HOSP POLICIES

TITLE POLICY NO.

NURSING CARE DELIVERY SYSTEM DP200.025
POINT OF CARE TESTING HP 2.174/MSD-PFR-
003
SOCIAL CARE SERVICES POLICY (HP 2.098)
FALL HP. 2.143
MANAGEMENT OF ABUSE, NEGLIGENCE AND DOMESTIC VIOLENCE HP 2.173
PATIENT AND FAMILY RIGHTS AND RESPONSIBILTY HP.2.016
VTE HP 2.004
INFORMED CONSENT (MSD-PFR-003)
TURN AROUND TIME(TAT) FOR LAB TEST (MSD-AOP-004)
INITIAL OBSTETRIC ASSESSMENT MSD-H-1-AOP-001
Patient and Family education (PFE) (HP 2.169)
INCIDENT REPORTING (HP.1.008)
PATIENT IDENTIFICATION PROCESS (HP 2.131)
NARCOTICS/CONTROLLED DRUGS (HP.2.150)
ISOLATION RELATED POLICY (HP.2.057-2.064)
ABSCONDED/MISSING PT (HP.2.065)
AMA (HP 2.068)
REFUSAL OF TREATMENT (HP 2.073)
BLOOD/BLOOD PRODUCTS ADM. (HP 2.087)
ASEPTIC TECHNIQUE (HP.2.139)
ADVERSE DRUG REACTION (HP.2.144)
CODE PINK (HP 3.044)
N95 FIT TESTING (HP 3.062)
PUMPS W/FREE-FLOW AND CLINICAL ALARMS (HP 3.066)
SHARPS INJURY AND BODY FLUIDS EXPOSURE (HP 3.003)
SAFE SHARP PRACTICE (HP.3.025)
AVOIDANDANCE OF CATHETER AND LINE MISCNNECTION (LINE TRACING (HP.3.067)
HIGH ALERT MEDICATION HP 2.142
LASA MEDICATONS HP 2.181
MEDICATION ERRORS HP 2.152
CORRECT SITE IDENTIFICATION FOR SURGICAL HP 2.107
INTERVENTIONS/INVASIVE PROCEDURE
HAND HYGIENE GUIDELINES & MONITORING OF HH PRACTICES HP 3.005
NEEDLE STICK/SHARP IMJURY &BODY FLUIDS EXPOSURE HP 3.002
MONITORING OF NEGATIVE PRESSURE ROOM HP 3.055
PAR LEVEL HP 5.024
HANDOVER COMMUNCATION HP 2. 157
CRITICAL /PANIC LAB & RADIOLOGY RESULT MSD H-1-IPSG 201
VERBAL AND TELEPHONE ORDER HP 2.010
 Turn around time-Three interval of time when as specimen is received by the laboratory and
the results are reported;
- Within 3 hours – Urgent and emergency laboratory
- Within 24 hours - Routine laboratory test
- 1 weeks-1 month= Specialize test
POCT (Point of Care Testing) - Bed side testing provides quick results that enable clinical
staff to rapid diagnose, screen or monitor patients
- Urine dipstick
- Glucometer

Blood transfusion
BT consent validity- til discharge

In doctor’s order:

- Blood component required

- No. of units required to transfused
- Date , time and location
- Indication for request of BT
- Patient diagnosis
- Name and Signature of doctor ( stamped)

Compatibility label:

- Patient ID/MRN
- Date of birth
- Gender
- ABO group /RH D group of patient
- ABO group and RH D of the unit
- Donation number
- Expiry date
- Location of patient

In case of Blood transfusion reaction

- Stop the blood and run the Normal Saline 0.9% at KVO
- Informed the physician
- Informed the blood bank
- Record to Nurses Notes
- Fill up the Work up form signed by the physician and send direct to blood bank
- Send the remainder bag with infusion set to blood bank for checking

What to send to laboratory?

1. One labelled of 7ml of EDTA (Purple) tube cross match sample to be extracted away
from the site of infusion
2. Urine sample
 Critical Panic result-
Critical results are defined as results that, if left untreated could be life threatening, or
place the patient at serious risk, whether the specimen was submitted as routine or STAT. Any
diagnostic test, procedure and/or study may be considered a critical test based on the assessment
of the physician of the patient’s status. Also, it is considered a test that has been ordered as
STAT.
All critical laboratory/radio-diagnostic test results must be communicated to the
responsible healthcare provider by phone within 60 minutes of obtaining the results.

“STAT” Test:
Are those tests determined by the physician for emergency life threatening situation . This
designation should be used judiciously, as STAT order takes precedence over all other laboratory
work.

“Read Back/Verification” by the person receiving the result is mandatory to ensure that there is
no misunderstanding of verbal communication.
“Read Back/Verification” must be documented in patient medical record by receiving person.
The following information must be documented in the patient record when receiving critical
laboratory results:
1. Patient’s complete name.
2. Patient’s hospital number.
3. Type of test performed.
4. The critical results.
5. Name of the laboratory or Radiology technologist phoning the report.
6. The name of the healthcare provider receiving the report.
7. Date & time of the communication.

PATIENT AND FAMILY EDUCATION (PFE) Policy no.: HP 2.169

PURPOSE:
1 To establish a guide on how healthcare providers, extend patient's health teaching related to
the patients' condition, rights and responsibilities, hospital regulations, and in
decision making involvement.
2 To ensure that patients and their families are assessed regarding their health education needs
and to identify any learning barriers.
3 To ensure that patients and their families are provided with necessary and sufficient health
education so they have the knowledge and skills to participate in the patient care
processes and care decisions.

Patient and Family Educational Needs are assessed and planned in the
following aspects:
1. Ability and willingness to learn and Learning Barriers
2. Educational Needs Assessment
3. Patient and Family can be educate thru:
1. Orientation to the ward/ unit (e.g. room, emergency bill, bathroom, watchers
guidelines and safety measures).
2.Communicable and non-communicable diseases: Disease process, condition
treatment options and procedures, prognosis and/or health promotion.
3. Nutrition
4. Education on Medication usage, effect, side effects, & interactions
5. Daily activities, safe & effective use of equipment, exercise and/or rehabilitation
techniques
6. Available community resources & follow up:
7. Others

Management of suspected Abuse,Neglegence and Domestic violence

LOOK ALIK SOUND A LIKE - medication with generic or brand names that looks or sound
alike other medications names, which may lead to a potentially harmful medication error
because of confusion in the process of ordering, dispensing ,transcribing or administering
medications.
TALL MAN lettering: is the practice of writing part of a medications from one another to
avoid medication errors.

Admission Criteria for High Risk Cases:

1. Patients with active antepartum hemorrhage for close observation.
2. Severe anaemia (Haemoglobin (Hb) <7 gldl with requiring close observation.
3. Patients in active preterm labour (<37 weeks of gestation, with cervical
dilatation of >3 cm and effacement of >75%o).
4. Patients with non-cephalic presentation in active labour.
5. Patients with revealed thick meconium stained liquor, regardless of cervical
dilatation.
6. Patients with previously scarred uterus in active labour.
7. Patient who developed complications during Caesarean Section.
8. Patients with previously scarred uterus in active labour.
 9. Patient who developed complications during Caesarean Section.
10. Patient who had home/car delivery in the same day.
11. Patients with uncontrolled medical problems
12. Patients with multiple pregnancies in active labour.

INTERNATIONAL PATIENT SAFETY GOALS

IPSG 1: PATIENT IDENTIFICATION

- Two ( 2 ) unique identifiers that must be used patient full name and Medical
Record Number (MRN)
- Must be written or printed in English with clear legibility using either or blue
colored ink.
ID band must be attached top the following body parts as per possibility:
1. Right wrist
2. Left wrist
3. Right ankle
4. Left ankle
In the event that the patient is unable to participate in identification process ( unconscious,
mentally unstable, infant, Incapacitated, under anaesthesia) and in the absence of a parent,
Identification should be carried out by two (2) hospital staff using identification information
available in medical records.
For Unknown patients:

- For unknown identity or unconscious patient brought in Emergency Department

i.e trauma patients, identification can be made by a member of the resuscitation
team or ED staff.
- The identity band must state xxx1, xxx2, xxx3 and so on .( as code name of the
unknown patient) and the temporary assigned ED unique patient identifier
number.
- Once patient identity established, All medical record file shall be updated with the
assigned medical record number.
Newborn Identifications:

- ID band
- Footprint

Identification information:
1. ID band should start with baby name i.e B/O Al (mother name)
2. Baby’s MRN
3. Mothers complete name
4. Mothers MRN
5. Date and time of birth
6. Gender of the baby
For undetermined gender, to refer to the paediatrician advices.

IPSG No. 2. Improve Effective Communication

- ISBAR tool ( Introduction,Situation,Background,Assessment and

Recommendation)- used during hand over of patient

Verbal/telephone Orders ( HP 2.010 )

1. Verbal/telephone communication orders should be limited to urgent situations where

Immediate written or electronic communication is not feasible.

2. Verbal orders are not allowed when the prescriber is present and the patient's chart is

available, except during a sterile procedure or in a Life threatening situation, in which a

Repeat-back is acceptable if the staffs' is unable to write it down.

3. Verbal / telephone orders will NOT be accepted for:

1. Physical Restraints

2. Starting Patient Controlled Analgesia (PCA)

3. Starting Narcotic or Scheduled Medications

4. Initiating TPN Therapy

5. Category of care (DNR/Code Status)

6 .Withdrawal of Life Support

7 .Chemotherapy

8 .High Alert Medications

4. Only licensed physicians shall be allowed give Verbal or Telephone Orders.

5. Only licensed nurses are allowed to receive Verbal/Telephone Orders.
PRECEDURE:

The staff member taking the order shall record the order ("WRITE DOWN") and read

the order back ("READ BACK") to the physician and request confirmation

("CONFIRM").

What to document?
 All verbal/telephone orders will be documented in the physician order sheet
(Appendix 1) with the following:

1 Full name of patient and Medical Record Number (MRN)

2 Date and time
3 Name and Stamp Number of Physician

All verbal orders must be authenticated (physicians signature) before the doctor leaves
the clinical area.

All telephone orders must be authenticated (physicians signature) within 24 hours of the
Order.

IPSG no 3: Ensure the safety of high alert medication

High Alert Medications

- Are drugs that bear a higher risk of causing significant patient harm when they are used
in error.

Independently double checking

- Is the procedure which two (2 ) health care professional separately check ( alone and
apart from each other ,then compare the results) each component of prescribing,
transcribing, dispensing and verifying the medication before administering to patient

High Alert Medications that look alike ( LASA ) should be :

1. Stored in RED coloured bin/shelf with TALLMAN

2. Identified by two (2) auxiliary labels standardized High alert Medications and
standardized LASA auxiliary labels.

3. Utilized medication segregation for LASA.

IPSG no. 4. Correct site, correct procedure and correct patient surgery

 Surgical Site Marking:

1. All patient going for surgery or invasive procedure must have their surgical site marked.

2. Surgical- and invasive procedure–site marking shall be done by the doctor performing the
procedure and must involve the patient in the marking process.

All patients going for a Surgical- and/or invasive procedure must have a surgical safety checklist
completed by the nurse before the procedure.

 VERIFICATION
- The pre-surgical verification must include verification of the following:

1. Consent is completed and appropriate to the procedure.

.2. Correct site, correct procedure, and correct patient are identified.

3. All documents and medical technology needed are on hand, correct, and functional.

 Timeout:
The pause in the patient care activity conducted by the medical team immediately before
starting the procedure to confirm the correct patient, site, and procedure will be performed.

1. Immediately before starting the surgery/invasive procedure, the full surgical team must
conduct and document a time-out procedure in the area in which the will be performed.

2. Components of the time-out must include:

- Correct patient identification.

- Correct side and site.

- Agreement of the procedure to be done.

- Confirmation that the verification process has been completed

-
Surgical Site Marking:
1. The physician conducting the procedure retains overall responsibility for ensuring
that the site of the surgery/invasive procedure has been correctly identified and
marked, and that the surgery/procedure is performed on the correct side and at the
correct site.

2. The site of the surgery or invasive procedure shall be marked with an arrow (↑) by
the person performing the surgical or interventional procedure.

3. Marking should take place with the patient involved, awake and aware, if possible.

4. If the patient refuses marking, this must be documented in the patient’s medical
records and alternative strategies must be employed to prevent the procedure being
performed on the wrong site.

IPSG No 5 .Reduced the risk of health care associated infection

IPSG no. 6 : Reduced the risk of patient harm resulting to fall

All in-patients must be assessed and re-assessed routinely for “fall risk” by a Registered
Nurse to determine the ongoing need for fall prevention precautions when any of the following:
1. at the time of admission.

2. Twice a day (Morning and evening).

3. Change of patient condition.

4. Following a fall.