CBAHI AND JCI COMMON ASKED QUESTIONS

HMG MISSION fall.

To develop and operate state of the art medical
facilities and provide innovative healthcare services Why is it important to have the WHAT ARE THE COMPONENTS OF TAKING TELEPHONIC
to create value for people. international patient safety goals? ORDER?
To promote specific improvement in the Always:
HMG VISION patient safety. Right down
To be the most trusted healthcare provider Read back
In medical excellence and patient experience HOW DO WE IDENTIFY OUR PATIENTS? Confirm
globally. Use of two identifiers:
1. Patient full name (minimum of 3 names) WHEN WE CAN RECEIVE VERBAL ORDER?
WHO ARE OUR CUSTOMERS? 2. Medical record number compare with the In EMERGENCY SITUATION ONLY, we should repeat back.
Everybody: patients, family, visitors, physicians, co- waterproof ID band. Order should be signed immediately before the physician
workers leaves the unit.
External customers: WHEN DO WE NEED TO IDENTIFY OUR
 Patients PATIENTS? WHAT YOU UNDERSTAND BY HIGH ALERT MEDICATIONS?
 Relatives 1. Before giving medications. 1. It should be labeled with HIGH ALERT (YELLOW )sticker.
 Visitors 2. Before giving blood and blood products. 2. It requires independent double check ( two individuals,
 Companies 3. Before specimen collection. separately check each component of the work process).
 Governments 4. Before taking blood samples and other 3. It carries a risk for errors that can lead to significant adverse
Internal customers: specimens for clinical testing out comes.
 Doctors 5. Before providing any other treatments/
 Nurses procedures/ surgery/ investigations HOW CAN WE IMPROVE THE SAFETY OF HIGH ALERT
 Technicians 6. At the time of discharge (NICU/Nursery) MEDICATIONS?
 Other employees 1. Always perform independent double check.
WHAT IS THE COMMUNICATION TOOL WE 2. Concentrated electrolytes are not stocked up in the ward.
WHAT ARE THE 6 INTERNATIONAL PATIENT SAFETY USE IN THE HOSPITAL? 3. Alert sticker are placed on high alert medications.
GOAL (IPSG)? Ans.: SBAR 4. Separate storage of high alert medications from regular
1. Identify the patient correctly. S - situation medications.
2. Improve effective communication. B - background 5. Keep the medication room locked at all time.
3. Improve safety of high alert medications A - assessment 6. High alert medications not accepted by verbal or
4. Ensure correct site, correct procedure, correct R - recommendation telephone order.
patient surgery.
5. Reduce the risk of health care associated
infection. HOW OFTEN DOES THE PHARMACY CHECK THE CONTENTS OF
6. Reduce the risk of patient harm resulting from ALL CRASH CARTS?
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The pharmacy checks the content of all crash carts
on a monthly basis and after a code for the
completeness and expiration dates.
HOW DO YOU ENSURE CORRECT SITE, CORRECT
PROCEDURE, AND CORRECT PATIENT FOR
SURGERY?
We have to make sure that TIME OUT is done
correctly.
TIME OUT IS PERFORMED...
WHEN: before performing any procedures.
WHERE: areas include and not limited to OR, ER,
ICU, Endoscopy
HOW: things to check
1. Patient identification
2. Site mark of the procedure (if indicated)
3. Type of procedure
4. Consent
5. Consent for anesthesia (if indicated)
6. Necessary equipments/supplies/implants
7. Diagnostic report/medical report (if indicated)
INFECTION CONTROL
WHAT IS THE DEFINITION OF HAI? (Health-care
Associated Infection) - Infection the patient
contracted in hospital 48 - 72 hours after admission
or any invasive procedure.
WHAT IS THE DEFINITION OF CAI? (Community
Acquired Infection) infection the patient was
admitted in hospital with.
WHAT ARE THE 5 MOMENTS OF HAND HYGIENE?
HOSPITAL WIDE
CBAHI AND JCI COMMON ASKED QUESTIONS
1. Before patient contact
2. Before aseptic Procedure
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings
WHAT ARE THE THREE ISOLATION
PRECAUTION?
1. CONTACT precaution (skin infection,
MRSA, infected patients, HEPA A,B,C,HIV)
2. DROPLET precaution (pertussis,
meningitis, mumps, influenza)
3. AIRBORNE precaution (pulmonary TB,
Chicken pox, Measles)
WHAT ARE THE DIFFERENT WASTE COLOR
BAGS?
BLACK (food, catering)
BLUE - non bio hazardous waste, regular
waste (paper, flower, lunch papers, plastics)
YELLOW - bio hazardous medical, infectious
waste (medical waste, gloves, PPE etc.)
RED (placenta, fetus, body tissue,
amputations)
HOW DO YOU PREVENT NEEDLE STICK
INJURIES?
P - prepare everything
R - recap not allowed
I - inspect the surroundings
C - care and communicate
K - keep all sharps properly disposed
S - save lives
STEPS YOU WILL TAKE IN CASE OF NEEDLE STICK INJURY
1. First aid
2. Report to in-charge/head nurse/supervisor/ ICN
3. Complete relevant forms
 Blood/body fluid exposure
 IR
4. See doctor in family medicine during working hours/ doctor
in ER for after OPD hours
5. Blood to be taken for patient: HIV, HEPA B &C and Staff:
HBsAg, HBsAb, HCV, HIV
6. Follow up for further management
WHICH TECHNIQUE WE ARE USING FOR HAND HYGIENE?
Ans.: AYLIFFE TECHNIQUE
FALLS
What is the scale used in the HMG'S for FALL RISK
ASSESSMENT?
PEDIATRIC - Humpty Dumpty Scale
ADULT - Morse Scale
HOW DOES THE HOSPITAL REDUCE THE RISK OF PATIENTS
HARM RESULTING FROM FALLS?
1. Fall risk assessment and prevention
2. Environmental risk assessment prevention
3. Adhering to a system of reporting falls, near falls and fall
hazards
4. Established a post fall protocol of care
5. Provide staff, patient, and family education
6. Conducting regular program evaluation
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WHEN DO WE PERFORM PATIENT FALL RISK
ASSESSMENT?
1. On admission
2. When the patient transfer within the hospital
3. Following any change in clinical status
4. Following a fall or near fall
5. Following any procedure
HOW WE COMMUNICATE A PATIENT'S FALL RISK
STAUS?
1. Include during SHIFT ENDORSEMENT
2. Place a HIGH RISK STICKER IN THE PATIENT'S
ROOM for patients identified to be at high risk
3. Place a HIGH RISK STICKER ON THE COVER OF
THE PATIENT'S CHART for patients identified to be
at high risk
SAFETY
WHAT ARE THE PATIENT AND FAMILY BILL OF
RIGHTS?
1. Rights of MEDICAL CARE
2. Rights of INFORMATION
3. Rights of CONFIDENTIALITY AND PRIVACY
4. SAFETY AND SECURITY
HOW DO YOU ENSURE THE PATIENTS RIGHTS TO
CONFIDENTIALITY AND PRIVACY?
1. Not allowing unauthorized access to the medical
record.
2. Not talking about patient in areas that can be
overheard
3. Not allowing public postings with patient
personal information in view
4. There is physical separation between each
HOSPITAL WIDE
CBAHI AND JCI COMMON ASKED QUESTIONS
patient
HOW DO WE RESPECT OUR PATIENT'S
CULTURE ,VALUES, AND BELIEFS?
1. Providing separate male/female waiting
areas
2. Announcing prayer time
3. Providing Quran, prayer mat and Qibla
sign
4. Providing female physician as per patient's
request
HOW DO YOU PROTECT YOURSELF,
PATIENTS, STAFF, AND VISITORS FROM
INFECTION INSIDE THE HOSPITAL?
1. Comply with the policies and procedures
related to Prevention and Control of
Infection (PCI)
2. Attend the new hire orientation program
on PCI
3. Review with the supervisor/designee, the
current infection control policies and
practices for any specific work area prior to
commencing any working in any area
4. Participate in an annual prevention control
of infection in-service
WHAT SHOULD YOU DO IF THE PATIENT
REFUSED TREATMENT/PROCEDURE?
1. Respect patient's refusal
2. Inform the responsible physician
3. Document and ask the patient to sign
"AMA" form
WHO ARE CONSIDERED VULNERABLE PATIENTS?
1. Children, adolescents, and elderly patients
2. Patients with altered mental status: confused, comatose
3. Patients with altered neurologic status: disturbed gait
4. Patients with emotional or psychiatric disorder
5. Patients with suspected abuse: physical, emotional, sexual
or neglect
HOW DO YOU PROTECT YOURSELF?
1. Follow the infection control policies
2. Be aware of safety measures against fire:
 Know the RACE & PASS protocol
 Know the nearest exit and location of fire extinguisher
3. Document any care properly in the medical records
WHAT DO YOU DO IF SOMEONE BECOMES EXTREMELY
AGITATED OR VIOLENT?
Remain calm
Allow them to verbalized
Keep distance
Keep exit open
Call code purple
WHAT ARE THE RULES THAT GUIDE OUR POLICIES?
HMG'S POLICIES AND PROCEDURE
WHERE CAN WE FIND THE HMG'S POLICY?
On the desktop and nursing station
WHAT IS OVR?
Occurrence Variance Report
WHAT IS INCIDENT REPORT?
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 CBAHI AND JCI COMMON ASKED QUESTIONS

Incident reporting - is one of a number of

mechanism for detecting adverse events WHAT ARE THE EMERGENCY CODES IN OUR HOW DO YOU EXTINGUISH A FIRE?
HOSPITAL? P - Pull the pin on the fire extinguisher
WHEN TO REPORT? CODE BLUE - Medical emergency/cardiac A - Aim the nozzle just above the base of the fire
Reporting of an adverse incident should be done arrest S - Squeeze the handle on the fire extinguisher
immediately not later than 24 hours after the CODE RED - Fire S - Sweep side to side
incident. CODE SILVER - Active shooter
CODE WHITE - Physical Assault and Violence WHAT ARE THE TYPES OF HOSPITAL EVACUATION?
WHAT TO REPORT? CODE BLACK - Bomb threat Horizontal
1. Clinical incident CODE GRAY - Severe weather Vertical
2. Equipment incident CODE ORANGE - Chemical, Biological, Complete Evacuation
3. Personal incident Radioactive spill
4. Violence, abuse or harassment CODE BROWN - Utility Failure WHERE CAN YOU FIND THE DISASTER CONTROL ROOM?
5. Security incident In ER
WHAT IS THE NUMBER YOU SHOULD
HOW TO REPORT? ACTIVATE IN CASE OF EMERGENCY CODE? WHAT ARE THE THREE ELECTRICAL OUTLETS?
An incident form should be completed as soon as BLACK OUTLET - normal power
possible by the staff member involve and passed to 111 - OTHER CODES BLUE OUTLET - long back up without interruption
ward/department head, supervisor and then Except : RED OUTLET - back up with interruption
forwarded to quality office. 2222 - CODE BLUE
4848- CODE BLACK WHAT IS ALLOWED FIRE EXTINGUISHER FOR MRI FIRE?
WHAT IS SENTINEL EVENTS? Aluminum CO2 fire extinguisher
An unexpected occurrence involving death, serious WHAT SHOULD YOU STATE?
physical or psychological injury or risk. 1. State the code WHAT IS MSDS STANDS FOR?
2. Location (floor), department name, your Material Safety Data Sheet
SERIOUS INJURY INCLUDES: name and ID number
1. An unanticipated death or major permanent loss 3. Repeat the code announcement 3x WHAT TYPE OF FIRE EXTINGUISHER CAN BE USED IN CLASS
of limb or function "B" FLAMMABLE LIQUID FIRE?
2. Infant abduction or discharge to the wrong HOW TO CONTAIN A FIRE? Dry powder fire extinguisher
family R - Rescue CO2 fire extinguisher
3. Significant medication errors A - Alarm
4. Patient suicide in hospital C - Contain
5. Maternal death E - Extinguish
6. Surgery on the wrong patient or body part WHAT WILL YOU DO FOR UTILITY MANAGEMENT FAILURE?
DIAL 2000
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 CBAHI AND JCI COMMON ASKED QUESTIONS

service and report to Bio-med.

WHERE ARE THE OXYGEN SHUT - OFF VALVES?
Nursing Stations
WHAT IS THE PROCESS FOR THE CLEANING OF
HAZARDOUS MATERIAL OR CHEMICAL SPILL?
1. Secure the area
2. Contain the spill
3. Identify the chemical before cleaning up
4. Check the MSDS for precautionary measures
COMMONLY USED ABBREVIATIONS:
PPE: personal protective equipment’s
PPM: planned preventive maintenance
SSI: surgical site infection
EOC: environment of care
HAZMAT: hazardous materials

WHO ARE THE RESPONSIBLE FOR SAFETY OF OUR

HOSPITAL?
The Safety Committee:
1. General Safety
2. Fire Safety
3. Security
4. Emergency preparedness
5. Hazardous materials and waste
6. Medical equipment, procurement and
maintenance
7. Utilities management

Safety is an important part of every employee's

responsibility.

WHERE DO YOU FIND INFORMATION REGARDING

EMPLOYEE RESPONSIBILITY?
In the emergency disaster plan which is located in
each department

HOW DO YOU REPORT AN EQUIPMENT

MALFUNCTION?
Put on OUT OF ORDER TAG on it and take it out of
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