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Guide to understanding essential safety requirement standards

PREPARED BY DR. MOHAMED RAMZY YOUSEF HOSPITAL QUALITY COORDINATOR QUALITY & PATIENT SAFETY DEPARTMENT 25-10-2017

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GUIDE TO UNDERSTANDING
ESSENTIAL SAFETY REQUIREMENT
STANDARDS
‫ى‬ ‫املرض‬ ‫لسالمة‬ ‫االساسية‬ ‫املتطلبات‬
PREPARED BY
DR. MOHAMED RAMZY YOUSEF
HOSPITAL QUALITY COORDINATOR
QUALITY & PATIENT SAFETY DEPARTMENT
25-10-2017
TOGEATHER WE
CAN DO IT
2
QUALITY
A WAY OF LIFE
Guide to understanding essential safety requirement standards
‫مقدمة‬
•‫املنش‬ ‫العتماد‬ ‫السعودي‬ ‫املركز‬ ‫وضع‬‫آت‬
‫األس‬ ‫الوطنية‬ ‫املتطلبات‬ ،‫الصحية‬‫اسية‬
‫من‬‫قائمة‬ ‫في‬ ‫ى‬ ‫املرض‬ ‫لسالمة‬20
ً
‫ا‬‫ر‬‫معيا‬‫من‬
‫و‬ ،‫للمستشفيات‬ ‫الوطنية‬ ‫املعايير‬‫ها‬‫ر‬‫اعتبا‬
‫به‬ ‫ام‬‫ز‬‫االلت‬ ‫يجب‬‫أساسية‬ ‫اطات‬‫ر‬‫اشت‬‫ا‬
‫م‬ ‫ى‬ ‫املرض‬‫سالمة‬ ‫لضمان‬ ‫كامل‬ ‫بشكل‬‫ن‬
‫الصحية‬ ‫بالرعاية‬ ‫املتعلقة‬ ‫األخطاء‬.
•‫عل‬ ‫الحالية‬ ‫املرحلة‬ ‫في‬ ‫ة‬‫ر‬‫ا‬‫ز‬‫الو‬ ‫ركزت‬‫ى‬
‫ا‬ ‫في‬ ‫البالغة‬ ‫ألهميتها‬ ‫املعايير‬ ‫هذه‬‫ملرحلة‬
‫املعايير‬ ‫هذه‬ ‫وشملت‬ ‫اهنة‬‫ر‬‫ال‬9‫أقسام‬
‫التالي‬ ‫النحو‬ ‫على‬ ‫مختلفة‬
The Central Board for
Accreditation of Health care
Institutions has set the basic
national requirements for patient
safety in a list of 20 national
hospital standards as key
requirements that must be fully
adhered to, to ensure patient
safety from healthcare errors.
In the current phase, the
Ministry has focused on these
criteria for its very importance at
the current stage.
These standards included 9
different sections as follows
‫البشرية‬ ‫د‬‫ر‬‫املوا‬Human Resources ( HR )
‫الطبية‬ ‫ة‬‫ر‬‫اإلدا‬MedicalStaff ( MS )
‫الرعاية‬‫توفير‬Provision of Care ( PC )
‫الجودة‬ ‫ة‬‫ر‬‫إدا‬QualityManagement ( QM )
‫التخدير‬Anesthesia Care ( AN )
‫ومكافحتها‬‫ى‬‫العدو‬‫من‬‫الوقاية‬InfectionPrevention andControl (
IPC )
‫األدوية‬ ‫ة‬‫ر‬‫إدا‬MedicationManagement ( MM )
‫املختبر‬Laboratory (LB )
‫والسالمة‬ ‫املرافق‬ ‫ة‬‫ر‬‫إدا‬FacilityManagement and Safety ( FMS )
Essential Safety
Requirements
• ESR are essential practices -
represented by a selected
group of standards that the
hospitals must Fully Met, to
minimize the risk of adverse /
sentinel events & near miss.
• There are 20 ESR standards
for hospitals
& 14 ESR standards for
Primary Healthcare Centers.
• Separate list of all ESR
standards with sub
standards is available for
hospitals & PHCs.
‫األساسية‬ ‫الممارسات‬ ‫هي‬-‫ممثلة‬
‫بمجموعة‬‫التي‬ ‫المعايير‬ ‫من‬ ‫مختارة‬
‫على‬ ‫يجب‬‫المستشفيات‬‫بها‬ ‫االلتزام‬
‫تماما‬‫من‬ ‫للحد‬ ،‫المخاطر‬/‫األحداث‬
‫الحدوث‬ ‫وشيكة‬ ‫و‬ ‫الجسيمة‬.
‫هناك‬20‫معيار‬ESR‫للمستشفيات‬
‫و‬14‫معيار‬ESR‫للمراكز‬‫الرعاية‬
‫األولية‬ ‫الصحية‬.
‫المعايير‬ ‫جميع‬ ‫من‬ ‫منفصلة‬ ‫قائمة‬ESR
‫مع‬‫الفرعية‬ ‫المعايير‬‫للمستش‬ ‫متاحه‬‫فيات‬
‫األولية‬ ‫الصحية‬ ‫الرعاية‬ ‫و‬.
Total ESR Standards: 20
Total ESR Sub-Standards: 113

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Guide to understanding essential safety requirement standards

  • 1. GUIDE TO UNDERSTANDING ESSENTIAL SAFETY REQUIREMENT STANDARDS ‫ى‬ ‫املرض‬ ‫لسالمة‬ ‫االساسية‬ ‫املتطلبات‬ PREPARED BY DR. MOHAMED RAMZY YOUSEF HOSPITAL QUALITY COORDINATOR QUALITY & PATIENT SAFETY DEPARTMENT 25-10-2017 TOGEATHER WE CAN DO IT 2 QUALITY A WAY OF LIFE
  • 3. ‫مقدمة‬ •‫املنش‬ ‫العتماد‬ ‫السعودي‬ ‫املركز‬ ‫وضع‬‫آت‬ ‫األس‬ ‫الوطنية‬ ‫املتطلبات‬ ،‫الصحية‬‫اسية‬ ‫من‬‫قائمة‬ ‫في‬ ‫ى‬ ‫املرض‬ ‫لسالمة‬20 ً ‫ا‬‫ر‬‫معيا‬‫من‬ ‫و‬ ،‫للمستشفيات‬ ‫الوطنية‬ ‫املعايير‬‫ها‬‫ر‬‫اعتبا‬ ‫به‬ ‫ام‬‫ز‬‫االلت‬ ‫يجب‬‫أساسية‬ ‫اطات‬‫ر‬‫اشت‬‫ا‬ ‫م‬ ‫ى‬ ‫املرض‬‫سالمة‬ ‫لضمان‬ ‫كامل‬ ‫بشكل‬‫ن‬ ‫الصحية‬ ‫بالرعاية‬ ‫املتعلقة‬ ‫األخطاء‬. •‫عل‬ ‫الحالية‬ ‫املرحلة‬ ‫في‬ ‫ة‬‫ر‬‫ا‬‫ز‬‫الو‬ ‫ركزت‬‫ى‬ ‫ا‬ ‫في‬ ‫البالغة‬ ‫ألهميتها‬ ‫املعايير‬ ‫هذه‬‫ملرحلة‬ ‫املعايير‬ ‫هذه‬ ‫وشملت‬ ‫اهنة‬‫ر‬‫ال‬9‫أقسام‬ ‫التالي‬ ‫النحو‬ ‫على‬ ‫مختلفة‬ The Central Board for Accreditation of Health care Institutions has set the basic national requirements for patient safety in a list of 20 national hospital standards as key requirements that must be fully adhered to, to ensure patient safety from healthcare errors. In the current phase, the Ministry has focused on these criteria for its very importance at the current stage. These standards included 9 different sections as follows
  • 4. ‫البشرية‬ ‫د‬‫ر‬‫املوا‬Human Resources ( HR ) ‫الطبية‬ ‫ة‬‫ر‬‫اإلدا‬MedicalStaff ( MS ) ‫الرعاية‬‫توفير‬Provision of Care ( PC ) ‫الجودة‬ ‫ة‬‫ر‬‫إدا‬QualityManagement ( QM ) ‫التخدير‬Anesthesia Care ( AN ) ‫ومكافحتها‬‫ى‬‫العدو‬‫من‬‫الوقاية‬InfectionPrevention andControl ( IPC ) ‫األدوية‬ ‫ة‬‫ر‬‫إدا‬MedicationManagement ( MM ) ‫املختبر‬Laboratory (LB ) ‫والسالمة‬ ‫املرافق‬ ‫ة‬‫ر‬‫إدا‬FacilityManagement and Safety ( FMS )
  • 5. Essential Safety Requirements • ESR are essential practices - represented by a selected group of standards that the hospitals must Fully Met, to minimize the risk of adverse / sentinel events & near miss. • There are 20 ESR standards for hospitals & 14 ESR standards for Primary Healthcare Centers. • Separate list of all ESR standards with sub standards is available for hospitals & PHCs. ‫األساسية‬ ‫الممارسات‬ ‫هي‬-‫ممثلة‬ ‫بمجموعة‬‫التي‬ ‫المعايير‬ ‫من‬ ‫مختارة‬ ‫على‬ ‫يجب‬‫المستشفيات‬‫بها‬ ‫االلتزام‬ ‫تماما‬‫من‬ ‫للحد‬ ،‫المخاطر‬/‫األحداث‬ ‫الحدوث‬ ‫وشيكة‬ ‫و‬ ‫الجسيمة‬. ‫هناك‬20‫معيار‬ESR‫للمستشفيات‬ ‫و‬14‫معيار‬ESR‫للمراكز‬‫الرعاية‬ ‫األولية‬ ‫الصحية‬. ‫المعايير‬ ‫جميع‬ ‫من‬ ‫منفصلة‬ ‫قائمة‬ESR ‫مع‬‫الفرعية‬ ‫المعايير‬‫للمستش‬ ‫متاحه‬‫فيات‬ ‫األولية‬ ‫الصحية‬ ‫الرعاية‬ ‫و‬.
  • 6. Total ESR Standards: 20 Total ESR Sub-Standards: 113
  • 8. ESRs scoring system for each standard: • Fully Met---------- Score “2” = Satisfactory compliance when ≥ 80 % • Partially Met----- Score “1” = Partial compliance when ≥ 50 to < 80 % • Not Met------------ Score “0” = Insufficient compliance when < 50 % • Not Applicable--- (NA) = If standard does not apply to the hospital Hospital passed if overall score ≥ 85 %
  • 10. HR.5 ‫الممارسين‬ ‫العتماد‬ ‫مناسبة‬ ‫آلية‬ ‫المستشفى‬ ‫لدى‬ ‫للمرضى‬ ‫الصحية‬ ‫الرعاية‬ ‫لتقديم‬ ‫المؤهلين‬ ‫الصحيين‬ The hospital has a process for proper credentialing of staff members licensed to provide patient care .1‫املستشفى‬ ‫لدى‬‫مكتوبة‬ ‫سياسة‬‫تصف‬‫الع‬‫ملية‬ ‫االعتماد‬ ‫بيانات‬ ‫من‬ ‫للتحقق‬ ‫املستخدمة‬ .2‫يجمع‬‫املستشفى‬‫ويراجع‬‫ويقيم‬‫االع‬ ‫وثائق‬‫تماد‬ (‫ات‬‫ر‬‫والخب‬ ‫والشهادة‬ ‫يب‬‫ر‬‫والتد‬ ‫والتعليم‬ ‫الرخصة‬) ‫املهن‬ ‫من‬ ‫وغيرهم‬ ‫يب‬‫ر‬‫التد‬ ‫وطاقم‬ ‫الطبية‬ ‫للكوادر‬‫يين‬ ‫ل‬ ‫الصحية‬ ‫الرعاية‬‫لتقديم‬ ‫لهم‬ ‫املرخص‬‫الصحيين‬‫ى‬ ‫لمرض‬ .1‫يتم‬‫التحقق‬‫املصدر‬ ‫من‬ ‫االعتماد‬ ‫بيانات‬ ‫من‬ ‫االصلي‬ .2‫العمل‬ ‫مسئوليات‬‫السريرية‬ ‫العمل‬ ‫ومهام‬ (‫ات‬‫ز‬‫االمتيا‬)‫االعت‬ ‫بيانات‬‫تقييم‬ ‫على‬ ‫بناءا‬ ‫تتم‬‫ماد‬ 1. The hospital has a written policy describing the process used to verify credentials 2. The hospital collects, reviews and evaluates accreditation documents (license, education, training, certification and experience) for medical staff, training staff and other health professionals licensed to provide patient health care 3. The credentials are verified from the original source 4. Work responsibilities and clinical work assignments are based on the assessment of credentials
  • 11. .5‫جميع‬ ‫تسجيل‬‫الصح‬ ‫الرعاية‬‫في‬‫املتخصصين‬‫في‬ ‫ية‬ ‫الصحي‬‫للتخصصات‬ ‫السعودية‬ ‫الهيئة‬‫ة‬ .6‫ال‬‫الرعاية‬ ‫بتقديم‬ ‫لهم‬ ‫املرخص‬‫املوظفين‬‫جميع‬‫صحية‬ ‫لديهم‬‫ن‬‫يكو‬‫ان‬‫يجب‬‫ف‬ ‫ل‬‫املفعو‬‫ية‬‫ر‬‫سا‬‫عمل‬ ‫خصة‬‫ر‬‫ي‬ ‫تخصصاتهم‬ .7‫من‬‫محدثة‬‫بنسخة‬‫املستشفى‬‫يحتفظ‬‫ال‬‫خصة‬‫ر‬‫هيئة‬ ‫والتسجيل‬‫التصنيف‬‫وشهادة‬‫العاملين‬‫لجميع‬‫في‬ ‫طل‬‫حال‬‫في‬ ‫اليها‬ ‫للرجوع‬‫الصحية‬ ‫الرعاية‬ ‫تقديم‬‫من‬‫بها‬ ‫جية‬‫ر‬‫خا‬‫او‬‫داخلية‬‫جهة‬ .8‫طرف‬‫خالل‬ ‫من‬‫االعتماد‬‫اق‬‫ر‬‫او‬ ‫من‬‫التحقق‬‫يتم‬‫عندما‬ ‫للتأك‬‫وثائق‬ ‫طلب‬‫املستشفى‬‫على‬ ‫يجب‬ ‫ثالث‬‫يد‬ .9‫تنطبق‬‫املوظف‬‫فئات‬‫جميع‬‫على‬‫التحقق‬‫عملية‬‫ين‬ ‫االكلينيكية‬(‫او‬‫ار‬‫و‬‫ز‬ ‫او‬‫جزئي‬‫او‬‫كامل‬‫دوام‬locum) 5. Registrationofall healthcareprofessionalsin the SaudiCommission forHealth Specialties 6. All employees licensedto providehealthcare musthavea valid workpermit in theirspecialties 7. The hospitalshall keep anupdatedcopyofthe license ofthe Authorityandthe certificateof classificationandregistrationforall healthcare workersforreference ifrequested byaninternal orexternalentity 8. Whenthe credentialsareverified throughathird party,thehospitalmustrequestdocumentsfor confirmation 9. The verificationprocessapplies toall categories of clinical staff(full orparttime,visitorsorlocum)
  • 12. Why it is an ESR • This standard aims to improve the safety of the services provided to patients by holding the hospital accountable for ensuring that all staff members who provide patient care have the required qualifications that enable them to provide safe and effective patient care. Staff qualifications are believed to influence personal, professional, and practice characteristics, and consequently, can significantly impact the provision of high- quality patient care •‫يهدف‬‫إلى‬ ‫المعيار‬ ‫هذا‬‫سالمة‬ ‫تحسين‬ ‫للمرضى‬ ‫المقدمة‬ ‫الخدمات‬‫خالل‬ ‫من‬ ‫ضمان‬ ‫مسؤولية‬ ‫المستشفى‬ ‫تحمل‬‫أ‬‫ن‬ ‫يقدمون‬ ‫الذين‬ ‫الموظفين‬ ‫جميع‬‫الرع‬‫اية‬ ‫للمرضى‬‫المطلوبة‬ ‫المؤهالت‬ ‫لديهم‬ ‫آمنة‬ ‫رعاية‬ ‫توفير‬ ‫من‬ ‫تمكنهم‬ ‫التي‬ ‫للمرضى‬ ‫وفعالة‬. •‫تؤ‬ ‫الموظفين‬ ‫المؤهالت‬ ‫أن‬ ‫ويعتقد‬‫ثر‬ ‫والمهني‬ ‫الشخصية‬ ‫الخصائص‬ ‫على‬،‫ة‬ ‫والممارسة‬،‫وبالتالي‬ ،‫تؤث‬ ‫أن‬ ‫يمكن‬‫ر‬ ‫ع‬ ‫رعاية‬ ‫توفير‬ ‫على‬ ‫كبير‬ ‫بشكل‬‫الية‬ ‫للمرضى‬ ‫الجودة‬
  • 13. MS.7 ‫سريرية‬ ‫امتيازات‬ ‫جميعا‬ ‫يمتلكون‬ ‫الطبي‬ ‫الطاقم‬ ‫أعضاء‬ ‫وسارية‬ ‫محددة‬ Clinical Delineated Privileges .1‫س‬‫ر‬‫باملما‬ ‫الطبي‬ ‫الطاقم‬ ‫ألعضاء‬ ‫يسمح‬‫ة‬ ‫تمنحها‬ ‫التي‬ ‫ات‬‫ز‬‫االمتيا‬ ‫حدود‬ ‫في‬ ‫فقط‬‫اللجنة‬ .2‫وتحدي‬ ‫السريرية‬ ‫ات‬‫ز‬‫االمتيا‬ ‫اجعة‬‫ر‬‫م‬ ‫تتم‬‫ثها‬ ‫الحاجة‬ ‫وحسب‬‫سنتين‬ ‫كل‬ .3‫الت‬ ‫ف‬‫و‬‫الظر‬ ‫بتحديد‬ ‫املستشفى‬ ‫يقوم‬‫تمنح‬ ‫ي‬ ‫مؤقتة‬ ‫او‬ ‫ئة‬‫ر‬‫طا‬ ‫ات‬‫ز‬‫امتيا‬ ‫فيها‬ .4‫أل‬ ‫تمنح‬ ‫ال‬ ‫املؤقتة‬ ‫او‬ ‫ئة‬‫ر‬‫الطا‬ ‫ات‬‫ز‬‫االمتيا‬‫كثر‬ ‫من‬90‫للتجديد‬ ‫قابلة‬‫غير‬ ‫وهي‬ ‫يوما‬ .5‫اد‬‫ر‬‫أف‬ ‫أحد‬ ‫قبل‬‫من‬ ‫جديد‬ ‫امتياز‬‫طلب‬ ‫عند‬ ‫اق‬‫ر‬‫او‬‫من‬ ‫التحقق‬ ‫يتم‬ ‫الطبي‬ ‫الطاقم‬ ‫املو‬ ‫قبل‬ ‫وتقييمها‬ ‫الصلة‬ ‫ذات‬ ‫االعتماد‬‫افقة‬ • Medical staff members are allowed to practice only within the limits granted by the Commission • Clinical privileges are reviewed and updated every two years as needed • The hospital determines the circumstances in which emergency or temporary benefits are granted • Temporary or temporary privileges are not granted for more than 90 days and are non-renewable • When a new license is requested by a medical staff, the relevant credentials are verified and evaluated prior to approval
  • 14. QM.17 ‫على‬ ‫الصحيح‬ ‫التعرف‬ ‫لضمان‬ ‫مناسبة‬ ‫آلية‬ ‫المستشفى‬ ‫لدى‬‫المرضى‬ - The hospital has a process to ensure correct identification of patients .1‫هناك‬‫االقل‬‫على‬‫ع‬ ‫للتعرف‬ ‫معرفين‬‫لى‬ ‫املريض‬(‫مثل‬‫و‬‫كامال‬‫املريض‬ ‫اسم‬‫قم‬‫ر‬ ‫الطبي‬‫امللف‬)‫عند‬‫تستخدم‬‫اخذ‬ ‫او‬‫االدوية‬ ‫إعطاء‬‫او‬‫الدم‬ ‫عينات‬ ‫العمليات‬‫اء‬‫ر‬‫إج‬‫عند‬‫او‬‫الدم‬‫مشتقات‬ .2‫مو‬‫وطريقة‬ ‫منهج‬‫لديه‬‫املستشفى‬‫حدة‬ ‫املرض‬‫على‬‫الصحيح‬‫التعرف‬‫لضمان‬‫ى‬( ‫إستخدام‬ ‫مثل‬‫املعصم‬‫سوار‬‫مع‬ ‫موحدة‬ ‫معلومات‬) .3‫عملي‬‫في‬ ‫بفعالية‬‫ى‬ ‫املرض‬‫ك‬‫ر‬‫يشا‬‫ة‬ ‫املريض‬‫هوية‬‫تحديد‬ • At least two ways of identifying the patient (such as the patient's full name and medical file number) are used when taking blood samples, giving medicines or blood derivatives, or performing operations • The hospital has a standard approach and method to ensure proper identification of patients (such as using wrist band with uniform information) • Patients actively participate in the identification process
  • 15. Why it is an ESR •Identifying patients correctly is vital for patient safety. •The healthcare services are of a multidisciplinary nature, wherein many professionals provide care to each patient. -Therefore, there is increased chance for Misidentifying patient that can result in harm to patient throughout the healthcare organization including medication errors, blood transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. •Misidentifying patients is identified as a common root cause of many incidents and near misses.
  • 16. QM.18 The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure ‫ا‬ ‫لدى‬‫للمريض‬ ‫جراحة‬ ‫اجراء‬ ‫لمنع‬ ‫آليه‬ ‫لمستشفى‬،‫الخطأ‬‫بالموقع‬ ‫الخطأ‬ ‫الجراحة‬ ‫أو‬ ، ‫الخطأ‬ •Surgeries on the wrong patient or body part such as removing a kidney from the wrong patient or amputating the wrong limb are rare but extremely unacceptable. •Such errors are classified as “ NEVER EVENTS “because they should never occur. •“However, such mishaps can be prevented by adopting certain strategies and procedures that improve communication among staff and between staff & patient, support patient involvement, improve patient assessment, and improve legibility of information in medical records
  • 17. IPC.4 There is a designated multidisciplinary committee that provides oversight of the infection prevention and control program ‫مكافحة‬ ‫برنامج‬ ‫على‬ ‫لإلشراف‬ ‫معينة‬ ‫التخصصات‬ ‫متعددة‬ ‫لجنة‬ ‫المستشفى‬ ‫لدى‬ ‫ومراقبتها‬ ‫العدوى‬ .1‫الطبي‬ ‫املدير‬ ‫اللجنة‬ ‫أس‬‫ر‬‫ي‬ .2‫العاملين‬ ‫عن‬‫ممثال‬ ‫تشمل‬ ‫اللجنة‬ ‫عضوية‬‫في‬ ‫املختب‬‫و‬ ‫التمريض‬ ‫وطاقم‬ ‫الطبي‬ ‫املجال‬‫ر‬ ‫والرع‬ ‫ي‬‫املركز‬ ‫والتعقيم‬ ‫العمليات‬ ‫وغرفة‬‫اية‬ ‫من‬ ‫وممثل‬ ‫التغذية‬ ‫وخدمات‬ ‫الصيدالنية‬ ‫وممثلي‬ ‫النظافة‬ ‫بأعمال‬ ‫القائمة‬ ‫الشركة‬‫من‬ ‫ن‬ ‫قسم‬ ‫وأي‬ ‫اقبتها‬‫ر‬‫وم‬ ‫ى‬‫العدو‬ ‫مكافحة‬ ‫قسم‬ ‫الحاجة‬ ‫حسب‬ ‫آخر‬ .3‫ومحددة‬ ‫منتظمة‬ ‫ة‬‫ر‬‫بصو‬ ‫اللجنة‬‫تجتمع‬ ‫سابقا‬(‫كل‬3‫على‬ ‫أشهر‬‫االقل‬) .4‫عل‬ ‫تقتصر‬‫وال‬ ‫تتضمن‬ ‫اللجنة‬ ‫مهام‬‫ى‬ (1‫ى‬‫العدو‬ ‫مكافحة‬ ‫قسم‬ ‫اءات‬‫ر‬‫وإج‬ ‫سياسات‬ ‫اجعة‬‫ر‬‫م‬ ‫اقبتها‬‫ر‬‫وم‬ (2‫اقبتها‬‫ر‬‫وم‬ ‫ى‬‫العدو‬ ‫مكافحة‬ ‫قسم‬ ‫ير‬‫ر‬‫تقا‬ ‫اض‬‫ر‬‫استع‬ ‫املناسبة‬ ‫اءات‬‫ر‬‫االج‬ ‫اح‬‫ر‬‫واقت‬ ‫اجعتها‬‫ر‬‫وم‬ (3‫ا‬ ‫االضافات‬ ‫اح‬‫ر‬‫واقت‬ ‫للقسم‬ ‫السنوية‬ ‫الخطة‬ ‫اجعة‬‫ر‬‫م‬‫و‬ ‫االمر‬ ‫لزم‬ ‫اذا‬ ‫ات‬‫ر‬‫التغيي‬ (4‫ا‬ ‫اءات‬‫ر‬‫وإج‬ ‫لسياسات‬ ‫املستمر‬ ‫والتنقيح‬ ‫التقييم‬‫لقسم‬ ‫بها‬ ‫ل‬‫املعمو‬ ‫واملعايير‬ ‫االهداف‬ ‫لخدمة‬ (5‫اقبتها‬‫ر‬‫وم‬ ‫ى‬‫العدو‬ ‫مكافحة‬ ‫لقضايا‬ ‫االنتباه‬ ‫لفت‬‫ومتابعة‬ ‫اال‬ ‫في‬ ‫ومكافحتها‬ ‫ى‬‫العدو‬ ‫اقبة‬‫ر‬‫م‬ ‫ر‬‫امو‬ ‫من‬ ‫مايستجد‬‫قسام‬ ‫ل‬‫الحلو‬ ‫وتقديم‬ (6‫فيم‬ ‫صحي‬ ‫كمثقف‬ ‫يعمل‬‫اللجنة‬ ‫اعضاء‬ ‫من‬ ‫عضو‬ ‫كل‬‫ا‬ ‫ت‬‫ر‬‫ادا‬ ‫او‬ ‫قسمه‬ ‫في‬ ‫ومكافحتها‬ ‫ى‬‫العدو‬ ‫اقبة‬‫ر‬‫م‬ ‫يخص‬‫ه‬ ‫الصحيح‬ ‫بالشكل‬ ‫تطبيقها‬ ‫وضمان‬
  • 18. IPC.15 Facility design and available supplies support isolation practices ‫الحاجة‬ ‫عند‬ ‫المرضى‬ ‫عزل‬ ‫ممارسات‬ ‫االمدادات‬ ‫وتوفر‬ ‫المنشأة‬ ‫تصميم‬ ‫يدعم‬ .1‫املستشفى‬ ‫في‬‫يوجد‬‫سلبي‬ ‫ضغط‬ ‫ذات‬ ‫ل‬‫عز‬ ‫غرف‬‫في‬ ‫ى‬ ‫املرض‬ ‫عاية‬‫ر‬ ‫مناطق‬ ‫في‬ ‫و‬‫ئ‬‫الطوار‬(‫االقسام‬) .2‫التهوية‬ ‫نظام‬‫ع‬ ‫يضمن‬‫ل‬‫العز‬ ‫غرف‬ ‫في‬‫املستخدم‬‫دم‬ ‫ع‬‫املستشفى‬ ‫من‬‫ى‬‫اخر‬ ‫مناطق‬‫الى‬‫ى‬‫العدو‬‫انتقال‬‫لى‬ .3‫ى‬‫العدو‬ ‫من‬‫التحذير‬ ‫بطاقات‬(‫ل‬‫العز‬ ‫ات‬‫ر‬‫اشا‬)‫تتف‬‫ق‬ ‫العربية‬ ‫باللغتين‬‫ن‬‫وتكو‬ ‫املريض‬‫تشخيص‬ ‫مع‬ ‫مة‬‫ز‬‫الال‬ ‫االحتياطات‬ ‫نوع‬‫الى‬‫وتشير‬‫واالنجليزية‬ .7‫التنفس‬ ‫اقنعة‬‫تستخدم‬(N-95/ N-99)‫قبل‬ ‫من‬ ‫للمريض‬ ‫املباشرة‬‫الرعاية‬‫تقديم‬ ‫عند‬‫املوظفين‬‫ن‬‫وتكو‬ ‫األقسام‬ ‫جميع‬ ‫في‬ ‫متوفرة‬ .8‫نفس‬ ‫قبل‬ ‫من‬‫االقنعة‬‫استخدام‬ ‫اعادة‬‫يمكن‬ ‫الشخص‬(‫الصحية‬‫الرعاية‬ ‫مقدم‬)‫املدة‬ ‫حسب‬ ‫املصنعة‬‫الشركة‬ ‫من‬ ‫املحددة‬ .1 • The hospital has isolation rooms with negative pressure in emergency and in patient care areas (sections) • Infection warning cards (isolation signals) are consistent with patient diagnosis and are in both Arabic and English and indicate the type of precautions required • (N-95 / N-99) masks are used by staff when providing direct patient care and are available in all sections Masks can be reused by the same person (healthcare provider) according to the manufacturer's specified duration
  • 19. Total No. ESR Standards Name 4 department Name two identifier of identifying the patient When we should use two identifier Q1 Q2 Q3 Q4
  • 20. MM.5 ‫الخطرة‬ ‫االدوية‬ ‫لسالمة‬ ‫نظام‬ ‫المستشفى‬ ‫لدى‬ (high alert medication) .1‫هناك‬‫االختصاصات‬‫متعددة‬‫مكتوبة‬ ‫خطة‬‫ة‬‫ر‬‫إلدا‬ ‫الخط‬‫الدوائية‬‫والكيماويات‬‫ة‬‫ر‬‫الخطو‬‫عالية‬‫االدوية‬‫رة‬ .2‫بعمل‬‫املستشفى‬‫يقوم‬‫لألد‬‫سنويا‬ ‫تحدث‬ ‫قائمة‬‫وية‬ ‫الخطرة‬‫الدوائية‬‫والكيماويات‬‫ة‬‫ر‬‫الخطو‬‫عالية‬: .3‫الخطو‬‫عالية‬‫االدوية‬‫ة‬‫ر‬‫إلدا‬‫خطة‬‫املستشفى‬‫ينفذ‬‫ة‬‫ر‬ ‫تقتص‬‫وال‬ ‫تشتمل‬‫الخطرة‬ ‫الدوائية‬‫والكيماويات‬‫على‬‫ر‬: (1‫فرص‬‫تحسين‬‫املعلومات‬‫على‬‫ل‬‫الحصو‬‫االدوي‬‫ل‬‫حو‬‫ة‬ ‫ة‬‫ر‬‫الخطو‬‫عالية‬ (2‫ة‬‫ر‬‫الخطو‬‫عالية‬‫االدوية‬‫الى‬‫ل‬‫الوصو‬ ‫من‬‫الحد‬ (3‫توفرها‬‫حال‬‫والحوسبة‬‫البطاقات‬‫استخدام‬ (4‫اقب‬‫ر‬‫وامل‬‫ة‬‫ر‬‫واإلدا‬‫والصرف‬‫واإلعداد‬ ‫الكتابة‬‫توحيد‬‫ة‬ ‫ة‬‫ر‬‫الخطو‬‫عالية‬‫لألدوية‬ (5‫اثنين‬‫موظفين‬‫قبل‬ ‫من‬‫التحقق‬ ‫يتم‬ 1. Thereis a multidisciplinary written policy for the managementof high-riskdrugs and hazardous pharmaceutical chemicals 2. Thehospital makesan annual list of high-risk drugs and hazardous pharmaceutical chemicals: 3. Thehospital carries out a plan for the management of high-riskdrugs and hazardous pharmaceutical chemicals, includingbut not limited to: 4. Improveaccess toinformation on high-riskdrugs 5. Reduce access to high-riskdrugs 6. Usecards and computingas they become available 7. Standardization of writing, preparation, drainage, management and control of high-riskdrugs 8. Two employees are checked
  • 21. MM.6 ‫الشكل‬ ‫متشابهة‬ ‫تبدو‬ ‫التي‬ ‫االدوية‬ ‫من‬ ‫للسالمة‬ ‫نظام‬ ‫المستشفى‬ ‫لدى‬ ‫واالسم‬ ( LASA ) .1‫املستشفى‬‫لدى‬‫سياسات‬ ‫االدوية‬ ‫مع‬ ‫للتعامل‬ ‫اءات‬‫ر‬‫واج‬ ‫الشكل‬ ‫متشابهة‬‫تبدو‬ ‫التي‬ ‫واالسم‬(LASA) .2‫اج‬‫ر‬‫وت‬ ‫املستشفى‬‫تستعرض‬‫ع‬ ‫وتعدل‬‫االدوية‬‫قائمة‬‫تب‬ ‫التي‬‫دو‬ ‫واالسم‬ ‫الشكل‬‫متشابهة‬( LASA )‫اماكن‬‫في‬‫سنوية‬‫ة‬‫ر‬‫بصو‬ ‫الصرف‬‫واماكن‬ ‫التخزين‬ ‫يع‬‫ز‬‫والتو‬ 1. Thehospitalhas policiesand procedures for dealingwith drugs thatlooksimilar in shapeand name(LASA) 2. Thehospitalwillreviewand revise thelistofdrugs that appear tobe similarin shape and name(LASA) annually in storage,drainageand distributionsites
  • 22. .3‫تبد‬ ‫التي‬ ‫باألدوية‬‫املعلقة‬‫االخطاء‬ ‫ملنع‬ ‫اءات‬‫ر‬‫اج‬ ‫باتخاذ‬ ‫املستشفى‬ ‫تقوم‬‫متشابهة‬ ‫و‬ ‫يلي‬‫ما‬‫ذلك‬ ‫في‬‫بما‬ ‫واالسم‬ ‫الشكل‬: (1‫تقديم‬‫يب‬‫ر‬‫والتد‬‫التعليم‬‫التعري‬ ‫من‬‫كجزء‬‫الصحية‬ ‫الرعاية‬ ‫ملقدمي‬‫االدوية‬ ‫هذه‬‫يخص‬‫فيما‬‫والتعليم‬ ‫ف‬ ‫املستمر‬ ‫الطبي‬ (2‫استخدام‬‫العلمي‬ ‫االسم‬‫لألدوية‬‫ي‬‫التجار‬‫واالسم‬ (3‫كتابة‬‫التشخيص‬‫األدوية‬‫وصف‬ ‫عند‬ (4‫جي‬‫ر‬‫الخا‬‫املظهر‬‫تغيير‬‫الشكل‬‫متشابهة‬‫لألدوية‬ (5‫بعناية‬‫التسمية‬ ‫قراءة‬‫الصرف‬‫وعند‬ ‫العالج‬‫الى‬‫ل‬‫الوصو‬‫عند‬ (6‫الهاتفية‬‫واالوامر‬ ‫اللفظية‬‫االوامر‬ ‫استخدام‬ ‫تقليل‬ (7‫التشخيص‬‫من‬ ‫التحقق‬‫الدواء‬‫صرف‬‫قبل‬ (8‫في‬‫واالسم‬ ‫الشكل‬‫متشابهة‬ ‫تبدو‬ ‫التي‬‫االدوية‬ ‫تيب‬‫ر‬‫ت‬‫منفصلة‬‫اماكن‬‫تعتمد‬‫ال‬ ‫بطريقة‬‫الترتيب‬‫على‬ ‫الهجائي‬
  • 23. Why it is an ESR •: Look-alike, Sound-alike (LASA) medications account for an estimated 25- 30% of medication errors. • Look-alike medications: Names of medications, which due to their spelling, may look similar to other medications’ names, and the distribution/administration of these medications may be prone to errors. Also refer to product labeling/packaging. Example: Prozac® and Proscar® • Sound-alike medications: Names of medications, which due to their pronunciation, may sound similar to other medications’ names, and the distribution/administration of these medications may be prone to errors. Example: Ceftazidime and Ceftizoxime
  • 24. MM.41 ‫الطب‬‫االخطاء‬ ‫عن‬ ‫والتبليغ‬ ‫على‬ ‫والتعرف‬‫للرصد‬ ‫مناسبة‬ ‫آلية‬‫املستشفى‬ ‫لدى‬‫ية‬ ‫الحدوث‬‫القريبة‬‫األخطاء‬ ‫ذلك‬ ‫في‬‫بما‬ ‫الجسيمة‬nearmisses‫الخطرة‬ ‫والحاالت‬ hazardouscondition ‫للمخاطر‬‫املعرض‬ ‫والسلوك‬ at-risk behaviors‫التي‬ ‫املريض‬‫تضر‬ ‫ان‬‫يحتمل‬ .1‫هناك‬‫واجراءات‬ ‫سياسات‬‫متعددة‬ ‫الدوائ‬ ‫االخطاء‬‫مع‬ ‫للتعامل‬ ‫التخصصات‬‫ية‬ ‫الخط‬ ‫والحاالت‬ ‫الحدوث‬ ‫القريبة‬ ‫واالخطاء‬‫رة‬ .2‫و‬‫و‬‫ل‬‫مقبو‬ ‫تعريف‬ ‫على‬ ‫السياسة‬‫ي‬‫تحتو‬‫اضح‬ ‫الحد‬ ‫القريبة‬ ‫واألخطاء‬ ‫الدوائية‬ ‫لألخطاء‬‫وث‬ ,‫الخطرة‬ ‫الحاالت‬ .3‫حدوث‬ ‫عند‬ ‫املعالج‬ ‫الطبيب‬ ‫إخطار‬‫يتم‬ ‫الوقت‬ ‫في‬ ‫الدوائية‬ ‫األخطاء‬ .4‫ض‬ ‫الدوائية‬ ‫االخطاء‬‫عن‬ ‫التقرير‬ ‫اكتمال‬‫من‬ ‫الخط‬ ‫اكتشاف‬ ‫بعد‬ ‫املحدد‬ ‫الزمني‬ ‫االطار‬‫أ‬ .5‫عن‬ ‫لإلبالغ‬ ‫موحد‬ ‫نموذج‬ ‫املستشفى‬ ‫لدى‬ ‫الدوائية‬ ‫االخطاء‬ • There are multidisciplinary policies and procedures to deal with drug errors, near misses, and hazardous situations • The policy contains an acceptable and clear definition of drug errors and near- occurrence errors, dangerous situations • The doctor is notified when medication errors occur in time • The report of drug errors is completed within the specified timeframe after the error has been detected • The hospital has a standard form for reporting drug errors
  • 25. .6‫العمل‬ ‫طاقم‬ ‫توعية‬‫الدوائية‬ ‫االخطاء‬‫عن‬‫التبليغ‬‫عملية‬ ‫بأهمية‬ .7‫وجود‬‫الدوائية‬ ‫األخطاء‬ ‫عن‬ ‫نشطة‬‫ير‬‫ر‬‫تقا‬‫الخطرة‬ ‫والحاالت‬ ‫الحدوث‬ ‫القريبة‬ ‫واألخطاء‬ .8‫اء‬‫ر‬‫بإج‬ ‫املستشفى‬ ‫تقوم‬‫ية‬‫ر‬‫الجذ‬ ‫لألسباب‬ ‫مكثفة‬ ‫تحاليل‬( RCA )‫او‬‫الكبيرة‬ ‫الدوائية‬ ‫األخطاء‬ ‫لجميع‬ ‫الحدوث‬ ‫ة‬‫ر‬‫متكر‬ .9‫يتم‬‫الدوائية‬ ‫االخطاء‬ ‫توثيق‬‫الطب‬ ‫السجل‬ ‫في‬ ‫الخطرة‬ ‫والحاالت‬ ‫الحدوث‬ ‫قريبة‬ ‫واالخطاء‬‫للمريض‬ ‫ي‬ .10‫البيانات‬ ‫هذه‬ ‫املستشفى‬ ‫تستخدم‬‫الدواء‬ ‫استخدام‬ ‫عملية‬ ‫لتحسين‬‫الدوا‬ ‫االخطاء‬‫ومنع‬‫وتحسين‬ ‫ئية‬ ‫سالمة‬ .11‫الخط‬ ‫والحاالت‬ ‫الحدوث‬ ‫القريبة‬ ‫واالخطاء‬ ‫الدوائية‬ ‫األخطاء‬ ‫ير‬‫ر‬‫لتقا‬ ‫اجعة‬‫ر‬ ‫تغذية‬ ‫عمل‬ ‫يتم‬‫الى‬ ‫رة‬ ‫الرعاية‬‫مقدمي‬‫الصحية‬ .12‫املعنية‬ ‫الجهات‬ ‫الى‬ ‫الجسيمة‬ ‫الدوائية‬ ‫االخطاء‬ ‫ير‬‫ر‬‫تقا‬ ‫املستشفى‬ ‫ترفع‬
  • 26. Why it is an ESR •Medication errors compromise patient confidence in the health- care system and increase health-care costs. •Many medication errors are probably undetected. •The outcome(s) or clinical significance of many medication errors may be minimal, with few or no consequences that adversely affect a patient. •TRAGICALLY, however, some medication errors result in serious patient morbidity or mortality. •A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
  • 27. •Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
  • 28. FMS.9 ‫اإلشعاعات‬‫أخطار‬ ‫من‬ ‫آمنين‬‫شاغليها‬ ‫كل‬ ‫ان‬ ‫املستشفى‬‫ضمن‬ The hospital ensures that all its occupants are safe from radiation hazards .1‫التنفيذ‬ ‫قيد‬ ‫وهي‬ ‫اإلشعاع‬ ‫من‬ ‫السالمة‬‫سياسة‬ ‫لديه‬ ‫املستشفى‬ .5‫مست‬ ‫لضمان‬ ‫بانتظام‬ ‫وتختبر‬ ‫السينية‬ ‫األشعة‬ ‫لغرف‬ ‫يع‬‫ر‬‫التد‬ ‫شهادة‬‫ويات‬ ‫بها‬ ‫املسموح‬ ‫اإلشعاع‬ .6‫التناسلية‬ ‫الغدد‬ ‫ع‬‫و‬‫در‬/‫واحتياج‬ ‫ى‬ ‫املرض‬ ‫لتغطية‬ ‫متاحة‬ ‫قية‬‫ر‬‫الد‬ ‫الغدة‬‫ات‬ ‫وجردها‬ ‫سنويا‬ ‫ها‬‫ر‬‫اختبا‬ ‫ويتم‬ ‫املوظفين‬ .7‫الشخصية‬ ‫اإلشعاع‬ ‫جرعات‬ ‫مقاييس‬ ‫تتوفر‬(TLD cards)‫كل‬ ‫وتختبر‬3‫اشهر‬ ‫االختبار‬ ‫ز‬‫تتجاو‬ ‫عندما‬ ‫اءات‬‫ر‬‫االج‬ ‫اخذ‬ ‫يتم‬ ‫ومن‬
  • 29. FMS.21 ‫الحريق‬‫ضد‬‫لإلنذار‬ ‫فعال‬ ‫نظام‬ ‫املستشفى‬ ‫لدى‬ The hospital has an effective fire alarm system .1‫للحريق‬ ‫إنذار‬ ‫نظام‬ ‫هناك‬ ‫بانتظا‬ ‫فحصه‬ ‫ويتم‬‫يعمل‬‫م‬ ‫حسب‬‫املدن‬ ‫الدفاع‬ ‫تعليمات‬‫ي‬ .2‫اختبار‬ ‫نتائج‬ ‫توثيق‬ ‫يتم‬‫نظام‬ ‫الحريق‬ ‫إنذار‬ .3‫لنظام‬ ‫وقائية‬ ‫صيانة‬ ‫يوجد‬ ‫الحريق‬ ‫ضد‬ ‫اإلنذار‬ •A fire alarm system operates and is regularly inspected according to Civil Defense instructions •The results of the fire alarm system test are documented •There is preventive maintenance of the fire alarm system
  • 30. FMS.22 ‫املطلوبة‬‫املناطق‬ ‫في‬‫فعال‬ ‫حريق‬ ‫إخماد‬ ‫نظام‬ ‫املستشفى‬ ‫لدى‬ The hospital has a fire suppression system available in the required area(s). .1‫الذاتي‬‫الرش‬‫نظام‬ .2‫الرش‬‫نظام‬‫النظيف‬(clean agentsuppression system) .3‫الكيميائية‬‫ة‬‫ر‬‫البود‬‫نظام‬‫الر‬‫طبة‬ (wetchemicalsystem .4‫على‬ ‫معتمد‬‫إطفاء‬ ‫نظام‬‫يوجد‬ ‫اطيم‬‫ر‬‫والخ‬ ‫االنابيب‬ 1. Sprinkling system 2. Clean agent suppression system 3. Wet chemical system 4. There is a fire extinguishing system based on pipes and hoses
  • 31. FMS.23 ‫املستشفى‬ ‫انحاء‬ ‫في‬‫صحيح‬ ‫بشكل‬‫عة‬‫ز‬‫ومو‬ ‫متوفرة‬‫ئ‬‫الطوار‬ ‫مخارج‬ There are fire exits that are properly located in the hospital .1‫بش‬ ‫وتقع‬ ‫الحريق‬ ‫مخارج‬ ‫تتوفر‬‫كل‬ ‫املستشفى‬ ‫في‬ ‫صحيح‬ .2‫االبواب‬‫مقفلة‬ ‫ليست‬ .3‫اليها‬ ‫ل‬‫الوصو‬ ‫يعيق‬ ‫ما‬ ‫يوجد‬ ‫ال‬ .4‫دفع‬ ‫قضيب‬ ‫عليها‬( panic hard ware ) .5‫للحريق‬ ‫مقاومة‬ .6‫ل‬ ‫بتثبيت‬ ‫وذلك‬ ‫بوضوح‬ ‫معلمة‬‫وحة‬ ‫مضيئة‬ ‫مخارج‬ • Fire outlets are available and located correctly in the hospital • The doors are not locked • There is no impediment to access • Panic hard ware • Fire resistant • Clearly marked by installing a panel of luminous exits
  • 32. FMS.24 ‫الحريق‬ ‫من‬ ‫مأمن‬ ‫في‬ ‫وشاغلوه‬ ‫املستشفى‬ ‫مبنى‬ The hospital and its occupants are safe from fire and smoke .1‫يطبق‬‫املستشفى‬‫سياسة‬"‫التدخين‬‫ممنوع‬"‫بص‬‫امة‬‫ر‬ .2‫وصنادي‬ ،‫الحريق‬‫طفايات‬‫على‬ ‫عوائق‬ ‫أية‬‫توجد‬‫ال‬‫ق‬ ،‫السالمة‬‫ودش‬ ،‫ئ‬‫الطوار‬‫وبطانيات‬ ‫الحريق‬‫إنذار‬ ‫العين‬‫غسل‬‫ومحطات‬ .3‫اآلمن‬‫لإلخالء‬‫كافية‬ ‫ئ‬‫الطوار‬‫حاالت‬‫في‬‫اإلضاءة‬ ‫للمستشفى‬ .4‫وآمن‬‫صحيح‬ ‫بشكل‬ ‫ين‬‫ز‬‫التخ‬‫مناطق‬‫تنظيم‬‫يتم‬ (1‫جيدة‬ ‫حالة‬‫وفي‬ ‫قوية‬ ‫الرفوف‬ (2‫على‬ ‫مباشرة‬‫ن‬‫تخز‬ ‫سلع‬‫يوجد‬ ‫ال‬‫ض‬‫ر‬‫األ‬(‫ع‬‫يقل‬ ‫ال‬ ‫ما‬ ‫ترك‬‫ن‬ ‫ضيات‬‫ر‬‫اال‬ ‫لتنظيف‬ ‫ات‬‫ر‬‫سنتيمت‬ ‫عشرة‬) (3‫مسطحة‬ ‫قاعدة‬ ‫على‬ ‫العناصر‬ ‫توضع‬ ‫أن‬ ‫يجب‬ (4‫االص‬ ‫او‬ ‫نا‬‫ز‬‫و‬‫واألخف‬،‫ض‬‫ر‬‫األ‬ ‫من‬ ‫قريبة‬ ‫الثقيلة‬ ‫األشياء‬‫في‬ ‫غر‬ ‫األعلى‬ 1. hospital applies a "no smoking" policy strictly 2. There areno barriers to fire extinguishers, fire alarmboxes, emergency blankets, safety showers, and eye wash stations 3. Emergencylighting is sufficient for safe evacuation of the hospital 4. Storage areas are organized correctly & safely 1. Theshelves are strong and ingood condition 2. Thereare no items stored directly on the floor (leaving at least 10cmfor floor cleaning) 3. Theitems should be placed on a flat base 4. Heavy objects areclose to theground, lighteror smaller at the top
  • 33. FMS.32 ‫ات‬‫ز‬‫الغا‬‫لنظام‬‫املناسبة‬‫الصيانة‬ ‫يضمن‬ ‫املستشفى‬‫الطبية‬ The hospital ensures proper maintenance of the medical gas system .1‫م‬ ‫بانتظام‬‫يختبر‬ ‫الطبية‬ ‫ات‬‫ز‬‫الغا‬ ‫نظام‬‫أجل‬‫ن‬ ‫التسرب‬ ‫الضغط‬ (2‫الضغط‬ ‫وعداد‬ ‫واإلنذار‬ ‫الصمامات‬ ‫عمل‬ ‫واملفاتيح‬ (3‫مكا‬ ‫في‬ ‫املركزية‬ ‫الطبية‬ ‫ات‬‫ز‬‫الغا‬ ‫محطة‬‫آمن‬ ‫ن‬ (4‫االوكسجي‬ ‫اسطوانات‬ ‫يوفر‬ ‫املستشفى‬‫ن‬ ‫س‬ ‫بعين‬‫ر‬‫وأ‬ ‫لثمان‬‫يكفي‬ ‫ملا‬ ‫االحتياطية‬‫من‬ ‫اعة‬ ‫االستهالك‬ ‫متوسط‬ (5‫مل‬ ‫بانتظام‬ ‫الغاز‬ ‫اسطوانات‬ ‫اختبار‬ ‫يتم‬‫عرفة‬ ‫تسريب‬ ‫وجود‬ ‫وعدم‬ ‫والكمية‬ ‫الغاز‬‫نوع‬ • The medical gas system is regularly tested for Pressure Leakage • Working valves, alarm, pressure gauge and switches • Central medical gas station in a safe place • The hospital provides backup oxygen cylinders for 48 h. of average consumption • Gas cylinders are regularly tested to determine the type of gas, the quantity and the absence of leaking
  • 37. Q1 •‫المرضى؟‬ ‫لسالمة‬ ‫االساسية‬ ‫المتطلبات‬ ‫معايير‬ ‫عدد‬ Number of patient safety standards? •‫بالمعايير‬ ‫المشمولة‬ ‫االقسام‬ ‫عدد‬‫؟‬ Number of sections covered by standards? •‫اذكر‬4‫؟‬ ‫اقسام‬ Name 5 sections? Q
  • 38. Q2 •‫وسيلتين‬ ‫اذكر‬‫على‬ ‫للتعرف‬‫المريض‬ •Identify two ways to identify the patient? •‫المرض‬ ‫لسالمة‬ ‫حيوي‬ ‫أمر‬ ‫صحيح‬ ‫بشكل‬ ‫المرضى‬ ‫تحديد‬ ‫لماذا‬‫ى‬ •WHY Identifying patients correctly is vital for patient safety ? • Q
  • 39. Q3 •HOW to prevent wrong patient, wrong site, and wrong surgery/procedure ? •‫منع‬ ‫كيفية‬‫للمريض‬ ‫اجراء‬ ‫عمل‬،‫الخطأ‬‫الخطأ‬ ‫بالموقع‬ ‫الخطأ‬ ‫أوالجراحة‬? • Q
  • 40. Q4 •‫االجراءات‬ ‫بعض‬ ‫اذكر‬‫لمنع‬ ‫المتخذة‬‫الت‬ ‫باألدوية‬ ‫المعلقة‬ ‫االخطاء‬‫ي‬ ‫الشكل‬ ‫متشابهة‬ ‫تبدو‬‫واالسم‬ •Indicate some of the measures taken to prevent errors with drugs that look similar in shape and name Q
  • 41. Q5 •‫اذكر‬5‫ال‬ ‫المعايير‬ ‫من‬20‫المرضى‬ ‫لسالمة‬ •List 5 of the 20 Standard for patient safety Q
  • 42. ‫الخاص‬ ‫االستبيان‬ ‫بتعبئة‬ ‫مشاركتكم‬ ‫تسعدني‬ ‫المادة‬ ‫تطوير‬ ‫فى‬ ‫للمساهمة‬ ‫المحاضرة‬ ‫بتقييم‬ ‫العرض‬ ‫وطريقة‬ ‫التعليمية‬ ‫على‬‫التالي‬ ‫الرابط‬ https://www.surveymonkey.com/r/QHMXTPL