ESR & IPSG Audit Tool Date: __________________

1: Compliant O: Observation
0: Non-compliant Auditor: ______________________ I: Interview
N/A: Not Applicable D: Document Review

No Test of Compliance Tool Techniques Position Location Remarks

1. IPSG.1: The hospital develops and implements a process to improve accuracy of patient identifications.
Rating
QM.17: The hospital has a process to ensure correct identification of patients.
Check ID Band in place (Full Name and MRN) (Visible,
Patient
1.1 NOTE: Observe that the staff DO NOT use Readable, Clear)
room number to identify patients (Listen to Observe patient identification (Medication Administration,
All Clinical All Clinical
the staff how they communicate Blood sampling, Blood Transfusion, Medication Dispensing,
staff Areas
information about patients: do they say before performing procedures)
patient room O Observe patient with similar names (Alert card on files &
N/A
patient’s bed)

Involvement of patient in patient identification

How do you identify the patient?

I Clinical staff All Clinical
Areas
When are you going to perform patient identification? Clinical staff

To whom will we apply the ID band? Clinical staff

How will we apply correct patient identification for new- LDR/NICU
LDR/NICU
born’s? nurses
How do you identify unknown/unconscious/patients (e.g. Physicians & All Clinical
comatose)? Nurses Areas

Patient information sheet

N/A Patient File
D Addressograph

2. IPSG 2: Improve Effective Communication Rating

Observe the clinical staff performing the process of write

down, read-back and confirm Physicians/
O Clinical Areas
Nurses
Ask the staff about the procedure of telephone and verbal Physicians/
2.1 Write Down, Read Back, and Confirm order Nurses
I
Ask physicians how to confirm the order is correct when
Physicians
giving telephone/verbal order
D Telephone and verbal order form N/A Patient Fie
Physicians/
O Observe the clinical staff on how they are using ISBAR.
2.2 Using ISBAR technique Nurses Clinical Areas
I Ask the clinical staff what is ISBAR and how they implement Physicians/

Page 1 of 10
 it Nurses
Multidisciplinary ISBAR Communication Tool
D N/A Patient Fie
Physician Reassessment and handover Form
Ask the process of critical result reporting for emergency, Physicians/
I Clinical Areas
2.3 Critical result reporting outpatient, and inpatient Nurses
D Critical Result Reporting policy & form N/A Patient Fie
3. IPSG 3: Improve the Safety of High-alert medications
MM.5: The hospital has a system for the safety of high-alert medications Rating
MM.6: The hospital has a system for the safety of look-alike and sound-alike (LASA) medications.
Availability of high alert medication and hazardous
medication list (annually updated)
Auxiliary labelling “Red warning sticker Clinical areas

Storage (separate, double-door, locked and properly labelled)

O
High Alert medication dispensing and administration Pharmacy/
(independent double-checking) N/A Clinical area

Access to high alert medication is limited/locked Clinical areas

Pharmacy/
HAM prepared on standard concentration and dilutions Clinical area
How can you identify High-Alert medication and give me
example of these drugs used in your area?
What are the Safety strategies to prevent errors associated
3.1 General Information for HAM I with high alert medication? Clinical staff Clinical Areas
Ask the staff if they received training on HAM

Is telephone order permitted for HAM)

Medication Administration Record (MAR) Patient File

D Standard concentration of medication administered by IV
Clinical Areas
infusion
N/A
Review the availability of multidisciplinary plan for managing
high-alert medications and hazardous pharmaceutical Clinical areas
chemicals

Medical
Pharmacy & Therapeutic committee meeting minutes
Office
3.2 LASA Availability of LASA medication list (updated annually)

O Observe Tallman lettering for LASA N/A Clinical areas

Storage (separated, non-alphabetical order)

I What are the Safety strategies to prevent errors associated Clinical staff Clinical areas
with LASA medication?

Page 2 of 10
 Ask if training is received for LASA

O Check availability of concentrated electrolytes N/A

3.3 Concentrated Electrolytes Ask the staff about the precautions to take in preparing and Clinical areas
I Clinical staff
administering concentrated electrolytes
Labeling of narcotics
Clinical
O Access to narcotics in units Areas/
N/A Pharmacy
Storage of narcotics

3.4 Narcotic and Controlled Drugs Ask who has privilege to order narcotic medications
I Clinical staff Clinical areas
Disposal methods & replacement of broken narcotic

Narcotic & controlled drugs prescription Patient File

D N/A
Narcotic & Controlled Drug logbook Clinical Areas
4. IPSG 4: Ensure Safe Surgery
Rating
QM.18: The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure.
Check pre-operative verification and actual patient’s site
marking Physicians/
O
Nurses OR
Observe the time-out and sign-out process

Ask staff how to verify patient pre-operatively Nurses

I Physicians/
Who, where and how to do site marking? Wards/OR
Nurses
List of invasive procedures that need time-out Clinical staff Clinical areas

Ensure safe surgery policy Portal

4.1 Surgical, Anesthesia/Conscious Sedation and Medical
Invasive Procedure Consent form
Peri-operative Nursing Record

D Peri-Anesthesia Form N/A

Patient File
Operative Notes

Peri-procedural Form

Nursing Endoscopy Flow Sheet

5. IPSG 5: Reduce the Risk of Health Care Associated Infection Rating

Check if alcohol- based hand rubs are accessible and properly
places at the point of care
5.1 Hand Hygiene O All staff All areas
Check if SINKS are available

Page 3 of 10
 Check the availability of soap and tissues

Observe hand washing and hand rub technique

Ask the staff if there are no instances that they run out of hand
I
rubs, soap and towel
6. IPSG 6: Reduce the risk of patient harm resulting from fall Rating
Check patients who are at risk for fall if fall prevention
O strategies are implemented (call bell working, side rails up, N/A
fall risk signs/posters, lavender wrist band) Clinical Areas
If the patient is at risk for fall, how often do you re-assessed? Physicians/
I
Nurses
ER Ambulatory Flow sheet

Adult Nursing Initial Admission Assessment Form

Neonatal/ Pediatrics Nursing Initial Admission Assessment
Form
6.1 Fall Prevention Strategies
OB-GYNE Nursing Initial! Admission Assessment Form

D Adult Daily Nursing Flow sheet N/A Patient File

ICU Flow sheet

NICU Flow sheet

Fall Prevention and Management Tool

Fall screening, risk assessment, prevention and management
for Outpatients (ER/ OPD)
7. HR.5 The hospital has a process for proper credentialing of staff members licensed to provide patient care. Rating
7.1 Document Review Policy Review (Credentials Verification) Portal
Credentials verification (PSV-license, education, experience,
training)
Job Description HR &
N/A Department
7.2 Personnel File Review D Clinical Privileges Shadow File

Part-timer, locum credentials

Medical
Document Review Credentialing & Privileging Meeting Minutes
Office
8. MS 7 Medical staff members have current delineated clinical privileges Rating
Privileging policy (process of granting temporary, emergency
Portal
& new privilege)
8.1 Policy D
N/A Medical
Credential & privileging meeting minutes
Office
8.2 Personnel File Review D/O Availability & accessibility of physician’s privileges Portal &

Page 4 of 10
 Current & updated privileges Personnel files

9. PC.25 Policies and procedures guide the handling, use, and administration of blood and blood products. Rating
Accessibility and availability of blood transfusion policy in
O the visited areas (such as ICU, ER or Surgical Ward)
Verification of samples during collection and administration

Ask the signs and symptoms of Transfusion Reaction Clinical staff Clinical areas
Observe the blood request form (requested I
by physicians only) Ask the steps to do if the Transfusion Reaction occur

9.1 Ask the awareness in blood administration policy &

Two staff members shall verify the transfusion reaction investigation
patient’s identity prior to specimen Blood/Blood Products Cross Matching and
collection and prior to blood transfusion. Transfusion Request From
Blood and blood products Patient file
D transfusion consent N/A
Blood Administration sheet
Medical
Blood Utilization committee meeting minutes
Office
10. Patients at risk for developing venous thromboembolism are identified and managed. Rating
Ask the steps to do for patients at risk for VTE
Physicians/
I Ask the staff how frequent the re-assessment for inpatient at Clinical Areas
nurses
risk and not at risk for VTE
10.1 Venous thromboembolism screening (Adult Surgical Patients,
Adult Medical Patients, Ob-GYNE Patients.
D N/A Patient File
Prophylaxis given for VTE patients

11. AN2. Anesthesia staff members have the appropriate qualifications. Rating
Personnel File Review (License, Privileges, Training (ACLS, Personnel file
PALS) & Shadow file
11.1 D N/A
Anaesthesia Rota Anesthesia
Peri-anaesthesia record (involvement of anaesthesia in
Patient File
surgery)

Rating
12. AN.15 Qualified staff perform moderate and deep sedation/analgesia.
12.1 Designated areas for Procedural sedation (OR, Critical Care, Personnel file
O N/A
L&D, Endoscopy, ER, Radiology, Cath Lab) & Shadow file
I Ask the staff who are authorized to do procedural sedation, Clinical staff Clinical Areas
deep and moderate sedation

Page 5 of 10
 Personnel file
BLS, ACLS, PALS, moderate & deep sedation training
D N/A & Shadow file
Peri-moderate sedation record Patient File
13. IPC 4. There is a designated multidisciplinary committee that provides oversight of the infection prevention and control
Rating
program.
IPC committee Terms of Reference if these are available in
the function:
 Review of the IPC policies and procedures.
IPC committee must be chaired by Medical  Review of the reports of healthcare associated
Director. infections surveillance and action taken
13.1  Revision of the IPC yearly plan (signed by the N/A IPC office
D
Check the 9 mandatory members if they are committee)
present in the members list.
IPC members list

IPC Meeting Minutes

14. IPC 15. Facility design and available supplies support isolation practices. Rating
Observe the availability of hand washing facilities, toilets, and
N/A All areas
shower in negative pressure isolation rooms
Observe the availability of transmission-based precaution card
that should be consistent with diagnosis, posted in both N/A Clinical Areas
English & Arabic.
O
Observe the availability of different sizes of N95 masks

Observe the availability of N-95 Fit test card Clinical staff Clinical Area

Hospitals are expected to have at least one
14.1 negative pressure room in ER and one for
every 25-30 beds in general hospitals.
15. MM.41 The hospital has a process for monitoring, identifying, and reporting significant medication errors, including near
misses, hazardous conditions, and at-risk behaviors that have the potential to cause patient harm.
Medication error Management Policy:
▪ Reference to the reporting form
15.1  Notification of provider about the
error
 Feedback to reporters
Observe donning and doffing of N95.
Interview the staff to assess their knowledge about the use of
appropriate PPEs for airborne cases and fit test All staff
I All areas
Assess staff knowledge about the policy of re-suing high
filtration masks.
Review completeness of engineering control records for air
changes per hour, HEPA filter, negativity, humidity, and
Clinical Areas
temperature; (review standard's intent to understand
D engineering records requirements) N/A
Review hospital’s policy on single use or re-use of N95
masks: Portal
Isolation precaution policy
Rating
Interview physicians (treating/attending/most responsible) on
how they get to know/informed about a medication error and Physician
I when. Clinical Areas
Interview healthcare providers on when they report
Clinical staff
medication errors.

Page 6 of 10
 Interview healthcare providers on the process and importance
of medication error reporting and if they are trained.
Interview healthcare provider on how they received a
feedback regarding medication error
Medication errors, near misses, and hazardous situations
 Timeframe for reporting and reports (categorized as per stakeholder)
notification of provider
D Root-cause analysis of all significant or potentially significant N/A Pharmacy
 Documenting medical errors and
medication errors.
who should document and where
Pharmacy & Therapeutic committee meeting minutes
(discussing medication error and action taken)
16. LB.51 The blood bank develops a process to prevent disease transmission by blood/platelet transfusion Rating
Interview personnel to assess their competence with TTDT
I with bacterial contamination prevention and detection
procedures
Laboratory
16.1 Laboratory
staff
D Outsource contract for TTDT

17. FMS.9 The hospital ensures that all its occupants are safe from radiation hazards. Rating

Availability of Radiation Protection Equipment (Unique ID Radiology

Radiology
number) staff
O
Radiology
Observe the wearing TLD badge (2 TLD per patient) Radiology
staff

Radiology
No nuclear medicine unit and radioactive I TLD Testing and permissible radiation levels Radiology
staff
17.1 materials in our hospital

Radiology
Shielding certificate/leak test Radiology
staff

D Annual testing of lead aprons, gonad, and thyroid Radiology

N/A

Inventory of RPE Radiology

18. FMS.21 The hospital has an effective fire alarm system. Rating
Observe fire alarm control panels and make sure that they
Ground
18.1 O work properly with no alarms or errors. N/A
Observe random smoke detectors, make sure they are All areas

Page 7 of 10
 operational, have number tags, and not obstructed.
Check availability of functional fire alarms in the elevator
Mechanical
mechanical room. Inspect for physical connection between
Room
fire alarm and elevator control panel.
Fire alarm inspection schedule and reports.

Fire alarm testing schedule and reports

D N/A FMS office
Fire alarm maintenance schedule and preventive maintenance
work orders
Fire alarm system distribution drawings

19. FMS.22.2 The hospital has a fire suppression system available in the required area(s). Rating
Visit Fire Pump area, make sure that the jockey, electrical and
19.1 O diesel pumps are set to auto mode. B2

Check the sprinkler system test valve/drain valve.

O All areas
Sprinkler heads should not be obstructed X-ray rooms can have sprinkler system with precaution valve.
nor painted and distance between each in
19.2 Sprinkler system inspection schedule and inspection reports
ordinary
D FMS Office
risk area should not be more than 5 meters.
Sprinkler system preventive maintenance schedule and reports

Check if the hospital has a fire water tank or a 2-level general

19.3 O B2
tank
Clean agent suppression system installed at the medical
B1, B2,
records department, the servers’ room (data centre), electrical
O N/A Ground
Check the inspection tag. Review rooms, and generators’ rooms
19.4
corrective action for identified findings. Clean agent system inspection schedule and inspection reports
D FMS Office
Clean agent preventive maintenance schedule and reports

Check wet chemical system inspection tag. O Inspect hospital wet chemical system in the kitchen Kitchen
19.5 Review corrective action for identified
findings. D Inspection and PPM for the wet chemical system FMS office

Check the pressure in at least one hose reel O Inspect hospital's stand pipes and hose system Ground
19.6 to ensure that it’s functioning
automatically, and the pressure is adequate. D Inspection and PPM for the stand pipes and hose reel system FMS office

20. FMS.23 There are fire exits that are properly located in the hospital. Rating
Observe fire exits are available, not locked, not obstructed,
20.1 O have panic hard ware, fire resistant, and clearly mark with exit N/A All areas
sign.
21. FMS.24 The hospital and its occupants are safe from fire and smoke. Rating

Page 8 of 10
 No obstructions to fire extinguishers, fire alarm boxes, and
fire blankets

Perform functional test for emergency
lighting.
21.1
Check the storage areas (heavier close to
the floor, items are laid flat, 10 cm above
the floor)
Emergency lighting is adequate for safe evacuation of the
hospital.
O Fire rated doors are available according to the hospital zones N/A All areas
with no separation between walls and ceiling to prevent
smoke spread between rooms and areas.
Storage areas are properly and safely organized.

Rating
22. FMS.32 The hospital ensures proper maintenance of the medical gas system.
Observe that medical gases manifold room and compressors
rooms are safe and secure (locked, signage, clean, no oil, no
exposed wiring…etc.).

Observe that all PMG outlets are functioning and unified in

label and connection type for each gas.
B2
Compare average consumption rate with the number of
O standby cylinders to ensure sufficiency for 48 hours N/A

Observe that the gas cylinders are regularly tested for gas
type, amount and any leaks.

Observe availability of labels indicating room numbers served

by the gas valve box at wards.
Clinical Areas
Maintenance & effective use of medical Observe that the PMG outlets are adequate in-patient care
22.1
gas system areas and are to be error proof.

Utility manager(s)/engineer(s) are aware of the average daily

Biomed Tech Biomed office
consumption rate of oxygen and medical air.

Interview clinical staff to ensure their awareness of PMG

I shutoff valves location and affected rooms. In addition to their
ability to demonstrate how to shut-off valves safely.
Clinical staff Clinical Areas
Interview of the risk associated with valve shut off,
Breaking valve box cover, and what rooms are affected by
closing the valve.
Review preventive maintenance schedule and reports for
D piped medical gas system (manifolds, air compressor, liquid N/A Biomed office
oxygen and suction system).

Page 9 of 10
Review compressed medical air testing reports to include
humidity and purity (annual testing by company)

Page 10 of 10