Hand wash

Ward: Enclosure no:

Code no-

Name:

(1) Name of solution used for hand wash:

(2) Duration of hand wash:
(3) Hand washing technique.

Steps Actions Compliance

serial (YES/NO)
number
1 Rub palm to palm
2 Rub the back of both hands
3 Interface fingers and rub hands together
4 Interlock fingers and rub the back of both hands
5 Rub thumb in a rotating manner followed by the area
between index finger and thumb for both hands.
6 Rub fingertips on palm for both hands
(4) When to wash hands or to use hand rubs?

Sl. No. Situations Compliance

(YES/NO)
1 On arrival for duty, before going for meals and
before leaving the ward or patient contact
area.
2 After cleaning of equipment and patient
furniture.
3 After completing patient observations and bed
making.

4 After using the toilet.

5 After contact with blood or body fluids.

6 Before and after every contact with an

infectious or neonatal patient.
 BIOMEDICAL WASTE MANAGEMENT

Ward: Name:
Code no: Enclosure no:

(1) Segregation of BMW

Sl.No. Types of Waste type Compliance

container (YES/NO)
1 Green Non Infectious Waste
-Paper waste
- Cartons
- Packaging material
- Plastic sheets
- Waste food

2 Red Infectious Plastic Waste

- Blood bags
- Urine bags
- Catheters
- IV drip
- Ryle’s tube
- Airways
3 Yellow Infectious Cotton / Anatomical
Waste
- Bandages
- Dressings
- Cotton Swabs
- Plaster casts
- Blood or body fluids soaked
napkins.
- Human tissues
- Lab waste
- Masks & caps
4 White container Sharp Waste Infectious
Sharp objects
- Destroy needles at point of
generation
How to prepare 1% sodium hypochlorite solution?
- Lancelets
Sl.no. - Actions
Blades Compliance
5 Blue Sharp Waste Non Infectious (yes/no)
1 For 1 litre solution:Take IV drip
200bottles
ml of the concentrate
- Injection vials
solution and add 800 ml- of water to it to get 1 % Solution
Ampoules
(total quantity will be l litre).

2 For 5 litres solution:Take 1 lt. of concentrate + 4 lt.

water to prepare 5 litre of 1 % solution.

Aware of disposal of blood and body fluids (including suction & drainages).

All specimen containers received in the laboratory (like

Pus, Pleural, peritoneal, drain fluid, Sputum, Bronchial
lavage sample, gastric lavage, Stool, Semen) Blood
culture bottles with blood after culture should be sent
for autoclaving.
Ward: Name:
Code no: Enclosure no:
Barrier Nursing

Awareness on barrier nursing techniques

Sl.No Nursing techniques Compliance

(Yes/No)
1. Hands must be washed and dried thoroughly after attending to the
patient’s care procedure, after removing the plastic apron and before
leaving the room.
2. Disposable Plastic Aprons to be used when required
3. Non-sterile latex gloves must be worn for direct contact, helping with
personal care and handling contaminated materials.
4. After bed making soiled linen must be placed into red bags whilst in the
room, taking care not to contaminate the outside label then taken
directly to the laundry.
5. Once this has been taken into the room it should remain there until the
patient has recovered. It may however be necessary to decontaminate a
piece of equipment for use elsewhere.
6. The patient charts/notes must be kept outside the room
7. Laboratory specimens should be placed in “biohazard” bags.
8. Clinical Waste items should be discarded into a waste bag sealed before
being taken out of the room to the clinical waste store.
9. The room and all surfaces should be cleaned with an EPA registered
disinfectant solution.
Awareness on PPE
1. Types of PPE
 Gloves
 Eyewear/goggles
 Gown
 Mask
 Head cap
 Shoe cover
2. Gloves are last put on & 1st taken off
3. Remove PPE in the following order:
 Remove gloves
 Remove eyewear/goggles
 Remove gown (pull off inside out)
 Remove mask
 Wash hands immediately

Disinfection

Ward: Name:
Code no: Enclosure no:

Awareness on disinfection of Digital Thermometer

Sl.no Actions Compliance
(Yes/No)
1 Use rubbing alcohol (70% isopropyl).
 2 Change the alcohol at least once a week.
3 Use a clean cloth or paper towel and dip it in the alcohol solution.
4 Carefully wipe the thermometer with the alcohol solution and hold the cloth
around it for 30 seconds. Discard the cloth. Let the thermometer air-dry.
Disinfection of BP cuffs
1 Put on latex or nitrile gloves to protect yourself from blood and other bodily
fluids that might be on the equipment.
2 Examine the entire cuff for muck or bodily fluids. Ensure you thoroughly
check the tubing and bulb.
3 Lay the cuff flat on a counter or table. Put several drops of liquid dish
detergent onto a paper towel.
4 Wipe both sides of the cuff, tubing and bulb completely. You might want to
use a clean scrub brush to remove heavy soil
5 Rinse the cuff and tubing with running warm water. A wet paper towel can be
used on the tubing so water does not get into it.
6 Pat dry the pressure cuff and tubing with a dry towel.
7 Put rubbing alcohol into a spray bottle and spray both sides of the cuff with it.
You should spray the tubing and bulb as well. Spray the cuff over a sink or
tub, when possible.
Alternately, you can mix 1 tsp. (5 ml) of bleach with 2 cups (473 ml)
of water and pour it into the bottle. Shake the bottle and spray the mixture
onto the blood pressure cuff as described above.
8 Allow the cuff and tubing to air dry before use
Disinfection of oxygen humidifier
1 Take disinfecting solution and soak humidifier in the solution for 10 minutes.
2 Remove the humidifier and shake out the excess solution
3 Rinse with distilled water
4 Allow to air dry
Disinfection of laryngoscope blade & handle
1 For Laryngoscope blades, use steam sterilization (by autoclaving) or high-level
disinfection by wet heat pasteurization at 158°F(˃70°C) for 30 minutes.

Vulnerable patient/Restraint policy

Ward: Name:
Code no: Enclosure no:
Sl.No. Actions Compliance
Yes/No
Identification of vulnerable patients
1 Patients come under vulnerable group are
(i) Children below 12 years of age
(ii) Pregnant women
(iii) Physically/Mentally challenged patient
(iv) Old aged person (above 75 years of age )
 (v) Any patient who cannot perform ADL “Activity of Daily Living”.
(vi) Those on Immunosuppressive and/or chemotherapeutic agents.
2 Identification band for vulnerable patients being used at DMC & H is “Red”
Action plan to take care of vulnerable patients
3 For paediatric patients: Bed and crib side rails should be remain up and
bed left in lowest possible position when patient is not under direct care of
nurse or attendant.
4 Accommodation for parents at bedside should be made whenever
practical.

5 Pillows should be firm and offer support. Light plastic wrappings are not
permitted on sheets and pillows.
6 Children receiving heat treatment of any kind should be kept under close
supervision.
7 Baby scales should be placed safely on a table top so that should the infant
fall, baby would not land on the floor.
8 No child should be left unsupervised while he/she is eating. Food shall be
soft and age specific.
9 Small candies and toys should not be accessible to a small child, lest he/she
choke or insert them in a body orifice.
10 When a small child has finished eating, his/her feeding equipment should
be removed and he/she shall be returned to his/her crib immediately.
11 All cleaning supplies should be kept in locked cabinets when not in use.
12 Medication should be left on the bedside.
13 For pregnant women: The admitting Office should facilitate the admission
of the pregnant women to the hospital.
14 The transport of the pregnant women to the labour room should be
facilitated.
15. For Elderly patients: Evaluation of the vulnerable elderly patients on
admission should include diagnosis, pre-hospital and current medications,
and cognitive status.
16. Special care should be given to prevent deep vein thrombosis and
pulmonary embolisation by using the available physical and pharmaceutical
means as determined by the medical staff.
17 Special care should be given to elderly bed-ridden, diabetic patients to
prevent pressure ulcer.
18 Nursing and medical staff should evaluate elderly patients with suspected
delirium within 8 hours of admission and take appropriate measures as
CAM score.
19 Wheelchair accessibility should be there within the hospital
20 Handrails should be provided for the senior citizens to move in & around
the hospital
21 For children, disabled and elderly patients where ever possible
arrangement should be made for bed side accommodation of bystanders.
22 Signage boards with contrasting colours; large fonts in English as well as the
regional language should be placed to help senior citizens.
23. Clear pathways should be provided for the disabled and senior citizens to
move around at their own pace.
24 Washrooms with grab bars should be designed mainly for the disabled and
aged people.
25 In registration counters, senior citizens and physically handicapped should
be given priority.
26 All staff involved in the care of vulnerable group should be adequately
trained in identifying and meeting their needs.
27 The medical and nursing staff should encourage family members of
 vulnerable patients to spend more time with them while in the medical
centre.
28 The medical and nursing staff should educate family members of vulnerable
patients on the proper safety and security measures adopted by the
Medical Centre.
29 The patient’s psychosocial needs should be assessed by the medical,
nursing and social services staff and findings shall be documented on the
multidisciplinary notes in the patient’s medical record.
Awareness on Restraint policy
30. “Restraint is an intervention that prevents a person from behaving in ways
that threaten to cause harm to themselves, to others, or to property.”
31. Types of restraint
(i) Physical restraint
(ii) Chemical restraint
Awareness on indications
32 Nurse must examine the patient for circulation, safety etc. after every 30
minutes and document it in the progress chart.
33. Documentation include
(i) Reasons for restraint
(ii) Type of Restraint-physical/chemical
(iii) Duration (approximate)
(iv) Release criteria- if circulation is effected
(v) Bluishness of digits/ extremities
(vi) Digits & extremities are cold and clammy
(vii) Patient complaints of tingling and numbness
34 Cases where physical restraints are used-
(i) Head injury
(ii) Alcohol Withdrawal Delirium
(iii) Delirium (Including all types of Encephalopathy)
(iv) Psychosis
(v) Aggressive behavior – harmful to self & caring staff
35 Cases where chemical restraint shall be used are-
(i) All types of Aggressive Behaviour
(ii) Psychosis (Delusions & Hallucinations)
(iii) Acutely Suicidal Patients
(iv) Acute Anxiety
(v) Delirium due to any cause (Acute Brain Syndrome)

Awareness on hospital wide policy

Ward: Name:
Code no: Enclosure no:
Sl.no Hospital wide policies Compliance
Yes/no
Patient Rights and Responsibility
1 RIGHTS: To be treated with respect, consideration, compassion and
dignity, in a safe and clean environment regardless of your age,
gender, race, national origin, religion, sexual orientation or disabilities.
2 To privacy and confidentiality in care discussions, examinations and
treatments
3 To a clear and understandable explanation by the doctor about the
diagnosis, as well as the benefits and risks of each treatment and
expected outcome.

4 To participate in decisions involving healthcare, except when such

participation is contradicted for medical reasons.

5 To review, obtain, request and receive a detailed explanation of

hospital charge and bills.

6 To give informed consent (written) before any non-emergency

procedure or treatment begins.

7 To be informed about pain and pain relief measures and to actively

participate in pain management plan.

8 To a second opinion and change of doctor.

9 To agree or refuse, to take part in medical research studies.

10 To a discharge summary containing adequate information

11 To receive the scope of services available at the hospital and accurate
information regarding the competence and capabilities of the
organization.
12 To inspect and request a copy of the medical information
13 To make suggestions and express grievances; to receive a timely
personal response to same, if so requested; and to have continued
access to care without intimidation, threat, coercion, discrimination,
and other retaliatory action..

14 To have an interpreter, if explanations are not understood.

15 RESPONSIBILITY: To be on time for appointment and to inform the

doctor / hospital if appointment cannot be kept.

16 To provide accurate and complete information about current and past

illness, medications and other matters pertaining to health.

17 To follow the treatment plan recommended by the doctor or express

concerns regarding ability to comply.

18 To actively participate in the pain management plan and to keep the

doctors and nurses informed of the effectiveness of the treatment.

19 To be responsible, if treatment is refused or doctor’s instructions are

not followed

20 To take care of personal belongings. To leave valuables at home and

only bring necessary items necessary for hospital stay.

21 To treat all hospital staff, other patients and visitors with courtesy and
respect; abide by the hospital rules and safety regulations; be
considerate of noise levels, privacy and number of visitors.

22 To provide complete and accurate information about health insurance

coverage and pay bills timely.

23 To report any issues, complaints or concerns that may effect care. To

complete the patient satisfaction questionnaire before leaving the
hospital so as to help us constantly improve our services.
 24 Vision of the hospital: To be a model of excellence in healthcare,
medical education and research.

25 Mission of the Hospital:

(i) To provide medical care with compassion and competence.
(ii) To deliver highest standards of education in medical and
allied fields.
(iii) To continuously strive for quality improvement.
Sentinel events policy and its reporting
Sentinel Event: A relatively infrequent, unexpected incident, related
26 to process or system deficiencies, which leads to death or major and
enduring loss of function for a recipient of healthcare services.

27. Policy: Event has resulted in unanticipated death or major permanent

loss of function, not related to the natural course of the patient’s
illness or underlying condition.
 A sentinel event:
28. I. Potentially involves a continuing threat to a patient care or
safety;
II. Has significant potential for being reflective of serious
underlying systems problems in the organization;
III. Potentially undermines public confidence in the hospital.

29. Reporting: Whenever a sentinel event occurs, the occurrence report

shall be immediately reported to the Quality Control Cell and the
Clinical Audit and Sentinels Events Task Force

30. The attending physician shall be notified immediately when the

variance involves a patient
If a patient or visitor is injured in a common area (i.e. sidewalks,
31. stairwell, elevator, waiting area, etc.) the Security Office shall be
responsible for initiating a Sentinel Events report.
Following are the Sentinel Events identified and defined by the Hospital:
32.
(i)
Wrong Patient / Wrong Procedure / Wrong Part.
(ii)
Retained instruments in patients discovered after surgery.
(iii)
Patient’s death during or immediately post-surgical
procedure.
(iv) Anaesthesia related event.
(v) Discharge of an infant to the wrong person.
(vi) Patient suicide or attempted suicide or deliberate self harm
resulting in serious disability.
(vii) Patient death or serious disability associated with:
 Nosocomial infection or disease.
 A burn / a slip, trip or fall / electric shock / use of
restraints or bedrails.
 Mismatched blood transfusion.
 Labour or delivery in a low risk pregnancy.
 Medication error due to incorrect administration of
drugs.
An avoidable delay in treatment or response to abnormal test results.

Emergency codes of hospital

(i) Code Red-Fire Management
33. (ii) Code Blue-Cardiac arrest
(iii) Code Pink-Child abduction
(iv) Code Yellow-Disaster management
(v) Code HAZMAT-Spill management
(vi) Code Gray-Security Threat