Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
A standard is a statement of excellence, or an explicit predetermined expectation that defines the key functions, activities, processes and structures required for healthcare facilities to assure the provision of safe and quality care and services.
Standards are developed by peer experts in the field and it is against the standards that conformity of the healthcare facility is evaluated. Simply stated, the standard describes a healthcare facility’s acceptable performance level. Broadly speaking, CBAHI’s standards are of three major types depending on which area they are addressing.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
A standard is a statement of excellence, or an explicit predetermined expectation that defines the key functions, activities, processes and structures required for healthcare facilities to assure the provision of safe and quality care and services.
Standards are developed by peer experts in the field and it is against the standards that conformity of the healthcare facility is evaluated. Simply stated, the standard describes a healthcare facility’s acceptable performance level. Broadly speaking, CBAHI’s standards are of three major types depending on which area they are addressing.
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
There are several main dimensions most frequently used to measure hospitals performance via clinical efficiency ( Clinical quality , evidence -based practices , health improvement and outcomes for individual and patients)
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
A hospital faces challenges to safety almost every day-right from spillage and radiation exposure to the risk of being the focal point in the face of disaster and expected to work beyond capacity. Each of these challenges expect the management and staff of a hospital to be stable in their thought process and be well-coordinated in their efforts to avoid chaos and act with responsibility.
Safety training for hospital prepares the hospital to be prepared for failures-identifying them, avoiding them, responding to them and managing them efficiently. Useful for JCI, CBAHI,NABH,NABL,CODA
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
There are several main dimensions most frequently used to measure hospitals performance via clinical efficiency ( Clinical quality , evidence -based practices , health improvement and outcomes for individual and patients)
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
A hospital faces challenges to safety almost every day-right from spillage and radiation exposure to the risk of being the focal point in the face of disaster and expected to work beyond capacity. Each of these challenges expect the management and staff of a hospital to be stable in their thought process and be well-coordinated in their efforts to avoid chaos and act with responsibility.
Safety training for hospital prepares the hospital to be prepared for failures-identifying them, avoiding them, responding to them and managing them efficiently. Useful for JCI, CBAHI,NABH,NABL,CODA
Good Manufacturing Practices in Ayurveda Pharmaceutics (Past, Present & Future)Mohd Ehsan
Hello,
Dear friends, this ppt has been created by keeping in mind about GMP in Ayurveda pharmaceutics. This presentation help you all to understand how GMP works in Ayurveda Industries and how much quality is concerned with Ayurveda Drugs. You all get lots of ppts on slideshare regarding GMP but only few of them is related to Ayurveda.
The interfering effects of biotin concentrations ranging between 625 ng/mL and 10 µg/mL were
tested in a separate study. Biotin concentrations up to 1.25 µg/ml did not lead to false results.
Biotin concentrations ≥2.5 µg/ml can cause false-negative COVID-19 results with the
CareStart™ COVID-19 Antigen.
High-dose Hook Effect
The CareStart™ COVID-19 Antigen was tested up to 105 TCID50/ml of heat-inactivated SARSCoV-2 strain and no high-dose hook effect was observed.
Point of Care Use
The CareStart™ COVID-19 Antigen was demonstrated at near patient or Point of Care (POC)
testing that non-laboratory personnel can perform the test accurately in the intended use
environment. In addition, the robust use of the CareStart™ COVID-19 Antigen for near patient
or Point of Care (POC) testing was demonstrated by thirteen (13) Flex studies.
Technical Support
For questions, or to report a problem, please call Technical Support at +1-888-898-1270
(Available Hours: Mon. to Fri.: 8 a.m. – 5 p.m.) or TShelp@accessbio.net (24/7 available).
Test system problems may also be reported to the FDA using the MedWatch reporting system
(phone: 1-800 FDA-1088; fax: 1-800 FDA-1078: or http://www.fda.gov/medwatch)
For Emergency Use Authorization (EUA) Only
The CareStartTM COVID-19 Antigen test is a lateral ow immunochromatographic assay intended for the qualitative detection of the nucleocapsid protein antigen from SARS-CoV-2
in nasopharyngeal swab specimens directly collected from individuals who are suspected of COVID-19 by their healthcare provider within ve days of symptom onset.
IMPORTANT!
- Refer to the Package Insert for Warnings and Precautions, Specimen Collection Procedures, Storage and Handling Conditions, and Quality Control Recommendations.
- Warning and Precautions - All kit components can be discarded as Biohazard waste according to local guidelines. Refer to the product safety data sheet for risk and safety phrases and disposal information.
- Biotin Interference: False negative results may occur in patients who have indicated or whose clinical status or history would indicate they are currently taking high doses of biotin (> 10 mg per day). Biotin
levels of 2.5 µg/mL have been demonstrated to result in false negative test results.
- The extracted sample must be used within 4 hours of preparation when stored at room temperature.
- Refer to the CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19)
https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html
“CFDA Registration – Market Access Before Investment” delivered by Tim Lin, T...ulmedical
Due to a large population, increasing middle class and government plans to build tens of thousands of hospitals, there is a lot of demand for high quality medical devices in China. For many foreign medical device manufacturers, the regulatory barriers are still significant obstacles.
The medical device regulation in China is less harmonized and generally unique from other major markets. The primary challenges tend to be: actual testing, drafting standards, language barriers and license parking. These additional requirements create a delay in the registration process.
Foreign manufacturers need to specifically understand the Chinese medical device regulation in advance, and then are able to determine appropriate strategies aimed at successful China market entry.
This is the content for a live webinar, "CFDA Registration, Market Access before Investment...Solving the CFDA Challenge" delivered by UL's Tim Lin. Tim is the Senior Technical Consultant working in the Greater China Region. He majored in public health and medical device engineering, and worked as a reviewer in the Taiwan FDA for high and moderate-risk medical device and clinical trial protocol for over 5 years; and also drafted guidance for industry. He is now responsible for risk management file, usability engineering, software validation and CE MDD technical documentation.
The Science of Launching and Achieving Growth in Oncologyaccenture
We have conducted research to understand how oncology companies are responding to New science, more treatment choices and changing economics. Visit https://accntu.re/2Jn72wq to learn our key takeaways for launching and achieving growth in oncology.
The United States has always been and remains to be the leading place
for the conduct of clinical trials. According to Clinicaltrials.gov, the largest
clinical trials registry, 32% of registered clinical trials were conducted in
the U.S. as of May 2022 (1). Factors such as the availability of qualified
healthcare professionals, high-quality infrastructure and facilities,
cutting-edge research, an efficient regulatory system, and a high
standard of ethics and participant protection make the U.S. the leading
country for clinical trials.
Clinical trials follow extensive preclinical research to test the safety and
efficacy of a new drug, medical device, or biological in humans. They are
usually divided into three phases: phases I, II, and III which are designed
to ascertain safety, pharmacokinetics, efficacy, dosage, and adverse
events. Figure 1 shows the typical route from discovery and preclinical
studies to the post-marketing phase (phase IV).Clinical trials represent the longest and most expensive step in bringing
drugs to the market and have the highest attrition rate, only 10% of drugs
that enter phase I trials are granted marketing approval. Therefore,
clinical trials should be conducted by experts that are
well-versed with all the regulations and guidelines in a particular region to
boost the chances of drug approval.
The United States Food and Drug Administration (US FDA) is the
regulatory body that approves and oversees the conduct of clinical trials
for drugs, medical devices, and biologicals that are intended to be
marketed in the U.S and is touted to have the most stringent standards
for drug approval. The primary role of the FDA is to protect public health
by ensuring that medicinal products and devices are safe and efficacious.
Therefore, it is necessary for sponsors/investigators or contract research
organizations (CRO) that are conducting clinical trials to be familiar with
regulations and guidances that govern the conduct of clinical trials.Conducting a clinical trial in the United States requires a deep understanding of the
regulations and guidelines set by the FDA. It is important to know what is needed for a
successful clinical trial, from selecting an appropriate study site to obtaining informed
consent from participants. Additionally, it is essential to understand the requirements for data
collection and analysis, as well as how to develop an effective protocol. Clinical trial services
in USA can provide guidance on all of these aspects and more, helping you ensure that your
clinical trial meets all necessary standards
A presentation on Pharmacovigilance System in United States.
We at PharmXL International Pvt. Ltd., offer wide range of services for pharma industry like Pharmacovigilance services, Clinical Trials services, Regulatory Affairs services, Medical writing services etc to comply with required regulatory obligations across major regions.
For details visit: www.PharmXL.com
Email us: contact@pharmxl.com
multidimensional approach to impulsivity.pptxehab elbaz
understanding impulsivity and its relation to psychiatric disorders. history of the concept and evidence based pharmacological and psychological interventions
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
5. 5
Copyright
Reproduction of this material in whole or in part is
totally prohibited without a written permission from
the General Authority for Healthcare Accreditation &
Regulation (GAHAR).
6. AGENDA
3/11/2021 6
GAHAR
Day 1
Session1 Session 2
GAHAR registration
requirements for
Hospitals
System for GAHAR registration
Steps for GAHAR registration
National Safety Requirements
(NSR) for Hospitals:
A. General Patient Safety
Standards
7. AGENDA
3/11/2021 7
GAHAR
Day 2
Session1 Session 2
National Safety Requirements
(NSR) for Hospitals:
B. Medication Management
Safety Standards
C. Operative & Invasive
Procedure Safety Standards
National Safety Requirements
(NSR) for Hospitals:
D. Environmental Safety
Standards
12. GAHAR
OBJECTIVES
12
Identify & apply GAHAR national safety
requirements for hospitals
Adopt application of GAHAR national
safety requirements (NSR)
By the end of this training day each participant will be able
to:
47. GAHAR
The NSR are Grouped into 4 groups (A, B, C, and D).
A hospital has to score 80% or more in each group
separately &a total of 90% or more in all groups.
No standard should be scored Not Met (NM) for a
hospital to pass the NSR evaluation.
47
49. GAHAR 49
NSR
1
STANDARD
The patient’s safety policy defines Egyptian & WHO
Patient Safety recommendations & solutions, including
at least the following:
50. GAHAR 50
NSR.1.1
Accurate standardized
patient identification in
all service areas
NSR.1.2
Standardized process for
dealing with verbal or
telephone orders
NSR.1.3
Handling critical
values/tests
NSR.1.4
Hand hygiene
throughout the
organization
NSR.1.5
Prevention of catheter
& tubing
mis-connections
NSR.1.6
Prevention of patient's
risk of developing
pressure ulcers
52. GAHAR
RATIONALE
52
NSR
1
To address the most common & critical identified areas,
thus preventing adverse events & to ensure full
awareness regarding the Egyptian & WHO standards for
patient safety.
53. GAHAR
SURVEY PROCESS
53
NSR
1
Review the patient safety policy & procedures & check if
it includes all the standard’s items.
Interview hospital staff to ensure awareness of policy
54. GAHAR 54
NSR
2
STANDARD
At least two (2) ways are used to identify a patient when
giving medicines, blood, or blood products, taking blood
samples & other specimens for clinical testing, &/or
providing any other treatments or procedures.
55. GAHAR 55
NSR
2
RATIONALE
Providing care or performing interventions to the wrong
patient are significant errors, which may have grave
consequences.
Using two identifiers for each patient is the key driver in
minimizing such preventable errors, which is especially
important with administration of high alert medications
or conducting high risk or invasive procedures.
56. GAHAR 56
NSR
2
SURVEY PROCESS
Review relevant policy & procedures & check whether it
states those two identifiers (personal) & the occasions
when they should be used.
Review an appropriate number of medical records &
check each sheet for the presence of the two identifiers
mentioned in the policy & procedures document.
57. GAHAR 57
NSR
2
SURVEY PROCESS
Interview a number of healthcare staff (at least 10)
& ask them about the two identifiers & when should
they be used according to what is mentioned in the
standard.
Observe patient identification wrist bands for the two
identifiers.
Observe patient identification before procedures or care
processes.
58. GAHAR 58
NSR
3
STANDARD
A process for taking verbal or telephone orders & for
the reporting of critical test results, that requires a
verification by write down & "read-back" of the
complete order or test result by the person receiving
the information is implemented.
59. GAHAR 59
NSR
3
RATIONALE
Miscommunication is the commonest root cause for
adverse events. Writing down & reading back the
complete order or test result, by the person receiving
the information, minimizes miscommunication &
reduces errors from unambiguous speech, unfamiliar
terminologies or unclear pronunciation. It also provides
an opportunity for proper verification.
60. GAHAR 60
NSR
3
RATIONALE
Alarms are intended to induce immediate appropriate
action from staff to either check device malfunction or
initiate action that will revert the situation.
This can be ensured when all the staff become fully
aware of alarm settings (values & volume) & their
significance & are trained on the required actions to be
taken when triggered.
61. GAHAR 61
NSR
3
SURVEY PROCESS
Review the policy of receiving verbal or
telephone orders & of the critical test results
reporting & check whether it clearly describes
the process of documentation & "read-back" by
the recipient & also the measures to be taken in
case of critical test results.
Review documentation in dedicated registers
&/or medical records.
Interview clinicians & technicians to assess
knowledge & implementation
62. GAHAR 62
NSR
4
STANDARD
Current published & generally accepted hand hygiene
guidelines, laws & regulations are implemented to
prevent healthcare-associated infections.
63. GAHAR 63
NSR
4
RATIONALE
Hand hygiene is the cornerstone for reducing infection
transmission at all healthcare settings. It is considered
the most effective & efficient strategy for hospital wide
infection prevention & control.
64. GAHAR 64
NSR
4
SURVEY PROCESS
Review relevant policy & procedures of hand
hygiene.
Review hand hygiene guidelines.
Interview hospital staff, enquiring about hand
hygiene technique & WHO five moments of
hand hygiene
65. GAHAR 65
NSR
4
SURVEY PROCESS
Observe hand washing facilities at each patient
care area.
Check availability of supplies (soap, tissue
paper, alcohol hand rub, etc).
Observe compliance of clinicians with hand
hygiene technique & the 5 moments.
67. GAHAR 67
NSR
5
RATIONALE
Patients, especially within critical & specialized care
areas, are connected to many tubes & catheters, each
with a special function (monitoring, access, drainage).
During care, these tubes & catheters may be
misconnected leading to the administration of wrong
material via the wrong route resulting in grave
consequences.
68. GAHAR 68
NSR
5
SURVEY PROCESS
Review the policy & procedures for catheter &
tubing misconnections & check for catheter
differentiation, catheter maps.. etc.
Interview clinicians to ensure their
understanding of misconnection prevention
Observe compliance of clinicians with
misconnection prevention.
69. GAHAR 69
NSR
6
STANDARD
Each patient's risk of falling, including the potential risk
associated with the patient's medication regimen, is
assessed & periodically reassessed.
Action is taken to decrease or eliminate any identified
risks of falling.
70. GAHAR 70
NSR
6
RATIONALE
All patients are liable to fall; however, some are more
prone to. Identifying the more prone is usually done
through a risk assessment process in order to offer
them tailored preventative measures against falling.
Effective preventive measures to minimize falling are
those that are tailored to each patient & directed
towards the risks being identified from risk assessment.
71. GAHAR 71
NSR
6
SURVEY PROCESS
Review the policy & procedures for fall
prevention & check for patient risk assessment at
admission & status change; noticing that
medication review is part of the assessment &
also check for the presence of general measures
generated to reduce risk of falling & for tailored
care plans based on individual patient fall risk
assessment.
72. GAHAR 72
NSR
6
SURVEY PROCESS
Check availability of fall risk assessment forms
(including mediation care view).
Review medical records for fall risk assessment.
Review fall prevention care plan forms & fall risk labels.
Review medical records for general measures & tailored
care plans.
Review patient & family education material.
Interview nurses & physicians to ensure their
understanding & implementation of fall risk assessment.
73. GAHAR 73
NSR
6
SURVEY PROCESS
Interview clinicians to ensure their understanding
& implementation of fall prevention care plans.
Interview patients & families to ensure their
awareness & involvement
Check organization wide general preventive
measures (Call systems, lighting, corridor bars,
bathroom bars, bedside rails, wheelchairs &
trolleys with locks).
74. GAHAR 74
NSR
7
STANDARD
Each patient's risk of developing pressure ulcers is
assessed & documented. Action is taken to decrease or
eliminate any identified risks of developing pressure
ulcers.
75. GAHAR 75
NSR
7
RATIONALE
Identifying patients who are more prone to
develop pressure ulcers is a better preventive
strategy than trying to treat them, as this, not
only consumes lots of resources, but also has a
negative impact on the patients themselves.
Effective preventive measures to minimize
pressure ulcer development are those that are
tailored to each patient & directed towards the
risks identified from proper risk assessment.
76. GAHAR 76
NSR
7
SURVEY PROCESS
Review the policy & procedures for pressure
ulcer prevention, check for patient risk
assessment at admission & at status change, &
check for general measures generated to reduce
risk of pressure ulcer & for tailored care plans
based on individual pressure ulcer risk
assessment.
Check availability of pressure ulcer risk
assessment forms.
77. GAHAR 77
NSR
7
SURVEY PROCESS
Review medical records for pressure ulcer risk
assessment.
Review pressure ulcer prevention care plan forms
in medical records.
Review patient & family education forms &
material.
Interview clinicians to ensure their understanding
& implementation of pressure ulcer risk
assessment & their preventive care plans
78. GAHAR 78
NSR
7
SURVEY PROCESS
Interview patients & families to ensure their
awareness & involvement
Check organization wide general measures
(pressure relieving devices).
Check specific patient’s measures such as
changing position when applicable.
80. GAHAR 80
NSR
8
RATIONALE
The primary objective of a ‘handover’ is the
direct transmission of accurate patient care
information among staff to ensure the
continuity of care.
Moreover, it ensures adequate chance for
clarifications which subsequently decreases
medical errors.
81. GAHAR 81
NSR
8
SURVEY PROCESS
Review the policy & procedures for of handover
of patients in-between different shifts (in same
department) as well as in-between different
levels of care (different department/ services)
& check for the presence of recommended
framework (such as, SBAR, ISOBAR, I PASS the
BATON.. etc), staff responsible, recommended
environment, & documentation.
82. GAHAR 82
NSR
8
SURVEY PROCESS
Review medical record, Handover log book,
Endorsement form, Electronic Handover tool,
&/or other methods as evidence of
implementation.
Interview staff to ensure their knowledge of
handover agreed framework.
83. GAHAR 83
NSR
9
STANDARD
Preventive maintenance & testing of critical alarm
systems is implemented & documented.
Alarms are tested & activated with appropriate settings
& are sufficiently audible with respect to distances &
competing noise within the unit.
84. GAHAR 84
NSR
9
RATIONALE
Medical devices especially those related to vital
functions are fitted with alarms that alert staff
on conditions of device malfunction or patient’s
critical situation.
Losing that function exposes patients to
increased risk of morbidity & mortality.
85. GAHAR 85
NSR
9
RATIONALE
Review the policy & procedures for of handover
of patients in-between different shifts (in same
department) as well as in-between different
levels of care (different department/ services)
& check for the presence of recommended
framework (such as, SBAR, ISOBAR, I PASS the
BATON.. etc), staff responsible, recommended
environment, & documentation.
86. GAHAR 86
NSR
9
SURVEY PROCESS
Review policy & procedures developed for
maintenance & testing of critical alarm systems,
which should include staff responsible, control
measures, assurance measures, & remedial action.
Also check whether the procedures cover testing
of alarms, appropriate settings procedures,
priorities for competing alarms, staff authorization
for disabling alarms or changing their settings, &
monitoring of response to alarm activation.
87. GAHAR 87
NSR
9
SURVEY PROCESS
Review inventory of all devices with critical
alarms including setting guidelines.
Review maintenance document for evidence of
responsible staff, responsible company,
schedule, agreed settings, evidence of function,
reporting of malfunction, & remedial action.
Review the schedules of alarm tests & list of
current active settings at difference care areas.
88. GAHAR 88
NSR
9
SURVEY PROCESS
Interview staff around devices with critical
alarm & check their knowledge of critical alarm
settings & response to their activation.
Observe (listen) or activate critical alarms to
check for suitability of alarm volume to working
space.
Interview maintenance staff & check for
implementation.
90. GAHAR 90
NSR
10
RATIONALE
Functional & long-term outcome of early
detection & timely providing urgent care to
deteriorating patients is more superior to
resuscitation of patients with cardio-pulmonary
arrest.
Studies have shown that this strategy has
positive impact on reducing in-hospital
mortality & improving patient safety.
91. GAHAR 91
NSR
10
SURVEY PROCESS
Review the policies, procedures &/or process to
develop, implement & maintain a hospital-wide
system established for recognition of & response
to clinical deterioration.
Review the process established to measure &
document observations via general observation
chart including; respiratory rate, oxygen
saturation, blood pressure, heart rate,
temperature, consciousness level, etc.
Review the process established to build rapid
response teams & to ensure regular rehearses.
92. GAHAR 92
NSR
10
SURVEY PROCESS
Review minutes of meetings of the concerned
committee (such as Code Blue or Medical
Emergencies committee) as evidence of regular
auditing & monitoring of the processes.
Check evidence & staff training concerning
recognition & communication of clinical
deterioration
Observe compliance with policies & procedures
for recognition of & response to clinical
deterioration.
94. GAHAR 94
NSR
11
RATIONALE
Venous thromboembolism (VTE) is considered
an important silent killer in hospitals. Adopting
guidelines to reduce the risk of developing this
condition is important for decreasing
preventable adverse events & mortalities.
95. GAHAR 95
NSR
11
SURVEY PROCESS
Review the guidelines of identifying patients at
risk of venous thromboembolism (deep venous
thrombosis & pulmonary embolism) &
providing appropriate thrombo-prophylaxis.
Interview relevant medical staff trained on
guidelines to reduce venous thromboembolism
(deep venous thrombosis & pulmonary
embolism) to check their full awareness.
96. GAHAR 96
NSR
11
SURVEY PROCESS
Interview patients/families to check whether
the staff provided them with full information
about the risks of venous thromboembolism &
the preventive measures
Observe compliance with guidelines to reduce
venous thromboembolism (deep venous
thrombosis & pulmonary embolism).
