‫المديرية العامة للشئون الصحية بمنطقة نجران‬

‫مستشفى الملك خالد‬

‫ادارة التمريض‬

ESR QUESTIONNAIRE
QUESTIONS/TOPICS
What is ESR?
What are the categories of
ESR
The hospital has a process
for proper credentialing of
staff members licensed to
provide patient care
ANSWER
 Essential Safety Requirement
 ESR has set of the basic national requirements for patient safety in a list of 20
national hospital standards as key requirements that must be fully adhered to ensure
patient safety from health care errors.
 HUMAN RESOURCES (HR)
 MEDICAL STAFF (MS)
 PROVISION OF CARE (PC)
 QUALITY MANAGEMENT (QM)
 ANESTHESIA CARE (AC)
 INFECTION PREVENTION AND CONTROL (IPC)
 MEDICATION MANAGEMENT (MM)
 LABORATORY (LB)
 FACILITY MANAGEMENT AND SAFETY (FMS)
 The hospital has a written policy describing the process used for the verification of
credentials
 The hospital gathers, verifies and evaluate the credentials of those medical staff,
nursing staff and other health professionals licensed to provide patient care.
 Job responsibilities and clinical work assignments are based on the evaluation of the
verified credentials.
(IPP: AD-HR-001 (5) / NR-181)

Medical staff members List of medical staff name, specialty, approved privileges and renewal date as per
have current delineated credentialing and privileging committee. Such list is accessible in all clinical practice areas
clinical privileges for quick verification of privileges.

BLOOD TRANSFUSION 1. CONSENT:

What is to be secured prior
to blood transfusion
 Unless the situation is a lifesaving emergency, doctors will have gained parental
consent for the transfusion. Ensure that the consent form is signed and filled in the
notes.
 Consent is valid for the current admission and only needs to be documented once. For
patients requiring regular or frequent transfusions consent will remain valid for 12
months unless there is a significant change in the risk profile of transfusion.

2. PRESCRIPTION:
 The medic will have written on the prescription chart the blood product, the volume
required, date and duration of infusion. This must be signed by them. In addition, as a
medico-legal requirement, the notes must clearly state the reason for transfusion.

3. AVAILABILITY OF BLOOD PRODUCT

 Check on with the laboratory (Extn.1833) that the blood is available for collection.

4. CHECK PATIENT:
 Ensure IV access. Ensure pre-transfusion observations have been checked and
recorded.
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5. COLLECT BLOOD:
 Blood must be collected by staff trained in this process. Generally this is done by
nursing staff.
(IPP: LB-BBD-005 (5))

Who can be the witness Nurse or Patient affair can sign informed consent as witness for inpatients.
during obtaining the BT
consent?
(IPP: LB-BBD-005 (5) / MS-047(4))

Who can give orders to Treating physician

blood transfusion (IPP: LB-BBD-005 (5))

Who is responsible to Physician

obtain and explaining
consent for BT procedure
to the patient/significant
others? (IPP: LB-BBD-005 (5))

Safe collection of blood  Two nurses verify the patient’s identity prior to blood drawing for cross match.
samples for pre-  The blood collector must sign the cross match requisition
transfusion compatibility  The specimen tube is labeled at the BED SIDE(not pre-labeled)
testing  The sample must be labeled immediately after the blood has been added, before
leaving the patient.
(IPP: LB-BBD-011 (5))

Safe Administration of
Blood Products
How often the vital Signs
must be monitored during
the Blood Transfusion
Blood transfusion reaction
Checking the unit of blood will take place at the patient’s bedside by” INDEPENDENT
DOUBLE CHECK “or by the two registered nurses.
(IPP: LB-BBD-011(5))
 Transfusion should commence within 30 minutes of a pack of red cells being removed
from the blood bank.
 Vital signs must be taken before starting the transfusion of all blood products. It must be
recorded every 15 minutes in the first hour of transfusion then every 30 min until the
end of transfusion. It must be recorded after finishing the transfusion.
(IPP: LB-BBD-011 (5))
1. Stop transfusion immediately
2. Notify Physician
3. Check vitals, start IV fluid NS by using other IV set.
4. Recheck cross match record with unit.
5. Obtain 2 blood samples
6. Obtain first Urine Analysis test for hemoglobinuria
7. Monitor fluid /electrolyte balance
8. Evaluate serum calcium levels
9. Fill up blood transfusion reaction form, return the blood unit with transfusion set to
blood bank.
10. Initiate OVR.
(IPP: LB-BBD-011 (5))
 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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What is VTE Venous Thromboembolism(VTE)

-All patients admitted to King Khalid hospital must be assessed for the risk of VTE within
24 hours of admission.
-The initial risk assessment should be reviewed by a senior clinician within 24 hours of
admission.
-Cover all adult patients (18 years and older)
-Re-assessment of VTE:
.If the score is 0-1(low risk): Reassess regularly after 72 hours.
.If the score is from 2 and more: Need to be reassessed weekly or on the 8th day.
(IPP: MS-056 (3))

Conscious Sedation
Conscious Sedation Areas
Areas in which conscious
sedation is performed
should have the following
necessary
equipment to provide safe
care
How do you identify the  Patient full name and medical record number are required whenever taking blood
Patient? When do you
identify the Patient?
 The hospital has a standardized approach to patient identification.(Use of ID bands).
 Conscious sedation may be used for patients who meet the criteria for moderate &
deep sedation at this hospital, outside of the OR, who receive anxiolytic, analgesic
or hypnotic drugs in an attempt to obtain moderate or deep sedation for diagnostic,
invasive or minor surgical procedures in areas that is fully equipped
 Conscious sedation shall not be given without an order from the physician.
 "Time-Out" is conducted immediately before starting the procedure as described in
the universal protocol.
 All patients receiving conscious sedation will be appropriately monitored, by a
nurse in physical presence of the physician, from the time of administration of
sedation until discharge criteria for conscious sedation have been met.
 The registered nurse (trained in conscious sedation) managing the care of the
patient receiving conscious sedation shall have no other responsibilities that would
leave the patient unattended or compromise continuous monitoring .The registered
nurse (trained in conscious sedation) shall assist the physician in supportive or
resuscitation measures.
 All documentation for patients receiving conscious sedation will be done in the
approved Moderate and Deep Sedation Intra-Monitoring form.
 Minimum personnel during the procedure shall be two qualified professionals (1
physician & 1 nurse with one patient).
(IPP: MS-AN-010 (7))
 Emergency department
 Radiology department (Angiogram, MRI, CT Scan).
 Cardiac Catheterization Unit
 Endoscopy
 ICU
 OR
(IPP: MS-AN-010 (7))
 Wall suction or suction equipment
 Pulse oximetry
 Oxygen source
 Automated blood pressure monitoring, ECG monitor
 A crash cart with defibrillator, medications, IV access, and intubation equipment
that is appropriate to age of the patient.
(IPP: MS-AN-010 (7))
samples, administering medications or blood products or performing procedures.
(IPP: AD-QM-006 (6))
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To ensure correct site, 5 process:

correct procedure and -Surgical site marking: The unambiguously intended site of an incision or insertion, which
correct patient surgery has been previously agreed by the patient with informed consent.

-Pre-op verification check list: Done by the nurse in charge of the patient using a check list
to make sure that all requirements for surgery/procedure carried out.

-Sign-in :Pre-operative procedure verification process conducted in operating room before

induction of anesthesia

-Time-out: The final verification process of the patient before performing any
surgical/invasive procedure in operating/invasive procedure room and is conducted before
incision.

-Sign-out: before patient leaves the operating or procedure room to ensure safe completion
of the procedure.
(IPP: AD-QM-004 (8))
Anesthesia staff members 1. Physician who performs moderate and deep sedation has competency based privileges
have the appropriate granted to perform moderate and deep sedation/analgesia.
qualifications
2.Clinical staff who participate in caring for patients receiving moderate or deep sedation
are certified in ACLS.

3.Clinical staff who participate in conducting sedation must successfully complete a proper
education/training on moderate and deep sedation .
(IPP: MS-AN-SOS-001 (5))
What is the discharge
criteria for conscious
sedation
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Hand Hygiene
Types of Hand Hygiene
l) Routine Handwash ----- 40-60 seconds
2) Alcohol-Based Handrub ---- 20-30 seconds
3) Anti-septic Handwash----- l-2 minutes
4) Surgical Handwash ------ 3-5 minutes

Types & lndication of Hand Hygiene:

l. Routine Hand washing - Wash hands with soap and water when visibly dirty or visibly
soiled with blood or other body fluids, or after using the toilet.

2. Antiseptic hand wash - removal or destruction of transient microorganisms washing

hands with water and soap or other detergents containing an antiseptic.

3. Alcohol-based hand rub - as the preferred means for routine hand antisepsis in all other
clinical situations it applies, if hands are not visibly soiled.

4. Surgical hand hygiene/antisepsis - Surgical hand antisepsis should be performed using

either a suitable antimicrobial soap or suitable alcohol-based hand rub, preferably with a
product ensuring sustained activity, before donning sterile gloves, the duration of entire
procedure is 3 - 5 minutes duration.

5 Moments of Hand Hygiene:

Moment #1. Before touching the patient
Moment #2. Before clean Aseptic procedure
Moment #3. After blood body fluid exposure risk
Moment #4. After touching the patient
Moment #5. After touching patient surroundings
(IPP: IC-007 (5))
What are the 2 kinds of Standard Precaution
Isolation Precaution? Expanded Precaution
What is Standard -Standard precautions must be designed for the care and safety of all patients regardless of
Precaution their diagnosis or presumed infection status and for the safety of all personnel and visitors
- Standard precaution (SP) is the primary strategy for preventing transmission of
microorganisms to patients; they are applied to all patients.
Examples:
Proper Hand Hygiene
Proper Use of PPE
Proper disposal of medical waste and sharps
Proper handling of laboratory specimen and blood products
Cough etiquette
Patient Placement
Environmental Services
Removing spill of Blood and body fluids
(IPP: IC-006 (5))
What is Expanded Expanded precautions are the designed precautions for patients with documented or
Precaution suspected infection with communicable or epidemiology important pathogens for which
additional precaution beyond standard are needed to interrupt transmission.

The aim of isolating a patient is to prevent the spread of communicable.

 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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TYPES OF EXPANDED PRECAUTIONS

(Transmission Based Precaution):

Airborn Precaution (BLUE sign on the door)

- N95 Mask -- prevent transmission by air current)

Droplet Precaution (GREEN sign on the door)

- Surgical Mask - prevent transmission by small and large droplets

Contact Precaution (RED sign on the door )

- Gloves and Gown -- prevent transmission by direct or indirect contact
(IPP: IC-009 (5))

Reading of negative -2.5 to -20 pascal (To be monitored daily if there is patient, and weekly if there is none)
Pressure Room With Nurse’s Signature
(IPP: IC-009 (5))
Negative Pressure Air Minimum of 12 air exchange per hour (To be monitored every 3 months) with Engineer’s
Exchange Signature
(IPP: IC-009 (5))
Personal protective DONNING OF PPE:
equipment(PPE)
a.Hand Hygiene
b.Gown
c.Mask(N95/surgical mask)
d.Eye Protection/Googles
e.Face shield
f.Gloves

DOFFING OF PPE:

a.Gloves
b.Hand Hygiene
c.Face shield
d.Gown
e.Hand Hygiene
f.Mask(Outside of the isolation Room)
g.Hand Hygiene
Key performance 1. Hand Hygiene by hospital wide/departmental/professions
Indicators for infection 2. MDRO project (ICU, surgical ward and oncology)
control 3. Reduction of CLABSI in ICU.
What is medication error? A medication error is any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the health care
professional, patient, or consumer. Such events may be related to professional practice,
health care products, procedures, and systems, including prescribing; order communication;
product labeling, packaging, and nomenclature; compounding; dispensing; distribution;
administration; education; monitoring; and use.
.(IPP: PH -012 (8))
 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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What are the 7 rights of Observe the 7 rights of MEDICATION ADMINISTRATION

MEDICATION
ADMINISTRATION? Right Medication
Right Patient
Right Dosage
Right Route
Right Time
Right Frequency
Right Documentation
(IPP: PH-012 (7) / NR-129(4))
Medication Error Form Process Involved with Description of the error:

Selection/Procurement
Ordering/Prescribing/Transcribing
Preparing/Dispensing
Administration
Monitoring )
Compliance
Impact of the error
Outcome of the Error if it reached the patient
Immediate Actions Taken
Physician Follow-up: (If error reached the patient)
Action taken by The Responding Department to prevent recurrence of such an error
(IPP: PH-012 (7))
What do you do if a -Look for possible intervention to correct it if detected before reaching the patient.
Medication Error is -Detected after reaching the patient call the MRP for any interventions to be made for
detected? preventing further harm to the patient, and then initiate a medication error report within 24-
48 hours and send to the pharmacy.
(IPP: PH-012 (7))
What does the pharmacy Step-1 :A pharmacist assigned by the Director of Pharmacy gets an explanation from the
do with the report? concerned person who is responsible for the error through his/her immediate supervisor.
Step-2: The report with the explanation and suggestions from pharmacy to prevent
recurrence such errors is sent to the chief of the concerned department for his/her response.
Step-3: Then a copy of the completed reports is sent to the quality improvement and patient
safety department.

The reports are discussed in the pharmacy and therapeutics committee and the concerned
department heads notified to take process improvement projects to prevent such errors in
future.
(IPP: PH-012 (7))
Floor stock in the ward A list of medications and their quantities to be kept as stable stock and should be kept to the
minimum.
(IPP: PH-007 (5))
LASA Medications Look Alike and Sound Alike Drugs‐ also known as confused medications. medications
labeled with the yellow "LASA" sticker

-Minimizing the use of verbal and telephone orders for LASA medicine
-Placing LASA medications in locations separate from each other or in non-alphabetical
order.

To ensure the safety of LASA is by following the TALLman method of labeling

 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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(Eg,hydrOXYzine,hydrALAzine),and by independent Double Checking by the nurses upon

administration.
(IPP: PH-048 (7))
High Alert Medications These are medications that are handled with extra precaution and heightened risk of causing
significant patient harm when used in error which may result in serious patient harm. To
ensure the safety should be stored in a special and secured place separated from the regular
stocks and all such drugs should carry a RED warning sticker "HIGH ALERT”.
(IPP: PH-069 (1))
LIST OF HIGH ALERT MEDICATION (JAN 2017) PH-023 Appendix 1
What special procedure Independent double check is performed before administration of high alert medications.
should be followed before
administration of high
alert medications?
Medication Reconciliation It is "the process of comparing a patient's medication order to all of the medications that the
patient has been taking. It should be done at every transition of care in which new
medications are ordered or existing orders are rewritten.

This process comprises (5) five steps:

l) develop a list of current medications the patient is taking before admission,
2) develop a list of medications to be prescribed,
3) compare the medic*ions on the two lists,
4) make clinical decisions based on the comparison to sort out discrepancies, and
5) communicate the new list to appropriate caregivers and to the patient when he/she is
discharged.
(IPP: PH-055 (4))
Near Miss Is an event or situation that could have resulted in an accident, injury or illness, but did not,
either by chance or through timely intervention.

Eg-1:Prescribing a medication not indicated for the patient but discovered before dispensing
of medication meant for one patient to another patient but discovered before the patient
used it.
Eg-2:Preparing a wrong medication or a wrong dose for administration to a patient but
discovered before administration.
(IPP: AD-QM-013 (2))
Sentinel Event An unanticipated occurrence involving death or serious physical or psychological injury
specifically loss of limb or function. Such events are called sentinel because they signal a
need for immediate investigation and response

(IPP: AD-QM-003 (7))

Sentinel Event includes but
not limited to:
 An unexpected death including but not limited to:
 Death that is unrelated to the natural course of the patient's illness or underlying
condition (for example, death from a postoperative infection or a hospital-acquired
pulmonary embolism
 Death of a full-term infant
 Suicide of patient in an inpatient unit.
 Unexpected loss of limb or function unrelated to the patient’s natural course illness or
underlying condition
 Wrong patient, wrong procedure, or wrong site surgery
 Transmission of a Chronic or fatal disease or illness as a result of infusing blood or
blood products or transplanting contaminated organs or tissues
 Retained instruments or a sponge
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 Serious medication error and adverse drug reactions leading to death or major
morbidity Infant abduction or infant who was discharge of a wrong family
 Intravascular gas embolism
 Hemolytic blood transfusion reaction
 Air embolism
 Maternal Death
 Rape, workplace violence such as assault (leading to death or permanent loss of
function); or homicide (willful killing) of a patient staff member, practitioner, medical
student, trainee, visitor' or vendor while on hospital property.
(IPP: AD-QM-003 (7))
Root Cause Analysis Is a process for identifying the basic or causal factors that brings about variation in
performance, including the occurrence. Or possible occurrence, of a sentinel event. A root
cause analysis focuses primarily on systems and processes, not on individual performance
(IPP: AD-QM-003 (7))
Process of OVR / RCA AD-QM-003 Appendix 1
Do you use any No
investigational or
radioactive medications in
the hospital?
Are sample medications No
allowed to be used in the
hospital?
Do you keep any sample No
medications in the OPD
clinics or the nursing
units?
Which concentrated Sodium chloride 3%,potassium chloride (KCL)15%
Electrolytes are available
in the hospital?

Are the concentrated

Electrolytes present in the
patient care areas as floor
stock?
What is TLD?
NO, the pharmacy supplies only the diluted ones when required.
Thermoluminescent dosimeter for monitoring occupational radiation doses exposed to by
radiology workers and other staff exposed to radiation.

(IPP: MS-RD-079 (4))

How long is the TLD  3 months
Badge wearing period? (IPP: MS-RD-079 (4))
Action taken when test  The annual limit of occupational dose for workers is 20 mSv.
result exceeds permissible  If the reading of TLD exceeds 5.0 mSv quarterly, these action should be applied
level  RSO and/or Radiation Safety Committee will conduct an investigation on the
way you are wearing & keeping the TLD.
 Transferring of the worker to non - ionizing radiation area.
 Sending the worker to Bioassay blood test which includes:
 Red Blood cell Count (RBC)
 White Blood cell Count (WBC)
 Neutrophils
 Lymphocytes

The hospital ensures that
all its occupants are safe
from radiation hazards
The hospital has an
effective fire alarm system
The hospital has a fire
suppression system
available in the required
area
There are fire exits that are
properly located in the
hospital
The hospital and its
occupants are safe from
fire and smoke.
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
‫مستشفى الملك خالد‬
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 Basophils
 Eosinophils
 Platelets (PLT)
(IPP: MS-RD-079 (4))
 The hospital has a radiation safety policy and procedure and it is implemented.
 All radioactive materials are clearly labeled and safely and securely stored.
 Lead aprons and gonad/thyroid shields are available to cover patients and staff needs
and are annually tested according to a hospital wide inventory
 There is fire alarm system that is functioning and regularly inspected.
 The fire alarm system testing results are documented.
 The fire alarm system has preventive maintenance.
 The elevators are connected to fire alarm system.
 The hospital has a functional sprinkler system.
 The hospital has wet chemical system
 The hospital has stand pipes and hose system.
 Fire exits are available and are properly located in the hospital
 Fire exits are not locked.
 Fire exits are not obstructed
 Fire exits are fire resistant
 Fire exits are clearly marked with illuminated exit sign.
 The hospital implements a strict “ no smoking” policy
 There are no obstructions to exits, fire extinguishers, fire alarm boxes, emergency
blankets, and safety showers.
 Emergency lighting is adequate for safe evacuation of the Hospital.
 Storage areas are properly organized
 Shelves and racks are study and in good condition
 No items stored directly on the floor(Minimum of ten centimeters is left to manage
spills)
 Items should be stacked on a flat base.
 Heavier objects are close to the floor and smaller objects are higher
 Items are not stacked so high to block sprinklers or come and contact with the
overhead lights or pipes (Minimum distance of fifty centimeters from ceiling level.)
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RACE
(IPP: FMS-SF-005 (4))
What you must do if fire starts?

R
RESCUE
 Keep calm. Do not PANIC.
 Follow your fire plan.
 Get your patients and residents
out of danger.
 Move them to a safe place inside
if you can.
 Move them outside if there is no
safe place indoors.

ALARM

A
 You must then pull the fire alarm.
Fire alarm panels shall have lamps
and fuses tested periodically.

 Where the fire alarm panel is

monitored remotely from the site,
the connection shall be tested
monthly.
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Examples

E
Extinguish the fire
if you can safety do it without
causing any danger to yourself
and others and if needed
EVACUATE.
 If the fire is a very small one
that you can quickly and
safely put out using water or
a fire extinguisher, do it.
 If the fire is too big, get
everyone out and pull the
alarm.
 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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All personal items should be left

behind. No one should go back to
get personal items. They may never
get the chance to leave again.
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‫‪PASS‬‬
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How to use fire blanket Remove the fire blanket by pulling down sharply on the tapes hanging from the bottom
of the package. Fire blankets are generally stored in small bags with two black tapes
hanging down. Pulling on the tapes will quickly release the blanket, allowing for quick
access in the event of an emergency.

Proper maintenance of the
medical gas system
OPENED GAS VALVES
 The medical gas system is regularly tested for PRESSURE, LEAKS,
FUNCTIONALITY OF VALVES, ALARMS, PRESSURE GAUGE AND
SWITCHES.
 The Gas cylinders are regularly tested for gas type, amount and any leaks.
 Only head nurse or team leader should shut of medical gas after ensuring the patients
are shifted to portable Oxygen.

Things to remember 1. How to identify patients?

2. How to request blood?
3. How to monitor blood transfusion?
4. Do you have screening for patient from DVT/VTE, do you have prophylaxis
guideline for patients at risk?
5. Where and who will do site marking?
6. Where do you conduct conscious sedation?
7. Are the physicians and nurses conducting conscious sedation is privileging?
8. What is your policy for High Alert Medications?
9. What is your policy for LASA medications?
 ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
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10. How to repost medication error?

11. Do you have RCA “Root Cause Analysis”?
12. What do you do in case of fire?
13. Is your isolation room supported with –ve pressure?
14. How to assure radiation safety?
15. Where are the nearest fire exits and assembly point?
16. Where is your nearest fire break glass point?
17. Where is your nearest fire extinguisher?
18. How many emergency exits are there in the hospital? Which is the nearest to your
department?
19. Where your fire assembly area and what is is the number assigned for it?
20. What is the emergency number to call for all emergency codes?
21. When was the fire drill conducted in your unit and hospital wide?