Essential Safety Requirements (ESR) Program

Survey Agenda
( 1 Surveyor - (1) Day - < 200 Beds)

Time Activity Counterparts

08:00 – 8:30 Morning Planning Hospital leadership

Unit Visit
08:30 – 09:00 Hospital Designee
(Radiology)

Unit Visit
09:00 – 09:30 Hospital Designee
(Medical Gases and Compressors Rooms)

Unit Visit
09:30– 10:00 Hospital Designee
(Kitchen, Server Rooms, Medical Record)

Unit Visit
10:00 – 10:30 (Elevator Mechanical Room, Electrical Room, Hospital Designee
Fire Alarm Control Room, Wearhouse)

10:30 – 12:00 Documents Review Hospital Designee

12:00 – 12:30 Surveyors’ Business Lunch

Unit Visit
Inpatient Ward & Isolation Room
12:30 – 13:15 Hospital Designee
Conscious Sedation area
Operating Room (Holding Area/ Recovery)

Unit Visit
13:15 – 14:00 Hospital Designee
ICU/ER & Isolation Rooms

Unit Visit
14:00 – 15:00 Pharmacy (Inpatient & Outpatient) Hospital Designee
Blood bank -Laboratory

15:00 – 15:30 Closed Medical Record Review Hospital Designee

15:30 – 16:00 Personnel File Review Hospital Designee

16:00 – 16:30 Data Entry

ESSENTIAL SAFETY REQUIREMENTS SURVEY VISITS

 DOCUMENT REVIEW LIST
SN Document Required
1 Policy for Credentialing and Privileging
Multidisciplinary and/or Blood Utilization Committee Approved Policies and Procedures on Handling,
Use and Administration of Blood and Blood Components including:
2
a. Blood transfusion consent form.
b. NAT consent form (as applicable).
3 Policy for identification and management of venous thromboembolism
4 Policy for patient identification
5 Policy for preventing wrong patient, wrong site, and wrong surgery/procedure
6 Infection Control Annual Plan
7 Infection control committee’s term of references and meeting minutes
8 Policy for Standard and Transmission-based Precautions
9 Policy for Personal Protective Equipment
10 High-alert Medications and Hazardous Chemicals Multidisciplinary Plan
11 High-Alert Medications and Hazardous Chemicals List
12 Policy for Handling Look-alike/Sound-alike Medications
13 Hospital List of Confusing Drug Names (Both look alike and sound alike in separate tables/lists)
14 Policy for Handling Medication Errors, Near-misses, and Hazardous Situations
15 Pharmacy and Therapeutics Committee Meeting Minutes
16 Evidence of reporting sentinel events related to serious medication errors to the relevant authorities.
17 Laboratory policy, process and procedures on transfusion transmitted disease testing
18 Laboratory policy, process and procedures on limiting and detecting bacterial contamination in PC
19 Radiation Safety Policy
20 KACST License for Radioactive Materials
Valid Civil Defense license for private hospitals. For governmental hospital, civil defense reports and
21
approved action plan.
22 Fire Alarm Inspection Schedule and Reports
23 Fire Alarm Testing Schedule and Reports
24 Fire Alarm Preventive Maintenance Schedule and Reports
25 Fire Alarm System Distribution
26 Sprinkler System Inspection Reports
27 Clean Agent System Inspection Reports
28 Wet Chemical System Inspection Reports
29 Stand Pipes and Hose System Inspection Reports
30 Policy for No Smoking
31 Medical Gas System Testing Schedule and Reports
32 Policy and Procedure on Effective Use of Medical Gas System

ESSENTIAL SAFETY REQUIREMENTS SURVEY VISITS