S.

Departmen
NC Corrective action
N t
There was no evidence of calibration of The process has been established for the continuous quality improvement
1 pipettes at the laboratory. and pipettes were calibrated by authorized persons on regular basis. Lab
1. Copies Calibration report of the elaborate pipettes with reports.
Wheel chairs at Emergency and OT did Process initiated to strength towards patient safety on monthly basis facility
2 not have safety belt safety rounds. Hospitals
1. Photos of Safety Belt all wheel chair in the Hospitals.
Mother and baby identification tags The new process initiated for easy identification of Mother and baby to
3 were not available during the prevent errors /incidents new tags have been introduces. Srinivas
assessment and are not being used. 1. Photo of identification mother & bay
There was no evidence of obtaining A new HIV consent is papered for HIV screening patient. Process initiated to
consent before testing for HIV at the take HIV consent from the entire HIV screening patients.
4 Lab
laboratory. 1. Training Record on HIC Connect
2. Copies of HIV consent.
Personal files of resident medical To strength organization process the HR personal file is creation being
officers, paramedical staff and support initiated all categories of staff. A circular sent all staff for the for requirement
staff were not maintained. document of HR personal file.
Srinivas &
5 Copies of HR personal Files
Lab
1. DMO -2
2. Para Medical -2
3. Supportive staff -2
House-keeping check-lists were not Process initiated to strength towards hospital infection control on daily basis Srinivas
6 available at wards and patient rooms. to wards daily patient room cleaning check list.
1. Copies of Patient Room check list.
Staff training on procedure of cleaning Reinforced session is been conducted all the Housekeeping staff on Spill Srinivas
blood spill needs to be strengthened. management & Hospitals
7 1. Training Record
2. Training PPT
3. Spill Management photos & Videos
There was no evidence of using For the continuous Quality improvement all CSSD Register is been Revised Srinivas &
8 hospitals
chemical indicators to monitor The use of Chemical indicators monitor effectiveness of sterilisation process is
S. Departmen
NC Corrective action
N t
been implementation started.
effectiveness of sterilisation process. 1. Copy of Newly Revised Register
2. Copy of Chemical Indicator register with Expiry date
ETO packs did not have expiry dates on The process is revised to established the expiry date of all ETO packs Srinivas &
9 them. 1. Copy of Newly Revised ETO Register hospitals
2. Copy of ETO Pack with Expiry date
Breakdown register was not available A new register is been introduced for to register the equipment complains & Srinivas &
10 during the assessment. Breakdown time details. hospitals
1. Copy of Breakdown register.
Floor plans with exit routes were not The floor wise fire exit plan is prepared & implemented the all floor Srinivas &
11 maintained. 1. Photos’ of floor wise fire exit plans. hospitals