HOS MEETING

16 August 2012
@ 10.00 am

By : Saniah Abu
Clinical Surveyor
 Audit Report for Maternity Ward
on 2/8/2012 :
Findings Standard Recommended Responsible Time
ME Action Person Frame

IPSG 1 IPSG 1 • Staff to know All staffs Immedia

Identify Patient the 6 IPSG tely
Correctly •Staffs to
• Found that staff
attend
unable to explain the 6 training/
IPSG, manage to awareness
answer 3 IPSG only
• Observed that staffs

did not adhered policy

& procedure of IPSG 1
upon serving of
medication.
Findings Standard Recommended Responsible Time
ME Action Person Frame
IPSG 3: •Staffs to All staffs Immedia
Improve the safety of IPSG 3 attend training tely.
high alert medication. / awareness.
• Found that staff did

not fully understand

what is High Alert
Medication.

Medication The
• Consultant Immedia
Management and Use MMU 4.1 Frequency of in charge of tely
(MMU) QID shall be the patient.
• Found that PCM 1 gm off before the
has change the new frequency
frequency from QID to to be start.
TDS, however the
consultant did not off
the QID frequency but
just write TDS and the
date to start.
Findings Standard Recommended Responsible Time
ME Action Person Frame
Patient and Family •To ensure All Immedia
Rights ( PFR) PFR 1 that patients admission tely.
• Found that staff are are informed and ward
able to understand about PFR and staff
what is PFR, however to ensure that
patient is not aware phamlet are
about PFR and no given upon
phamlet was given to admission.
the patient upon
admission
Assessment Of Patient •Staffs to All staffs. Immedia
(AOP) adhered Policy tely.
•Found that Initial
AOP and Procedure
Assessment was done
upon admission
however the
reassessment not
consistently done.
Patient has been
Findings Standard Recommended Responsible Time
ME Action Person Frame
Admitted for 3 days but
reassessment only done
twice.
•Noted that incomplete
•Staffs to All Staffs Immedia
of documentation. complete the tely.
Initial
Assessment
Form.
Prevention And Control
Of Infection ( PCI) • Proper
• Found that medication cleaning of
PCI 7.2
Trolley bin is dirty, general waste
waste is not properly bin.
thrown and also found • Proper
that used swab with disposal of
blood stained. waste.
Findings Standard Recommended Responsible Time
ME Action Person Frame
• Found recap needle PCI 7.3 •Strictly no All staffs. Immedia
inside the sharp bin. recapping of tely
needle.

•General •Reinforce staff All staffs.

waste are PCI 7.2 Immedia
thrown into clinical to adhered tely
waste bin. policy and
procedure
proper
disposable of
waste.
•