Jci Booklet Eng

JCIA BOOKLET

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TOPIC CEO Message KSMC Mission, Vision, Core Values Me and My Job Joint Commission International Accreditation International Patients Safety Goals FOCUS PDCA

PAGE NUMBER 3 5 5 6 8 12

Performance Improvement Projects JCIA Chapters Patient and Family Rights

13 13

Privacy and Confidentiality Informed Consent Patient and Family Education

18 19

Assessment and Care of Patient Physicians` Documentation Physical Restraint Moderate And Deep Sedation Medication Safety Infection Prevention and Control Sentinel Event and Root Cause Analysis Occurrence Variance Accidental Report Emergency Color Codes Fire Safety Safety and Security KSMC web site

Prepared by: Dr. Yousef Sharif Ms Anhar Al Bousi Mrs. Sujamol Mathew

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22 23 25 27 28 29 32 37 39 41 42 44 45

Supervised by: Dr. Saif Ibrahim Director Total Quality Management Department

MESSAGE OF CEO Dear KSMC family, Patients Safety First: - is the shared commitment in the King Saud Medical City and main goal of Ministry of Health. The approach is strengthening the organization’s ability to achieve world class outcomes in education and patient care through an atmosphere of team work, trust, passion and pursuit of excellence. To reflect the implementation of our vision, mission and values that in consistent with MOH vision, mission and values and to implement royal decision and MOH minister’s instruction to improve the quality of health care services. Based on that, we are moving towards the continuous quality improvement. We got CBAHI accreditation, which is the first step of our system improvement as national accreditation program. Now we will move towards the JCIA program for continuous quality improvement through the implementation implementing all standards which will maintaining and ensuring patient safety and staff development. Total Quality Management department team in collaboration with other departments developed this booklet in English and Arabic to outlines the most important standards, safe practices as well as pertinent policies and procedures. I have found them most useful and I am sure you will also get benefited from them. I would like to thank you on behalf of all the patients and their families for your excellent hard work and congratulate you for your firm commitment and loyalty to our organization in its pursuit of excellence. Sincerely, DR. NABIL AL GOSAIBI Chief Executive Officer, King Saud Medical City

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MESSAGE OF TQM DIRECTOR Dear colleagues, Thanks to our staff members’ for their dedicated service and commitment towards achieving excellence. The achievements of KSMC are the results of the combined efforts of all KSMC members. Our focus is now to continuously distinguish ourselves as a regional health care leading institution. We’re committed to continuously search for new ways to improve our quality and make our hospital the best place for patients to receive care, for physicians to practice and for employees to work. I extend my sincere thanks for all your support to our hospital. The TQM department staff members are always here for you as a consultant, facilitator, advisor and also as educators for the patient safety improvement initiatives. As a part of our progress towards innovation and the accreditation process TQM prepared the educational material (JCIA booklet) for all KSMC employees that I hope you will find this booklet most useful.

Sincerely, DR. SAIF IBRAHIM TQM Director, King Saud Medical City

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives”.

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KSMC Mission We are committed to provide safe and distinct health care for our patients through effective management and qualified staff while seeking to achieve good training and continuous development with the optimal use of the available resources KSMC Vision King Saud Medical City will be the Pioneer Health Organization in providing the best health care in the Kingdom. KSMC Core Values • Adhering to the rules of Islamic religion, laws and regulations in KSA. • Respect of patients and their rights. • Transparency and mutual respect among workers • Work with team spirit. • Adhering to medical ethics and professional morale. Me and My Job KSMC needs qualified and skilled people to meet its mission and exceed patient satisfaction needs. Our staff is recruited as per the organizations staffing plan. They are oriented to the organization and assigned a specific job description. Each staff is provided an opportunity to learn and develop both personally and professionally. Some of the questions that ALL staff must be able to answer:  What is my role in KSMC? How does my job contribute to or support those who provide patient care of KSMC?  How was I oriented to the hospital and to my

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job?  How am I being evaluated and supervised?  Do I keep all my license, registration and / or certification current?  What are ongoing in-service education and Training and Competition I participated in?  Does my HR file contain copies of my in-service education attendance?  How do I identify my privileges as a clinician before certain procedures?  What quality improvement projects I participated in?

Joint Commission International Accreditation What is Accreditation? Accreditation is a voluntary process in which an entity (e.g. JCI), separate and distinct from health care organization, usually non-governmental, assess the health care organization to determine if it meets a set of international standards to improve the quality of care provided. What to expect from JCI? Surveyor will review the medical record with the direct care provider (knowledge and practice) and ask questions. Sample questions:    

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Tell me about your patient? (History, reason for admission, tests, current condition) How do you assess your patients on admission? Show me where you document this? How do you assess patients for pain? Show me…..



What is your role in patient education?....where do you document?  How do you prepare patients for discharge?  What skill do you need to work in this area?....Surveyor may then review the staff file. What to Do and What Not to Do?  Don’t run away…  Welcome the surveyor to your area  Introduce yourself; explain your position and how long you’ve been here.  The surveyor wants to hear about your everyday practice (safe and competent care)  Answer only what you’re asked  Do not volunteer additional information  Ask for clarification if you do not understand the question  If unsure of the answer, the safest response is that you’d check the policy or ask your supervisor  Try to allocate appropriate space for the tracer team to do the interviews  Don’t show panic behaviors, or inappropriate body language Focus Areas  Environment- medical record charts, computers, (clean organized unit) Fire Safety (RACE, nearest fire exits, extinguishers, alarms).  Patients and family rights  Assessments- nutritional, functional, discharge planning, etc..  Pain assessment (scales, documentation & reassessment)  Patient identification (using 2 unique identifier)  Using read back with verbal/telephone order and critical result  Falls assessment and reassessment  Procedural sedation  Orientation/competencies/training  Patient and family educationdocumentation  Quality improvement activities

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 

Restraint management Hand hygiene compliance

International Patient Safety Goals Joint Commission introduced its 6 patient Safety Goals in 2007 to highlight problematic areas in health care and to describe evidence based-and expert based solutions for these problems. IPSG 1 Identify Patients Correctly APP-KSMC-028-(V2) Patient Identification 1. Use at least two (2) ways to identify a patient when: 1.1. Giving medications 1.2. Giving blood and blood products 1.3. Taking blood samples 1.4. Taking other samples for clinical testing 1.5. Providing treatment or procedure 1.6. Also when food is served. 2.

The two unique identifiers are: 2.1. Patient’s medical record number (MRN) 2.2. Patient’s full name

3.

The patient’s Room Number or Bed Number must never be used to identify patients.

IPSG 2 Improve Effective Communication APP-LB-007 Critical Result Reporting Policy Communication can be verbal, electronic or written 1. Staff must use “read back” to identify the complete order or test result in the following situation: 1.1. Verbal order

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1.2. Telephone order 1.3. Reporting of critical result value

2.

The receiver of the information will write down the complete order or test. A colleague will then be requested to read back the written order or test result to the individual who gave the order or test result.

3.

The order or test result is confirmed by the individual who gave the order or test result.

IPSG 3 Improve the Safety of High-Alert Medications APP-KSMC-137- (V1) High Alert Medication Management 1.

Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas permitted by policy.

2.

Remove concentrated electrolytes from patient care units, including, but not limited to the following: 2.1. Potassium Chloride 2.2. Potassium Phosphate 2.3. Sodium Chloride > 0.9%

IPSG 4 Ensure Correct-Site, Correct- Procedure, Correct-Patient Surgery APP KSMC 045 Surgical and/or Procedural site verification. 1.

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Make sure it is the correct patient using two patient identifiers.

2.

Verify the correct documents (medical records, consent, radiological images, laboratory test results, etc….)

3.

Mark the correct site, side, or level with the patient’s and/or legal guardian’s involvement.

4.

Verify correct equipment and implants, if needed.

5.

Conduct the “Time-Out” process, just before the surgery and/or invasive procedure, by way of final verification of the correct patient, correct procedure, correct site, and correct implants( if applicable) through active communication among all members of the surgical and/or procedure team).

IPSG 5 Reduce the Risk of Health Care Associated Infections APP-KSMC-180Hand Hygiene 1.

The hospital implements an effective hand hygiene program.

2.

The hospital has adopted or adapted currently published and generally accepted hand hygiene guidelines (can be national or international).

3.

Need data to demonstrate effectiveness. (Know your Unit’s hand hygiene compliance)

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IPSG 6 Reduce the risk of Patient Harm Resulting from Falls APP- KSMC – 216 Patient Falls Prevention 1.

Assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen.

2.

Take action to decrease or eliminate any identified risks.

3.

Document all the assessments.

International Patient Safety Goals (IPSG) Goals

Goal 1

Goal

Identify Patients Correctly

Improve Effective 2 Commun ication

Goal 4

Goal 5

Ensure CorrectSite, CorrectProcedure, CorrectPatient Surgery

Reduce the Risk of Health Care– Associated Infections Reduce the

Improve the Safety of High-Alert Medications

Goal 3

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of Goal 6 Risk Patient Harm Resulting from Falls

FOCUS-PDCA MODEL F- Find a process to improve O- Organize a team that knows the process C- Clarify current knowledge U- Understand variation S- Select potential process improvement -

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Plan Do Check Act

Examples of Performance Improvement Projects in KSMC: 1. Reduce the risk of improper patient identification prior to surgical procedure. 2. Reduce the risk of ineffective communication between staff (regarding to verbal orders). 3. Reduce the risk of patient harm resulting from improper storage and identification of high alert medications. 4. Increase the rate of documentation of surgery safety check list. 5. Reduce the rate of CLABSI (Central line associated blood stream infection). 6. Increate the rate of compliance to hand hygiene guidelines. 7. Reduce the risk of patient falls and fall related injuries. 8. Reduce the occurrence of pressure sore during hospitalization. 9. Improve the employee health program. 10. Increase the patient satisfaction regarding to cleaning services. 11. Establish an educational channel for patients. Joint Commission International Accreditation for Hospitals 2011 14 Chapters Summary: Chapter1: International patient safety goals chapter IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections

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IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls Chapter 2: Access and Continuity of Care Chapter (ACC) Access and continuity of care chapter require from health care organization to provide the care as part of an integrated system of services, health care professionals, and level of care to make up a continuum of care. Chapter 3: Patient and Family Rights Chapter (PFR) Patient and Family Rights chapter require from health care organization to understand and protect each patients’ cultural, psychosocial, and spiritual values. Chapter 4: Assessment of Patients (AOP) Assessment of patient chapter requires the healthcare organization to have an effective patient’s assessments process results in decisions about the patient’s immediate and continuing treatment needs for emergency, elective or planned care, even when the patient’s condition changes. Chapter 5: Care of Patient Chapter (COP) Care of patient chapter require from health care organization to provide the most appropriate care from all discipline that care for the patient. Chapter 6: Anesthesia and Surgical Care (ASC) This chapter focus on the use of anesthesia, sedation in a health care organization, this require complete and comprehensive patient assessment, integrated care planning, continued patient monitoring. Anesthesia and sedation are commonly viewed as a continuum from minimal sedation to full anesthesia.

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Chapter 7: Medication Management and Use(MMU) Medication Management and Use Chapter require the healthcare organization to manage medication effectively in order to ensuring patient safety. Chapter 8: Patient and Family Education Chapter (PFE) Patient and Family Education Chapter requires the health care organization to provide patients’ and their families with effective education according to their needs. Chapter 9: Quality Improvement and Patient Safety (QPS) Quality Improvement and Patient Safety (QPS) Chapter describes a comprehensive approach to quality improvement and patient safety. Integral the overall improvement in quality is the ongoing reduction in risks to patient and staff. Chapter 10: Prevention and Control of Infection Chapter (PCI) Prevention and Control of Infection Chapter requires the health care organization to determine infection control program activities depending on institution clinical activities and services, patient population, geographic location, patient volume, and number of employees. Chapter 11: Governance, Leadership and Direction Chapter (GLD) The Governance, Leadership and Direction Chapter requires the healthcare organization to identify organizational leaders and others who hold positions of leadership, responsibility, and trust and involve them in defining its mission and ensuring that the organization is an effective, efficient resource for the

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community and its patients. It consists of 26 standards and a total of 91 measurable elements. Chapter 12: Facility Management and Safety (FMS) Health care organization work to provide a safe, functional and supportive facility for patient families, staff and visitors. The physical facility medical and other equipment and people must be effectively managed. Chapter 13: Staff Qualification & Education (SQE) This chapter will work on providing an appropriate variety of skilled, qualified people to fulfill the health care organization’s mission and meet the needs of the patients it serves. Chapter 14: Management of Communication and Information (MCI) Management of Communication and Information (MCI) requires the healthcare organization to manage information effectively in order to provide, coordinate and integrate the services provided to patients. Effective communication with the community, patients and their families and to other health professionals is an integral part of the patient care process.

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Patients & Family Rights APP-KSMC-163 Patient Rights & Responsibilities 1. PRIVACY The patient has the right to refuse to talk to or meet anyone who is not officially and directly involved in the healthcare provided to him/her including visitors. Medical assessment and examination are to be conducted in designated areas out of the sight and hearing of others.

2.

CONFIDENTIALITY Only direct health care providers have access to patient’s files and details of their condition.

3.

REFUSAL OF TREATMENT When a patient refuses care or chooses to discontinue treatment/, he/she will be advised of the consequences of his/her refusal and the expected outcome of this decision.

4.

COMPLAINTS RESOLUTION

The Patient Relations Department and its representatives at KSMC medical facilities familiarize patients and their families with valid rules and regulations and how to submit proposals, opinions, and complaints and provide them with the required feedback. 5.

INFORMED CONSENT The patient (or his/her family) is entitled to have a complete explanation of the medical procedure required for his/her treatment, including risks and benefits of the proposed procedure, its complications, and alternative treatments.

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6.

PAIN MANAGEMENT Patient has the right to have his/her pain assessed and addressed as part of his treatment plan.

7.

SAFETY The patient has the right to expect appropriate and reasonable provision of personal safety insofar as KSMC treating/healthcare facilities, environment, and personnel practices are concerned.

8.

RESPECT, DIGNITY AND CONSIDERATION Patients have the right to considerate and respectful care at all times and under all circumstances with due recognition of his/her personal dignity

Privacy and Confidentiality These are some best practices to maintain patient privacy and confidentiality: DO’s    

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Log-out after using the computers in patient care areas. Close doors and curtains during treatment and examination. Cover patients appropriately during treatment and transport. Modulate voice volume in areas where privacy could be compromised.

Think about what you say and where you say it DON’T’s     

Do not share computer passwords. Do not discuss patient-specific information in public areas like elevators, food courts and hallways. Do not display patient-specific information on notice boards accessible to the public. Do not leave medical records in public areas or unattended by staff. Do not give treatment, or perform physical examination or procedure if the patient belongs to the opposite gender, without the presence of a person/chaperone/care-provider of the same (patient’s) gender present.

Informed Consent APP-KSMC-093 Obtaining General Consent APP-KSMC-027 Informed Consent It is the policy of the King Saud Medical City (KSMC) to administer consent for admission to hospital for general treatment, and all invasive or special procedures, surgical procedures and medical treatment. Consent for general treatment will be obtained by the Registration/Admissions clerk at the time of registration or admission. Informed Consent 1. It is the process whereby the attending physician or designee, from the team performing the surgery/procedure, provides the following information to the patient, legal guardian, custodian about specialized (non-routine) procedure(s). 2.The patient‘s condition  The proposed treatment  Potential benefits, risks, and complications of

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the procedure Possible alternatives The likelihood of success Possible problems related to recovery Possible risks of non-treatment

   

3. The legal age to give consent is 18 HEGIRA years (17 years and 6 months by the Gregorian calendar) for both males and females. 4. Consent must be obtained by the attending physician or designee who is going to perform the treatment procedure/intervention from the patient, legal guardian. 5. The attending physician or designee will write in full on the respective consent form (no abbreviations will be accepted), the name of the procedure, the site, side, and level (if applicable) of the procedure to be performed. 6. The consent form shall be completed in English for non-Arabic speaking patients and in both English and Arabic for Arabic speaking patients. 7. Consent must be obtained from a patient or legal representative on behalf of the Patient (should the patient by unable to give consent) for all treatments, procedures/interventions in one of the following consent forms: SL #

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Type of Consent

1

General Consent

2

Surgery/Procedure consent

Validity Period

Inpatient: On admission for all patient Outpatient: All follow up

14 Days only

3

Anesthesia/ Sedation consent (includes

4.

Blood & Blood Products transfusion Consent (used when only blood transfusion is the only treatment needed)

14 Days only

14 Days only

8. It is the responsibility of the attending physician or designee to ensure that the procedure is explained fully to the patient or representative, or legal guardian. Surgical Procedure and Intervention Requiring Consent The following list is not an exhaustive one. It is prudent upon the attending physician to include any other similar ones that may in this list:              

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All surgical procedures (that involve breaking skin integrity) classical or minimal invasive. All types of diagnostic or therapeutic endoscopies. All types of biopsies. Central nervous system ventricular taps, pressure monitoring probes. Exchange transfusion. Supra-pubic bladder aspiration/catheterization. Temporary trans-venous pacing. Pericardiocentesis, thoracocentesis, peritoneal paracentesis. Abscess drainage with or without incision. Percutaneous nephrostomy. Intra-uterine transfusion. Other non-venous percutaneous invasive procedure. Lumbar puncture, myelography. All angiographic diagnostic and therapeutic procedure.



Hysterosalpingography, amniocentesis, placenta. Cordocentesis, aspiration of fetal fluid. Any other similar procedures.

 

Patient and Family Education APP-KSMC-159- (V1) Multidisciplinary Patient and Family Education Providing education to the patients and their families about their health or medical problems enables them to make informed decisions about their healthcare needs. It is important for our patients and families to assume a proactive role in the maintenance and/or improvement of their own health. What must you do before teaching patients and their families? Before conducting patient and family education, you need to assess their:  Education level  Preferred language  Readiness to learn  Barriers to learning (psychological, financial, mental)  Knowledge of the disease, treatment, complications, and prevention  Assistance from their family What can you teach? You can teach patients and their families:      

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Their rights and responsibilities The disease process Pain Management Falls prevention Self-care needs Medication (safe use of medication, food,

     

interaction, safe use of medical devices used for consumption of medication) Diet and Nutrition The procedure they will be undergoing The use of medical equipment The rehabilitative techniques The home environment and emergency care Community resources

All teaching must be summarized & documented in the interdisciplinary patient / family education record form No. 569 Remember, all staff plays a role in patient and family education.

Assessment & Care of Patients APP-KSMC-135- Patient Assessment and Reassessment Assessment of patients To consistently assess patient’s needs, the scope and content of assessment performed by physicians, nurses and other clinical disciplines as well as forms to be used must be defined in writing. The new Physician Admission Assessment form and the Nursing Assessment Form contain information required by the standards. To ensure that patients are treated promptly, assessments must be completed in a timely manner. A physician’s assessment must be completed within 24 hours. Nurse’s Admission assessment must be completed within 4 to 24 hours. When there is no time to record the complete history and physical examination of an emergency patient requiring urgent surgery, a note on the presenting condition and a preoperative diagnosis is recorded before surgery.

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Functional Screening** APP- KSMC – 216 Patient Falls Prevention The most effective way to identify patients with functional needs is through screening criteria. Nurses Complete the fall Risk Assessment as part of their initial assessment, and reassess at least each shift, OT, PT and Clinical Pharmacist is auto referred based on preset criteria. Pain Screening and Assessment APP-KSMC-085- (V1) Pain Assessment, Reassessment Management During the initial assessment and reassessment, patients must be screened for pain. When pain is identified, a more comprehensive assessment is performed. This assessment is appropriate to the patient’s age and measures pain intensity and quality such as pain character, frequency, location, and duration. Reassessment of Patient Reassessment by all of the patient’s care providers is the key to understanding whether care decisions are appropriate and effective. Reassessment by a physician is integral to ongoing patient care. Hospital policy requires a consultant physician to assess all acute care patients daily, including weekends and holidays. Integration and Coordination of Patient Care APP-KSMC-135- (V1) Patient’s Assessment & Reassessment Assessments must be integrated and the most urgent care needs identified. To effectively integrate and coordinate care activities, the organization has implemented the Integrated Plan of Care Form. All those who care for the patient must document a summary of care planned with established goals and timeframe for reassessment.

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Ensure consistent and appropriate care by using clinical pathways and guidelines e.g. pediatric bronchial asthma. Discharge Summary Report A summary of the patient’s care is prepared at discharge and a copy is given to the patient, as appropriate, the patient’s family. To ensure a smooth flow of information, the organization has implemented the In-patient Discharge summary Report which must be completed and given to the patient/family upon discharge. ** Physician’s documentation must acknowledge the results of the Nursing screening.

Physical Documentation Write it Right     

Write legibly Use Black/Blue Ballpoint Pen Gregorian date; (dd/mm/yy) Time : Use 24 hr clock e.g. (1300 for 1pm) The heading of all physician entries should include the Date, Time, Physicians Name and Title Intern, Resident, Consultant, etc..)  The tail of all Physician entries should include signature, Name, Badge Number, and Bleeper, Physicians should include their stamp. Cross It Right 

Cross out wrong entries with a single horizontal line  Write “Mischarted” or” Error” next to it  Put your initials beside it

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Do not Use     

Prohibited and Unapproved abbreviations NAD, instead Use Not Relevant NIL NA O

Complete the History and Physical  

Within 24 hours of admission H & P by junior staff physicians reviewed, validated and co-signed by the consultant within 24 hours  H & P is legible  H & P is dated  H & P is timed History And Physical Includes:                   

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Admission Date / time Chief Complaint History of Present Illness Specialty Specific History Medical and Surgical History Family History Nutritional and Functional Psychosocial Status Allergy Medications Review of Systems Pain Assessment Physical Exam Investigations Assessment / Impression Plan of Care Educational Needs Discharge Planning Consultant Notes

Physical Restraint APP- KSMC – 238 Uses of Restraints Physical Restraint is an approved mechanical device or devices which restrict the movement of the whole or a portion of the patient’s body for the purposes of preventing harm to self or others. Points to Remember: 1. Initiation of Physical Restraint is by the Physician’s order only. Orders for the restraints shall not exceed twenty-four (24) hours in duration. 2. Recurrent use of Restraint: a registered Nurse or Physician shall document in the patient’s record the justification for recurrent use of restraints in addition to the patient’s physical and behavioral status. 3. Assessment of patient’s physical and psychological well-being shall be made throughout the restraint period with a maximum of two (2) hours interval a. Application of restraint devices- ensuring that patients have as much freedom as possible. b.Circulation and degree of movement in the extremities are evaluated. c. Each restrained limb is released from restraints and examined from bruising or skin tears and exercised (range motion) every two (2) hours. 4. Meals are provided at regular time and fluids are offered every two (2) hours to ensure nutrition and hydration. 5. Elimination needs are met at least every two (2) hours or as requested. Hygiene is offered on a daily basis. Restraint should not be started before physician assessment and order, patient are assessed every 2 hours, and restraint order evaluated every 24 hour

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Moderate and Deep Sedation APP –KSMC- 045 (V2) Moderate and Deep Sedation Policy Anesthesia and Surgical care (ASC) 1.

2.



Hospital Sedation committee is in-charge of evaluating the ongoing practices of sedation by the non-anesthesiologist throughout the hospital to ensure the adherence to standard of care.

The non Anesthesiologist and the assisting RN / EMT must be appropriately qualified. And competent in following:  Techniques of various modes of sedation  Appropriate monitoring  Response to complications Use of reversal agents (Narcan Flumazenil)  At least Basic Life Support

3.

Pre-sedation Assessment (Risk assessment): an appropriate evaluation of the patient shall be undertaken prior to initiation of sedation.

4.

Informed Anesthesia / Sedation consent: anesthesia must be obtained by physician providing the sedation, to explain all the benefits, risks and the alternatives to the patient, parent and family.

5.

A qualified individual monitors the patient during sedation (Intra sedation monitoring) and during the period of recovery from sedation (Post sedation monitoring) and documents the finding.

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Document all sedation activity in the hospital in the hospital sedation form.

Medication Safety Medication is the leading cause of patient harm in health care institutions the following strategies are used to decrease the incident of medication error. 1.

Patients (6) |rights:      

2.

Right patient Right drug Right time Right dose Right route Right documentation

Prohibited abbreviations.

APP-KSMC-008-(V2) The Prohibited Abbreviations and Symbols In accordance with “Prohibited abbreviations”, the use of certain abbreviations is prohibited. The list includes fourteen (14) prohibited abbreviations that include the eight (8) mandated by JCI.

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Look –Alike, Sound Alike and High Alert Medications.

3.

APP-KSMC-137- (V1) High Alert Medication Management.  Look –Alike: drugs/medication which due to their spelling, may look similar with other drugs / medications names and the distribution/ administration/ of this medication may be prone to errors. Sound-Alike: Drugs/ Medications which due to their pronunciation may sound similar with other drugs/medications names and the distribution administration of these medications may be prone to errors. All Look- Alike &Sound -Alike drugs/medications must be stored separately. High Alert: Drugs medications that have increase risk of causing significant harm to a patient when used incorrectly i.e. insulin and heparin.

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All High Alert medication should have an independent double check before administration. 4.

Medication Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Errors can occur during prescribing, dispensing /or administration.

Medication error shall be reported immediately through OVAR PHASES OF MEDICATION ERROR Phase 1- Ordering/Prescribing Phase 2- Transcribing Phase 3 – Dispensing Phase 4 – Preparation Phase 5 – Administration Phase 6 – Documentation Phase 7 – Monitoring 5.

Adverse Drug Reaction A detrimental response to medications, excluding therapeutic failure, that in unexpected unintended undesired or excessive response to a drug. Adverse drug reaction includes anaphylaxis, arrhythmias, convulsions, hallucination, a shortness of breath rashes and other reactions.

Adverse drug reaction shall be reported through the Adverse Drug Reaction Report (ADR) available on the intranet- Department of Pharmacy One strategy to decrease ADR is to make sure the patient allergy Status is documented in Physician order sheet or pre-printed physician medication admission form.

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6.

Medication reconciliation Medication reconciliation is a formal process aimed at preventing of medication errors / adverse occurrences. It involves: 1. Obtaining an accurate and complete list of patient’s home medications. 2. Comparing the physician’s' medication orders on admission to the list of home medication. 3. Justifying any discrepancies between home medications and admission orders. 4. Documenting any changes. All Patients should have a medication reconciliation done on admission.

Infection Prevention and Control Infection Prevention and Control Manual Standard precautions to prevent infection transmission Foundation for preventing transmission of infectious agent during interactions between healthcare personnel and patient are the work practice having basic level of infection control to reduce the risk of transmission. These infection control practice should be applied to all blood & body fluids, non – intact –skin and mucous membranes, and should be used for all patients regardless of their diagnosis or presumed infectious status and they includes:

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1. Hand Hygiene A –5 moments of Hand hygiene (When and Why)

1 BEFORE TOUCHING PATIENT 2 BEFORE AN ASEPTIC TASK

3

AFTER BODY FLUID EXPOSURE RISK

4 AFTER TOUCHING THE PATIENT

5

AFTER TOUCHING PATIENT SURROUNDINGS

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When: Clean Your hands before touching a patient when approaching him/her Why: To protect the patient against harmful germs carried on your hands When: Clean Your hands immediately before any aseptic task. Why: To protect the patient against harmful germs, including the patient’s own from entering his/her body When: Clean Your hands immediately after an exposure risk to body fluids(and after glove removal) Why: To protect yourself and the health care environment from harmful patient germs When: Clean Your hands after touching patient and her/his immediate surroundings when leaving the patient’s side. Why: To protect yourself and the health- care environment from harmful patient germs When: Clean Your hands after touching any object or furniture in the patients immediate Surroundings, when leaving-even if the patient has not been touched. Why: To protect yourself and the health- care environment from harmful patient germs

B- Hand hygiene (how)

How to hand wash? WASH HANDS ONLY WHEN VISIBLY SOILED! OTHERWISE USE HANDRUB

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Limitation of alcohol based hand rub (ABHR): ABHR is inactive when hands are visibly dirty and when dealing with spore forming bacteria (clostridium defficile) 2.

Use of Personal protective equipment (PPE) a. Donning: (Hand hygiene), Gown, mask or respirators, goggles/ face shield, gloves. b. Removing: gloves, goggles or face shield, Gown, mask, (hand hygiene)

3.

Use of aseptic techniques

4.

Patient care equipment o Handle equipment soiled with blood and body fluids, secretion and excretion in a manner that prevents skin and mucous membrane exposure, contamination or clothing and transfer of pathogens to other patients or the environment.

5.

Collection and handling of Lab specimens (they are considered infectious at all times)

6.

Respiratory hygiene and cough Etiquette (Cover the nose/mouth when coughing sneezing, using tissue to maintain respiratory secretion and dispose them in the nearest waste disposal and then perform hand hygiene).

7.

Waste Disposal: Ensure safe waste management o Safe handling and disposal of sharp o Linen management o Medical waste Management o Use the appropriate color code waste Bags: -

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Use yellow bag for: infectious waste, container with blood/body fluids cannot be emptied, all specimens: Blood ( more than 20ml ), body fluids. Swab etc., items moderately or grossly

-

-

-

soaked in blood or body fluids, chemotherapy waste. Use Blue bag / Water Soluble Bag for: Contaminated Linen/gown/pillow. Use red bag for: body parts, organs, fetuses,and placenta. Use Black bag for: general waste, items not moderately or grossly soiled in blood/body fluids. Use water soluble bag for: linen which is using in Isolation rooms.

Needle Stick/Sharp Injury 1. First Aid  Allow the site to bleed gently  Wash generously with soap and water  Cleanse with alcohol wipes  Cover with appropriate bandages 2.

Fill out OVAR (Occurrence/Variance /Accident Report)  Report for medical assessment at employee health clinic or ER (weekends)  Comply with follow up recommendations

Body Fluid Exposure 1. First Aid  Irrigate affected area with copious amount of water 2.

Fill out OVAR  Report for medical assessment at Employee health clinic or ER (weekends)  Comply with follow up recommendations

Infection control is everybody’s business Refer to the Infection Control Manual for more details For more information contact infection control department ext…3214, 3216, 1697,134 ,201

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Sentinel Event &Root cause analysis RCA APP-KSMC-006 Sentinel Event & RCA

A sentinel event: A sentinel event signals need for immediate investigation and response. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury “or the risk thereof”. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a reoccurrence would carry a significant chance of a serious adverse outcome. Root Cause Analysis (RCA) -is a process for identifying the basic or causal factor of an adverse event. Root Cause Analysis primarily focuses on system and processes, not individual performance. Sentinel events are defined as the result or outcome of the following occurrences: 1.

Any event that results in an unanticipated death or major permanent loss of function, not related to the natural cause of the patient’s illness or underlying condition or;

2.

The event is one of the following (Even if the outcome was not death or major permanent loss of function: a)

b)

c) d) e) f) g)

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An unanticipated major permanent loss of organ or function, not related to the natural course of the patient’s illness or underlying condition. Death, paralysis, coma, or other major permanent loss of function associated with a medication error. Suicide of any patient receiving inpatient care. Maternal Death. An unanticipated death of a full-term infant. Abduction of any patient receiving care, treatment or services. Patient fall resulting in death or permanent loss of function.

h) Discharge of an infant to the wrong family. i) Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities. j) Surgery on the wrong patient or wrong body part. k) Unintended retention of a foreign object in a patient after surgery or other procedure. l) Rape Team Formation- once a Sentinel Event has been identified the sentinel event Committee will immediately appoint members for RCA team to direct the investigation. The team utilizes the root cause analysis template and completes an action plan. Sentinel Event Reporting Flow Chart

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Occurrence Variance Accident Report (OVAR) and Safety Reporting System APP-KSMC-005 Occurrence Variance Accident Reporting An incident may be defined as any event that has caused harm, or has the potential to harm a patient, visitor or staff member, or any event which involves malfunction, damage or loss of equipment or property, and event which might lead to a complaint. The policy on Occurrence/Variance /Accident Report (OVAR) provides a mechanism for reporting risk management/ safety variance or accident related to practice, process or outcome. Near Miss- any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome.

An OVAR report should be completed if any of the following occur: 1.

An error o mistakes that injuries or could have injured a patient, employee or visitor.

2.

Failure or shortage of direct patient care equipment, utility or material had adverse impact or could have adverse impact upon patient care outcome.

3.

An incident that cause an angry reaction by a patient or family member.

4.

An incident that inhibits a process or system and has an adverse effect upon patient care.

PROCEDURE FOR COMPLETION 1.

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The Quality Designee is responsible for ensuring the report information is complete and that applicable boxes are indicated. Where an addressograph is not available, the name and ID

badge number or medical record number should be written in the box provided. 2. In cases resulting in employee injury, the report should be completed by the injured person when possible or by the immediate supervisor if the employee is physical unable to do so. 3. OVAR report is routed to the Quality Management Department for further actions according to the risk severity of the events.

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Emergency Coding System APP-KSMC-125 Emergency Codes (Code Blue, Code Red, Code Yellow, Code White, Code Pink, Code Orange, Code Green, Code Black, Mr. Strong

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Hospital Fire Safety Program When you discover a fire

Remember: Always use proper type extinguisher to fight fire ● FM 200 7DRY POWDER ● CO2SUBSCRIPT ● WATER

: CLASS “B”& “C” : CLASS “B”&“C” : CLASS “A” ONLY

CLASS A: Solid or ordinary combustible materials (Paper, Wood, Rubber, Plastic) CLASS B: Flammable liquids and gasses

CLASS C: Involving energized electrical equipment

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Observe effective fire safety and fire prevention measures: 1.

2. 3. 4. 5.

6. 7.

Ensure that your department/ ward practice good housekeeping. Dispose of all oily rags in left on top of closed containers. Report any faulty equipment. Store flammable/ combustible items properly. Ensure that staff is aware of the procedure for safe handling of such items. Ensure that staff are aware of the evacuation routes and assembly points of the department / ward. Know where your fire extinguisher is and how to operate them. Familiarize yourself with the safety manual and attend regularly fire safety drill & Fire safety inservice training. 



8.

9.

In case of fire the nurse in charge of the unit/area is responsible with the shutting off of oxygen valve by breaking the glass or removing the acrylic cover (pulling out) In case of emergency, call the emergency number of KSMC

Always treat a spilled substance as hazardous unless identified as non-hazardous by proper authority Hazardous Material Spill Procedure (by code orange Team/or fire department):

Management of Spills of Hazardous Material     

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Report immediately by calling 1970 or 555. Isolate the area immediately. Try to identify the spilled material and inform the code orange Team/or fire department. Do not attempt to clear the spill unless properly trained or wearing proper protective equipment. Meet the code orange Team/or fire department and relay relevant information.

Important numbers

General Hospital

IN CASE OF FIRE

1970

ER HOT LINE

1234

SECURITY EMERGENCY MAINTENANCE REQUEST URGENT MAINTENANCE OPEARATOR UTILITY SYSTEM FAILURE

Maternity Hospital and Pediatric Hospital

1888 1747/1364

555 / 188

1616 9 1747/1364/212

Safety and Security KSMC has dedicated security team available around the clock to ensure that the hospital environment is safe for staff and patient. For security assistance please calls security EXT: 1888 or Hospital administrator on duty EXT: 1230

General Guidelines:  Staff should were their ID badge, prominently or left chest.  Be alert when you see visitors unidentified in the staff and patient area.  Ensure that door; especially number-accessed doors are closed properly.

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Safety and Security System for Newborns APP-KSMC-010 Infant/ Child Abduction The purpose is to identify areas and conditions where newborn and pediatric patients are exposed to the risk of abduction, and implement security measures that prevent abduction of new born and pediatric patients. All staff in the clinical areas must be aware and uphold the provisions for visitors by allowing no more than two visitors at any given time. All babies shall be transported in the hospital and discharged accompanied by a nurse. Code pink will be activated when an infant and/or child is missing or is known to have been kidnapped. “Every one is responsible for safety. Your safety is our concern” KSMC WEB SITE

Home Page

For Medical Record Forms

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http://www.ksmc.med.sa or http://100.43.100.62/ksmcportal

http://100.43.100.62/ksm cportal/system/applicatio n/views/admin/upload/

Journey is continuous

to get

JCIA

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