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PATIENT SAFETY GOALSGOAL 1: IDENTIFY PATIENTS CORRECTLYIntroductionThe purpose of the Patient Safety Goals is to promote s...
4.0         Policies and Procedures      4.1      Every patient is given a unique MRN and this number is                Pe...
4.10       For outpatients, identification is done by checking against                 the name and MRN on the patient’s a...
PATIENT SAFETY GOALS GOAL 2: IMPROVE EFFECTIVE COMMUNICATION Introduction The purpose of the Patient Safety Goals is to pr...
3.0   Policies and Procedures       4.1 All verbal and telephone orders / test results shall be           Immediately reco...
6.3 Allied Health                    6
PATIENT SAFETY GOALSGOAL 3: IMPROVE THE SAFETY OF HIGHALERTMEDICATIONIntroductionThe purpose of the Patient Safety Goals i...
Wards, Critical Care areas, Operating Theatre, Radiology                 Department and OPD3.0         Definition / Abbrev...
4.6       The pharmacist / physician is contacted if the dose to be                administered exceeds the maximum permit...
PATIENT SAFETY GOALSGOAL 4: ENSURE CORRECT SITE, CORRECTPROCEDURE AND CORRECT PATIENTSURGERYIntroductionThe purpose of the...
2.1       Operating Theatre          2.2       Endoscopy Department  3.0           Policies and Procedures          3.1   ...
PATIENT SAFETY GOALSGOAL 5: REDUCE THE RISK OF HEALTH CAREASSOCIATED INFECTIONIntroductionThe purpose of the Patient Safet...
4.0   Definition / Abbreviation      3.1   WHO- World Health Organization      3.2   CDC- Centers for Disease Control     ...
of the hospital including public areas.         4.6 Indication for Hand hygiene              4.6.1     Before patient cont...
PATIENT SAFETY GOALSGOAL 6: REDUCE THE RISK OF PATIENTHARM RESULTING FROM FALLSIntroductionThe purpose of the Patient Safe...
Wards, Critical Care areas, operating Theatre, Radiology            Department, Physiotherapy Department, Laboratory and  ...
Preventive condition or medications      4.6   Reassessment of patient is required when indicated by a            change i...
ADMISSION TO THE ORGANIZATION1.0 Objectives    1.1 This policy is established to provide effective screening method       ...
a) Patient with the relevant information (patient’s                medical history, clinical examination, investigation   ...
3.6.1   Outpatient follow-up appointment          3.6.2   Referral for elective surgery          3.6.3   Non Elective Admi...
2.0     PROCEDURES ADMISSION        ACTIVITIES                                                 RESPONSIBILITY2.1     ADMIS...
2.1.10 On admission patient should be instructed not to               Ward Staff       leave the ward area without permiss...
DISCHARGE1.0 Objectives    1.1 To ensure a smooth discharge process including documentation,        medication,subsequent ...
ward round and upon agreement from the patient’s response to     treatment, clinical status and investigation results (e.g...
i) Follow up instructions    3.5 Where possible, the discharge process must be completed by        11am.    3.6 The discha...
ACTIVITIES                                                 RESPONSIBILITY2.3     DISCHARGE OF PATIENT2.3.1   Obtain approv...
2.4   PROCEDURES OF AT OWN RISK (AOR) DISHARGE      AND LEAVE PROCEDURE                                   27
ACTIVITIES                                                   RESPONSIBILITY2.4      At Own Risk Discharge2.4.1    Confirm ...
FLOW CHART OF DISCHARGE PATIENT                  Receive order from doctor regarding                         patient can d...
Prepare as below: -                            -     TTA medication by consultant.                            -     Medica...
3.1      Inform Doctor / Medical Officer Immediately              SRN / Trained Staff3.1.1    Push emergency trolley to th...
Carry out manual bagging / defibrillator                         Initiate cardiac massage on the patient          Administ...
Medical officer will examine the patient inside the car to                    confirm whether the patient still alive or n...
2.3    The triage nurse must consult the medical officer on duty when it is unclear as to         which discipline the pat...
Pediatric Parameters:                                  DANGER ZONE VITALS        Age               Blood Pressure    Heart...
3.5.1     Certified death.                                                 Medical Officer or                             ...
not to bring valuable or excessive amount of cash to the      hospital by the booking personnel.4.2   The patient at the t...
4.4     Custody of patient’s properties.                     i)    Properties received must be wrapped                    ...
5.0     POLICIES AND PROCEDURES FOR CHECKING EMERGENCY        TROLLEY         ACTIVITIES                                  ...
ACTIVITIES                                                   RESPONSIBILITY5.2     Replenish of Emergency Trolley5.2.1   R...
TROLLEY                               Daily Checking            Check items listed for :-              a) Stock level     ...
ACTIVITIES                                                   RESPONSIBILITY6.0.1   Inform to the doctor or primary consult...
A) CLINICAL   •   Anaesthesia Event: An event that occurred in the process of receiving anaesthesia that caused harm or   ...
APPENDIX DEFINATION OF INCIDENTS REPORT      INCIDENT                                                  DEFINITION ( For Al...
6.2     POLICIES AND PROCEDURES NEEDLE STICK INCIDENT         ACTIVITIES                                                 R...
7.0    POLICIES AND PROCEDURES STOCK REQUISTION        ACTIVITIES                                                RESPONSIB...
7.1     POLICIES AND PROCEDURES OF UNCONTROLLED DRUGS         ACTIVITIES                                               RES...
FLOW CHART FOR UNCONTROLLED DRUGS                                 WARD          Storage :-                a) Fridge       ...
ACTIVITIES                                                 RESPONSIBILITY7.5.1   Checking of Controlled Drugs        (Inje...
Recording of Controlled Drugs7.5.10   Immediately document any drugs used.                   SN In Charge                 ...
ACTIVITIES                                          RESPONSIBILITY         Collection of Drugs7.5.18   Check the following...
FLOW CHART FOR MANAGEMENT OF CONTROLLED DRUGS (CHECKING DRUGS)                  Checking Of DD during the Passing Over    ...
7.6      POLICIES AND PROCEDURES STORING LIVE VACCINE          ACTIVITIES                                                R...
8.0   POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION       ACTIVITIES                                       ...
FLOW CHART                           DIAGNOSIS                        NOTIFICATION FORM                    (COMPLETELY FIL...
ACTIVITIES                                               RESPONSIBILITY9.1     Renting of Oxygen Cylinder9.1.1   Received ...
9.2     Returning of Oxygen Tank9.2.1   Received phone call from admission counter regarding           Staff Nurse        ...
10.0   POLICIES AND PROCEDURES IN MAINTENANCE REQUISITION       ACTIVITIES                                              RE...
11.0     POLICIES AND PROCEDURES CARE OF PATIENT UNDERGOING RADIOGAPHIC         AND OTHER IMAGING STUDIES         ACTIVITI...
ACTIVITIES                                                 RESPONSIBILITY11.2    Transportation Of Patient For Radiographi...
ACTIVITIES                                                RESPONSIBILITY11.4      Ultra Sound Examination11.4.1    Abdomen...
12.0    POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE        ACTIVITIES                                            ...
ACTIVITIES                                                RESPONSIBILITY  12.3.   Never fill yellow bag more than ¾ full  ...
Housekeeping Personnel to Dispose into Clinical                     Waste Carriage 13. 0 POLICIES AND PROCEDURES MANAGEMEN...
15.1.   GXM ordered by the doctor.                                     Doctor151.1   Patient’s particular in GXM form (PMC...
GXM FORM                 (COMPLETELY FILLED UP)              INFORM LABORATORY TECHNICIAN   SUPPLY AVAILABLE              ...
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Policies and procedure nursing

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Transcript of "Policies and procedure nursing"

  1. 1. PATIENT SAFETY GOALSGOAL 1: IDENTIFY PATIENTS CORRECTLYIntroductionThe purpose of the Patient Safety Goals is to promote specific safety.The goals highlight problematic areas in health care and the policy isdesigned to address these issues and provide strategies to improvepatient safetyGOAL 1- IDENTIFY PATIENTS CORRECTLY1.0 Objectives 1.1 To ensure patients safety by correctly identifying every patient in all aspects of diagnosis, treatment and administrative process2.0 Scope 2.1 All PMC healthcare facilities involving patient Care3.0 Definition / Abbreviation 3.1 MRN - Medical Record Number 3.2 Name – Full name of the patient as per NRIC / Passport 3.3 Patient – outpatients and inpatients 3.4 Patients sticker – a label that is printed with patient data 3.5 Patient data – name, IC Number, MRN, age, gender, nationality, episode number, chief physician, payor and location of the department 1
  2. 2. 4.0 Policies and Procedures 4.1 Every patient is given a unique MRN and this number is Permanent 4.2 Registration personnel must ensure that the patient data is correctly entered during registration 4.3 If a patients is brought in unconscious to the Emergency Department, the patients is registered and identified as ‘UNKNOWN’ and an MRN is given until full details are available 4.4 All patients admitted to the hospital are given the wristband. Wristbands are removed at discharge. If wristband is removed for various reasons, (e, g. surgical procedures) a new band is attached at alternate site or immediately after completion at the procedure 4.5 The admitting nurse must verify the patient’s particulars before sticking the name label on the patient’s wrist. The nursing staff must verify the information on the wrist band with the patient or PAP and ensure patient wears the wristband. 4.6 Before giving any medications, blood, and blood products, taking blood and other specimens for clinical testing, or providing any other treatment or procedure, every patient shall be identified by the two identifiers, i.e. name of patient and MRN. The doctors, nurses and allied health staff must read the wristband, if available, and whenever possible, ask the patient to state his/her full name and IC/ or birthdate. This information must be checked against the PMR. 4.7 In a conscious patients, identification is done by checking against the name and MRN on the patient’s wristband 4.8 In an unconscious patient, identification is done by checking against the name and MRN on the patient’s wristband 4.9 In patients who are unable to identify themselves (especially the young, elderly and mentally challenged) the care provider has to ask the parents or guardians for the name and double check with the MRN on the wristband 2
  3. 3. 4.10 For outpatients, identification is done by checking against the name and MRN on the patient’s appointment card or name and identity card number as stated on the patient’s identity card.5.0 Responsibility 5.1 Physicians 5.2 Nurses 5.3 Allied Health 5.4 Administrative Personnel 3
  4. 4. PATIENT SAFETY GOALS GOAL 2: IMPROVE EFFECTIVE COMMUNICATION Introduction The purpose of the Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and the policy is designed to address these issues and provide strategies to improve patient safety. GOAL 2- IMPROVE EFFECTIVE COMMUNICATION1.0 Objectives 1.1 To improve the effectiveness of communication among Caregivers 1.2 To reduce communication errors and improve patient safety2.0 Scope 2.1 This policy applies to all forms of communication; including writen, verbal and telephone orders among all caregivers 2.2 It applies to all situations, including emergency situations 4
  5. 5. 3.0 Policies and Procedures 4.1 All verbal and telephone orders / test results shall be Immediately recorded, dated and signed by the registered Nurse or allied health staff receiving the order 4.2 The receiver should read back the order to the ordering physician or the test results to the person who gave the verbal report. 4.3 The person who gave the order or test results should confirm after the read-back 4.4 All order / test results shall be documented in the PMR by the receiver and the person who instructed it. 4.4.1 The doctor, nursing and allied health staff must verify the verbal and telephone orders per policy ( write,read back,confirmand witnessed by), and document it in PMR ( Doctor Clinical Notes) PMC023 and PMC 266. 4.4.2 The doctors must document the verbal or telephone order and counter sign, as per hospital requirement within 24 hours. 4.5 In an emergency situation, the receiver will repeat the order verbally or by telephone and must be witnessed by another staff. The instruction must be carried out stat and documentations should be done as soon as possible4.0 Reference 5.1 Private Healthcare Facilities and Services (Private Hospitals and Other Private Facilities) Regulations 20065.0 Responsibility 6.1 Physicians 6.2 Nurses 5
  6. 6. 6.3 Allied Health 6
  7. 7. PATIENT SAFETY GOALSGOAL 3: IMPROVE THE SAFETY OF HIGHALERTMEDICATIONIntroductionThe purpose of the Patient Safety Goals is to promote specificimprovements in patient safety. The goals highlight problematic areas inhealth care and the policy is designed to address these issues andprovide strategies to improve patients safety.GOAL 3 - IMPROVE THE SAFETY OF HIGH ALERTMEDICATION1.0 Objectives 1.1 To provide specific written procedures for the safe storage and handling of medications that has been designated as high-alert medications 1.2 To emphasize high-alert medications so that all health care providers involved in the prescribing, dispensing, and administration of these medications recognize potential risks2.0 Scope 2.1 Patient care areas- Emergency Department, General 7
  8. 8. Wards, Critical Care areas, Operating Theatre, Radiology Department and OPD3.0 Definition / Abbreviation High – alert medications are medications that have a heightened risk of causing significant patient harm when used in error. 3.1 Concentrated electrolytes: 3.1.1 Potassium chloride 3.1.2 Potassium phosphate 3.1.3 Sodium chloride greater than 0.9% concentration 3.1.4 Magnesium sulfate 3.1.5 Calcium gluconate4.0 Policies and Procedures High – alert medications will be prescribed, dispensed, and administered using practices that are stated below in this policy 4.1 Concentrated electrolyte solutions are only stored in the Pharmacy Department and the locked cabinet / trolley 4.2 Name and strength of medication must be verified before administering to the patient 4.3 An independent verification of the medication name, strength, and amount to be administered is conducted by a second trained and qualified individual. Calculations used in determining the amount to be administered are also performed by this individual 4.4 The dose of medications to be administered is prepared just prior to administration as per doctor’s order 4.5 The medication, strength and dose to be administered are compared and confirmed with the patient’s record as per doctor’s order. 8
  9. 9. 4.6 The pharmacist / physician is contacted if the dose to be administered exceeds the maximum permitted 4.7 The double checks are documented in the patient’s record.5.0 Responsibility 6.4 Physicians 6.5 Nurses 6.6 Pharmacists, Dispenser 9
  10. 10. PATIENT SAFETY GOALSGOAL 4: ENSURE CORRECT SITE, CORRECTPROCEDURE AND CORRECT PATIENTSURGERYIntroductionThe purpose of the Patient Safety Goals is to promote specificimprovements in patient safety. The goals highlight problematic areas inhealth care and the policy is designed to address these issues andprovide strategies to improve patient safetyGOAL4- ENSURE CORRECT SITE, CORECT PROCEDUREAND CORRECT PATIENTSURGERY1.0 Objectives 1.1 To establish a uniform process to verify and ensure the correct site, correct procedure and correct patient, including procedures done in settings other than the operating theatre 1.2 To ensure patient’s safety before any surgery or procedure.2.0 Scope 10
  11. 11. 2.1 Operating Theatre 2.2 Endoscopy Department 3.0 Policies and Procedures 3.1 All the patients shall be informed of the location of their Surgical or procedure site in the ward especially when there is more than one possible site. 3.2 The doctor in charge of the patient shall ensure that the exact site of procedure is mentioned in the consent form 3.3 The exact site of procedure shall be recorded in the operating schedule list. 3.4 Pre operative verification shall be done in the ward and in OT using the standard OT checklist. The checklist shall be completed by the ward nurse who sends the patient to OT and the receiving nurse In OT. 3.5 All relevant documents, x-ray films, equipment, instruments and / or implants are available and functional. Team members involved in the procedure are responsible to check the required equipments, instruments/implants.4 Responsibility 4.1 Physicians 4.2 Nurses 4.3 Allied Health5 Related Document 5.1 Operation Theatre Department P & P 5.2 Operation theatre Patient check list (PMC 029) 11
  12. 12. PATIENT SAFETY GOALSGOAL 5: REDUCE THE RISK OF HEALTH CAREASSOCIATED INFECTIONIntroductionThe purpose of the Patient Safety Goals is to promote specificimprovements in patient safety. The goals highlight problematic areas inhealth care and the policy is designed to address these issues andprovide strategies to improve patient safetyGOAL5 - REDUCE THE RISK OF HEALTHCAREASSOCIATED INFECTIONS2.0 Objectives To reduce the risks of health care- associated infections in patients, staff and health workers To prevent and control the transfer of pathogenic micro-organisms between patients and healthcare workers through hand contact.3.0 Scope 2.1 All patient care patient support departments / services 2.2 All staff and visitor/visiting areas 12
  13. 13. 4.0 Definition / Abbreviation 3.1 WHO- World Health Organization 3.2 CDC- Centers for Disease Control 3.3 ICC- Infection Control Committee 3.4 ICN- Infection Control Nurse4.0 Policies and Procedures 4.1 The department and ward incharge/manager, or designee, or ICN shall instruct each employee in his or her role in the prevention of health care associated infection . The incharge/manager will incorporate infection control and prevention practices into departmental policies and procedures according to those formulated by the ICC. 4.2 Educational programs reviewing principles of infection control and prevention will be given to current and newly hired employees involved directly or indirectly in patient care.These programs will include the practical application of infection prevention techniques specific to the nature of service of that department. 4.3 Each department incharge/manager or designee will supervise employees in infection prevention practices, evaluate the need for further training and provide as needed in consultation with ICC. 4.4 The ICC incorporate Standard Precautions into the Hospital – wide Infection Control policies. Proper hand hygiene is the most important measurement for the prevention of spreading infection. 4.5 ICC shall be responsible for the setting up and implementation of hand hygiene guidelines and monitoring compliance for an effective hand hygiene programs. This includes basic hand hygiene instructions/poster in all parts 13
  14. 14. of the hospital including public areas. 4.6 Indication for Hand hygiene 4.6.1 Before patient contact 4.6.2 Before aseptic tasks 4.6.3 After body fluid exposure risk 4.6.4 After contact with patient 4.6.5 After contact with patient’s surrounding5. Responsibility 5.3 Infection Control Committee 5.4 Healthcare workers 14
  15. 15. PATIENT SAFETY GOALSGOAL 6: REDUCE THE RISK OF PATIENTHARM RESULTING FROM FALLSIntroductionThe purpose of the Patient Safety Goals is to promote specificimprovements in patient safety. The goals highlight problematic areas inhealth care and the policy is designed to address these issues andprovide strategies to improve patient safetyGOAL6 - REDUCE THE RISK OF PATIENT HARMRESULTING FROM FALLS1.0 Objectives 1.1 To identify the patient who are at risk of falls 1.2 To reduce the risk of patient harm resulting from falls2.0 Scope 2.1 All patient care areas – Emergency Department, General 15
  16. 16. Wards, Critical Care areas, operating Theatre, Radiology Department, Physiotherapy Department, Laboratory and Blood Services and OPD3.0 Definition / Abbreviation 3.1 A fall – a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions 3.2 An un-witnessed fall- occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there.4.0 Policies and Procedures 4.1 All patients shall be assessed by the nurses for the risk of falls on admission using the Modified Morse Scale. 4.2 All patient categorized with high risk of falls, shall be Identified with a graphic label which is attached to the bed side, room door or PMR. 4.3 The patient and family shall be educated about falls prevention 4.4 The patient and family shall be accompanied by a hospital staff / family member whenever they are out of the bed / ward 4.5 Patient with high risk of falls shall be provided with Fall 16
  17. 17. Preventive condition or medications 4.6 Reassessment of patient is required when indicated by a change in condition or medications 4.7 All falls shall be reported in accordance to the hospital requirements such as incident reporting5.0 Responsibility 5.1 Physicians 5.2 Nurses 5.3 Allied Health 17
  18. 18. ADMISSION TO THE ORGANIZATION1.0 Objectives 1.1 This policy is established to provide effective screening method for patients who may require PMC’s clinical services as patient2.0 Scope 2.1 All patients who are electively referred by their physicians for evaluation 2.2 All patient who present at the PMC’s Emergency Department3.0 Policies and Procedures 3.1 All elective referrals shall be screened for elective outpatient appointment 3.2 All patients presenting to the Emergency Department shall be screened. 3.3 Elective Referrals 3.3.1 Letter by referring physician 18
  19. 19. a) Patient with the relevant information (patient’s medical history, clinical examination, investigation results, medication and past treatment) shall be given an outpatient appointment. b) When patient’s referring letter indicates the need for early appointment, the letter shall be given to the respective on-call consultants or base on patient request 3.3.2 Phone call by referring physician a) The appointment counter staff (Front Office registration assistant) shall request clinical information and schedule an outpatient appointment. When there is a request from referring physician, the phone call shall be transferred to the consultant on- call3.4 Outpatient registration 3.4.1 There is a standardized procedure for outpatient registration3.5 Outpatient Consultation 3.5.1 ECG, Chest X-Ray and necessary blood tests will be done if the patient does not have recent reports. 3.5.2 Clinical evaluation requires medical history, medication history, previous treatment and physical examination 3.5.3 All the results of diagnostic tests will be reviewed by the attending physician for determining if the patient is to be admitted, transferred, or referred3.6 After the outpatient consultation, the patient will be referred for 19
  20. 20. 3.6.1 Outpatient follow-up appointment 3.6.2 Referral for elective surgery 3.6.3 Non Elective Admission for a) Patient from outstation who prefers one visit for consultation and treatment 3.6.4 The patient shall be discharged to the referring physician if he or she does not have follow up in PMC 3.7 Patient shall be informed when there will be a wait or delay in care and treatment. The patient shall be informed the reasons for the delay or wait. This information will be documented.4.0 Responsibility 4.1 Physicians 4.2 Nurses 4.3 Allied Health 4.4 Front Office Registration Assistant 20
  21. 21. 2.0 PROCEDURES ADMISSION ACTIVITIES RESPONSIBILITY2.1 ADMISSION2.1.1 All ambulance patients entering hospital should be A & E Staff provided with expedient attention and care as soon as possible.2.1.2 Patients who are experiencing difficulty in breathing, A & E Staff have unstable vital signs, in severe pain or in a state of unconscious must be attended immediately.2.1.3 The patient should be protected of his legal rights. General2.1.4 All patients must be given an identification band on Ward staff admission. (In patient only)2.1.5 Patients and relatives should be informed of hospital A+R Staff rules and regulation e.g. visiting hours and the hospital telephone number should they wish to phone and enquire about the patient.2.1.6 All valuables and cash are referred to policy on care Ward Staff of property.2.1.7 All medication brought from home and medic alert Ward Staff should be identified and noted to physician.2.1.8 All admission should notify physician immediately. A & E Admission Doctor / Ward Staff2.1.9 Patients with no relatives or unconscious, next-of-kin Sister / Administrator should be notified via police. On Call 21
  22. 22. 2.1.10 On admission patient should be instructed not to Ward Staff leave the ward area without permission of ward sister or nursing staff on duty. ACTIVITIES RESPONSIBILITY SRN / Nursing2.2 TRANSFER OF PATIENT TO OTHER Supervisor HOSPITAL.2.2.1 Obtain approval from respective consultant / medical officer on duty for all patients to be SRN transferred.2.2.2 For patient transfer out of the hospital, obtain referral letter from respective consultant and release it as SRN & Consultant below :- a) To PAP / patient if by own transport b) To accompanying nurse if using hospital ambulance facility. Consultant2.2.3 Ensure that the referring consultant inform the consultant concerned of the hospital regarding the SRN referral.2.2.4 Explain and obtain consent from the patient / PAP Nursing Supervisor / regarding the reason of transfer. Medical officer on duty. a) Transfer of patient to another hospital is requested by PAP / patient, to issue PMC SRN 037. b) Either SRN / Ward aide must accompany the patient if using hospital facilities E g: ambulance2.2.5 Upon transfer of patient, to document and complete the PMC 021. 22
  23. 23. DISCHARGE1.0 Objectives 1.1 To ensure a smooth discharge process including documentation, medication,subsequent management plan, follow up care and patient education.2.0 Scope 2.1 General Wards 2.2 Day Care 2.3 Critical care areas3.0 Policies and Procedures 3.1 Discharge planning is done early in the process of patient care depending on subsequent physician and nursing assessment 3.2 The discharge process is initiated after the daily physician’s 23
  24. 24. ward round and upon agreement from the patient’s response to treatment, clinical status and investigation results (e.g. CXR, ECG, echocardiography following cardiac surgery) allows for patient to be managed at home by the family.3.3 Family members shall be included in the discharge planning. They shall be informed once the discharge decision/process is finalized.3.4 The discharge process involves the following 3.4.1 Medications 3.4.2 Follow up appointment a) Understandable follow up instructions are given to patient and family. b) The instruction include any return for follow up care and when to obtain urgent care c) MC when applicable d) Letter of discharge summary when required by the patient or PAP. 3.4.3 Subsequent management plan 3.4.4 Diet Counseling 3.4.5 Discharge summary / reply to referring institution should be prepared by the attending or designated physician. The discharge summary includes the following information a) Reason for admission b) Diagnosis ( principal and secondary ) c) Relevant physical findings d) Procedures done and copies of operative notes e) Hospital course and complications f) Important investigation results g) Condition upon discharge h) Medications 24
  25. 25. i) Follow up instructions 3.5 Where possible, the discharge process must be completed by 11am. 3.6 The discharge summary / reply shall be prepared in 2 copies. 3.6.1 A copy will be given to the patient at point of discharge. If not completed at the time of discharge, it will be the responsibility of patient to collect it within 2 weeks. 3.6.2 A copy to be retained in the Patient Medical Record. 3.7 PMC will help to arrange for transportation , or to collect patient’s family or friends for transporting ,depending on the patient’s condition and status.4.0 Responsibility 4.1 Physicians 4.2 Nurses 4.3 Physiotherapists 4.4 Dietitians 4.5 Billing clerk. 4.6 Pharmacist/Dispenser 25
  26. 26. ACTIVITIES RESPONSIBILITY2.3 DISCHARGE OF PATIENT2.3.1 Obtain approval from respective consultant / medical SRN officer on duty (with written evidence) for all patients to be discharged.2.3.2 Inform all the secondary consultants regarding the SRN patient been discharged2.3.3 Refer work instruction for nursing procedure, page 5-6 SRN/ward aids as a guideline for discharge2.3.4 Refer nursing policies & procedure 16.1 till 16.1.7, SRN/Nursing page 28 for At Own Risk Discharge Supervisor2.3.5 Discharging of patient who is absconded SRN (a) Notify the primary consultant as soon as the patient found missing (b) To notify the next of kin / PAP/ police (c) Attempt to locate the patient within 1 hour. If still fail to locate within 24 hours, the patient must be discharged by the consultant (d) To notify the nursing supervisor on duty / administrator on call2.3.6 Upon discharge of patient, to document and complete SRN the PMC 021and click in I-Care system after alerted by billing staff 26
  27. 27. 2.4 PROCEDURES OF AT OWN RISK (AOR) DISHARGE AND LEAVE PROCEDURE 27
  28. 28. ACTIVITIES RESPONSIBILITY2.4 At Own Risk Discharge2.4.1 Confirm AOR discharge by doctor’s ordered. Doctor2.4.2 Inform to Sister incharge and Public Relation Manager SN during working hours.2.4.3 After working hours, inform to administrator on call and SN sister on duty.2.4.4 To inform the other hospital doctor if requested by PAP Consultant In Charge / patient with written referral letter before discharge.2.4.5 Explain regarding AOR. Sister, SN Get signature from PAP by using form PMC 037.2.4.6 Refer flow chart of discharge patient.2.4.7 Enter in AOR discharge / leave book. SN, Trained Nurse At Own Risk Leave2.4.8 Inform to consultant to obtain permission after requested SN by patient / PAP2.4.9 Explain regarding AOR Leave procedure SN2.4.10 Get signature from patient / PAP by using form PMC SN 037 and confirm with patient / PAP of time back to unit.2.4.11 Inform to insurance counter in charge if patient admit SN under insurance2.4.12 Supply indicated medication as prescribed in PMC 036 SN2.4.13 If the patient did not return to the ward according to the SN time granted;which should not be more than 24 hours Consultant In Charge otherwise, it will be considered as “ Absconded incident” and the respective consultant is compulsory to discharge the patient automatically. 28
  29. 29. FLOW CHART OF DISCHARGE PATIENT Receive order from doctor regarding patient can discharge 29
  30. 30. Prepare as below: - - TTA medication by consultant. - Medication chart, nursing & doctor notes with tickets and medication, patient in ward. - TCA appointment card. - Record/enter in all admission book. During office hours After office hours Inform ward clerk Inform A & R Once bill ready Inform patient to collect TTA and settle bill. Produce green chit to ward staff (Ward Aids / SRN) Remove name tag and off IV line and vasocan Send patient by wheel chair to patient’s with patient’s property3.0 POLICIES AND PROCEDURES OF CARDIAC PULMONARY ARREST ACTIVITIES RESPONSIBILITY 30
  31. 31. 3.1 Inform Doctor / Medical Officer Immediately SRN / Trained Staff3.1.1 Push emergency trolley to the patient’s bedside. SRN / Trained Staff3.1.2 Maintain airway and observe whether patient is SRN / Trained Staff breathing. Observe vital sign of patient.3.1.3 Carry out manual bagging or defibrillator if SRN / Trained Staff indicated3.1.4 Perform cardiac massage on the patient (CPR) SRN / Trained Staff while waiting for the arrival of the doctor if condition indicated.3.1.5 Administer drug ordered by doctor and record in SRN / Trained Staff PMC 1753.1.6 Observe patient closely by monitoring the SRN / Trained Staff patient’s vital signs and general condition.3.1.7 Prepare patient for intubations if condition Doctor deteriorates.3.1.8 Inform family member by consultant when patient Doctor / Consultant under DIL3.1.9 Emergency case in A&E Refer 2.1 Till 2.18 Refer Triage Accident & Emergency Department : 2.4 3.2 FLOW CHART OF CARDIAC PULMONARY ARREST Inform Doctor / MO immediately 31 Push emergency trolley to the patient’s bedside
  32. 32. Carry out manual bagging / defibrillator Initiate cardiac massage on the patient Administer drugs ordered by doctor. Monitor the patient’s vital signs and general conditions. Observe patient closely Put on ventilator if patient’s condition deteriorates. Inform family member by consultant when patient under DIL 3.3 FLOW CHART FOR EMERGENCY CASES Critical cases / emergency brought in to Putra Medical Centre (PMC) by patient’s relatives using their own transport. Patient to send inICU under the care Old Bring in the patient to 32 patient / of the concern start A&E Dept. and consultant. simple Explain to the resuscitation process. Regular patient ? cases patient’s relatives. If Not
  33. 33. Medical officer will examine the patient inside the car to confirm whether the patient still alive or not. Patient alive Patient dead Survive Yes No Yes No Issue the death Unknown certification & cases buried permit Call up the Ask patient’s concern police and relative to inform the case make police and doctor report by handover the post themselves mortem letter to pathologist GH Body must dispose within 30 minutes to 1 hour. If not, Release the body to police hospital will arrange undertaker when they arrive. to take away.3.4 Triage Accident & Emergency Department1.0 POLICY To ensure patients who arrive at the Accident & Emergency Department will be triaged and treated promptly according to their need for emergency treatment and evacuation.2.0 IMPLEMENTATION 2.1 All patients that arrive at the Accident & Emergency Department shall be triaged by a trained staff / medical officer on duty. 2.2 The triage nurse shall determine the appropriate code of triage based on the trained personnel assessment of the patient. 33
  34. 34. 2.3 The triage nurse must consult the medical officer on duty when it is unclear as to which discipline the patient should be placed. 2.4 Patient who have been triaged GREEN may be allowed to be consulted in the respective clinics or wait for consultation at the waiting area. 2.5 Patient arriving by ambulance is to be triaged by the ambulance nurse.3.0 PROCEDURES There are 3 levels of triage: Critical: - RED (immediately) Semi- critical: YELLOW (5- 15 mins) Non- critical: GREEN (16- 30 mins) Initially the triage nurse assesses the acuity level:- • Stability of vital signs. • Potential life, limb or organ threatened. This is done based on the algorithm of BLS and ACLS. Criteria for triage RED : a) Cardiac arrest, respiratory arrest, severe respiratory distress SPO2<70%. b) Overdose with respiration of < 10 per minute. c) Severe brady/tachycardia with hypo perfusion. d) Polytrauma e) Chest pain, pallor and diaphoretic. f) Anaphylactic shock. g) Epilepsy. h) Hypotension with hypo perfusion. i) Hypoglycemia with change in mental status. j) Baby or child that is flaccid. Criteria for triage YELLOW : a) Chest pain with? Coronary syndrome but stable vital signs. b) Impending stroke c) Ectopic pregnancy with stable haemodynamics. d) Neurological compromised eg: sudden onset of confusion, disorientated and child drowsy. e) Patient in severe pain with changes in vital signs changes eg: renal colic acute abdomen. f) Compound fracture. g) Closed fracture of femur. h) Pelvic fractures Criteria for triage GREEN : a) Close fractures other than femur. b) Soft tissue injuries. c) Urinary tract infection and upper respiratory tract infection. d) Headache with no neurological changes. Assessment also based on physiological changes and vital signs. Adult Parameters: Heart Rate SBP DBP GCS SpO2 Respiratio Temperatur (bpm) (mmHg) (mmHg) (per (%) n e 15) (per min) ( ۫۫ ) C 60- 100 100- 140 60- 90 13- 15 >90 15- 25 36.5- 37.5Green 40- 59 70- 99 40- 59 8- 12 70- 90 10- 14 37.6- 40Yellow 101- 120 141- 200 91- 120 26- 30 34- 36.4 <40 <70 <40 3- 7 <70 <10 <34 Red >120 >200 >120 >30 >40 34
  35. 35. Pediatric Parameters: DANGER ZONE VITALS Age Blood Pressure Heart Rate Respiratio Temperature (SBP)(mmHg) (bpm) n ( ۫۫ C) ˚ (per min)0.1 Month <50 _ >200 >60 <1001 month – 1 year <60 >50 1801 – 4 years <70 >100 <80 >40 >38.5˚ C4 – 8 years <75 1508 – 12 years <80 >140** Indication of Poor Circulation : Cold to touch ,peripheral cyanoses & capillary refill > 3seconds3.5 POLICIES AND PROCEDURES PROCESS OF DECEASED BODY ACTIVITIES RESPONSIBILITY 35
  36. 36. 3.5.1 Certified death. Medical Officer or Doctor In Charge3.5..2 Explain to family the time and cause of death to family Doctor In Charge members.3.5.3 Complete document as below Staff Nurse a) Borang Pengakuan Pegawai Perubatan (JPN LM09) b) Borang Permit Menguburkan (AM138- pin a/78) c) Daftar Kematian (JPN LM02)3.5.4 Discharge procedure to be completed and send for billing Staff Nurse process as soon as possible.3.5.5 Arrange according to family request.3.5.6 Perform last office in proper manner according to the culture Staff Nurse and religion3.5.7 Inform the family members to settle the bill. Staff Nurse3.5.8 After receiving inpatient discharge release form (PMC 097) Staff Nurse from family members, call for transportation.3.5.9 Inform family members the above documents (3.5..3) must Staff Nurse be sent to the registration office within 3 working days.3.5.10 Send the deceased body with the transport as arranged3.5.11 PAP to sign the below document before releasing the Staff Nurse deceased body. a. X-Ray if available b. 3 document as stated above (3.5.3) c. Patient property. d. Panduan melapor kematian.3.5.12 The deceased body should release by maximum of 2 hours. Staff Nurse3.5.13 Send the body to body holding area if PAP unable to collect Staff Nurse within 1 hour.3.5.14 Release body to next of kin with documentation ( maximum A&E Staff Nurse hours to clear the body is within 4 hours )4.0 POLICIES AND PROCEDURES CARE FOR PATIENT’S PROPERTY ACTIVITIES RESPONSIBILITY 4.1 All patients admitted electively must be emphasized Admission Clerk 36
  37. 37. not to bring valuable or excessive amount of cash to the hospital by the booking personnel.4.2 The patient at the time of admission is notified that the Admission Clerk/ hospital authorities cannot accept responsibility for money and personal property unless they are handed Ward Staff over to the authorities for safekeeping.4.3 Record of patient’s properties i) All properties received from the patient must be recorded in the patient’s property form, which must SN be kept locked. ii) One SN and a witness are to receive SN and record patient’s properties. iii) When listing down the patient SN properties, it must be witnessed by the patient and by another third party (it can be patient’ relative or another nurse). iv) Below the signature of the nurse receiving of the properties, the patient and the witness, their full SN name and I/C Numbers must be clearly written for their purpose of identification. v) Care is taken to ensure that descriptions of valuable are accurate SN e.g. metal will be described by color instead of diamond or gold. ACTIVITIES RESPONSIBILITY 37
  38. 38. 4.4 Custody of patient’s properties. i) Properties received must be wrapped and labeled clearly with the following particular :- a) Name of patient b) R/N, I/C no. c) Date received ii) Properties collected must be kept under lock and key at all time. The key must be kept by the medication SN of every shift. iii) Properties must be checked and handed over from shift to shift. 4.5 Handling over patient properties i) All properties must be returned to the patient upon request / discharge ii) The patient must sign in the patient’s property form. iii) The handling over procedure must be witnessed and acknowledged by a third party. In case of death, the properties belonged to the deceased must be surrendered to the immediate relative and documented in similar manner. 4.6 LOSS OF PROPERTY 4.6.1 During office hours the nursing staff must inform the nursing in-charge who will inform the P.R. manager for further investigations. 4.6.1 After office hours, the nursing staff on ‘E’ shift must.1 be informed and she should fill up the incidence reporting form PMC 140 and inform the sister on duty & the P.R. manager A.S.A.P.4.6.1. If it is after 10 pm, to inform the administrator/A & R 2 night supervisor on duty. Advise patient to make a police report4.6.1.3 38
  39. 39. 5.0 POLICIES AND PROCEDURES FOR CHECKING EMERGENCY TROLLEY ACTIVITIES RESPONSIBILITY5.1 Check Emergency Trolley Check emergency trolley every shift as listed in PMC0495.1.1 Check for :-5.1.2 a) Stock level b) Expiry date c) Par level of items listed SN, Trained Nurse d) Working condition of each equipment5.1.3 Check for presence of :- a) Cardiac board b) Drip stand The above checking needs to be documented completely5.1.4 and clearly. 39
  40. 40. ACTIVITIES RESPONSIBILITY5.2 Replenish of Emergency Trolley5.2.1 Replenish trolley immediately after each use.5.2.2 Replace drugs or disposables 3 month prior to expiry date.( Utilize color coding) SN / Trained Staff5.2.3 Report to unit head of any malfunction of equipment.5.2.4 Restore cardiac board and drip stand after use.5.3 Care of Emergency Trolley5.3.1 Check wheels of the trolley are functioning well. Ward Assistant5.3.2 Damp dust and keep trolley clean and tidy always5.4 Position emergency trolley back to its place and ready for use FLOW CHART FOR CHECKING OF EMERGENCY 40
  41. 41. TROLLEY Daily Checking Check items listed for :- a) Stock level b) Expiry date Replenish Stock – PRN a) Replace expiring items b) Report malfunction of equipment Check floor chart emergency trolley correspond to respective sections of the drawers Document in Emergency Trolley Checklist for job done Check for presence of cardiac board and drip stand General cleanliness of trolley6.0 POLICY & PROCEDURE FOR INCIDENT REPORT 41
  42. 42. ACTIVITIES RESPONSIBILITY6.0.1 Inform to the doctor or primary consultant to review SRN / HOD patient immediately upon incident occur Inform to the head of department (H.O.D) immediately6.0.2 SRN / Staff on Duty or nursing supervisor on duty during absence of the H.O.D6.0.3 Obtained and documented the immediate observation of patient involve as a baseline parameter in PMC 140 SRN SRN / HOD6.0.4 Continue monitor the patient accordingly to the need of Observation6.0.5 Issue incident occurred according to PMC 140 (Appendix Event Categories is attach as reference ) HOD6.0.6 Make sure the attending Doctor complete the report after attended the patient SRN6.0.7 Make sure treatment been ordered is carry out accordingly SRN6.0.8 Alert the incident to the investigation team as soon as possible SRN6.0.9 Send the PMC 140 to Quality Assurance department within 24 hours HODINCIDENT REPORTING EVENT CATEGORIES The following categories are reportable events and near misses; 42
  43. 43. A) CLINICAL • Anaesthesia Event: An event that occurred in the process of receiving anaesthesia that caused harm or had possibility of causing harm to a patient. • Surgical Event: An event that occurred in the process of any surgical procedure that caused harm or had the possibility of causing harm to a patient. • Cardiology Event (Adult and Paediatric): An event that occurred in the process of receiving treatment and procedure that caused harm or had possibility of causing harm to a patient. • Blood Administration: An event that caused or had the possibility of causing inappropriate blood product administration. Such events may be related to professional practice, procedures and systems including, but not limited to, ordering, labelling, dispensing, storage, administration and education. • Fall Event: An event in which a patient or visitor is on the ground as a result of an unplanned occurrence. • Medical Device: An event that includes any unintended functioning of any product, device, instrument, or machine that is used to diagnose, treat, or prevent disease. This includes, but not limited to, implants, infusion pumps, catheters, monitors, scopes and gauze pads. If event involves malfunction of Medical Device, the Bio-Medical Engineering Department also must be informed. • Restrain / Seclusion: An event that caused or had the possibility of causing harm to a patient directly related to the use of restrains or seclusions. • Treatment Delay: An event that caused or had the possibility of causing a delay in treatment and/or a prolonged hospital stay. Such events may be related to procedures and systems including, but not limited to, patient transportation, availability and scheduling of diagnostic tests, and timely ordering and processing or orders. • Medical Records: An event that caused incomplete medical records such as missing specimen result, X- Rays, notes, procedures report, surgical report or other patient’s medical record was found in another patient’s medical record. • Nursing Care: An event that caused or had the possibility of causing harm to a patient directly related to nursing care • Medication: An event that cause or had the possibility of causing inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient , or consumer. Such event may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labelling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. • Other: Miscellaneous event is an event that caused or had the possibility of causing harm to a patient / visitor / staff. But that does not fit into any of the other clinical categories. B) NON CLINICAL • Building and Non Medical Equipment: An event that caused disruption in hospital operation due to malfunction of equipments such as interruption in telephone system/power supply, water leakage and others. • Interpersonal conflict: Conflicts between staff and patient / family, staff and staff. • Security Lapse: An event that occurred due to security lapse. • Administrative Error: An event that occurred as a result of mistake in clerical and administrative process. • Miscellaneous: Miscellaneous event is an event that caused or had the possibility of causing harm to a patient / visitor / staff. But that does not fit into any of the other event categories. Example; sexual harassment, absconded. 43
  44. 44. APPENDIX DEFINATION OF INCIDENTS REPORT INCIDENT DEFINITION ( For All Locations ) Fall from any place e.g.bed,stretcher,chair or anywhere e.g.toilet,bathroom or while Fall ambulating wrong drug,dosage,formulation,route of administration,rate of administration,timing Medication error of administration or diluting solution.Others include:omission or extra dosage of drug wrong identification of investigation e.g.radiology,laboratory etc resulting in treatment Investigation or procedure being carried out when it is not necessary or may even cause morbidity error to the patient Adverse outcome complication arising from a procedure resulting in morbidity or mortality of procedure e.g.pneumothorax following Subclavian venous access,bleeding following liver biopsy or OGDS,burn following defibrillation etc Transfusion error wrong pack of blood or its products for the intended patient,expired blood Needle stick injury caused by needle or sharp e.g.Scalpel blade. injury contaminated with patients blood when a piece of equipment or instrument played a part in the morbidity or mortality Equipment related e.g.ventilator failure causing hypoxic brain injury/death,electrocution,suction device injury malfunction causing aspiration,cyclinder ran out of oxygen while transporting patient, laser or diathermy burns etc. Birth Injury caused by instruments e.g. forcep and mismanagement by health care team ( For OT use ) Cardiac / respiratory any cardiac or respiratory arrest that occur intra-operative or in recovery room arrest Wrong procedure procedure or surgery carried out which was different from what was intended performed e.g.wrong limb being operated on,wrong space for laminectomy etcWrong patient operated uponUnplanned return to the e.g.relaporatomy to secure homeostasis following Cholecystectomy.Does not include OT within 24 hours planned procedure e.g.removal of pack after laporatomy with abdominal packing done surgery or staged procedure e.g.disloughing for burnsIncorrect surgical count e.g.gauze,sponge / instruments / needle 44
  45. 45. 6.2 POLICIES AND PROCEDURES NEEDLE STICK INCIDENT ACTIVITIES RESPONSIBILITY6.2 Needle Stick Incident6.2.1 Staff pricked by sharp. Staff involved6.2.2 Perform first aid → squeeze the blood from puncture site immediately. → run under tap water.6.2.3 Staff involved to inform sister in charge / senior staff during sister’s absent6.2.4 Inform the infection control nurse. SN / Sister In charge6.2.5 Staff involved to see medical officer immediately. Infection Control Nurse / Sister In Charge6.2.6 Fill up the incident reporting form together with staff involved and submit to QA.6.2.7 Inform the infection control doctor regarding the Medical Officer incident.6.2.8 Refer the case back to the infection control Doctor for further investigation and follow up.6.2.9 The incident will take over by infection control Doctor for follow up.6.2.10 Refer Putra Medical Centre Guidelines on the control All employees of hospital acquired infection flow chart for needle stick incident page 43. 45
  46. 46. 7.0 POLICIES AND PROCEDURES STOCK REQUISTION ACTIVITIES RESPONSIBILITY 1. Check the stock in hand and balance. In Charge 2. Fill in the request form- Icare system In Charge 3. Send the request form to storekeeper as schedule In Charge 4. Receive the stock and check as ordered. SN 5. Keep stock in respective storage areas. SN / WA FLOW CHART OF STOCK REQUISITION Check stock in hand and balance Fill in request form/Icare Send request form to storekeeper as schedule Receive stock and check Keep stock in respective storage areas 46
  47. 47. 7.1 POLICIES AND PROCEDURES OF UNCONTROLLED DRUGS ACTIVITIES RESPONSIBILITY7.1 Storage of Uncontrolled Drug7.1.1 Store drugs as indicated by manufacturer SRN7.1.2 Store drugs in fridge, medication trolley / patient’s individual slot and lotion cupboard for all under external use only.7.1.3 Keep storage place clean always7.2 Replenish of Uncontrolled Drugs (stock)7.2.1 Replenish daily Dispenser7.2.2 Check stock balance / par level before indenting.7.2.3 Use uncontrolled drugs requisition form (PMC 082) for SN indenting.7.3 Document of Drugs7.3.1 Write drugs strength dosage of drugs in medication SN In Charge chart as per column provided. Medication7.3.2 Initial in respective frequency column upon SN In Charge administration to patient. Medication7.4 Unit Dose Drugs7.4.1 Indent non – stock drugs from pharmacy using SN medication chart7.4.2 Check number of drug supplied whether tally with SN number written in quantity column in medication chart.7.4.3 Return all non – stock drugs to pharmacy on the same day when a patient is discharged. 47
  48. 48. FLOW CHART FOR UNCONTROLLED DRUGS WARD Storage :- a) Fridge b) Medication Trolley – stock individual slot c) Lotion cupboard Replenish – daily a) Stock b) Non – stock (unit dose) Documentation – Medication Chart7.5 POLICIES AND PROCEDURES OF CONTROLLED DRUGS 48
  49. 49. ACTIVITIES RESPONSIBILITY7.5.1 Checking of Controlled Drugs (Injectables and Oral Drugs) SRN In Charge7.5.2 Check DDA drugs every shift for the balance of each Medication / Trained drug as documented in DDA Record Book Staff7.5.3 Check drugs expiry date (if expiry date is 3 months before due date – send to Pharmacy for exchange).7.5.4 Passing Over of Controlled Drugs Pass over from shift to shift regarding drugs used and amount balance. SRN In Charge7.5.5 Check and receive the balance of all dangerous drugs Medication / Trained and document in DDA Record Book. Staff Keeping And Storage of Dangerous and Psychotropic Drugs7.5.6 Keep drugs in DDA cupboard with double lock at all times7.5.7 Keep DDA par level at all times. SN In Charge Medication / Trained7.5.8 Keep empty ampoules for exchange. Staff7.5.9 Any broken / missing dangerous drug ampoules to be reported immediately to pharmacist in charge Sister, SN ACTIVITIES RESPONSIBILITY 49
  50. 50. Recording of Controlled Drugs7.5.10 Immediately document any drugs used. SN In Charge Medication / Trained7.5.11 Document the following particulars :- Staff a) Name of patient b) Registration number of patient c) Date and time administered d) Specify drugs and dosage given e) Stock balance of the drug f) Name and initial of SN who has given the drug g) Name of consultant who ordered drug h) Two SN to counter check7.5.12 Document drugs and dosage in patient’s medication chart. Document time given. For outpatient: record in patient’s case note.7.5.13 Refer Centralized Psychotropic flow chart for overall handling7.5.14 Replenishment of Controlled Drugs Indenting SRN In Charge Medication / Trained7.5.15 Indent drugs in DDA indent book. Write in balance Staff and the amount required.7.5.16 Send the following items to Pharmacy when indenting :- a) DDA indent book b) DD Record Book c) Empty ampoules of injectables7.5.17 Follow indent schedule as given by the Pharmacist. 50
  51. 51. ACTIVITIES RESPONSIBILITY Collection of Drugs7.5.18 Check the following when collecting drugs from SRN In Charge Pharmacist:- (SRN to collect drugs) Medication / Trained Staff a) Amount supplied tally with requisition note b) Total of drugs supplied7.5.19 Sign at the following columns to indicate receipt SRN In Charge of correct amount Medication / Trained Staff a) DDA indent Books b) DDA Record Book Keep and store drug in DD cupboard under double7.5.20 lock. 51
  52. 52. FLOW CHART FOR MANAGEMENT OF CONTROLLED DRUGS (CHECKING DRUGS) Checking Of DD during the Passing Over Check all DD balance tally with amount in DD Record Book Lock DD & PD in cupboard DD key kept by SN / trained staff 52
  53. 53. 7.6 POLICIES AND PROCEDURES STORING LIVE VACCINE ACTIVITIES RESPONSIBILITY7.6.1 Receiving Life Vaccine7.6.1. Nursery staff will order in pharmacy requisition form Trained Staff1 for live vaccine. Collect the live vaccine from pharmacy in the prepared Trained Staff7.6.1. cold chain bag2 Storage of Live Vaccine7.6.2 Store in compartment temperature of 2°c to 8°c.7.6.2. To check temperature of the fridge two times a day Trained Staff1 and record it in the fridge temperature chart.7.6.2. If any changes in temperatures, the sister in-charge Trained Staff2 must be notified immediately. All live vaccine is to be disposed after use in a sharp Trained Staff7.6.2. bin.3 Ensure the temperature of the fridge is maintained at Trained Staff / Sister 2°c to 8°c. In Charge7.6.2.47.6.2.5 53
  54. 54. 8.0 POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION ACTIVITIES RESPONSIBILITY8.1 Diagnosed by the consultant in-charge with Consultant In Charge supporting investigation results (X-Ray, blood result) if available8.2 Patient’s particulars in notification form to be filled Trained Nurse up.8.3 Notification form (Borang : Health 1 Rev 2001) must Consultant In Charge be completely filled up regarding the final diagnosis8.4 Notification form must be stamped with the PMC SN chop and signed by the consultant on the lower left side corner of the form.8.5 Notify the Public Health Inspector (PHI) on call SN through the nearby state health office by phone or fax stat, when indicated.8.6 Dispatch the original copy to the nearby State Health Office Assistant/Sr. Office (SHO). To notify online first. Incharge8.7 Carbon copy must be kept in patient file / ticket. SN8.8 Notification chop must be stamped in the admission card inside the patient’s file & PMC 022 SN 54
  55. 55. FLOW CHART DIAGNOSIS NOTIFICATION FORM (COMPLETELY FILLED UP) NOTIFY STATE HEALTH OFFICE BY FAX OR PHONE ORIGINAL COPY CARBON COPY (KEPT IN (DESPATCH TO SHO) PATIENT’S OFFICE) NOTIFICATION CHOP STAMPED IN PATIENT’S FILE / TICKET (ADMISSION CARD)9.0 POLICIES AND PROCEDURES RENTAL OXYGEN TANK 55
  56. 56. ACTIVITIES RESPONSIBILITY9.1 Renting of Oxygen Cylinder9.1.1 Received phone call regarding rental of oxygen Staff Nurse cylinder.9.1.2 Prepare the items as below :- Staff Nurse i) Oxygen cylinder according to the request. ii) Flow meter. iii) Stand for oxygen cylinder iv) Precaution from for home oxygen use.9.1.3 Explain the rental procedure to the person concerned. Staff Nurse9.1.4 Fill in rental oxygen form in double copy and confirm Staff Nurse the size of oxygen tank before filling up.9.1.5 Bring the person concerned to billing department to Ward Aid / Staff Nurse collect deposit as below. i) Size E RM 1200.00 deposit and the usage is RM 280.00. ii) Size F RM 1800.00 deposit and the usage is RM 490.00.9.1.6 Send original copy to billing department and duplicate Ward Aid / Attendant copy will keep in A&E.9.1.7 After office hours the collection of deposit will be Admission Clerk carry out by admission counter.9.1.8 The person concerned to be reminded to keep the receipt of payment. ACTIVITIES RESPONSIBILITY 56
  57. 57. 9.2 Returning of Oxygen Tank9.2.1 Received phone call from admission counter regarding Staff Nurse returning of oxygen tank.9.2.2 Receive empty tank in proper condition and send to Staff Nurse / Ward maintenance for refill. Assistant9.2.3 Bring the person concerned to billing department to Ward Aid / Staff Nurse collect deposit with the duplicate form.9.2.4 After office hours the deposit to be collected the next Billing Clerk working day. 57
  58. 58. 10.0 POLICIES AND PROCEDURES IN MAINTENANCE REQUISITION ACTIVITIES RESPONSIBILITY10.1 Confirm the faulty equipment. Sister, Staff Nurse, Midwife10.2 Fill up the maintenance request form, PMC 051 Sister, Staff Nurse, Midwife10.3 Dispatch PMC 051 to the maintenance department. Female Attendant10.4 Maintenance staff comes to the ward to check the equipment.10.5 Repair is to be done stat if is possible. Maintenance Staff10.6 If repair cannot be done in the ward, then the Female Attendant equipment has to be sent to the maintenance department.10.7 Once the job is completed, the staff from maintenance Maintenance Staff department will fill up the last part of the form as evidence that job has been done. 58
  59. 59. 11.0 POLICIES AND PROCEDURES CARE OF PATIENT UNDERGOING RADIOGAPHIC AND OTHER IMAGING STUDIES ACTIVITIES RESPONSIBILITY11.1 Preparation For The Examination11.1.1 Patient must be informed of the Radiographic / Doctor Imaging Studies planned for him.11.1.2 All requests for Radiographic and Imaging Studies Doctor, SN must be ordered by the attending doctor and completed request form (PMC 058) with signature.11.1.3 PMC 058 to be sent to X-Ray Department A.S.A.P Ward Assistant / Female Attendant11.1.4 Ensure that all specific preparation and investigation Staff Nurse (if any) are carried out accordingly.11.1.5 All previous X-Ray films must accompany patient Staff Nurse when going for subsequent Radiographic / Imaging Studies.11.1.6 Ensure that all female patients are not pregnant before Staff Nurse / any radiographic examination. If a patient is suspected Radiographic to be pregnant, it must be notified to the doctor for further instruction.11.1.7 All female in-patients must change into hospital gown, Staff Nurse have jewellery and bras removed if the radiographic examination is required on the upper part of the body. 59
  60. 60. ACTIVITIES RESPONSIBILITY11.2 Transportation Of Patient For Radiographic / Imaging Studies.11.2.1 Assess the condition of patient to determine the type of Staff Nurse transportation suitable for the patient.11.2.2 All patients with intravenous therapy can be sent down to radiology department when call.11.2.3 Decide if ill cases need a staff nurse or ward aid to SN, Sister accompany throughout the examination.11.3 Patient Undergoing Radiographic Examination Using Radiopaque Contrast Medium.11.3.1 Obtain history for any indication of allergies that might SN cause an adverse reaction to the contrast medium.11.3.2 Obtain consent from patient if indicated Doctor11.3.3 Be encouraged to take plenty of fluid (if there is no SN contraindication) following administration of radiopaque contrast medium. 60
  61. 61. ACTIVITIES RESPONSIBILITY11.4 Ultra Sound Examination11.4.1 Abdomen and liver, gall bladder and pancreas. Ward Aid, Female Patient must be fasted from midnight or at least 4 Attendant hours before the examination. For afternoon appointment, breakfast is allowed then nothing by mouth thereafter. N. B. Infant – no preparation is required.11.4.2 Kidney, thyroid glands and liver only. No preparation SN is required.11.4.3 Organs in the pelvic cavity. A full urinary bladder is SN, Trained Nurse required. Patient is advised to take plenty of fluid if there is no contraindication.11.5 Magnetic Resonance Imaging (MRI)11.5 .1 Send PMC 058 to X-Ray department as requested SN Confirm with X-Ray coordinator regarding the appointment date and time.11.5.2 Patient is advised to remove all metal items / SN jewellery from the body.11.5.3 All patients are to change into MRI gown. WA11.5.4 Nurse in charge is to do MRI checklist before SN sending patient down with MRI stretcher / wheel chair for MRI procedure.11.5.5 N.B. For Infant, uncooperative children and restless patient, sedation may be necessary as ordered by the Doctor. 61
  62. 62. 12.0 POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE ACTIVITIES RESPONSIBILITY12.1 Types of Clinical Waste12.1. Segregate clinical waste in appropriate groups :- SN1 a) Sharps and objects b) Clinical waste Disposal of Sharps and Objects12.2 Discard sharp instrument and objects e.g. syringes, SN12.2. needles cartridges and scalper blades into sharps1 container. Do not re sheath or re-cap before discarding into sharp bins.12.2.2 Do not leave used sharps lying around Never fill sharp container more than two-third full.12.2.3 Ensure that sharp containers are securely closed before disposal.12.2.4 Replace with new sharp container as soon as possible. H / Keeping Personnel12.2.5 Place 2/3 full sharp container into clinical waste carriage H / Keeping Personnel12.2.6 Disposal of Clinical Waste SN Discard the bellow item listed clinical waste into12.2. yellow bag e.g. soiled surgical dressing, cotton SN7 wool, gloves, swabs material used to clean spillage.12.312.3.1 62
  63. 63. ACTIVITIES RESPONSIBILITY 12.3. Never fill yellow bag more than ¾ full SN 2 Tie the bag with plastic seal H / Keeping Personnel 12.3. 3 Tag with label and send to clinical waste carriage at H / Keeping Personnel holding area 12.3. 4 Replace with new clinical waste bag into bin H / Keeping Personnel 12.3. 5 FLOW CHART OF CLINICAL WASTE WARD SHARPS CLINICAL WASTE e.g. a) Dressings b) Drains Discard into Sharp Bin Dispose into Yellow Bag Seal Sharps Bin When 2/3 full when ¾ full with the sealerDiscard sealed sharp bin by Housekeeping to clinical waste carriage at holding area Seal Yellow Bag when ¾ full with the sealer Replace sharp bin by Housekeeping Dispose into clinical waste carriage (Yellow Bin) – as supply by company at holding area by Housekeeping Replace Yellow Bag by Housekeeping 63
  64. 64. Housekeeping Personnel to Dispose into Clinical Waste Carriage 13. 0 POLICIES AND PROCEDURES MANAGEMENT OF BLOOD GROUP AND CROSS MATCH PROCEDUREACTIVITIES RESPONSIBILITY 64
  65. 65. 15.1. GXM ordered by the doctor. Doctor151.1 Patient’s particular in GXM form (PMC 071) Trained Nurse. (original and CC) can be filled up by the trained Nurse (e.g. full name, 12 digit IC no / passport no, RN, etc). Patient’s diagnosis and reason for request must be Doctor151.2 clearly stated and signed the PMC 071.. Inform the laboratory technician for requested test / procedure.15.1.3 In any case that there’s no available supply in the Laboratory Technician center to be informed to ward staff stat15.1. Inform the doctor stat SN4 Send second set of PMC 071 for the doctor concern SN, Doctor to sign.15.1.5 To call the blood bank in-charge in General Doctor Hospital Alor Star (GHAS) to inform the needs and15.1. request of the supply urgently.6 Document the exact date and time in PMC 071 Doctor15.1. The 2nd PMC 071must be sent to laboratory stat Doctor, SN7 after the necessary requirements has be arranged15.1.815.1.9 FLOW CHART DOCTOR’S ORDER 65
  66. 66. GXM FORM (COMPLETELY FILLED UP) INFORM LABORATORY TECHNICIAN SUPPLY AVAILABLE SUPPLY UNAVAILABLE PROCEED WITH - Send 2nd GXM form to the doctorTRANSFUSION AS DOCTOR’S concern and arrange with blood bank ORDER GHAS in charge - Write the exact date & time in PMC 071 SEND THE 2nd GXM FORM TO LAB BLOOD SUPPLY AVAILABLE PROCEED TRANSFUSION AS DOCTOR’S ORDER 66

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