What is CBAHI?

Central Board of Accreditation for Healthcare Institution.

What is Accreditation?

Accreditation is a self assessment and external peer review process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the health care system.

What are the objectives of Accreditation? Why we need to be accredited?

To ensure the quality of healthcare through the application of quality concepts.

To foster a culture of patient safety and minimize the risks of medical errors.

To achieve optimum organizational results with the available resources.

What is the Vision of WDGH? To be the best healthcare provider in our region.

What is the Mission of WDGH?

To achieve the quality requirements of (CBAHI) to assure a safe and high quality healthcare.

What are the values of WDGH?

- Patient care is honor for us.

- Team work is our feature.

- Respect of patients and their rights.

- Continuous improvement of performance and

total quality achievement.

- Continuous medical education to improve the

quality of hospital staff.

- Adherence to religious ethics of our Islam.

What is the Performance Improvement Approach Or FOCUS – PDCA?

F – Find a process to improve.

O – Organize the team that knows the process.

C – Clarify current knowledge of the process.

U – Understand causes of process variation.

S – Select the process improvement.

P – Plan the improvement and continue data collection.

D – Do the improvement, data collection, and analysis.

C – Check the results and lesson learned from the team effort.

A – Act to hold the gain and to continue to improve the process.

What are the patient/family rights?

1. Right to get equal treatment regardless of age, gender, religion, race and disability at all times.

2. Right to be informed prior to obtaining consent in all the procedure and treatment to be performed.

3. Right to information.

To know the identity and professional status of all individual providing service to him/her.

To know which physician is primarily responsible for his/her care.

4. Right to privacy and confidentiality.

Have his/her medical record read only by individual directly involved in his/her care.

Not to discuss patient information in public.

Not to post patient information in view.

Not to be physically exposed when not necessary for tr

5. Right to personal safety, security and protection.

6. Right to refuse participation in any medical research.

7. Right to be provided with proper means to contact his family.

8. Right to obtain continuous care and referral to different treatment levels.

9. Right to be provided with interpreters to communicate if necessary.

10. Right to be transferred to another room if another patient or visitor is unreasonably disturbing.

What is Informed Consent?

A consent whereby the attending physician or designee provides information to the patient/ legal guardian about specialize procedure which include:

The patient condition

The proposed treatment

The potential benefits and drawbacks

Possible problems related to recovery

Possible results of non treatment.

What do you understand by patient confidentiality?

Not allowing unauthorized person to have access to patient’s medical record.

Not discussing patient information in public.

Not posting patient information in views.

When do you obtain General Consent?

Upon admission and for all diagnostic procedures.

What are Verbal/Telephone orders?

Verbal orders – are orders from a licensed practitioner, within the practitioner’s scope of practice and hospital privileges directly given ”verbal” to another practitioner whose scope of practice includes the authorization to receive and document such orders.

Telephone orders – are orders from a licensed practitioner, within the practitioner’s scope of practice and hospital privileges, given “over the telephone” to another practitioner whose scope of practice includes the authorization to receive and document such orders.

How long after a Verbal/Telephone orders should a Doctor sign the order?

Doctor must sign the “verbal orders” before leaving the area.

Doctor must sign “telephone orders” within 24 hours.

What will you do if a Doctor gave a telephone order?

“WDRB”

W – Write

D – Down

R – Read

B –Back

- The receiving nurse will document the order to be carried out in the physician’s order sheet, and then read the written order back to the ordering.

What is an OCCURRENCE?

What is an Incident Report/Occurrence Variance Report

An internal form used to document the details of the occurrence/ event and the investigation of an occurrence and the corrective action taken.

Who is the responsible person to report an Occurrence or incident?

The Employee who witness or discover an occurrence has the professional obligations and responsibility for:

1. Immediately notifying:

The physician on call if the occurrence involves any question of patient or employee injury or harm.

The Nursing Supervisor on duty.

2. Initiating the completion of OVR form before the end of the occurrence shift.

3. Submitting the original of the OVR form to the supervisor on duty.

What do you understand by near miss?

An event or a situation that could have resulted in an accident, injury or illness, but did not either by chance or timely intervention.

What are the different CODES of WDGH?

Code Red – FIRE

Code Blue – Adult CPR

Code Green – Pediatric CPR

Code Yellow – External Disaster

Code Orange – Hazardous Materials

Code White – Bomb Threat

Code Pink – Infant//Child Abduction

Mr. Strong – Agitated or Aggressive Person

What will you do before you turn off the oxygen in the ward during the Fire?

Transfer the patient to portable oxygen.

Mobilize the patient to safe area (follow the RACE procedure, move patient horizontally, if smoke or flame blocks your way proceed vertically).

Evacuate ambulatory patient first.

Stay calm.

What will you do in case of “Child Abduction” in your ward/unit?

Conduct a brief search of the unit and inform the Charge Nurse/Head nurse.

Activate “Code Pink” Dial – 0 (Central Paging System) or 1111.

State your name, ward room and bed number.

If the time permits before calling the code, the charge/head nurse and/or supervisor calls each of the other unit to notify them of the “Code Pink in progress.”

What is the evidence of checking the crash

cart in the ward/unit?

The crash cart checklist which is evident with legible signature of the charge/staff nurse every shift.

The quantity of the crash cart drugs floor stock varies from each unit/ward depending on the bed capacity and needs of the unit with list provided by the Pharmacist.

What are the International Patient Safety Goals?

1. Identify patient correctly(use 2 identifiers)

When giving medications, blood and blood products

When collecting and sending specimen for clinical testing

When performing any treatment or procedure

2. Improve effective communication

Implement correct procedure for taking verbal/telephone orders, date/time and signature

Give concise hand off communications (clear, legible handwriting with date/time and signature for each entry of nurse’s documentation)

Be familiar with the “do not use” abbreviations.

Document referrals for altered lab results with date/time of notification and reason if no action.

3. Improve the safety of high alert medication.

Hepatitis Screening for Employees:

screening prior to the application of residency identification (Iqama)

Senior nurses had screening for hepatitis virus

In the event of accidental exposure of the staff, OVR form shall be accomplished and referred to employee clinic for treatment and management.

Hand washing Technique (40-60 seconds)

1. Remove all jewelries

2. Roll the sleeves

3. Wet hands with water

4. Apply enough soap to cover all hand surfaces

5. Rub hands from palm to palm

6. Right palm over the left dorsum with interlaced fingers and vice versa

7. Palm to palm with fingers interlaced

8. Back of fingers to opposing palms with fingers interlocked

9. Rotational rubbing of left thumb clasped in right palm and vice versa

10. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

11. Rinse hands with water

12 Dry hands thoroughly with a single use towel

13. Use towel to turn off the faucet

When? 5 moments of Hand Hygiene

Before patient contact.

Before aseptic task.

After body fluid exposure risks.

After patient contact.

After contact with patient surrounding.

Nursing Process will be implemented to:

Provide direction and continuity of care by facilitating communication through documentation among nurses and other discipline in the health care setting.

Provide guidelines for accurate documentation and evaluate the delivery of patient care.

What are the patient’s care plan upon admission and OPD follow up:

Nursing Process Care Plan

Medication Reconciliation and Hands Off communication

Patient/significant others health education

24 hours discharge plan

What is Medication Reconciliation?

The process where the current medications are reviewed and compared to any new medication being ordered to prevent medication errors that could have a harmful effect on the patient.

What is the Nursing Operational Plan

Measurement of staff competencies level based on knowledge, skills, and aptitude.

Conduct monthly supervisors/head nurse’s meeting with the Nursing Director

Nursing process implementation to all the units of the organization.

Nurse’s Case Presentation 2x a month

Nursing Procedural Demonstration

Mandatory BLS course

Orientation Program for new staff nurse

What is the Performance Improvement Approach Or FOCUS – PDCA?

F – Find a process to improve.

O – Organize the team that knows the process.

C – Clarify current knowledge of the process.

U – Understand causes of process variation.

S – Select the process improvement.

P – Plan the improvement and continue data collection.

D – Do the improvement, data collection, and analysis.

C – Check the results and lesson learned from the team effort.

A – Act to hold the gain and to continue to improve the process.

What do you understand by Patient’s rights?

These are ethical legal principles/privileges in which patients are entitled.

What are the patient/family rights?

1. Right to get equal treatment regardless of age, gender, religion, race and disability at all times.

2. Right to be informed prior to obtaining consent in all the procedure and treatment to be performed.

3. Right to information.

To know the identity and professional status of all individual providing service to him/her.

To know which physician is primarily responsible for his/her care.

4. Right to privacy and confidentiality.

Have his/her medical record read only by individual directly involved in his/her care.

Not to discuss patient information in public.

Not to post patient information in view.

practitioner in the presence of the charge nurse or another nurse who will verbally confirm that the “read back order” is correct.

-Telephone orders will be accepted in situations that require actions that will facilitate care of the patient.

What would you do if a Doctor prescribes the wrong dose of medication?

Hold the medication and inform the physician/prescriber.

How will you transcribe a Physicians’ order?

A clear specific physician’s order is transcribed to the patient’s Kardex and medication sheet by the RN with legible name and signature, date and time, verified parallel to the order.

The nurse who prepares the medication is responsible of administering the drug evident with the legible signature immediately after the procedure observing the seven rules of medication administration.

What are the 10 Rights/Rules of Medication Administration to minimize the risk of medication error?

Right patient

Right drug

Right dose

Right frequency

Right route

Right time

Right documentation

Right to know the action and reaction of the drug

Right to refuse

Right to privacy

What is sentinel event?

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, not related to the course of patient’s illness or underlying condition.

What are the types of sentinel event?

Homicide

Surgery on the wrong patient or body part

Impairment ( major/permanent loss of bodily function)

Any unexpected death that is not the result of the patient’s underlying condition

Rape

Child Abduction or discharge to the wrong family

Significant Hemolytic Blood Transfusion

Suicidal Attempt

Significant Medication Error (overdose causing death).

What are other reportable occurrences?

Medication Error

Patient fall

Wrong procedure

Needle stick injury

What is Root Cause Analysis?

It is an in-depth investigation; a process for identifying the basic causal factors of an adverse event and analyze them.

Collecting, analyzing, integrating evidences and establish causes, make recommendations and drawing conclusions.

Guidelines for preventing “Falls and Fall related Injuries”?

C – Create a safe environment

A– Assess a patient’s risks

R- Reduce a patient’s risks

E – Evaluate interventions

How to activate CODE BLUE?

Dial – 0- (Central Paging system) or 1111

State nurse name, ward/unit, room and bed number of the coded patient.

Who are the members of the Code Blue Team?

Anesthesiologist on call

Anesthesia technician on duty/call

Medical Specialist on call

Medical resident on duty

Nursing Supervisor on duty

Charge Nurse/Head nurse on duty

Staff nurse in the unit

Pediatric specialist

Pediatric resident

What do you understand by External Disaster?

Emergency situation/events that occur in the community, when there is a disproportionate amount of hospital staff to care for the incoming emergency room patients or victims.

What do you understand by Internal Disaster?

Any situation within the hospital premises that may jeopardize patient and staff safety and security.

An event of fire, explosion or similar incident which necessitates the evaluation of patient to relocate them in safe area.

crash cart (potassium chloride)

Identify look alike/sound alike drugs and avoid mix up.

Label all meds, containers, and solutions on and off sterile areas

Do not draw up, transfer more than one med/solution at a time.

4. Ensure correct site, correct procedure, correct patient-surgery.

Marking the surgical site

Verification process prior to patient moving to procedural areas

Correct patient ,site, procedure, required document, functional equipment/device

A Time Out conducted prior to procedure when all activities are suspended interactive communication among other team members for verification

5. Reduce the risk of Health care Acquired Infection (HAI).

Comply with Hand Hygiene.

Implement practices to prevent MDR organism infections

Practice to prevent central-line associated blood stream infections.

Practices to prevent surgical site infections

6. Reduce the risk of harm from falls.

Education of patient and relative to fall prevention

Reassess fall risk daily

Use bed alarm/side rails as needed.

Where will you dispose sharps/needle?

Yellow thick bucket with cover to be changed when ¾ full.

What do you understand by Standard Precaution?

A procedure where in concerned staff or significant others must wear appropriate personal protective equipment to prevent the transmission of blood borne pathogens or any other body substance except sweat.

How do you manage “chemical spill” on the floor? (less than 50 ml)

Put on double latex gloves, gown and face shield

Confine and contain spill, cover with appropriate absorbent material, acid and base spills should be neutralized prior to clean up.

Use only one hand to directly clean spill and exposed surface.

Wipe area with alcohol dampened non-sterile 4x4 gauze and dispose gauze to red bag

Allow area to dry for 15 minutes.

How do you manage “infectious spill” on the floor?

Wear appropriate PPE

Cover the spills completely with paper towels

Gently pour chlorox 5.25% (1:10 dilution) over the towel from the outer to the center

Wait for 10 minutes, then remove the disinfectant paper towels.

What are the different color bins used in hospital?

RED – human body parts

YELLOW – infectious/hazardous med. waste

BLACK – ordinary waste

Lectures on Policies and Procedures 2-3x a week

How are the nurses oriented on the use of medical equipment?

Orientation is conducted by the charge/head nurse

The functional status will be used prior to use

In case of malfunction the Biomedical Department will be informed.

The machine will be segregated and properly labeled.

The Biomedical request form is filed as an evidence in the unit.

What is the evidence of the staff implementation on the internal transfer policy or transfer within the facility?

The availability of transfer notes, and re-order of the patient transfer and care plan upon receipt is evident with signature of both endorser and receiver.

The time the receiver signs the acceptance/transfer sheet will start the full responsibility of the patient.

What are some of the general safety procedure?

Asking for help if realistically you can’t lift or move a patient or an object.

Putting the bed and wheelchair in a locked position if not transporting a patient.

Putting the stethoscope in the pocket of uniform instead of putting around the neck.

Use flat shoes with non-skid sole.

Use of side rails.

Locked bed/trolley/wheelchair unless during transport.

Not to be physically exposed when not necessary for treatment.

5. Right to personal safety, security and protection.

6. Right to refuse participation in any medical research.

7. Right to be provided with proper means to contact his family.

8. Right to obtain continuous care and referral to different treatment levels.

9. Right to be provided with interpreters to communicate if necessary.

10. Right to be transferred to another room if another patient or visitor is unreasonably disturbing.

What is Informed Consent?

A consent whereby the attending physician or designee provides information to the patient/ legal guardian about specialize procedure which include:

The patient condition

The proposed treatment

The potential benefits and drawbacks

Possible problems related to recovery

Possible results of non treatment

What do you understand by patient confidentiality?

Not allowing unauthorized person to have access to patient’s medical record.

Not discussing patient information in public.

Not posting patient information in views.

What are the two (2) Patient Identifiers?

Patient three names

Medical Record Number

How are patients selected for admission to ICU?

According to the severity and complexity of care, assessment and recommendation of the admitting consultant.

What is Discharge Against Medical Advice?

It is the patient’s own desire to go home holding his/her responsible and the hospital has no legal responsibilities.

What do you understand by Discharge Planning?

It is an interdisciplinary, systematic process which aids patients and families to develop a plan of care after hospitalization and a plan of care 24 hours before physical discharge.

It involves the medical instructions that the patient will need to fully recover.

What precautions will you observe before starting blood transfusion?

Check the patient’s identifiers (three names and medical record number), ID band, prescribed blood product, number of unit, blood type and cross-matching, blood tag number, expiration date, ward/unit.

Check together with charge nurse or another RN before administration.

Verify signed consent for blood/blood product if present in patient’s file.

What are the 3 basic elements of Fire?

heat

fuel

oxygen

Enumerate the types of Fire:

Type A – combustible materials

Type B – flammable liquids oil and grease

Type C – involves electricity

Type D – K for kitchen

What do you understand by “RACE”?

R – Rescue the nearest patient in the disaster area

A – Activate the nearest fire alarm

C - Confine the fire

E – Extinguish

What do you understand by “PASS”?

P – Pull the pin

A – Aim the hose at the base of the fire

S – Squeeze the lever

S – Sweep the hose from side to side

How do you call for help during a Fire?

Activate the fire alarm.

Dial- 0- Central Paging System or 1111

State your name, ward, room, or bed number of the disaster area.

Who has the ultimate responsibility for calling “Code Yellow”?

The Hospital Director or his deputy during working hours

or

The Director-On-Duty after normal working hours.

Who is responsible for checking the crash cart and replace items used every after code and for expiring equipment?

Charge nurse/Head nurse

Procedure of sterilization of Laryngoscope blades and ambu bag?

Laryngoscope blades should be soaked in the prescribed disinfectant every after use. Make sure that no residues sticks on each equipment, use brush if indicated.

Rinse properly with running water after soaking from disinfectant.

Dry and wrap with sterile gauze, then attach to the handle of the laryngoscope.

The handle must be wiped with 70% alcohol.

Ambu bag must be dismantled every after use for disinfection, properly rinse,dry,reassemble and cover with CSSD paper including face mask .

Who is responsible in keeping the narcotic key?

The Charge Nurse on duty every shift.

What is the procedure of narcotic endorsement?

Both the incoming and outgoing charge nurses are responsible in checking the narcotic ampoules with signatures of the receiver and endorser in the endorsement book.

Policies and Procedures regarding Restraints:

Obtain written doctor’s order, if urgent an order will be written within 24 hours

Assess the skin of the site to be restrained

Check the site hourly for circulatory suppression

Release every 2 hours

Provide and assist for personal needs

Reassess for the reduction of the restraint and document as necessary

What is Nosocomial Infection?

Hospital Acquired Infection (HAI) can be prevented or minimize if there is staff adherence to the following:

Comply with Hand Hygiene

Practices to prevent central-line associated blood stream infections

Practices to prevent surgical site infections

What Standard Precaution appropriate for MRSA?

Contact precaution.

What is PPE?

Personal protective equipment consisting of:

Gloves,

Gown,

Face shield/mask

What is Job Description?

It is a summary of primary duties performed by the holder of the job, prepared

By the employer.

What is Nursing Process?

It is a systematic approach to meet the patients needs in health care setting, enabling the nurse to identify and understand, explain and analyze the problems and needs presented.

5 Steps of Nursing Process:

1. Assessment – a comprehensive gathering of information using our senses.

a. Subjective – verbalized by the patient

b. Objective – nurse observation based on clinical manifestation

2. Nursing Diagnosis – analyses of the data collected that leads to the areas of concerns or needs.

3. Plan – objectives or direct outcomes we want to achieve for the patients

4. Intervention/Implementation – appropriate actions taken to achieve the desired outcome based on the concerns or needs identified by

the clients, nurses, physician

5. Evaluation/Reassessment – the desired outcome on the nursing care delivered whether it has a positive or negative response to the patient.

When opening a door, do it slowly or look through the window to avoid hitting the person on the other side.

What safety precautions will prevent the incidents of back strains and injury?

Proper body mechanics

Correct handling and lifting techniques.

Proper positioning at work place.

What is the procedure of staff allocation based on the patient category and unit acuity?

The staffing plan identifies the patient category and acuity based on the care hours or activity level points in the patient care areas.

The categorization of general and sub nursing care into activity level points ranging from 1,2,3,4 depending on the complexity of care, is sum up utilizing the therapeutic intervention scoring system (TISS) that will classify the activity level points into patient acuity level.

The time required for each patient’s nursing procedure and the sum for all patients in the unit is calculated to predict the nursing care hours needed, divided by the number of productive work hours on a shift equals the personnel needed.

Productivity

– is defined as the output divided by the input related both to how efficiently clinical nurses deliver nursing care and how effective that care is relative to its quality and appropriateness.