ESR Orientation2022

‫إدارة الجودة والتميز االكلينيكي‬
‫برنامج معايير السالمة‬

‫االساسية(امان)‬
‫‪ESR Standards 2022‬‬
‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

‫‪INTRODUCTION‬‬

HUMAN
MEDICAL STAFF RESOURCES
FACILITY MANAGEMENT
HR.5
MS.7 SYSTEM
HR FMS.9-FMS.21-FMS.22
MS FMS FMS.23-FMS.24 -FMS.32.
PROVISION
OF CARE
PC.25
PC.26 LB LABORATORY
PC
LB.51
(ESR)
M
QUALITY
MANAGEMENT M Medication
Management
QM.17 QM
MM.5
QM.18
AN IPC MM.6
MM.41
INFECTION
ANASTHISA
PREVENTION
AN.2 & CONTROL

AN.15 IPC..4
IPC.15
‫‪HUMAN RESURCE‬‬
‫‪HR.5‬‬
‫‪DR. AYED ALRESHIDI‬‬

HR.5
Preparation
Standard – Substandard Description (Instructions)
Tools
HR.5 The hospital has a process for proper credentialing of staff members licensed to provide patient care
HR.5.1 ‐ The hospital has a  Document  HR.5 standard is applied for any new staff hired after January 1, 2016
written policy describing the Review  Review credentialing policy that should include a process for credential
process used for the verification for all healthcare professionals providing patient care.
verification of credentials.  This includes: Saudis and Non-Saudis, Medical, Nursing and Allied Healthcare
‫سياسة التحقق من االعتمادات‬ staff.
 The policy of credentialing verification should include the elements mentioned in
standard HR.5 (such as HR.5.2, 5.3, 5.8, 5.9)
 The policy should specify the procedure for verification of credentials and should
be signed by the process owner(e.g. HR).the policy and should specify if this
Third Party covers all credentials (education, license, training, experience).
ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

HR.5
Preparation
Tools
HR.5.2 ‐ The hospital gathers,  Personnel  This substandard consist of three (3) elements; gathering, verification and
verifies, and evaluates the File Review evaluation.
credentials (license, education,  Gathering; having copy of all credentials in personal file.
training, certification and  Verification; having primary source verification for credentials (license,
experience) of those medical education, training and experience). Primary source verification can either be
staff, nursing staff, and other from a third party such as dataflow or done directly by the hospital.
health professionals licensed
 Evaluation;having documented evidence in personnel file or meeting minutes
to provide patient care.
that credentials were evaluated (signed by credentialing committee for medical
‫وثيقة التحقق من االعتمادات في الملف‬
staff, and a relevant entity for nursing and allied health staff. An entity could be a
‫الوظيفي‬
committee, a group or an area manager).

HR.5
Preparation
Tools
HR.5.3 ‐ Credentials are  Personne

 Qualification needs to be verified from the original source,
verified from the original l File
source. Review  If staff experience (in current position) exceeding the required years of experience
‫االعتمادات تم التحقق منها من منشأ إصدارها‬
as per job description (JD), experience verification is not required,
 Training should be based on JD

 Personne
 Verification is not required for life support certificates such as BLS, ACLS, PALS
l File
Review
HR.5.4 ‐ Job responsibilities  All personal files of healthcare professionals should include copy of current job
and clinical work assignments/  Personne
description. Additionally, privileges should be included for medical staff.
privileges are based on the l File
evaluation of the verified Review  If the hospital does not conduct primary source verification or staff is assigned out of
credentials. his/her profession (e.g., nurse working as anesthesia technician), then the score will
‫الوصف الوظيفي واالمتيازات مبنية على‬
be affected.
)‫االعتمادات (المؤهالت‬

HR.5
Preparation
Tools
HR.5.5 ‐ The hospital ensures the  Files of medical, nursing, pharmacy, laboratory, social work, and other
registration of all healthcare  Personnel
healthcare providers contain valid and current license from the Saudi
professionals with the Saudi File
Commission for Health Review
Commission for Health Specialties (i.e., SCFHS card is valid).
Specialties.
‫التسجيل في الهيئة السعودية للتخصصات الصحية‬
HR.5.6 ‐ Staff licensed to provide  This substandard requires hospital to have a valid copy of Ministry of Health
patient care must always have and  Personnel
(MOH) license in the personnel file.
maintain a valid license to practice File
only within their profession. Review
 Thus, this will be scored in private hospitals accordingly and scored as NA in
‫قرار التكليف بالوظيفة في حدود التخصص‬ governmental hospitals.

HR.5
Preparation
Tools
HR.5.7 ‐ The hospital maintains  Files of medical, nursing and allied healthcare staff providing patient care shall
an updated record of the contain credentialing documents (valid license from SCFHS; education, training,
current professional license,  Personnel certification and experience).
certificate, or registration, File Review
when required by laws,
regulations, or by the hospital
for every medical staff, nursing
staff and other healthcare
professionals.
‫ترخيص عمل محدث وساري المفعول‬
HR.5.8 ‐ When verification of  Confirmatory documents supporting the process of verification of credentials by
credentials is conducted the third party if applicable.
through a third party, the  Personnel  This can be scored NA if a hospital doesn’t conduct any verification through third
hospital must request for a File Review party and all verification for license, experience, training and education
confirmatory documentation. conducted internally.
‫وثيقة تأكيد التحقق من االعتمادات عن طريق‬  Payment receipt from third party is not considered as confirmatory
‫طرف ثالث‬ documentation.
HR.5.9 ‐ Verification process  Review samples of part-time, visitor, and locum clinical staff (e.g., in OR, OPD)
applies to all clinical staff files to ensure they contain credentialing documents (valid and current license
categories (full time, part time,  Personnel from SCFHS; education, training, certification and experience verified from
visitor, and locum). File Review original source).
‫كل فئات منسوبي المستشفى يخضعون للتحقق‬  Note: use HR.5.3 to score Full time and HR.5.9 to score part time, visitor and
‫من االعتمادات‬ locum (The scores are independent of each other)

‫‪MEDICAL SERVICES‬‬
‫‪MS7‬‬
‫‪DR. Mohammed Aleidi‬‬

MS.7
Standard– Substandard Preparation Description (Instructions)

Tools
MS.7 Medical staff members have current delineated clinical privileges.
 Document  In visited units such as ICU, OR, ER and Radiology, it is required to verify the availability
MS.7.1 ‐ Medical staff members Review and accessibility of valid copy of privileges for the physicians working in these areas (hard
are allowed to practice only copy or controlled electronic copy).
within the privileges granted by  Note: Although the validity of privileges will be assessed by MS.7.2, such finding needs to
the credentialing and privileging be verified as part of MS.7.1 too since both sub-standards are linked.
committee.
‫قوائم االمتيازات لجميع الطاقم الطبي‬
‫موجودة في األقسام‬
MS.7.2 ‐ Clinical privileges are  Review Sample of physician’s personnel files to make sure that clinical privileging is
reviewed and updated every  Personnel reviewed and updated every two years and as needed. Updated privileges imply both
two years and as needed. File upgrading/downgrading.
‫يتم تحديث االمتيازات كل عامين (بقاء‬ Review
)‫القديمة لالثبات‬

MS.7

Tools
MS.7 Medical staff members have current delineated clinical privileges.
 Privileging policy should include; 1) definition of temporary and emergency privileges

MS.7.3 ‐ The hospital identifies 2) the circumstances and process of granting temporary and emergency privileges.
the circumstances under which  Document  Review physician personnel file to check the implementation of the hospital policy on
temporary or emergency Review granting temporary or emergency privileges.
privileges are granted.  Personnel  Although emergency privilege can be scored NA if it is not used, temporary privilege
‫االمتيازات المؤقتة والطارئة في السياسة‬ File Review cannot be scored NA as it’s the initial step in granting privileges for newly hired staff
‫ومنفذة في الملف الوظيفي‬
MS.7.4 ‐ Temporary or  Document  Review the hospital policy on granting temporary or emergency privileging. Both
emergency privileges are not Review elements (not granted more than 90 days and not renewable) should be written in the
granted for more than 90 days policy.
and are not renewable.
‫يكتب في السباسة االمتيازات المؤقتة والطارئة‬
‫ يوما والتجدد‬٩٠ ‫حدها‬
MS.7.5 ‐ When a new privilege is  Personnel  Review sample of physicians’ files to assess the implementation of privileging process
requested by a medical staff File Review in case of requesting new privileges.
member, the relevant credentials  Review the last 3 meeting minutes for the privileging committee to check if there were
are verified and evaluated prior to medical staff requesting new privileges.
approval.
‫االمتيازات الجديدة بحاجة لتحقق كامل من‬
‫المؤهالت الجديدة‬

‫‪PROVISION OF CARE‬‬
‫‪PC 25.26‬‬
‫‪DR. Mohammed Aleidi‬‬

PC.25
Standard– Substandard Preparation Tools Description (Instructions)
PC.25 Policies and procedures guide the handling, use, and administration of blood and blood products.
‫سياسة استخدام الدم والعاملون على اطالع بمحتوياته‬
PC.25.1 ‐ There are policies and  Policy on blood handling/administration should be reviewed and
procedures that are developed
signed/approved by the Blood Utilization Committee and include clear process
collaboratively by the blood utilization  Document
committee, guiding the handling, use, Review
for handling, use and administration of blood and blood products.
and administration of blood and blood  Staff Interview  Interview clinical staff (e.g., physicians and nurses) in different areas to
products. confirm their competency and awareness of blood administration policies and
‫سياسة استخدام الدم والعاملون على اطالع‬ procedures.
‫بمحتوياته‬
PC.25.2 ‐ Only physicians order blood  Document  Review the hospital policies and procedures on handling, use, and
and in accordance with a policy Review
administration of blood and blood products to confirm the clear identification of
clarifying when blood and blood  Closed Medical
products may be ordered. Record Review
medical staff authorized to order blood transfusion.
‫ الطبيب فقط هو من‬،‫في السياسة وسجل المريض‬  Check the record of a patient who received blood to make sure that the blood
‫يأمر بنقل الدم‬ order is only made by physician and in accordance with hospital policy.
 Electronic or handwritten orders are accepted.
 Open and closed medical record may be reviewed, if open medical record is
breached, this should be reflected in the score.

PC.25
PC.25.3 ‐ The physician obtain informed consent for transfusion of blood and blood products. Elements of patient consent include:
‫ اختيار المريض‬،‫ أسئلة المريض‬،‫ البدائل‬،‫ فوائده‬،‫ مخاطره‬،‫االقرار المسبق لنقل الدم في السياسة ومنفذ في سجل المريض ويشمل (وصف اإلجراء‬
PC.25.3.1 Description of the transfusion  Review the hospital policies and procedures on handling, use, and administration of blood and
process. blood products. The policy mandate documenting informed consent and identify the elements of
PC.25.3.2 Identification of the risks and  Document proper consent
benefits of the transfusion. Review
 Closed Medical  Check the record of a patient who received blood to make sure that the patient appropriately
PC.25.3.3 Identification of alternatives Record Review consented for the transfusion after being educated by a physician.
including the consequences of refusing
the treatment.
PC.25.3.4 Giving the opportunity to ask
questions.
PC.25.3.5 Giving the right to accept or
refuse the transfusion.

PC.25
PC.25.4 ‐ Two staff members verify the  Closed  Review the hospital policies and procedures on handling, use, and administration
patient’s identity prior to blood drawing Medical of blood and blood products. The implemented system mandate two staff
for cross and prior to the administration Record Review members verify the patient’s identity prior to specimen collection and prior to
of blood.  Document
‫السياسة وسجل المريض يوضحان التأكد المزدوج من‬
blood transfusion. • If the hospital mandates taking two (2) samples to verify cross
Review
‫هوية المريض عند سحب الدم إلجراء التطابق وقبل‬ match and that clearly written in the policy, it is accepted.
‫إعطاء الدم للمريض‬  Check the medical record of a patient who received blood to make sure the
patient identity has been verified by two staff members prior to blood drawing and
transfusion.
 Review policy to confirm consent mandate for "transfusion without NAT testing"
in emergencies,
PC.25.5 ‐ In dire emergencies,
 (a) hospital has donation area and conduct NAT testing internally, policy should
patient/family signs consent for  Document
"transfusion without NAT testing” Review
mandate consent for transfusion without NAT.
‫إقرار نقل الدم دود اجراء فحص الحمض النووي‬  (b) hospital has donation area & NAT testing is outsourced, policy should
‫للحاالت الطارئه‬ mandate consent for transfusion without NAT.
 (c) hospital does not have donation area and receiving tested blood from
outsource facility (based on written agreement), PC.25.5 will be NA.

PC.25
PC.25.6 ‐ Blood is transfused according  Closed Medical  Review hospital policies that developed collaboratively by the blood utilization committee to
to accepted transfusion practices from Record Review confirm that blood transfusion guidelines adopted from recognized professional organizations
recognized professional organizations.  Document Review and best practice (e.g., blood transfusion process, blood monitoring, and duration of
transfusion in congruent with the best practices).
‫سياسة إجراء نقل الدم تتم وفق أفضل الممارسات‬
‫ومنفذة في السجل الطبي للمريض‬  Accepted references used in developing transfusion policy should be based on recognized
professional organization.
 Check medical record of patients who received blood to make sure that Blood is transfused
according to hospital policy and using accepted transfusion practices from recognized
professional organizations (e.g., blood transfusion process, blood monitoring, and duration of
transfusion in congruent with the best practices)
PC.25.7 ‐ Policies and procedures guide  Observation  Observe the accessibility and availability of blood transfusion policy in the
the administration of blood transfusions.
visited areas (such as ICU, ER or Surgical Ward).
‫مالحظة سياسة نقل الدم في متناول يد طاقم بنك الدم‬
PC.25.8 ‐ Patients receiving blood are  Document Review  Review hospital policies and procedures to confirm that the policy mandate
closely monitored.  Closed Medical
close monitoring of the patient during the transfusion and the policy specify
‫السياسة وسجل المريض يوضحان المراقبة‬ Record Review
monitoring intervals and procedure.
‫الدقيقة لنقل الدم‬
 Check the medical record of a patient who received blood to make sure that
the patient was closely monitored during transfusion.

PC.25
PC.25.9 ‐ Transfusion reactions  Review the hospital policies and procedures on recognizing, handling and
are reported and analyzed for  Document reporting of adverse transfusion events.
preventive and corrective actions. Review  It’s acceptable to have transfusion reaction policy as part of the blood
‫السياسة وسجل المريض يوضحان التعامل‬  Closed administration policy.
‫مع التفاعالت الناتجة عن نقل الدم بكتابة‬ Medical  Check the medical record of a patient who experienced adverse transfusion
‫التقرير وإجراء التحليل واإلجراء‬ Record Review event to confirm proper reporting, investigation and actions.
‫التصحيحي‬
 This substandard can be scored as NA, if the rate of transfusion is confirmed
to be too low.

PC.26

Tools
PC.26 Patients at risk for developing venous thromboembolism are identified and managed.
 This standard is Not Applicable in Pediatric Hospitals (pediatric group).
 Although the activity required for PC.26.1 and PC.26.2 is medical record review, VTE prophylaxis policy needs to be reviewed to ensure
consistency of practice.
PC.26.1 ‐ Patients are screened  Review medical record to check if patients are screened for the risk of developing
for the risk of developing venous  Opened venous thromboembolism. Form used for VTE screening should include all
thromboembolism. Medical identified risk factors according to patients’ categories (medical/surgical,
‫سجالت جميع المرضى (البالغين) توضح‬ Record antenatal, and postnatal) and the calculation of these risks result in adequate
‫توثيق خضوعهم لتقصي خطورة االصابة‬ Review treatment.
‫باالنسداد التخثري لألوردة‬  Although the activity required for PC.26.1 and PC.26.2 is medical record review,
VTE prophylaxis policy needs to be reviewed to ensure consistency of practice
PC.26.2 ‐ Patients at risk receive  Review medical record to check if patients at risk of developing venous
prophylaxis according to current  Opened thromboembolism receive prophylaxis according to current evidence-based
evidence‐based practice. Medical practice. Ensure that prophylaxis given according to risk factors identified in
‫هذه السجالت توضح خضوع المرضى‬ Record PC.26.1. Observe the availability of mechanical prophylaxis.
‫ذوي الخطورة للعالج الوقائي‬ Review

‫‪QUALITY MANAGEMENT‬‬
‫‪QM 17.18‬‬
‫‪SHIRLEEN CRUZ‬‬

QM.17
QM.17 The hospital has a process to ensure correct identification of patients.
QM.17.1 ‐ At least two patient  Staff Interview  Interview staff to ensure that they are aware of the policy and using at least
identifiers (e.g., patient full name 2 patient identifiers before procedures, blood sampling, medications
and medical record number) are administration… etc.
required whenever taking blood  Although the activity required for QM.17.1 is staff interview, identification
samples, administering policy/protocol needs to be reviewed to ensure consistency of practice.
medications or blood products, or
performing procedures.
‫الحوار مع جميع الطاقم الفني يوضح اطالعه‬
‫بضرورة اعتماد معرفين لهوية المريض (رقم‬
)‫السجل الطبي واالسم الرباعي للمريض‬
QM.17.2 ‐ The hospital has a  Observation  Visit and observe different location to ensure consistency and
standardized approach to patient standardization of patient identification process.
identification  Suggested areas for observation: (Observe if patients in ER having ID and
‫مالحظة وجود سوار التعريف لجميع المرضى‬ its content is visible, readable and clear, observe staff administering
‫يحتوي على المعرفين‬ medications without verification against medication records, observe
newborn identification, observe to make sure NOT using room number as
identifier in medication drawers)
QM.17.3 ‐ Patients are actively  Staff Interview  Interview staff and patients to assess implementation.
involved in the process of patient  Most common areas to assess: outpatient pharmacy, phlebotomy area,
identification. patient pre-procedure.
‫الحوار مع الطاقم الفني يوضع معرفته بضرورة‬  This substandard is not applicable (NA) in mental health hospitals.
‫إشراك المريض في تعريف نفسه ويسأل (ما‬
)‫اسمك الرباعي؟‬
QM.18
Tools
QM.18 The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure.
 Interview staff to verify adherence to surgical safety protocol.
QM.18.1 ‐ There is a process  Although QM.18.1 activity is staff interview, policy on preventing
implemented to prevent wrong patient,  Staff wrong patient, wrong site, and wrong surgery needs to be reviewed
wrong site, and wrong surgery/procedure Interview to ensure practice consistency. Process should include invasive
during all invasive interventions procedures (intraoperative and outside OR e.g., endoscopy,
performed in operating rooms or other radiology…etc.).
locations.  QM.18 is NA in Mental Health Hospitals, unless they are conducting
‫الحوار مع طاقم الجراحة يوضح اطالعه على إجراءات‬ ECT procedure
‫منع اإلجراء الخطأ للمريض الخطأ في الموضع الخطأ‬
QM.18.2 ‐ The process consists of three  This substandard consists of 3 elements; verification, site marking, &
phases: verification, site marking, and time- out. Review medical records to ensure a proper timely
time out.  Closed documentation of verification, site marking, & time- out (e.g., in
‫السجل الطبي لحاالت الجراحة يوضع اتباع المراحل‬ Medical recovery room).
‫ التحقق من هوية المريض ووسم موضع الجراحة‬:‫الثالثة‬ Record  Verification and time-out need to be reviewed in surgical operations
‫وإجراء الوقت المستقطع‬ Review and invasive procedures too, to ensure compliance.
QM.18.3 ‐ A pre‐procedure verification of  Review medical records of patients went for invasive procedure to
the patient information is carried out  Closed make sure that the pre-procedure verification is documented in the
including the patient’s identity, consent, Medical chart.
full details of the procedure, laboratory Record
tests and images, and any implant or Review
prosthesis.
‫يوجد في السجل الطبي لحاالت الجراحة إقرار الموافقة‬
‫على الجراحة والفحوصات واألدوات المطلوبة‬
QM.18

Tools
QM.18 The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure.
QM.18.4 ‐ The surgical/procedural site is marked before conducting the surgery / procedure.
)‫ وضوح الوسم أثناء العملية‬،‫ توحيد شكل الوسم‬،‫ إشراك المريض‬،‫ اسم الجراح الواسم‬،‫تدوين وسم موضع العملية في السجل الطبي للمريض على أن يشمل (االحتياج للوسم‬
QM.18.4.1 The site is marked  Review medical records of patients went for intraoperative surgical
especially in bilateral organs procedures to make sure that the pre-procedure verification, site marking,
and multiple structures ( e.g. and time out are documented in the chart.
fingers , toes and spine)  Closed
 In mental health hospitals, site marking for ECT is Not Applicable.
QM.18.4.2 The site is marked Medical
by the individual who will Record
perform the procedure. Review
QM.18.4.3 The patient is
involved in the marking
process.
QM.18.4.4 The marking
method is consistent
throughout the hospital.
QM.18.4.5 The mark is visible
after the patient is prepped and
draped.

QM.18
Tools
QM.18.5 ‐ A final check )time‐out) is conducted before the procedure is initiated.
‫مالحظة تنفيذ الوقت المستقطع أو سؤال طاقم الجراحة عن خطواته (يجرى في غرفة العمليات قبل البدء باإلجراء ويشارك فيه الجميع بفاعلية ويتم بموافقة الجميع على معرفة‬
)‫المريض واإلجراء وموضعه‬
QM.18.5.1 The time‐out is conducted
in the location where the procedure  Hospitals need to have a clear documented evidence in medical
records for conducting time-out (prior to skin incision). • Observation
will be done, just before starting.
activity can be replaced by staff interview (e.g., in recovery room or
QM.18.5.2 The time‐out is initiated by
surgical wards) if there are no cases of invasive procedures to
a designated member of the team and observe during the visit to ensure staff awareness of time-out
involves the members of the team, process.
including the individual performing  Observation
the procedure, the anesthesia  Staff Interview  Assess awareness of concerned staff regarding the time out process
providers, and the nurse(s) involved.
QM.18.5.3 The entire procedure team
uses active communication during the
time out.
QM.18.5.4 During the time‐out, the
team members agree on the correct
patient identity, the correct procedure
to be performed, the correct site, and
when applicable, the availability of the
correct implant or equipment.
QM.18.6 ‐ The hospital documents its  Open Medical  Review medical records of patients went for invasive procedure/surgical
processes for preventing wrong Record Review operation to make sure that the pre-procedure verification, site marking,
and time out are documented in the chart.
patient, wrong site, and wrong
surgery/procedure.
‫‪ANESTHESIA‬‬
‫‪AN 2-15‬‬
‫‪SHIRLEEN CRUZ‬‬

AN.2

Tools
AN.2 Anesthesia staff members have the appropriate qualifications.
AN.2.1 ‐ Qualified  Personnel  Review random sample of anesthetist’s personnel files for qualification
anesthesiologists provide File Review and Privileges. Qualified anesthesiologist could be specialist, senior
anesthesia services. specialist or consultant.
‫الملف الوظيفي يوضح مؤهالت طبيب‬
‫التخدير‬
AN.2.2 ‐ Qualified  Review medical records to verify having a documented evidence that
anesthesiologist is present  Closed anesthesiologist is present in OR throughout the operation.
inside the operating room Medical  Discharge recovery sheet, intraoperative anesthesia operation sheet,
throughout the operation Record coupled with adequate match between number of available
‫السجل الطبي يوضح تواجد طبيب التخدير‬
Review anesthesiologist (using anesthesia Rota) can be used to verify the
‫طوال إجراء العملية‬
availability of anesthesiologist in OR throughout operation time.

AN.2

Tools
AN.2.3 ‐ Anesthesia consultant administers and supervises anesthesia for major/specialized operations or high risk patients,
including:
‫ (جراحات األطفال والقلب والرئة واألعصاب وزرع األعضاء‬:‫السجل الطبي يوضح وجود استشاري تخدير عند اجراء العمليات التالية‬
AN.2.3.1 Pediatric operations.  Closed  Review medical record of patient who had major or high-risk surgery
Medical (Pediatric operations, cardio-pulmonary operations, neurosurgery
AN.2.3.2 Cardio‐pulmonary Record operations, and transplant operations) to make sure that anesthesia
Review consultant administers and supervises anesthesia.
AN.2.3.3 Neurosurgery
operations.
AN.2.3.4 Transplant
operations.
AN.2.4 ‐ Anesthesia staff are  Personnel  Review sample of anesthesia medical staff personal files to verify having an
certified in advanced life File Review evidence of advanced life support training as appropriate to the patient’s age
support as appropriate to the (e.g., if anesthesiologist participating in pediatric operations, PALS certificate
patient’s age. should be checked).
‫الملف الوظيفي ألطباء التخدير يحتوي‬
‫على شهادة اإلنعاش المتقدمة‬

AN.15

Tools
AN.15 Qualified staff perform moderate and deep sedation/analgesia.
AN.15.1 ‐ Physicians who perform  All physicians (non-anesthesiologist) who perform

moderate and deep moderate/deep sedation must have evidence of training or
sedation/analgesia have  Personnel File specific privileges on moderate sedation in their personal files.
competency‐based privileges Review ICU Intensivist and ER Physicians classified by SCFHS do not
granted to perform moderate and
require such training.
deep sedation/analgesia.
 If moderate/deep sedation given by anesthesia staff inside and
‫الملف الوظيفي لألطباء القائمين بإجراء التسكين‬
‫المتوسط والعميق يوضح حصولهم على هذا االمتياز‬
outside operating room, this will satisfy the requirement of this
sub-standard.

AN.15
AN.15.2 ‐ Clinical staff who  Personnel  Clinical staff such as nurses, anesthesia technicians,
participate in caring for patients File Review radiology technicians, labor and delivery staff who
receiving moderate or deep participate in caring of patients received moderate sedation
sedation are certified in are required to have evidence of advanced life support
advanced life support as
training (and PALS if they serve pediatric group) in their
appropriate to the age of the
personal files.
patients served.
‫الملف الوظيفي لجميع المشاركين في إجراء‬
‫التسكين المتوسط والعميق به شهادة اإلنعاش‬
‫المتقدمة سارية التاريخ‬
AN.15.3 ‐ Clinical staff who  Personnel File  Clinical staff such as nurses, radiology technicians, labor and
participate in conducting sedation Review delivery staff who participate and conduct sedation must
must successfully complete a complete adequate training in moderate and deep sedation that
proper education/training on conducted by a qualified anesthesiologist and kept in their
moderate and deep sedation.
personal files.
‫الملف الوظيفي لجميع المشاركين في إجراء‬
 Anesthesia physicians and technicians do not require training on
‫التسكين المتوسط والعميق به شهادة تدريب على‬
‫إجراء التسكين المتوسط والعميق‬
moderate/deep sedation as it is already part of their study.

INFECTION PREVENTION AND
CONTROL
IPC 4.15
AFAF ALRESHIDI

IPC.4
IPC.4 There is a designated multidisciplinary committee that provides oversight of the infection prevention and control program.
IPC.4.1 ‐ The infection prevention and  Review Infection Prevention and Control Committee term of
control committee is chaired by the  Infection reference (TOR) and meeting minutes to verify that the committee is
hospital director or the medical director. Prevention and chaired by hospital director or medical director (i.e., committee’s
‫ميثاق لجنة مكافحة العدوى برئاسة مدير المستشفى أو‬ Control chairman name should be reflected in TOR and meeting minutes). If
‫المدير الطبي ومحاضر االجتماعات والحوار مع‬ Committee IPC Committee is reporting to the corporate IPC Committee, it is still
‫األعضاء يوضح مهام هذه اللجنة‬ necessary that the Chairman be the Medical Director or Hospital
Director at the hospital level.

IPC.4

Tools
IPC.4.2 ‐ The membership of the  Review Infection Prevention and Control Committee term of
infection prevention and control  Infection reference (TOR) and meeting minutes to verify multidisciplinary
committee includes Prevention involvement.
representatives from the medical and Control  Medical staff involvement should include a representative from
staff, nursing staff, microbiology, Committee critical care areas (adults and pediatrics) depending on the scope
operating room, central of service.
sterilization service,  Issues discussed in IPC committee meetings are assigned to
pharmaceutical care, dietary concerned representatives and should be traceable and timely
services, housekeeping, infection closed.
prevention and control staff, and
other departments as needed.
،‫ أعضاء ( ممثل الطاقم الطبي‬٩ ‫الميثاق يوضح‬
،‫ غرفة العمليات‬،‫ الكائنات الدقيقة‬،‫التمريض‬
‫ النظافة‬،‫ التغذية‬،‫ الصيدلية‬،‫التعقيم المركزي‬
)‫ومكافحة العدوى ويضاف غيرهم حسب األجندة‬
IPC.4.3 ‐ The infection prevention  Infection  Review Infection Prevention and Control Committee term of reference
and control committee meets on a Prevention (TOR) and meeting minutes to verify that the committee is meeting on
regular basis (at least quarterly). and Control regular basis. Also, make sure they have been discussing critical issues
‫ مرات‬٤ ‫محاضر االجتماعات توضح انعقاد اللجنة‬ Committee related to infection control as applicable (e.g. outbreaks).
‫في السنة‬

IPC.4
IPC.4.4 ‐ Functions of the infection prevention and control committee include, but are not limited to, the following:
‫ مراجعة تقارير العدوى‬،‫وظائف اللجنة مكتوبة في الميثاق والحوار مع فريق مكافحة العدوى يوضح معرفتهم بهذه الوظائف وهي (مراجعة سياسات واجراءات مكافحة العدوى‬
‫ متابعة‬،‫ مراجعة تنفيذ سياسات وإجراءات مكافحة العدوى‬،‫ مراجعة الخطة السنوية لمكافحة العدوى‬،‫المرتبطة بالرعاية الصحية واإلجراءات التصحيحية المترتبة عليها‬
)‫ رفع األعضاء بكل ما يتعلق بمكافحة العدوى في أقسامهم‬،‫مستجدات العدوى في األقسام المختلفة‬
IPC.4.4 ‐ Functions of the infection prevention and control committee include, but are not limited to, the
following:
IPC.4.4.1 Review of the hospital infection  Review Infection Prevention and Control Committee term
prevention and control policies and procedures.  Infection Prevention of reference (TOR) and meeting minutes to ensure
IPC.4.4.2 Review of the reports of and Control incorporating IPC.4.4.1-IPC.4.4.6.
healthcare‐associated infections surveillance Committee  Hospitals need to ensure incorporating these six (6)
submitted regularly by the infection prevention functions in the terms of reference. Additionally, must be
and control team and suggestion of appropriate verify that the infection prevention and control team
actions. decides the need for more airborne isolation rooms
IPC.4.4.3 Revision of the yearly plan submitted depending on the volume of patients in need for airborne
by infection prevention and control team and isolation admitted to the hospital.
suggestion of additions/changes if necessary.
IPC.4.4.4 Evaluates and revises on a continuous  Infection prevention and control annual plan need to be
basis the procedures & the mechanisms developed reviewed and signed by the committee (IPC.4.4.3).
by the infection prevention & control team to
serve established standards and goals.
IPC.4.4.5 Brings to the attention of the infection
prevention & control team new infection control
issues arising in different departments of the
hospital & suggests solutions.
IPC.4.4.6 Each member of the committee acts as
an advocate of infection prevention & control in
his department, trying to promote its principles,
and ensures application of its rules
IPC.15
IPC.15 Facility design and available supplies support isolation practices.
 Hospitals are expected to have at least one negative

pressure room in ER and one for every 25-30 beds in
general hospitals (In certain hospitals (e.g., mental
health, rehabilitation, eye hospitals), one negative
IPC.15.1 ‐ There is at least one negative pressure airborne isolation
pressure isolation room in ER and one in inpatient
room in the emergency room and one in patient care areas (one
wards is acceptable regardless of hospital’s bed
negative pressure room for every 25‐30 beds in general hospitals).  Observation
‫ سرير من‬٢٥ ‫مالحظة وجود غرف العزل سالبة الضغط واحدة في الطوارئ وواحدة لكل‬ capacity. In addition, they should have clearly written
 Document
‫أسرة األقسام واإلطالع على توثيق الصيانة الدورية لها‬ Evidence
agreement with comprehensive transfer plan for
referral of infectious cases.
 Having adequate number of negative pressure

isolation rooms for inpatient, with no isolation room in
ER will partially meet IPC.15.1 requirement.

IPC.15
 Interview infection control staff and hospital staff to verify

 Staff Interview their awareness of negative pressure isolation rooms’
IPC.15.3 ‐ The ventilation system serving
 Document Evidence engineering control records.
airborne isolation facilities provides pressure
patterns that prevent airborne pathogens from Review completeness of engineering control records for air
being distributed to other areas of the hospital. changes per hour, HEPA filter, negativity, humidity, and
‫سجالت الصيانة والحوار مع المهندس يوضحان نظام التهوية‬ temperature; (review standard's intent to understand engineering
،‫لغرف العزل السالبة الضغط والذي يشمل (مقدار الضغط السالب‬ records requirements)
‫ تغيير في الساعة ويقاس يوميا عد‬١٢ ‫معدل التهوية ال يقل عن‬
‫ التبديل الدوري‬،‫وجود مريض واسبوعيا عند عدم وجود مريض‬
‫للهيبا فيلتر‬
IPC.15.3.1 Rooms designed for airborne isolation

patients are under negative pressure.
IPC.15.3.2 Air is exhausted to the outside and is
not re‐circulated unless it is filtered through
High‐Efficiency Particulate Air (HEPA) Filter.
IPC.15.3.3 The negative pressure for the isolation
room should be validated on daily basis when
patient is isolated (admitted in the room). Weekly
validation is done when the room has no patients.
A minimum of 12 air changes per hour should be
maintained by testing and documentation as per
manufacturer's recommendation/hospital's policy

IPC.15
IPC.15.5 ‐ Toilet, shower, or tub and hand  Observe the availability of hand washing facilities,
washing facilities are provided for each  Observation toilets, and shower in negative pressure isolation
isolation room. rooms (note: shower and toilet in ICU isolation room
‫مالحظة وجود دش أو بانيو وحوض لغسل األيدي داخل حمام‬ are not mandatory).
‫المريض‬

IPC.15
IPC.15.6 ‐ Transmission‐based precaution cards (isolation signs) are consistent with the patient diagnosis and are posted in
Arabic and English and indicate the type of precautions required.
‫سياسة مستويات العزل المبنية على طرق االنتقال ومالحظة البطاقات الملونة الخاصة بها وعليها جمل قصيرة باللغتين وصور توضيحية وتبين اجراءات العزل عند االنتقال لألقسام األخرى‬
IPC.15.6.1 Transmission‐based  Review isolation precautions policy that should include the specification
precaution cards (isolation signs) of isolation precaution cards.
are color coded for isolation of
different categories (e.g., contact:
Observe the availability of transmission-based precaution card that should
green, airborne: blue, droplet:  Document Review
be consistent with diagnosis, posted in both Arabic and English, color coded,
pink or red).  Observation
contain short statements, contain figures, and include transportation
IPC.15.6.2 Transmission‐based
instructions.
precaution cards (isolation signs)
should contain short statements
and supported with the required
figures.
IPC.15.6.3 Isolation instructions
must highlight the
transmission‐based precaution
cards (isolation signs) needed
while transporting the patients
under transmission‐based
precautions to other department
(e.g., radiology).
IPC.15
IPC.15.7 ‐ Respirator (high  Observe the availability and appropriate use of N95 by staff when
filtration) masks (N‐95, N‐99)  Observation dealing with patient with airborne diseases and ensure; 1) the
are used by staff during direct  Staff Interview availability of different sizes of N95 masks, 2) having fitting test and
care of patients on airborne staff are aware about their results, 3) observe donning and removing of
precautions and are available N95.
on all units likely to admit  Interview the staff to assess their knowledge about the use of
patients on airborne appropriate PPEs for airborne cases and fit test
precautions.
‫مالحظة وجود األقنعة عالية الترشيح‬
‫والحوار مع الطاقم الطبي يوضح معرفتهم‬
‫باشتراطات االستخدام‬
 Review hospital’s policy on single use or re-use of N95 masks: - If

IPC.15.8 ‐ Respirator (high  Document Review policy stated single use of N95, document review (DR) and staff
filtration) masks (N95, N‐99)  Staff Interview interview (SI) activities will be scored “Not Applicable”. - If policy does
can be reused by the same not decide on single or reuse of N95, DR and SI activities will be
patient care giver as per the scored “Not Met”. - If policy stated reuse of N95, it should specify the
period specified by the reuse criteria; for the same patient, reuse duration, and way to store
manufacturer. used masks… Then DR and SI activities will be scored accordingly.
‫سياسة إعادة استخدام األقنعة عالية‬ The policy should mention that “If any other precaution added in top of
‫الترشيح والحوار مع الطاقم الفني يوضح‬ airborne isolation (e.g. MERs Cov, chicken pox etc..), N95 mask re use
‫معرفتهم باشتراطات اعادة االستخدام‬ is prohibited”.
 Assess staff knowledge about the policy of re-suing high filtration
masks.
MEDICATION MENAGEMENT
MM 5-6-41
DR.AREEJ ALJASEER

MM.5

Tools
MM.5 The hospital has a system for the safety of high‐alert medications.
MM.5.1 ‐ There is a written  Review the multidisciplinary plan/policy for managing high-alert
multidisciplinary plan for medications and hazardous pharmaceutical chemicals. Policy should be
managing high‐alert signed by the process owners (Pharmacy Director, Nursing Director,
medications and hazardous Medical Director). It should include high-alert medications and
pharmaceutical chemicals.  Document hazardous pharmaceutical chemicals, and specify the process of
It includes identification, Review identification, location, labeling, storage, dispensing and administration
location, labeling, storage, of these medications.
dispensing, and
administration of high‐alert
medications.
‫خطة األدوية عالية التأهب والكيماويات‬
‫الخطرة وتشمل )تعريفها ومواقع‬
‫تخزينها ووسمها وطريقة تخزينها‬
)‫وصرفها واعطاءها‬2

MM.5

Tools
MM.5 The hospital has a system for the safety of high‐alert medications.
MM.5.2 ‐ The hospital identifies an annually updated list of high‐alert medications and hazardous pharmaceutical chemicals
based on its own data and national and international recognized organizations (e.g., Institute of Safe Medication Practice,
World Health Organization). The list contains, but is not limited to, the following:
‫ موانع‬،‫ األمالح المركزة‬،‫ العالج الكيماوي‬،‫ الحاصرات العصبية العضلية‬،‫القائمة السنوية لألدوية عالية التأهب والكيماويات الخطرة وتشمل ) األدوية المخدرة والخاضعة للرقابة‬
)‫ وغيرها‬،‫ أدوية التجارب العلمية‬،‫ أدوية التخدير‬،‫ االنسولين‬،‫التجلط‬
MM.5.2.1 Controlled and

narcotics medications.
MM.5.2.2 Neuromuscular
Review the updated list (annually) of high-alert medications and hazardous
blockers.
pharmaceutical chemicals.
MM.5.2.3 Chemotherapeutic  Document MM.5.2.1 to MM.5.2.9 are examples that need to be part of the list along with
agents. other intra-hospital frequently used high alert medications.
Review
The list needs to be approved by Pharmacy and Therapeutics Committee;
MM.5.2.4 Concentrated otherwise it would partially meet the standard
electrolytes (e.g., hypertonic List must be from within the hospital’s formulary
sodium chloride, concentrated Covers to a minimum the list mentioned in the standard, as applicable
potassium salts). List should include the specific drug names, not just categories.

MM.5
MM.5.2.5 Antithrombotic
medications (e.g., heparin,
warfarin).
MM.5.2.6 Insulins. Review the updated list (annually) of high-alert medications and hazardous
MM.5.2.7 Anesthetic pharmaceutical chemicals.
medications (e.g., propofol,  Document MM.5.2.1 to MM.5.2.9 are examples that need to be part of the list along with
other intra-hospital frequently used high alert medications.
ketamine). Review
The list needs to be approved by Pharmacy and Therapeutics Committee;
MM.5.2.8 Investigational otherwise it would partially meet the standard
(research) drugs, as List must be from within the hospital’s formulary
applicable. Covers to a minimum the list mentioned in the standard, as applicable
MM.5.2.9 Other medications List should include the specific drug names, not just categories.
as identified by the hospital.

MM.5
MM.5.3 ‐ The hospital plan for managing high‐alert medications and hazardous pharmaceutical chemicals is implemented. This
includes, but is not limited to, the following:
‫ توحيد عملية الوصف‬،‫ وسمها‬،‫ الحد من الوصول اليها‬،‫مالحظة تنفيذ خطة األدوية عالية التأهب ومعرفة الطاقم المعني بها والتي تشمل (تحسين التوصل الى معلومات عنها‬
)‫ واعتماد التأكد المستقل المزدوج‬،‫والنسخ والتحضير والصرف واإلعطاء والمراقبة‬
MM.5.3.1 Improving access to  Observe for evidence of implementation of high alert plan (from MM.5.3.1 to
information about high‐alert  Observation MM.5.3.5). MM.5.3.2 does not mean having all high alert medications in a
medications.  Staff Interview locked cabinet, but we need to ensure limiting access to these high alert
MM.5.3.2 Limiting access to medications.
high‐alert medications.  Staff interview to verify awareness of strategies to prevent errors associated
MM.5.3.3 Using auxiliary with using of high-alert medications and hazardous pharmaceutical chemicals.
labels or computerized alerts Independent double check should be carried out in both dispensing and
if available. administration. In addition, improving access to drug information on high alert
MM.5.3.4 Standardizing the medications include having access to dosing, storage, precautions, adverse
ordering, transcribing, reactions, etc.
preparation, dispensing,
administration, and
monitoring of high‐alert
medications.
MM.5.3.5 Employing
independent double checks

MM.5
MM.5.4 ‐ The hospital  Interview staff (nurses, physicians, and pharmacists) for evidence of
develops and implements  Staff implementation of standard concentrations of all high alert medications
standard concentrations for Interview administered by intravenous infusion.
all medications administered
 Document  Review the hospital approved standard concentration for all high alert
by intravenous infusion
‫إرشادات التركيزات النموذجية للمحاليل‬ Evidence medications administered by intravenous infusion. (Note: this
‫ومعرفة الطاقم المعني بها‬ substandard cannot be scored NA in any hospital setting).

MM.6
MM.6 The hospital has a system for the safety of look‐alike and sound‐alike (LASA) medications.
MM.6.1 ‐ There is a  Review the multidisciplinary plan/policy on handling LASA.

multidisciplinary policy and Policy should be signed by process owners (Pharmacy
procedure on handling look‐ Document  Director, Nursing Director, Medical Director). It should include
alike/sound‐alike (LASA) Review both look alike and sound alike medications (in separate
medications tables or lists), and specify the process of identification,
‫سياسة األدوية المتشابهة شكال ونطقا‬ location, labeling, storage, dispensing and administration of
LASA medications.
MM.6.2 ‐ The hospital reviews and
revises annually its list of Document  Review the updated list (annually) of confusing drug names 
confusing drug names, which Review including look alike and sound alike medications. Hospitals
include LASA medication name need to have annually updated list for LASA medications. The
pairs that the hospital stores, list must be:
dispenses, and administers. Approved by Pharmacy and Therapeutics Committee 
‫القائمة السنوية المحدثة لألدوية المتشابهة شكال‬ From within the hospital’s formulary 
‫ونطقا‬ Updated Annually 

MM.6

Tools
MM.6 The hospital has a system for the safety of look‐alike and sound‐alike (LASA) medications.
MM.6.3 ‐ The hospital takes actions to prevent errors involving LASA medications including the following, as applicable:
‫مالحظة صف األدوية المتشابهة والتدوين المطلوب لها والحوار مع التمريض في األقسام ومنسوبي الصيدلية يوضح اطالعهم على اجراءات التعامل مع األدوية المتشابهة والتي تشمل )سجالت‬
)‫ التفريق بين المتشابهات‬،‫ تقليل الوصف الهاتفي والشفهي‬،‫ الوسم‬،‫ تغيير األشكال المتشابهة‬،‫ كتابة التشخيص ودواعي االستخدام‬،‫ كتابة اإلسم العلمي والتجاري عند الوصف‬،‫التدريب‬
MM.6.3.1 Providing education on

LASA medications to healthcare  Observation  Observe for evidence of error prevention due to LASA medications
professionals at orientation and as  Staff Interview (from MM.6.3.2 to MM.6.3.8)
part of continuing education.  Document  Interview staff for evidence of implementation of error prevention
MM.6.3.2 Using both the brand and Evidence strategies due to LASA medications (from MM.6.3.1 to MM.6.3.8)
generic names for prescribing LASA  Ensure having evidence (material and attendance record) that
medications. adequate number of relevant staff members were educated on LASA
medications.

MM.6
MM.6.3.3 Writing the diagnosis/

indication of the LASA medication on  Observation  Observe for evidence of error prevention due to LASA medications
the prescription.  Staff Interview (from MM.6.3.2 to MM.6.3.8)
MM.6.3.4 Changing the appearance  Document  Interview staff for evidence of implementation of error prevention
of look‐alike product package. Evidence strategies due to LASA medications (from MM.6.3.1 to MM.6.3.8)
MM.6.3.5 Reading carefully the label  Ensure having evidence (material and attendance record) that
each time a medication is accessed, adequate number of relevant staff members were educated on LASA
and/or prior to administration. medications.
MM.6.3.6 Minimizing the use of
verbal and telephone orders.
MM.6.3.7 Checking the
purpose/indication of the medication
on the prescription prior to
dispensing and administering.
MM.6.3.8 Placing LASA medications
in locations separate from each other
or in non‐alphabetical order.

MM.41
MM.41 The hospital has a process for monitoring, identifying, and reporting significant medication errors, including near misses,
hazardous conditions, and at‐risk behaviors that have the potential to cause patient harm.
MM.41.1 ‐ There is a multidisciplinary policy and  Review the multidisciplinary policy on handling medication
procedure on handling medication errors, near errors. Policy should be signed by process owners
misses, and hazardous situations (e.g.,  Document (Pharmacy Director, Nursing Director, Medical Director). It
confusion over look‐ alike/sound‐alike drugs or Review should highlight the following: ▪ Reference to the reporting
similar packaging). form
‫سياسة التعامل مع األخطاء الدوائية‬  Notification of provider about the error
 Feedback to reporters
 Timeframe for reporting and notification of provider
 Documenting medical errors and who should document
and where
 Review the multidisciplinary policy on handling medication
MM.41.2 ‐ The policy has a clear and acceptable errors. Policy should include clear and acceptable definition
definition of significant medication error, near  Document of significant medication error, near misses, and hazardous
misses, and hazardous situations. Review situations.
‫في السياسة تعريف واضح لألخطاء الدوائية‬

MM.41
MM.41.3 ‐ The treating physician is notified of  Staff Interview  Interview physicians (treating/attending/most responsible)
the medication error at the appropriate time. on how they get to know/informed about a medication error
‫الحوار مع التمريض يوضح معرفتهم بضرورة تبليغ الطبيب المعالج فور‬ and when.
‫حدوث خطأ دوائي‬
MM.41.4 ‐ Medication error reporting is  Interview healthcare providers on when they report
completed within the specified time frame after  Staff Interview medication errors. Match the timeframe in the policy with
discovery of the error. staff awareness
‫الحوار مع األطباء والتمريض يوضح معرفتهم باالطار الزمني للتبليغ عن‬
‫ ساعة‬٢٤ ‫األخطاء الدوائية خالل‬
MM.41.5 ‐ The hospital has a standard format for  Document  Ensure that pharmacist, physicians, and nurses in different
reporting medication errors. Evidence areas (clinical areas and pharmacy) are using the same
‫النموذج الموحد للتبليغ عن األخطاء الدوائية‬ standardized format for reporting medication errors.
MM.41.6 ‐Staff are education on the process and  Staff Interview  Interview healthcare providers on the process and
importance of medication error reporting. importance of medication error reporting. If a documented
‫الحوار مع األطباء والتمريض يؤكد تدريبهم على التعامل مع األخطاء‬ evidence shown (list of trained staff), we need to ensure
‫الدوائية‬ that education involves the highest possible number of staff
and not limited to specific area.

MM.41
MM.41 The hospital has a process for monitoring, identifying, and reporting significant medication errors,
including near misses, hazardous conditions, and at‐risk behaviors that have the potential to cause patient harm.
MM.41.7 ‐ There is active reporting of  Review medication errors, near misses, and hazardous situations
medication errors, near misses, and  Document reports
hazardous situations. Evidence  Active reporting means reporting different types of errors by
‫ملف التبليغات الدوائية يوضح أدا ًء نشطا ً للتبليغ‬ different stakeholders (medical, nursing, pharmacist) and number of
reported events should be relevant to the size and scope of service.
MM.41.8 ‐ The hospital conducts intensive  Document  Review root-cause analysis of all significant or potentially significant
root‐cause analysis for all significant or Evidence medication errors.
potentially significant medication errors.  This substandard is linked with MM.41.7, if the hospital doesn’t have
‫تقارير التحليل الجذري لألخطاء الدوائية المهمة‬ an active reporting system.
MM.41.9 ‐ Medication errors, near misses, and  Open Medical Review medical records for selected cases of reported medication
hazardous situations are documented in the Record Review errors (reached the patient). Inserting a copy of the report in the
patient’s medical record. medical record is NOT ACCEPTABLE
‫تدوين الخطأ الدوائي في السجل الطبي للمريض‬

MM.41
MM.41.10 ‐ The hospital utilizes reported data  Interview members of pharmacy and therapeutics committee and
to improve the medication use process,  Pharmacy and review the Committee’s meeting minutes to ensure that hospital is
prevent medication errors, and improve Therapeutics analyzing the reported event to take corrective and preventive
patient safety. Committee actions to improve the patient safety. A subcommittee reporting to
‫الحوار مع أعضاء لجنة الصيدلة والعالجات يؤكد استخدام بيانات‬ P&T or any other equivalent committee is acceptable to be
‫األخطاء الدوائية في تحسين استخدام الدواء ومنع تكرار األخطاء‬ responsible for the analysis.
‫الدوائية وتعزيز سالمة المرضى‬
MM.41.11 ‐ Healthcare professionals are  nterview healthcare provider who previously reported medication
provided with feedback on reported  Staff Interview error to verify if and how they received a feedback regarding the
medication errors, near misses, and analysis of the reported event and the action taken to prevent
hazardous situations. reoccurrence of the event or not. If the reporter is known, then he or
‫الحوار مع األطباء والتمريض يؤكد حصولهم على إفادة على ما‬ she should get feedback based on the hospital’s process in providing
‫رفعوه من تقارير األخطاء الدوائية‬ feedback. If the reporter is anonymous then the
unit/section/department should get feedback..
 Document  Review documents supporting the fact that the hospital reports
Evidence sentinel events related to serious medication errors to the relevant
MM.41.12 ‐ The hospital reports sentinel  Pharmacy and authorities.
events related to serious medication errors to Therapeutics  Interview members of pharmacy and therapeutics committee on
the relevant authorities. Committee reporting sentinel events related to serious medication errors to the
‫تقارير األخطاء الدوائية الجسيمة التي تم رفعها للجهات المعنية‬ relevant authorities. (note: hospitals need to report all sentinel events
‫والحوار مع منسوبي الصيدلية يوضع معرفتهم بخطوات التبليغ‬ to CBAHI if they are accredited). This activity CANNOT be NA

‫‪LABORATORY‬‬
‫‪LB 51‬‬
‫‪MANSOUR ALGHUNAIM‬‬

LB.51
LB.51 The blood bank develops a process to prevent disease transmission by blood/platelet transfusion.
 This standard can be scored NA, if blood transfusion service is out of the hospital scope of services neither by having donation area nor by outsourced
blood bank (e.g., mental health hospitals, convalescent hospitals).
LB.51.1 ‐ There are policies and procedures mandating that a sample of blood obtained from the donor during blood/ blood component collection is subjected
to the following infectious diseases testing: HBsAg, Anti-HBc ,Anti-HCV, Anti-HIV-1/2, Anti-HTLV-I/II, HIV-1 RNA, HCV RNA, HBV DNA ,Serologic test for Syphilis
and others
‫سياسة فحص دم المتبرع لألمراض المنقولة بالدم تشمل الفحوصات التالية وهي موجودة في بنك الدم والحوار مع منسوبي بنك الدم يوضح اطالعهم على محتوياتها‬
Intent:
Hospitals need to have written process/policy to prevent disease transmission by blood/platelet transfusion. This process mandate that a sample of blood
obtained from the donor during blood/ blood component collection is subjected to the following infectious diseases testing; HBsAg, Anti-HBc, Anti-HCV, Anti-
HIV-1/2, Anti-HTLV-I/II, HIV-1 RNA, HCV RNA, HBV DNA, Serological test for syphilis, and other additional or supplemental tests as mandated by relevant
health authorities. If hospital does not have donation service and used to receive blood from another facilities/ central blood banks, a written agreement
should ensure conducting such tests by providing facility and this agreement should be signed by both parties, include agreement conditions, specify the role
of involved party in looking back to monitor how they release blood and blood component, include infectious diseases testing conducted, dated with valid
date, and includes the process of resolving disputes. Moreover, if a hospital has donation service but outsourcing the transfusion transmission disease testing
(TTDT), written agreement is needed too. Bacterial contamination of blood components (mainly platelets) is a major cause of transfusion-related fatalities. To
limit blood component contamination by bacteria from donor skin, two elements of the blood collection process are critical. Before venipuncture, the donor
skin must be carefully disinfected using a method with demonstrated efficacy. Second, diversion of the first 10 to 40 mL of donor blood away from the
collection container. Furthermore, the blood bank needs to use a method sensitive enough to detect significant bacterial contamination in platelet
components. Insensitive methods including pH, glucose and microscopy are no longer acceptable. This standard is not applicable if blood transfusion service is
out of the hospital scope of services neither by having donation area nor by outsourced blood bank (e.g., mental health hospitals, convalescent hospitals).

LB.51
LB.51.1.1 HBsAg.  Review the laboratory policies and procedures on Transfusion

LB.51.1.2 Anti‐HBc  Document Review Transmitted Disease Testing (TTDT) of donor specimen to confirm its
LB.51.1.3 Anti‐HCV  Observation comprehensive cover of the requirement.
LB.51.1.4 Anti‐HIV‐1/2.  Staff Interview  If a hospital does not have donation service, written agreement is
LB.51.1.5 Anti‐HTLV‐I/II.  Document Evidence needed (review standard's intent to understand agreement
LB.51.1.6 HIV‐1 RNA. requirements)
LB.51.1.7 HCV RNA. LB.51.1.8 HBV DNA.  Observe TTDT process to confirm compliance
LB.51.1.8 HBV DNA.  If a hospital does not have donation service, written agreement is
LB.51.1.9 Serological test for syphilis. needed (review standard's intent to understand agreement
LB.51.1.10 Other additional or supplemental tests requirements)
as mandated by relevant health authorities..  Interview personnel to assess their competence with TTDT procedures.
 If a hospital does not have donation service, written agreement is
needed (review standard's intent to understand agreement
requirements)

LB.51

LB.51.2 ‐ The blood bank has a process to limit and detect bacterial contamination in platelet components. The process:
‫سياسة التعامل مع التلوث البكتيري لوحدات الصفائح الدموية وهي موجودة في بنك الدم والحوار مع منسوبي بنك الدم يوضح اطالعهم على محتوياتها‬
LB.51.2.1 Describes the blood bank approach  Document  Review randomly-selected records to confirm the laboratory
to limit bacterial contamination and the Evidence compliance with TTDT policy. • If a hospital does not have
investigations of positive cases.  Document donation service, written agreement is needed (review standard's
LB.51.2.2 Ensures the employed detection Review(1) intent to understand agreement requirements)
method is sensitive enough to detect  Observation(4)  Review the laboratory policies and procedures on limiting and
significant bacterial contamination.  Staff Interview(7 detecting bacterial contamination in bacterial contamination.
 Document  Observe practices to confirm implementation of strategies to limit
Evidence bacterial contamination in platelet components. Make sure to
observe a demonstration for proper site preparation and the use
of diversion pouch.
 Interview personnel to assess their competence with bacterial
contamination prevention and detection procedures.
 Review randomly-selected records of platelets units to confirm
the laboratory compliance with bacterial detection policy.
 Review the validation documents of the employed bacterial
detection method to confirm that the employed method is
sensitivity in detecting significant bacterial contamination.

FACILITY MANAGEMENT AND
SAFETY
FMS 9-21-22-23-24-32
ENG. MOHAMMED ALSAADOUN
ENG.TURKY ALDOSSAY

FMS.9

FMS.9 The hospital ensures that all its occupants are safe from radiation hazards.
 Review the radiation safety policy and procedure to ensure having the following;
 Testing of lead aprons, thyroid and gonad shields
FMS.9.1 ‐ The hospital has a radiation  Monitoring personnel TLD badges (quarterly)
safety policy and procedure and it is  Document  Annual testing/calibration of radiology equipment.
implemented. Review  Procedure for pregnant radiology staff
‫سياسة السالمة اإلشعاعية‬  Permissible Exposure limits for staff
 Safe handling/storing of radio-active materials
 Radiation emergencies (spills)
 Radioactive waste disposal
FMS.9.2 ‐ All radio‐active materials are  Observe all radio-active materials are clearly labeled and safely and securely stored
clearly labeled and safely and securely  Observation
stored.
‫مالحظة المواد المشعة وأنه قد تم وسمها وتخزينها‬
‫بطريقة آمنة‬

FMS.9

FMS.9.3 ‐ The hospital has the
relevant valid license(s) from King  Review the validity of the hospital’s license (K.A.CARE) (King Abdullah City for Atomic and
Abdulaziz City for Science and  Document Renewable Energy) for dealing with radio-active materials and all used radio-active materials are
Technology Review listed in the license.
‫رخصة سارية المفعول من مدينة الملك عبد العزيز‬
‫للعلوم والتكنولوجيا لقسم التصوير النووي‬
FMS.9.4 ‐ Staff handling nuclear
materials are qualified and certified by  Personnel File  Review personal file(s) of staff handling nuclear materials and check availability of K.A.CARE (King
King Abdul‐Aziz City for Science and Review Abdullah City for Atomic and Renewable Energy) certificate.
Technology  Staff Interview  Interview staff handling radio-active materials and evaluate their implementation of the radiation safety
‫الطاقم المسؤول عن المواد المشعة لديه شهادة من‬ policy.
‫مدينة الملك عبد العزيز للعلوم والتكنولوجيا والحوار‬
‫معه يوضح إطالعه على المهام المسؤول عنها‬
FMS.9.5 ‐ There is a valid shielding  Observation  Review the validity of shielding certificate of the X-ray (mammography, CT, fluoroscopy and
certificate of the x‐ray room(s) including  Staff Interview conventional x-ray) room(s) and ensure that there is no exposure leak for the rooms regularly or after
regular test to ensure permissible  Document constructions/ renovations. Observe that calibrated survey meters used are in use.
radiation levels. Evidence
 Interview medical physicist (radiation safety officer) on how he/she regularly tests concerned areas for
‫مالحظة شهادة التدريع السارية والفحص البيئي‬ permissible radiation levels.
‫ والحوار مع طاقم األشعة‬،‫المنتظم لمستوى األشعة‬
‫يوضح وصف هذه العمليات‬

FMS.9

Tools
FMS.9 The hospital ensures that all its occupants are safe from radiation hazards.
FMS.9.6 ‐ Lead aprons and

gonad/thyroid shields are  Make sure that all lead aprons and gonad and thyroid shields are available to
available to cover patients and  Observation cover patients and staff needs and regularly tested (annually) according to a
staff needs and are annually  Document hospital- wide inventory, not only those available at the radiology department
tested according to a Evidence (e.g., OR, ER and Cath Lab). Additionally, make sure that identified defective
hospital‐wide inventory. aprons and shields are not returned back to service.
‫سجالت الفحص السنوي لمراييل‬
‫الرصاص واألوقية الدرقية والنتاسلية‬
‫ومالحظة هذه المواد ومقارنتها‬
‫بالسجالت‬
FMS.9.7 ‐ Personal radiation  Personal radiation dosimeters (TLD cards) are regularly tested and the results
dosimeters (TLD cards) are  Observation are reviewed by a radiation physicist or radiation safety officer to ensure staff
available, tested every 3  Document safety and cumulative results are interpreted.
months, and actions taken Evidence  Make sure that personal radiation dosimeters (TLD cards) are available to
when test results exceed cover staff needs and staff are provided with replacement TLDs during the
permissible levels testing period.
‫سجالت الفحص الربع السنوي لمراقبات‬
‫األشعة الشخصية ومالحظة هذه األدوات‬
‫ومقارنتها بالسجالت‬

FMS.21
Tools
FMS.21 The hospital has an effective fire alarm system.
FMS.21.1 ‐ There is a fire  Review the fire alarm inspection schedule and reports. (The inspection
alarm system that is  Observation can be done by the hospital technical staff).
functioning and regularly  Document  The checklist and records should include; list of devices of zones to be
inspected as per civil defense Evidence inspected, inspection points and criteria for each zone, inspection date,
guidelines technician’s name and signature, and comments that are resolved.
‫جداول وتقارير مراقبة نظام انذار‬  This sub-standard is linked to FMS.21.3 and its score can’t be higher
‫الحريق ومالحظة النظام‬ than FMS.21.3.
 Observe fire alarm control panels and make sure that they work
properly with no alarms or errors. Observe random smoke detectors,
make sure they are operational, have number tags, and not
obstructed. This sub-standard is linked to FMS.21.3 and its score can’t
be higher than FMS.21.3.
FMS.21.2 ‐ The fire alarm  Document  Review the fire alarm testing schedule and reports. (The weekly or
system testing results are Evidence monthly testing can be done the hospital own technical staff).
documented.  The checklists and records should include; list of devices in zones to
‫جداول وتقارير فحص نظام إنذار‬ be tested, testing points and criteria for each device or zone, testing
‫الحريق‬ date, technician’s name and signature, and comments that are
resolved.
 This sub-standard is linked to FMS.21.3 and its score can’t be higher
than FMS.21.3.

FMS.21

Tools
FMS.21 The hospital has an effective fire alarm system.
FMS.21.3 ‐ The fire alarm  Review the fire alarm maintenance schedule and preventive
system has preventive  Document maintenance work orders (Maintenance must be
maintenance. Review performed by company certified by civil defense). The preventive
‫ جداول وتقارير صيانة نظام إنذار‬ Document maintenance checklists and records should include;
‫الحريق‬ Evidence list of devices in zones to be maintained, maintenance points and criteria
for each device or zone, and maintenance
date, technician’s name and signature, and comments that are resolved.
 Review corrective action plans for identified findings.
FMS.21.4 ‐ The elevators are  Check fire alarm system distribution drawings to ensure that elevators
connected to the fire alarm  Observation are connected to the fire alarm system or certificates from a certified
system  Document contractor.
‫مخطط رسمي يبين توصيل المصاعد‬ Review  Check availability of functional fire alarms in the elevator mechanical
‫بنظام إنذار الحريق ومالحظة األجهزة‬ room. Inspect for physical connection between fire alarm and elevator
‫الخاصة بهذا التوصيل في غرفة التحكم‬ control panel. Test one elevator to ensure it lands on the assigned floor
‫بالمصعد‬ level

FMS.22

Tools
FMS.22 The hospital has a fire suppression system available in the required area(s(.
 Rule: each sub-standard under FMS.22 (i.e., FMS.22.1, FMS.22.2, FMS.22.3, & FMS.22.4) includes two activities; observation (OB) & documented
evidence (DE).
FMS.22.1 ‐ The hospital has a  Visit Fire Pump area, make sure that the jockey, electrical and diesel pumps are set to
functional sprinkler system. auto mode. Check the sprinkler
‫ جداول وتقارير المراقبة والصيانة لنظام الرش‬ Observation system test valve/drain valve. Sprinkler heads should not be obstructed nor painted and
‫ المائي ومالحظة مناطق التوزيع‬ Document distance between each in ordinary risk area should not be more than 5 meters. Check if
Evidence the hospital has a fire water tank or a 2-level general tank. x-ray rooms can have
sprinkler system with precaution valve.
 Review sprinkler system inspection schedule and inspection reports. All corrective
actions are performed.
 Review sprinkler system preventive maintenance schedule and reports. All corrective
actions are performed. This activity is linked to observation and cannot be scored
higher.
 Monthly inspection and PPM for the sprinkler system can be done by the hospital
maintenance department while the quarterly maintenance schedule and preventive
maintenance work orders must be performed by company certified by civil defense.
Preventive maintenance checklists and records should include; list of devices /
components to be maintained, maintenance points and criteria for each device,
maintenance date, technician’s name and signature, and comments that are resolved.

FMS.22
FMS.22.2 ‐ The hospital has clean  Make sure that hospital has clean agent suppression system installed at the medical
agent suppression system. records department, the servers’ room (data center), electrical rooms, and generators’
‫جداول وتقارير المراقبة والصيانة لنظام المادة‬ rooms
‫النظيفة ومالحظة مناطق التوزيع‬  Observation  Check clean agent suppression system inspection tag to verify that inspection
 Document performed.
Evidence  Some clean agent systems (e.g. Novec, FM200, or Fire pro) can be installed in public
areas. CO2 suppression system can be installed in none occupied areas such as
generators or electrical rooms. Small electrical rooms (dry electrical room with no
combustible material stored within) that has fire rated doors and walls and sealed opening
with fire stop materials do not require clean agent systems, only CO2 fire extinguishers
located by the room door.

FMS.22

Tools
 Rule: each sub-standard under FMS.22 (i.e., FMS.22.1, FMS.22.2, FMS.22.3, & FMS.22.4) includes two activities; observation (OB) & documented
evidence (DE).
FMS.22.1 ‐ The hospital has a  Visit Fire Pump area, make sure that the jockey, electrical and diesel pumps are set to
functional sprinkler system. auto mode. Check the sprinkler
‫جداول وتقارير المراقبة والصيانة لنظام الرش‬  Observation system test valve/drain valve. Sprinkler heads should not be obstructed nor painted and
‫المائي ومالحظة مناطق التوزيع‬  Document distance between each in ordinary risk area should not be more than 5 meters. Check if
Evidence the hospital has a fire water tank or a 2-level general tank. x-ray rooms can have
sprinkler system with preauction valve.
 Review sprinkler system inspection schedule and inspection reports. All corrective
 Review sprinkler system preventive maintenance schedule and reports. All corrective
 This activity is linked to observation and cannot be scored higher.
 Monthly inspection and PPM for the sprinkler system can be done by the hospital
maintenance department while the quarterly maintenance schedule and preventive
maintenance work orders must be performed by company certified by civil defense.
Preventive maintenance checklists and records should include; list of devices /
components to be maintained,maintenance points and criteria for each device,
maintenance date, technician’s name and signature, and comments that are resolved.

FMS.22
FMS.22.2 ‐ The hospital has clean  Make sure that hospital has clean agent suppression system installed at the medical
agent suppression system. records department, the servers’
‫جداول وتقارير المراقبة والصيانة لنظام المادة‬ room (data center), electrical rooms, and generators’ rooms
‫النظيفة ومالحظة مناطق التوزيع‬  Observation • Check clean agent suppression system inspection tag to verify that inspection performed.
 Document
Evidence Some clean agent systems (e.g. Novec, FM200, or Fire pro) can be installed in public areas.
CO2 suppression system can
be installed in none occupied areas such as generators or electrical rooms. Small electrical
rooms (dry electrical room with
no combustible material stored within) that has fire rated doors and walls and sealed opening
with fire stop materials do
not require clean agent systems, only CO2 fire extinguishers located by the room door.

FMS.22
Tools
 Rule: each sub-standard under FMS.22 (i.e., FMS.22.1, FMS.22.2, FMS.22.3, & FMS.22.4) includes two activities; observation (OB) &
documented evidence (DE).
FMS.22.3 ‐ The hospital has  Review clean agent system inspection schedule and inspection reports. All corrective actions
are performed.
wet chemical system.  Review clean agent system preventive maintenance schedule and reports. All corrective actions
‫جداول وتقارير المراقبة والصيانة لنظام‬ are performed.
‫المادة النظيفة ومالحظة مناطق التوزيع‬  Observation  This activity is linked to observation and cannot be scored higher.
 Document Monthly inspection and PPM for the clean agent system can be done by the hospital maintenance
Evidence department while the quarterly maintenance schedule and preventive maintenance work orders must
be performed by company certified by civil defense. Preventive maintenance checklists and records
should include; list of devices and components to be maintained,
maintenance points and criteria for each device, maintenance date, technician’s name and signature,
and comments that are resolved.
FMS.22.4 ‐ The hospital has  Inspect hospital wet chemical system in the kitchen during building tour to ensure that its
function is not jeopardized by adjacent installations.
stand pipes and hose system  Check wet chemical system inspection tag to verify that inspection is not due.
‫جداول وتقارير المراقبة والصيانة لنظام‬  Observation
‫المادة النظيفة ومالحظة مناطق التوزيع‬  Document Monthly inspection and PPM for the wet chemical system can be done by the hospital maintenance
department while the quarterly maintenance schedule and preventive maintenance work orders must
Evidence be performed by company or personnel certified by civil defense. Preventive maintenance checklists
and records should include; list of devices and components to be maintained, maintenance points and
criteria for each device, maintenance date, technician’s name and signature, and comments that are
resolved.
• Review corrective action plans for identified findings.

• This activity is linked to observation and cannot be scored higher.
FMS.23

Tools
FMS.23There are fire exits that are properly located in the hospital.
FMS.23.1 ‐ Fire exits are  Observe fire exits are available, properly located in the hospital. (It is not mandatory to
available and are properly located  Observation have 2 exits for each room/area, it depends on the number of occupants, travel
in the hospital. distance, area and type of materials stored). Please refer to Saudi Building Code (SBC)
for specific cases.
‫مالحظة مخارج الحريق ومالءمة مواقعها‬
 This sub-standard will affect the score of sub-standards FMS.23.2, FMS.23.3,
FMS.23.4, and FMS.23.6. If fire exits are not available, then these sub-standards will
not meet the requirements.
FMS.23.2 ‐ Fire exits are not  Test three to five fire exits and make sure that they are not locked by any means
locked  Observation (chains, access control, keys, local
‫مالحظة عدم إغالق مخارج الحريق‬ lock…). If doors are locked by access control or keys, assess proper signage and that the
hospital has taken proper
action to reduce risks (key boxes, manual exit press buttons) to ensure smooth
evacuation.
 The score of this sub-standard can’t be higher than FMS.23.1.
FMS.23.3 ‐ Fire exits are not  Observe fire exits and make sure that there are no obstructions from both ends
obstructed.  Observation (furniture, project debris, cartoons...etc.)
‫مالحظة عدم انسداد مخارج الحريق‬  The score of this sub-standard can’t be higher than FMS.23.1.

FMS.23

Tools
FMS.23.4 ‐ Fire exits have  Check escape exits to ensure they have necessary panic hardware to allow
panic hard ware  Observation opening in the direction of evacuation.
‫مالحظة وجود مقابض الذعر في مخارج‬  The score of this sub-standard can’t be higher than FMS.23.1.
‫الحريق‬
FMS.23.5 ‐ Fire exits are fire  Observation  Observe fire exits are clearly marked with illuminated exit signs.
resistant.  The score of this sub-standard can’t be higher than FMS.23.1.
‫مالحظة مايثبت أن مخارج الحريق مقاومة‬
‫للحريق‬
FMS.23.6 ‐ Fire exits are clearly  Observe fire exits are available, properly located in the hospital. (It is not mandatory to
marked with illuminated exit  Observation have 2 exits for each room/area, it depends on the number of occupants, travel
sign. distance, area and type of materials stored). Please refer to Saudi Building Code (SBC)
for specific cases.
‫مالحظة أن مخارج الحريق تعلوها عالمة‬
 This sub-standard will affect the score of sub-standards FMS.23.2, FMS.23.3,
‫خروج مضاءة‬
FMS.23.4, and FMS.23.6. If fire exits are not available, then these sub-standards will
not meet the requirements.

FMS.24

Tools
FMS.24The hospital and its occupants are safe from fire and smoke
FMS.24.1 ‐ The hospital implements a  Document  Review the “No Smoking” policy to ensure that it includes all types of smoking (e-
strict “No Smoking” policy. Review
cigarettes, pipe, water pipe incense...etc.), disciplinary actions against violators.
‫سياسة منع التدخين ومالحظة تطبيقها في أنحاء‬  Observation
‫المستشفى ومالحظة وجود أماكن مخصصة للتدخين‬
 Smoking is totally prohibited on premises of healthcare facilities. Observe any
‫إن سمح بها النظام‬ thrown cigarette butts on hospital’s premises (e.g. hospital’s roof, mechanical
rooms, entrances...etc.)
FMS.24.2 ‐ There are no obstructions to  Observe that there are no obstructions to fire extinguishers, fire alarm boxes, and
exits, fire extinguishers, fire alarm boxes,  Observation
fire blankets.
emergency blankets, safety showers, and
eye wash stations
‫مالحظة عدم وجود عوائق أمام أدوات مكافحة‬
‫الحريق‬
FMS.24.3 ‐ Emergency lighting is  Observe that emergency lighting is adequate for safe evacuation of the hospital.
adequate for safe evacuation of the  Observation
(Light batteries are mandated only in OR and generator room).
hospital
‫مالحظة عدد كاف من مصابيح الطوارئ‬
 Perform functional test for emergency lighting to ensure that it is charging/working
properly
FMS.24.4 Storage areas are properly and safely organized
‫مالحظة مناطق التخزين وسالمة تنظيمها‬

FMS.24

Tools
FMS.24.4.1 Shelves and racks are sturdy
and in good condition.
FMS.24.4.2 No items stored directly on  Observe storage areas are properly and safely organized (note: pay special
the floor )a minimum of ten centimeters attention to the central supplies store). In Central supply store; Test
is left to manage spills).
FMS.24.4.3 Items should be stacked on a
emergency doors, observe exit signage, inspect fire extinguishers, access
flat base control and safe storage protocol.
FMS.24.4.4 Heavier objects are close to
the floor and lighter/smaller objects are
 Observation
higher.
FMS.24.4.5 Items are not stacked so  Observe Fire rated doors are available according to the hospital zones
high to block sprinklers or come in
contact with overhead lights or pipes (a
with no separation between walls and ceiling to prevent smoke spread
minimum distance of fifty centimeters between rooms and areas.
from ceiling level).  Make sure to remove ceiling tiles on 3 different locations to ensure that
the fire wall is intact.
 In relations to hospital’s identified zones, lack of fire rated doors or
having fire wall penetrations between zones would not fulfill the
requirement of this substandard.

FMS.32

Tools
FMS.32 The hospital ensures proper maintenance of the medical gas system.
 Piped Medical Gas (PMG) system is mandatory for healthcare facilities with; high consumption rate, active operating theaters, emergency
departments which use ventilators or handle trauma cases.
FMS.32.1 ‐ The medical gas system is regularly tested for: ‫جداول وتقارير فحص نظام الغاز الطبي‬
FMS.32.1.1 Pressure.  Document Evidence  Review preventive maintenance schedule and records for piped medical
gas system (manifolds, air compressor, liquid oxygen and suction system).
FMS.32.1.2 Leaks.
FMS.32.1.3 Functionality of valves, alarms,

pressure gauge, and switches.
FMS.32.2 There is a policy and procedure that ensures effective use of medical gas system. Areas covered include, but are not limited to, the following:
‫سياسة االستخدام الفعال لنظام الغاز الطبي يشمل ( إجراءات الفصل الجزئي للنظام وإضافة التفريعات والتعديالت في الشبكة والفحص التابع لذلك وإجراءات طلب وتعبئة األكسجين السائل وتقارير الفحص و‬
(‫اإلصالحات والتعديالت وبيانات التعبئة واالستهالك‬

FMS.32
FMS.32.2.1 The procedures to follow  Document Review  Review medical gases policy and procedure to ensure covering the
for taking any part of the system following:
offline.  1) Procedure of taking part of the system offline,
FMS.32.2.2 Commissioning and testing  2) Procedure of modifying, altering, commissioning, testing any part of
new branching or modifications. PMG,
FMS.32.2.3 The procedure for ordering  3) Procedure of ordering/refilling liquid oxygen,
and filling liquid oxygen  4) Documenting repairs/ alterations/ tests/ filling logs/consumption.
FMS.32.2.4 Documenting all
repairs/alterations/tests/filling
logs/consumptin
FMS.32.3 ‐ Compressed medical air is  Document Evidence  Review compressed medical air testing reports to include humidity and
regularly tested for humidity and purity purity (particles, water =< 0.05mg/L / dewpoint of -46oC, CO =< 5ppm,
‫جداول وتقارير فحص الرطوبة والنقاء للهواء‬ CO2 =< 500ppm, SO2 =< 1ppm) measurements.
‫الطبي المضغوط‬
FMS.32.4 ‐ The central medical gas  Observation  Observe that medical gases manifold room and compressors rooms are safe
station is in a safe and secure place and secure (locked, signage, clean, no oil, no exposed wiring…etc.).
‫مالحظة محطة الغاز المركزي وموقعها اآلمن‬  In specialized hospitals that use only local anesthesia, mental health,
rehabilitation and convalescent hospitals
 this substandard is applicable to ensure storing medical gas cylinders in safe
and secure place.

FMS.32
FMS.32.5 ‐ The outlets of medical gases in patient  Observation  Observe that all PMG outlets are functioning and unified in label
care areas are clearly marked with the type of gas and connection type for each gas.
and have different connections according to the gas
type.
‫مالحظة مخارج الغاز المختلفة في غرف المرضى واختالف‬
‫توصيالتها‬
FMS.32.6 ‐ All medical gas pipes are clearly marked  Observation  PMG pipes are clearly identified for type and direction.
and labeled for the contents and direction of gas
flow.
‫مالحظة جميع أنابيب الغاز موسومة بنوع واتجاه تدفق الغاز‬
FMS.32.7 - In case of gas pipe repairs or new  Document
extensions, outlets are tested for the type of gas to Review
ensure the correct type is delivered through the new
pipe. Results of testing are recorded and maintained
with engineering and the unit manager.

FMS.32
FMS.32.8 ‐ The hospital keeps standby oxygen and  Observation  Compare average consumption rate with the number of
medical air cylinders enough for forty eight hours  Staff Interview standby cylinders to ensure sufficiency for 48 hours.
of average consumption.  Make sure there are no active alarms for low pressure
‫مالحظة اسطوانات الغاز والحوار مع مسؤول الغازات يؤكد أن‬ during your visit the medical gas manifold
‫ ساعه‬٤٨ ‫احتياطي األكسجين والهواء كاف المداد المستشفى لمدة‬  Utility manager(s)/engineer(s) are aware of the average daily
consumption rate of oxygen and medical air.
FMS.32.9 ‐ The gas cylinders are regularly tested for  Observation  Observe that the gas cylinders are regularly tested for gas type,
gas type, amount, and any leaks. amount and any leaks.
‫مالحظة مايؤكد الفحص المنتظم السطوانات الغازات الطبية من حيث‬
‫الكمية والمحتوى والتسريب‬
FMS.32.10 ‐ Emergency shut off valves are available  Staff Interview  Interview clinical staff to ensure their awareness of PMG shutoff
in all units and are clearly marked with areas/rooms  Observation valves location and affected rooms. In addition to their ability to
affected demonstrate how to shut-off valves safely.
‫الحوار مع الطاقم الطبي مع المالحظة يوضح وجود صمامات الطوارئ‬  Observe availability of labels indicating room numbers served
‫للغازات الطبية في جميع الوحدات‬ by the gas valve box at wards.

FMS.32

Tools
FMS.32.11 ‐ The hospital  Staff  Interview staff responsible for valve shut off and make sure that he/she is aware of the
dedicates the responsibility of the Interview risk associated with valve shut off, breaking valve box cover, and what rooms are
closure of shut off valves to affected by closing the valve.
well‐trained individual(s) available
in the unit concerned
‫الحوار مع الطاقم الطبي يوضح وجود طاقم‬
‫مدرب على إغالق صمامات الطوارئ‬
‫للغازات الطبية‬
FMS.32.12 - The hospital has  Observation  Observe that the PMG outlets are adequate in patient care areas and are to be error
adequate medical gases outlets in proof.
the
patient care areas as appropriate
and these outlets are to be error
proof medical gas outlets‐ in
accordance with DIN standards
related to gases piping, outlets and
valves
‫مالحظة أن مخارج الغازات في غرف‬
‫المرضى غير قابلة للتبديل‬

ESR Visit Requirements
2022
DOCUMENT REVIEW LIST (Clinical)
SN Document Required
1 Policy for Credentialing and Privileging

Multidisciplinary and/or Blood Utilization Committee Approved Policies and Procedures on
2 Handling, Use and Administration of Blood and Blood Components
3 Policy for identification and management of venous thromboembolism
4 Policy for patient identification
5 Policy for preventing wrong patient, wrong site, and wrong surgery/procedure
6 Infection Control Annual Plan
7 Infection control committee’s term of references and meeting minutes
8 Policy for Standard and Transmission-based Precautions
9 Policy for Personal Protective Equipment
10 High-alert Medications and Hazardous Chemicals Multidisciplinary Plan
11 High-Alert Medications and Hazardous Chemicals List
12 Policy for Handling Look-alike/Sound-alike Medications
13 Hospital List of Confusing Drug Names,
14 Policy for Handling Medication Errors, Near-misses, and Hazardous Situations
15 Pharmacy and Therapeutics Committee Meeting Minutes
16 Evidence of reporting sentinel events related to serious medication errors to the relevant
authorities.
17 Laboratory policy, process and procedures on transfusion transmitted disease testing
18 Laboratory policy, process and procedures on limiting and detecting bacterial contamination in
PC
DOCUMENT REVIEW LIST (FMS)
SN Document Required
1 Radiation Safety Policy
2 KACST License for Radioactive Materials
Valid Civil Defense license for private hospitals. For governmental hospital, civil defense reports and
3
approved action plan.
4 Fire Alarm Inspection Schedule and Reports

5 Fire Alarm Testing Schedule and Reports
6 Fire Alarm Maintenance Schedule and Reports
7 Fire Alarm System Distribution
8 Sprinkler System Inspection Reports
9 Clean Agent System Inspection Reports
10 Wet Chemical System Inspection Reports
11 Stand Pipes and Hose System Inspection Reports
12 Policy for No Smoking
13 Medical Gas System Testing Schedule and Reports
14 Policy and Procedure on Effective Use of Medical Gas System
15 Medical Gas Outlets Testing Records for Gas Type

DOCUMENT REVIEW SESSION
1. Ensure to cover the required documents
2. Civil defense report & action plan
3. IC and P&T committee’s members should
present to guide the surveyors on the minutes
4. Other members related to the standards are
advised to be in the same room
MOST Common Questions:
1. How to identify the patients?

2. How to request blood?
3. How to monitor blood transfusion?
4. Do we have any blood reaction from blood transfusion?
5. Do you have screening for patient from DVT/VTE; Do you have prophylaxis
guidelines for patient at risk?
6. In case of surgery, where you do site marking?
7. Where you conduct conscious sedation?
8. Are the physicians and nurses conducting conscious sedation privileged?
9. What is your policy for HIGH Alert Medications?
10. What is your policy for LASA?
11. How to report Medication Error?
12. Do you have any RCA “Root Cause Analysis “?
13. What to do in case of fire?
14. Where are the nearest fire exits?
15. Is your isolation room supported with – ve pressure

‫‪THANK YOU‬‬

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‫إدارة الجودة والتميز االكلينيكي‬

‫برنامج معايير السالمة‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

AN.2 & CONTROL

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

HR.5.3 ‐ Credentials are  Personne

 Training should be based on JD

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Description (Instructions)

 Privileging policy should include; 1) definition of temporary and emergency privileges

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

‫ادارة االعتماد والتميز المؤسسي ‪ -‬برنامج امان ‪ESR‬‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Description (Instructions)

AN.15.1 ‐ Physicians who perform  All physicians (non-anesthesiologist) who perform

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

IPC.15 Facility design and available supplies support isolation practices.

 Hospitals are expected to have at least one negative

 Having adequate number of negative pressure

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

 Interview infection control staff and hospital staff to verify

IPC.15.3.1 Rooms designed for airborne isolation

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

Standard– Substandard Preparation Tools Description (Instructions)

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬

 Review hospital’s policy on single use or re-use of N95 masks: - If

ESR ‫ برنامج امان‬- ‫ادارة االعتماد والتميز المؤسسي‬