KAMALNAYAN BAJAJ HOSPITAL

NABH BOOKLET
 Index

Sr.No. Topic/Policy Page No.

1 NABH Information 6

2 Hospital Mission Vision Ethical Value & Service 8-9

standards & Quality policy

3 Board Of Trustee 9

4 Scope of hospital services 10-14

5 Physical Layout 14

6 Codes 15

7 Code Red 15

8 Extinguisher uses & types 15

9 Code Yellow 18

10 Code Pink 19

11 Patient identification Registration & Admission 20

process
12 Policy on Non-Availability of Beds 21

13 Transfer / referral of patients 21

14 Policy on Unidentified Patients 22

15 Policy on prioritization of Access 22

16 Discharge Process 23

17 International Patient Safety Goal 25-29

18 Policy on Patient Brought Dead 30

19 Policy on Patient dies on arrival to the emergency 30

department

20 Triage 31

21 Medico legal cases 32

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22 Policy on Absconded patient 33

23 End of Life Care 34

24 Vulnerable policy 35

25 Restrain Policy 35

26 Blood Transfusion practices 37

MOM(Management of Medication ) 38-52

27 Storage ,preparation and administration of high 38

alert drugs

28 Sound alike and look alike drugs 40

29 Rights Of medication 41

30 Adverse drug reaction 42

31 Drug formulary 42

32 Medication Error 44-45

33 Drug reconciliation and recall 46

34 Near Expiry & PPE components 47

35 Multi dose vial usage policy 47

36 Narcotic drug Policy 48

37 Emergency Medication/Crash cart Policy 50

38 Drug calculation 51-52

39 Verbal order policy 52

PRE( Patient’s Rights and Education )

40 Patient’s Rights& Responsibilities 53

41 Informed Consent 54

HIC (Hospital Infection Control) 55-78

42 Standard precautions ,Hand hygiene, Use of PPE 55-63

43 Cough Etiquette 64

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44 Safe injection and infusion practices 64

45 Cleaning Protocol of Tubing & Lines 66-67

46 Hospital Acquired Infection control care bundle 67

47 Transmission based precaution 70

48 Needle stick injury prevention & post exposure 71

prophylaxis , Body fluid exposure

49 Bio Medical Waste segregation protocol 73

50 Central Sterile supply department (CSSD) 74-78

Reuse Policy
PSQ (Patient Safety & Quality)

51 Incident reporting 79

52 Committees 80

FMS (Facility Management & Safety )

53 Medical gas cylinder/ pipeline 82

54 Equipment Training 82

55 Managing & handling spills of hazardous materials 83-85

(MSDS sheet / spill kit )

HRM (Human Resource Management) 86-91

56 Policy on joining 86

57 Grooming policy 86

58 Policy on terms of employment 87

59 Annual appraisal policy 87

60 Leave policy 87

61 Policy on late coming 88

62 Policy on Gate pass 88

63 Employee benefits 88

64 Annual Health check up 89

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65 Immunization and post exposure prophylaxis 89

66 Staff grievance handling process 90

67 Policy against sexual harassment(ICC ) 91

68 Employee rights and responsibilities 91

IMS (Information Management System) 92-97

69 Medical record documentation 92

70 Medical record maintenance 92

Screening, completion, storage, retrieval,

tampering of medical record

71 Retention time of medical record 93

72 Protocols to access patient record 93

73 Content of medical record file 95

74 Destruction of medical record 96

Key Points 97

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WHAT IS NABH?

National Accreditation Board for Hospitals & Healthcare Providers. National Accreditation
Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council
of India (QCI), set up to establish and operate accreditation programme for healthcare
organizations

NABH is an Institutional Member as well as a member of the Accreditation Council of the

International Society for Quality in HealthCare (ISQua). NABH is the founder member of
proposed Asian Society for Quality in Healthcare (ASQua) being registered in Malaysia

BENEFITS OF ACCREDITATION

Benefits for Patients

 Patients are the biggest beneficiary among all the stakeholders.

 Accreditation results in high quality of care and patient safety.
 The patients are serviced by credential medical staff.
 Rights of patients are respected and protected.
 Patient’s satisfaction is regularly evaluated.

Benefits for Hospitals

 Accreditation to a hospital stimulates continuous improvement.

 It enables hospital in demonstrating commitment to quality care.
 It raises community confidence in the services provided by the hospital.
 It also provides opportunity to healthcare unit to benchmark with the best.

Benefits for Hospital Staff

 The staff in an accredited hospital is satisfied lot as it provides for continuous learning,
good working environment, leadership and above all ownership of clinical processes.
 It improves overall professional development of Clinicians and Para Medical Staff and
provides leadership for quality improvement with medicine and nursing.

Benefits to paying and regulatory bodies

 Finally, accreditation provides an objective system of empanelment by insurance and

other third parties.
 Accreditation provides access to reliable and certified information on facilities,
infrastructure and level of care.

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NABH EDITION: -

5th Edition 10 CHAPTERS, 100 STANDARDS, 651 Objective Elements (OE)

10 CHAPETRS NAME:

01. Access, Assessment and Continuity of Care (AAC) – (Standards: 14, OE: 91)

02. Care of Patient (COP) – (Standards: 20, OE: 142)

03. Management of Medication (MOM) – (Standards: 11, OE: 68)

04. Patient Rights and Education (PRE) – (Standards: 8, OE: 53)

05. Hospital Infection Control (HIC) – (Standards: 8, OE: 51)

06. Patient Safety Quality (PSQ) – (Standards: 7, OE: 49)

07. Responsibility of Management (ROM) – (Standards: 5, OE: 32)

08. Facility Management and Safety (FMS) – (Standards: 7, OE: 45)

09. Human Resource Management (HRM) – (Standards: 13, OE: 76)

10.Information Management System (IMS) – (Standards: 7, OE: 44)

The chapters divided into 2 parts:

Section – I Patient-Centred Standards (1st five chapters),

Section II Health Care Organization Management Standards (2nd five chapters)

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MISSION

“The mission of the Kamalnayan Bajaj Hospital is to provide compassionate healthcare of the
highest quality at a reasonable cost to all the sections of the society. Fulfilling the needs of
the patient will be our priority."

VISION

• The hospital would try and create facilities which do not exist in Marathwada to provide
relief so that the patients don't have to travel long distances for treatment.

• To provide excellent Nursing and Medical care by constant education and training of all
concerned and induction of new talent where required.

• The needy and poor will be provided treatment concessional or free.

• We propose to set the standards for ethical medical practice based on the value
system. All efforts will be directed towards creating this environment.

ETHICAL VALUES

• Only those tests, treatments, medicines will be given; based on best judgment of
medical professional.

• Standard charges will be levied as per laid down system.

• The medical referral/recommendation system practiced or in existence is not a practice

in this hospital.

• Transparency and accountability will be maintained at all levels.

• We will sit a committee for values related grievances addressal.

SERVICE STANDARDS

• Compassion
• Teamwork
• Confidentiality
• Effective Communication
• Safety
• Quality
• Cost Effectiveness

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QUALITY POLICY
• Patient safety shall always be our top priority.
• To protect the rights of the patients and their relatives and, to inform them of every
step of treatment.
• To give an international level of health care services with highly qualified professional
staff.
• Complying with the benchmarks of National and International Standards.
• We believe in continuous quality improvement by focusing mainly on patient
satisfaction.
• All patients shall be treated equally regard less of the economic status.

BOARD OF TRUSTEE

Shri. Rahul Bajaj Bajaj Auto Ltd. Patron

Shri. Niraj Bajaj Chairperson

Shri. Madhur Bajaj Bajaj Auto Ltd. Trustee

Shri. Rishikumar
Bagla Group of Industries Trustee
Bagla

Shri. Kevin D’Sa Bajaj Auto Ltd. Trustee

Shri. Naveen Nijhavan Bajaj Auto Ltd. Trustee

Shri. Gupta N.K R. L. Group of Industries Trustee

Smt. Kumud Bajaj Trustee

Shri. Kagliwal N. L. Nath Group Trustee

Shri. Jain Tarang Varroc Group of Industries Trustee

Shri. Lila R. K. Lilasons Industries Ltd. Trustee

Shri. Tripathi C. P. Bajaj Auto Ltd. Trustee

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SCOPE OF HOSPITAL SERVICES

24-Hours Services

 Emergency
 Ambulance Service
 Pharmacy
 Blood storage centre
 Laboratory
 Imaging

Broad Specialty:

 Anaesthesiology
 Biochemistry
 Dermatology and Venereology
 Diabetology
 Emergency Medicine
 General Medicine
 General Surgery
 General Surgery Including Laparoscopic Surgery
 Microbiology
 Obstetrics and Gynaecology
 Ophthalmology
 Orthopaedic Surgery
 Orthopaedic Surgery Including Joint Replacement
 Arthroscopic Surgery
 Otorhinolaryngology
 Paediatrics
 Pathology
 Psychiatry
 Radiation Oncology
 Radiology
 Respiratory Medicine

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  Transfusion Medicine
 Day care Services
 Immune-Haematology

Super Specialty

 Cardiac Anaesthesia
 Cardiology
 Cardiothoracic Vascular Surgery
 Clinical Cytogenetics
 Clinical Haematology
 Colorectal Surgery
 Critical Care
 Endocrinology
 Haematology
 Haemato-pathology
 Hepatology
 Medical Gastroenterology
 Neonatology
 Nephrology
 Neurology
 Neuro Radiology
 Neurosurgery
 Nuclear Medicine
 Organ Transplant Anaesthesia
 Paediatric Anaesthesia
 Paediatric Cardio Thoracic Vascular Surgery
 Paediatric Gastroenterology
 Paediatric Cardiology
 Paediatric Surgery
 Paediatric Hepatology
 Paediatric Nephrology
 Plastic and Reconstructive Surgery
 Pulmonary Medicine
 Spine Surgery

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  Thoracic Surgery
 Urology
 Vascular Surgery
Oncology

 Medical Oncology
 Radiation Oncology
 Surgical Oncology
 Haemato-oncology
Transplantation Services

 Kidney Transplant
 Heart Transplant
 Cornea Transplant
 Liver Transplant
 Bone Marrow Transplant

Diagnostic Service

Diagnostic Imaging:

 Bone Densitometry
 CT Scanning
 DSA Lab
 Gamma Camera
 Mammography
 MRI
 PET Scan
 Ultrasound
 X-Ray
Laboratory Services:

 Blood Transfusion Services

 Clinical Bio-Chemistry
 Clinical Microbiology and Serology
 Clinical Pathology
 Cytopathology
 Genetics
 Haematology

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  Histopathology
 Molecular Biology

Other Diagnostic Services:

 2DEcho
 Audiometry
 EEG
 EMG/EP
 Holter Monitoring
 Spirometry
 Tread Mill Testing
 Urodynamic Studies
Support Services:

• Biomedical Engineering
• Nutrition & Dietetics

• Physiotherapy

• Engineering Services

• Information Technology

• Medical records
• Marketing &TPA
• Billing & Front Office
• Finance &Accounts
• Housekeeping
• Security
• Laundry
• Human Resources
• Purchase &Stores
• Mortuary
• Patient Care Department
• Laundry
• CSSD (Central Sterile Service Department)
• Food &Beverage
• Risk &Legal

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 • research & academics
• Quality

Services not available in the Hospital are:

 Dental
 Telemedicine
 Burn
PHYSICAL LAYOUT

EMERGENCY CODES IN THE KBH: -

Basement Floor: Ground Floor: First Floor:

Radiation Cardiology & Cardiac
Blood storage
Oncology Care Unit
Ground Floor: CSSD Ophthalmic Department
Administration
Physiotherapy Dialysis Unit
department
Human Resource Mother Child Health
Dietetics & Nutrition
department Care Ward
Conference Hall
Marketing department Labour room
/Board room
Accounts Health Check Up General ward - 1
Admission & Engineering &
Nursing office
Billing Maintenance department
Help Desk Store Quality Office
Registration &
Laundry Research department
Reception
Medical Record
Mortuary Second Floor:
room
OPD Crèche Semi Private ward
Day-care Canteen Shared Private ward
Pharmacy IT department Isolation Ward
Casualty First Floor: PICU / NICU
Emergency O.T Intensive Care Unit General ward - 2
Radiology Operation Theatre Third Floor :
Nuclear Medicine Cath lab Deluxe Rooms
Laboratory Endoscopy unit BMT /KT

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What is the number for intimation of emergency codes?
Dial intercom NO. 808

Dial for Emergency Codes on * 808

State the Announcement three times as following
''CODE NAME & LOCATION WARD / DEPARTMENT.’’

CODE BLUE
Medical Emergency
(Announcement mention Adult or Pediatrics)

CODE RED
Fire
CODE YELLOW
External Disaster (Mass casualty situation) or Internal Disaster
IN EMERGENY ROOM (If 10 patients in the hospital at a given point
of time)
IN HOSPITAL (If >10 patients in the hospital at a given point of
time )

CODE PINK
Child Abduction

CODE BLACK
Bomb Threat

CODE VIOLET
Violent Relative or Patient

CODE RED: FIRE

In case of a fire in your area,

RACE method

R: Rescue the patient

A: Activate the alarm and announce the code through PA Call -808

C: Contain the fire by closing all doors and windows.

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E: Extinguish if safe to do. Evacuate if necessary.

• After RACE procedure, extinguish the fire using a fire extinguisher, by PASS method.

HOW TO USE FIRE EXTINGUISHER - PASS PROTOCOL

P= Pull the pin –This will allow you to discharge the extinguisher

A = AIM the nozzle –Aim low, pointing the extinguisher nozzle (or its horn or hose)

at the base of the fire

S = SQUEEZE – squeeze the handle to release the extinguishing agent

S =SWEEP –sweep from side to side at the base of the fire until it appears to be out.

• Watch the area. If the fire re-ignites, repeat steps 2-4.

• Open the door of fire exit (if it is in closed position)

• Evacuate patients through the fire exit.

• Do not use Lift.

• Do not be panic.

• Everybody should assembly at fire assembly point.

The assembly point for Evacuation in case of fire

In front of hospital main gate and staff parking area.

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17
CLASSIFICATIONOF FIRE EXTINGUISHERS

CODE YELLOW: EXTERNAL DISASTER

• Code Yellow is announced from emergency department (Casualty) through PA system

when 10 or more than 10 patients are coming to casualty at a time from the same type
of incident (e.g.: road traffic accident, natural calamities, bomb blast etc.)

• When we hear the announcement of code yellow be ready to go to Emergency

Department as per the supervisor / senior leaders’ instruction.

Command Centre-

• The hospital has set up a command center for handling External & Internal Disasters.
In the disaster conditions all the instructions will be passed from this command center,
under the leadership of CEO.

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19
CODE PINK: CHILD ABDUCTION

Employee suspects’ child has

been missing

Dial 808 and Announce

“Code Pink” with Area

NURSING UNIT:
1. Recheck rooms. Medical Director/CEO:
SECURITY:
2. Secure the area.
 1.Alert the Security 1. Lock down hospital.
3. Notify In charge & Administration
2. Obtain information from infant’s/child’s nurse.
4. Move parents to private room.  2.Calls up lab to preserve
3. Search the facility and hospital ground.
5. Notify Primary Physician
the blood sample of 4. Secure all Exits, check any suspicious person or
luggage.
missing child
5. Alert all staff about incident and take their help
for search

Recovery – If the child is found

If the child is not found
1. Take child to the parents.
CEO will inform the police
2. Security will authorize code pink clearance
3. All staff returns to their work area

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PATIENT IDENTIFICATION: - 2 identifiers- MRN number, Patient name- from patient ID
band & MRD files.
REGISTRATION & ADMISSION PROCESS

Registration
 Patients are admitted at KBH & Hospital only if the Hospital can provide the
required services to the patient.
 All patients, out-patients, in-patients and emergency who are willing to avail
services at KBH Hospital should undergo Registration / Admission process.
 In case of Emergency, the same to be carried out in parallel to treatment.
 Patient shall be registered only if they match the hospital services
 When there is no provision to treat the patient in the hospital, assist to transfer the
patient to other hospitals where provision exists.
 For this a list of nearby Hospitals shall be maintained at the Front office.
Registration Process
 Patient approaches Reception to avail consultation.
 Reception staff to check with patient whether it is patient’s first visit or subsequent
visit.
 Patient information is software to generate the unique Hospital ID.
 If it is not first visit, reception staff enquires to patient for the registration number.
 If registration detail is not available, a new registration number is given to Patient
for the consultation.
Admission
 Patients are admitted from the following areas:
 Admission from Outpatient Clinics: Patients may be directly admitted from one of
the Outpatient Clinics.
 Admissions from the Casualty : Emergency Room patients requiring inpatient
admission must have the Admission recommendation by treating consultant .
 Admission of Outpatient Observation Patients: When an observation patient is
determined to require inpatient care, based on recommendation by consultant the
patient is admitted.

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  Transfer of stable patients: Admission of stable patients transferred from other
facilities. Transfer of unstable patients: Admission of unstable patients transferred
from other facilities.
Admission process
 All patients who are to be admitted should complete registration process.
 The doctor advices for the admission in the Admission note form for OP patients.
 Billing staff explain the tariff details and availability of type of bed.
 Patient is admitted based on their choice and availability of type of beds.
 Every patient is provided unique Inpatient Number at the time of admission.

POLICY ON NON-AVAILABILITY OF BEDS:

 In the event of non-availability of the room of choice, the patient shall be allotted
the best alternative rooms available.
 If the patient is agreeable, then the admission procedure is completed.
 In case it is beyond the capacity of the hospital, the patient shall be referred to
other matching healthcare facility, namely – MGM Hospital, Aurangabad.
 Patient to be monitored in holding area,(Not requiring ventilator support) for not
more than 2 hours.
TRANSFER/ REFERRAL OF PATIENT TO OTHER CENTRE

 If there is no possibility of bed availability or if the patient is not agreeable to be

admitted in another class or if services matching the patient needs are not available,
then the treating doctor is asked to possibly defer the admission of the patient or
refer the patient to another centre.
 TRANSFER OF CRITICAL PATIENTS
In case of transfer of patients in a life threatening situation (like those who are on
ventilator) to another organization, a doctor / ACLS Trained Staffs accompanies the
patient. The ambulance driver helper, male nurse (Trained in BCLS and / or ACLS),
or doctor accompany during transfer for unstable Patients to other organizations
 TRANSFER OF STABLE PATIENTS
Stable Patient is transferred to another organization through the ambulance,
accompanied by ambulance driver.

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  Patients being transferred from KBH Hospital shall be accompanied by a transfer
summary that shall include details of the patient medical condition, interventions
done and the ongoing needs of the patient.
POLICY ON UNIDENTIFIED PATIENTS:

 Registration and admission of unidentified emergency patients requiring emergency

treatment shall be registered as unknown patient with date and time (UKN / Date /
Time, Identity of patient) and left thumb impression shall be taken in the medical
record.
 Unidentified patients shall be provided with all required treatment necessary for
stabilization and if necessary, transferred to Medical College Hospital (Government
Medical College Aurangabad) in our Ambulance.
 The patients/ relative may be advised to go to facility of their choice as per their
need on considering given situation.
POLICY ON PRIORITIZATION OF ACCESS:

Patients’ access for healthcare services is prioritized based on the clinical needs of
the patients in all care settings of the organization. In case prioritizing needs to be
done for clinical needs; the treating consultant will approach the Medical Director
and as per advice of Medical Director and availability of beds/ service the
prioritization will be effected

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 DISCHARGE PROCESS FLOW CHART

Consultant on daily morning/ evening round advices for Discharge

Ward RMO or physician assistant writes the draft of Discharge summary

Written summary send to Medical Transcriptionist for Typing & returned back to ward

Typed summary verified & checked by the RMO & get signed from Consultant or DNB Doctors

Nurse attaches typed discharge summary & discharge slip in medical record file and sends to
billing department for Bill payment with Ward attendant &sends patient’s relative to the
billing counter for final bill payment along with returned medicine.

(Simultaneously billing person checks & verifies the medical record file with vouchers, in patient folio,
Doctor’s visit, Procedure sheet, and other procedure, Diagnostics voucher etc)

Patient’s relative returns the Insurance patient first takes on discharge

medicine on Pharmacy refund medication & refund the medicine before final
counter billing

Patient’s relative takes final bill Billing person prepares Provisional bill & send the
from billing counter & pays the file towards insurance counter. Insurance billing
cash on cash counter person or sends the bill & scanned discharge
summary to Insurance Company. Insurance
company approval comes against bill if bill has any
difference amount then difference amount to be
paid by the patient.

Patient or relative produces paid bill copy to the billing person .Billing person
puts the paid stamp on Bill & Discharge slip and signed on it.

Billing person sends Medical record file in ward with attendant

24 the nurse. The discharge summary and

Patient’s relative produces copy of paid bill to
investigation reports will be handed over to the patient / relative and received
signature is obtained from the patient / relative in discharge ward register
 PLANNED DISCHARGE PROCESS

Before 24 hrs Consultant will planned & advised for Discharge

with discharge medication , follow up date& follow up
instructions

Ward RMO or physician

assistant will type &keep Nurse will complete vouchers and
ready the printed ensure file is complete in the
discharge summary. evening and night duties

Then Nurse will send the file to

Billing department and send the
patient’s relative to the
Pharmacy department for refund
of the medicine in the night itself.

Billing person will complete updating

the file in the night & again send back
to the ward. Complete bill amount will
be informed to patient .Patient will be
asked to pay either immediately or by
next morning.

Next day morning discharges will be

done after doctor confirms
discharge.

TAT FOR DISCHARGE

CASH PATIENTS: 2 HRS
INSURANSE /MJPJAY : 4HRS
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 IPSG-INTERNATIONAL PATIENT SAFETY GOALS

Identify Patients Correctly.

Improve Effective Communication.

Improve the safety of high-Alert Medications.

Ensure Correct-Site, Correct-Procedure, Correct Patient Surgery

Reduce Risk of Health Care-Associates Infections.

Reduce the risk of patient harm resulting from falls

1. Patient identification: -
The identifiers used for OP and IP are the same.
 In patient/ Out Patient: Patient Name in full and MRN (Patient room number or
location must not be used as identifiers in IP)
 In the Laboratory
 Sample is identified by full name admen
 Labelling of containers is done in the presence of patient. All lab staffs are
trained to crosscheck with the request during pre- analytical, analytical and
post- analytical processes.
 Wrong labelling (discrepancy between patient identification information on the
sample and requisition) is considered as a sample rejection criteria.* For
precious samples as in lab quality manual)
 A non-transferable identification band shall be prepared and affixed to the
inpatients including day-care by nursing staff.
 If neither wrist is suitable for use either ankle may be used. In case of an upper
limb amputee the band will be fixed at the ankle.
 Identification of Comatose /Confused

The identity bands of patients who cannot confirm their own identity.

(e.g., those who cannot communicate unconscious, or confused) must be.

checked by two staffs (Nurses/Drs) against the patient file and

attendants and document in the Doctors & Nurses notes as “Name (as

obtained from attendant) and MRN” followed by signature, date, and time.

of endorsing staff, prior to the identity band being placed on the

patient. After the band placement identification of patient prior to

26
 treatment will be as per hospital policy (single staff will identify name in

full and MRN)

 Patients who are unable to wear an identity band because of their clinical condition or
treatment,
e.g., multiple intravenous lines, dermatological conditions, alternative secure
methods, and identity should be applied e.g., Fix the label to clothing and two staff
shall check prior to the initiation of every treatment.
 Neonatal: ID band to be applied on cradle
 Pediatrics patients: ID band to be applied on bed.

2. IPSG 2 – IMPROVE EFFECTIVECOMMUNICATION

WDRB- Write down read back

 Verbal orders are not allowed for Chemotherapy Medications.

It is advisable to avoid the use of verbal and telephonic orders in situations such as
High Alert Medications, look-alike, and sound alike medications.
 Staff must ensure the following while communicating verbal orders
 Identify themselves and where they are calling from
 Identify the patient
 Reason for phone call
 Inputs from the caller (Not limited to patient assessment, urgency for
action, any recommendations (if applicable)).
 To write down the orders in the WDRB and read back the orders received
 These orders should be countersigned within 24hrs by the person
issuing the order except for communications of results from diagnostic
services as they have their separate registers for verbal orders.

Exceptions: In work areas like operation theatres, emergency room & intensive care
areas when drugs have to be administered in emergency situations it will be written in
the drug chart by the medical personnel as “WDRB” in the margin. The doctor issuing
the order (in OT the doctor being only anesthetist) has to countersign within in 24
hours.

 For Outpatients
1. Critical values of laboratory & Radio diagnostics, are informed to doctors
by telephonic communication from the laboratory.
2. The requesting doctor at his discretion on receiving the information (via
telephone) will inform the patient.
3. In the event that the doctor is not contactable or in case of external requests the
laboratory/radiology

27
/Other diagnostics department will send the information to Customer care. Customer
care dept will call on the registered phone to the patient & inform suitably.
4. When such patients visit the emergency department the ER doctor co-
ordinates for the care along with the treating doctor /doctor on call / visiting doctor
(whenever applicable) and necessary treatment is initiated.
 For Inpatients
o In IP, critical reports are informed to the ward doctor or nurse telephonically.
o Documentation of the critical results follows the WDRB policy as above in
its contents of documentation.
o All such communications from the Diagnostic services department and
further orders from the treating doctor should all be endorsed in separate WDRB.
o As the Diagnostic services have their separate registers for verbal orders,
counter sign by them is not needed on the WDRB.

IPSG 4 – ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT PATIENT

SURGERY

The essential components to ensure correct-site, correct-procedure, correct-patient

surgery is.
A. Site-marking
B. Preoperative verification process and
C. Time out

A) Site Marking - Site marking is done by the surgeon / clinician

performing the procedure with
involvementofthepatient(ensuringthatthepatientisawareandawake),usingasite-
marking
pen. The mark as per the hospital policy is a tick with a circle around it with
an indelible ink. Wherein the skin mark may be correctsurgery in cases of unilateral
surgery the same marking will be done at the closest proximity to the incision
site.
-For cases done in major OT, site marking is done in the wards by the surgeon
before the patient is shifted to the OT prior to administration of any pre-
medications. At other areas of care, it is done in the same unit areas prior to
administration of any pre-medications.
For spine surgeries the level marking is done intra-operatively.
In situations where patient is not in a position to participate in the site marking
and verification process, the patient attendant is involved in the same along with
relevant documentation.

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Exclusions:
a) Procedure related.
1. All endoscopy
2. Cases wherein laterality is decided following examination under anaesthesia.

b) Organ Related:
1. Single specific organs e.g.: Uterus
2. Marking anatomically and technically difficult (perineum, friable skin)
3. Wounds if they are points of surgical intervention
b) Emergency situations wherein any delay can compromise patient safety.
Note: The documentation of site marking is documented as NOT APPLICABLE
(NA) to unpaired organs and when planned bilateral procedures are being done
for paired organs. However, if levels or areas are important, they should also be
marked. The marking of the tooth is done by their anatomical numbers (dental
records and radiographs).
B) Preoperative verification process – is done by the OT nurse at the
hand over from the ward nurse in the OT with referral to the preoperative
checklist available to ensure that all relevant documents, images and studies
are available, that they are reviewed and that they are consistent with each
other; special equipment and or implants are present and there is an agreement
on the correct patient, procedure andesite.

C) Time out– is called out by the circulating nurse in the presence of

entire team (Inclusive of Surgeon and anaesthetist (in OT)) prior to the incision.
At the time of time out the nurse verifies the patient identification with the
patient / against the ID band, Procedure, Consent, Incision site and Correct
position. During time out everyone should stop what they are doing and
participate (to say “agreed”) in the timeout.
This is documented. The surgical team should not leave the OT after time out.
In the event of any disparity during the time out the circulating nurse will
not endorse & immediately call for suspending the procedure pending
clearing of disparity.
In issues where the disparity cannot be resolved the procedure is considered
cancelled & is identified as the reason for cancelled surgery.

29
 IPSG 6. How to prevent Patient fall in hospital?
The fall prevention program is implemented through the following procedure

 In the OP Unit, all patients who are at high risk for fall are educated about
fall prevention strategies which includes availability of wheelchairs, walking
support (sticks, crutches) low level beds, adequate lighting etc. Attendants
are counselled not to leave the patients unattended
 OP & IP units has a dedicated toilets for physically challenged and high risk patients.
 Following category of patients as listed below but not limited to are identified
by the Doctors/nurses as vulnerable for fall;
o Age- less than twelve years
o Age more than sixty five years
o Co morbid conditions not limited to (terminally ill, imbalances
in gait, patient on sedative medications, patients who need
restraints as part of their management, patient with
circulatory compromised, patient more vulnerable for
dehydration)
o Physically challenged patients
o Patients who cannot perform their normal daily activities.
o ICU patients
o PICU Patients
o Comatose Patients
 In the IP unit, fall risk assessment is done on admission and once every shift.
If the patients risk status changes (for e.g. after sedation ; post-operative;
change in level of care; post fall), reassessment is to be done immediately.
 Efforts are made to ensure that these patients are not left unattended.
 All hospital beds are provided with railings, calling bells at the bedside and
toilet alarms. Patients and attendants are orientated on the same.
Wheelchairs and stretchers are provided with safety straps and brakes.

30
WHAT TO DO IF PATIENT FOUND DEAD ON ARRIVAL TO EMERGENCY DEPARTMENT
(BROUGHT DEAD)?

 ER Doctor and the ER Nurse assess the patient i.e. Breathing, Carotid
Pulse, Pupils dilated. ECG is taken. ER doctor will make entry in Emergency
assessment form
 In the absence of breathing, Carotid Pulse, pupils are dilated & ECG is flat
line the ER Doctor informs the relatives of patient death.
 Such a case is registered as medico legal and police notification is done.
 ER notes & ECG will be retained in Brought dead file in ER.
 MD to be informed about the same.
 After these explanations if relatives still insist to initiate resuscitation or
demanding for Death Certificate then, inform the MD for further
Instructions.
 If the patient is previously registered and taken treatment in our hospital,
then ER Doctor will inform the primary consultant for further instructions.
WHAT IF PATIENT DIES ON ARRIVAL TO THE EMERGENCY DEPARTMENT?
 When history reveals that the patient was alive few minutes ago, start CPR.
 CPR Should be done for minimum of 45minutes.
 DC Shock may be given as per ACLSPROTOCOLS.
 If the patient is a child, CPR Should be done for at least one hour before the child is
declared dead
 Always look out for any marks of injury / abuse /violence
 In cases where resuscitative measure fail to restore life the patient is declared
as DEATH ON ARRIVAL
 At times a body is brought in with history by attendant that when noticed by
them there was no sign of life .If the doctor on duty in his clinical judgment
opines it as a brought in dead no CPR is done.
 The patient / deceased will be fully registered and given a registration number
 The particulars of the patient are obtained from the accompanying persons. The
particulars of the attendants are also noted. The patients are registered as
“unknown” if unidentified and the same is entered in the death notification form
 All such cases are notified to the police
 Relatives should be instructed to take the body to their family doctor or to the
Civil Hospital to obtain Death Certificate, as hospital cannot issue a Death
Certificate under such circumstances.
 After these explanations if relatives still insist to initiate resuscitation or
demanding for Death Certificate then, inform the Medical director for
further Instructions.
 In Case of MLC Body should be handed over to the Police along with one copy of the
MLC notification form and the history written by the ER Doctor

31
 

WHAT IS TRIAGE?
Triage is defined as sorting out. This “Sorting Out” includes assessment and categorization.
It is a process of prioritizing patients based on the severity of their condition so as
to treat as many as possible when resources are insufficient for all to be treated
immediately.

 To efficiently sort out patients based on specified criteria to maximize the number of
lives saved.
 To provide early qualified evaluation and correct placement of patients attending
emergency room.
 Criteria for Adults
 RED- URGENT; Critical needs immediate treatment
 YELLOW- Needs admission or observation
 GREEN- Stable. Walking wounded
 BLACK-DESEASED
PROTOCOL
1. Patient reports to emergency room
2. The triage nurse makes an initial nursing Assessment of the patient: Airway,
Breathing, and Circulation. Temperature, pulse, respiratory rate, blood
pressure and SpO2 monitoring is mandatory
3. Brief nursing history is taken by the Nurse including:
 Chief complaint / mechanism of injury.
 Medical history
4. The above findings are documented in the TRIAGE for ER section and
categorized as per the priorities.
Priority 1(RED): ICU nurse receives hand over and triage nurse returns to post.
Priority 2(YELLOW): Patient is placed in cubicles/ general ward area as
appropriate and the nurse in that area is informed.
Priority 3(GREEN): Patient may be placed as for priority 2 or may be asked to

wait if area is full. The triage nurse continues to observe these patients for deteriorating
condition.

32
WHAT IS MLC? HOW TO HANDLE MLC CASES?
MLC- MEDICO LEGAL CASE.
 It can be defined as a case of injury or ailment, etc., in which investigations
by the law-enforcing agencies are essential to fix the responsibility regarding
the causation of the said injury or ailment or any case which is admitted in
the hospital which comes under the preview of any of the existing Law of the
Land.

REGISTRATION OF CASE AS MLC:

 The Emergency Room Doctor on duty will decides whether a case should be
labelled as medico legal one or not in consultation with Primary consultant/
Treating Doctor.
 The cases coming under the preview of Section 39 of Criminal Procedure
Code (Cr PC) along with the cases coming under the preview of any of the
existing Law of the Land are registered as MLC.
TIME LIMIT FOR REGISTERING An MLC

 Though there is no statutory time limit specified to register a case of MLC

however the registration of such case(s) should be done as early as possible.
There should not be any unnecessary delay in doing so.
 For medical management (i.e., clinical examination, any investigation,
treatment etc) of any suspected MLC patient, police formalities are not a
prerequisite. Patients care is the priority by all means. So, no doctor should
hold up the treatment as well as the reports of any investigation for the sake
of non-completion of medico-legal formalities.
(Ref: The Honorable Supreme Court in Parmanand Katara v/s Union of India
and others dated 28/08/1989)

REPORTING OF MEDICO-LEGAL CASE

The ER Doctor who is attending the patient under the supervision of Primary
consultant/ Treating doctor, should prepare the MLC intimation to police on
admission/OPD/ER admission/discharge /Death.
 The report should contain the complete name (including Fathers name), age,
sex and complete address of the patient admitted.
 It should include two identification marks, if possible ideal identification mark of
the patient.
 It should include the date and time of incidence, the manner in which the
injury has occurred and place of incidence.
 It should include the name, address and phone number of the person who
has brought the patient to hospital and/or person who initially informs the
hospital. It should also include the relation (if any) with the patient admitted.
33
  Avoid use of short-forms / abbreviations (e.g. write Head Injury instead of HI).
 Avoid over writings.
 Correction if any, should be initiated with date and time.
 Reports must be prepared in duplicate.
 It should be signed by ER doctors.
PROCESS OF INFORMING THE POLICE-
 MLC form is filled in duplicate by the Doctor who is attending the patient
(form should be filled by Primary consultant/ Treating Doctor or by ER
doctor), with minimum two identification marks one copy for Medical Records
Dept. and one for the police. Send duplicate copy to the police station. One
copy will remain with police & one copy will be sent back by police personnel
with their acknowledgment. This copy should be scanned & retained in
electronic record of the respective patient & hard copy can be kept in medical
Record.

MLC DISCHARGE

Normal Discharge

 Photocopies of the previous of referring hospital e.g.: referral letter,

investigation should be retained in the medical record of the patient.
 The Discharge Summary, all the Biochemical and Haematological
Investigation reports, the Radiological Investigation films along with their
Reports should be handed over to relatives with proper acknowledgement
and proper instructions.

DISCHARGE/ LEAVE against medical advice (DAMA/ LAMA)

 The Primary Consultant/ Treating Doctor of the patient should be informed.

 An “Informed Consent of DAMA/ LAMA” should be documented and
signatures of relatives should be taken.
 The Discharge Summary, investigations done, investigations advised and
 further treatment advised should be given with proper acknowledgement.

ABSCONDED PATIENT

 Medical Director / Primary Consultant should be immediately informed.

 An immediate telephonic intimation to the police station should be given and
a proper written complaint regarding the same should be made by MD to the
police station

34
MLC DEATHS
 The concerned Police authorities should be immediately informed by MLC Intimation
of Death.
 The Dead body should be preserved in Cold Storage cabinets (Mortuary) till
the arrival of police authorities.
 The Dead body, Death Report, medical Records file should be handed over to
police authorities only with proper acknowledgement. It should never be
handed over to relatives.

HOW TO DISPOSE OF THE SURGICALLY AMPUTED PART?

 The surgically amputee body parts would be disposed of by any of the following
2methods:
1) Handing it over to relatives for disposal by further religious rituals along
with the required certificate for the same. The relatives should be made
aware regarding the hazards of bio- medical waste and its chances of
decomposition.
2) Disposing off through hospital biomedical waste policy.

 A proper written Consent regarding the method of disposal should be taken from
the relatives and retained in the file.
 The body part is placed in the yellow polythene and all details of the part is
written on it with date & time, area.

WHAT IS “END OF LIFE CARE”?

End of Life care: Helps all those with advanced, progressive, incurable illness to
live as well as possible until they die. It enables the supportive and palliative care
needs of both patient and family to be identified and met throughout the last phase
of life and into bereavement. It includes management of pain and other symptoms
and provision of psychological, social, spiritual, and practical support.

PROTOCOL: -
 Primary and secondary symptoms of disease and pain relief managed.
 Information to patient and family on all the aspects of care including,
interventions. Symptomatic relief and complications to the extent reasonably
possible.
 To ensure the comfort and dignity of the patient and family is taken care of at all times.
 Cultural and religious concerns for end of life discussed with patient and relatives.
 Psychological, spiritual and emotional concerns of the patients / family are taken care
of.

35
 VULNERABLE PATIENTS & SPECIAL CARE GIVEN TO THEM

Vulnerable patient is one who is:

• Geriatric patients (>65 years of age)
• Pediatric patients (<14 years of age)
• All ICU patients
• Terminally ill, dialysis patients, chemotherapy patients, Comatose patients.
• Physically / Mentally challenged patients.
• Pregnant Women
• Patients unable to perform activities of daily living.
• Two or more diagnosis
• Language barrier patients
Action to be taken for Vulnerable patients.
• Side rails on bed
• Apply ORANGE Band
• Must be attended by family attendant / nurse.
• Individualized assessments & reassessments
• Safety First program to be followed.
• Modified mores fall risk assessment (Assessments& reassessments).

What is RESTRAINT? TYPES?

Restraints: Devices used to ensure safety by restricting and controlling a person ‘s
movement. Many facilities are―restraint free‖ or use alternative method to help
modify behavior. Restraint maybe physical or chemical (by use of sedatives.
Restraints may also be physical or pharmacological (Chemical).

EXAMPLES: -
Examples of these situations include the following:
• Protect patients from physically harming themselves (e.g., self-extubating).
 Protect staff and/or patients' families from patient violence
• Allow assessment of disoriented and uncooperative patients or those under the
influence of alcohol or drugs
• Facilitate medically necessary procedures (e.g. Gastric lavage)in
uncooperative patients
• Prevent elopement while patients are being evaluated for potential suicidal or homicidal
behaviour
• Protect disoriented patients from falls.
PROTOCOL: -
 Restraints to be used only in accordance with the written order of a General
practitioner or Specialist doctor.
 Shift in charge / nurse supervisor may initiate restraints in an emergency
situation before obtaining the written order.

36
 Written orders for restraints will include: the time limitation start time end time, type of
restraint, frequency of monitoring, reevaluation, Reason for restraint.
Name and signature of the staff ordering the restraints.

ASESSMENT DURING RESTRAINT: -

Assessment of the patient with physical restraints -
 Patient should be assessed every hour and this should be documented on the
Restraint flowchart.
 Assess general comfort.
 Inspect the skin for breakdown or injury.
 Assess circulation and range of movement of restrained limb.
 Assess the general condition/behaviour of the patient (restless, agitated,
resting, normal voice, yelling etc)
 Assess the need for activities of daily living (hunger, thirst, personal hygiene,
toileting)
 Change the patient’s position every 2 hours.

Although physical restraints generally are the first method employed when
restraints are necessary, pharmacological restraints may be used as an
alternative or adjunct to physical restraints.

Chemical restraints (Adults)

Chemical restraints are any medication used for the purpose of restraining
patients involuntarily to prevent them from harming themselves or staff.
Patient should be assessed every 15minutes and this should be documented on
the Restraint flow chart. Monitoring should include temperature, pulse,
Respiratory rate, BP, GCS, and gag reflex.

EXAMPLES OF PHYSICAL & CHEMICAL

RESTRAINT? CHEMICAL AGENTS: -

• Major tranquilizers/neuroleptic agents
 Haloperidol
 Benzodiazepines
 Diazepam
 Lorazepam
 Midazolam
 Alprazolam

PHYSICAL RESTRAINTS

 Padded Mitts
 Arm restraints
 Wrist/ankle restraints
37
BLOOD TRANSFUSION & TRANSFUSION REACTIONS

• Consent to be obtained

• Not to administer any pre-medications

• Observe for transfusion reactions

TRANSFUSION REACTIONS

• STOP the transfusion

• Inform to the consultant and follow the instructions

• Fill the transfusion reaction form

Submit transfusion reaction form along with Blood sample, Urine sample , Blood bag and blood set
to the blood bank for analysis.

38
 MOM (MANAGEMENT OF MEDICATION)

WHAT IS HIGH- ALERT/HIGH RISK MEDICATION?

High Alert / High risk medications that bear a heightened risk of causing
significant patient harm when they are used in error.

STORAGE, PREPARATION, PRESCRIPTION,

ADMINISTRATION OF HIGH ALERT DRUGS?

Prescribing Precautions:

 Prescription for All Medication Including (High alert) should be legible and in Capital
letters
 Use only approved abbreviations while prescribing high alert medications

Dispensing precautions:
 High alert medications shall be dispensed from the Pharmacy after proper
identification of the patient with “Stamp of Supplied” to be applied on
Prescription for prevention of Misuse of Prescription, & Label on Usage of Drugs
for Patient Education .

 Pharmacist must double check all High-Alert medications: Checking patient

identification and the drug order in prescription for dose, unit, route, frequency
and time of administration before dispensing shall be done by two pharmacist.

Labelling Precautions:

 High alert/ High risk medication must be properly labelled with Red
warning Sticker showing“ HIGH ALERT” , “HIGH ALERT , DILUTE BEFORE
 USE” for concentrated electrolytes and small ampoules are marked with
“High risk medications Sticker”

HIGH RISK DRUGS

Preparation:
 High risk medications are to be prepared safe clean and safe environment & to be
verified by Senior nurse, for right dose.

39
Administration

 Counter Check Mechanism to be followed with either Nurse – Senior nurse or

Nurse- Doctor Prior to administration of high risk medications . Checking the
patient identification and the drug order sheet for dose, unit, route,
frequency and time before administering shall be done by two nurses and
signed by both in the drug chart in all patient care areas.

 Ensuring the accuracy of infusion pump programming for continuous

intravenous infusion of high alert medications.

 Rights of medications to be followed at the time of administration of High risk

medications i.e. (right patient, right medication, right dose, right frequency
right time, right route, right documentation, right assessment, right to refuse
, right drug interaction & evaluation , right to education).

Storage Precautions:
 High alert medications shall be identified by special label “High risk drugs” and
shall be placed in special high alert medications cupboard/ box within the
pharmacy and clinical area where it is necessary.
 Drugs, which need refrigeration, shall be stored in patient care units in a
separately labelled container in the refrigerator.
Verbal Order for High Alert medications
 Verbal orders are accepted for all drugs within the Formulary, Except
Multivitamins, Contrast Media,& Narcotic drugs.

 Read back policy to be followed in case of Verbal orders, i.e. Order given by
consultant should be read back by the one who is receiving order.

 Ensure another nursing staff is listening the read back process.

 The medicine should be administered and signature of the ordering doctor

should be taken within 24 hours of accepting verbal order / Telephonic order.

Monitoring:

 Monitoring of the High alert medication shall be done in every step of the

40
 process by the doctor, nurse, pharmacist and clinical pharmacist and all the
standard precautions shall be taken to prevent any inadvertent use.

WHAT ARE SOUND ALIKE AND LOOK ALIKE DRUGS (LASADRUGS)

 Examples of Sound Alike drugs(Green color sticker) ( Pronunciations sounds same but
has different content)- Tab Doxycycline and Tab dyphylline .

 Example of Look Alike (Blue Colored sticker) ( Looks Same but has different
Content)- Omnipause 100 ml &Viviparus 100 ml..

Storage Precaution
 Look alike and sound alike medication should be kept separately and labelled
appropriately in all patient care areas and pharmacy

 To be kept separately in different racks (A ciloc 400 mg and 100 mg will be in

separate racks)
 All “Look alike” drugs should be identified with Blue Colored sticker.

 All “sound alike” drugs should be identified with Green color sticker.

Pharmaco-Therapeutic Committee
 New drug brand that are similar to existing brand should be approved
only after appropriate screening by the Pharmaco-Therapeutic
Committee members.
 LASA drug list to be reviewed once in year.

WHAT IS CHEMOTHERAPY DRUG?

 Antineoplastic (Chemotherapy) drugs are known to be carcinogenic, teratogenic or
mutagenic.
PROCESS OF CHEMOTHERAPY ADMINISTRATION?
 All mixing of antineoplastic drugs shall be performed in the Class II Type
B biological safety cabinet (laminar flow).

WHAT WILL YOU DO IF PHARMACY IS CLOSED?

 Pharmacy is never closed in our Hospital. It is 24*7operational.

41
WHAT ARE THE 10 R’S OF MEDICATION ADMINISTRATION?
-Right patient

-Right medication
-Right dose
-Right frequency & time

-Right route
-Right documentation
-right assessment
-Right to refuse
-Right drug interaction & evaluation
-Right to education).

42
WHAT IS ADR? HOW IS IT IDENTIFIED AND REPORTED?
 ADR is adverse drug reaction
 It the unwanted reaction to any drug ,Unwanted, unintended drug reaction
at therapeutic doses occurs
 The World Health Organization (WHO) defines an ADR as “any response to
a drug, which is noxious and unintended, and which occurs at doses used
in man for prophylaxis, diagnosis, or therapy or for modification of
physiologic function.
 The reaction should meet at least one of the following criteria:
 Hospital admission
 Adjustment or discontinuation of drug therapy

 Requirement of systemic treatment

 Prolongation of hospital stay

 Complication of diagnosed disease state

 Patient death

ADR Reporting
 Serious ADR’s should be reported within 24 hours and Non serious ADR’s
should be reported within 24-72 hours of occurrence of ADR.
 ADR’sreportedaredocumentedinSuspectedAdverseDrugReactionReportingFormVersio
n-reported directly to Quality department through Incident Report Form.
 All reported ADRs shall be reviewed monthly by the Pharmacy and Therapeutic
committee
Common signs of ADR involve fever, chills, and redness.

WHAT IS HOSPITAL DRUG FORMULARY?

 To serve as a guide to the Medical, Pharmacy, Nursing and Other healthcare

professional about the list of drugs currently stocked at the
HospitalPharmacy.
 The formulary is the official publication of the Pharmacy & Therapeutics
committee. It is the compilation of Generic drugs approved, reviewed and
accepted by the Pharmacy & Therapeutics committee to meet the clinical

43
 needs of the medical team.
 The formulary shall be revised periodically and edited at least every 6 months. once
as per P & T committee
 Content:- Each generic has three brands in Formulary with the exception of
some fast moving generics. Drugs shall be listed according to generic name,
brand name, strength, formulation, Pharmacological category and
subcategory
How to add drug (not in list) in drug formulary?
 Addition of drugs to the formulary shall be made by submitting a “New
Drug Request form” to the Pharmacotherapeutic Committee and criteria
for addition of new drugs involves
 New Generic /Molecule
 New Dosage form

 New Strength
 New Drug Combination
 Single or Two Brands in Formulary
 Short supply of Formulary brand
 Cost effective

 Prescription habit
 Therapeutic value
 Safety profile

How to obtain drugs not in list of drug formulary?

Non-Formulary items:

 Non formulary drugs and drug items shall be obtained when needed to
treat a specific illness or disease.
 Whenever such a drug is needed for patients, signed local Purchase
Request form for Medicines shall be submitted by the requestor along with
a signed prescription to the clinical pharmacist
 Clinical pharmacist will review the request for need, availability of other
suitable brand/generic available in the formulary before approval.
44
  Clinical pharmacist shall inform the doctor verbally if the request is
denied with proper justification
 Approved local purchase forms will be forwarded to pharmacy to initiate the
purchase process
 Requested item will be made available in the pharmacy as soon as possible
from outside sources by the pharmacy within 12 hours. In case medication is
not locally available that will be informed to the requestor from pharmacy.
 This process shall not lead to stocking of the drugs in the pharmacy.
 Pharmacy manager and Clinical pharmacist shall review the non-formulary
drug prescriptions and bring into the notice of P & T Committee, to
include the drugs in the formulary or to take necessary actions to avoid
such use.
WHAT IS MEDICATION ERROR?

 Medication Error: Any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the
control of the healthcare professional, patient or consumer.
 Such events may be related to professional practice, healthcare products,
procedures and systems, including: prescribing, order communication,
product labelling, packaging and nomenclature, compounding, dispensing,
distribution, administration, education, monitoring and use.
 Serious Medication Error: Any medication error that if not prevented may
cause significant harm to the patient (i.e. permanent harm or death).
 Near Miss: Any process variation that did not affect an outcome (did not
reach the patient), but for which a recurrence carries a significant chance of
a serious adverse outcome. Such a “near miss” falls within the scope of the
definition of an adverse event.
TYPES OF MEDICATION ERROR?
Medication errors could occur during any of the five stages of medication use
process (Each of them could be considered as “Error Prone”). These processes
are:

 Prescription error(Error in prescribing- failure to comply with capital letters,

45
 route, date, time , name , sign)
 Dispensing error- Mistake made while dispensing drug from pharmacy
 Transcription error- Mistake made in copying drug from one place to another,
mistake made during improper communication during verbal order etc
 Missed Dose.
 Wrong Drug.
 Wrong route.

 Administration error (Any variation is actual drug administered and prescribed

drug in terms of route, dose, frequency, drug name etc,).

Categories of medication Error

Category of
Level of harm Explanation of Events / errors
Error
Circumstances or events that have the capacity
NO ERROR Category A
to cause error
An error occurred but the error did not reach the
ERROR, NO HARM Category B patient (An error of omission " does reach the
patient.)
An error occurred that reached the patient but did
Category C
not cause patient harm
An error occurred that reached the patient and
required monitoring to confirm that it resulted in
Category D
no harm to the patient and / or required
intervention to preclude harm
An error occurred that may have contributed to
ERROR, HARM Category E or resulted in temporary harm to the patient and
required intervention.
An error occurred that may have contributed to
Category F or resulted in temporary harm to the patient and
required initial or prolonged hospitalization.
An error occurred that may have contributed to
Category G
or resulted in permanent patient harm.
An error occurred that required intervention
Category H
necessary to sustain life.
An error occur that may have contributed to or
ERROR, DEATH Category I
resulted in the patient's death.

46
HOW TO REPORT MEDICATION ERROR?
Steps to Be Followed When a Medication Error is Discovered:

 Any staff member who discovers a medication error whether it’s a physician,
pharmacist, clinical pharmacist or a nurse must immediately inform the
prescriber
 All Medication errors will be reported in Pharmacy and therapeutic committee
meeting and Quality Department once in every month
 Sentinel medication errors will also be presented in Morbidity and Mortality Meeting.
 A Route Cause Analysis (RCA) will be done for all major medication errors that
reached the patient

WHAT IS DRUG RECONCILIATION?

 Reconciliation is the process of comparing what medication the patient is
taking at the time of admission or entry to new setting or level of care to
avoid error such as conflicts or unintentional omissions.
 All inpatient medications should be reconciled within 24 hours of admission.
The final outcome of this activity is to generate the most accurate
medication list available.
 Medication reconciliation process should happen at three levels
a) During Admission
b) During Internal Transfer
c) During Discharge

WHAT IS DRUG RECALL?

Action taken to remove a product/medication from pharmacy, stores, and clinical
areas if there is any contamination, recall notice, expiry, banned drug,
manufacturing problems etc. This is mostly issued by manufacturer/supplier. In
rare cases, it can be issued by hospital authorities also.

Procedures

Upon receipt of a drug recall notice or Banned medicine from Medicine Company,
higher drug control authority or authority concerned, or locally detection of
47
 damaged or Severe ADR causing medication, the Pharmacy Manager shall assign
pharmacy personnel to visit and check each area of the hospital.

The Recalled medications shall be received and returned to concerned suppliers /

manufacturers from the Pharmacy.
WHAT IS A NEAR EXPIRY DRUG AS PER HOSPITAL POLICY?

A drug in our stock which has less than 3 months of expiry. All such drugs are sent
to central drug stores for returns to the supplier

WHAT IS PPE? NAME FEW COMPONENTS?

PPE is Personal Protective Equipment.

 Gloves: protect hands

 Gowns/aprons: protect skin & clothing of HCW
 Masks and respirators: protect mouth &nose
 Respirators: protect respiratory tract from air borne infections
 Googles: protect eyes

 Face shields: Protect face, mouth, nose and eyes.

HOW TO USE MULTI DOSE VIAL?

 Multiple dose/multi-dose medication vials must be handled in accordance with

the manufacturer's instructions.
 Place the expiry date on the opened vial. The expiry date is 28 days after the
vial is opened or the manufacturer’s recommended expiration date (whichever
comes first) and discard at time of expiration.
 Cleanse the access diaphragm of multi-dose vials with 70% alcohol (such as
alcohol swabs) before inserting a device into the vial.
 Use a sterile device to access a multi-dose vial and avoid touch contamination
of the device before penetrating the access diaphragm.
 Discard the multi-dose vial be if user suspects vial sterility has been compromised.
 Visual inspection of the vial should be accomplished each time medication is
withdrawn to determine
o Turbidity
o Discoloration
o Integrity of rubber stopper seal.
 Avoid opening more than one multi dose vial of the same medication at the same
48
 time.

 Components on labels include:

a. Date and Time of Opening:
b. Date and Time of Expiry (28 days of opening date or expiry by
manufacturer whichever is earlier)
c. Signature of the staff labelling the vial.
WHAT IS HOSPITAL POLICY ON PRE-FILLED SYRINGES?
All Loaded syringes are Labelled with name of patient IP No, name of drug,
dilution and concentration of drug, date of preparation initials.
WHEN SHOULD THE AMBULANCE MEDICATIONS & INVENTORY BE CHECKED?
 Once daily
 Before the ambulance leaves the hospital for patient pickup.
WHAT ARE NARCOTICDRUGS?
Narcotic Drugs – are addictive drugs that reduce the user's perception of pain and
induce euphoria (a feeling of exaggerated and unrealistic well- being). They are
substances that lead to increasing tolerance and physiological dependence.

HOW TO STORE NARCOTIC DRUGS? NAME A FEW?

Pharmacy department is responsible for receiving, storing, and dispensing narcotic
drugs to authorized patient care areas and maintain proper documentation of drug
count and accountability.

 All Narcotic drugs shall be stored in a separate double locked cupboard in the
Pharmacy store
Following Narcotic drugs are used in hospital: -
 Inj. Fentanyl Citrate
 Fentanyl Patches

 Tab. Morphine

HOW ARE NARCOTICS DRUGS PRESCRIBED?

 Narcotic drugs shall be issued and administered only on registered medical
practitioner’s prescription which is signed,& stamp by a consultant whose
names are in the RMI prescribers list.

 The Narcotic order shall be written on the narcotic prescription form. There
should be no strikeover, erasures or misspellings of the drug name, strength

49
 or quantity. If any error happens, cancel the prescription form and write a
new prescription.
 Only authorized personnel shall handle these drugs in accordance with policy.
 Telephone order for Narcotics is not acceptable.
 Narcotic cupboard should always be opened by 2 staff members.
 Triplicate Prescription.

HOW TO DISCARD NARCOTIC DRUG?

 The Nurse should withdraw the solution from the ampoule near the safe
cabinet. When the Ampoules are used to patients the empty ampules should
be given back to pharmacy.
 The balance amount in the ampoule is the wasted amount and the wasted
narcotic drug should be discarded in the presence of a registered
nurse/authorized employee and signed by both.
 Narcotic usage entry should be done in narcotic register, counter signed by a
witness.
 All entries on the Narcotic administration & disposal record.
WHAT IF MEDICINE IS NOT AVAILABLE IN THE PHARMACY?
 Every Generic item is having minimum 3 brands for the product so In case of
Non availability of 1 brand, substitute for the same is always available & same
is informed to all staff.
 In a situation where a prescribed medication is not available with the hospital
pharmacy; prescriber request the drug through Local purchase form
 Approved local purchase forms will be forwarded to Pharmacy.

HOW TO STORE MEDICATION IN THE HOSPITAL?

 Non refrigerator item below 25 degree centigrade ( Temperature Between 18
to 25 degree centigrade)
 Refrigerator item between 2-8 degree centigrade
 No direct sunlight, and

 No excess humidity (Humidity between 30 to 60%)

50
WHAT IS CRASH CART?
 A trolley carrying medicine and equipment for use in emergency resuscitations.

HOW TO MAINTAIN CRASH CART?

 Emergency medications shall be kept in crash trolley in the specified located
areas (where emergency medications necessary.

 After use in a cardiopulmonary arrest, the Nursing Officer or team leader on

duty is responsible for immediate restocking and rechecking of the crash
trolley medicines for reuse.

 The crash cart medicines which are refrigerator stored should be kept in a
box labelled crash cart medicines.

Nursing staff shall be responsible for replacement of the items after a crash trolley is
opened. The replacement of items shall be done within two hours.

HOW TEMPERATURE SHOULD BE RECORDED?

The temperature shall be checked and recorded in the log. If there is any problem
with the refrigerator, then same should be informed to the maintenance
department immediately and to be recorded.
WHAT TO DO WITH UNUSED MEDICATIONS ONCE THE PATIENT IS DISCHARGED?
 Unused drugs at the time of discharge can be returned to the pharmacy
provided they are kept in the same envelope with expiry and batch number.
 Opened medications not required post discharge are discarded in yellow-colored
bins after discarding the drug in the sink under running water by ward
pharmacist after medication reconciliation. Bottles will be discarded in Blue
colored boxes/ bags.
 Multi dose vials, ointments, creams etc. are discarded after the expiry
mentioned as in the Expiry of Multi dose vials chart (see antibiotic policy) unless
an alternate period is specified by the manufacturer.

51
 FLOW RATE & DRIP RATE CHART
Drop factor.

1. Adults Macro set = 15 drops / min

2. Pediatric Micro set = 60 drops / min

3. Adult BT Set = 10 drops min

Flow rate = Volume / Time Unit = ml / Hour

Drop (Drip) rate = Flow Rate x Drop Factor/ 60 Unit = drops / Min

Sr.no Iv Fluid in ml Flow Flow Drop (Drip) rate in drops /min

rate in rate in
ml /hr ml /min

Macro set Micro set Blood

(Std. flow (Std. flow transfusion
rate : 15 ) rate : 60 ) set (Std. flow
rate: 10 )

1 100 ………… 3.3 50 198 33

……..

2 ………… 6.7 101 402 67

……..

3 500 / 1000 40 ………… 10 40 7

……..

4 60 ………… 15 60 10
……..

5 80 ………… 20 80 13
……..

6 100 ………… 25 100 17

……..

7 120 ………… 30 120 20

52
FORMULA FOR DRUG / DOSE CALCULATION

Body Surface area (BSA)

BSA = √Ht in cm x Wt in Kg

3600

• Clark rule

It uses Child's Wt
Who are less than 1 years of age?
Wt in Pounds & never in Kg
Child's Dose = Avrg Adult dose x (child's wt. in pounds)
(150lb)
 Fried's rule
Who are less than 2 years of age

It uses age in months.

Child's Dose = Average Adult dose x (Child's age in months)

150

• Young's rule

Children with 2 or more years

Child's Dose = Average Adult dose x child age in years

Childs age in years +14

VERBAL ORDER
Verbal order occurs when the health care provider gives an order to a nurse/ resident doctor
while they are standing near each other.
 Take a pen & paper to write down (During Conversation & Not after)
 Read back any order given by DR.
 Use Clarification Questions to avoid misunderstanding.
 Ex: Say one five milligrams to distinguish between 15 & 50
 Clarify whether an order for Nitro is for Nitroglycerine OR Nitro preside.
 Fill the verbal order form.
 Follow Hospital policy – signed by nurse after review of consultants, & to be signed by
consultant within 24 hours.

53
 PRE (PATIENTS RIGHTS AND RESPONSIBILITIES)

PATIENTS RIGHTS: -

• Right to be informed of their rights and review policies regarding them.

• Right to express complaints and satisfaction regarding services rendered and to

comment and make suggestion for improvement of the quality of care and services.

• Right to refusal of treatment.

• Right to special preferences related to spiritual and cultural needs.

• Right to receive information regarding their illness, the course of treatment and the
prognosis in the language that they can understand.

• Right to know in advance of services, the cost of services and any applicable payment
policy.

• Right to know hospital rules and regulation.

• Right to access medical record.

• Right to expect dignity while providing care.

• Right to confidentiality & privacy

• Right to second opinion.

• Right to safety and hazard free environment.

PATIENTS RESPONSIBILITIES: -

• To cooperate with healthcare providers involved in their care and to conduct themselves
in a polite and respectful manner.

• To provide accurate and complete information needed for correct diagnosis and
treatment.

• To follow treatment advised by the doctor.

• To follow hospital’ rules and regulations.

• To save electricity and water.

• To help us in maintaining cleanliness and protect hospital environment.

• To settle bills.

 Patient Rights are displayed at various locations in Hospital.

54
INFORMED CONSENT

Consent: 1. Willingness of a party to undergo examination/procedure/treatment by

a healthcare provider. It may be implied (e.g., patient registering in OPD),
expressed which may be written or verbal. Informed consent is a type of consent in
which the healthcare provider has a duty to inform his/her patient about the
procedure, its potential risk and benefits, alternative procedure with their risk and
benefits so as to enable the patient to take an informed decision of his/her
healthcare.
List of procedures requiring informed consent are.
1. HIV testing
2. PNDT act
3. All Procedure / Surgical consents (for invasive procedures/surgeries)
4. Leaving/Discharge against medical advice
5. Anaesthesia related consents
6. High Risk Consent
7. Transfer of High Risk patient Consent
8. Administration of moderate sedation
9. Consents for diagnostics procedures
10. Contrast usage
11. Radiation Therapy
12. Nuclear Medicine
13. Blood Transfusion Consent
14. Dialysis
15. Administration of chemotherapeutic agents
16. Restraint Consent
In the outpatient unit, a general consent is taken on registration and in the
inpatient unit, at admission and this is considered as an implied consent as per
hospital policy and implies that the patient has willingly agreed to the examination,
investigations, and treatment (excluding those conditions which require an informed
consent as mentioned above).

Staff member shall clearly explain the proposed treatment or procedure to the
patient or his legal guardian (in case of minors i.e., under 18 years of age) and
when appropriate the family.

Is radioactive drug /Radio-active material used in our hospital?

Yes, we use radioactive drugs. In Nuclear Medicine department and

Radiotherapy department.

55
 HIC (HOSPITAL INFECTION CONTROL)

WHAT IS INFECTION CONTROL PROGRAMME?

It is a program/initiative to minimize the hospital acquired infections and

to continuously improve the quality of healthcare offered to patients.

Define high risk areas?

All areas which have high risk of cross transmission of infection, all areas where there
are vulnerable patients who are quickly susceptible to infection.
High risk areas: - Emergency, OTs, ICUs, Recovery, blood bank, CSSD and the
rooms in which patients with droplet and/or air borne precautions are placed
(Isolation and Super isolation rooms in ICU and 3rd Floor private wards) Mortuary.
WHAT IS STANDARD OR UNIVERSAL PRECAUTION?

According to HICPAC and the CDC Standard Precautions include a group of infection
prevention practices that are intended to break the cycle through which
microorganisms are transmitted through unprotected contact with the patient’s
blood, all body fluids, secretions, or excretions (except sweat) or contact with their
mucous membrane or nonintact skin. They apply to all patients and residents,
regardless of suspected or confirmed infection status in any setting in which
healthcare is delivered.

 Standard precautions include:

▪ Hand hygiene
▪ Use of personal protective equipment (e.g., gloves, gowns, facemasks),
depending on the anticipated exposure
▪ Respiratory hygiene / cough etiquette
▪ Cleaning and Disinfection
▪ Sterilization and Disinfection of patient care equipment’s and instruments/ devices
and Appropriate environmental cleaning: Refer to CSSD manual and Policy on
Environmental cleaning
▪ Safe Injection and Infusion Practices
▪ Biomedical waste management:
▪ Linen management
▪ Use of masks for insertion of catheters or injection of material into spinal or
epidural spaces via lumbar puncture procedures.

56
HAND HYGIENE

Indications:
WHO has recognized the “FIVE MOMENTS OF HAND HYGIENE”

a. Before touching the patient

b. Before any clean/aseptic procedures
c. After body fluid exposure risk
d. After touching the patient
e. After touching the patient surroundings
Table 4. Five moments of hand Hygiene: When and Why (Adapted from WHO)

When we do Hand wash & when to perform hand hygiene?

Types of Hand Hygiene

a. With soap and water: Removes transient flora, i.e. micro-organisms
acquired from the environment and other people.
b. With alcohol based hand rubs (ABHR): Removes transient flora and
reduces the number of resident flora on the skin.
c. Surgical: Surgical scrub removes transient flora and reduces resident flora to
the lowest level possible.
NB:
▪ For specific agents used for Hand Hygiene refer to Skin Antisepsis and
disinfection.
▪ The ABHR preparation should be available within reach, preferably
closer to the point of care within 3 feet or should be carried by the
health care professionals for personal use.
Technique:

57
  With soap and water: For 40-60sec.
▪ When hands are visibly dirty or visibly soiled with blood or other body fluids.
▪ After using the toilet
▪ Before and after eating food
▪ If exposure to potential spore-forming pathogens is strongly suspected or
proven, including outbreaks of Clostridium difficult,
▪ Exposure to Bacillus anthracic is suspected or proven
 With Alcohol Based Hand Rub: Rub Hands until they are dry (20-30sec)
▪ Before having direct contact with patients
▪ Before donning sterile gloves when inserting a central intravascular catheter
▪ Before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical
procedure
▪ After contact with a patient’s intact skin (e.g., when taking a pulse or
blood pressure, and lifting a patient)
▪ If moving from a contaminated-body site to a clean-body site during patient
care
▪ After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient
▪ After removing gloves
Types of Hand Hygiene
d. With soap and water: Removes transient flora, i.e. micro-organisms
acquired from the environment and other people.
e. With alcohol based hand rubs (ABHR): Removes transient flora and
reduces the number of resident flora on the skin.
f. Surgical: Surgical scrub removes transient flora and reduces resident flora to
the lowest level possible.
NB:

▪ For specific agents used for Hand Hygiene refer to Skin Antisepsis and
disinfection.
▪ The ABHR preparation should be available within reach, preferably
closer to the point of care within 3 feet or should be carried by the
health care professionals for personal use.
Technique:
With soap and water: For 40-60sec.
▪ When hands are visibly dirty or visibly soiled with blood or other body fluids.

58
▪ After using the toilet
▪ Before and after eating food
▪ If exposure to potential spore-forming pathogens is strongly suspected or
proven, including outbreaks of Clostridium difficult,

▪ Exposure to Bacillus anthracic is suspected or proven

With Alcohol Based Hand Rub: Rub Hands until they are dry (20-30sec)

▪ Before having direct contact with patients

▪ Before donning sterile gloves when inserting a central intravascular catheter
▪ Before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical
procedure
▪ After contact with a patient’s intact skin (e.g., when taking a pulse or
blood pressure, and lifting a patient)
▪ If moving from a contaminated-body site to a clean-body site during patient
care
▪ After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient
▪ After removing gloves

59
60
61
 Surgical Hand Hygiene 6 Minutes.
The purpose of surgical hand antisepsis is to effectively remove or destroy
transient microorganisms and inhibit the growth of resident microorganisms.
Scrubbing with antiseptic soap solution/ surgical hand preparation using alcohol-based
hand rub)
▪ Steps before starting surgical hand hygiene.
 Keep nails short and pay attention to them when washing your hands
 Do not wear artificial nails or nail polish.
 Remove all jewellery (rings, watches, bracelets) before entering the operating
theatre
 Wash hands and arms with a non-medicated soap before entering the
operating theatre area or if hands are visibly soiled.
 Clean subungual areas with a nail file. Nailbrushes should not be used as
they may damage the skin and encourage shedding of cells. If used,
nailbrushes must be sterile, once only (single use). Reusable auto cleavable
nail brushes are on the market.
▪ Procedure for surgical scrubbing with antiseptic soap solution:
 Start timing. Scrub each side of each finger, between the fingers, and the
back and front of the hand for 2minutes
 Proceed to scrub the forearms, keeping the hand higher than the arm at all
times. This helps to avoid recontamination of the hands by water from the
elbows and prevents bacteria-laden soap and water from contaminating the
hands
 Wash each side of the forearm from wrist to the elbow for 1 minute.
 Repeat the process on the other hand and forearm, keeping hands above
elbows at all times. If the hand touches anything at any time, the scrub
must be lengthened by 1 minute for the area that has been contaminated
 Rinse hands and forearms by passing them through the water in one
direction only, from fingertips to elbow. Do not move the forearms back and
forth through the water
 Proceed to the operating theatre holding hands above elbows
 At all times during the scrub procedure, care should be taken not to splash
water onto surgical attire.
 Once in the operating theatre, hands and arms should be dried using a
sterile towel and aseptic technique before donning gown and gloves
▪ Surgical hand preparation using alcohol-based hand rubs:
On arrival in the operation theatre hands must be washed with soap solution
and water. The hand rubbing technique for surgical hand preparation must be
performed on dry hands.
After the operation when removing gloves, hands must be rubbed with an

62
 alcohol based formulation or washed with soap and water if any residual talk
or biological fluids are present(e.g. glove is punctured)

HOW TO WEAR PPE AND HOW TO REMOVE PPE?

63
64
COUGH /RESPIRATORY ETIQUETTES?
Easy availability of source control measures
- tissue, surgical masks, covering mouth and nose with tissue when
coughing/sneezing or wiping and blowing nose)
- Easy availability of hand hygiene located close to facility entrance and wait in grooms.
Practice respiratory hygiene and cough etiquette (technique described below)
 Cover the mouth and nose with a tissue or with elbow or shoulder when coughing or
sneezing;
 Use appropriate masks whenever indicated
 Dispose of the used tissue in the nearest waste receptacle
 Perform hand hygiene after contact with respiratory secretions and
contaminated objects/materials
 HCW with respiratory illness should avoid providing direct patient contact. A
barrier mask should be worn if patient contact cannot be avoided.
Masking and Separation of Persons with Respiratory Symptoms
 Provide face masks to all persons (including persons accompanying patients)
who are coughing and have symptoms of a respiratory infection.
 Place the coughing patient in an isolation room with a closed door as soon as
possible (if suspicious for airborne transmission, refer to Airborne
Precautions); if isolation room is not available, the patient should sit as far
from other patients as possible in the wait in groom.
 Encourage patients and visitors with respiratory symptoms to sit more than
3 feet apart or in a separate area when feasible.

WHAT IS SAFE INJECTION AND INFUSION PRACTICES?

WHO defines a safe injection as “A safe injection does no harm to recipient, does
not expose the health care worker to any risk, and does not result in waste that is
dangerous for the community?
Four Best Practice Areas (WHO)
 Using sterile injection equipment
 Preventing contamination of equipment and medication
 Preventing needle stick injuries
 Preventing access to used needles and syringes
Rub skin (circular outward motion) with clean cotton wool damped with rubbing
alcohol or other antiseptics (povidone iodine, chlorhexidine) as per HIC policy.
LET SITE AIRDRY
Keeping Sterile Injection Equipment Sterile

 Use aseptic technique to avoid contamination of sterile injection equipment.

 Do NOT touch parts that come in contact with the inject able drug
 If you accidentally touch any of these parts, the syringe and needle are NOT sterile.
 Discard them immediately in the appropriate container and use a sterile
syringe and a sterile needle.

65
HOW TO MAKE INJECTIONS AND INFUSIONS SAFE TO PATIENTS

 Needles, cannula and syringes are sterile, single-use items; they should not be
reused for another patient or to access a medication or solution that might be
used for a sub sequent patient.
 Use correct gauge and length of needle required for injection
 Use correct site depending on volume and age of the patient for delivering the
injection.
 Use correct angle for insertion of the needle depending on route of administration.
 Check expiry date of drugs and vaccines before using them on the patient.
 Make sure that the vial/ampoule contains right drugs in the appropriate
Strength and doses for the patient
 The drug/vaccine should be kept in the appropriate storage conditions / cold
chain. All UIP vaccines should be kept in an Ice Lined Refrigerator at 2-8
degree Celsius.
 Ensure that no air bubble is seen in the syringe prior to delivery of the medication
 Follow product-specific recommendations for use, storage and handling
 Use fluid infusion and administration sets (i.e., intravenous bags, tubing and
connectors) for one patient only and dispose appropriately after use.
 If more than one injection needs to be delivered at a time, use different
anatomical sites for every injection.
 If different anatomical sites are not possible, then the injections should be
sufficiently separated (3-5 cm)
 Aspiration is not required during Immunization when AD syringes are used.
 Antero lateral thigh preferred site for IM injection in children less than 1 year
old (Target muscle: Vastus lateralis). Strictly avoid the gluteal region in
infants.
 Make sure that syringes are not reused intentionally or downstream (reuse
prevention syringes or auto disable syringes are therefore preferred).

POLICY ON INTRAVENOUS LINE MANAGEMENT

 Use aseptic technique at all times
 All IV ports should be closed
 Verify patency of line by gently flushing with normal saline.
 Ensure that lines are labelled (date, time, signature)
 Remove line on any sign of redness, swelling, pain.
 Change IV set after every 72hrs.
 Cannula to be inspected in every shift.
 For giving antibiotics or bolus drugs SAS (Saline followed by Antibiotic
followed by Saline) must be followed.

66
CHANGING PROTOCOLS OF LINES AND TUBINGS
LINES CHANGING PROTOCOL DAYS / HRS
IV TUBING In patient not receiving blood, blood products or 96 Hrs.
fat emulsions, replace administration sets that are
continuously used, including add-on-devices.

IV TUBING Tubing used to administer blood, blood products, Maximum of 24 HRS.

or fat emulsion (those combination with amino
acid and glucose in a 3-in-1 admixture or infusion
separately) within 24 hours of initiating the
infusion.
IV TUBING Tubing used to administer propofol infusions Every 6 hours, when
every 6 or 12 hours, when the vial is changed. the vial is changed
Needless Change needleless connectors on more frequently 72 Hours
connectors
Needleless at least as frequently as
components the administration set
Arterial Catheter when there is a clinical indication Remove the arterial
catheter as soon as itis
no longer needed
Transducers Disposable or reusable
transducer at 96 Hours
intervals.
Peripheral catheter 96 hours / VIP Score is
in adults 2
Peripheral catheter if the dressing becomes damp, loosened, or
in children’s visibly soiled or at least every 7 days
(transparent
Dressing)
catheter site Every 2 Days
dressing (gauze
dressings)
Breathing circuits Change the circuit when it is visibly soiled or
with Humidifiers mechanically malfunctioning
Ventilator Change an HME that is in use on a As per Intensivist
breathing circuits patient when instructions
with HMEs it malfunctions mechanically or
becomes visibly soiled

67
WHAT IS CLEANING, DISINFECTION & STERLIZATION?
Cleaning is the removal of visible soil (e.g., organic, and inorganic material) from
objects and surfaces and normally is accomplished manually or mechanically using
water with detergents or enzymatic products. Thorough cleaning is essential before
high-level disinfection and sterilization because inorganic and organic materials that
remain on the surfaces of instruments interfere with the effectiveness of these
processes.

Decontamination removes pathogenic microorganisms from objects, so they are

safe to handle, u.se or discard.

Disinfection is a process where most microbes are removed from defined object or
surface, expect bacterial end spores.

What is a HAI and name type of HAI?

HAI is Hospital Acquired infection.
 Types: -
CLABSI- Central Line Associated Blood Stream Infection
CAUTI-Catheter Associated Urinary Tract Infection
VAE- Ventilator Associated Event
SSI- Surgical site infection

CLABSI- Central Line Associated Blood Stream Infection

o A laboratory confirmed bloodstream infection where BSI organism is identified
and an eligible central line is present on the Date of Event or the day before.
o Eligible Central Line: A CL that has been in place for more than two
consecutive calendar days (on or after CL day 3), following the first access
of the central line, in an inpatient location, during the current admission.

CLABSI- Care bundle

 Adherence to Hand Hygiene Guideline

 Chlorhexidine for Skin Antisepsis
 Remove Unnecessary Lines
 Use of Maximal Barrier Precautions
 Avoid femoral lines
 Insertion site covered with transparent dressing and checked daily for purulent
discharge I leakage / inflammation especially for central line
 Change dressing if soiled or more than 3 days
 Ports accessed using a clean technique

68
 CAUTI-Catheter Associated Urinary Tract Infection
A UTI where an indwelling urinary catheter (IUC) was in place for >2 calendar
days on the date of event, with day of device placement being Day 1, AND an
indwelling urinary catheter was in place on the date of event or the day before. If
an indwelling urinary catheter was in place for > 2 calendar days and then
removed, the date of event for the UTI must be the day of discontinuation or the
next day for the UTI to be catheter-associated.

CAUTI Care bundle

 Hand hygiene and Standard (or appropriate isolation) Precautions
 Insert catheters only for appropriate indications.
 Leave catheters in place only as long as needed.
 Ensure that only properly trained personnel insert and maintain Catheter.
 Insert catheters using aseptic technique and sterile Equipment’s.
 Following aseptic insertion, maintain a closed drainage.
 Maintain unobstructed urine flow.
 Confirm that urinary catheter bag has been emptied regularly as separate
procedures into a clean container.
 Use closed drainage system with sampling port.
 Obtain Sample after cleaning the port alcohol swab.

VAE- Ventilator Associated Event

VAEs are identified by using a combination of objective criteria: deterioration in
respiratory status after a period of stability or improvement on the ventilator,
evidence of infection or inflammation, and laboratory evidence of respiratory
infection. (The VAE definition algorithm is for use in surveillance; it is not a
clinical definition algorithm and is not intended for use in the clinical management
of patients.)

VAP care bundle

 Conduction of active Surveillance for VAP I Education/Training

 Adherence to hand hygiene guidelines
 Maintenance of patient in a semi recumbent position (30°-45°)
elevation of head end
 Dally assessments of readiness to wean and use of weaning protocols.
 Sedation Control/Interval
 Restricted blood transfusion
 Performance of regular oral care with antiseptic solution
 Removal of condensate from ventilator circuits and keeping circuits
closed during condensate removal IHME filters.
69
  Use of NIV whenever possible and minimization of duration of
ventilation
 Preferable use of or tracheal instead of nasotracheal intubation
 Avoid reintubation.
 Maintenance of an or tracheal cuff pressure of atleast20cmsof H20
 Change of the ventilator circuit only when visibly soiled or
malfunctioning and for each new patient
 Avoidance of gastric over distention
 AvoidanceofH2blockersandPPls
 Use of sterile water rinse reusable respiratory equipment’s
 Vaccines for appropriate infection
 Closed endotracheal suction.
 Subglottic secretion drainage Use of protocol bundles
 Adequate nursing staff
 Rotational beds

SSI- Surgical site infection

For an SSI, the date of event is the date when the first element used to meet the
SSI infection criteria occurs for the first time during the SSI surveillance period.
The date of event must fall within the SSI surveillance period to meet SSI criteria.
The type of SSI (superficial incisional, deep incisional, or organ/space) reported
should reflect the deepest tissue layer involved in the infection during the
surveillance period.
SSI care bundle

 Aseptic Technique
 Avoid d hair removal if hair removal is necessary surgical clippers to be
used.
 Pre-Operative chlorhexidine cleaning
 Antibiotic prophylaxis(30-60minutespriortoskinincision)
 Maintain Patient's body temperature, blood glucose level and
hemoglobin level normal throughout intra-operative and post-operative
period.
 Protect incision with sterile dressings for 24 to 48 hours post
operatively.

Educate the patient and family regarding following things.

 Regularly hand washing must be done. If there is any\problem to the

wound never touch it with soiled hands.
 Always do hand washing before touching the surgery area to avoid
infections.
70
  Dressing: Make sure surgical side dressing is clean and tidy. If advised
clean the wound with Dettol swab at home, while in hospital betadine
can be used.
 Monitor Blood glucose level strictly post operatively and educate patient
and relative about diet.

NAME THE TRANSMISSION BASED PRECAUTIONS?

Four categories of transmission-based precautions are followed at BMC.

▪ Contact Precautions
▪ Droplet Precaution
▪ Air-borne Isolation
▪ Protective isolation

HOW TO HANDLE SHARP INJURY?

For Skin: -
If the skin is broken after needle stick or sharp instrument immediately wash
the wound and surrounding skin with water.
Do not scrub.
Do not use antiseptics or skin washes (bleach, chlorine, alcohol, betadine).
Inform your supervisor or HOD about incident. / if not available directly to
HOD or supervisor will inform ICN or microbiologist

Prevention of Sharp Injury

• Avoid recapping needles.
• Before beginning any procedure using needles, plan for safe handling and proper
disposal.
• Help your employer select and evaluate devices with safety features.
• Use devices with safety features.
• Dispose of used needles in appropriate sharps disposal containers.
• Participate in blood borne pathogen training and follow recommended infection
prevention practices, including hepatitis B vaccination.

HOW TO HANDLE BLOOD AND BODY FLUID EXPOSURE?

 Stop procedure as soon as safely as possible
 Wash affected area with soap and water, if mucus membrane wash with
water for at least 15 minutes
After a splash of blood or body fluids: -
 To unbroken skin:
 Wash the area
 Do not use antiseptics
For the eye: -
 Irrigate exposed eye immediately with water or normal saline.
 Sit on a chair, Tilt head back and ask a colleague to gently pour water or
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 normal saline over the eye.
 If wearing contact lens, leave them in place while irrigating as they form a
barrier over the eye and will help protect it.
 Once the eye is cleaned, remove the contact lens and clean them in the
normal manner. This will make them safe to wear again.
 Do not use soap or disinfectant on the eye.
 For mouth: -
 Spit fluid out immediately
 Rinse the mouth thoroughly using water or saline and spit again. Repeat this process
several times
 Do not use soap or disinfectant in the mouth.

Dos AND Don’ts’ after Blood and body fluid exposure

DO’S DON’T’S
Remove gloves, if appropriate Do not panic
Wash the exposed site thoroughly Do not put the pricked finger in mouth
with running water
Irrigate with water or slain if eyes or Do not squeeze the wound to bleed it
mouth have been exposed
Wash the skin with soap and water Do not use bleach, chlorine, alcohol,
antiseptics on the wound.
Report incident to Consultant Microbiologist.
Risk assessment to be done by the Emergency Medical Officer/ Consultant
Microbiologist/ by the Medical Director
HANDLING SOILED LINEN
• Any linen soiled with body fluids of a patient is to be treated as contaminated and is
separated from the rest of the linen on the floors itself. At laundry, there is a special
procedure for cleaning and disinfecting of soiled linen before sending it back on the floors.

HANDLING CONTAMINATED FILES

• If any body fluid like blood is spilled onto the file that file is treated as contaminated, and
following is to be done.
• Place the file in an impervious black bag and label it as “contaminated file”.
• The nurse shall send the file to medical record department where it will be photocopied,
attested and that copy of the file shall be sent back to the ward.
• Write an incident report and submit to quality department.

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WHAT ARE THE VARIOUS BIOMEDICAL WASTE AND CATEGORIES?

73
CSSD (CENTRAL STERILIZATION AND SUPPLY DEPARTMENT)

RECEIVING OF UNSTERILIZED ITEMS: -

 Unsterile and soiled items from the OTs, wards & OPDs are transported to CSSD in closed
unsterile trolleys.
 The items are received and washed in the receiving zone.
 Each department is assigned with a separate log book. When instruments are brought
in they are duly signed and received.

RECALL POLICY FOR CSSD:

 In the event of sterilization failure, such as positive biological indicators/Failed Load

Controls or sterilizer malfunction, items from that test and previous loads after the last
known good test must immediately be recalled.
 All affected trays must be recalled in the event of failed quality management tests i.e.
Biological, Load Control
 A written Recall Procedure must be followed in the event of a sterilization failure
 The sterilization record sheets should be checked for a list of “sterilized” items that need to
be recalled.
 The recall procedure should be documented on the sterilization record sheets listing what
items have been retrieved and reprocessed and which items had already be used and on
whom. Note items that may have already been used on theist.
 As it becomes apparent that items need to be recalled reprocessing personnel will
immediately notify users and retrieve the supplies from storage and from user as soon as
possible.
 A recall is usually authorized by the most senior staff member on the shift.
 Other responsible persons i.e. Infection Control may be advised of the recall according to
hospital policy.
 Affected departments should be advised verbally as soon as possible, with a follow up
written confirmation advisory stipulating which items, trays from a particular batch are
suspect and should be returned.
 Departments should be requested to check their sterile stock as well as used stock for the
suspect batch.
 The following details will begiven:
o The name of the sets to be recalled
o The sterilizing date
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 o Details of the action to betaken
o Reasons for the recommended actions and any likely associated hazards
 Recalled items should be labelled ‘Under Quarantine’ whilst in transit to the cleaning area
of the reprocessing area where it will be reprocessed or be put into quarantine.
 All items retrieved from a Recall must be completely reprocessed.
o If test failed again the sterilizer must be shut down and all staff must be made
aware that it is out of operation. Complaint to be raised to biomedical department
for the correction.
 All items must be disassembled, processed with fresh linen, assembled, rewrapped
and sterilized.
 Once the sterilizer has been repaired all monitoring results must be checked before
the sterilizer is used.
 IR reporting to be done for root cause analysis.

ISSUE / RECEIVING TIMING AT CSSD

 Dirty items received from wards & OPDs during
following hours: 09 am to 10.30am(Morning)
04 pm to 05 pm (Evening)
 Sterile items are collected from CSSD during the
following hours 8am to 9.30 am (Morning
session)
4pm to 5pm (Evening session)
Moreover, items on emergency demand can be collected within two hours after giving to
CSSD for processing.

WHEN WE NEED TO SEND ITEMS FOR RE-STERILIZATION?

 The shelf life of sterile items is over as mentioned over the packed material
 If the sterile package is found damaged, torn, damp, soiled or rusty, it can
immediately be send for re- sterilization
 It either of indicators were found to be failed- chemical indicator outside & inside the
packed material.
 When biological indicator report was found negative.

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 HOW TO CHECK STERILIZATION EFFICIENCY?

S. No Types of Indicators Frequency Corrective action to take if test

used fails
1 Vacuum test Weekly Repeat- if passed no further action,
if fails
call the biomedical
2 Biological test Recall all items
Steam- Weekly
(Bacillus
stearothermop Per
hilus)
ETO- Bacillus atrophies Cycle
3 Bowie Dick test Daily Repeat- if passed no further action,
if fails
call the biomedical
4 Lot control indicator With each lot Repeat- after repacking all items;
if passed no further action, if fails
call biomedical
5 Double marking label On each Repeat- after repacking the
pouch/wrapper particular item; if passed no
pack further action, if fails call
biomedical
6 Steam integrator Inside each Repeat- after repacking the
wrapper pack particular item.
if passed no further action, if
fails call biomedical
7 Sterilization tape On each Repeat- after repacking the
wrapper pack particular item; if passed no
further action, if fails call.
biomedical
8 Inbuilt indicators On each pouch Repeat- after repacking the
(arrows/circles) on particular item.
pouches if passed no further action, if
fails call biomedical

What is SUD?
Single-use device (SUD) means a device that is intended for one use, or on a single patient
during a single procedure.

PROTOCOL FOR SUD?

 FDA divides reprocessed SUDs into three categories:
o Class III: a high-risk reprocessed SUD, intended to contact normally sterile tissue or
body spaces during use
o Class II: a medium-risk reprocessed SUD, intended to contact intact mucous
76
 membranes and not penetrate normally sterile areas of the body
o Class I: a low-risk reprocessed SUD, intended to make topical contact and not
penetrate intact skin.
 List of Reprocessed SUDs
o The List of the single use devises is being decided by the HIC committee in liaison with
the end user department taking into consideration the useful life of the device and its
continued functionality and integrity.

 *SUD is not re-used if the viral status of the patient is sero-positive, user is
responsible to discard the same on first use itself.
 Rejection Criteria of each Suds
o The time to withdraw/ reject the medical device is decided considering the useful life
of the devices and its continued functionality and integrity.
 When to discard
o If the number of usages equal to the number of reuses as per Policy, approved for that
particular device.
o Any kinks, curves leading to loss of functional integrity
o Blood clots not getting removed
o Loss of Lumen patency
o In case signals are not being received
o Any leaks
o In case smooth functioning is absent
o In case inflation is not taking place
o In case of breakage
o In case tip is blunted
o In case tip is broken
o In case sharp edge is blunted
 Marking/Identification
o CSSD is responsible for making the devices for the number of times the items has
been sterilized for re-use Marking is usually done by dot / line with permanent ink.
o Each single use items shall be checked for the number of cycles/ sterilization done
against the list as finalized by the individual department.
o The user department shall be responsible for discarding the items once the maximum
number of reuses permitted has been done.
o The items can be discarded prior to maximum permissible reuses if item is deemed unfit
for use by the user.
 Distribution:
• A record shall be maintained for all the reprocessed devices giving details about
their further distribution in dispatch register.

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 List of SUD: Submitted to respective departments Cath lab, ICU, OT & Daycare

What to inspect before using a sterilized set?

 On receiving a sterile reprocessed device, the sterilization, package integrity, useful
shelf-life and any damage should first be ascertained before use on a patient. One should
also ascertain that there is no moisture inside the pack.

CHEMICAL INDICATOR:
 Chemical indicator to be used for routine monitoring as the result is available
immediately. Indicator to be placed outside packs & inside packs for checking sterility
 Chemical indicator systems consist of a carrier and an ink impregnated on the carrier.
 As per EN ISO11140-1
o Class I : Process Indicators (External indicators)
o Class II: Specific Test Indicators (Bowie – Dick test pack)
o Class V: Biological Indicator
o Class VI: Emulating Indicator

Bowie Dick Test Pack:

 Bowie Dick Test pack used to detect air leaks and inadequate air removal. Test pack to
be used each day before the first cycle on vacuum type sterilizer. Pack to be placed
horizontally in the bottom rack over the drain. If sterilizer fails bowie dick test, do not
use the sterilizer until it is inspected by the sterilizer maintenance personnel and passed
the bowie dick test.

Biological indicators:
 A biological indicator (BI) is a spore forming bacteria and the only type of monitor that
provides direct evidence that sterilization process conditions are sufficient to kill spores.
 It contains 1 million spores of bacillus stearothermophilus, comes in self-contained
vial. After sterilization, spores to mix with growth medium and incubated at 55° for
24 to 48 hrs., a change in the colour of the growth medium or cloudy appearance
would indicate a failure.
 It uses microbes that are highly resistant to the type of sterilization process we are
monitoring.
 Biological indicators used weekly for Steam sterilizer, ETO and Plasma Sterilizer.

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 PSQ(Patient Safety & Quality)

Incident Reporting: -

 Adverse Event – an event that causes harm, or has potential to cause harm
to a patient. For the purposes of this Standard, an adverse event includes
sentinel events and near misses defined below.
 Near Miss: circumstances or events that had the capacity to cause an
adverse event, but which did not reach the patient.
 Sentinel Event – Any unanticipated adverse event in a healthcare setting
resulting in death or serious physical or psychological injury to a patient or
patients, not arising from the natural course of the patient's illness,
including: A patient fall that results in death or major permanent loss of
function as a direct result of the injuries sustained in the fall.

Incident report process flow:

 Person involved or person noticed the incident fills up the incident report
 It is recommended that incidents (other than Sentinel events) should be reported
within 24hours.
 Will forward it to the HOD for sign and comments.
 Incident reports should be signed by the HOD of the concerned department
before submission to quality department.
 The filled incident report to be dropped in incident report box.
 Quality team will collect all the incident reports and allocate a reference
number to the incident reports as IR Number: Organization of origin
KBH/IR / MM/YY
 Incident reports are categorized as follows
 Patient care related
 Medication error
 Behavioural (in coordination with HR)
 Safety and Security
 Infection Control
 Miscommunication
 Environment related
 Equipment related
 Needle Stick Injuries
 Sentinel event
 Adverse event

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  Near miss
 Others
An approach to IR is an immediate response, further investigation to establish
the root cause and Correction plans to prevent recurrence through education
and departmental coordination.
 Quality representative (QR) will coordinate with the staff concerned
and document their findings.
 Quality team in coordination with the staff involved as applicable initiates
analysis to identify the root cause.
 QR in coordination with the concerned department staff and respective
HODs/ directors plans out the corrective action.
 Corrective actions will include not limited to ensuring compliance of
existing policies, drafting and implementation of new policies, counselling.
 The incident report will be closed within 7 days and it should be to the
concerned stakeholders by email with the corrective action. This is done
within a period of seven working days starting from the date of collection
of IR. After the analysis the incident reports are identified as near miss or
adverse events as applicable.
 The affectivity of implementation of IR is reviewed periodically during audits
 The incident report is a confidential document and is stored in the quality
department.
The incident form is available on desktop of departments and can be used by all
staff.

Committees
Sr.No Name of the Committee Chairperson of the Frequency
Committee
1 Medical Advisory Board Dr Milind Vaishnav Quarterly

CORE COMMITTEES

2 Quality Assurance (NABH Steering) Dr S P Ekbote Quarterly

Committee
3 Infection control Committee Dr Bhagyashri Jadhav Bi Monthly

4 Pharmacotherapeutics Committee Dr Sameer Mahajan Quarterly

5 Safety Committee Dr Abhinav Zawar Bi monthly

6 Credentialing & Privileging Dr Milind Vaishnav Quarterly or as &

Committee when required

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7 Mortality Review Committee Dr Ajit Bhagwat Monthly

SUB COMIITTEES

8 Medical Ethics Committee (EOLC) Dr Vinod Gosavi As & when

required
9 CPR Committee Dr Geeta Ferwani Bi Monthly

10 Medical Record Audit Review Dr S P Ekbote Quarterly

Committee
11 Blood transfusion Dr Ajay Rotte Quarterly
Committee
12 OT Committee Dr Balaji Asegaonkar Bi monthly

13 Tumour board Committee Dr Rajesh Saoji Weekly

14 Antimicrobial Stewardship Committee merged with HICC Quarterly

15 Clinico Pathological Committee Dr Shobhana Ekbote Quarterly

16 Clinico Radiological Committee Dr Thomas George Quarterly

17 Dietary Committee Dr Ramesh Sharma Quarterly

18 Internal Complaints’ Committee Dr. Mrs. Shobhana Ekbote As & when

required
19 Brain Stem Death Committee Dr George Noel Fernandes As per requirement

20 Competent committee for Dr Milind Vaishnav As per requirement

Authorisation for organ transplant
21 Internal Ethics Committee Dr Mrs. Anjali Deshpande Quarterly or as &
when required

OTHER COMMITTEE

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22 Purchase Committee Dr Ajay Rotte Quarterly or As &
when required
23 Condemnation Committee Dr Ajay Rotte Quarterly or As &
when required

24 Pricing Committee Dr Ajay Rotte Quarterly or As &

when required
25 Digital Committee Dr Ajay Rotte Quarterly or As &
when required

26 KAIZEN Driving committee Dr Ajay Rotte Quarterly or As &

when required

27 Works Committee Mr Kiran Pande Quarterly or As &

when required

28 Hostel Committee Mr Kiran Pande 6 monthly

29 Laboratory Management Review Shri C P Tripathi Chairman 6 monthly

committee

30 Laboratory Advisory Committee Dr George Noel Fernandes 6 monthly

FMS (Facility Management &Safety)

When should cylinder pressure check be done?

Daily. To be returned to Engineering for refilling when pressure reaches 50.

What is the Color coding for medical gases which we are using in our hospital?
 Cylinders-
1. Black body with White shoulder -Oxygen
2. Blue- Nitrous Oxide
3. Black body with Grey shoulder -CO2
 Pipeline
1. Black and white / Grey colour -Compressed air
2. Yellow colour -Vacuum
3. White colour -Oxygen
4. Blue colour - Nitrous Oxide

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When user training on medical equipment is done?
This process is to ensure proper training to the end-users on equipment
operation and daily if applicable to maintain maximum level of user
compliance with equipment guidelines. Following are the key elements
associated with this process.

 After the installation of any new equipment in the hospital the company
engineer along with Biomedical Engineer demonstrates the equipment to the
user staff.
 A theoretical and practical training session is carried out explaining features,
 Operating sequences and precautionary measures.
 Hands on training is provided to the users.
 A copy of operating manual is kept with the respective department for ready
reference
 During regular usage if any clarification is needed should be provided.
Company engineers’ support in such regards can also be taken whenever
required.
 Time to time user feedback is also asked.
 A new joined staff will be trained on operations by Head of Department.
 Intermittently & as and when required the refreshment course will be conducted.

SPILL MANAGEMENT
What is MSDS? –

Material Safety Data Sheet –This sheet gives critical information on how to handle the
situation if exposed to hazardous chemicals like Disinfectant solution, Acids, solvents etc.
Every area has a list of hazardous materials.

Each floor has HAZMAT Kit & is displayed.

Content of HAZMAT KIT: Waste collection bag –Yellow, Paper Towel/tissue paper, Thin
Films, Surface Disinfectant, Micro pore tape, Empty plastic container, Syringe, Cotton mop
round, Floor wiper, Dustpan, Rubber hand gloves, rough duster bin, PPE (gloves, mask, cap,
shoe cover, gown, protective goggle)

How to handle a minor spill:

• Softly soak excess chemical/solvent with tissue paper

• Wash the affected area with water for at least 15 minutes.

• Call for medical attention if needed.

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 Major Chemical Spill (All other spills) - Procedure:

• Alert people in the immediate area to evacuate.

• If spilled material is flammable, turn off ignition and heat sources.

• Close doors to affected area.

• Notify the following about the spill:

Safety officer

Housekeeping services

Engineering services

• Keep people away from the spill

• Have people knowledgeable of incident and work area available to assist emergency
personnel.

• Write an incident report and submit to quality department.

A. BLOOD SPILL MANAGEMENT

• Block the area using caution board

• Wear Personal Protective Equipment’s (PPEs)

• Mark the area. Spread tissue paper over the spillage

• Pour 1% hypochlorite solution . Wait for 10-15 minutes

• Remove the tissue paper using scrapper to a yellow cover

• Clean the area again using 1% Hypochlorite solution

• Remove the PPEs to the same yellow cover, tie it, mark it as infected and sent to
housekeeping for safe disposal.

• Wash your hands

• Write an incident report and submit to quality department.

B. MERCURY SPILL MANAGEMENT

• Block the area

• Non ventilate the area by closing windows and switching off the fan
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• Remove jewels and wear PPEs

• Search for the mercury particle using a torch

• Bring all the particles to location using a hard board piece

• Aspirate the mercury using syringe and dispose to a half filled container

• Mark the container as mercury waste

• Use adhesive plaster to remove the remaining mercury particle

• Both container and plaster is to be disposed to a sealed bag and mark it as mercury waste.

• Remove PPEs and wash hands

• Write an incident report and submit to quality department.

C. CYTOTOXIC SPILL MANAGEMENT

• Do not touch the spills without wearing gloves.

• Open spill kit and wear two sets of gloves.

• Wear gown, goggles (mask if needed), pour zinc metal powder & cover the spillage with
towels.

• Wait for 5 to 10 minutes.

• Use Scoop and brush to pick any glass pieces.

• Wash the area with soap and then with disinfectant.

• Discard all waste items in Yellow Bin.

• Wash hands.

• Write an incident report and submit to quality department.

D. CHEMICAL SPILL MANAGEMENT

• Minor Chemical Spill –procedure

• Alert people in immediate area of spill

• Caution spill area

• Wear appropriate protective equipment, include safety goggles, gloves, and long –sleeve lab
coat.

• Avoid inhaling vapours from spills.

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 HR (Human Resource Management)

On date of Joining, what documents were given or submitted??

On the day of joining, HR makes following arrangement:

 The medical fitness pre – employment of the employee is done. The

staff is allowed to join only once he/she if found fit as per medical
officer.
 Certify all credentials with original and Collect all documents as per the Joining
requirement.
 Must sign joining report.
 The New employee shall be issued detailed appointment letter by the HR
department.

 Each Employee will be given a Job Description & it will be updated periodically.

 Process for ID card.

 Employee is introduced to the Head of the Department
 Any other assistance sought by the candidate and other HR formalities
 Followed by INDUCTIONTRAINING.

GROOMING POLICY
Guidelines for Employees having mandated uniforms:

• Wear your designated uniform and ID badge.

• Clean and trim nails give the confidence in good hygiene. Nail Paint
Is not recommended.
• Small earrings are recommended with other Jewelry, make up and perfume being
minimalistic.
• Hair should be clean and well-groomed and neatly tied up.
• Footwear: Neat and clean Socks and Black Shoes and for ladies Black Sandals.
• Personal grooming like shaving, proper haircuts and tucked in shirts.
for men.
Guidelines for Employees not having mandated uniforms:
• Professional dressing and sober colors are recommended.
• Please avoid Casual dressing like Jeans, T-shirts, multicolored clothes.
• Please avoid low back/neck/back patterns / sleeveless dressing

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 POLICY On terms of employment

Trainee Contractual
Appointment
(11 Months) (12 months)
Weekly off and 7 paid 21 days per year and 7
holidays paid holidays

Probation

(6 months)
CL 7 days & SL 8 days

Confirmation
CL 7 days & SL 8 days
EL 15 days (January)

ANNUAL APPRAISAL POLICY

• Appraisal forms filled by respective Appraisers/ Head of Departments.
• Employees are marked as Excellent, Good, Satisfactory and Poor based on their rating
related to Attitude, Behavior, Competence, Attendance, Multi-skilling, Teamwork, and
Initiative.
• The information is compiled by the HR Department and verified with the respective HOD’s.
• The Employees are informed about their assessment.
• The increment is done in two components. – Base Rise and Percentage rise. Base rise is a
fixed rise given to employees based on salary slabs.
• The Percentage based rise is given in four categories based on performance.
• For each of the employee categories (Attendants, Nurses, technicians, others) the average
increment is determined to arrive at fixed amount of increment for rating applicable to that
group.
• The Employees are given Increment Letters stating rating and total increment awarded.

LEAVE POLICY
• CL cannot be combined with any other type of leave.
• CL cannot be taken for more than 2 days at a time.
• SL of more than 2 days will be granted on evaluation of fitness certificate of qualified
medical practitioner.
• EL should be of 3 days or more and must be sanctioned minimum eight days prior.
• EL can be taken up to three times a year.

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 • Contract Leave is sanctioned on pro-rata basis.
• Maternity leave of 84 days can be availed by female employee having completed more than
two years in confirmed service.

POLICY ON LATE COMING

• Employees will be allowed to come late up to 05 minutes maximum for 3 times in a month.
• Remaining Late coming unto 5 mins will be deducted from payment.
• The employees will not earn any wages on the principle of “No Work No Wages” for the
period they are away from the place of work without any valid reason / prior permission of
their superior.

GATE PASS policy

• While leaving the premises for personal work, an employee shall fill-up the prescribed gate
pass and then approach dept. head for signature and then to HR dept. for approval, and also
it should enter in spine app in short time off feature.
• At the main gate, each employee will hand over the Gate Pass to Security Guard who will
mark out going time on Gate Pass and also on Gate Pass Register maintained at the gate for
the purpose.
• When such employee returns to the Hospital, he/she will inform the Security, while entering
through the main gate itself. Security will mark in coming time on his/her Gate Pass and
also in the register maintained for the said purpose.
• Security will collect all the Gate Passes and handover the same to HR Dept. on next day
morning at 10.00 a.m. along with Gate Pass Register.
• HR Dept. will verify the timings on the Gate Pass and Register and return the register to the
security. Gate pass will be retained by the HR Dept. for records.
• HR Dept. will do the scrutiny of timings recorded on the Gate Pass by the security and will
advise Time Office to deduct wages if outgoing time duration is more than one hour and Half
Day leave in case the out time is more than two hours.
• Maximum 2 gate passes of 1 Hr each are allowed in a month.

EMPLOYEE BENEFITS
• Salary Advance
Confirmed Employees are permitted to take salary advance amount three times in a year. It
is deducted in next salary. It is sanctioned only if take home salary is more than 60% of
Gross Salary.
• Festival Advance
Confirmed Employees can take festival advance of Rs. 5000 in a year. Rs. 500 will be
deducted from salary per month.
• Medical Benefits up to Rs. 3500
• Education Loan
It is provided for Professional courses only. It may be given to maximum two children and
only once for each child.
Maximum Rs. 20,000 may be sanctioned.
Monthly installment is of Rs. 1000.
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• First ten cases only will be approved.
• Ex- Gratia
8.33% of basic wages earned in the previous financial year as per eligible employees.
MEDICAL BENEFITS
ANNUAL HEALTH CHECK UP
• Every year annual health check-up of all employees shall be organized post Diwali.
• HR shall prepare list of employees eligible for the annual health check-up.
• All employees who have completed more than six months as on 1st November of the year
will be eligible for Annual Health checkup to be held in November – December each year.
• The policy is applicable to all categories of employees.
• The annual health check-up is categorized in 2 types of age group-(Above 40 & below 40).
• If the employee is found to be Medically Unfit during the Annual Health check-up, she/he is
required to complete the medical advice given by the Hospital Physician in the suggested
manner.
• All medical check-up records will be handed over to the employee and the fitness report
given by the Hospital Physician shall be attached in the personnel records.

IMMUNIZATION & POST PROPHYLAXIS

 Employees who are required to go through immunization and post prophylaxis will be
identified by the HIC Team.
 Employee will undergo test immunization as per the policy.
 Upon completion of immunization and availability of reports, the designated Medical
Practitioner will certify the completion of activity.
 The employee file is send back to HR and HR will file all reports in employee personal
file and update HIC Department on completion of Immunization.
Immunization

Hepatitis B virus Vaccination All Clinical staffs and Housekeeping and Food &
Beverages staffs

Typhoid Vaccination Food & Beverages staffs

TT (Tetanus Toxoid) All staff handling Bio medical waste (e.g., nurses
and Housekeeping Staff) if not taken in last 10 years.

COVID Vaccine All staff

Post Exposure Prophylaxis

Against HIV: Three drug PEP (e.g. For staffs after significant exposure

Duovir + Lopimune)

Against HBV: Hepatitis B immune globulin For non-immune staffs after significant exposure

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 Follow-up After Sharps Injury or Splash Exposure

Follow-up after sharps/splash exposure (HIV For all staffs after significant exposure
Ag/Ab+ HBsAg +HCV Ab/HCV- PCR)- baseline,
3 month and 6 months

STAFF GRIEVANCE POLICY: -

Grievance Defined
• A grievance as a complaint of one or more workers with respect to wages and allowances,
conditions of work and interpretation of service, condition covering such areas as overtime,
leave, transfer, promotion, seniority, job assignment and termination of service.
Features of Grievances
• Discontent or Dissatisfaction
• Dissatisfaction must arise out of employment & not due to personal reasons.
• The discontentment can arise out of real or imaginary reasons.
• The discontent may be voiced or unvoiced, but it must expression in some form.
• Broadly speaking a grievance is noticeable & traceable to real or
• perceived non-fulfillment of one’s expectations.
BENEFITS OF GRIEVANCE HANDLING PROCEDURES
• It encourages employees to raise concerns without fear of reprisal.
• It provides a fair & speedy means of dealing of grievances.
• It prevents minor disagreements developing into more serious
Disputes.
• It saves employer’s time & money as solutions are found for workplace problems.
• It helps build in organizational climate based on openness and trust.
GRIEVANCE PROCEDURE

• Approach HOD with grievance.

1 • HOD will resolve in 3 days time.

• If not satisfied approach HR Manager

2 • HR will resolve in 1 week’s time

• If not satisfied, employee can approach COO

3
• If still not satisfied matter will be put forward to
4 Chairman, Management Committee for final decision

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ICC POLICY

Sexual Harassment includes:

– Physical contact and advances.
– Demand or request for sexual favors.
– Making sexually colored remarks.
– Showing pornography.
– Circulation or publication of any form of physical or electronic form of photographs,
pictures, or any form of graphical material of an employee, either directly or
indirectly, so as to create disrepute.
– Implied or explicit promise of preferential treatment.
– Implied or explicit threat of detrimental treatment.
– Implied or explicit threat of present / future employment status.
– Interference with work or creating hostile work environment.
– Humiliating treatment related to health/safety.
– Any other unwelcome physical, verbal, or non-verbal conduct of sexual nature.
INTERNAL COMPLAINT Committee
– Chairperson: Dr. Mrs. Shobhana S. Ekbote
– Member: Mr. Prashant Patwari
– Member: Mr. Kiran Pande
– Member: Mr. Pravin Kangle
– Member: Dr. Swati Thorat
– Member: Ms. Shilpa Soni
– External Member: Ms. Anita Deshmukh
EMPLOYEE RIGHTS &RESPONSIBILITES: -
Employee Rights
 Not to be unfairly discriminated
 Equal opportunity in the workplace
 Working environment which is free of threats.
 Treated with dignity and respect.
 Free to voice complaints, grievances, and concerns.
 Easy access to regulation, codes, circulars, policies, and procedures
 Safe working environment work as per the shift timing.
Employee Responsibilities
• Work as per the shift timing
• Responsible for equipment, uniforms, files etc.
• Shall maintain confidentiality about organization.
• Shall take necessary precaution to safeguard hospital property.
• Should be courteous to superiors, fellow colleagues, patients, and their visitors.
• Shall behave with honesty, integrity, and loyalty.
• Shall not reveal to the media (press, tv, radio etc.) Regarding hospital without
prior written approval from Managing Director.
• Shall always be neat and tidy; wear clean clothes or uniform while on work in the
hospital.

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 IMS(Information Management System)

RULES FOR ENTRY IN PATIENT RECORDS:-

 Healthcare providers responsible for the care of the patient identify themselves in
the “Signature sheet” with name, designation, signature, initial and stamp before
making any entries in the patient record.
 Each entry in the medical record shall have date & time with initial / signature of the
author (wherever applicable). Time may be in the form of 12 or 24 hour clock and
the date should be in date/month/year format. All entries should be documented
immediately but no later than one hour of completion of the assessment/procedure.
For electronic records, e signature issued.
 All the entries in the patient file must be written legibly. No water soluble ink to be
used to make entries in the patient clinical record.

HOW TO MAKE CHANGES / CORRECTIONS OR OTHER MODIFICATIONS IN THE

MEDICAL RECORD?
Whenever a correction has to be made the previous error has to be struck off with a
single line and mentioned as “error” and signed with date, time. The use of correctors
is not permissible such as (white ink) or any form of erasable pens.

WHAT IF THE RECORDS ARE LOST/ DAMAGED PERMANENTLY?

 If and when a medical record is non retrievable (Lost or permanently damaged),
the physical file is remade with available data such as encounter summary and
lab reports. The concerned clinicians are also informed of the same and incident
report is generated and root cause has to be done.

WHAT IF THE RECORDS ARE SOILED WITH BLOOD OR BODY FLUID?

 When medical records are soiled with blood or body fluid, a copy of it is obtained,
filed and the contaminated documents are discarded as medical waste.
 However, if these documents are of medico legal significance (e.g., consent forms
patient education forms or documents requiring patient signature), then, a copy
of the original document is made and the soiled document (original) is placed
in a bio-waste bag and this bag is filed in the medical record.

 All files where the documents have to be replaced for above reasons will be done
only with written approval of administrative head/medical director.
WHAT TO DO WHEN TAMPERING OF RECORDS IS NOTICED?
Whenever any staff realizes or notices a tampering in the medical record the
matter should be immediately escalated to the concerned staff whose
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 records have been tampered, to the treating/primary consultant and MD and
an IR for the INCIDENT should also be generated.

RETENTION OF FILES:

Medical records department is responsible for the retention of patient

Physical health records, data and information and Information
technology departments is responsible for retention of patient
electronic records including the investigation reports of lab and
radiology.
TheHospitalshallretainthefollowingrecordsintheoriginalformforthe
period specified:

No. Record Name Retention period

1. In Patient files 3 years

OPD records (OPD registers and

2. Duplicate 5years

OPD record if any)

30 years or till the disposal of
3. Medico Legal Case Sheets and ongoing cases in any of the courts
Registers
related to these.
records
Samples / belongings of Medico
4. Legal Cases 3 months from the date of collection

(Ex: Body fluids, clothes etc.)

WHO HAVE RIGHT TO ACCESS THE RECORDS?

Information in the medical record shall be accessible only to following as per law.
1. To the healthcare provider who are directly involved in provision of care to the
patient
2. To the patient
3. To the third party payer LIC, Insurance companies, TPAs , court of law.
4. To any other person only after valid consent from the patient
(Husband/Wife/Son), with submission of self- attested identity
based on Government documentary evidence. Such document is to be
kept with charts.
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WHAT IS THE PROTOCOL TO ACCESS THE PATIENT RECORDS?
Following protocols shall be followed in case of request for access
to information in medical record.
1 Request from treating staff

1. Information/medical records will be provided to the concerned clinical

care provider for the continuity of care of the patient.
2. If treating faculty or administrative staff requests for information in
medical record other than patient continuity of care, it will be provided
through approved request though M.D.
2 Request from patient

1. Patient has to be provided with his/her medical record information if he sought for it
2. If the patient requests for a copy of the medical records he/she shall
be provided the same (indoor case papers) after collecting charges (if
applicable) as per Hospital Policy within 72hours.
3. Check the identification detail of the patient and cross check with medical
record entry, before permitting the access.
4. Release of Information

3. Request from TPA / Insurance

1.Proper application or letter should be submitted to hospital to access record
2.Access shall be given only for specific and identified queries related to medical
treatment
3.Insurance shall check the identification details of the person requesting
the access on account of TPA organization.
4.TPA personnel can access the medical record only in presence of MRD staff
5.If they seek a copy of a specific test result, it shall be provided & acknowledgment
should be taken on application or request letter.
4. Request from Government organization
1. They shall be allowed to access only for specified purpose as stated by state
authorities
2. Access shall be provided in presence of MRD staff
3. Check a written evidence of permission from state authorities regarding
access, which should specify the purpose for access
4. Keep a note of this access in medical record

WHAT ARE THE CONTENTS OF MEDICAL RECORD FILE?

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Documents Documents

Admission Form Transfer Form

Provisional Gate pass Admission In ICU

Final Bill Copy In Patient Transfer Summary (Pink)

Discharge Slip Physician order sheet

Discharge Summary, DAMA Summary ICU Daily Notes

Death Summary

Medical Certificate of Cause Death Continuation Sheet

OPD Paper Consent for Surgery &anaesthesia

Temperature Chart High Risk Consent

Investigation Chart Pre-Operative Checklist

Blood Sugar Chart Pre-Anaesthesia Check-up

Consultant referral form Patient Declaration Form

IPD Initial Assessment form Operation notes

Paediatric Admission Assessment Anesthesianotes

Neonatal Admission Assessment Time out safe surgery Checklist

Emergency initial Assessment sheet Recovery Room Monitoring

Trauma/Medico-Legal Case Sheet Procedure Notes

Daily Patient Record Blood Consent

Daily Prescription Blood-Pre Administration Bedside

Checklist

Blood Monitoring Form Patient/Family Counselling form

Consent for Angiography, Angioplasty Fluid balance Chart

Pre-Angiography Data Nurse’s Initial Assessment

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 Post Cardiac Catheterization Orders Nurse’s Daily Assessment

PTCA Procedure Notes Nurses Notes

Post-PTCA Form Time taken for Initial Assessment to

Admission of Emergency Patient

Angiography /PTCA Note /Transfer Restraint Form

summary

Chemo, Restain,DAMA, Discharge on Care Bundle Check list

request

Consent for STK Lab Reports

administration,Haemodialysis,Critically
ILL Patient

General Consent for Admission Radiology Reports

Nutritional Assessment Handover-ISBAR Tool Kit

Physiotherapy Assessment Critical Care Flow Sheet

Hospital Acquired Infection Form

What is the time frame within which a medical record of discharge patient
should reach Medical Record Department?

Within 24 hours of patient discharge

HOW MRD WILL DESTRUCT THE FILES?

 Destruction can be done after the retention period is over and after taking
approval of the concerned authority(internal/external).
 Prior to the initiation of this a list of to be destroyed files sent to the administration
and patients are notified in coordination between administration and IT. However
the electronic components of the physical files will not be destroyed.
 The sole responsibility for the destruction of all physical health records lies with the
medical records department and electronic records with the IT department.
 In order to ensure the patient's right of confidentiality, physical health records are
destroyed or disposed of by shredding.

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 KEY POINTS

How many Types of Patient Identity Bands are available for Patient Identification?
White : All other patients
Orange : Vulnerable patients
Pink : Allergic patients

When is discharge planning initiated? –

At the time of admission along with Plan of care

SMOKING CONTROL POLICY

Smoking and alcohol consumption by staff, patients and visitors in the facility is not allowed
within the hospital premises.

Name few radiation safety devices monitoring and protection?

TLD badges, Lead aprons, Thyroid Shield, Gonad Shield, Lead goggles

PASystem number : 808

Notifiable diseases Inform to ICN, Which is sent further to the public health Department

Do Not Resuscitate: We do not follow DNR as it is against Indian Laws.

• The hospital does not allow any kind of self-medication by the patients except Insulin.

• Open vials have to be labeled for its date of opening and date of discard and signed with
name.

• Triage performed on Daily practice & in disaster.

• In External disaster (above 10 patients at a time) Casualty Triage shall be immediately

established in the ENTRANCE PORCH and all the designated beds and supplies shall be
moved to the area.

• In case there is a fire in the Emergency Area, Emergency Triage shall be set up in patient
waiting area outside Casualty. The area shall be closed to public immediately.

• The hospital has set up a command center for handling External & Internal Disasters. In the
disaster conditions all the instructions will be passed from this command center, under the
leadership of CEO.

• Drugs is stored between 2 to 8 degrees centigrade and others as per the Manufacturer’s
instructions.

• Barrier nursing: Type of nursing for immune compromised patients with a view to prevent
any secondary infections e.g., use of gloves, masks, and relatively disinfected environment.

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 ASSESSMENT SCALE:

1. IV maintenance- Thrombophlebitis VIP

2. Pressure Ulcers - Braden’s Scale

3. Pain Assessment -Wong-baker scale

4. Neurological Assessment –GCS (Glasgow Coma Scale)

5. Fall Assessment- Morse scale.

6. DVT prevention- AUTAR DVT scale

KEY ASPECTS OF PATIENT TRANSPORTATION:

Wheel of stretchers, wheelchairs, scales, and beds are locked when a patient is lifted from or
assisted onto them. Side rails are raised on stretchers when the patient is been transported.
Where no side rails exist, safety belts are fastened. Patient must be accompanied by nurse /
doctor for critically ill patient.

BLANKET ORDERS: Medication orders such as “continue medications from home” or “continue
medications as previously ordered” are not acceptable. In the event that the physician writes such
orders, the nurse must call the prescribing physician and obtain written orders for each individual
medication ordered.

TIME FRAMES

• Incidents & Medication errors are to be reported within 24 hours to Quality Department.

• 3 months prior to expiry will be considered as near expiry.

• Verbal order form to be signed by consultant within 24 hours.

• Defibrillator, oxygen cylinders & Refrigerators medications are checked every day.

• Crash cart is checked monthly and as and when used. After usage of emergency Medicines
from crash cart, same should be replaced immediately.

• Compliance of Stat orders to be done immediately.

• Hand rub – 20 – 30 seconds (As per WHO guidelines)

• Hand wash – 40 – 60 Seconds (As per WHO guidelines)

• IV set to be changed every 72 hours for IV fluids. (3days)

• IV set to be changed every 24 hours for Antibiotics. (1day)

• IV canula to be changed every 72 hours. (3days)

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 • Initial medical, Nutritional & functional assessments to be completed within 24 hours of
patient’s admission, Nursing assessments to be completed within 2 hours of patient’s
admission.
• Critical values to be communicated within 30 minutes.
• Most of the consents are valid for single day.
• Fall risk score & Braden scale assessment at least once every day.

• Pre anesthetic check completed before surgery.

• Restraints orders every 24 hours.

• Shelf Life of ETO sets are of 6 months& autoclave sets packed in SMM sheet is of 3 months
and linen wrap is of 48 hrs.

• Foleys Latex Catheter to be changed every 8 days and silicon catheter to be changed every
28 days.

CELEBRATIONS

• Annual Day of the Hospital – On 19th March

• Doctors Day – On 1st July

• Nurses Day – On 12th May

OVERALLSERVICE PROVIDERS (HELP DESK FOR PATIENT/RELATIVES)

• Patient Experience coordinator

• 24X7 availability

• VIP Management

• Handling Complaints / Resolve Issues

• Coordinates for matters if any

• Support to other functions

• Managing patient feedback and suggestion

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