Title Page
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Site conducted
- MH
- RH
- WSH
- CSH
- NNI
- KSHC
- CCC
- CCNA
- ERNA
- ORNA
- ACNA (OPD)
- NASA
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Unit
- Adult Endoscopy
- OHIPC
- Adult Renal Dialysis
- Medical Ward 8
- Medical Ward 7
- Medical Ward 6
- Medical Ward 5
- Male Surgical Ward
- Female Surgical Ward
- Surgical Ward 5
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- WSH ED
- REIMD
- URO-GYNE
- L&D
- WARD 1
- WARD 2
- WARD 3
- WARD 4
- NURSERY
- GYNE-ONCO
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- CCU
- Cardiac Ward 1
- Cardiac Ward 2
- Cardiac Telemetry Ward
- Cardiac Surgical Ward
- NIL
- ACCL
- PCCL
- Pediatric Cardiac Ward / PHDU
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Unit
- Pediatric Endoscopy
- 2FW1
- 3FW1
- 3FW2
- 3FW3
- 3FW4
- 4FW1
- 4FW2
- PSRU
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Unit
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Unit
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Unit
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Unit
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Unit
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Unit
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Unit
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Unit
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Conducted on
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Prepared by
CLINICAL AREA AND STOCK ROOM INSPECTION FINDINGS
Infection Control
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Type of isolation precaution displayed before each patient’s room and practiced appropriately
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There are sufficient PPEs ready for use for each patient’s room.
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PPEs used and disposed appropriately.
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Range of negative and positive pressure for the isolation rooms regularly monitored and documented.
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Hand rub dispenser available in ever patient’s room, toilet and nurse’s station.
Facilities
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Each bedside call bell is functioning
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No obstructions to (a) fire exits, (b) fire extinguishers, (c) fire boxes
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Shut off valves are: (a) not obstructed, (b) labeled, (c) inspected (inspection card up-to-date)
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Signs for emergency/fire exits are present, clear, working and leads path to exit.
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Signs for “no smoking” and “wet floor” are clearly seen
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Each patient’s bathroom has a non-slipping floor surface and handrails/bars.
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Each patient bathroom has an emergency pull cord long enough for a patient in low position to reach (at least 20 cm from the floor level).
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All Primary Nurses are able to demonstrate how to open the bathroom if it is locked from the inside.
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Fire extinguisher and fire blanket available inside the patient and/or staff pantry.
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Separate utility areas for clean and dirty equipment.
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Fire equipment have been inspected and up-to-date.
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Each room is with label or signage and functioning according to its signage.
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Childproof outlet caps are in place in pediatric units or in areas where children may be present.
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Only hospital provided extension cords used
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Plugs and receptacles in good condition.
Stock Room
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Stock room locked when not in use
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Protective clothing and equipment for hazardous materials available
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Hazardous materials stored in its original container and labelled clearly.
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Hazardous materials are placed in a separate container on the lowest shelf with ‘Hazardous Materials’ signage on the shelf.
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Blood and chemical spill kits available as required in the area
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List of hazardous materials is up-to-date, contains information on how to use the material, its purpose, type, where it’s located, responsible person and quantities permitted to the stored
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There is a list of required stock items inside the unit/ward stock room indicating the maximum, minimum and critical number required per week.
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Stocks are stored and organized in an accessible manner that permits easy identification of supplies
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Sterile items separated from non-sterile items.
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Top items are 50 cm from the ceiling.
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There is a heat/smoke detector and sprinkler.
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Separate items kept in separate labelled containers or shelf space.
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Heavy items at waist height.
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Fluids are stored in lower shelves
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Room temperature and humidity monitored and recorded if IV fluids are kept in the stock room
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No boxes/items stored on the floor
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Shelves and containers are clean and dust-free.
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Items in the shelves arranged in a first-in first-out order.
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No items that are expired or have an expiry date of less than 3 months.
Linen Room
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Linen room is locked when not in use
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Clean laundry covered in lockable linen room.
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Clean linens stored separately from dirty/used linens
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Problems with amounts, availability or quality are documented on a Linen Problem log and followed-up.
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A minimum/maximum/critical quantity of linens required per day is maintained and recorded.
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Laundry hampers are covered
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No linen on the floor
Medication Room
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Narcotic cupboard double locked.
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Multi-use vials/bottles are labeled with expiration date with the date of opening, name and signature of Primary Nurse upon opening.
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Medication storage areas (room and cart) locked (except when in use).
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Medication cassettes labeled with the patient’s MRN and complete name.
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No expired medications
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Stock medication list updated regularly
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KFMC Formulary and List of Approved/Not Approved Abbreviations available in the medication room.
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Externally and internally used products separated in the medication cassette.
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Medication room temperature and humidity monitored and recorded every shift.<br>a. Medication room temperature maintained between 15 to 25oC.<br>b. Medication room humidity is maintained between 35-60 RH
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Medication refrigerator temp is maintained bet 2-8 C and is recorded every shift.
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In the event when the refrigerator temp goes beyond or below prescribed temp:<br>a. An action was taken to correct the malfunction (notify pharmacy and Biomed)<br>b. Medications transferred to another refrigerator.<br>
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Refrigerator PPM is up-to-date
Medical Equipment
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There is an inventory of all medical equipment and their location in the unit/ward.
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With up-to-date PPM stickers (testing date and due date).
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Broken equipment removed or labeled/tagged if out-of-order.
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Treatment trolleys clean and organized.
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Stretchers with straps or side rails; wheelchairs with straps.
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Oxygen tanks are stored in appropriate holders, out of entranceways and walkways – empty cylinders are separated from full
Notice Boards
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KFMC Mission and Vision
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Emergency disaster color codes
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Fire response
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Patient’s rights and responsibilities
Waste Disposal
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Regular and infectious wastes disposed in appropriate containers. Not overfilled.
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Sharps’ container lids must be fixed and no more than ¾ full at any given time.
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Sharps containers present in appropriate locations.
Other Findings
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Other findings not covered by the above criteria