Kingdom of Saudi Arabia

Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT

Surveyor
1. What is CBAHI?
 stands for Central Board for Accreditation of Healthcare Institutions
2. What is ESR?
 Substandard of CBAHI stands for Essential Safety Requirements
3. What are your Hospital Mission /Vision?
 Mission: To provide safe medical services to all
patients using the updated scientific
technology in accordance with the international quality
standards.
 Vision: To be one of the best hospital in the kingdom practicing
evidence based medical
services and to be one of the healthcare knowledge centers .
 Values: C- continuous quality improvement
A- Achieve more than the patient expectation
R- Respect the right of the patients and staff
E- Effective care based on international quality standards
S- Safe and productive work environment
T- Teamwork
4. What are the 6 International Patient Safety Goals (IPSG)?
 Identify patient correctly
Nursing &  Improve effective communication
 Improve the safety of High Alert medications
Leadership/Qu  Ensure correct site, correct procedure, correct patient surgery
 Reduce the risk of healthcare associated infection
ality  Reduce the risk of patient harm resulting from fall
5. What is the 2 patient identifier in patient identification?
Management  Patient Name (asking “what is your name? / 4 names for Saudi and 3
names for non-Saudi)
 Medical Record Number (MRN)/Temporary # for E.R patients
 Note: Room and/or bed number Are Never Used as patient identifiers
 When to identify patient:
a) Upon admission
b) Upon giving medicines, blood or
blood products.
c) Taking blood samples and other specimens for clinical
testing
d) Surgical intervention or any invasive procedure
e) Confirmation of death
f) X- ray and imaging
g) Patient transfer
If no information regarding patient identity is available, a
temporary name using letters (i.e. Name: unknown A) will be
assigned until identification process is completed
NEW BORN shall have three ID bands:
 The ID band shall be applied to the infant's right and left ankles and to the
wrist.
 The band have the following information:
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
Baby’s Name using Mother’s First and Surname
Infant’s Date and Time of Birth
Infant’s Gender
Mother’s Individual Hospital Number (MP)

4) What is your Nursing Department Vision/Mission?

Mission:
The Nursing Service in Prince Mohd bin Nasser Hospital is committed to serving
all patients through provision of patient centered & safe nursing care by
competent Nurses utilizing modern equipment with Continuous Quality
Improvement perspective.

Vision:
Nursing Service & Education excellence with local, national and international
recognition for provision of culturally-appropriate and high quality nursing
care that exceeds all expectations.

Values:
RESPECT- we value our patients
INTEGRITY-we do right thing with accordance to Islamic morals
COMMITMENT- we keep our words
EXCELLENCE- we provide our best standard of quality care to our patients
SELFLESS SERVICE- we prioritize our patients

6) How you will ensure that staff is able to care for critically-ill patient?
-through Annual Competency & On-going education
6) What is your Nursing Department Scope of Service?
7) What is your Unit Scope of service
8) What is your patient care delivery system?
- Total patient care
9) How you create staffing plan?
-Telford method & California nursing staff ratio by
MOH through patient volume
10) How are you making patient daily staff assignment?
-according to patient acuity and staff competency
11) How are you communicating with other health care team regarding patient
care?
-following ISBAR method (Identify, Background, Assessment and
Recommendation) which is use in hand over of patient to improve safety in the
transfer of critical information. This may improve communication within
multidisciplinary teams, ensuring accurate handover of information between
shifts.)
12) What form is used for hand over?
Critical Care unit –Endorsement sheet form
Kardex- for general wards
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
6. What is Occurrence Variance Report (OVR)?
 OVR - this is an internal form which is issued to document the details of
the event, the investigations of an occurrence and the corrective actions
taken. The documentation of any incident involving patients, visitors,
equipment or any other situation that is likely to lead to undesirable effects
or that varies from established policies and procedures or practices. Non-
punitive
7. Define Sentinel Event.
 SENTINEL EVENT is defined by JCI as any unanticipated event in a
healthcare setting resulting in death or serious physical or psychological
injury to a patient/s not related to the natural course of illness.
a) Wrong Patient
b) Wrong Site Surgery
c) Hemolytic Blood Transfusion Reaction (depends on the severity,
otherwise Adverse Event)
d) Suicide in an Inpatient Unit
e) Retained Instruments or Sponge
f) Intravascular Gas Embolism
g) Major Medication Error leading to Death or Major Morbidity
h) Maternal Death
i) Infant Discharged to a Wrong Family.
j) Infant Abduction
k) Unexpected Death
l) Unexpected Loss of a Limb or a Function
m) Rape/ physical assault of patient, staff, or visitor
 OVR and Sentinel Event Reporting Form (SERF) must be used
8. Define Near Miss.
 NEAR MISS is an unplanned event that did not result in injury, illness, or
damage but had potential to do so. Also known as CLOSE CALL.
Note: all sentinel events & Near Miss must have Root Cause Analysis (RCA)

What is Performance Improvement Tools?

 FOCUS-PDCA is a strategy that provides a roadmap for continuous process
improvement and to guide the improvement efforts. It’s simply a nine step
process guide to quality improvement.
F-FIND a process that needs improvement
O-ORGANIZE a team who is knowledgeable in the process
C-CLARIFY the current knowledge of the process (draw flowchart / collect
data relevant to desired
outcomes
U-UNDERSTAND the causes of variation
S-SELECT the potential process and improvement

P-PLAN identify the problems

D-DO test potential solutions
C-CHECK study results
A-ACT implements the Best Solution
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
What is KPI and what’s your unit KPI?
KPI-Key Performance Indicators
How you educate patient and their families?
-through Interdisciplinary patient and family education form and patient
orientation checklist
How are you planning your nursing care?
-through Nursing Care plan (ADPIE)
What is discharge planning?
-starts from first patient contact until discharge by assessing socio-economic &
functional status
How to ensure correct site, correct patient, and correct patient?
 See the availability of privilege file in OR , complete all privilege signed
,updated ,approved by medical director
 Use the Pre-operative Checklist & Surgical Safety Checklist to ensure all
preparations are done; and needed documents are in the patient files as the
diagnostic results, patient’s identity, and consent, full details of the
procedure and any implant or prosthesis.
 The pre-operative checklist shall be part of the patient’s record to be
endorsed to the Operation Room department
 What is SURGICAL MARK?
A) Use an indelible uniform colored marker pen that is universal all
over the hospital.
B) The mark should be SS means surgical site, or near to, the incision
site and remain visible after the application of skin preparation. Before
shifting patient to O.R
C) It is desirable that the mark should also remain visible after the
application of theatre drapes
D) Surgical marking from must be filled up by the surgeon and nurse as
witness
 What is the VERIFICATION PROCESS (Time Out)?
-TIME OUT- immediately before starting the procedure by:
Active communication among all members of the surgical/procedure team,
consistently initiated by the Surgeon or a designated member of the team,
conducted in a “fail-safe” mode, i.e., the procedure is not started until any
questions or concerns are resolved.
VERIFICATION PROCESS (Time out) is done before procedure (must be
read out LOUD)

Sign in Time Out Sign Out

If there is discrepancy:
1. A discrepancy at any point must stop the case from proceeding until
resolved.
2. All team members and patient (if possible) must agree on the
resolutions to the identified.
3. The discrepancy and resolution must be documented by the physician,
registered nurse, radiology technician or other appropriate healthcare
professional involved in the case.
 All patient having invasive procedures must have surgical safety checklist
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
even outside O.R
e.g. E.D patient for I & D
Hema/Onco patient for bone marrow
Patient for central line
Cath. Lab. patients for pci/angio
Infection  What is Negative Pressure?
-The isolation room with negative pressure must have Ante-Room that serves as a
Control & site for hand washing, gowning and storage of protective clothing (gloves, aprons,
masks Toilet, shower, or tub and hand washing facilities are provided for each isolation
Precaution room)
 The isolation room must be monitored for the following:
-Weekly monitoring if no patient
-Everyday monitoring if there is patient
 Nurse must check:
-Pressure (-2.5 to -16 Pascal)
-Temperature (make sure thermometer inside the room)
 Maintenance must check:
-Humidity
-Air flow (12 air exchange/hour)
 If there is HEPA , the filter must be replaced every 6 month
 Airborne Precaution ( as Pulmonary tuberculosis, Chicken pox Measles, MERS-
COV ) Blue Card
-Use a single room with a negative air pressure system
-HCWs must wear an N95 mask/respirator before entering the room
- instruct patient with Cough etiquette
-Transporting Patients on Isolation practitioner (Limit the transport of patients to
essential medical purposes., notify the department before transporting patient, Place
a surgical mask on the patient if he/she must leave the room follow the nearest way
to reach the needed location, cover the transporting chair with clean dressing, and
clean the chair with antiseptic after return back of patient
 Droplet Precautions ( as Mumps, Scarlet fever, Pneumonia, Streptococcal
Pharyngitis diphtheria (pharyngeal), Pneumonic plague, Rubella) Pink Card
-Use a single room. A negative air pressure room is not indicated.
-Wear appropriate PPE (surgical mask, gloves, and gown) as needed.
-Place a surgical mask on the patient if he/she must leave the room
 Contact Precaution (MRSA,VRE, Pseudomonas Aeroginosa, MDR) Green Card
-Use a single room. A negative air pressure room is not indicated.
-Wear appropriate PPE (surgical mask, gloves, and gown) as needed.
-Place a surgical mask on the patient if he/she must leave the room
 Standard statement of the number of isolation room (one isolation room for every
25-30 bed) in addition one isolation room in ER.
 N95, N99, and fit test- Fit test card must be in numbers
Follow the manufacturer’s user instructions, including
conducting a user seal check.
-Follow the employer’s maximum number of donning
(or up to five if the manufacturer does not provide a
recommendation) and recommended inspection
procedures.
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
-Discard any respirator that is obviously damaged or
becomes hard to breathe through.
-Pack or store respirators between uses so that they do
not become damaged or deformed.
- N95 respirators must only be used by a single wearer
-Label containers used for storing respirators or label
the respirator itself between uses with the user’s name
to reduce accidental usage of another person’s
respirator.
 What is PPE?
-Personal Protective Equipment (Donning &
Doffing)

 What is the Universal precaution?

-Hand Hygiene
a) Hand wash-with soap and water (40-60 seconds)
b) Hand rub- Alcohol-based hand sanitizers (20-40 seconds)
 What are the 5 moments of Hand Hygiene?

 What are the Infection Control Bundles?

-CLABSI- Central Line Associated Blood stream Infection
CAUTI- Catheter Associated Urinary Tract Infection
VAP- Ventilator Associated Pneumonia
SSI-Surgical Site Infection
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
 How to ensure sterility of instruments after CSSD?
-By following Event-related sterility
a) No Discoloration
b) No breakage in the pouch
c) No touching 3x
LABORATORY What is Panic or Critical Values?
-Panic value is any value defined to be outside the normal range for the patient’s laboratory
investigation/ medical imaging may result in harm to the patient.
How to report Panic values?
- Once confirmed, critical values will be directly communicated to
the patient’s nurse who will be asked to “READ BACK” the
critical values to the technologist to verify correct
communication. It will be the responsibility of the nurse to
contact the physician to convey the critical value and request
orders.
What is Policy & Procedure in handling, use & administration of Blood & Blood
Products?
 The nurse must identify patient before cross matching ,
-the patient is identified by name and medical record
-the patient must be involved in identification
-the identification must be double check and must be documented
- the EDTA tube must be labeled in front of patient after blood
drawing
 Physician is responsible to obtain informed consent or documenting
refusal on consent form
 Blood Transfusion should not be withheld in emergency situation.
Document in the patient file the circumstances requiring transfusion.
Using Blood transfusion without NAT form by the physician
 The criteria of informed consent is:
-Description of the transfusion process.
-Identification of the risks and benefits of the transfusion.
-Identification of alternatives including the consequences of refusing
the treatment.
-Giving the opportunity to ask questions.
-Giving the right to accept or refuse the transfusion
 All blood in PMNH has NAT (Nucleic Acid Amplification Testing ) is a
highly-sensitive method of testing blood that is used to detect Hepatitis C
virus (HCV), Human Immunodeficiency Virus (HIV-1) and West Nile Virus
(WNV) in blood. Most traditional screening tests require the presence of
antibodies to trigger a positive test reaction
 If blood transfusion occurs nurse must do the following:
1. Stop the infusion immediately; keep the line open with a slow
infusion of normal saline
2. Notify the treating physician immediately (carry out orders as
ordered)
3. Re-Check the identification of the patient and the identification of
the blood infused
4. Monitor and document the vital signs
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
5. Notify the Blood Bank
6. Extract 5 ml blood specimen in EDTA tube and send to the blood
bank, send Urine specimens, send blood culture to microbiology unit
(especially if there is more than one degree rise in the patient
temperature)
7. Completely fill a Blood Transfusion Reaction Form, Blood wastages
form if there is any
8. Submit to Blood bank together with the blood bag and IV tubing’s
9. OVR to be completed and send to Nursing Quality
 TYPES OF BLOOD REACTION :
Symptoms & Signs Interpretation
 Chills, fever , Hemolytic transfusion
Haemoglobinuria,hypertensio Reaction.
n, back pain, DIC,(oozing from
IV sites) pain along the
infusion site with anxiety
 Fever (>38.5oC), chills, Febrile Non Hemolytic
headache, vomiting
 Urticaria, pruritus, flushing Allergic Reaction
 Hypotension, urticaria, Transfusion-related
bronchospasm acute lung injury (TRALI
Local edema, anxiety )
- acute lung injury caused
by blood transfusion
9. What is High-Alert-Medication (HAM)?
MEDICATION  High-Alert-Medication (HAM) defined as those medications which could cause harm/
immediate life threatening condition on patient if an error in administration occurs.
MANAGEMEN  Precaution:
T UNIT (MMU)  Prescribing:
a) Staff nurse must ensure physician order written legibly (Kcl is not allowed must be
written potassium chloride)
 Storage:
a) Must be stored in locked cupboard in Medication Room
 Labeling:
a) Must be labeled with RED STICKER (HIGH ALERT)
 Administering:
a) Independent Double Checking must be done by two nurses during preparation
b) Medication should be countersigned by two nurses
 Telephone order for HIGH ALERT MEDICATION (HAM) & Narcotic
Medication is NOT ALLOWED
 Verbal order only given during life threatening situation (Code Blue).
Narcotic Medication is NOT ALLOWED as verbal order
 Must be stored in LOCKED CUPBOARD
 Must be labeled with RED sticker
 Must do Independent Double Checking (2 nurses checking separately
together with loud voice)
 Must be ordered by doctor legibly and in generic
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT
name
10. What are Look-Alike-Sound-Alike (LASA) medications?
 Look-alike-Sound- alike (LASA) medications must be stored separately
using BLUE sticker using TALLman (Capital letter)
 Sample of LASA medications:
DOPAmine DOBUTAmine ATENOlol TIMOlol
11. What is Medication Error and how to report it?
 Medication error- any preventable event that may harm or not harm the
patient that occur in any stage of medication process (prescribing,
transcribing, dispensing ,administration, monitoring ),using prohibited
abbreviations
 Near miss or close call -A medication error that was detected and
corrected before it reached the patient'
 Using Medication Error Reporting Form (M.E.R.F) No Blame, No
Punishment
 Original copy in file
 Photocopy to pharmacy
The person who discover
error

Error did not Error reach patient

reach patient
(Near Miss)
Inform physician

The physician monitor

patient for any
complication

The person who discover error, report the error in the

form (MERF), the physician write his comment in the
specified space

Forward the copy of the form to pharmacy to make

analysis and recommendation
12. What are hospital Codes?
FACILITY  Code Blue-Cardiac Arrest
 Code Red- Fire
MANAGEMEN  Code Yellow-External Disaster
T SAFETY  Code Pink- Infant/Child abduction
 Code Orange- Chemical Spill
(FMS)  Code Grey-Sever Weather
 Code White- Bomb Threat
 Code Brown- Utility Failure
 Mr. Strong- Violent behavior
 Code Green- All clear
 Code Silver- Active Shooter/Weapon
 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING DEPARTMENT