NABH FAQ's

1. What is NABH stands for?

National Accreditation Board for Hospitals and Health Care Providers.
2. What is Mission Statement of the hospital?
To provide state of the art healthcare services especially the poor and socially backward people at an
affordable price with all modern support facilities in an eco-friendly integrated hospital campus.
3. What is vision of KIMS?
To be the foremost healthcare services provider of higher standard focusing on accessible, safe, ethical &
research based medical practice in a patient friendly atmosphere.

4. What is Quality Policy of the Hospital?

We are committed to maintain the highest standard of care & treatment with special emphasis to patient
safety and satisfaction. We constantly strive on improving quality indices and make it our hallmark of
practice.
5. Define Quality?
 Doing it right the first time - every time.
 Having the best achievable outcome for each patient.
6. Name the two standard patient identifiers?
 Full Patient Name.
 Medical Record No. or UHID
7. What protocol is followed for identification of patient in case of an emergency?
If no proof is found, the care provider should give a false name “Unknown” to the patient and 2 (two)
identification marks on body should be noted by which patient should be identified by all the care providers.
8. What is the retention period for an MLC file?
Medico-Legal files are kept for lifetime or till the case disposed off.
9. What is the retention period for an In-Patient file?
5 Years
10. What is the retention period for a death file?
10 Years
11. What is MSDS? What does it contain?
Material Safety Data Sheet. It contains the list of chemicals, which are hazardous, and their potential
hazards.
1. Acetone
2. Betadine
3. Carbon Dioxide Cylinder
4. Ethylene Oxide
5. Formalin Solution
6. Hydrogen Peroxide
7. Nitrogen
12. What is the hospital policy on smoking?
Our Hospital has no smoking & no alcohol policy.
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13. What is surrogate consent?
Consent Signed by a family member of the patient in a situation when patient is not in a position to give
his own signature or in case the patient is < 18 years of age.
14. Who deals with patient complaints/feedbacks?
Medical Superintendent, General Manager-Ops., Sr. Administrative Officer.
15. Who are vulnerable patients?
 Geriatric patients (>75 years of age).
 Pediatric patients (<12 years of age).
 Physically/ mentally challenged patients.
 Comatose patients.
 Unescorted female patients.
 Patients unable to perform ADL (Activities of Daily Living).
16. Who all can identify the vulnerable patient?
 Doctors (based on medical condition).
 Nursing Staff.
17. Who informs patients about rights and responsibilities?
 Floor Managers/ PCC & Nursing Staff.
 Citizen Charter kept at admission counter and in patient’s room.
18. State three measures to ensure patients right to confidentiality?
 Refraining from discussing patient related information in a public area.
 Examination room- One Patient at a time.
 Controlled movement of Patient record.
19. Name a few high- risk medicines?
i. Insulin.
ii. Narcotics.
iii. Potassium chloride concentrate.
iv. Heparin (and other anticoagulants).
v. Concentrated sodium chloride (above 0.9 percent).
20. Who identifies the patient needs and how?
Nurses, Residents and Consultants identify patient’s physical, psychological, social, cultural, and
spiritual needs by questioning them.
21. How to store and administer narcotic drugs?
Narcotic drugs are stored under double lock until needed for the patient. After administering the drug
the responsible nurse signs the narcotics register.
22. What is ADR? How is it identified and reported?
Adverse Drug Reaction-Unwanted, unintended event at therapeutic doses occurring within a specified
time of drug administration, reported on ADR form and sent to Quality Manager through Nursing
Superintendent & to be analyzed in Drugs & Therapeutic Committee.

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23. What is a medication error? How is it reported?
Medication errors are mishaps that occur during prescribing, transcribing, dispensing, administering,
adherence, or monitoring a drug. Examples of medication errors include misreading or miswriting a
prescription. Reported on Incident Reporting Form and sent to Drug & Therapeutic Committee through
Nursing Superintendent.
24. How to add a new drug in the formulary?
The form named “ Requisition Form for addition and deletion of drugs from formulary. It is to be filled
and sent to the Drugs & Therapeutic committee.
25. What is the definition of restraint?
A restraint is any method that limits a patient’s ability to move around freely or reach normal body
parts.
26. What are the various types of restraint?
 Physical Restraint.
 Chemical Restraint.
27. What is drug recall?
Action taken to remove a product / medication by pharmacy if it is
 Damaged/ contaminated as reported by the medical staff.
 Regulatory authorities ban it or recall it.
 Company recalls.
 If extra stock is kept with any clinical department.
28. What is near expiry drug as per hospital policy? What do you do when you have one?
Any drug which is due for expiry within 3 months from the date mentioned by manufacturer on the label. It is
to be returned back to Pharmacy as short expiry.

29. How do we dispose off Expired Drugs?

All the expired drugs throughout the hospital are sent back to the pharmacy in a Black bag with a label
of expired medications and it is further sent to a landfill.
30. What do we do for pain management in the hospital?
Pain management is taken care by Anaesthesiologist, Doctors & Nurses, pain score recorded as per
form.
31. What is PPE? Name few components?
Personal Protective Equipment:
 Goggles, Gloves (Separate for chemical and solvents), cap, gown, Gum boots
 Face mask, tongs, and spatula.
 Solvent pads / sweeps for chemical and solvents.
32. How to handle a minor spill on a health care worker?
In case of spill on a Health Care Worker (HCW) following steps are to be followed:
a. Softly soak excess chemical / solvent with tissue paper/ news paper.
b. Wash the affected area with water for at least 15 minutes.
c. Call for medical attention if needed.

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33. How to handle a minor spill using PPE kit?
 Wear goggles, gloves, and Face mask before clearing the spill.
 Softly soak excess chemical/ solvent with the solvent pad / news paper.
 Use tongs to pick the solvent pad or any other absorbent material, which has come in contact with the
chemical/ solvent.
 Dispose it in the yellow bag given in the PPE kit.
34. When is discharge planned?
The discharge is planned the day before, as per the packages or Treating Doctor’s advise..
35. What are the various categories of medication error?
 Fatal Error, Death
 Gross Error, Harm
 Simple Error, No Harm
 No Error, Near Miss
36. What does current medication imply on nursing assessment form?
Any medication the patient is taking prior to admission.
37. What is the Identification method used for dead bodies?
a. Place an identification band, if not already placed.
b. Write down the name, age, gender of patient & I.P. Number & address on sticker.
c. Stick one sticker on the chest, 2nd sticker on the dress and 3rd sticker on the body wrap..
38. What is the policy for self-medication?
The hospital does not allow any kind of self-medication by the patients.
39. What are Blanket Orders? Do we accept them?
Blanket orders: Medication orders such as “continue medications from home”, or “continue medications as
previously ordered” are not acceptable. In the event that the physician writes such orders, the nurse must
call the prescribing physician and obtain written orders for each individual medication ordered.
40. What is the protocol on open vials?
Open Vials have to be labeled for its date of opening and date of discard and signed.
41. Are herbal medications used in our facility?
No
42. How are the sharps disposed off?
Sharps are disposed off in the sharps container with a biohazard symbol on it.
43. What goes in yellow, red, Puncture Proof Container and black bags?
 Yellow bags with a Biohazard symbol for body parts and tissues, blood & blood product,
 Red Bags with a Biohazard symbol for plastics
 Puncture Proof Container with a Biohazard symbol for needles and sharps.
 Black bags for general waste.

44. What do you do in case of sharp (needle stick) injury?

 Do not suck the injury site
 Wash with soap and running tap water.

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  Inform your Incharge for further action.
45. What are the five movements of Hand Hygiene?
 Before touching a patient.
 Before clean / aseptic procedure.
 After body fluid exposure risk.
 After touching a patient.
 After touching patient’s surroundings.
46. What are Quality Indicators? Who analysis the data?
Quality Indicators are a set of functional parameters, which have been selected across Hospital. The
respective departments every month collect data for these and the reports are analyzed by the Quality
Assurance Committee, which looks into gross deviations in any of this data.
47. What is KIMS approach to Quality Improvement?
PDCA (Plan, Do, Check & Act)
48. What is a Sentinel Event? List down types of sentinel events?
Any unexpected occurrence involving permanent injury/ death / more then 2 weeks of hospitalization of
patient/ employee/ visitor in the hospital is termed as a sentinel event.
1. Therapeutic Events.
2. Device or Product events.
3. Patient Protection Events.
4. Environmental Events.
5. Care Management Events.
6. Criminal Events.
49. Elucidate six patient safety goals?
Goal 1: Physical safety, safety from theft, assault.
Goal 2: Identification of patient before administrating any procedure especially through patient
identification band.
Goal 3: Elimination of wrong patient, wrong medication, wrong procedure, wrong site error.
Goal 4: Identification of vulnerable patient and special care to the vulnerable patient.
Goal 5: Promotion of infection control.
Goal 6: Filling of respective sentinel event form if any untoward event happens
50. How do you report a sentinel event or an untoward incident?
a. On recognition of a sentinel event report to immediate incharge.
b. Participate in filling of incident reporting form.
c. Send the form to respective office.
 Needle Stick Injury (NSI) - Microbiologist (Lab)
 Adverse Drug Reaction (ADR) - Doctor on duty, Individual HOD and NABH Coordinator
 Cardio Pulmonary Resuscitation (CPR) – CPR Team/ Code BLUE Team
 Incident / Accident form – Respective HOD through.
d. The Root Cause Analysis (RCA) is then initiated. Provide as much information as possible during
investigation.

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51. What are the three plans of the hospital?
 Disaster Management Plan.
 Hazardous Materials Management Plan.
 Fire Safety Plan.
52. Why is patient and family education important?
To facilitate patient /family in participation of care being provided.
53. What would ‘YOU’ do if you get a bomb threat call?
Try to collect as much of details from the caller as I can. Immediately inform on number 44.
54. What would you do in case of fire?
Remember…….
 R: Rescue
 A: Alarm
 C: Contain the fire
 E: Extinguish (if trained) and evacuate.
55. What is the extension for calling Fire team?
EXT- 77
56. How many types of fire extinguishers are there?
 Water types for solid inflammable material such as paper, cardboard, ply wood, etc., coded as
A Type.
 CO2 types for electrical, electronic fire, coded as BC Type
 Dry powder type for multi-purpose use, coded as ABC Type.
57. How should dirty linen be transported?
Soiled linen is transported to the Laundry by separate covered linen-carrying trolleys.
58. What is the different color coding in triage?
 The four colors of triage and they come in the form of:
o Black (Deceased) which entails no care needed
o Red (Immediate) which entails life threatening injuries
o Yellow (Delayed) which entails non-life threatening injuries
o Green: (Minor) which entails minor injuries
59. When is triage performed?
 As & when required & in case of a disaster.
60. What are the different agents used to clean surfaces? In what strength/ratio they are used?
Sodium Hypochlorite 1% to 2% (disinfectant)
Aldasan
61. How many times the patient’s room is cleaned in a day?
a. The housekeeping personnel are available 24 hours on call
b. As per Mopping Schedule
62. How do we dispose the waste generated in the hospital?
 Biomedical waste is transported off-site to Sani Clean Pvt. Limited, which is authorized by Odisha
Pollution Control Board.

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63. What are the various notifiable diseases?
 Cholera
 Plague
 Yellow Fever
 Polio
 Influenza
 Rabies
 HIV/AIDS
 Louse-borne typhus
 Tuberculosis
 Leprosy
 Leptospirosis
 Viral hepatitis
 Dengue fever
64. How to report notifiable diseases?
A written notification has to be sent to the Medical Superintendent Office, which is sent further to the CMO
Office, Bhubaneswar.
65. What are Emergency Codes?

S.NO. VARIOUS CODES CODE STANDS FOR

1 BLUE(33) CARDIAC ARREST

2 RED (77) FIRE

3 PINK (44) CHILD ABDUCTION

66. Anatomical waste treated/disposed in which colour bag?

Yellow Bag.
67. Name the departments/areas where conscious sedation is administered?
Endoscopy, Bronchoscopy, Intensive care units, Emergency, Under
Anesthesiologist's supervision
68. What is the no. for calling Code Blue team?
The no. for calling Code Blue Team is. 33
69 . Which services are not available in your hospital?
Organ Transplant and Radiation Therapy
70. Name few committees exist in the hospital?
1. Hospital Core Committee
2. Infection Control Committee
3. Medical Audit Committee

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 4. Drugs and Therapeutic Committee
5. Hospital Safety Committee
6. Disaster Management Committee
7. Grievance Redressal Committee
8. Credential & Privileging Committee
71. What is PASS? When it is implemented.
P- Pull the safety pin
A – Aim the Nozzle at the base of Fire
S- Squeeze the Handle / Lever
S – Sweep the Nozzle from one side to other.
72. What are the patient safety devices installed in the Hospital?
1. Safety Belts in Wheel Chairs & Stretchers.
2. Hand Grabs in lifts, staircases & corridors.
3. Hand grabs in toilets
4. Bilingual Signages all over the hospital

73. What are the six R’s of drug administration?

 Right patient
 Right drug
 Right dose
 Right time
 Right route
 Right documentation
74. Who is the Accreditation Coordinator ?
Mr. S.K.Satpathy.
75. What are the documents in medical records, those show evidence for continuity of care?
 Patient progress notes
 ICU Charts
76. What are the systems for aiding evacuation?
 Automatic Fire Alarm and smoke / Fire detection system.
 Manual Call Points (MCP)
 Public Address System
 Defined exit routes and points of egress put up as displays in each independent ward/ area for all to
see.
77. Who is the Fire Officer/ Safety Officer?
Mr. G.C.Mohapatra

78. How can we ensure for prevention of adverse events like wrong site, wrong
Patient and wrong surgery?
A double check is done at three levels by

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  OT sister
 Anesthesiologist
 Surgeon who tallies the name & registration (UHID) number by asking the patient and checking
with the Patient file and the wristband at the Patient hand.
79. In case of an External disaster where would the casualty Triage be set?
Casualty Triage shall be immediately established in the Emergency waiting area and
All the designated beds and supplies shall be moved to the area.
80. In case of fire in Emergency area where would the triage be set?
In case there is a fire in the Emergency Area, Emergency Triage shall be set up main lobby near
reception, if required. The reception area shall be closed to public immediately.
81. In which medical document is the initial and functional need of the patient assessed?
Initial Assessment Form and Nursing Assessment form
82. Name the regulatory control body for radiation safety?
Atomic Energy Regulatory Board (AERB)
83. Who all comprise of the code blue team?
 Intensivist
 Anesthesiologist
 ICU Nurse
84. What personnel shielding is used in case of radiation exposure?
 Lead aprons
 Thyroid Shield
 TLD Batches
85. What is command centre?
Command Centre: The hospital has set up a Command centre for handling External & Internal
Disasters. In the disaster conditions all the instructions will be passed from this command centre. Under
the leadership of MS.
86. What is the composition of the HAZMAT kit?
 N 95 mask: 2
 Face shield/ goggles:2
 Nitryl gloves:4
 Yellow bags: 2 each
 Tissue Papers: 1 box
 Plastic disposable gown:2
 Gum Boots (2)
87. What are the quality indicators of your department? (Every body should learn it)

88. What is the hospital policy for organ donation?

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 Organ donation is not done in our organization but it facilitates in the process by providing no. of
various organizations where organ donation can be done and the numbers are provided with the
reception.
89. Whom to report for the Adverse Drug Reactions and Medication Error?
Chair person Drugs and Therapeutic Committee . Nursing Superintendent / Nursing Incharge / Doctor
on Duty.
90. Where are the following forms available?
i. Incident/ Accident Reporting- NABH Coordinator, Matron Office, All wards, Front Office, Security, OT
ii. Adverse Drug Reaction/ Medication error Form- All Clinical Areas
iii. Needle Stick Injury Form- All clinical areas
91. Who are the following personnel?
 Fire Officer – Mr. G. C. Mohapatra

 Security Officer – Mr. S.N.Giri

 Infection Control Officer – Dr. Nirmala Poddar

 Radiation Safety Officer – Mr. C.R.Panda.

92. What is the validity period of a signed consent?
During the period of hospitalization.
93. The tools for Information Management are?
1. HMS
94. How to store and administer narcotic drugs? Name a few?
Under double lock, keys with separate Nursing incharges. A separate narcotic register is maintained
where the usage and administration of such drugs is mentioned.
e.g. morphine, Fentanyl, pethidine.
95. Structure of NABH Standards?
- 10 Chapters
- 105 Standards
- 683 Objective Elements
96. Can you use Lift incase of Fire?
No
97. In case of needle stick injury what to do?
Do not panic, Do not put injured part in mouth, wash the area with soap and running water. Then report
to your supervisor or incharge. They will do the rest of the procedure.
98. Who obtains informed consent?
Treating Doctor
99. What are patients Rights?
Respect for dignity
Privacy during examination,procedures & treatment.
Treating Patients information as confidential
Refusal of treatment / right to take 2nd opinion.
Information on how to voice a complaint.
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100. Where is assembly point in case of Fire?
Lawn (In-front of Blood Bank).

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