Cemonc Ot Sop

GOVERNMENT VILLUPURAM
MEDICAL COLLEGE AND HOSPITAL,

MUNDIYAMPAKKAM, VILLUPURAM.
CEMONC OPERATION THEATRE

Document Name
STANDARD OPERATING PROCEDURE Issue Status :- 01
Revision Status :- 01
Document No: GVMCH / LAQ / OT / SOP
Issue Date :- 28-11-2018
Revision Date :- 04-06-2021
Authorization certificate GVMCH / LAQ / OT / SOP / AUTH
Effective Date :- 04-06-2021
AUTHORIZATION`
1. This manual of CEMONC OPERATION THEATRE STANDARD
OPERATING PROCEDURE is developed to fulfill LaQshya Labour Room
and Operation Theatre Quality Improvement Initiative, 2017 launched by
Ministry of Health and Family Welfare, Government of India.
2. This manual is the property of Government Villupuram Medical College and
Hospital, Villupuram, 605601
3. The contents of this manual shall not be printed or reproduced either in part or in
full without written permission of The Professor and Head of Department,
Department of Anesthesiology, Government Villupuram Medical College and
Hospital, Villupuram.
4. This manual has been authorized by The Professor & Head of Department,
Department of Anesthesiology, Government Villupuram Medical College and
Hospital, Villupuram.
Professor and HOD,

Department of Anaesthesiology,
Government Villupuram
Medical College & Hospital,
Villupuram.
Verified By:- Dr. Arun Sundar, MD, Chief Anaesthesiologist Prepared By:- Dr. S. Arivazhagan, MD, Asst Prof
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DESIGNATION NAME & SIGNATURE
PROFESSOR AND HOD,

AUTHORIZED BY DEPARTMENT OF
ANAESTHESIOLOGY
ASSOCIATE PROFESSOR
VERIFIED BY
ANAESTHESIOLOGIST
OPERATION THEATRE
PREPARED BY
NODAL OFFICER
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AMENDMENT
Details of Revision Signature Signature
Section
Amendment Status / of the of the
No Date No &
with Effective Preparatory Approval
Page No
Reason Date Committee Authority
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INDEX
SOP Page
Contents / SOP Title
No. No.
Introduction GVMCH 7
Mission & Vision 8
Quality Policy, Plan and Objectives 9
Procedures for General Patient Care Processes- SOP 1-12
1 Procedures for Identification of Patients 10
2 Procedures for Safe Drug administration 12
3 Procedure for High Alert Drugs 15
4 Procedures for obtaining specialist opinion within the hospital 18
5 Procedure for Issuing blood 19
6 Procedure for Blood Transfusion 21
7 Management of blood Transfusion Reaction 23
8 Referral of patients to Higher Institution 24
9 Nursing Care 26
10 High Risk and Vulnerable patients 31
11 Diagnostic services 32
12 Procedures for End of Life care and Death including NB death and 37
Stillbirth
Procedures for Specific Processes in the department- SOP 13- 29
13 OT Scheduling for Surgery and its booking 40
14 Procedure of Receiving patient in OT 43
15 Pre-operative Anaesthesia Checkup (PAC) 44
16 Monitoring during Anaesthesia 46
17 Post-anaesthesia Care 48
18 Pre-operative procedure 49
19 Identification of patients for Surgery 52
20 In process check during surgery 53
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SOP Contents/ SOP Title Page No.

No.
21 Post-operative care of patient –in OT 55
22 Procedure for C-Section and Assisted deliveries 57
23 Procedures for management of Obstetric emergencies 59
24 Procedures for NB Resuscitation and NB Care 61
25 Procedures for Stabilization/treatment/referral of postnatal 62
complications in NB
26 Post-operative care to mother and baby 64
27 Procedure for documentation 67
28 Procedure of handing over patients from OT to Indoor and ICU 68
29 Procedure of patient handover whenever staff duty changes 69
30 Procedures for ensuring Patients‘ rights including consent, 70
privacy, confidentiality & entitlements
31 Procedures for Safety and Risk management 71
Procedures for General Patient Care Processes- SOP 1-12
32 Procedures for Support services and facility management 77
33 Procedures for Infection control & BMW management 91
34 Procedures for Quality Management and Improvement 112
35 Procedures for Quality Indicators ( data collection, analysis & 116
use for improvement)
Key Performance Indicators 118
References 119
ANNEXURE-I
Guidelines for using WHO Safe Surgery Checklist 120
ANNEXURE-II Maximum Surgical Blood Order Schedule 122
ANNEXURE-III Surgery Consent Form 124
ANNEXURE-IV Procedure Identification Card 125
ANNEXURE-V Anaesthesia Consent Form 126
ANNEXURE-VI Pre- Anaesthesia Checkup 127
ANNEXURE-VII Anaesthesia Record 128
ANNEXURE-VIII Modified Alderete Score 129
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INTRODUCTION - GVMCH
 The Government Villupuram Medical College & Hospital is a 611 bedded
hospital, and dedicated CEmONC Ward with 81 beds sanctioned.
 More than 2000 patients come here to get the services from this hospital daily.
 The hospital has six operation theatres –1) General Surgery OT 1 & 2
2) Endoscopy OT 3) Speciality OT (ENT, Plastic, Dental, Urology, Paediatric
Surgery), 4) Opthal OT , 5) Orthopaedic and Neurosurgery OT,
6) CEmONC OT. 7) Emergency OT for Trauma and General Surgery.
 It serves as a referral centre for the nearby PHCs & District Hospitals .
 The Hospital also Function as TAEI Centre.
 The Available Specialities are General Medicine, General Surgery, Non
Communicable Disease Clinic, Naturopathy and Yoga Clinic Orthopedic,
Physical Medicine , Neuro Surgery, Neuro Medicine, Paediatrics, Dental,
Ophthalmology, Dermatology, ENT, Plastic Surgery, Paediatric Surgery,
Surgical Gastro Enterology, Urology, Thoracic Medicine, Psychiatry,
Cardiology, 24 Hours CT Scan, Cath Lab, District Early Intervention Centre for
Paediatrics, Comprehensive NICU, Emergency Care and Recovery Centre for
Mentally Challenged.
 It is also a CEmONC centre , with emergency obstetrics and neonatal care
services provided round the clock.
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CEMONC OT:-
We have Dedicated CEmONC OT, Running 24 X 7, for
Elective and Emergency Cases,
From 8.00 am to 2.00 pm Elective OG Cases, Family
Planning Cases Treated and After That for Emergency Cases
The Operation Theatre team strives to provide Quality
Assurance as per the National Quality Assurance Standards
Operation Theatre Personnel are trained in Theatre
Procedures, Quality Management, Respectful Maternity Care
and They are posted exclusively for CEmONC operation theatre
MISSION:-
“Knowledgeable Meticulous Prompt Maternal Care in
Hygienic Environment”
VISION:-
To achieve professional excellence in delivering maternal
and neonatal health care through multispeciality team work
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QUALITY POLICY:-
To Provide Safe and Quality Maternal and Neonatal
Services to the needy people.
QUALITY OBJECTIVES:-
 To Reduce the Primary Caesarian Section Rate
 To Maintain Use of Safe Surgery Checklist in the Rate
100% for all Cases.
 To guard, measure and improve patient / employee safety.
 To involve all employees to participate in quality
improvement.
QUALITY PLAN :-
 Signages, Information and Education for Patients and
General Public.
 Availability of Specialist Doctors Nurses and Support
Staffs round the clock
 Availability of Diagnostic services – as per requirements
 Free of Cost of Services (Drugs, Consumables, Blood, etc)
 Arrangement of free ambulance - 108 for referred cases
 Standardized processes and procedures are followed to
deliver services
 Improving the service quality by focusing on identified gaps
 Continuously review resolving of identified problems
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SOP NO:- LaQ:MEL:OT :01

SOP TITLE:- “IDENTIFICATION OF PATIENTS”
SCOPE:- Labour Room, Wards, Operation Theatre
PURPOSE:- To ensure safety of patients before any clinical procedures
COMPLIANCE TO:- NQAS ME.E.4.1
Procedure for identification of patients :-
 Identification is ensured before any clinical procedure

 All the patients are registered with a PIN NO.-(Personal Identification No.) and
OP No (Outpatient Number) - Hospital Worker at registration counter
 For Admitting the patients at the time of admission IP No.(Inpatient Number)
is given- Hospital Worker at registration counter.
 Identification Band affixed around the wrist with name and IP No.by the
Staff Nurse at the time of admission. The Identification band is removed at the
time of discharge .
 For death patients, the Identification band is removed (but if unidentified, it is
not removed )
 Name of the patient with name of spouse is written in case record.-ward Staff
Nurse
 For surgery cases, a Procedure card is attached to the case record. This
contains the patient name, age, sex, IP Number, name of ward, name of the
procedure, site of surgery- where applicable.
 For NEWBORN – Foot prints (right for male and left for female)is affixed
on the mother‘s case sheet along with the mother‘s left thumb impression-
Labour room resuscitation staff nurse
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 For Medico Legal Case patients- 2 Identification marks are documented in

the Accident Register - Casualty Medical Officer.
 Unknown / Unidentified patient- Patient is registered and admitted as
‗unknown‘; Identification marks are documented and intimation given to
Outpost police (if at a later date, the identification is made, the same shall be
modified in the registration and admission records through back entry by the
record clerk with instructions from Junior Administrative Officer)
 Exception- In emergencies, the patient is first stabilized prior to identification
 The Health Care providers verify the patient by using at least 2 identifiers
(patient name and IP Number ) prior to treatment, medication
administration, Laboratory tests, procedures, transfer and discharge.
 Verbal confirmation is also done.
S.No. Activity Responsibility

Decided for performing clinical procedure –
1.1 eg. Injection, investigation, catheter insertion , Performer
Lumbar Puncture etc.
1.2 Case record checked Performer
1.3 Identification of patient checked Performer
1.4 Procedure done Performer
1.5 Document in case record Performer
RECORDS: 1) Case Record, 2) Identification Band
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SOP TITLE:- “SAFE DRUG ADMINISTRATION”
SCOPE:- All Staff involved in patient care
PURPOSE:- To ensure safety of patients during drug administration
COMPLIANCE TO:- NQAS ME.E.7
Procedure for Safe Drug Administration.
 Drugs are checked for expiry and other inconsistency (Turbidity, Leakage,
Colour change, fungus) before administration.
 Check single dose vial are not used for more than one dose
 Check for separate sterile needle is used every time for multiple dose vial
 In multi dose vial needle is not left in the septum
 The treatment order is checked before administration of drugs
 Administration of medicines done after ensuring
o Right Patient,
o Right Drugs ,
o Right Dose,
o Right Route,
o Right Time,
o Right Documentation,
o Right Reason,
o Right Respond.
 Fluid and drug dosages are calculated according to body weight
 Drip rate and volume are calculated and monitored
 Disposable syringe and needle are used for each patient and for each injection
 Patient is informed about the injection and possible side-effects, warning
signs and symptoms
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 Patient is made to sit or lie down while administering injections.
 The Medication charts are maintained for each patient – i) Name ,IP No., H/O
Drug Allergy ii) Name of Medications iii) Dosage iv) Frequency v) Date &
Time of administration vi) Sign of S/N and Verified by SN and signed. Vii)
Counter-Sign by MO.
 Verbal / Telephonic orders:- Any verbal or telephonic order by specialist is
recorded in the case record by the Duty MO. The specialist verifies that the
correct documentation is done by asking the Duty MO to Read (Read-Back
Policy) the order written in the case sheet. Only then medications are
administered by the staff nurse.
 Patients are monitored after drug administration/intake for possible side effects
 Any adverse drug reaction is recorded and reported to MO.

 Patient is counseled for self drug administration - Patient is advice by
doctor/nurse about the dosages and timings .
 A List of High Alert Drugs and their maximum dose is maintained and the
same displayed. Error prone abbreviations are avoided while prescribing them.
The drugs are checked by S/N and MO before administration.
 Examples of High Alert Drugs potassium chloride, opioids, neuro-muscular
blocking agents, anti-thrombolytic agents, insulin, warfarin, Heparin, Adrenergic
agonist etc.
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Prescription in Case record or instructions shall be MO

2.1
written legibly, with date time and signature
2.2 Patient identity checked S/N
Drug checked and all instructions of MO about the S/N

2.3
drug administration verified
Patient relative / mother informed about adverse S/N
2.4
signs and symptoms
2.5 Drug administered S/N
Entry in Drug Administration chart (Treatment S/N

2.6
Chart)
2.7 Patient observed for few minutes S/N
Adverse Drug Event – inform MO and record in S/N

2.8
Incident form and Adverse event register
RECORDS:- 1) Case record 2) Medication chart 3)Incident form
4) Adverse event register
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SOP TITLE:- “IDENTIFICATION OF CAUTIOUS ADMINISTRATION
OF HIGH ALERT DRUGS”
SCOPE:- Whole Hospital
PURPOSE:- Guidelines for High Alert drugs management
COMPLIANCE TO:- NQAS:ME.E.7.1
Procedure for identification cautious administration high alert drugs
 High Alert drugs are identified in each department and the list maintained
 Examples of High Alert drugs-- Electrolytes like Potassium chloride,opiods,
Neuro muscular blocking agent, Anti Thrombolytic agent, Insulin, Warfarin,
Heparin, Adrenergic agonist etc.
 Maximum dose of High Alert drugs are defined; Value for maximum doses as
per age, weight and diagnosis are available with nursing station and doctor
 Error prone abbreviations are avoided while prescribing High Alert drugs
 The drugs shall be checked cautiously by S/N before administration and MO
shall check the Medication charts
Definition:High-alert medications are drugs that posses a heightened risk of causing
significant patient harm when they are used in error.
 Require special safeguards to reduce the risk of errors.
List of High Alert drugs:-
Injection: 25 mg in
1. Atracurium 0.3 – 0.6 mg / kg IV
ampoules (as besylate)
Injection: 50 Micrograms
2. Fentanyl 2-4 mg / kg IV
/ ml in 2 ml ampoule,
Injection: 5 mg on 1ml
3. Haloperidol 2 – 20 mg / day
ampoule
Injection:2.5 mg, 1 ml
4. Neostigmine 30 – 50 mg / kg
Ampoule
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5. Isoflurane Solution: 250 ml bottle MAC 1.2 %

Injection: 50 mg (as
3-5 mg / kg for IM
6. Ketamine Hydrochloride)/ ml in 10
1-2 mg / kg for IV
ml vial
Induction: 2mg / kg IV
Injection: 1% in 10 ml in
7. Propofol Maintenanc: 100 – 200
vial
mg/kg/min IV
Injection:50mg/ml
8. Suxamethonium 0.5 – 0.8 mg/kg/min IV
(chloride) / in 10 ml vial
Powder for Injection 10
9. Veccuronium 0.08 – 0.1 mg/kg IV
mg (bromide)in vial
250 ml Bottle:
10. Halothane MAC 1.9%
Inhalational Anaesthetic
1-2.5 mg IV Followed
by 1/4 th
Injection: 1 mg / ml in 5
11. Midazolam Supplemental doses
ml vial
0.02-0.1 mg/kg/ hrs IV
infusion
Injection: 2mg/ml in 2 ml 0.04 mg/kg IV
12. Lorazepam
ampoule (2 – 4 mg IV)
Injection:BP 50 mg/ml in
13. Pethidine 30-60 mg IM
1 ml ampoule
Injection: 200 mg/ml 100-200 mg IM/IV
14. Phenobarbitone
(Phenobarbitone Sodium) Lethal Dose: 5-10 gm
Injection: 50 mg / ml in 2
100 mg/day in adults
15. Phenytoin ml ampoule (Sodium
5-8 mg/kg in children
Salt).
Potassium Injection: 150 mg / ml in Not toexceed 10-40
16.
Chloride 10ml ampoule meq/hr
Injection 5 mg / ml in 2 ml
17. Diazepam 0.2 – 0.5 mg / kg IV
ampoule
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1 st dose of drugs to be confirmed from the prescribing doctor regarding the

Name of drugs route dose and record the same in the case record
Procedure for High Alert Drugs:-
3.1 Check the prescription in case record S/N
Identify High Alert Drugs prescribed in case record and

3.2 S/N
entry in Medication chart
MO shall check the Medication chart- for name of drug

3.3 MO
and dosage prescribed
Administer the drug as prescribed, checking the

3.4 S/N
maximum dose before administration
3.5 Monitor the patient S/N
RECORD:1.Case record 2. Medication chart 3. High Alert Drug checklist with

maximum dosage
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SOP TITLE:- “PROCEDURE TO OBTAIN SPECIALIST OPINION
WITHIN THE HOSPITAL”
Purpose: To follow uniform practice to obtain specialist opinion
Scope: Hospitalwide
Compliance to NQAS: CME.E.3.1
S.No. Responsibility Activity
Duty/Ward Mo records in case sheet requesting opinion of

4.1 Duty/Ward MO
the specialist
The concerned specialist is informed over phone or a memo

4.2 S/N
sent
4.3 The specialist arrives at the ward/place
Case record checked for details of patient and the opinion

4.4 required. The specialist discusses about the patient with the Specialist
ward/ Duty MO
4.5 Patient examined after obtaining the necessary history Specialist
Opinion of the Specialist recorded in the case sheet and any

4.6 Specialist
investigations and treatment to be followed are suggested.
4.7 Duty /Ward MO informed about the opinion obtained. S/N
RECORD:1.Case record, 2.Memo – where required
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SOP Title:- PROCEDURE FOR ISSUING BLOOD
Purpose: To ensure provision of blood transfusion services
for emergency management
Scope:- Blood bank staff and all staff involved in patient care
Compliance to NQAS:ME.E.13.8
 The stock of Blood bags available as per different blood groups is displayed
 Blood is issued for all emergency patients, at the earliest after receiving the
requisition
 Blood Bank staff are available round the clock
 In case of non-availability of Blood bags, blood is arranged from other Blood
Banks.
 No Donor replacement is requested in case of emergencies
 Maximum Surgical Blood Order Schedule for most of the Surgeries :i) Blood
availability is checked before all surgeries. ii)Blood samples are taken only if
there is requirement of blood. iii)Cross matching is done only on requisition
with Blood samples
5.1 Blood Transfusion decided Treating MO
5.2 Documented in Case record Treating MO
5.3 Requisition for blood signed Treating MO
5.4 Blood sample taken and labeled with patient name and S/N
IP no.
5.5 Blood sample, Requisition for blood and Case record is S/N
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sent to Blood Bank
5.6 Case sheet, Requisition for blood and Sample received BB S/N
by Blood Bank staff
5.7 Blood Group of patient checked BB S/N
5.8 Cross matching done BB S/N
5.9 Blood bag issued with Identification card along with it . BB S/N
Name and Identification of patient- entries made
5.10 Blood received in OT S/N
5.11 The Card, entries in Blood Bag is checked before Blood S/N
transfusion
Record: 1.Blood Transfusion-consent form, 2.Case Record, 3.Requisition form for

blood, 4. Blood Identification card
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SOP TITLE: PROCEDURE FOR BLOOD TRANSFUSION
Purpose: To ensure safe practices for blood transfusion
SCOPE: Labour Room, Wards, Cemonc OT
Compliance to NQAS: ME.E.13.9.
Duty MO decides on the need to transfuse blood/ blood

6.1 Duty MO
component
6.2 Order for transfusion written on case record Duty MO
6.3 Informed consent obtained from patient Duty MO
6.4 Requisition signed by MO Duty MO
6.5 BB staff informed over phone Ward SN
Blood sample taken by Staff nurse and with proper identification

6.6 of sample, it is sent to Blood Bank along with Requisition and Ward SN
Case Record through HW
Blood Bank staff verifies the Blood Group again and then Cross
6.7 BB staff
Matching is done
Blood bag issued through HW along with Blood Issue card

6.8 BB staff
attached to Case record
6.9 Blood bag received by ward staff along with case record HW
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6.10 Identification of blood bag verified Ward SN
6.11 Patient identification and vitals checked Ward SN
6.12 MO informed Ward SN
6.13 Blood started using Blood set Ward SN
Patient monitored throughout the transfusion, intensively during

6.14 Ward SN
the first 10 minutes- pulse, respiration, rashes, complaints
After completion of transfusion, blood bag and set disposed as

6.15 Ward SN
per BMW management rules
Entries made in case record – Starting time and completion time

6.16 Ward SN
and patient monitoring
6.17 Any reaction is treated as per protocol Duty MO
Blood transfusion reaction form signed by MO – one copy

6.18 Ward SN
attached to case record and another sent to BB
Record:
1.Case sheet 2. Blood requisition form 3. Informed consent 4. Blood bank register 5.
Blood Transfusion reaction form 6. Nurses record
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SOP TITLE: MANAGEMENT OF BLOOD TRANSFUSION REACTIONS
Purpose: To ensure safe practices
SCOPE: Labour Room, Wards, Cemonc OT
Compliance to NQAS: ME.E.13.10

7.1 Reaction following blood transfusion- major or minor
7.2 Stop transfusion Ward SN
7.3 Keep IV line open with 0.9 % NaCl Ward SN
7.4 Notify ward MO and blood bank Ward SN
7.5 Transfusion is terminated Ward SN
Send freshly collected post–transfusion sample of blood
7.6 (preferably from opposite arm) and sample of urine to Ward SN
blood bank.
Send the residual blood component unit along with
7.7 Ward SN
administration set toBlood bank
Fill in the adverse blood transfusion reaction form and
7.8 Ward SN
forward the same to the Blood bank
Record:-1.Case record,2.Blood Transfusion reaction form, 3.Transfusion reaction

register
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SOP TITLE: REFERRAL OF PATIENT TO HIGHER INSTITUITION
SCOPE: Labour room, Ante Natal OP, wards
Purpose: Guidelines for staff for referral of patients
 Patient is referred with Referral slip
 Referral Out register is maintained
 Contact no. of the Higher institutions is maintained
 Patients are followed up over phone later (entered in the Referral register) and
the outcome is documented .
 Patients are referred with Referral slips
 Referral linkage maintained with Higher centres- Advance information given
over phone when required
Treating MO decides to refer the patient and records

8.1 Duty MO
the same in the case record
Patient is stabilized – where required – IV line, drugs,

8.2 Duty MO
catheter etc.
Patient and relatives informed ( consent obtained)
8.3 In case the patient or relative is not willing – a negative Duty MO

consent is obtained in the case record and further
management proceeded with existing facilities.
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108 Ambulance called by the Staff Nurse and entered in

8.4 Ward SN
108 Register
Referral slip prepared by MO and also entered in

8.5 Duty MO
Referral out register
Higher Institution informed over phone- enter the same

8.6 Duty MO
in the Referral out register
8.7 Time of arrival of ambulance entered in 108 register Ward SN
Patient handed over to 108 personnel along with the

8.8 Referral slip ( in case of unstable patients – staff nurse Ward SN
or MO accompanies patient in the ambulance )
8.9 Copy of Referral slip attached to case record Ward SN
8.10 Follow-up of outcome – by phone Ward SN
 Referral In Register is maintained – in Labour room and functional linkages

maintained with Lower centres. Referral slip from lower centres are attached in
the Register
Records maintained:-1) Referral out register;2) 108 register; 3)Referral slip;4) case
sheet
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SOP TITLE: NURSING CARE
SCOPE: Hospital wide
Purpose: Guidelines for Nursing staff in patient care
Compliance to NQAS:ME.E.4
Responsibility: Staff Nurse
 Nursing assessment and screening of patients to be done within 15-30 minutes
of receiving the patient
 Treatment charts ( Medication charts) to be maintained. Treatment chart are
updated and drugs given are marked and signed
 Identification is done before any clinical procedure – ID band, case record
 Verbal / telephonic orders are rechecked before administration. Read Back
policy is followed during verbal orders. Drug administration chart is verified later
by the ordering MO. Verbal orders are recorded in a separate register.
 Patients are monitored , vitals checked and recorded periodically
 TPR chart, Input Output chart are maintained where required
 Critical patients are monitored - using Monitors- CTG, BP, pulse, temp., RR,
FHR, uterine contractions. Partograph monitoring is done when the patient
enters in the Active phase of labour
 Maintenance of cleanliness and House-keeping checklist
 Maintenance of equipments and checklist
 Maintenance of records - nursing notes maintained.
 Safety of patients ensured before and after any procedures
 Safe Injection practices
 Handing over and taking over during shifts at bed side- to maintain continuity of
care. Register is maintained
 In case of doubt, Duty MO is contacted
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9.1 Ensures safe and clean environment in the S/N
department and culture swabs taken monthly .
Provide all medical and logistic support for patient care
as per the advice of the Nursing Superintendent.
9.2 Maintain duty room trays, send instruments to CSSD S/N
for sterilization and keep procedural trays in readiness.
9.3 Assign and supervise work allotted for various S/N
categories of nursing and non nursing personnel
working in the department.
9.4 Adhere to appropriate PPE and infection control S/N
policies, procedures and practices.
9.5 Affix identification band prepared by the Registration S/N
staff after verbally confirming with the patient and/ or
family about the details of the patient‘s name, age,
sex, IP/ UHID number written on the identification
band.
9.6 Provide life support measures and stabilize all patients S/N
requiring emergency care prior to identification,
registration and police procedures.
9.7 Identify and ensure safe care of vulnerable patients S/N
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9.8 Assist the Medical Officer in conducting initial S/N

assessment of all patients.
9.9 Monitor and document medications administered as S/N
per the treating doctor‘s instructions. Document
adverse drug reaction, if any.
9.10 Assist doctors in various medical and surgical S/N
procedures by preparing patients and getting ready
with the required things.
9.11 Assist the Medical Officer to obtain Specialists S/N
opinion, wherever appropriate.
9.12 Assist the Medical Officer to obtain informed consents S/N
from patient and/ or family as per documented
procedures in situations where informed consent is
required for decision making.
9.13 Provide a copy of the treatment summary to the S/N
patient and / or family who are referred to another
organization for further diagnostic and /or therapeutic
purposes after stabilization.
9.14 Assist the Medical Officer in transfer of patients to S/N
respective wards after stabilization.
9.15 Conducting Normal vaginal delivery . Initiation of S/N
Breast-feeding within ½ - 1hour of delivery
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9.16 Bed management in case of non-availability of beds/ S/N

boards
9.17 Monitoring the AN patient during the 4 stages of labour S/N
and the New Born
9.18 Parturition Registration and Birth Registration S/N
9.19 Allowing Birth Companion and restriction of visitors S/N
9.20 Educate patient and relatives in a language and format S/N
that they can easily understand about their healthcare
needs:
 Importance of timing of medication administration,
drug interaction and the potential side effects.
 Food-drug interactions.
 Disease specific diet and nutrition requirements.
 Importance of ongoing treatment and regular
medication in controlling the disease.
 Prevention of further complications and disease
progress – life style modification.
 Personal hygiene and prevention of Health Care
Associated Infections.
 Pain management techniques wherever
appropriate.
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9.21 Educate patient and relatives in a language and format S/N

that they can easily understand about their rights and
responsibilities.
9.22 Direct patients to other departments for investigations / S/N
procedures.
9.23 Deal appropriately with any adverse situation that S/N
occurs in the department and report to the concerned
authorities.
9.24 Maintain all records pertaining to the department. S/N
9.25 Maintain and ensure submission of departmental S/N
statistics regularly.
Record: Case record, Nurses report book, Handing over taking over register, all
registers
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SOP TITLE: HIGH RISK AND VULNERABLE PATIENTS
SCOPE: Maternity ward staff, Cemonc OT staff
Purpose: Guidelines to identify High Risk and Vulnerable patients
and ensure their safe care
Compliance to NQAS:ME. E. 5.1 and 5.2
S.No Activity Responsibility
10.1 High Risk patients andVulnerables are identified in the S/N
ward.
10.2 Check case record and doctors notes S/N
10.3 Vulnerable patients include- all AN patients and New S/N
Born. Measures are taken to protect them from harm.
Measures are taken to prevent new born theft,
swapping and baby fall. Provide facilities required for
them ( Birth companion allowed, CCTV monitoring,
RFID Tag Allowed, Visitors Restriction)
10.4 Document in Nurses report book S/N
10.5 High Risk pregnant patients include- AN patients with S/N
complications , which are listed out in the ward ( eg.
PIH, previous LSCS, Anaemia, abortions, APH , Multi
gravid, PROM , preterm, IUGR) . Patients in 2nd stage
of labour are also at high risk. Delivered patients are
monitored intensively during the first 2 hours after
delivery.These patients are placed in intensive
monitoring
Monitor them more frequently, as required
10.6 High Risk Patients- posted for surgery. High risk Concerned MO
consent for surgery and anaesthesia obtained
separately
Record: 1.Case record 2. Nurses report book
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SOP TITLE: DIAGNOSTIC SERVICES
SCOPE: Labour room, wards, OT staff
Purpose: Guidelines for managing patients requiring
Diagnostic services
(Pre Testing and Post Testing Activities)
a) Imaging services ( Ultrasonography)
 Imaging services provided as per the requirements of the patient.

 USG scan services provided to AN mothers comply with legal and other
requirements(PNDT act .)The PNDT Act is displayed.The patient and the
Gynecologist sign the Form F that the gender of the fetus was not revealed
during the procedure.
 USG done for delivered patients, if required.
 Duty MO (trained in Obstetric Basic level USG performs the USG .
 Patient is transferred to the scan room by walk/ wheel chair / stretcher by the
hospital worker depending on the condition of the patient.
 The results are entered in the scan register and in the AN card/ OP slip / IP
case papers.
 Early pregnancy- patients are instructed to come with full bladder. But
emergency cases should be on Nil oral and hence IV fluids started.
Ultrasonography of pregnant women if required is performed during ANC visits.

The reason for performing ultrasonography must be covered any of the 23
indication prescribed in PC&PNDT Act 1994.
A declaration is taken on form F from doctor as well as from pregnant women.
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a) Management of IP cases:-
11.1a Duty MO in the Labour ward decides on the scan and Duty MO
writes in the case record
11.2a PNDT form F signed by the patient and the scanning Sonologist
MO (for all Obstetric cases)
11.3a Patient taken to the scan room in the ward Ward SN/ANM
11.4a Patient details entered by the staff nurse/ANM in the Ward SN/ANM
Scan IP register
11.5a Scan done by the Duty MO ( Basic Level I scan) Duty MO
11.6a Results entered in the Scan register and in the case Ward SN/ANM
record with date and time and in the format
11.7a Patient informed about the findings Sonologist(Duty

MO)
11.8a Patient leaves the scan room and goes to the ward Ward SN
Record: Case record, OP slip/ AN card, Requisition slip, PNDT form, Scan register
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b) X-Ray-
 X-ray of pregnant women is avoided it is allowed only if approved by
radiologist/physician who overweighs the benefit against risk of performing x-
ray procedure.
 MRI preferred
 Pregnancy status of woman of child bearing age is confirmed before performing
the procedure by radiographer. A notice for this purpose is displayed at X-
Rayroom.
 Lead shield is provided if X-ray procedure is performed on pregnant woman.
 Sending Specimen for HPE and Biopsy.
C) Procedure for requisition of Lab Services ( Requisition of Diagnosis and

receiving of Reports)
11.1c Duty MO writes for investigations in the case sheet Duty MO
11.2c Requisition for the investigations is written with provisional Ward SN

diagnosis where required
11.3c Sample is taken by ward SN and labeled (Name ,IP,ward Ward SN

name)
11.4c Labelled Sample along with requisition is sent to Lab Ward SN

through HW
11.5c Sample and requisition slip received in Lab Lab Asst.
11.6c Entries made in lab register Lab Asst.
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11.7c Lab tests done Lab Asst.
11.8c Report sent to ward Lab Asst.
11.9c Critical values are reported over phone and the same Lab Asst.
recorded
11.10c Report shown to Duty MO Ward SN
b) Procedure in ward / OT :-
Bed side Lab tests available:-
1. Urine - Albumin & Sugar – dipstick

2. BT, CT
3. Urine - Pregnancy Test card test
4. Hiv card test
5. Capillary Blood Glucose Glucometer
6. Blood Grouping and Typing
Out-sourcing of Lab tests:- done for non-available tests, (all tests are free of cost).
These are entered in separate register in the Labour ward. Samples are
collected by the private Lab asst. and taken to their lab and reports are informed over
phone in case of emergency or sent to the lab
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CRITICAL VALUES AND REPORTING TIMES
1. HAEMOGLOBIN 12-16 gm/dl Immediately

2. WBC 4000 -11000 cells Immediately
3. PLATELETS 1.4 – 4.0 cells / mm3 Immediately
4. BLEEDING TIME 2 – 6 minutes Immediately
5. CLOTTING TIME 3-10 minutes Immediately
6. FBS 70-90 mg/dl 2 Hours
7. PPBS Upto 14 mg/dl 2 Hours
8. RBS 80-120 mg/dl 2 Hours
9. UREA 15-40 mg/dl 2 Hours
10. CREATININE 0.9-1.3 mg/dl 2 Hours
11. TOTAL PROTEIN 6.7-8.6 g/dl 2 Hours
12. ALBUMIN 4.1-5.3 g/dl 2 Hours
13. TOTAL BILIRUBIN 0.3-1.3 mg/dl 2 Hours
14. TOTAL CHOLESTROL 150-200 mg/dl 2 Hours
15. SERUM SODIUM 136-145 mg/dl 2 Hours
16. SERUM POTASSIUM 3.5 – 5.1 mg/dl 2 Hours
17. SERUM CALCIUM 8.6 – 102 mg/dl 2 Hours
18. URIC ACID 2.5 – 5.6 mg/dl 2 Hours
19. SGOT Upto 46 u/l 2 Hours
20. SGPT Upto 49 u/l 2 Hours
For Emergency Cases all reports will be provided immediately
Record: Case Record, OP Slip / AN Card, Lab Register, Lab Report
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SOP TITLE: PROCEDURES FOR END OF LIFE CARE AND DEATH
INCLUDING NEW BORN DEATH AND STILLBIRTH
SCOPE: Labour room, wards, OT staff
Purpose: Guidelines for end of life care and death
a)Maternal Death:-
 For Patients whose condition is deteriorating – explained to relatives and sign

obtained (DIL)
 Resuscitation done as per guidelines
 Death notes and cause of death (immediate cause and underlying cause ), date
and time recorded
 Death summary is attached to case record .
 Postmortem is recommended for all maternal death cases. Body is sent to
mortuary. In case the relatives are not willing, the same recorded and sign
obtained from relatives. Body handed over and Death certificate issued to the
nearest of kin and sign obtained
 If body is sent for PM, outpost police is informed. After police inquest is
received PM done and body handed over to police .
 All Maternal deaths, verbal autopsy is done and the same attached to case
record. Higher authorities are informed within 24 hours
 Maternal Death Audit – i) Internal Death audit is done in the facility ii) Referral
case Death audit – also in the facility iii) District level-Audit is done by JD
during CEmONC co-ordination meetings iv) Death audit by District Collector-
where relatives also attend v) State level- Death Audit by Expert team- directly
or through video conference
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b) New Born Death and Still Birth
PURPOSE: TO DISTINGUISH BETWEEN NEW BORN DEATH AND STILL BIRTH

Still birth:-
Definition:-Stillbirth is a baby born with no signs
of life at or after 28 weeks' gestation
 Death may occur in the uterus at any stage of
pregnancy or in labor. Most stillbirths occur prior
12.1 to onset of labor and the most common symptom MO
is loss of fetal movement. Some hours after the
death of a fetus in the uterus, the skin begins to
peel. On delivery, such a fetus is known as a
macerated stillborn, as compared to fresh
stillbirth.
Diagnosis of Fetal Death
Stillbirth may be detected by :
 History – the most common symptom is loss of
fetal movement. Vaginal bleeding or pain in the
lower abdomen, back and pelvis may be present.
Inability to detect fetal heart sounds by a
12.2 MO
stethoscope, Doppler ultrasound, or
cardiotocography.
 Ultrasound can confirm the diagnosis of stillbirth –
there is no fetal movement, such as heart beat,
on ultrasound.
 Stillbirth may be diagnosed after delivery.
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Stillbirth vs Miscarriage
Stillbirth should be differentiated
from miscarriage (spontaneous abortion) although
the distinction is arbitrary. A death occurring prior to 28
weeks gestation, or delivery of a fetus weighing less
12.3 MO
than 500 gm, or before a fetus is viable, is known as
spontaneous abortion, while the loss of a fetus beyond
this period is known as fetal death, fetal demise, or
stillbirth. Stillbirth is also referred to as intrauterine fetal
death (IUFD).
New Born Death:
Neonatal death:the death of a baby within the first 28
days of life
Causes of neonatal death:-
12.4  Prematurity (causing particularly respiratory and MO
neurological conditions)
 Congenital abnormality
 Obstetric complications
 Infection
Record: Case record of Mother and New Born, Parturition Register, Death Register
 Infant Death Audit –

o i) Internal Death audit is done in the facility- Responsibility –
Paediatricians
o ii) Referral case Death audit – also in the facility
o iii) District level-Audit is done by JD during CEmONC co-ordination
meetings
o iv) Death audit by District Collector- where relatives also attend
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Document Name
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SOP TITLE:- OT SCHEDULING FOR THE SURGERY
AND ITS BOOKING
Purpose:- To provide guidelines for preparation of OT Schedule
Scope:- LR,Ward and OT staff
Compliance to NQAS:- ME.E.15.1.
 The facility maintains OT schedule for Planned Surgeries and for Emergency
surgeries.
 These OT schedules ( Elective OT schedule and Emergency OT schedule) are
prepared in the respective wards by the ward mo in consultation with the chief
and anaesthesiologist.
 The OT schedule list is then sent to RMO for information.
 The signed OT list is then sent to the OT staff, so that she can prepare for the
surgery and be in readiness to receive the patients as per schedule and also
verify the identity of the patients.
 The OT schedule is prepared as per patient requirements and availability of
Surgeons, anaesthesiologists and Operation room readiness
 The OT is booked for the surgeries in the Schedule
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A) PROCEDURE FOR ELECTIVE OT LIST:-

13.1a Surgeon decides on Surgery for the patient Surgeon
13.2a Patient informed about the decision Surgeon
13.3a Patient sent to Anesthetist to obtain Anesthesia fitness Ward S/N
Anesthetist examines patient and either gives the fitness or
rejects or delays with reasons for the same.
13.4a Anaesthesiologist
Pre-anaesthesiafitness form is filled by the
anaesthesiologist and pre-operative medications advised.
Staff informs the surgeon about the anesthetist fitness
13.5a Ward S/N
obtained and OT List is prepared
Sign is obtained in the list on the preceding day of surgery –
13.6a Ward S/N
from Surgeon, HOD OG, Anaesthesiology HOD, RMO
The OT list is then sent to the OT staff on the previous day,
13.7a so that she may prepare the OT for the surgery and plan Ward S/N
accordingly.
The surgeries are done as per the order of patients in the
13.8a OT list and patients are verified for procedure and OT S/N
identifications as per the OT list
The OT list is checked for completion of surgeries and
13.9a compiled for record. Any cancellation of surgery, is to be OT S/N
informed to RMO and marked in the OT list
Any cancellation of surgery must be informed to RMO with
13.10a OT S/N
reasons
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B)PROCEDURE FOR EMERGENCY OT LIST
S.N. Activity Responsibility
13.1b Surgeon decides on Surgery for the patient Surgeon
13.2b Patient informed about the decision Surgeon
13.3b Anaesthesiologist informed about the emergency . Ward S/N
Anaesthesiologist examines patient and either gives the

fitness or subjecting the patients for further investigation
13.4b depending upon the condition of the patient. Anaesthesiologist
Pre-anaesthesia assessment form is filled by the
anaesthesiologist and pre-operative medications advised.
13.5b Emergency OT list is prepared Ward S/N

Signture is obtained in the list – from Surgeon and
13.6b Ward S/N
Anaesthesiologist
The OT list is then sent to the OT staff, so that she may
13.7b Ward S/N
prepare the OT for the surgery and plan accordingly.
The OT list is checked for completion of surgeries and

13.8b OT S/N
compiled for record.
Record: Case record, OT Schedule, OT Schedule register
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Document Name
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SOP TITLE:- PROCEDURE OF RECEIVING PATIENT IN OT
Purpose:- To provide guidelines for receiving patients in OT
Scope:- OT staff
14.1 OT schedule received from ward /OP Ward/OP S/N
Patient received in OT along with case record and the
14.2 Ward /OP S/N
necessary catheterizations- which are checked while receiving
14.3 Patient placed in Bed in the Patient waiting room OT S/N
Identification of patient and the procedure is verified by
14.4 OT S/N
checking the case record, schedule and also verbally
14.5 Pre- Medications and other treatment in the ward are checked OT S/N
The Informed consent obtained for Anaesthesia and Surgery
14.6 OT S/N
are checked for completion
14.7 Patient‘s vitals are checked – Pulse, BP, RR OT S/N
14.8 Patient is informed about the approximate timing of surgery OT S/N
Anaesthesiologist and Surgeon are informed about the arrival
14.9 OT S/N
of patient
Handing over and Taking over is recorded in case sheet and
14.10 OT S/N
in register
Record: Case record, OT Schedule, Pre-operative checklist, Informed consent forms
for surgery and anaesthesia
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SOP TITLE:- PRE-OPERATIVE ANAESTHETIC CHECKUP (PAC):-
Purpose: To ensure that Anaesthesia fitness is obtained before
surgery for patient safety
Scope:- Ward and OT staff
Facility has established procedures for Pre Anaesthetic Check up (PAC) and
maintenance of records-- There is procedure to ensure that Pre Anaesthetic Check
up has been done before surgery. There is procedure to review findings of Pre
Anaesthetic Check up
 Pre- Anaesthesia Assessment is done before Surgery- format is used for

recording
 Pre-Induction Assessment is done just before induction of anaesthesia- format
is used for recording

15.1 Surgeon decides on procedure/ surgery to be done in OT Surgeon
and documents the same in the Case record
15.2 Surgeon informs the patient about the decision Surgeon
15.3 Surgeon instructs Ward staff nurse to obtain Surgeon
Anaesthesiologist fitness
15.4 Staff Nurse informs anaesthesiologist Ward S/N
15.5 Anaesthesiologist examines patient and opines in the Pre- Anaesthesiologist
anaesthesia Assessment Form whether the patient is fit or
not fit.
A detailed history about the patient and general examination
is done.
Any High risk is identified and the level of risk for
anaesthesia is documented and High risk consent obtained.
Any treatment required or investigations required are
mentioned in the form.
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The weight of the patient is noted.

Any previous history of Drug allergy, anaesthesia, surgery
are obtained.
The vitals are recorded and the type of anaesthesia to be
given is planned.
The pre-anaesthesia medications and IV fluids to be given
and the Induction drugs to be used and the monitoring
equipments required are recorded.
15.6 Surgeon informed about the anaesthesiologist opinion Ward S/N
15.7 Instructions and advice of the anaesthesiologist are noted Surgeon
and patient prepared accordingly.
15.8 Patient assessed again by anaesthesiologist , just before Anaesthesiologist
Induction of anaesthesia( Pre-Induction assessment ) and
the respective form is filled. Induction is attempted only
when the anaethetist is satisfied with the condition of the
patient, or due precautions are taken according to the
condition of the patient.
Record: Pre-Induction anaesthesia assessment form, Pre-operative anaesthesia
assessment form, Case record
See
ANNEXURE VI- Pre- Anaesthesia Assessment
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SOP TITLE:- MONITORING DURING ANAESTHESIA
Purpose: Provide guidelines for monitoring during anaesthesia
Scope: OT staff
 Anaesthesia plan is documented before entering into OT
 Food intake status of Patient is checked
 Patients vitals are recorded during anaesthesia-- Heart rate , cardiac rate , BP,
O2 Saturation- Intra-operative monitoring form is used for documentation
 Airway security is ensured-- Breathing system is securely and correctly
assembled
 Potency and level of anaesthesia is monitored
 Anaesthesia notes are recorded
 Any adverse Anaesthesia Event is recorded in the Adverse Events register and
reported through Incident reporting form
 Patient Vitals are monitored and recorded periodically Multi paramonitor is
used

16.1 Patient is received in the Operation room OT S/N
The Identity of the patient is verified verbally and case
16.2 Anaesthesiologist
record checked
The Pre-anaesthesiaassessment done earlier and the
Anaesthesia plan documented is checked
Patient is examined again and a Pre-induction assessment
16.4 is done and vitals checked. The time of food and fluid taken Anaesthesiologist
last is checked verbally.
Patient is explained about the anaesthesia procedure before
induction
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The IV lines and monitors – pulse oximeter or multi

paramonitor are connected to the patient.
After induction of anaesthesia with aseptic precautions, the
level of anaesthesia is checked
During the entire course of surgery, patient‘s vitals are
16.8 monitored. Blood loss assessment is done and urine output Anaesthesiologist
checked. Blood may be ordered if required.
Injections required to stabilize patient and for the particular
procedure are given as per requirement.
Vitals , O2 saturation and condition of patient is recorded in
16.10 the Intra-operative Anaesthesia monitoring form. Any Anaesthesiologist
Adverse events are recorded.
Record: Case record, Intra-operative anaesthesia monitoring form
See ANNEXURE VII- Anaesthesia Record
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SOP Title:- POST –ANAESTHESIA CARE
Purpose: To provide guidelines for post-anaesthesia care of patients
Scope: OT and ward staff
Compliance to NQAS: ME.E.13.3, ME.G.4.2
17.1 Completion of Surgery
17.2 Post anaesthesia status is monitored and Anaesthesiologist and
documented,Modified AldretecScore chart is used S/N
to monitor the patient following anaesthesia,
before discharge the patient from the OT.
The following are checked :-
1)Oxygenation 2)Respiration
3)Blood Pressure 4)Consciousness
5)Activity
Ideally, the patient is discharged when the score is
10, but a minimum of 8 is required.
17.3 Patient‘s vitals checked both physically and in Anaesthesiologist and
Multiparamonitor. BP checked. Patient‘s response S/N
and conscious level checked in OT
17.4 Anaesthesiologist instructs to shift the patient to Anaesthesiologist
Recovery room or patient kept under observation
in OT itself
17.5 Patient discharged from OT/Recovery room when Anaesthesiologist/ OT
Aldrete score is 9 or 10 and anaesthesiologist is staff
satisfied with the condition of the patient.
Documentation done in Aldrete score chart
17.6 Patient shifted to ward and handed over to ward HW
nurse.
Record: Case record, Alderete Score chart

See ANNEXURE VIII – Modified Alderete Score Chart
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SOP Title:- PRE-OPERATIVE PROCEDURE:-
Purpose:- To ensure patient safety and see that the right procedures
are followed for preparation of patients for
procedures/surgeries
Scope:- Labour Room, Wards, Cemonc OT
Compliance to NQAS: ME.G.4.2
 Facility has established procedures for Preoperative care – by Surgeon and

Anaesthesiologist
 Patient evaluation before surgery is done and recorded-- Vitals , Patients

fasting status etc.
 Antibiotic Prophylaxis given as indicated
 Tetanus Prophylaxis is given if Indicated
 There is a process to prevent wrong site and wrong surgery- Procedure card
attached to case record –(Surgical Site is marked before entering into OT- in
applicable cases only)
 Surgical site preparation is done as per protocolCleaning , Asepsis and

Draping
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18.1 Surgeon decides on procedure/ surgery to be done in OT and Surgeon

documents the same in the Case record
18.2 Surgeon informs the patient about the decision Surgeon
18.3 Surgeon obtains Informed consent for surgery- explaining the Surgeon
surgery, possible complications, outcome etc. Any High risk is
explained and sign obtained from patient.
18.4 Anaesthesiologist is informed about the surgery Ward S/N
18.5 Anaesthesiologist examines the patient and either gives the Anaesthesiologist
fitness for Surgery or delays or subjecting the patients for further
investigation depending upon the condition of the patient.
18.6 If patient is found fit for anaesthesia, Anaesthesia Informed Anaesthesiologist
consent is obtained from patient , explaining the procedure ,
possible complications etc. Any High risk is explained and sign
obtained from patient.
18.7 Pre-anaesthesia Assessment form is filled Anaesthesiologist
18.8 OT list is sent to OT staff Ward S/N
18.9 Patient asked to bathe and Sterile gown provided for patient. Ward S/N
18.10 Patient is prepared for Surgery- IV Lines, Bladder catheterization Ward S/N
for cases where indicated, Surgical site preparation and draping
with sterile cloth. ID band is affixed on the patient‘s wrist, site
marking in selective cases
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18.11 Pre-anaesthesia medications and prophylactic antibiotics given Ward S/N

as per order. Inj. TT given.
18.12 Patient is wheeled to the OT along with the case record with Ward S/N
Procedure card( for identification of patient and the procedure)
attached
18.13 Patient received in OT and case record , consent and OT S/N

medications, preparations are verified
18.14 Patient is taken to Operation room after checking identity and OT S/N
the procedure. I)The details in OT list is cross checked with the
details in case record. 2)Name of patient and the procedure is
verified verbally 3)ID band is checked 4)surgery identity card
attached to the case record is verified. These are some of the
measures to prevent wrong patient and wrong surgery
Surgical site marking in applicable cases- is checked ( measure

for prevention of wrong site)
18.15 Pre-induction anaesthesia assessment is done by the Anaesthesiologist

anaesthesiologist
18.16 Before Induction of anaesthesia and before skin incision - Surgeon,

Surgeon, Anaesthesiologist and OT staff discuss with each other Anaesthesiologist
about the patient‘s condition and expected problems as given in and OT S/N
the safe Surgery checklist
Record: Case record, Pre- operative checklist, Consent forms- Surgery and
Anaesthesia, Pre- Anaesthesia assessment form, Procedure card
See ANNEXURE IV- Procedure Identification card
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SOP Title:- IDENTIFICATION OF PATIENTS FOR SURGERY
Purpose:- Policy for Identification of patients
Scope:- OT staff
 Patient is identified before any clinical procedure.
 Identification band is affixed to the wrist of all patients at the time of admission.
This contains the name of the patient , ward, and PIN No.,
 PIN No./ IP No. is given to every patient admitted and is recorded in the case
sheet. This number is used for identification of patients.
 Verbal confirmation is also done by verifying with the patient his/her name and
the procedure to be performed
 OT list signed by Surgeon and Anaesthesiologist– is checked for patient name
and procedure
19.1 Surgeon decides on the procedure to be done on the patient Surgeon
19.2 Surgery Identification card ( Procedure card)is attached to the Ward S/N
case record which is signed by the Surgeon
19.3 Site marking is done for selective cases Ward S/N
19.4 Patient received in the OT Ward S/N
19.5 OT staff checks the ID band and the case sheet and the OT S/N
Procedure card and also verbally confirms with the patient. OT
list is also checked
19.6 Patient taken to the Procedure room OT S/N
19.7 Anaesthesiologistchecks the ID band and the case sheet and Anaesthesiologist
the Surgery Identity card and also verbally confirms with the
patient
19.8 Before starting the surgery, the Surgeon confirms with the Surgeon
patient and checks the Identity.
Record: Case record, Procedure card
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SOP Title:- IN PROCESS CHECK DURING SURGERY:-
Purpose: Guidelines to ensure Patient safety during Surgery
Scope: OT staff
Compliance to NQAS: ME. G.4.2
 Facility has established procedures for Surgical Safety Surgical Safety Check
List is used for each surgery
 Sponge and Instrument Count Practice is implemented-- Instrument, needles
and sponges are counted before beginning of case, before final closure and on
completing of procedure
 Adequate Haemostasis is ensured during surgery . Ligation sutures are used
to control bleeding sites and Electric Cautery used if required.
 Appropriate suture material is used for surgery as per requirement-Vicryl is
used for closing uterine wound. 0- Catgut is used for Tubectomy.

20.1 Check that the patient has confirmed their identity, the surgical Anesthetist,
site, and the procedure to be done and that the patient has Surgeon and
given informed consent. assisting S/N
20.2 The surgical site should be marked, if applicable. Ward S/N
20.3 The anesthesia safety check should be completed Anaesthesiologist
20.4 The pulse oximeter should be placed on the patient and Anaesthesiologist
functioning
20.5 Check to see if the patient has (1) A known allergy. If so, Anaesthesiologist
these should be documented. (2) An anatomically difficult
airway to intubate or aspiration risk. If so, additional equipment
and assistance should be available. (3) Risk of more than 500-
mL blood loss in adults or 7 mL/kg in children. If so, provision
should be made for adequate intravenous access and fluids.
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20.6 Confirm that all team members have introduced themselves Anaesthesiologist,
both by name and by their role on the surgical team. Surgeon, Assistant,
OT S/N
20.7 The surgeon, anesthesia professional, and nurse should Anaesthesiologist,
verbally confirm the patient's identity, surgical site, and Surgeon, Assistant,
procedure to be performed OT S/N
20.8 Anticipated critical events to be reviewed by the surgeon- are Surgeon
any critical or unexpected steps, estimated operative duration,
and anticipated blood loss.
20.9 Anticipated critical events to be reviewed by the anesthesia Anaesthesiologist
team are whether there are any patient-specific concerns
20.10 Anticipated critical events to be reviewed by the nursing team OT S/N
are confirmation of sterility of the tools, supplies, and field
(including indicator results); documentation and discussion of
any equipment issues or concerns; whether antibiotic
prophylaxis has been given within the last 60 minutes, if
applicable; and whether essential imaging is displayed, if
applicable
20.11 The nurse verbally confirms with the team the name of the OT S/N
procedure to be recorded and verifies instrument, sponge, and
needle counts, if applicable; labeling for the surgical
specimen, including patient name; and whether there are any
equipment problems to be addressed.
20.12 The surgeon, anesthesia professional, and nurse review the Anaesthesiologist,
key concerns regarding recovery and management of the Surgeon, OT staff
specific patient Nurse
Record: Case record, WHO- Safe Surgery Checklist
Reference : WHO Guidelines for Safe Surgery
See ANNEXURE I: Guidelines for usage of WHO Safe Surgery Checklist
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SOP Title:- POST OPERATIVE CARE OF THE PATIENT
Purpose: To identify the measures and instructions to be given
for post-operative care of patients
Scope: Ward and OT staff
Compliance to NQAS:ME.E.14.2, ME.G.4.2
 Facility has established procedures for Post operative care-- Post operative
monitoring is done before discharging to ward.Patients are not immediately
shifted to wards after surgery
 Post operative notes and orders are recorded
 Post operative notes contains Vital signs, Pain control, Rate and type of IV
fluids, Urine and Gastrointestinal fluid output, other medications and Laboratory
investigations

21.1 Surgery completed Surgeon
Surgery – Intra-operative findings and surgery done and vitals
at the completion of Surgery are documented in Case record
21.2 Surgeon
. Patient checked for vitals ,BP, any undue bleeding and urine
output- before shifting to the Post-operative ward.
Post-operative care to be given- written in case record
following the Surgery notes
1)Nil oral- for how long . When diet or fluids can be given
2)IV fluids- how many pints and rate of flow
3)Pain management drugs. Any sedation to be given at night.
21.3 4)Antibiotics where required Surgeon
5)Vitals monitoring 6)BP check
7)Temperature monitoring 8)Intake Output chart
9) Any other medication
10)Any special instruction or monitoring
11)Ambulation of patient
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Patient is re-assessed after the Surgery. General examination

done, vitals recorded. Local examination
IV fluid requirement
Starting of oral fluids and diet
21.4 Surgeon
Medications to be given
Pain relieving agents
Early ambulation advised
Early removal of in-dwelling urinary catheters
Patients are monitored for any post-operative complications
21.5 like fever, bleeding, severe pain, distension , respiratory Surgeon
distress etc.
Patient is monitored for any Health Care Associated infection-
21.6 Catheter associated urinary infection and Blood stream Surgeon
infection, Surgical site infection and respiratory infections
Patient discharged when fit. Warning signs and symptoms
21.7 Surgeon
explained. Patient followed up after discharge in the OP
Record: Case record, Nurses report, Handing over Taking over register
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SOP Title:- PROCEDURE FOR C- SECTION
AND ASSISTED DELIVERIES
Purpose:- To ensure standard protocols for C- section
and assisted deliveries
Scope:- OT staff
a)Pre-operative care:-
22.1a The Basic investigations to be done and report available – Ward S/N
1) Urine albumin and sugar 2) Hb 3)Blood Group and Rh
typing 4) USG report 5) BT , CT 6) In PIH cases- Blood
Urea, Serum Creatinine, Platelet count, SGOT and SGPT,
Serum Bilirubin
22.2a Blood availability is verified for all Surgery patients. In case of Ward S/N
anaemia, sample blood is sent for cross matching and blood
is reserved, which can be given Intra-op or post-op.
22.3a IV line is established with IV fluid on flow – RL or NS Ward S/N
22.4a With aseptic precautions, Bladder is catheterized Ward S/N
22.5a Pre-medications- as advised by Anaesthesiologist are given Ward S/N
22.6a Inj. TT is given for those mothers not immunized antenatally Ward S/N
22.7a Prophylactic Antibiotic is administered within 1 hour of skin Ward S/N
incision
22.8a Abdomen and Back are cleaned with antiseptic solution and Ward S/N
wrapped with sterile towel
22.9a Patient is given a sterile gown Ward S/N
22.10a Anaesthesia Plan is formed by Anaesthesiologist after a Pre- Anaesthesiologist
Anaesthesia Assessment. Spinal or General Anaesthesia is
opted depending on the condition of the patient
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b)Intra-operative care:-
22.1b Measures are taken to prevent Supine Hypotension- by Anaesthesiologist
keeping folded cloth under the lower back to tilt the uterus
22.2b The preferred Skin incision – Pfannensteil or Transverse Surgeon
incision.
22.3b Opening of Uterus- Lower Segment Caesarean Section is Surgeon
done
22.4b Delivery of foetus- Cephalic presentation- The foetal head is Surgeon
levered out with help by the Assistant. Mobile head is fixed
before uterineincision.In difficult cases, delivered as breech
or Pattuvardhan technique in Obstructed labour or push
given from below through vagina ;Breech is delivered as
Breech ; Transverse and Oblique lie are delivered as
breech.
22.5b Placental delivery is done after placental separation. Surgeon
Placental separation done , if it is adherent or there is
bleeding
22.6b Uterine incision is closed in 2 layers, preferably with 1- Vicryl Surgeon
C)Post-operative Care:-
22.1c Vitals monitored- ½ hourly PTR chart POP ward S/N
22.2c BP checked POP ward S/N
22.3c Intake output chart POP ward S/N
22.4c Check whether uterus is firm and contracted POP ward S/N
22.5c Check for any undue vaginal bleeding POP ward S/N
Record: Case record
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SOP Title:- PROCEDURE FOR MANAGEMENT OF
OBSTETRIC EMERGENCIES:-
Purpose:- To follow Standard protocols for management of
Obstetric emergencies
Scope:- OT staff
Responsibility: Anaesthesiologist, Surgeon, OT staff

1)Management of PIH:- The BP is maintained at 140/90
Anaesthesiologist,
23.1 mm Hg by giving Labetolol. IV fluid rate is monitored
Surgeon, OT staff
and watched for Pulmonary oedema.
2)Eclampsia :-
 Secure airway and breathing
 Inj. Magnesium Sulphate regimen.Loading dose
IV, followed by maintenance dose IM;
Mgso4-50% solution-1 amp.= 2ml= 1gm
IV Loading dose:- 4 amp(8ml)+12 ml NS in 20cc
syringe give slow IVover
5-10min) + 5 amp(10ml in 10ml syringe in right buttock, 5
amp(10ml in 10ml syringe in left buttock; give RL at the
Anaesthesiologist,
23.2 rate of 30ml/hour
Surgeon, OT staff
Maintenance dose :- 5 amp. Deep IM in one buttock
4thhourly – after looking for 3 signs of toxicity(knee jerk,
urine output, RR)
Toxicity:-1)Absent DTR 2)urine output< 25-30ml/hour
3)RR<16/min.; Antidote – Inj. Calcium Gluconate 10 ml,
10% in 10min. slow IV
 Administration of Anti-hypertensive drugs:- Inj.
Labetolol 10-20 mg is given slow IV , if DP > 100
mm Hg
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3)Postpartum Haemorrhage:-
 Two IV lines with wide bore needle are started
and Crystalloids ( RL or NS) are given rapidly till
blood arrives
 Uterotonics given- 20 units oxytocin drip is started
in the Uterotonic line; Inj. Carboprost 250 micgm
given IM
Anaesthesiologist,
23.3  T. Misoprostol 800 mic gm placed rectally.
Surgeon, OT staff
 Urine output maintained.
 If atonic uterus, uterus is compressed. If bleeding
continues, uterine arteries are ligated on both
sides close to the uterine incision. Subtotal
Hysterectomy is done , if there is no control of
bleeding.
4)Management of shock:-
 The cause of shock to be identified-- i)Spinal
shock- IV fluids given ; elevate head end slightly;
Inj. Ephedrine given ii) Haemorrhagic shock—IV Anaesthesiologist,
23.4
fluids, Blood transfusion iii) Anaphylactic shock- Surgeon, OT staff
due to Drug allergy- Inj. Adrenaline ; Inj.
Hydrocortisone given
5)Ruptured uterus:-
 Medical management:- Management of shock – IV
fluids, Blood
Anaesthesiologist,
23.5  Surgical management:- If the rupture cab be
Surgeon, OT staff
repaired, it is sutured and Tubectomy done or else
Hysterectomy is done.
Record : Case record
Reference: SOP- Labour Room, STG
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SOP Title:- PROCEDURE FOR NEW BORN RESUSCITATION
AND NEW BORN CARE
Purpose: To provide guidelines for new born care
Scope:- Paediatric team attending newborn in OT
Responsibility: Duty Paediatrician

24.1a Baby is covered with towel Paediatrician
24.2a Eyes and mouth are cleaned and secretions removed Paediatrician
24.3a Cord clamped and cut with sterile precautions Paediatrician
24.4a APGAR score done at 1 min and 5 min Paediatrician
24.5a Inj. Vitamin K given IM Paediatrician
If respiration is not established, Bag and mask
24.6a ventilation given; O2 administered; if necessary, Paediatrician
endotracheal intubation is done.
24.7a If there is no heart beat , CPR is given Paediatrician
Meconium aspiration- secretions from trachea are
24.8a Paediatrician
suctioned
Hypothermia- Baby is wiped and wrapped in clean
24.9a Paediatrician
towel; kept in radiant warmer
24.10a Hypoglycemia- IV line is started and Dextrose given Paediatrician
NEW BORN CARE AT OPERATION THEATRE
24.1b Caesarean section done Surgeon
24.2b Baby Handed over to Paediatrician Paediatrician
24.3b Baby taken to the Resuscitation corner in OT Paediatricain
24.4b New Born care/ Resuscitation given Paediatrician
Record: Case record- New Born
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SOP Title:- PROCEDURES FOR STABILIZATION / TREATMENT /
REFERRAL OF POST NATAL COMPLICATION
IN NEW BORN
Purpose:- To provide guidelines for post-natal care complications
in New Born
Scope:- Paediatrician and NBCC staff
Criteria for shifting Newborn to NICU:-

The New Born is shifted to NBSU during the following conditions:-
 Poor cry
 Baby not feeding properly
 Signs of aspiration
 Jaundice
 Signs of respiratory distress
 Incessant cry
 Poor activity
 Convulsions
 Signs of Hypoglycaemia
 Signs of Hypothermia
 Cyanosis
 Signs of clinical sepsis
 Preterm for observation
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25.1 Baby handed over to Paediatrician , wrapped in sterile Operating Surgeon
towel,during Caesarean Section
25.2 Baby placed in New Born Corner in OT Paediatrician
25.3 Baby rapidly assessed - APGAR score Paediatrician
25.4 Complication/ High Risk detected Paediatrician
25.5 Resuscitation started and baby stabilized Paediatrician
25.6 Baby re-assessed after resuscitation- Criteria for shifting Paediatrician
New bBorn to NICU
25.7 Decided on shifting baby to NBSU Paediatrician
25.8 Baby shifted along with resuscitation team in Stretcher trolley Paediatrician
Record: Case record
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SOP Title:- POSTPARTUM CARE TO MOTHER AND BABY:-
Purpose: To provide guidelines for post-Natal care
Scope: Staff in Post-operative ward and
Post – Natal ward, Paediatric staff, Maternity staff
Responsibility: Ward MO -for mother, Ward MO- Paediatrician –for baby

26.1 Post-partum Care of mother: Obstetrician and
Mother in Postnatal and post-operative wards Ward S/N
arei)observed for danger signs and symptoms ii)
Counselling given iii)Advice given iv) Medications
 Watch for undue vaginal bleeding
 Watch for anaemia, PPH, PIH
 Check for any complaints of giddiness, fever,
headache, palpitation, reduced or absent urine ,
difficulty in defaecation, pain abdomen ,
excessive vaginal bleeding, any allergic reaction
of drugs
 Check for any Nutritional deficiency
 Watch for firmness and well contracted uterus
 Fever- any signs of Puerperal sepsis
 Adequate hydration and urine output
 Vital signs- Pulse, Temperature, respiration, BP,
pain
 General examination
 Examination of CVS and RS
 Breast examination-- for flat or inverted nipple ;
breast engorgement
 Counselling given about:- a)Family planning-
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spacing methods and permanent methods b)

Nutrition counseling c) Counselling on Breast
feeding d) Discharge counseling e)Followup-
routine followup after 7 days and after 1 month;
followup in case of any warning symptoms –
bleeding, fever, severe abdominal pain,
breathlessness, fainting or drowsiness, severe
pain in perineum or episiotomy wound
 Mother is advised about the following:- a)Baby
care b) Breast feeding c) Personal hygiene –
including perineal wash and keeping the
perineum and episiotomy wound clean and hand
washing d)Nutrition- intake of milk, plenty of
fluids, adequate vegetables and protein intake
and iron rich foods e) Post Natal exercises-
taught by Physiotherapist f) Environmental
cleanliness
 Medications:-
i) Pain management – depending on the Pain
score on the Visual Analog scale.
Score 9,10- Sedation - Inj. Pentazocine Lactatate
30mg + Inj. Promethazine 25mg. given IM or
Inj.Tramadol 100mg given IM when required
Score 7,8- Inj. Tramadol 100mg. IM when
required
Score 5,6 – Inj. Paracetamol 300mg IM given
when required or Tab. Ibuprofen 200mg twice
daily
Score 1-4 – Tab. Paracetamol 500mg thrice
daily.
ii)Antibiotics – if any infection is anticipated
iii)IFA tablets
iv)Specific drugs indicated
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26.2 Post-partum care of New Born:- Paediatrician

in Postnatal and post-operative wards are taken care
of by the Paediatricians and i)observed for danger
signs and symptoms ii) Counselling given iii)Advice
given iv) Medications
 Breast Feeding- initiation within 1 hour after birth
 Prevention of Hypothermia- wiping the baby and
keeping the baby wrapped in towel with rooming
in and if necessary baby is placed in Warmer
 Watch for good activity and vigorous cry.
 Watch for the following warning signs -Poor cry ;
Baby not feeding properly ;Signs of aspiration ;
Jaundice ; Cyanosis ; Signs of respiratory
distress ; Incessant cry ; Poor activity ;
Convulsions ; Signs of Hypoglycaemia ;Signs of
Hypothermia ; Signs of clinical sepsis ;Preterm
and Low Birth weight babies monitored more
frequently
 Counselling:- Breast feeding method ; warmth of
baby including Kangaroo mother care for pre-
term ; general care of new born ; Followup of the
babies
 Advice : Breast feeding, Immunization, Care of
New born, Warning signs in New born
Medications: Inj. Vitamin K given IM; Immunization –
zero dose given
Record: Case Record

Reference: SOP- Labor room, SOP- NBSU
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SOP Title:- PROCEDURE FOR DOCUMENTATION
Purpose:- To provide guidelines for documentation in OT
Scope:- OT Staff
Informed Consent – obtained before surgery and
attached to case record Surgeon and
27.1
Surgery consent Anaesthesiologist
Anaesthesia consent
Pre-operative checklist- preparations, medications
27.2 Ward S/N
given, vitals noted
Anaesthesia forms documented- Pre-anaesthetic
assessment, Pre-Induction assessment, Intra-
operative monitoring, Alderete score chart for post-
operative monitoring
Surgeon,
27.4 Safe Surgery checklist –entries made Anaesthesiologist
and Assisted S/N
Surgery notes: date, time, duration, name of surgery,
indication, name of surgeon, anaesthesiologist,
27.5 assisting S/N and approximate blood loss and Surgeon
procedure done and intra-operative findings are
documented
Post-operative instructions: PTR,IO chart, IV fluids,
27.6 medications, diet advice are written and signed by Surgeon
Surgeon
Registers in OT:-
Surgery register, Adverse event register, Needle Prick
27.7 injury register, Instrument and pad count check OT S/N
register, Anaesthesia register are maintained
Nurses report register maintained
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SOP Title:- PROCEDURE OF HANDING OVER PATIENTS
FROM OT TO INDOOR AND ICU
Purpose : To provide guidelines for Handing over patients after
procedures and to ensure safety in patient care
Scope: OT staff
S.No. Activity Responsibilty

28.1 Surgery / Procedure completed
28.2 Patient placed in the Recovery room OT S/N
Aldrete score chart maintained in the Recovery room and
patient is monitored for vitals
28.4 Patient is ordered to be discharged from OT Anaesthesiologist
28.5 Patient‘s vitals are checked OT S/N
Post-operative Ward staff is informed about the shifting of
28.6 OT S/N
patient from OT
Patient is shifted from OT and case sheet sent to Post-
28.7 OT S/N
operative ward after completion of notes.
Handing over and Taking over is maintained in the case
28.8 OT S/N
record and in register
Record: Case record, Handing over- Taking over register
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SOP Title:- PROCEDURE OF PATIENT HAND OVER,
WHENEVER STAFF DUTY CHANGE HAPPENS
Scope: OT Staff
Purpose: To follow uniform procedure for handing over patients
to ensure patient safety
 Patient hand over is given during the change in the duty during shifts—Nurses
record of patient care is maintained for each patient and attached to the case
sheet. These are handed over during shifts by the Staff nurse at the bedside of
each patient. The condition of the patient, vitals and medications given are
recorded and any instructions from MO are also recorded .
 Handover and Takeover of patients between wards and OT is maintained in
register .

29.1 Patient in OT . OT Staff shall not leave or Handing over OT S/N
hand over before completion of surgery
29.2 Check vitals and condition of patient and Handing over OT S/N
enter in the nurses report
29.3 Patient side hand over done to the next Handing over OT S/N
staff during shift
29.4 At the end of each shift nurse on duty Handing over S/N
handsover, the details of treatment
provided and patient progress, in writing to
the nurse on duty for the next shift.
Record: Case record, Nurses report
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SOP TITLE: PROCEDURES FOR ENSURING PATIENT RIGHTS
INCLUDING CONSENT, PRIVACY, CONFIDENTIALITY
AND ENTITLEMENTS.
SCOPE: Hospital Wide
Purpose: To ensure respecting the Rights of the patient.
Compliance to NQAS: ME B3 , ME.B.4 , ME B 5, ME. G.4.2
Responsibility: Duty MO
a) Procedures for taking Informed consent
Purpose:- To provide guidelines for taking Informed consent
Consent shall be obtained from the patients and family for informed decision
making about their care.
Consent is to be given by
1. By the patient, unless he or she is a minor.
2. If patient is incapable of informed decision making, consent shall be obtained
from next of kin/ parent / guardian, as per law of the land.
3. In case of unidentified patient in unconscious condition, treating doctor shall
take a decision in life saving circumstances. Permission will be sought from
Residential Medical Officer for surgery
4. In case the patient incapable of independent decision-making is a prisoner, the
consent shallbe taken from the Jail Superintendent.
The Hospital requires consent for all invasive or therapeutic procedures. In
case of a patientincapable of giving informed consent, it is taken from the patient
representative or guardian.
Life-sustaining measures are not withheld for lack of formal consent if there is
no time toobtain the consent for urgent procedures. The consent process is
postponed and treatment is started immediately in such cases.
Consent is required for elective blood transfusions that are not life threatening
Consent is written in a language that the patient can understand. If the
language is notunderstood, the services of an Interpreter may be obtained, and their
name sign and address obtained.
Consent is obtained before treatment and procedures
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SOP TITLE: PROCEDURES FOR SAFETY AND RISK MANAGEMENT
SCOPE: Hospital wide
Purpose: To ensure safety of patients
Compliance to NQAS: ME.G.4.2 G.10.6
S.No. Activity Responsibiliy

31.1 Incident occurs
31.2 Immediate information to MO S/N
31.3 Measures to tackle the Incident S/N
31.4 Incident form is written S/N
31.5 Documentation in Adverse Events register S/N
31.6 Incident form handed over to Casualty staff S/N
31.7 Entered in Casualty Incident Reporting Casualty S/N
Register
31.8 Incident Form handed over to Department in Casualty S/N
charge
31.9 Analysis of Incident Department-in –charge
31.10 Corrective and Preventive actions undertaken Department-in –charge
See Annexures in SOP LR : Incident Form and CPR Form
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 Hazards are identified ,Risk assessment is done and measures are

implemented to eliminate the risks
a)Clinical Risk Assessment:- The following guidelines are used
(Responsibility – Department in charge)
S.no. Hazard (Risk) Risk Assessment Risk Management-Action

Identification /Analysis to be taken to eliminate
the risks
1. Physical risks:- Serious/ Possible Incident reporting and
1)Risk of slips and fall on monitoring
floor Monitoring of sentinel
2)Risk of fall of baby events
3)Risk of fall from stretcher Redressal of complaints and
and wheel chair audit of complaints
4)Electric shock Training
5)Fire
2. Medication related risks Serious/ Likely Supervision and training
1)Medication error
2)Adverse drug reactions
3)Stock outs- drug shortage
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3. Infection risks Serious/ Likely Infection Surveillance and

audits
1)HAI- mother
Training
2)HAI- baby
4. Obstetric clinical risks Serious/ Likely 1)Credentialling, privileging
1)Non-adherence to 2)Training and maintenance

protocols of Competency
2)Adverse events- maternal 3)Protocols and Guidelines

morbidity, death and Policies
3)Adverse fetal outcome 4)CME
4)Prolonged length of stay 5)Reporting of Maternal and

Infant deaths
5)Near miss
6)Maternal and Infant death
audits and Lessons learned
5 Surgical risks Major/unlikely Surgical safety Checklist

usage
1)Wrong procedure
2)wrong patient
3)retained instruments,
pads etc.
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6 Anaesthesia risks:- Major/unlikely Usage of Anaesthesia

checklists
1)Improper planning
7 Confidentiality of records Minor/Rare Safe keeping in ward and in

MRD.
1) Case Records
revealed to others
2) HIV status and other
communicable
diseases - revealed
8 Mental risks:- Moderate/possible Counseling of patient
1)Stress of Labor Birth companion
2)Abuse by workers Complaint box
3)Extortion of money Warning of workers/ display
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b) Periodic assessment :-
1. Periodic assessment for Medication and Patient Care Safety ( Maternal)
1)Maternal
Severe postpartum haemorrhage

Peripartum blood product transfusion
Anaesthetic complications
Admission to a critical care area outside of the maternity unit - HDU
Thromboembolic events
Caesarean section at full dilatation (all presentations)
3rd/4th degree tears
Uterine rupture
Unplanned readmission
Transfer to a higher level facility
Maternal death
2. Periodic assessment for Medication and Patient Care Safety- Fetal/ Neonatal
2)Fetal
Shoulder dystocia
Apgar score <7 at 5 minutes
Term baby admitted to NICU
Transfer to a higher level facility
Still Birth
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3.Periodic assessment for Medication and Patient Care Safety-

Organization/others
3)Organisational/ others:-
Unavailability of health record

Delay in responding to call for assistance
Faulty equipment
Conflict over case management
Potential patient complaint
Failure to follow local protocol
Falls
Bed Sores
Injuries
Infections
4.Periodic assessment for Medication and Patient Care Safety-Medication

Safety
4)Medication Safety:-
Medication error- wrong drug, dose, route, patient, time, documentation, drops
Adverse drug reaction
Adverse Drug events
Prescription error
Stock out of drugs
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SOP Title: PROCEDURES FOR SUPPORT SERVICES AND
FACILITY MANAGEMENT
Scope: Labour room staff
Purpose: To provide guidelines for Support services and facility
management
a)Equipment maintenance and Calibration
b )House keeping and Security
c) Storage and Inventory management
a) Guidelines for Equipment maintenance and Calibration:-

Procedure for equipment management and maintenance and Calibration
Log book:-
Document the name of the equipment, serial number, name and
contact details of the manufacturer, name and contact details of the
local supplier, source of equipment, date of purchase, date of
commissioning and installation, warranty period, equipment code
number, warranty / AMC / CAMC details, preventive maintenance, Biomedical
32.1a calibration agency, calibration status, due date of next calibration and Engineer
break down maintenance in the equipment log book, spares
inventory, technical manual – circuit diagrams and literatures.
-Maintain equipment log book for all the equipments available in the
hospital along with a copy at the user department.
-Update the equipment log book as per the set parameters.
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Calibration:- Internal or External

Calibrate all measuring instruments / equipments either in-house or
through the AMC / CAMC provider or through the third party
calibration agency as per manufacturer‘s defined frequency.
- Calibrate equipment following codal procedures maintaining Biomedical
32.2a traceability to national or manufacturer‘s guidelines / standards. Engineer,
- Document the calibration status in the equipment log book and The HOD
maintain the calibration certificate.
- Affix calibrationlabels/stickersontheequipment denotingthedateof
calibrationandindicatingthe statusof calibration/verificationwhere
calibrationis due.
General Maintenance :-
Maintain up to date manufacturer‘sinstructions in the department for
quick reference to operation and maintenance of equipments by staff
when required.
- Clean the equipment surface with damp cloth soaked in detergent
and water and dry. Wipe with clean cloth dampened in surgical spirit
on a daily basis.
- Do a daily visual check on the electrical safety and functioning of Staff nurse on
32.3a
equipments every morning before using the equipment. duty
- Label defective equipments as ―OUT OF ORDER‖ or ― Not in use‖
and store appropriately until it has been repaired.
- Document the equipment breakdown details in the handing over-
taking over register and pass on the information to the staff during
shift changes.
- Document equipment breakdown details and report to the
Biomedical Engineer immediately.
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Preventive maintenance:-
All equipments shall be covered under AMC/CMC including
The HOD,
preventive maintenance.
Administrative
-Perform scheduled preventive maintenance for each equipment as
office and
per manufacturer‘s recommendations by the AMC /CAMC contract
Biomedical
agency / in-house in conjunction with the user departments.
Engineer
- Check following during preventive maintenance:
32.4a
 Physicalconditionof theequipment.
 Lubrication.
Biomedical
 Calibration.
Engineer, User
Cleaningor replacingpartsthat areexpectedto
department and
wearorwhichhaveafinitelife.
Contract agency
- Obtain service portfrom service agency after verification of
equipment function.
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Breakdownmaintenance:-
Do not use faultyor defectiveequipment. Document the breakdown
details and report to the Biomedical Engineer immediately. Label S/N
defective equipments as ―OUT OF ORDER‖ or ― Not in use‖ and store
appropriately until it has been repaired. Document equipment
breakdown details in the handing over-taking over register and pass
on the information tothe staff during shiftchanges.
- Repair and restore the equipment to working status as soon as
possible.
-Test the equipment thoroughly on restorationof theequipment to
working status. Remove the ―OUT OF ORDER‖ or ― Not in use ―label
32.5a
affixed on the equipment. AMC/CAMC
-Update the following equipment breakdown details in the equipment agency /
log book: Biomedical
 Date and time of breakdown Engineer / Third
 Cause/s of breakdown (Technical or others) party
 Breakdown time BME,S/N
 Response time (AMC/CAMC agency, BME)
 Rectification details (spares used, expenditure)
 Remarks with functional status BME
Reasons for delay in restoration of working status, if any
Record: 1.Breakdown register in department and 2.THE RMO room, 3.Equipment

Log 4.Calibration certificate and tag 5. Servicing certificate 6. AMC/CMC
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b) House-Keeping and Security

32.1b Cleaning of OT table:- OT
- Cleaned every morning with Silvecide and then with plain water Technician /
-Cleaned during each shift ( Disinfected with 0.5% chlorine Hospital
solution and then soap solution used, then cleaned with water and Worker /
dried ). Outsource
-Cleaned after each surgery with 0.5%chlorine solution and then Worker in
with water Duty
-Cleaned after patient is shifted
32.2b Cleaning of OT:- OT
-Wet mopping is done during each shift with disinfectants. 3 Technician /
Bucket system and uni-directional mopping to be followed. Hospital
Cleaning starts from around the OT table and directed towards the Worker /
periphery and then towards the entrance. Separate mop used for Outsource
OT. Worker on
-Walls are cleaned every morning with Silvecide / 0.5% Chlorine Duty
Solution and soap solution
-Washing done once a week with soap solution
- Cob-webbing Daily
-Fumigation done once a week – with Silvecide 1:5 i.e 200 ml
Silvicide and 800 ml Water
-Swabs for culture taken once a month. Air sampling done.
Reports and next Due date displayed
32.3b Toilets- cleaned every 2 hours. Stain removers used. Bleaching Sanitary
powders, Phenol / Lysol used for disinfection. Soap solution used Worker /
for removing organic matter. Outsource
Worker
32.4b Blood and Body Fluid spill- PPE worn, Disinfection with 1 % HW/SW/OW
Chlorine solution followed by normal mop on Duty
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32.5b Processing of equipment: OT

-De-contamination-soiled instruments are placed in a plastic Technician /
container containing 0.5% chlorine solution- for 10 min. Hospital
-The instruments are placed in the wash basin in the Dirty utility Worker /
area and washed with water Sanitary
-The instruments are then washed with detergents and scrubbed Worker /
and then washed with water Outsourced
-The instruments are placed on a clean surface and dried Worker on
- For Sterilization of instruments - Cleaned and dried instruments Duty
are packed in trays or bins and sent to CSSD
-MVA syringe is placed in 2% Gluteraldehyde solution for 10 hours
and then washed with NS and dried and placed in autoclaved
sterile container
32.6b Soiled linen placed in Yellow bins in leak proof covers and sent to HW/SW/OW
Laundry for de-contamination with 1% chlorine solution for 30 on Duty
mins, rinsed and then washed with detergent and rinsed and dried.
For sterilization- packed in bins and sent to CSSD
32.7b Bio-medical Waste bins – after the wastes are removed for HW/SW/OW
transport , the bins are disinfected every morning with 0.5% on Duty
chlorine solution and then with soap solution, dried and kept ready
for re-use.
32.8b Procedures for Pests, rodents and animal control–in the HW/SW/OW
facility on Duty
 Dogs are kept in abeyance by the Gate-keeper and security
staff
 Rat traps are used to trap rats – HW/SW/OW on Duty
 Mosquito nets are provided to reduce the menace.- S/N
 Fogging operations are done to reduce mosquito menace –
by the Outsourced Agency
 Anti-cockroach chalk used – if there are cockroaches only –
HW/SW/OW on Duty
 Pesticide powder, if there are ants – HW/SW/OW on Duty
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32.9b Security:- Security

Posted infront of OT / Ward during each shift
Prevention of baby theft
Control of visitors
Prevention of theft of items
Fire/ Disaster safety management
Management of unruly relatives behavior
Record: House-keeping checklist, Sanitation Plan , House-keeping schedule, BMW

register,Autoclave register
c) Storage and Inventory management:-
Compliance to NQAS: ME.D .2 ; ME.G.4.2

32.1c Forecasting and Indenting drugs and consumables:- OT S/N
manual indent is placed for every day
32.2c Storage of Drugs and consumables:- OT S/N
Medicine Racks :-i) contains Tablets , Injections , liquids
and syrups and ointments ii)Externally – there is a display
of the medicines available in each rack.
iii)Surgical items stored separately
iv)Heavy items are stored at the bottom
v)No items shall be in direct contact with floor or walls
vi)Manufacturer‘s recommendations for storage are followed
A) Arrangement:-
i)The medicines are arranged according to the
Alphabetical order in the racks
ii) The List of available medications in each rack is
maintained along with the Expiry dates
iii)Sound- alike andLook-alike drugs ( ampoules, vials
or tablets) are identified and stored separately
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iv)High risk medications are identified and these drugs

are High-lighted in the list
v) Lifting and Re-placement of drugs in the rack:- the
medications are so arranged that the First expiry drugs are
placed in front , and the medicines with longer expiry at
the back.(FEFO- First expiry, First out)
vi) A list of Fast moving, Slow moving and Non-moving
drugs ( FSN analysis) is maintained. This will influence the
amount of indent to be placed subsequently.
vii)VED analysis is done- Very essential, Essential,
Desirable drugs
Poison cupboard:- where Hazardous chemicals are
identified and kept separately.
The list of Hazardous chemicals is maintained along with
MSDS.
Medical supplies and Consumables cupboard:-
contains cotton, gauze, Venflon, IV sets, IV fluids etc.
Gas cylinders:- are stored separately and safely. The
cylinders are kept in standing position and well secured to
prevent fall. Empty cylinders and Full cylinders shall be
stored separately and the same identified with labels. Each
cylinder will have a chart – for the usage ( date-no. of
hours/minutes used- rate of usage in litres).Each cylinder
will have a Flowmeter connected to it during usage . Key for
opening the cylinder shall be available.
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32.3c Management of Expiry and Near-Expiry drugs:- OT S/N

 Expiry drugs and Near Expiry drugs ( less than 3
months are not accepted from the Store
 Expiry and near Expiry are watched in the Stock
register
 In case of near expiry- the same is intimated to Store
MO and returned so that it can be used elsewhere
 Near Expiry drugs are kept in a separate demarcated
place.
 Expired drugs are segregated in yellow BMW bins
32.4a Procedure for Inventory management of Drugs:- - S/N

Guidelines for Calculation for drug requirement:-
1.Name of Drug
2. Average Daily Consumption(of previous month)=Total
consumption
No. of days in the month
3. Lead Time(LT)= Average time between placement of
order and receipt of the material
Total LT=ILT+ELT
i)Internal Lead Time=Time between start of preparation of
demand to dispatch of order (ie. Time taken to place the
indent)
ii)External Lead Time=Time from dispatch of indent to
receipt of supplies (15 days)
eg.Total LT= ILT (0)+ ELT (15 days)=15 days
4.Minimum Order Level= Average daily consumption X

Total Lead time
(If you have less than this you may have Stock Out
condition)
5. Maximum Daily consumption ( find from the Sub-stock for
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the maximum consumption on any day)

6. Buffer Stock(BS) / Safe Stock =
Maximum (Daily consumption – Average Daily
Consumption) X Total Lead Time
7. Re-Order Level= Minimum Order Level+Buffer Stock (
This the order to be placed for procurement of stock
8. Maximum Order Level=maximum quantity of material to
be stocked
Record: Stock register, Indent, Electronic record
OR
Additional 20% of the calculated requirement ( from
previous consumption values) shall be the buffer stock
32.4c Procedure for storage of Drugs:-
-Indent is placed on electronic system – once in 2 weeks.
Emergency indent placed whenever required.
-Stock registers maintained
-Buffer stock kept in cupboards and arranged as Pharmacy
guidelines
-EDL copy available
-Drugs in Emergency trays, Crash cart always checked
every day during each shift. Drugs replenished immediately
after lifting
-Expiry and Near- expiry watched
32.5c Periodical replenishment of drugs:- S/N
Crash and Emergency Drug trays - checklist is maintained.
The drugs once taken from these are immediately replaced
from the buffer stock. There shall be no stock out of these
drugs at point .
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32.6c Storage of vaccines and other drugs requiring S/N

controlled temperature:-
Drugs and vaccines which need to be stored at 2-8o C as
per the manufacturer‘s recommendations - are stored in the
refrigerator . Temperature chart is maintained and updated
periodically. All the drugs are arranged with labeling
outside on the door of the fridge ( showing the supplies in
each rack)
32.7c Secure storage of Narcotic and Psychotropic Anaesthesiologist
substances:- and S/N
Purpose: Safe storage of Narcotic and Psychotropic
substances and prevent Drug abuse
 The NDPS drugs are stored separately under Double
Lock and key
 The key for one lock is available with the OT S/N.
The key for the other lock is available with the
Anaesthesiologist
 While opening both the Anaesthesiologist and the
OT S/N shall be present and both the locks opened
with their respective keys
 The list of NDPS drugs is maintained and displayed
 The drugs are also High risk and are verified twice
while issuing.
 Responsibility: In-Charge of the respective areas
 Record: NDPS register
32.8c Storage of records :-
Case sheets kept safely and when patient is discharged
sent to Medical Records Department
Registers arranged and numbered and kept safely
Linen placed in Linen cupboard
Hazardous materials kept safely
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d) Receiving drugs and supplies:-

Drugs are supplied to the patient care areas as per the Indent of required
drugs from these locations.
The Chief pharmacist supplies the drugs to these locations and keeps the duly
signed Indent from the employee who receive the drug (Staff nurse)

32.1d Indent is placed S/N / Pharmacist
32.2d Indent Book sent to the Store S/N / Pharmacist
32.3d Stock issue Voucher Book is selected Chief Pharmacist
32.4d Against he concerned ward / dispensary Chief Pharmacist
issuing amount entered
32.5d The Indent for the area also wrote in indent Chief Pharmacist
book
32.6d The drugs are made ready for dispatch Chief Pharmacist
32.7d The drugs and supplies are sent through Chief Pharmacist
trolley to the concerned area
32.8d A Duplicate copy of the Issue voucher is Chief Pharmacist
sent along with the issued items
32.9d Sign obtained in the issue voucher from the Hospital worker
Staff

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 Sign obtained from ward MO, Store MO and RMO by the S/N. Indent sent to
Store

32.1e Manual Indent is placed S/N / Pharmacist
Indent register is signed by the concerned
32.2e S/N / Pharmacist
Staff, ward MO, Store MO and THE RMO
32.3e Indent received in Store S/N / Pharmacist
32.4e A copy of the Indent is retained in the Store Chief Pharmacist
32.5e Items are supplied Chief Pharmacist
32.6e Issue is signed in the Indent Chief Pharmacist
Any drugs/ items not available is written –NA
32.7e Chief Pharmacist
in the Indent slip
Record: Indent, Electronic system
Procedure for issue of the drugs in emergency condition
S.No. Activity Activity

32.1f Emergency Indent is placed manually S/N
32.2f Sign obtained from MO S/N
32.3f Indent sent to Store S/N
32.4f Due book written and Drugs/ supplies issued Chief Pharmacist
32.5f The next day, regular Indent is received from the S/N
ward
32.6f Data recorded for Issue Chief Pharmacist
32.7f Cancellation done in the Due note Chief Pharmacist
Record: Indent, Due Book, Stock registers
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Procedure for local purchase of drugs/ generic drug stores
 Local Purchase is done when the drug is required for clinical care and is not
available in the Warehouse or the drug is not present in the EDL.
 Local purchase is also done during emergency , when the drug is not available
in the hospital and is needed for immediate patient care.
 Local Purchase: Life savingmedicines,/ emergency medicines required for day
to day functioning can be purchased from local venders selected by open
tendering system after approval from THE RMO.

32.1g Doctor requires drug for patient care MO
32.2g Staff Nurse prepares indent for the drug S/N
32.3g Indent signed by S/N,MO, Store MO and THE RMO S/N
32.4g Indent received in Store S/N
32.5g Drug is checked for availability in the Warehouse Chief Pharmacist
32.6g Indent is placed in the Warehouse and Non- Chief Pharmacist
Availability certificate obtained from the Warehouse
32.7g Letter written to the THE RMO for Local Purchase of Chief Pharmacist
the drug
32.8g THE RMO receives the letter and directs to Office for Chief Pharmacist
purchase
32.9g Office obtains three quotations for cost of the drug THE RMO
and selects the Pharmacy with lowest quotation
32.10g Drug purchased from the Private Pharmacy Office- JAO
selected
32.11g Drug is issued to Store Office- JAO
32.12g Drug received is entered in Local Purchase register Chief Pharmacist
32.13g Drug is entered in Main Stock register for drugs Chief Pharmacist
32.14g Drug is issued to ward Chief Pharmacist
Record: Indent, Requisition letter, Office records, Main Stock
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SOP Title: PROCEDURES FOR INFECTION CONTROL
AND BIO- MEDICAL WASTE MANAGEMENT
Scope: LR and OT staff
Purpose: To provide guidelines for Prevention
and Control of Infection
1)Hand wash:-
Scope: Hospital wide
Purpose: Guidelines for Hand wash
 Hand washing is the single most important practice to reduce the nosocomial
infection ( Hospital Acquired Infection )risk. Wash hands vigorously with soap
and water.
 Infra-structure/materials required:- Wide Wash Basin; Elbow tap ; Liquid
soap ; anti-septics when required ; water
a) 6 Steps of Hand washing:-

Remove all jewels. Wet hands with water and enough Liquid soap.
1)Rub palm to palm and fingers inter-laced
2)Rub palm over dorsum and fingers inter-laced
3)Back of fingers to opposing palms with fingers inter-locked (knuckles)
4)Wash thumbs
5)Wash fingertips
6)Wrists
Dry the hands before wearing gloves.
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b)Types of Hand wash:-
1)Social hand wash

2) Patient care hand wash ( Medical )
3) Surgical hand wash(Procedure)
Social hand wash –

a) time - 10- 15 secs b)Use liquid soap and running water c) done - before and after
eating, toilet, work, reaching home, visible contamination etc.
Patient care hand wash (Medical) –

a)time – 1-2 min. b)liquid soap followed by antiseptic solution (eg.Povidone iodine)
or alcohol based disinfectant (eg.Sterilium) c) done - before patient care
Surgical hand wash-

a) time- 3-5 min. b)liquid soap followed by antiseptic solution (eg.Povidone iodine)
or alcohol based disinfectant (eg.Sterilium) c)done - before invasive procedures
including surgery d)wash hands and fore-arm up to the elbow.
NB:- Learn 1) the contents of the liquid soap 2) contents of the antiseptic solution
3)dilution of the antiseptic solution (Povidone iodine) 4) quantity of Sterilium to be
used 5)contents of Sterilium 6)Anti-septic- write the date of opening on the label
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c) 5 Moments of Hand hygiene:- ( during patient care)

1)Before patient contact
2)Before aseptic task
3)After body fluid exposure risk
4)After patient contact
5)After contact with patient surroundings
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d) GUIDELINES FOR SURGICAL HANDWASH
 Before all Invasive procedures including Surgery

 Repeat after 4 cases/ 1 hour whichever is earlier
 Use Alcohol Hand rub (Sterilium) between cases
 All Surgical staff should have short fingernails; no nail polish
 Time – 3-5 min.
STEPS OF SURGICAL HANDWASH:-
 Remove all jewels, watch etc.
 Wear Cap, mask, Plastic apron, OT chappals
 Wet the hands and forearm with water
 Apply liquid hand wash and wash hands and fore-arm up to elbow (for hands –
follow the 6 steps of washing –i. Rub palm to palm and fingers interlaced ii.
Rub palm over dorsum with interlaced fingers iii. Knuckles iv. Thumbs v.
Fingertips vi. Wrists+ wash fore-arm up to the elbow.
 Wash thoroughly with water
 Hold the hands above the level of the elbow and apply the antiseptic (Povidone
iodine). Use a circle motion , begin at the fingertips of the hand and wash
between the fingers; continue from fingertips to the elbow
( up to 3 inches above the elbow) Repeat this with the second hand and arm.
Continue washing in this way for 3-5 min.
 Rinsing with sterile water :- Use clean warm water to rinse each arm
separately, fingertips first , holding your hands above the level of the elbow.
Rinse in 1 direction only (from fingertips to elbow)
 Air dry your hands and arm- from fingertips to elbow
 Keep the hands above the level of the waist and do not touch anything before
putting on the surgical gloves.
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e)When to wash hands- social

-before beginning work and before going home
-before direct patient contact
-before and after eating
-after washroom(toilet)
-after contact with patient‘s intact skin
-after contact with inanimate objects including medical equipment in the immediate
vicinity of the patient
-before wearing and after removing gloves
-whenever hands are visibly soiled
-whenever hands are contaminated
2) Personal Protective Equipment

Scope: Hospital wide
Purpose: Guidelines for use of PPE
It is the specialized clothing or equipment worn by an employee for protection against
infectious and hazardous materials
a) Personal Protective Equipment -includes

-use of gloves
-use of mask
-plastic aprons to reduce the risk of exposure to body fluids
-eye protection since there is risk of bodyfluid splashing into the eyes
-use of cap.
-shoes to cover the dorsum
 Remove the protective clothing as soon as the work is completed.
 Do not move with these clothing to other areas.
 Do not eat with gloves, aprons on.
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b)The sequence for donning PPE

Shoe Cover  Hand Hygiene  mask or respirator  goggles or face shield 
Gown  Gloves
(be practical)
c)Sequence of removing PPE:- Gloves first  face shield or goggles  Gown
mask or respirator  Shoe Cover  Hand Hygiene
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e)How to don the gloves:-
 Don gloves last

 Perform hand hygiene and dry the hands before wearing gloves
 Select correct type and size Insert hands in to gloves
 Extend gloves over isolation gown cuffs
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f)Steps to wear Surgical Gown:-
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g)How to remove Gloves:-
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d) PPE to be worn during the Procedures:-
1)Giving a bed bath - generally none
2)Suctioning oral secretions - Gloves and mask , sometimes gown
3)Transporting a patient in a wheelchair - Generally none required
4)Responding to an emergency where - gloves, fluid-resistant gown, mask
blood is spurting
5)Drawing blood from a vein - gloves
6)Cleaning an incontinent patient with diarrhoea - gloves w/ wo gown
7)Irrigating a wound - Gloves, gown, mask
8)Taking vital signs - generally none
3)Asepsis:-
 Aseptic precautions followed while conducting delivery :- 1) Ensure the 6

Cleans while conducting delivery – clean hands ; clean instruments ( sterile);
Clean surface ( boards should be clean, clean macintosh and drape sheets,
cleaning of perineum and thighs with saline before conducting delivery , sterile
perineal sheet , sterile perineal pad ); Clean cord – keep the cord clean. Should
not be contaminated ; Clean Cord tie – apply sterile cord clamps or cord tie.
Wipe the cord with saline. Keep it clean and dry; clean procedures- wear PPE,
do not the gloves to be contaminated by touching unsterile areas (oneself,
patient or environment) . Separate Delivery trays to be used for each patient.
One patient- One tray- practice shall be followed. Clean sanitary pads shall
be provided for the delivered patient .
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 Surgical site preparation- in case of Surgeries . Follow guidelines ( see SOP

for OT)
 Safe Injection and Infusion Practices
-Gloves to be worn
-clean the site with alcohol swabs
-―One needle, one syringe, Only one time‖ practice
-Venflon- Time and date to be written- to be changed after 72 hours- watch for
tenderness, redness, thrombophlebitis,fever
- Monitoring use of multi-dose vials- date of first prick (to be discarded after 1
month), no. of pricks marked (not more than 10 pricks), use separate needles,
keep it clean and closed, clean the diaphragm with alcohol before use, do not
leave the needle in the diaphragm.
-Labeling of pre-loaded syringes
-IV fluids- label the date and time of starting, aseptic precautions, monitoring
4)Sterilization:-
 Sterilization of Instruments- is by autoclaving . Physical and chemical

monitoring are done .Separate Delivery trays, Episiotomy trays, Forceps trays ,
Baby trays – are maintained as per requirement. Sterile Bins- Gauze bins, Bin
for Roller gauze, perineal sheet, baby towels, perineal pads – all these are
autoclaved and kept ready. The signaloc shall be affixed in the trays, bins and
also in the Autoclave register ( date, time, cycle and sign of S/N )
 Chemical Sterilization of MVA syringe – with 2% Gluterladehyde for 10 hours (
change gluteraldehyde every 14 days ). After sterilization wash with saline
thoroughly, then dry it and place in sterilized tray .
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5)Surveillance and monitoring of Infection Control practices:-
 Hand Hygiene Audits are done- by HIC MO and Nurse

 Infection control audits are done- by HIC MO and Nurse
 Microbiological surveillance – Swabs are taken for culture every month in
Labor room and OT.
 HAI (Health Care Associated infection)-Active and Passive surveillance – is
done to detect any Surgical site infection ( SSI), CAUTI – catheter associated
UTI, CABSI- Catheter associated blood stream infection, VAP- ventilator
associated pneumonia, respiratory devices associated respiratory infections .
Register maintained – in each ward and monitored by the HIC nurse.
 Standard precautions – in all health care settings
 Annual medical checkup is done for all staff
 Immunization – Hepatitis B, HINI vaccine ( during seasonal prevalence), Inj. TT
– when required.
 Needle stick injury- Any injury is informed and action taken for prophylaxis as
per guidelines
 Antibiotic policy followed
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6) Bio-medical Waste (BMW) Management –BMW Rules 2018 –to be followed
Bio-medical Waste (BMW) Management
Yellow
(a) Human Anatomical Waste: Human tissues, organs, bodyparts and fetus below
the eviability period (as per theMedical Termination ofPregnancy Act 1971,
amendedfrom time to time).
Yellow colored non-chlorinated plastic bags
(b) Animal Anatomical Waste: Experimental animalcarcasses, body parts,

organs,tissues, including the wastegenerated from animals usedin experiments or
testing inveterinary hospitals orcolleges or animal houses.
(c) Soiled Waste: Items contaminated withblood, body fluids likedressings, plaster
casts, cottonswabs and bags containingresidual or discarded bloodand blood
components.
Incineration or Plasma Pyrolysis or deep burial* In absence of above facilities,

autoclaving or
micro-waving/hydroclaving followed by shredding or mutilation or combination of

sterilization and shredding. Treated waste to be sent for energyrecovery.
(d) Expired or Discarded Medicines: Pharmaceuticalwaste like antibiotics,cytotoxic

drugs including allitems contaminated withcytotoxic drugs along withglass or plastic
ampoules, vialsetc. Yellow colored nonchlorinated plastic bags or containers Expired
cytotoxic drugs and items contaminated with cytotoxic drugs to be returned back to
the manufacturer or supplier for incineration at temperature > 1200 degree C or to
common BMW management facility or hazardous waste treatment, storage and
disposal facility for incineration at > 1200 degree C.All other discarded medicines
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shall be sent back to manufacturer or disposed by incineration.
(e) Chemical Waste Chemicals used in productionof biologicals andused/discarded

disinfectants.Yellow coloredcontainers or nonchlorinatedplasticbags
(f) Chemical Liquid Waste: Liquid waste generated due tochemicals in production
ofbiologicals and used or discarded disinfectants, Silver X-ray film developing liquid,
discarded Formalin, infected secretions, aspirated body fluids, liquid from
laboratories and floor washings, cleaning, house-keeping and disinfecting activities
etc. Separate collection system leading to effluent treatment system After resource
recovery, the chemical liquid waste shall be pre-treated before mixing with other
wastewater. The combined discharge shall conform to discharge norms.
(g) Discarded linen, mattresses, beddings contaminated with blood orbody

fluid.Non-chlorinatedyellow plastic bags orsuitable packingmaterialNon-chlorinated
chemical
disinfection In absence of above facilities, shredding or mutilation or combination of

sterilization and shredding. Treated waste to be sent for energy recovery or
Incineration or Plasma Pyrolysis.
(h)Microbiology, Biotechnology and other clinical laboratory waste: Blood bags,

laboratory
cultures, stocks or specimens of micro- organisms, live or attenuated vaccines,

human
and animal cell cultures used in research, industrial laboratories, production of

biologicals, residual toxins, dishes and devices used for cultures. Autoclave safe
plastic bags or containers
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Pre-treat to sterilize with non-chlorinated chemicals on-site as per National AIDS

Control
Organization or World Health Organization guidelines, thereafter for Incineration.
CategoryRed
Contaminated Waste (Recyclable) (a) Wastes generated fromdisposable items

such astubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes
(without needles and fixed needle syringes and vacutainers with their needles cut)
and gloves. Red colored nonchlorinated plastic bags or containers Autoclaving or
microwaving/ hydro-claving followed by shredding/ mutilation or combination of
sterilization and shredding. Treated waste to be sent to registered or authorized
recyclers or for energy recovery or plastics to diesel or fuel oil or for road making,
whichever is possible.
White (transluscent)
Waste sharps including Metals: Needles, syringes with fixedneedles, needles from
needle
tip cutter or burner, scalpels, blades, or any other contaminated sharp object
Puncture proof, leak proof, tamper proof containers Autoclaving or Dry Heat
Sterilization followed by
shredding or mutilation or encapsulation in metal container or cement concrete
Blue(a)Glassware: Broken or discarded andcontaminated glass includingmedicine

vials and ampoulesexcept those contaminatedwith cytotoxic wastes.Puncture Proof
bins used, Disinfection (by soakingthe washed glass wasteafter cleaning with
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detergent and Sodium Hypochlorite treatment) or through autoclaving or
microwaving or hydroclaving and then sent for recycling.
(b)Metallic Body Implants. Puncture proof blue containers used. This includes both
used, discarded and contaminated sharps.
autoclaving; and sent for final disposal to iron foundries (having consent to operate
from the State Pollution Control Boards or Pollution Control
Operation theatre infection control and bio medical waste management
Purpose: Policy for OT maintenance
Compliance to NQAS: ME.G. 4.2
Responsibility: OT Staff Nurse and OT Assistant
Scope: OT staff
S. Activity Responsibility
No.
33.1a Zoning is done – Zoning of Operation Theatre:(demarcated OT S/N
by red, yellow and green line markings); Sterile zone- Red ;
Semi-sterile zone- Yellow ; Clean Zone and Protective zone
- Green; Disposal zone – for unsterile goods .Dress code
followed (Separate OT dress).Patient given clean OT dress.
OT temperature chart maintained.Entry restricted to OT
staff only. No clutter in OT.
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33.2a  General cleaning of OT and annexes :-The OT is OT S/N

cleaned thoroughly to maintain a strict aseptic
environment
 House keeping schedule is followed.
 Every morning, the floor and walls are cleaned with
disinfectant solution .The equipment, OT table ,
trolleys and BMW bins are thoroughly cleaned. The
floor is cleaned during afternoon , after the Elective
case and in the night.
 After each surgery , the OT table is cleaned and the
sheets are changed. The masks are cleaned with
spirit and then with saline.
 The wheels in trolleys are cleaned by rolling across
gauze saturated with antiseptic solution(2%
Bacillocid--- 20 ml of solution in 1 litre of water).
 In case of any spillage of body fluids, it is cleaned
immediately.Every week, scrubbing, washing with
detergent solution and fumigation with Bacillocid 2%
is done and all the equipments are cleaned with 2%
Gluteraldehyde solution.
33.3a  Monitoring /Surveillance :- Air sampling is done in NS and OT

the OT with Hepafilter, every month . Culture swabs S/N
are taken once in 3 months. In case of any positive
report, the OT is closed and thorough disinfection is
done and OT is re-opened only after 3 negative
reports.
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33.4a  Instrument and linen preparation :- OT S/N

 De-contamination of instruments is done as per
protocols .
 Instruments, gauze, pads and linen are sterilized by
autoclaving in the CSSD every day and stored in a
separate corner.
 Soiled linen are segregated in red bins and sent for
de-contamination and washing in the Laundry.
33.5a  Dress code:- OT S/N
i) Outside chappals are not allowed inside. Separate
OT chappals are worn, which are washed and dried
every day
ii) OT dress is worn by the staff working in OT-
Anaesthesiologist- Blue gown or pant Vest,
Ogcian:- Purple Gown or Pant Vest
Staff nurse- Pink Gown or Pant Vest,
Anaesthesia Technician – Brown Gown or Pant Vest
OT Tech, MNA, Hospital Worker, Sanitary Worker –
Dark Blue Gown or Pant Vest
33.6a  Reception of dirty packs and issue of sterile OT S/N
packs from CSSD:-
 Instruments are de-contaminated with 0.5 % Chlorine
solution (freshly prepared) for 10 minutes and then
washed with tap water. They are then cleaned with
detergents and scrubbed with brush and washed in
water and allowed to dry on clean towels. The dried
instruments are then packed in clean Bins and sent
for Autoclaving after affixing Signaloc
 Sterile packs from CSSD are stored in separate
places inside the OT. These are checked for the
colour change in Signaloc indicating adequate
sterilization.
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Record: House-keeping checklist, Monitoring chart for temp. and humidity
Procedure for reception of dirty packs and issue of sterile packs from TSSU/
CSSD
Purpose: Guidelines for reception of dirt packs and issue of sterile packs from CSSD
Scope: OT Staff
 There shall be no crisis crossing of sterile and unsterile items

 Sterile items (after sterilization in CSSD/TSSU) are brought in through the
entrance of the OT
 Unsterile items- instruments and linen are taken through the Disposal zone for
processing and sterilization
 Dirty packs are sent to CSSD/TSSU after processing
 Sterile packs are issued from CSSD/TSSU- and sent in clean trolley
Instrument processing:-
33.1b Instruments are de-contaminated with 0.5 % Chlorine OT Assistant

solution (freshly prepared) for 10 minutes and then
washed with tap water
33.2b They are then cleaned with detergents and scrubbed with OT Assistant
brush and washed in water and allowed to dry on clean
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towels.
33.3b The dried instruments are then packed in clean Bins and OT Assistant
sent for Autoclaving
33.4b Bins received in CSSD are entered in register. The bins CSSD S/N
are opened and checked .Signaloc( date of autoclaving,
autoclave type, cycle,expiry date and sign of S/N) is
affixed on the bin. After autoclaving , the bins are sent to
OT in closed Trolley
33.5b Bins received in OT and entries made in Autoclave OT S/N

register.Sterile packs from CSSD are stored in separate
places inside the OT. These are checked for the colour
change in Signaloc indicating adequate sterilization.
Record: Autoclave register
111

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SOP Title: PROCEDURES FOR QUALITY MANAGEMENT
AND IMPROVEMENT
Scope: Quality Circle CEmONC OT
Purpose: To provide guidelines for Quality Management
and Improvement

.
34.1 Quality Circles:- Departmental in
1)2 Quality Circles formed- one for LR and one for OT charge
2)OT Quality Circle includes- Anaesthesiologists,
Obstetricians, Paediatricians, Nursing Superintendent, OT
STAFF NURSES, OT assistants and technicians, Hospital
Workers, Sanitary workers
3) Frequency of meeting- at least once a month. Minutes
documented. Meeting conducted in the department premises.
4)Functions-
i) Ensure adherence to protocols and guidelines
ii) Assessment of LR & OT using NQAS Departmental
checklists
iii) Prioritization and Action planning for closure of Gaps
iv) Management of the Rapid Improvement cycles
v) Collation of data elements required for monitoring Indicators
vi) SOP documentation
vi) Audits – LSCS, Maternal, Near Miss, Infant death
vii)Ensure PSS done – in Maternity wards
viii) Quality improvement using Quality tools, Process
mapping and PDCA – with help of Quality team
ix) Discussions about Infrastructure, process, output
x)Inform the Quality Committee in the facility – about the
deficiencies and corrections required
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34.2 Internal Quality assessment- Department in

i)Departmental checklist is used . charge /Nodal
ii)Done at least quarterly after a Baseline assessment. Officer
iii)Following the assessment- Gap analysis and Time Bound
Action plan with prioritization for closure of gaps prepared
34.3 PDCA cycle – For the gaps identified i)Plan-Action plan is Department in-
prepared ii)Do- this plan is tested iii)Check or Study -It is then charge/Nodal
checked whether there is any improvement iv)Act- It is then officer
decided whether this plan can be adopted , adapted or
abandoned .
34.4 Patient satisfaction survey Quality team
i)Format is used separately for OP and IP(in local
language).The data are collected and analysed. The last 2
scoring attributes are identified and action taken to improve the
quality to enhance patient satisfaction
(MERA aspatal platform Applied for User Id in GVMCH).
34.5 Process improvement :Process Mapping Department in-
i)As-Is Mapping – done by collecting data or interviewing charge /Nodal
patients or staff officer
ii)Analysis is done. Value adding and Non-value adding
activities identified .
iii)Wastes are eliminated
iv)Suggestions for improvement are discussed
v)Improved Map- the processes are improved and
implemented.
34.6 Audits:- done every month. Deficiencies identified and i)Department in-
preventive and corrective measures undertaken. charge
i)LSCS Audits ii) Department in-
ii)Referral audit charge
iii)Maternal Death audit iii) Department in-
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iv)Referral Death audit charge

v)Near Miss audit iv) Department in-
vi)Infant death audit charge
vii)HIC audits v) Department in-
charge
vi) Department in-
charge and
Paediatrician
vii)HIC MO and
nurse
34.7 Outcome Indicators: Designated staff
All the key indicators are calculated. Data Capture register is nurse in LR
maintained- from various sources the data is gathered and Analysis by
written in this register. Department in-
Analysis is done and action taken to achieve the benchmarks charge/ Nodal
officer
34.8 Quality policy:- Department in-
The department forms a Quality policy and the same is charge/Nodal
displayed. All persons in the department shall know and work officer
as required
34.9 Quality Objectives:- Department in-
charge/Nodal
Objectives are selected such that these can be measured and
officer
achievable – preferably selected from the Key Performance
Indicators
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34.10 Clinical Risk assessment for patient safety - is done using Department in
guidelines and formats- at least once in 3 months charge/ Nodal
officer
34.11 Training:- Guidelines from Dakshata skill Lab and OSCE Department in
checklists used for Obstetric skill based training charge/Nodal
officer
i)Training Needs assessment is made using checklists
ii)Training planned
iii)Training given as per needs
iv) Staff competency is checked – using checklists for these

eg. Operating equipment, fire safety, maintenance of registers,
5 S method, Infection control methods, OSCE checklists used
and scoring given , quality management, patient safety , OT
specific procedures
v)Mock drills conducted
(Fire safety, Hand wash, PPH, Mass Casualty management)
34.12 Documentation: Department in

charge/Nodal
i)SOP- prepared. All staff shall be aware about these.
officer and S/N
ii)Maternity case sheet- standard format used
iii)Forms – Safe childbirth checklist, Safe surgery checklist,

other forms used
iv)Registers
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SOP Title: PROCEDURES FOR QUALITY INDICATORS
- DATA COLLECTION, ANALYSIS AND USE FOR
IMPROVEMENT
Scope: Quality Circle OT
Purpose: To provide guidelines for Quality Indicators -
data collection, analysis and use for quality
improvement .
35.1 Calculation:- Designated S/N
Separate register for documentation of Quality

indicators is maintained.. The Indicators and
calculations required are also entered. The
indicators are calculated every month .
35.2 Data collection:- Designated S/N
Data Capture register is maintained - from

various sources the data is gathered and
written in this register.
Data required for numerator and denominators

are documented
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35.3 Analysis:- Department in charge/

Nodal officer
Graphs are used to present the Quality
indicators . The trendsanalysed .
35.4 Use for Improvement:- Department in charge/

Nodal officer
Those Indicators scoring low are selected.
Objectives are framed. Action is then taken to
improve the scores, thus ensuring improvement
in quality.
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S.No Parameters Formula

Total number of C-Section conducted*100/Total
1 C-Section Rate
number of deliveries conducted
Proportion of C-Section done Total number of C-Section conducted in night
2
in night time/Total number of C-Section conducted in OT
Total number of days critical equipment were not
3 Down time critical equipment functional during the month/Total number of
critical equipment*Total days in the month
No of C-Section per OBG Total number of C-Section done/No. of OBG
4
surgeon Surgeon available
Proportion of elective C- Total number of elective C-Section/Total number

5
Section of C-Section conducted(Elective+emergency)
6 No of stock out in the month

Total number of surgical site infection
7 Surgical site infection Rate detected*100/Total number of surgeries
Conducted
Total number of incidences of adverse
Number of adverse events
8 events*1000/ Total Number of surgeries
per thousand patients
conducted
Number of swab culture reported
% of environment swab
9 positive*100/Total number of swabs sent for
culture reported positive
culture from OT
Total number of deaths related to surgeries/
10 Perioperative death rate
Total number of surgeries conducted
Percentage of C-Sections
No. of C- Section Conducted using safe surgery
11 conducted using Safe
checklist *100/Total no. C-Section Conducted
Surgery Checklist
Number of cancelled operation*100/Total
12 Operation cancellation rates
surgeries conducted
Data source: OT schedule, Data capture register, OT register
118

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References:
1. Quality Improvement Division

2. National Health System Resource Centre’
3. Tamil Nadu Government Website
4. NRHM Website
5. WHO Website
6. Dakshata Skill Lab
7. NHM Protocol Posters
8. Laqshya Book
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ANNEXURE I:
GUIDELINES FOR USAGE OF

WHO SAFE SURGERY CHECKLIST
WHO – Safe Surgery Checklist
The checklist covers 3 phases of a surgical procedure: before anesthesia is induced,
before skin incision, and before the patient leaves the operating room. For each
phase, a checklist coordinator confirms that the team has completed the designated
tasks before the next phase of the operation occurs.
Before induction of anesthesia, key components of the checklist, using the
mnemonic "Sign In," are as follows:
 Check that the patient has confirmed their identity, the surgical site, and the
procedure to be done and that the patient has given informed consent.
 The surgical site should be marked, if applicable.
 The anesthesia safety check should be completed.
 The pulse oximeter should be placed on the patient and functioning.
 Check to see if the patient has (1) A known allergy. If so, these should be
documented. (2) An anatomically difficult airway to intubate or aspiration risk. If
so, additional equipment and assistance should be available. (3) Risk of more
than 500-mL blood loss in adults or 7 mL/kg in children. If so, provision should be
made for adequate intravenous access and fluids.
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Before skin incision, the checklist uses the mnemonic "Time Out" for the
following components:
 Confirm that all team members have introduced themselves both by name and
by their role on the surgical team.
 The surgeon, anesthesia professional, and nurse should verbally confirm the
patient's identity, surgical site, and procedure to be performed.
 Anticipated critical events to be reviewed by the surgeon are any critical or
unexpected steps, estimated operative duration, and anticipated blood loss.
 Anticipated critical events to be reviewed by the anesthesia team are whether
there are any patient-specific concerns.
 Anticipated critical events to be reviewed by the nursing team are confirmation of
sterility of the tools, supplies, and field (including indicator results);
documentation and discussion of any equipment issues or concerns; whether
antibiotic prophylaxis has been given within the last 60 minutes, if applicable; and
whether essential imaging is displayed, if applicable.
Before the patient leaves the operating room, the checklist uses the
mnemonic "Sign Out" for the following components:
 The nurse verbally confirms with the team the name of the procedure to be
recorded and verifies instrument, sponge, and needle counts, if applicable;
labeling for the surgical specimen, including patient name; and whether there are
any equipment problems to be addressed.
 The surgeon, anesthesia professional, and nurse review the key concerns
regarding recovery and management of the specific patient.
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ANNEXURE II:
MAXIMUM BLOOD ORDER SCHEDULE

Estimated Blood Loss Degree of Urgency Request
(ml)
(% Blood Volume)
Standby Standard
500 – 1000 ml Cross Match of
(10-20%) 2 Units
1000-1500 ml Urgent Urgent Cross
(20-30%) (Blood within 1hr to 30 Match of 6
Blood Loss Controlled Min) Units
1000-1500 ml Very Urgent 6 Units Type –

(20-30%) (Blood within 30 Min to 10 Specific Un
Actively Bleeding and Min) Cross Matched
1500 – 2500 Blood
(30-40%)
>2500 (>40%) or above Emergency (Immediate) 2 to 4 Unit O

with no response to Negative Blood
fluid resuscitation Followed by
Type Specific
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Maximum Surgical Blood Order Schedule(MSBOS)- OT
 MSBOS is a list of commonly performed procedures and the most appropriate

pre-transfusion testing including type and screen and number of units
crossmatched used to predict surgical blood needs prior to surgery.
 MSBOS are used to efficiently allocate blood on the day of surgery
 The ordering schedule shall be flexible depending on the circumstances to
allow for
exceptional cases and individual clinical judgment.
Policy:-
1.At least one unit of blood of the patient‘s blood group shall be available at the time
of Surgery. The Blood should be a typed and screened blood.
2.Blood sample is taken from the patient , if required and cross- matching is done only
if the Anaesthesiologist or Surgeon decide to give blood. Routine cross-matching is
not done for all cases.
3.For High risk patients – anaemia and in patients where blood loss is expected –
minimum 2 units blood shall be available . Blood sample is taken for cross-matching
before Surgery.
4.Patients with Internal Bleeding, such as Ectopic pregnancy, minimum 2 units of

cross-matched blood shall be available
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ANNEXURE III
SURGERY CONSENT FORM
124

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ANNEXURE IV
PROCEDURE IDENTIFICATION CARD

PROCEDURE IDENTIFICATION CARD
Name of Patient: IP No:
Age:
Diagnosis:
Name of Procedure:
Site of Procedure:
Emergency / Elective
Name of OT:
Date & Time:
Sign of ward S/N Sign of MO
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ANNEXURE V
ANAESTHESIA CONSENT FORM
126

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ANNEXURE VI
PRE ANESTHESIA CHECKUP
127

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Issue Date :- 28-11-2018
ANNEXURE VII
ANESTHESIA RECORD
128

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Issue Date :- 28-11-2018
ANNEXURE VII
MODIFIED ALDERETE SCORE
129

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Issue Date :- 28-11-2018
ANNEXURE VIII
SAFE SURGICAL CHECKLIST
130

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GOVERNMENT VILLUPURAM

MEDICAL COLLEGE AND HOSPITAL,

CEMONC OPERATION THEATRE

Professor and HOD,

CEMONC OPERATION THEATRE

DESIGNATION NAME & SIGNATURE

PROFESSOR AND HOD,

CEMONC OPERATION THEATRE

CEMONC OPERATION THEATRE

CEMONC OPERATION THEATRE

SOP Contents/ SOP Title Page No.

CEMONC OPERATION THEATRE

CEMONC OPERATION THEATRE

CEMONC OPERATION THEATRE

CEMONC OPERATION THEATRE

SOP NO:- LaQ:MEL:OT :01

Procedure for identification of patients :-

 Identification is ensured before any clinical procedure

CEMONC OPERATION THEATRE

 For Medico Legal Case patients- 2 Identification marks are documented in

S.No. Activity Responsibility

RECORDS: 1) Case Record, 2) Identification Band

CEMONC OPERATION THEATRE

SOP NO:- LaQ:MEL:OT :02

CEMONC OPERATION THEATRE

 Patient is made to sit or lie down while administering injections.

 Any adverse drug reaction is recorded and reported to MO.

CEMONC OPERATION THEATRE

S.No. Activity Responsibility

Prescription in Case record or instructions shall be MO

Drug checked and all instructions of MO about the S/N

Entry in Drug Administration chart (Treatment S/N

Adverse Drug Event – inform MO and record in S/N

RECORDS:- 1) Case record 2) Medication chart 3)Incident form

4) Adverse event register

CEMONC OPERATION THEATRE

SOP NO:- LaQ:MEL:OT :03

Procedure for identification cautious administration high alert drugs

 Require special safeguards to reduce the risk of errors.

List of High Alert drugs:-

CEMONC OPERATION THEATRE

5. Isoflurane Solution: 250 ml bottle MAC 1.2 %

CEMONC OPERATION THEATRE

1 st dose of drugs to be confirmed from the prescribing doctor regarding the

Procedure for High Alert Drugs:-

S.No. Activity Responsibility

3.1 Check the prescription in case record S/N

Identify High Alert Drugs prescribed in case record and

MO shall check the Medication chart- for name of drug

Administer the drug as prescribed, checking the

3.5 Monitor the patient S/N

RECORD:1.Case record 2. Medication chart 3. High Alert Drug checklist with

CEMONC OPERATION THEATRE

SOP NO:- LaQ:MEL:OT :04

S.No. Responsibility Activity

Duty/Ward Mo records in case sheet requesting opinion of

The concerned specialist is informed over phone or a memo