ESSENTIAL

SAFETY
REQUIREMENTS

Quality & Patient Safety Department

Al-Noor Specialist Hospital, Makkah
ESR Frequently Asked Questions
Patient safety is one of the principal foundations of our health
services and this is a magnificent chance to reflect and plan together
how we can deliver a safe, effective and good quality patient care as
our core interest and promote the culture of patient safety among all
hospital staff. Upon my appointment as the Director of Al-Noor
Specialist Hospital, we have noticed an increasing concern on
patient safety across all Ministry of Health hospital in the Kingdom
including accrediting body like Saudi Central Board for
Accreditation of Healthcare Institution (CBAHI), with the launch of
the Essential Safety Requirements (ESR) which is a selected
standard among all the CBAHI standards.
As part of promoting patient safety, the MOH thru their ESR survey
teams are visiting all MOH hospitals in the kingdom for compliance.
It is vital that we understand the perception that patient safety is in
our hand and not somehow external to the delivery of healthcare. I
expect from all staff, no less than the compliance of ESR standards
in your respective departments. Families had entrusted their loved
ones into the care of doctors and nurses in our hospital, and we can’t
take that trust for granted.
Finally, I wish us all the success in promoting patient safety culture
in our hospital. It is the responsibility of everyone worker in our
hospital, Clinician, Nurses, Managers, and Support staff – to ensure
that they take account of the patient safety aspects of their role and
to create a safe environment for all our staff, patients and visitors.
Your commitment to patient safety is our priority. I commend all of
you for those efforts and your commitment and leadership.

Dr. Fawaz Hamdi Al-Jehani

Hospital Director
Al-Noor Specialist Hospital, Makkah
This booklet would not have been possible without the support and
encouragement of the Hospital Leader Dr. Fawaz Hamdi Al-Jehani.
My appreciation to the QPS team and special thanks to
Dr. Harris Radzak Ali and Ms. Rania Shahzad for the wonderful job
they did on this project. The extra time and effort they put in this
booklet was certainly worthwhile. It is a pleasure for me to work
with such a hardworking and dedicated team of professionals.

Mr. Ghofran Homossani

Director, Quality and Patient Safety Department
Al-Noor Specialist Hospital, Makkah
A selected group of standards among the CBAHI standards have
been assigned as Essential Safety Requirements indicated in the
CBAHI manual with the icon ESR.
Essential Safety Requirements are selected based on their level of
risk on patients: proximity of risk, probability of harm, severity of
harm, and number of patients at risk. As the name indicates,
Essential Safety Requirements are defined as essential structures and
practices represented in the CBAHI manual by a selected group of
standards that the hospitals undergoing CBAHI accreditation must
have in place and be in full compliance with, to minimize the risk of
serious harm and/or death of a patient or a staff member.
The list was not meant to be all-inclusive of essential safety
requirements but rather, a focus on some areas that are relevant to
our national context. ESRs are scored similar to the old
physiological principle; the “All or None Law “, meaning that a
standard that represents an Essential Safety Requirement is scored
during the on-site survey as a full rate or zero, depending on the
level of compliance as evidenced by documentation/interview/or
observation of the surveyor.
Partial compliance will not be acceptable for any ESR and
accreditation award will not be granted unless all ESRs are in full
compliance.
 ESR FAQS

1. Human Resource ----------------------------------------- 2

2. Provision of Care ---------------------------------------- 4

3. Laboratory------------------------------------------------ 9

4. Medical Staff--------------------------------------------- 10

5. Anesthesia ------------------------------------------------ 11

6. Medication Management ------------------------------- 13

7. Quality Management & Patient Safety---------------- 19

8. Infection Prevention & Control------------------------ 26

9. Facility Management and Safety----------------------- 29

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 ESR FAQS

Q1. What is the process that gives the hospital staff members
licensed to provide patient care?
Ans: Staff credentialing and privileging by accreditation from Saudi
Council for Health Specialties.

Q2. How many days for a new staff to complete registration in

Saudi Council?
Ans: Maximum 90 days from joining work in our hospital.

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Q3. Who is responsible for verification and gathering of

credentials of qualifications from outside Saudi Arabia?
Ans: a. Dataflow
b. Our HR director sends verification thru email to the
university who issued the degree certificate and put in his
file the confirmation report.

Q4. How an employee does define his/her roles, responsibilities,

qualifications and organizational relationship?
Ans: His/her signed job description.

Q5. How do you make sure that a qualified medical staff can
admit and provide clinical services consistent with their
qualifications?
Ans: Through the medical privileges approved by the credentialing
and privileging committee.

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 ESR FAQS

Q1. What is blood Transfusion therapy?

Ans: Blood transfusion is the intravenous administration of the
whole blood or blood components for therapeutic purposes.

Q2. What is to be secured prior to transfusion of blood?

Ans: Consent for blood transfusion

Q3. Who is responsible to obtain consents or documenting

refusal on consent form?
Ans: Physician

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Q4. Who will explain the blood transfusion procedure to the

patient or significant others?
Ans: Physician.

Q5. What is the policy in case of an emergency blood transfusion

e.g. emergency, lifesaving, and there was no written
consent?
Ans: Blood transfusion should not be withheld in emergency.
Document in the patient file the circumstances requiring
transfusion. According to the hospital policy, two signature of
a physician will sign the consent for blood transfusion in case
of emergency.

Q6. What is to be done prior to requesting, collecting from

blood bank and before administering the blood?
Ans: Identify the patient by 2 unique identifiers:
a. At least 3 names according to hospital policy (preferably
3 names for Non-Saudi and 4 names for Saudi nationals).
b. MRN number or Temp. Number if patient is not yet
admitted.

Q7. What is to be done if signs of blood transfusion reaction

occur?
Ans: Step to do:
a. Stop immediately the blood transfusion and inform the
physician.
b. Fill up the transfusion reaction Investigation form.
c. Fill up the e-HERF form
d. Send the transfusion reaction Investigation form to the
lab together with the blood sample from the patient and
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e. Remaining blood bag. Keep a copy of the form inside

the patient file.
f. Submitting the e-HERF in the system
g. Document in the progress notes of patient file the blood
reaction incident that happened.

Q8. What the nurse should do upon initiating the blood

transfusion?
Ans: The nurse should observe the patient closely for the first 5 to
15 minutes after the blood transfusion is initiated.

Q9. How often the vital signs must be monitored?

Ans: Vital signs for the 1st hour must be monitored every 15
minutes, then 30 minutes on 2nd hour then hourly for the next
hours until transfusion is completed and for the next 2 hours
post transfusion.

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 ESR FAQS

Q1. What is VTE?

Ans: Venous Thromboembolism.
Q2. If the patient is immobile or bedridden, what risk is he/she
likely to develop?
Ans: VTE

Q3. What is to be done to avoid a patient from developing VTE?

Ans: VTE risk assessment is to be done on every adult patient and if
identified at risk of developing a VTE, appropriate
pharmacological and/or mechanical prophylaxis will be given.

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Q4. Who are to be assessed for the risk of VTE?

Ans: All adult patients (more than 18 years old) upon admission to
the hospital.

Q5. What is the form to be used in the assessment for VTE?

Ans: VTE Prevention/VTE patient Assessment Sheet
Note: Form attached in the policy and procedure Management
of patient at risk for developing VTE.

Q6. What are the types of prophylaxis for VTE?

Ans: Pharmacological (e.g. Heparin) and Mechanical Prophylaxis
(Compression Devices e.g. Elastic Compression stockings or
intermittent pneumatic compression(IPC).

Q7. As healthcare giver, what is one of the responsibilities to

promote patient's safety?
Ans: By proper identification of the patient.

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 ESR FAQS

Q1. Are you aware of policies and procedure mandating that a

sample of blood obtained from a donor during blood/blood
component collection are subjected to infectious disease
testing?
Ans: Yes (Please review the policies in the Public (Drop Box) in
the laboratory folder).
Q2. Are you aware of Transfusion Transmitted disease testing
for blood sample from a donor?
Ans: Yes, testing for Hepatitis B, Hepatitis C, HIV, serological test
for syphilis and other.

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 ESR FAQS

Q1. Do you have clinical privilege or competency?

Ans: Yes

Q2. Do you know the validity of your clinical privilege?

Ans: Yes, every 2 years

Q3. How do you access the clinical privilege of the physicians?

Ans: I can access through the hospital Drop-box then Public folder.

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Q1. Who will administer anesthesia in Al Noor Specialist

Hospital (NSH)?
Ans: Only qualified anesthesiologist will administer anesthesia in
our hospital.

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Q1. Do you know the conscious sedation area in your hospital?

Ans: Yes, conscious sedation areas are ER, ICU, Endoscopy,
Invasive radiology, Vascular Cath.

Q2. If you are a staff of the above conscious sedation area, do

you have conscious sedation certificate and privilege to
provide conscious sedation (Physician) or have competency
(nurses)?
Ans: Yes, if you have (make sure your personnel file contains both
certificate and privilege or competency.

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Q1. What do you mean by High Alert Medication?

Ans: The medication which are potentially lethal and can be
dangerous to the patient if used mistakenly.

Q2. Where can you find the High Alert Medication in NSH?
Ans: In ER, ICU, MICU, OR, Pharmacy department, Inpatient (both
medical and surgical), Dialysis units, CCU, Burn, Endoscopy.

Q3. How do you store the high alert medication?

Ans: All high alert medication will be stored in cabinet with lock
and properly labeled.

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Q4. What precaution to be done in preparing, dispensing and

administering of high alert medication?
Ans: Independent Double check and awareness of LASA
medication.

Q5. What is Independent Double Check (IDC)?

Ans: A procedure in which two clinicians separately check (alone
and apart from each other, then compare results) each
component of prescribing, dispensing, and verifying the
High- Alert Medication before administering it to the patient.

Q6. Give example of High Alert Medication?

Ans: Insulin, Heparin, Potassium Chloride, Magnesium sulfate,
Narcotics and controlled drugs.
Q7. From where you will get the list of High Alert Medication?
Ans: List distributed by the Pharmacy Department as attachment
policy and procedure regarding high alert medications.

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Q1. What are LASA medications?

Ans: Look Alike Sound Alike Medication.

Q2. Give example of LASA medications?

Ans: According to the list from Pharmacy Department.

Q3. Where can I find the LASA medication lists in your

Department?
Ans: In the medication room.

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Q1. What is Medication Error?

Ans: Any preventable event that may cause or lead to inappropriate
medication use of patient harm while the medication is in the
control of the healthcare professional or patient.

Q2. What are the types of Medication Error?

Ans: Prescribing error, Transcription error, Dispensing error,
Administration errors, and Monitoring errors, Documentation
error.

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Q3. What is Prescribing Error?

Ans: Incorrect drug product selection, dose, dosage form, quantity,
route of administration, concentration, rate or frequency of
administration, illegible prescription or medication order
leading to error, wrong patient, wrong timing.

Q4. What is Dispensing Error?

Ans: Any unintended deviation from an interpretable written
prescription or medication order including contents and
labeling errors; any unintended deviation from professional or
regulatory references.

Q5. What is Administration Error?

Ans: Any deviation from the prescriber's medication order as
written on the patient's chart, manufacturer's
preparation/administration instructions.

Q6. What is Near Miss Event?

Ans: An error which does not reach the patient or cause harm due to
timely intervention.

Q7. What is Hazardous Situation?

Ans: Circumstances in which patients may be exposed to one or
more medication error due to many reasons such as confusion
over LASA drugs or similar packaging.

Q8. How do you report Medication Error?

Ans: In an e-HERF Form and Medication Error Form which should
be filled by the discoverer and forwarded to the Quality and
Pharmacy Department respectively.

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Q9. Within how many hours should the Medication Error

Reporting Form be forwarded to the Pharmacy
Department?
Ans: 24 to 48 hours.

Q10. If Medication Error has reached the patient and either

cause harm or not, what should we do?
Ans: The treating physician should be informed immediately, the
patient should be kept under close observation and vital signs
should be monitored and medication error report should be
filled and submitted to the pharmaceutical department
immediately. Disclosure to the patient by the attending
physician and documentation in the patient file.

Q11. What is Adverse Drug Reaction (ADR)?

Ans: An unintended physical reaction to a drug when it is used in
the approved manner. An allergic reaction (immunologic
hypersensitivity, occurring as the result of unusual sensitivity
to a drug) and an idiosyncratic reaction (abnormal
susceptibility to a drug that is peculiar to the individual) are
also considered ADR’s.
Q12. How to prevent recurrence of Adverse Drug Reaction in
NSH?
Ans: By encoding the drug name that causes the adverse reaction to
the patient file in the Hospital Information System (HIS). So
next time the same drug will be prescribed to the same patient,
a red alert will flush in his/her electronic file, thereby
preventing the physician to prescribe the same medication
again to the same patient.
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 ESR FAQS

Q1. How do you identify your patient?

Ans: Patients are identified using at least two unique identifiers.

Q2. What are the 2 patient identifiers?

Ans: 1. Patient's name: at least 3 names according to hospital policy
(preferably 3 names for Non- Saudi and 4 names for Saudi)
2. Medical Record Number (MRN).

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Q3. When are we going to identify patient?

Ans: a. Before giving medications, blood or blood products.
b. Before taking blood and other specimen for testing.
c. Before providing any treatment and procedures
d. Before invasive procedures
e. Patients are identified in all situations and locations of the
hospital.

Q4. What are some processes of identifying patient?

Ans: a. By asking patient to state his full names (at least 3 names
plus family name)
b. By asking the attendant for pediatric patients or unable to
talk.
c. By checking the wristbands/ID band.

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Q1. What is Site Marking?

Ans: Site marking is identifying the site for surgery or invasive
procedure that involves:
a. Laterality (right or left)
b. Multiple structure (fingers, toes, lesions)

Q2. Who will do the site marking?

Ans: Attending Surgeon or Physician only (NO Nurse is allowed to
do the site marking even ordered by the physician or surgeon).

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Q3. Where do you document the Site Marking?

Ans: In the patient Medical Record (Physician progress notes,
Physician Orders, Nurses Progress Notes, Pre-Operative
Checklist Form)

Q4. How do you involve the patient in the marking site process?
Ans: By asking the patient (conscious patient) to state his/her full
name and to state the procedure and site of surgery as well as
point of the site.
Note: If the patient is a minor or unable to verify the information,
the verification process must, as possible, take place with
parents or legal guardian.

Q5. What is to secure before any surgery or invasive procedure?

Ans: Informed consent for Surgery/ procedure.

Q6. What is an Informed consent for Surgery/procedure?

Ans: Informed Surgical Consent is a deliberate decision given or in
writing agreeing to perform a procedure or operation on the
patient concerned, provided the person consenting is aware of
the nature and scope of the treatment, the risks involved and
the reason for carrying it out.

Q7. When the site marking is completed?

Ans: Preferably, the site marking is completed before patient enters
the Operating Room/Procedural Area.

Q8. Is it acceptable to mark the site with "X"?

Ans: NO, it is recommended this " " site marking to be used to
mark the procedure site.

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Q9. What is TIME-OUT?

Ans: Time-out is the second phase of the 3 phases of the safe
surgery checklist. It is the period before incision of the skin.
Also known as the "surgical phase" where the whole team
takes a momentary pause just before the incision of the skin in
order to confirm that several essential safety check is
undertaken and it involves everyone in the team.
The team should apply the following elements:
a. All team members have introduced themselves by name
and role.
b. Surgeon, Anesthesiologist and Nurse verbally confirm
patient, site and procedure.
c. Anesthesia team reviews if there are any patient specific
concerns.
d. The equipments are ideally sterilized.

Q10. When is TIME-OUT done?

Ans: Before skin incision during surgery and before starting the
procedure in any special procedure like ICT insertion.

Q11. What are to be read out loud and clear during the TIME-
OUT phase?
Ans: a. Confirm correct patient
b. Confirm correct procedure
c. Confirm correct site
d. Confirm correct side
e. Confirm correct patient position
f. Confirm all required equipments are available and
functioning.
g. Operative plans and possible difficulties
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h. Expected duration of the procedure

i. Anticipated blood loss
j. Anesthesia plans
k. Other issues and concerns

Q12. Where do you document the verification process in

operating room?
Ans: Safe Surgery/procedural checklist form.

Q13. What are the 3 phases of verification process in OR?

Ans: Sign-In
Time-out and
Sign-out

Q14. What is Sign –In?

Ans: In Sign-In, we have to ask and check these following elements
before Induction of Anesthesia/before starting the procedure:
a. Identity
b. Surgical site marking
c. Consent
d. Operation procedure
e. Confirm completion of pre-operative checklist
f. Known allergy
g. An anatomically difficult airway intubation or aspiration
risk
h. Risk of blood loss more than 500 ml in adult and 7ml/kg
in pediatric
i. Has Antibiotic given to the patient within the last 60
minutes.

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Q15. What is SIGN-OUT?

Ans: In these steps, the circulating Nurse verbally confirms with the
team these following elements before patient leaves OR:
a. The name of the procedure recorded.
b. The instrument, sponge and needles count complete and
correct.
c. Is the specimen labeled including patient name, file
number and tissue type.
d. Surgeon, Anesthesiologist and Nurse review the key
concern for recovery and management of the patient.

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Q1. Are you aware if your hospital has Infection Prevention and
control Committee?
Ans: Yes (Please review committees in the Drop-Box)

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Q1. Do you have a negative pressure isolation room in your

Department, and are you aware of isolation precaution?
Ans: If yes, know the location and ensure that Personal Protective
Equipment (PPE) is available all the time.

Q2. Are you aware of precaution-based transmission card

(isolation sign)?
Ans: Yes, it is posted outside the patient's room with color coding
in both English and Arabic according to the patient's

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diagnosis. We use isolation sign also during transport of the

patient to other areas e.g. Radiology.

Q3. Do you use N95 mask on airborne precautions patient?

Ans: Yes (ensure its availability all the time and fitting test).

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Q1. In cases of radiation safety compromise in the hospital,

whom to call?
Ans: Radiation safety officer at extension 1419.

Q2. How frequent are you monitoring your TLD badge?

(For radiology staff only)
Ans: Quarterly or every 3 months.

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Q1. What are the codes for Internal Disasters?

Ans:
a. Code RED ------------- Fire
b. Code BLUE-------------Cardiac arrest
c. Code WHITE-----------Combative Abuse
d. Code PINK -------------Child Abduction
e. Code ORANGE-------- Radioactive, Biological/Chemical spill
f. Code Black--------------Aggressive Person
g. Utility Failure-----------7333

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Q2: What are the codes for External Disasters?

Ans:
a. Code YELLOW----------------Alert
b. Code RED ----------------------Full
c. Code GREEN-------------------All Clear

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Q1. What are the firefighting systems in the Hospital?

Ans: a. Sprinkler system only in the stores.
b. Carbon dioxide system in Electrical Stations.
c. Fire extinguisher (Foam) System.
d. FM200 Information System Algorithm in the Medical
Records.
e. Cleaning System in the kitchen.

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Q1. Do you know the nearest fire exit in your location?

Ans: Find the exit signs and locate the fire exit nearest to you.

Q2. What will you do in case of fire?

Ans: Call 777 and Activate RACE and PASS.
R-escue P-ull the pin
A-larm A-im low at the base of the fire
C-ontain S-queeze the handle
E-xtinguish S-weep from side to side

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Q1. How does NSH maintain the integrity of safe healthy

environment from fire and smoke?
Ans: Strict compliance of "No Smoking Policy"

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Q1. Do you know how to shut-off the medical gas emergency

valve in you counter?
Ans: Charge nurse has the key to close the emergency panel located
behind the nursing counters that is available 24 hours.

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