Endoscopy and OPD
assistance to the floor or lower level by
nursing staff.

DENOMINATOR
EXCLUSION
INCLUSION CRITERIA
CRITERIA
Patient Care Days is defined as a unit in a
system of accounting used by health care
facilities and health care planners. Each day
All patients from OPD,
represents a unit of time during which the
patients in RDU and Day
services of the institution or facility are used
Care
by a patient; thus 50 patients in a hospital for
1 day would represent 50 patient care days
(Mosby’s Medical Dictionary, 2009)
No Harm No harm to patient
Low Harm Requiring first aid, minor treatment or extra observation
Moderate Harm Requiring admission to hospital, surgery or prolonged stay in hospital
Severe Harm Permanent harm such as brain damage or disability
Death Where death was directly attributed to the fall
INTERPRETATION
The rate of patient fall in nursing department was 0.31 per 1,000 patient care days, distributed as the following: Patient Falls in Medical areas -30, in Pediatric- 6, in
Obstetrics and Gynaecology -7, in DEM- 11 and in Surgical units -19, with a total of 73 falls all over nursing department. The majority of falls were of no harm (53
cases) which represented 0.26 per 1,000 patient care days; low harm (16 cases) which represented 0.07 per 1,000 patient care days; and moderately harm (4 cases)
0.019 per 1,000 patient care days. The Nursing Department took the following actions to keep the fall rate within the international benchmark (3 to 14 per 1,000
patient care days (Healey et al., 2008)):
1. Establish policy for fall prevention that all nursing staff has to follow.
2. Adopted Morse Scale for assessing patients’ susceptibility for fall.
3. All patients on admission have to be assessed for fall, then according to the need.
4. Nursing department considered “patient fall” as one of the nursing sensitive KPIs which was included to reflect on the quality of care provided to patients and
became one of the concerns during the quality forum.
5. Teaching session conducted to all nursing staff regarding fall prevention.
6. The nurse educators are playing an essential role regarding monitoring the staff and the implementation of fall prevention strategies in the clinical areas.
7. Each unit has to develop their own action plan to solve the problem of fall; copy will be submitted to nursing department.
8. Continuous monitoring of falls and prevention of injuries through proper interventional procedures.
9. The nursing department will carry on with all the previous activities in order to keep the patients' safety.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
PRESSURE ULCER 2013
Numerator: Number of patients who developed PRESSURE ULCER x 1000
FORMULA
Denominator: Number of Patient Care Days
Rate per 1000
Number of Patient
MONTH/2013 Number of Patient who developed Pressure Ulcers Patient Care Benchmark
Care Days
Days
January 20137 5 0.24
February 18049 1 0.05
March 19881 3 0.15
April 19565 0 0.00
May 20365 5 0.24
June 19653 2 0.10
KKUH 2012 rate
July 18876 1 0.05
was 0.13 per
August 17422 2 0.11 1000 patient care
September 19975 1 0.05 day
October 20583 7 0.34
November 19773 5 0.25
December 20930 3 0.14

Total 235209 35 0.15

NUMERATOR
INCLUSION 1. All patients admitted to the hospital and developed pressure ulcer, 24H after admission.
CRITERIA 2. Stage 2 Pressure Ulcer and above
1. Patients admitted to hospital with existing pressure ulcer.
2. Patients with skin lesion not related to pressure such a skin breaks and maceration from friction/moisture, even when found in bony
EXCLUSION
prominences.
CRITERIA
3. Stage 1 Pressure Ulcer
4. All patients in Day Care and RDU
DENOMINATOR
Patient Care Days is defined as a unit in a system of accounting used by health care facilities and health care planners. Each day
INCLUSION
represents a unit of time during which the services of the institution or facility are used by a patient; thus 50 patients in a hospital for 1
CRITERIA
day would represent 50 patient days (Mosby's Medical Dictionary, 2009). Total patient care days in the above ward in medical areas.
EXCLUSION
All patients in RDU and Day Care, and OPD.
CRITERIA
GRAPHIC PRESENTATION

INTERPRETATION
The Pressure Ulcer rate of the Nursing Department for the period of one year from Jan to Dec 2013 was 0.15/ 1000 patient care days which is slightly higher than
the benchmark of 2012 which was 0.13/1000 patient care days. The Pressure Ulcer rate of Medical Areas was 0.311/1000 patient care days, Surgery 0.190/1000
patient care days, DEM and Pediatric 0.011/1000 patient care days, OB wards and ward 15A the pressure Ulcer rate was 0.00/1000 patient care days. However, the
nursing department is still hoping to reduce the rate though it is still within the international acceptable range (6.9 per 1000 patient care days – NHS England).
Below were the interventions made:
1. The implementation of Braden (for adults) and Braden Q scale (for pediatrics) as part of the initial assessment for all admissions.
2. Each unit in the clinical areas developed their own action plan to decrease the rate of pressure ulcer.
3. The importance of pressure ulcer prevention was highlighted during the nursing department quality forum.
4. Teaching of all staff nurses all over the hospital regarding the above mentioned scales to assess pressure ulcer.
5. The hard work of the nurse educators in the clinical areas in terms of teaching the staff, developing new methods on how to use the scales, and continuous
monitoring of the staff.
6. For the next year, the nursing department planned to carry on with what they are doing for the time being, with the stress on providing the staff with the most
up-to- date evidence based practice.
7. Continuous monitoring of pressure ulcers through proper interventional procedures.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
NEEDLE STICK AND SHARP INJURY 2013
Numerator: Number of NURSES who had NEEDLE STICK & SHARP INJURIES x 1000
FORMULA
Denominator: Number of Patient Care Days

Rate per 1000

Number of Patient
MONTH/2013 Number of Nurses who had Needle Stick and Sharp Injuries Patient Care Benchmark
Care Days
Days

January 20137 1 0.04

February 18049 0 0.00
March 19881 1 0.05
April 19565 1 0.05
May 20365 3 0.14
KKUH 2011 rate
June 19653 1 0.05
was 0.18 and
July 18876 3 0.58 KKUH 2012 rate
August 17422 2 0.11 was 0.138 per
September 19975 1 0.05 1000 patient care
October 20583 0 0.00 days
November 19773 0 0.00
December 20930 1 0.04

Total 235209 14 0.05

NUMERATOR

INCLUSION CRITERIA EXCLUSION CRITERIA

All sharps or needle stick All needle and sharps

injuries of Nursing Staff injuries of students and
working in in-patient units. non- nursing staff.

DENOMINATOR

INCLUSION CRITERIA EXCLUSION CRITERIA

Patient care days are

defined as each day
All patients seen in the
representing a unit of time
Outpatient and Operating
during which the services
Room.
of the institution or facility
used by a patient.

INTERPRETATION
Based from the results, months of May and July have the highest rate of needle stick injury; months of
February, November and October with zero incidents. In comparison with the last 2 years, the rate has been
decreased from 0.18(2011) and 0.138 (2012) to 0.05 per 1000 patient care days for 2013.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
IV INFILTRATION 2013
Numerator: Total number of INFILTRATED INCIDENTS x 1000
FORMULA
Denominator: Total Number of IV Device Care Days

Total Patients Infiltration Rate per 1000

MONTH/2013 Number of Patients with IV Infiltration Benchmark
with IV Cannula Device Care Day

January 10880 8 0.7

February 9185 6 0.6
March 11658 7 0.6
April 10455 4 0.4
May 10838 8 0.7
June 10380 0 0.0
KKUH 2012 rate
July 10039 2 0.2
was 0.9 per 1000
August 8480 2 0.2 peripheral device
September 10180 2 0.2 care days
October 9585 1 0.1
November 9753 2 0.2
December 11633 1 0.08

Total 123066 43 0.34

INCLUSION CRITERIA
EXCLUSION CRITERIA
INCLUSION CRITERIA
EXCLUSION CRITERIA
NUMERATOR
All in-patients who had developed Stage 2 and above infiltration (Refer to Infiltration Chart).
All in-patients who had developed Stage 1 infiltration (Refer to Infiltration Chart).
DENOMINATOR
All in-patients that had IV cannulas were calculated as peripheral IV line care days. (Departments: Medicine, Surgery, OB-
Gyne, DEM, Pediatrics and 15A).
OR, PACU and Ambulatory.
GRAPHIC PRESENTATION

INTERPRETATION
The Rate of IV INFILTRATION for the Nursing Department for the year 2013 was 0.34 in comparison with the last year (2012) which was 0.9 per 1000 device care
days. This reveals improvement in the overall units performance and that were related to:
1. Strict compliance with the nursing policy regarding certifying nurses in the clinical areas for IV cannulation and phlebotomy in which nurses are supposed to pass
the written test and perform 5 successful cannulations before being privileged to provide IV therapy and phlebotomy care.
2. Staff nurses annual re-certification for IV cannulation and phlebotomy.
3. The IV team is using the evidence-based practice in terms of type of cannula, dressing material, frequency of care, insertion technique…etc.
4. The hard work of the IV team in the clinical areas in terms of teaching the staff, developing new methods in caring of the peripheral lines, and management and
continuous monitoring of the staff.
5. The IV team with the cooperation of nursing education, developed a Phlebitis and Infiltration Chart to guide the staff on how to detect and when to report
infiltration.
6. Conducted special courses regarding caring and management of peripheral IV lines.
7. For the next year, the nursing department planned to carry on with what they are doing for the time being, with the stress to provide the staff nurses
with the most up-to-date evidence based practice.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
PHLEBITIS 2013
Numerator: Total number of PHLEBITIS INCIDENTS x 1000
FORMULA
Denominator: Total Number of IV Device Care Days

Total Number of IV Rate per 1000 Device

MONTH/2013 Number of Patients with Phlebitis Benchmark
Device Care Days Care Day

January 10880 0 0.00

February 9185 1 0.10
March 11658 1 0.08
April 10455 1 0.09
May 10838 2 0.18
KKUH 2012 rate
June 10380 0 0.00
was 0.159 per
July 10039 1 0.09
1000 peripheral
August 8480 0 0.00
device care days
September 10180 1 0.09
October 9585 1 0.10
November 9753 1 0.10
December 11633 0 0.00
Total 123066 9 0.07
NUMERATOR
INCLUSION CRITERIA All in-patients who had developed Stage 2 and above phlebitis (Refer to Phlebitis Chart).
EXCLUSION CRITERIA All in-patients who developed Stage 1 phlebitis (Refer to Phlebitis Chart) and Out-patient department.
DENOMINATOR
All in-patients that had IV cannulas were calculated as peripheral IV line care days. (Department: Medicine, Surgery, OB-
INCLUSION CRITERIA
Gyne, DEM, Pediatrics and 15A).
EXCLUSION CRITERIA OR, PACU and Ambulatory.
GRAPHIC PRESENTATION

INTERPRETATION
The rate of phlebitis for the Nursing Department for the year 2013 is 0.07 which was within the benchmark, in comparison with last year (2012) which was 0.159 per
1000 device care days. This reveals improvement in the overall units performance and that were related to:
1. Strict compliance with the nursing policy regarding certifying nurses in the clinical areas for IV cannulation and phlebotomy in which nurses are supposed to pass
the written test and perform 5 successful cannulations before being privileged to provide IV therapy and phlebotomy care.
2. Staff nurses annual re-certification for IV cannulation and phlebotomy.
3. The IV team is using the evidence-based practice in terms of type of cannula, dressing material, frequency of care, insertion technique…etc.
4. The hard work of the IV team in the clinical areas in terms of teaching the staff, developing new methods of caring the peripheral lines and management and
continuous monitoring of the staff.
5. The IV team with the cooperation of nursing education, developed a Phlebitis and Infiltration Chart to guide the staff on how to detect and when to report
phlebitis.
6. Conducted special courses regarding caring and management of peripheral IV lines.
7. For the next year, the nursing department planned to carry on with what they are doing for the time being, with the stress to provide the staff nurses with the
most up-to-date evidence-based practice.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
EXTRAVASATION 2013
Numerator: Total number of EXTRAVASATED x 100
FORMULA
Denominator: Total Number of Patients on CHEMOTHERAPY

Total Number
MONTH/2013 of Patients on Number of Patients with Extravasation RESULT Benchmark
Chemo

January 358 0 0.00

February 340 1 0.29
March 464 0 0.00 Accidental
Extravasation
April 464 1 0.22
occurs in
May 423 0 0.00
approximately 0.1
June 398 0 0.00
to 6% of patients
July 499 0 0.00
receiving
August 431 0 0.00
Chemotherapy.
September 416 0 0.00
October 462 0 0.00
KKUH 2012 rate was
November 450 0 0.00 0.2%
December 453 1 2.21
Total 5158 3 0.06
NUMERATOR
INCLUSION CRITERIA EXCLUSION CRITERIA
All patients with signs and symptoms of extravasation like pain, change in
skin color, and integrity whether during or after chemotherapy, and who
Patients who had Extravasation of Dye.
had chemotherapy in all the wards and day care of medicine, surgery, OB-
GYNAE, pediatrics and critical care areas.
DENOMINATOR
INCLUSION CRITERIA EXCLUSION CRITERIA
Extravasation is the leakage of drugs into surrounding tissue. This refers
to chemotherapy extravasation via peripheral line. Patients who had Patients who had not received chemotherapy in all the wards and day
chemotherapy in all the wards, critical care areas and department of care of medicine, surgery, OB-GYNAE, pediatrics and critical care areas.
emergency medicine.
GRAPHIC PRESENTATION

INTERPRETATION
Chemotherapy is administered in different areas in the hospital for the year 2013. There were three (3) incidents of extravasation
recorded. The extravasation incident was 0.06% in 2013, which was lower as compared to the last year’s (2012) benchmark of
KKUH which was 0.2%. The staff nurses have to be vigilant and give proper treatment to prevent necrosis and functional loss of
tissue or limb involved. Since the occurrence of extravasation occurs only in MODC, close monitoring of infusion and checking of
blood back flow during infusion considering the desired infusion rate are encouraged in this unit. Strict compliance for safe
administration of chemotherapy needs to be adhered. To keep the staff nurses up-to-date, the nursing department conducted
series of chemotherapy courses by which after the staff nurses completed the said course, they will be certified and be able to
administer the chemotheraphy drugs.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
MEDICATION ERROR 2013
Numerator: Total number of MEDICATION ERRORS x 1000
FORMULA
Denominator: Total Number of Patient Care Days

Total Number
of Patient Care Medication
MONTH/2013 Number of Medication Errors Benchmark
Days in 5 Error Rate
AREAS

January 20137 1 0.05

February 18049 3 0.17
March 19881 4 0.20
April 19565 3 0.15
May 20365 7 0.34
June 19653 5 0.25
July 18876 0 0.00
August 17422 2 0.06
September 19975 0 0.00
October 20583 6 0.29
November 19773 3 0.15
December 20930 14 0.67

Total 235209 47 0.20

NUMERATOR

INCLUSION CRITERIA EXCLUSION CRITERIA

Dispensing, transcription, Medication errors by

and administration related physicians, e.g.
to nursing. prescriptions or wrong
orders.

DENOMINATOR

INCLUSION CRITERIA EXCLUSION CRITERIA

Patient care days are

defined as each day
representing a unit of time All patients in OPD, OR,
during which the services and Day Care Units.
of the institution or facility
used by a patient.

INTERPRETATION
There were 47 reports of medication errors for the whole period of one year 2013. The rate of
medication errors was 0.20% per 1000 patient care days. This rate will be the baseline for
monitoring the improvement of medication administration process within the Nursing Department. In
addition, the Nursing Department encouraged the concerned units to develop their Quality
Improvement Plan (QIP) focused on reducing medication errors.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
NURSES’ TURNOVER 2013
Numerator: Number of TERMINATION from the FIRST OF THE MONTH through the LAST DAY OF THE
FORMULA MONTH x 100
Denominator: Average Head Count of the Month

MONTH/1434 Number of Termination Average Headcount RESULT (%) TARGET

Muharram 7 2218 0.31

Safar 14 2224 0.62
Rabi 1 18 2227 0.80
Rabi 2 15 2233 0.67
Jumada 1 19 2229 0.58
Jumada 2 27 2232 1.20
RESULTS WERE:
Rajab 25 2221 1.12
2011 = 8.15%
Shaaban 11 2184 0.50 2012 = 9.58%
Ramadan 19 2181 0.87 2013 = 8.99%
Shawwal 23 2177 1.05
Dhu Al-qadah 6 2169 0.27
Dhu Al-Hijjah 14 2127 0.65

Total 198 26422 8.99%

NUMERATOR

INCLUSION EXCLUSION
CRITERIA CRITERIA

Number of terminations
from the 1st of the month
None
through the last day of
the month.

DENOMINATOR

INCLUSION EXCLUSION
CRITERIA CRITERIA

1. Number of
employees on the
1st of the month
2. Number of
employees on the
None
last day of the month
3. Average headcount
for the month (point
1 + point 2 divided
by 2)
INTERPRETATION
During the previous two years, 1432 and 1433, the rate of turnover was high (8.15% and 9.58%
respectively) in comparison with this year, the rate was 8.99%. This indicates that there is a need of
Root-Cause Analysis (RCA) and development of QIPs for more nursing staff retention.
 King Saud University – King Khalid University Hospital
NURSING DEPARTMENT
KEY PERFORMANCE INDICATOR
NURSING EMPLOYMENT RATE 2013
Numerator: Total Number of NEWLY HIRED STAFF (IN ONE YEAR) x 100
FORMULA
Denominator: Total Number of NURSING DEPARTMENT STAFF

MONTH/1434 Total Number of Newly Hired Staff Total Number of Staff Rate 100% BENCHMARK

Muharram 1 2218 0.045

Safar 11 2224 0.490
Rabi 1 12 2227 0.530
Rabi 2 19 2233 0.850
Jumada 1 16 2229 0.717
Jumada 2 38 2232 1.700
Rajab 62 2221 2.790
Shaaban 14 2184 0.640
Ramadan 23 2181 1.050
Shawwal 31 2177 1.420
Dhu Al-qadah 48 2169 2.210
Dhu Al-Hijjah 17 2127 0.799

Total 292 26422 13.24

NUMERATOR

INCLUSION EXCLUSION
CRITERIA CRITERIA

All staff who joined

All staff who joined from
BEFORE
01.01.1434 to
01.01.1434 or
29.12.1434
AFTER 29.12.1434

DENOMINATOR

INCLUSION EXCLUSION
CRITERIA CRITERIA

All nursing staff who

were present from
None
01.01.1434 to
29.12.1434

INTERPRETATION
Nursing employment rate was fluctuating from 0.045% to 2.795% and the overall rate was 13.24%. The total number of
nursing staff who were hired within the year 1434/2013 was 292, while the total nursing staff in the nursing department
until the end of the year 1434/2013 was 2127. The employment methods are thru any of the following:
1. Local recruitment
2. Telephone interview
3. International recruitment