This document outlines 4 goals to improve patient safety at a healthcare facility. Goal 1 is to correctly identify patients to ensure safety during diagnosis, treatment and administrative processes. Goal 2 aims to improve communication effectiveness among caregivers to reduce errors. Goal 3 focuses on improving safety of high alert medications by establishing specific handling and administration procedures. Goal 4 seeks to ensure correct site, procedure and patient for surgeries. The goals provide policies and procedures and designate staff responsibilities to address issues and enhance patient safety.

1. PATIENT SAFETY GOALS
GOAL 1: IDENTIFY PATIENTS CORRECTLY
Introduction
The purpose of the Patient Safety Goals is to promote specific 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 1- IDENTIFY PATIENTS CORRECTLY
1.0 Objectives
1.1 To ensure patients safety by correctly identifying every
patient in all aspects of diagnosis, treatment and
administrative process
2.0 Scope
2.1 All PMC healthcare facilities involving patient
Care
3.0 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
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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
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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. 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 COMMUNICATION
1.0 Objectives
1.1 To improve the effectiveness of communication among
Caregivers
1.2 To reduce communication errors and improve patient
safety
2.0 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. 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 possible
4.0 Reference
5.1 Private Healthcare Facilities and Services
(Private Hospitals and Other Private Facilities) Regulations
2006
5.0 Responsibility
6.1 Physicians
6.2 Nurses
5

6. 6.3 Allied Health
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7. PATIENT SAFETY GOALS
GOAL 3: IMPROVE THE SAFETY OF HIGH
ALERT
MEDICATION
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 patients safety.
GOAL 3 - IMPROVE THE SAFETY OF HIGH ALERT
MEDICATION
1.0 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
risks
2.0 Scope
2.1 Patient care areas- Emergency Department, General
7

8. Wards, Critical Care areas, Operating Theatre, Radiology
Department and OPD
3.0 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 gluconate
4.0 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. 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
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10. PATIENT SAFETY GOALS
GOAL 4: ENSURE CORRECT SITE, CORRECT
PROCEDURE AND CORRECT PATIENT
SURGERY
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
GOAL4- ENSURE CORRECT SITE, CORECT PROCEDURE
AND CORRECT PATIENT
SURGERY
1.0 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. 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 Health
5 Related Document
5.1 Operation Theatre Department P & P
5.2 Operation theatre Patient check list (PMC 029)
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12. PATIENT SAFETY GOALS
GOAL 5: REDUCE THE RISK OF HEALTH CARE
ASSOCIATED INFECTION
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
GOAL5 - REDUCE THE RISK OF HEALTHCARE
ASSOCIATED INFECTIONS
2.0 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
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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 Nurse
4.0 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
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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 surrounding
5. Responsibility
5.3 Infection Control Committee
5.4 Healthcare workers
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15. PATIENT SAFETY GOALS
GOAL 6: REDUCE THE RISK OF PATIENT
HARM RESULTING FROM FALLS
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
GOAL6 - REDUCE THE RISK OF PATIENT HARM
RESULTING FROM FALLS
1.0 Objectives
1.1 To identify the patient who are at risk of falls
1.2 To reduce the risk of patient harm resulting from
falls
2.0 Scope
2.1 All patient care areas – Emergency Department, General
15

16. Wards, Critical Care areas, operating Theatre, Radiology
Department, Physiotherapy Department, Laboratory and
Blood Services and OPD
3.0 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
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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 reporting
5.0 Responsibility
5.1 Physicians
5.2 Nurses
5.3 Allied Health
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18. ADMISSION TO THE ORGANIZATION
1.0 Objectives
1.1 This policy is established to provide effective screening method
for patients who may require PMC’s clinical services as patient
2.0 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 Department
3.0 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
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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-
call
3.4 Outpatient registration
3.4.1 There is a standardized procedure for outpatient
registration
3.5 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 referred
3.6 After the outpatient consultation, the patient will be referred for
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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
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21. 2.0 PROCEDURES ADMISSION
ACTIVITIES RESPONSIBILITY
2.1 ADMISSION
2.1.1 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. General
2.1.4 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 Staff
2.1.9 Patients with no relatives or unconscious, next-of-kin Sister / Administrator
should be notified via police. On Call
21

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 / Nursing
2.2 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. Consultant
2.2.3 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: ambulance
2.2.5 Upon transfer of patient, to document and complete
the PMC 021.
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23. DISCHARGE
1.0 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 areas
3.0 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. 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
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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. ACTIVITIES RESPONSIBILITY
2.3 DISCHARGE OF PATIENT
2.3.1 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 discharged
2.3.3 Refer work instruction for nursing procedure, page 5-6 SRN/ward aids
as a guideline for discharge
2.3.4 Refer nursing policies & procedure 16.1 till 16.1.7, SRN/Nursing
page 28 for At Own Risk Discharge Supervisor
2.3.5 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 call
2.3.6 Upon discharge of patient, to document and complete SRN
the PMC 021and click in I-Care system after alerted
by billing staff
26

27. 2.4 PROCEDURES OF AT OWN RISK (AOR) DISHARGE
AND LEAVE PROCEDURE
27

28. ACTIVITIES RESPONSIBILITY
2.4 At Own Risk Discharge
2.4.1 Confirm AOR discharge by doctor’s ordered. Doctor
2.4.2 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 Leave
2.4.8 Inform to consultant to obtain permission after requested SN
by patient / PAP
2.4.9 Explain regarding AOR Leave procedure SN
2.4.10 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 insurance
2.4.12 Supply indicated medication as prescribed in PMC 036 SN
2.4.13 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. FLOW CHART OF DISCHARGE PATIENT
Receive order from doctor regarding
patient can discharge
29

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 property
3.0 POLICIES AND PROCEDURES OF CARDIAC PULMONARY ARREST
ACTIVITIES RESPONSIBILITY
30

31. 3.1 Inform Doctor / Medical Officer Immediately SRN / Trained Staff
3.1.1 Push emergency trolley to the patient’s bedside. SRN / Trained Staff
3.1.2 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
indicated
3.1.4 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 175
3.1.6 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 DIL
3.1.9 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. 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 in
ICU 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. 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 Department
1.0 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.
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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- 37.5
Green
40- 59 70- 99 40- 59 8- 12 70- 90 10- 14 37.6- 40
Yellow 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. 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
<100
1 month – 1 year <60 >50
180
1 – 4 years <70 >100
<80 >40 >38.5˚ C
4 – 8 years <75
150
8 – 12 years <80 >140
** Indication of Poor Circulation : Cold to touch ,peripheral cyanoses & capillary refill > 3
seconds
3.5 POLICIES AND PROCEDURES PROCESS OF DECEASED BODY
ACTIVITIES RESPONSIBILITY
35

36. 3.5.1 Certified death. Medical Officer or
Doctor In Charge
3.5..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 religion
3.5.7 Inform the family members to settle the bill. Staff Nurse
3.5.8 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 arranged
3.5.11 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 Nurse
3.5.13 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. 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. 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 report
4.6.1.
3
38

39. 5.0 POLICIES AND PROCEDURES FOR CHECKING EMERGENCY
TROLLEY
ACTIVITIES RESPONSIBILITY
5.1
Check Emergency Trolley
Check emergency trolley every shift as listed in PMC049
5.1.1
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 equipment
5.1.3
Check for presence of :-
a) Cardiac board
b) Drip stand
The above checking needs to be documented completely
5.1.4
and clearly.
39

40. ACTIVITIES RESPONSIBILITY
5.2 Replenish of Emergency Trolley
5.2.1 Replenish trolley immediately after each use.
5.2.2 Replace drugs or disposables 3 month prior to expiry
date.( Utilize color coding)
SN / Trained Staff
5.2.3 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 Trolley
5.3.1 Check wheels of the trolley are functioning well.
Ward Assistant
5.3.2 Damp dust and keep trolley clean and tidy always
5.4 Position emergency trolley back to its place and ready for
use
FLOW CHART FOR CHECKING OF EMERGENCY
40

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 trolley
6.0 POLICY & PROCEDURE FOR INCIDENT REPORT
41

42. ACTIVITIES RESPONSIBILITY
6.0.1 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) immediately
6.0.2 SRN / Staff on Duty
or nursing supervisor on duty during absence of the
H.O.D
6.0.3 Obtained and documented the immediate observation
of patient involve as a baseline parameter in PMC 140 SRN
SRN / HOD
6.0.4 Continue monitor the patient accordingly to the need
of Observation
6.0.5 Issue incident occurred according to PMC 140
(Appendix Event Categories is attach as reference ) HOD
6.0.6 Make sure the attending Doctor complete the report
after attended the patient SRN
6.0.7 Make sure treatment been ordered is carry out
accordingly SRN
6.0.8 Alert the incident to the investigation team as soon as
possible SRN
6.0.9 Send the PMC 140 to Quality Assurance department
within 24 hours HOD
INCIDENT REPORTING EVENT CATEGORIES
The following categories are reportable events and near misses;
42

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. 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 patient's 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 etc
Wrong patient operated
upon
Unplanned 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 burns
Incorrect surgical count e.g.gauze,sponge / instruments / needle
44

45. 6.2 POLICIES AND PROCEDURES NEEDLE STICK INCIDENT
ACTIVITIES RESPONSIBILITY
6.2 Needle Stick Incident
6.2.1 Staff pricked by sharp.
Staff involved
6.2.2 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 absent
6.2.4 Inform the infection control nurse. SN / Sister In charge
6.2.5 Staff involved to see medical officer immediately. Infection Control
Nurse / Sister In
Charge
6.2.6 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. 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. 7.1 POLICIES AND PROCEDURES OF UNCONTROLLED DRUGS
ACTIVITIES RESPONSIBILITY
7.1 Storage of Uncontrolled Drug
7.1.1 Store drugs as indicated by manufacturer SRN
7.1.2 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 always
7.2 Replenish of Uncontrolled Drugs (stock)
7.2.1 Replenish daily Dispenser
7.2.2 Check stock balance / par level before indenting.
7.2.3 Use uncontrolled drugs requisition form (PMC 082) for SN
indenting.
7.3 Document of Drugs
7.3.1 Write drugs strength dosage of drugs in medication SN In Charge
chart as per column provided. Medication
7.3.2 Initial in respective frequency column upon SN In Charge
administration to patient. Medication
7.4 Unit Dose Drugs
7.4.1 Indent non – stock drugs from pharmacy using SN
medication chart
7.4.2 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. 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 Chart
7.5 POLICIES AND PROCEDURES OF CONTROLLED DRUGS
48

49. ACTIVITIES RESPONSIBILITY
7.5.1 Checking of Controlled Drugs
(Injectables and Oral Drugs)
SRN In Charge
7.5.2 Check DDA drugs every shift for the balance of each Medication / Trained
drug as documented in DDA Record Book Staff
7.5.3 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 Charge
7.5.5 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 Drugs
7.5.6 Keep drugs in DDA cupboard with double lock at all
times
7.5.7 Keep DDA par level at all times. SN In Charge
Medication / Trained
7.5.8 Keep empty ampoules for exchange. Staff
7.5.9 Any broken / missing dangerous drug ampoules to be
reported immediately to pharmacist in charge Sister, SN
ACTIVITIES RESPONSIBILITY
49

50. Recording of Controlled Drugs
7.5.10 Immediately document any drugs used. SN In Charge
Medication / Trained
7.5.11 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 check
7.5.12 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 handling
7.5.14 Replenishment of Controlled Drugs Indenting SRN In Charge
Medication / Trained
7.5.15 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 injectables
7.5.17 Follow indent schedule as given by the Pharmacist.
50

51. ACTIVITIES RESPONSIBILITY
Collection of Drugs
7.5.18 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 supplied
7.5.19 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 double
7.5.20 lock.
51

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. 7.6 POLICIES AND PROCEDURES STORING LIVE VACCINE
ACTIVITIES RESPONSIBILITY
7.6.1 Receiving Life Vaccine
7.6.1. Nursery staff will order in pharmacy requisition form Trained Staff
1 for live vaccine.
Collect the live vaccine from pharmacy in the prepared Trained Staff
7.6.1. cold chain bag
2
Storage of Live Vaccine
7.6.2 Store in compartment temperature of 2°c to 8°c.
7.6.2. To check temperature of the fridge two times a day Trained Staff
1 and record it in the fridge temperature chart.
7.6.2. If any changes in temperatures, the sister in-charge Trained Staff
2 must be notified immediately.
All live vaccine is to be disposed after use in a sharp Trained Staff
7.6.2. bin.
3
Ensure the temperature of the fridge is maintained at Trained Staff / Sister
2°c to 8°c. In Charge
7.6.2.
4
7.6.2.
5
53

54. 8.0 POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION
ACTIVITIES RESPONSIBILITY
8.1 Diagnosed by the consultant in-charge with Consultant In Charge
supporting investigation results (X-Ray, blood result)
if available
8.2 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 diagnosis
8.4 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. Incharge
8.7 Carbon copy must be kept in patient file / ticket.
SN
8.8 Notification chop must be stamped in the admission
card inside the patient’s file & PMC 022 SN
54

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. ACTIVITIES RESPONSIBILITY
9.1 Renting of Oxygen Cylinder
9.1.1 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 Nurse
9.1.4 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. 9.2 Returning of Oxygen Tank
9.2.1 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. Assistant
9.2.3 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. 10.0 POLICIES AND PROCEDURES IN MAINTENANCE REQUISITION
ACTIVITIES RESPONSIBILITY
10.1 Confirm the faulty equipment. Sister, Staff Nurse,
Midwife
10.2 Fill up the maintenance request form, PMC 051 Sister, Staff Nurse,
Midwife
10.3 Dispatch PMC 051 to the maintenance department. Female Attendant
10.4 Maintenance staff comes to the ward to check the
equipment.
10.5 Repair is to be done stat if is possible. Maintenance Staff
10.6 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. 11.0 POLICIES AND PROCEDURES CARE OF PATIENT UNDERGOING RADIOGAPHIC
AND OTHER IMAGING STUDIES
ACTIVITIES RESPONSIBILITY
11.1 Preparation For The Examination
11.1.1 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 Attendant
11.1.4 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. ACTIVITIES RESPONSIBILITY
11.2 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 Doctor
11.3.3 Be encouraged to take plenty of fluid (if there is no SN
contraindication) following administration of
radiopaque contrast medium.
60

61. ACTIVITIES RESPONSIBILITY
11.4 Ultra Sound Examination
11.4.1 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. WA
11.5.4 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. 12.0 POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE
ACTIVITIES RESPONSIBILITY
12.1 Types of Clinical Waste
12.1. Segregate clinical waste in appropriate groups :- SN
1 a) Sharps and objects
b) Clinical waste
Disposal of Sharps and Objects
12.2
Discard sharp instrument and objects e.g. syringes, SN
12.2. needles cartridges and scalper blades into sharps
1 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 Personnel
12.2.
5 Place 2/3 full sharp container into clinical waste
carriage H / Keeping Personnel
12.2.
6 Disposal of Clinical Waste
SN
Discard the bellow item listed clinical waste into
12.2. yellow bag e.g. soiled surgical dressing, cotton SN
7 wool, gloves, swabs material used to clean spillage.
12.3
12.3.
1
62

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
sealer
Discard 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. Housekeeping Personnel to Dispose into Clinical
Waste Carriage
13. 0 POLICIES AND PROCEDURES MANAGEMENT OF BLOOD GROUP AND
CROSS MATCH PROCEDURE
ACTIVITIES RESPONSIBILITY
64

65. 15.1. GXM ordered by the doctor. Doctor
151.1 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 Doctor
151.2 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 stat
15.1. Inform the doctor stat SN
4
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 and
15.1. request of the supply urgently.
6
Document the exact date and time in PMC 071 Doctor
15.1. The 2nd PMC 071must be sent to laboratory stat Doctor, SN
7 after the necessary requirements has be arranged
15.1.
8
15.1.
9
FLOW CHART
DOCTOR’S ORDER
65

66. GXM FORM
(COMPLETELY FILLED UP)
INFORM LABORATORY TECHNICIAN
SUPPLY AVAILABLE SUPPLY UNAVAILABLE
PROCEED WITH - Send 2nd GXM form to the doctor
TRANSFUSION 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