This document contains questions and answers related to medical staff privileging, clinical privileges, temporary privileges, blood transfusion procedures, patient identification, surgical site marking, informed consent, verification processes, high-alert medications, look-alike and sound-alike medications, and medication error reporting. Key topics covered include the duration of clinical privileges being 2 years, temporary privileges not exceeding 90 days, physicians ordering blood and blood products, informed consent requirements, and protocols for blood administration, transfusion reactions, and monitoring vital signs during transfusions.

1. 4/19/2019 1

2. Q1. Why is it necessary to have a
Medical Staff Privileging list in the
units?
4/19/2019 2

3. A1. In order to have a quick
verification of privileges granted by
the Credentialing & Privileging
committee to the doctor.
4/19/2019 3

4. Q2. What is the duration of clinical
privileges?
4/19/2019 4

5. A2. 2 years
4/19/2019 5

6. Q3. In what circumstances
temporary or emergency privileges
are granted?
4/19/2019 6

7. A3. Temporary or emergency privileges shall
be granted in the following situations:
1. Important patient care, treatment &
service need
2. When a new staff is awaiting review &
approval from the Privileging committee &
his/her application is compete & presents
no concerns.
4/19/2019 7

8. Q4. How many days temporary
privileges are valid?
4/19/2019 8

9. A4. Not to exceed 90 days and are
NOT RENEWABLE.
4/19/2019 9

10. Q5. Who is allowed to order blood
& blood products?
4/19/2019 10

11. A5. Only physicians can order
blood & blood products.
4/19/2019 11

12. Q6. Who will obtain the informed
consent for transfusion of blood &
blood products?
4/19/2019 12

13. A6. The attending physician will
obtain consent for transfusion of
blood & blood products.
4/19/2019 13

14. Q7. How many staff members
verify the patient’s identity prior to
blood drawing for cross match &
prior to the administration of blood?
4/19/2019 14

15. A7. TWO nursing staff will verify the
patient’s identity prior to drawing
blood for cross match from patient
and blood administration.
4/19/2019 15

16. Q8. Is transfusion without NAT
testing allowed?
4/19/2019 16

17. A8. YES, but only in dire
emergencies and consent shall be
obtained from the family.
4/19/2019 17

18. Q9. How many minutes interval for
monitoring of vital signs for patients
having blood transfusion?
4/19/2019 18

19. A9. In the first hour : Vital signs are
recorded every 15 minutes
In the second hour till transfusion
completion: Vital signs are recorded
every 30 minutes.
4/19/2019 19

20. Q10. What is the process of
reporting of blood transfusion
reaction?
4/19/2019 20

21. • A10. 1.Stop transfusion of blood.
2. Immediately notify the doctor, nursing
supervisor, blood bank.
3. Using new IV set, start Normal saline infusing at
15 gtts/minute.
4. Observe the patient & take vital signs.
5. Assess for signs & symptoms of shock.
6. Save urine specimen, label & send to laboratory.
7. Complete the transfusion reaction form.
8. Send blood samples, transfusion reaction form
& blood bag with infusion set & tag attached to the
blood bank.4/19/2019 21

22. Q11. State at least 2 patient
identifiers used in identification
process?
4/19/2019 22

23. A11. 1. Patient’s 4 names
2. Medical record
number
4/19/2019 23

24. Q12. What is the standardized
information in the ID band?
4/19/2019 24

25. A12. 1. Patient’s 4 names
2. Sex
3. Age
4. Ward
5. Medical records number
(MRN)
6. Date & time of admission
7. Nationality4/19/2019 25

26. Q13. How does the operating
surgeon mark the surgical site?
4/19/2019 26

27. A13. By marking SS (stands for
surgical site) and a line on the
operative site.
4/19/2019 27

28. Q14. Who marks the surgical site?
4/19/2019 28

29. A14. The operating surgeon marks
the surgical site.
4/19/2019 29

30. Q15. With whom does the
operating surgeon mark the
surgical site?
4/19/2019 30

31. A15. The surgical site is marked by
the operating surgeon along with
the patient or his/her family.
4/19/2019 31

32. Q16. When & where will the
operating surgeon mark the
surgical site?
4/19/2019 32

33. A16. The operating surgeon will
mark the site in the wards prior to
transfer of the patients to the OR.
Site marking should take place
prior to pre-medication.
4/19/2019 33

34. Q17. With what will the operating
surgeon mark the surgical site?
4/19/2019 34

35. A17. The operating surgeon will
mark the surgical site using
indelible ink.
4/19/2019 35

36. Q18. What surgeries are
exemptions from site marking?
4/19/2019 36

37. A18. 1. Surgical procedures involving single organs.
(Cesarean section, Cystectomy)
2. Surgical procedures around genitalia.
(Circumcision, D&C, Bartholin’s cyst excision,
Haemmoroidectomy)
3. Surgical procedures accessed from the mouth.
(Adeno- tonsillectomy)
4. Very obvious presentation (Fracture of right femur,
fracture of left forearm, Diabetic foot, large
wounds)
5. Surgical procedures involving teeth. (Marked on X
rays)
6. Surgical procedures performed on premature
infants. (For fear of tattooing on skin due to site
marking)
7. Surgical procedures done in life-saving situations.4/19/2019 37

38. Q19. What will you do if the patient
refuses site-marking?
4/19/2019 38

39. A19. 1. The operating surgeon will
document the refusal on the patient’s
operative consent form & shall refer to
the site description on the operative
consent form during the time-out
process.
2. An alternate process can be
used like a diagram.
4/19/2019 39

40. Q20. What are the phases of
verification process?
4/19/2019 40

41. A20. 1.Sign in : before induction of
anesthesia
2. Time out : before skin incision
3. Sign out : immediately after wound
closure
4/19/2019 41

42. • Q21. How long is the informed
consent valid?
4/19/2019 42

43. A21. TWO weeks
4/19/2019 43

44. Q22. What is independent double
check?
4/19/2019 44

45. A22. A process involving 2
individuals in which the
responsibility of the 2nd individual is
to verify the work performed by the
1st one.
4/19/2019 45

46. Q23. Who can prescribe High-alert
medications?
4/19/2019 46

47. A23. Only Specialist or Consultants
can prescribe high alert
medications.
4/19/2019 47

48. • Q24. Is abbreviations allowed in
prescribing High-alert
medications?
4/19/2019 48

49. • Q24. NO
4/19/2019 49

50. Q25. Concentrated electrolytes are
NOT to be kept in floor stock
except:
4/19/2019 50

51. Q26. Is telephone order or verbal
order allowed for high-alert
medication?
4/19/2019 51

52. A26. NO
4/19/2019 52

53. Q27. Give few examples of high-
alert medications….
4/19/2019 53

54. A27. 1. Insulin
2. Heparin
3. Potassium chloride
4. 3.5% Sodium
5. Digoxin
4/19/2019 54

55. Q28. Give examples of
concentrated electrolytes.
4/19/2019 55

56. A28. 1. Potassium
2. 3.5% Sodium
4/19/2019 56

57. Q29. What is look-alike
medications?
4/19/2019 57

58. A29. Look-alike medications are
medications in which the packaging
is visually similar to another
product or medications.
4/19/2019 58

59. Q30. What is sound-alike
medications?
4/19/2019 59

60. A30. Medications for which the
generic or trade name of the
product sounds similar in the
spoken or written word.
4/19/2019 60

61. Q 31. Give examples of look-alike
medications.
4/19/2019 61

62. A31. Prednisalone &
Metclopromide
Ampicillin & Penicillin G
4/19/2019 62

63. Q32. Give examples of sound alike
medications.
4/19/2019 63

64. A32. DOPamine and
DOBUTamine
CEFATAxime and
CEFUROxime
4/19/2019 64

65. Q33. Is telephone orders or verbal
orders allowed for LASA (look-alike
and sound-alike) drugs
4/19/2019 65

66. A33. Not Allowed
4/19/2019 66

67. Q34. How do you report medication
error?
4/19/2019 67

68. A34. 1. Inform the treating doctor
2. Monitor the patient
3. Complete the medication error
form
4. Submit the medication error
form to supervisor on duty
4/19/2019 68

69. • Q35. Do you have to report
medication error using OVR form?
4/19/2019 69

70. A35. OVR form should be filled
whenever the medication error falls
in the D classification and beyond.
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