Title Page

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  • MRNs

Patient Requirements


  • Patients are identified using two patient identifiers (MRN, Full Name)?

  • Patients are identified before performing diagnostic procedures, providing treatments, and performing other procedures?

  • The hospital ensures the correct identification of Unknown patients?

  • Standardized critical content is communicated between health care practitioners during handovers of patient care and Standardized forms and tools?

  • The hospital develops and implements a process for managing these high-alert medications /look-alike sound-alike medications and uniform throughout the hospital?

  • The hospital implements a preoperative verification process (Sign in, Timeout, Sign out) and documented in medical record

  • Surgical/invasive site marking is done by the person performing the procedure and involves the patient in the marking process and The full team actively participates in a time-out process

  • When surgical/invasive procedures are performed, in operating or other places there is uniform mark site

  • Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital

  • The hospital implements a process for assessing all inpatients and outpatient for fall risk and uses assessment tools/ methods appropriate for the patients and Patient interventions are documented

  • The hospital implements a process for the reassessment of inpatients and outpatient who may become at risk for falls due to a change in condition, or are already at risk for falls based on the documented assessment and Patient interventions are documented

  • Fall Risk Documentation is accurate and Education is given and documented

Access to Care and Continuity of Care (ACC)

  • Patients with emergent, urgent, or immediate needs are given priority for assessment and treatment

  • The hospital considers the clinical needs of patients and informs patients when there are unusual delays for diagnostic and/or treatment services

  • At admission as an inpatient, the patient and family receive education and orientation to the inpatient ward, information on the proposed care and the expected outcomes of care

  • During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care

  • Information related to the patient’s care is transferred with the patient. Discharge, Referral, and Follow-Up

  • There is a process for the referral or discharge of patients that is based on the patient’s health status and the need for continuing care or services

  • The complete discharge summary is prepared for all inpatients

Patient Centered Care (PCC)

  • The hospital is responsible for providing processes that support patients’ and families’ rights during care

  • The patient’s rights to privacy and confidentiality of care and information are respected

  • Patients are informed about all aspects of their medical care and treatment and participate in care and treatment decisions

  • The hospital informs patients and families about its process to receive and to act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes

  • General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits

  • Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, other high-risk treatments , procedures and Tissues donation

  •   Each patient’s educational needs are assessed and recorded in the medical record.

  • Patient Education methods according to patient’s and family’s values and preferences allow sufficient interaction among the patient, family, and staff for learning to occur.


  • Each patient’s initial assessment includes a physical examination and health history as well as an evaluation of psychological, spiritual/cultural (as appropriate), social, and economic factors

  • The patient’s medical and nursing needs are identified from the initial assessments, which are completed and documented in the medical record

  • The initial medical and nursing assessments of emergency patients are based on their needs and conditions

  • Patients are screened for nutritional status, functional needs, and other special needs and are referred for further assessment and treatment when necessary

  • All inpatients and outpatients are screened for pain and assessed when pain is present

  • Terminally ill / Dying patients and their families are assessed and reassessed according to their individualized needs

  • discharge need planning documented within 48 hr

  • All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge

  • For emergency operations a brief note documented for the patient prior to surgery

  • If there are any high value in the vital signs the measure is done every 1 hour till stabilization

  • Patient injected with radiated iodine must be in the designated room with lead shield


  • Clinical and diagnostic procedures and treatments are carried out and documented as ordered, and the results or outcomes, are recorded in the patient’s medical record

  • Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products

  • A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is available

  • Patients at nutrition risk receive nutrition therapy

  • Patients are supported in managing pain effectively

  • Oxygen Therapy (Physician Order is present, Accurate Administration (liters and Oxygen delivery method)

  • Restrain Order (Restrain physician order / updated every 24hrs,Restrain Initiation documentation , Restrain follow up documentation / 1hr

  • The care of high-risk patients and the provision of high-risk services are guided by professional practice guidelines, laws, and regulations (list who is high risk patient )

  • An individualized plan of care is developed and documented for each patient (Nurse - physician - nutrition- psychology )

  • ICU/SICU  check documentation of ventilator mode

  • In case of attendee code blue (all member attendee ,all member doing their role follow the guideline)

  • In case of bed sore (check documentation ,care , and glamorgan scale)

  • Assess the patient according to CCHEWs and take accurate measurements depending on the score result

  • In case of Dialysis Check ( Physician Order- Nursing assessment- Technician Follow up)

  • Assessment VTE patient and action taken

Management Of Information (MOI)

  • Staff are trained and understand those documents relevant to their responsibilities.

  • Every patient medical record entry identifies its author and when the entry was made in the medical record.

National Safety Requirements (Excess)

  • Standardized line reconciliation, rechecking process, and catheter maps as part of handover communication

  • Labeling done for high-risk catheters (e.g. arterial, epidural, intrathecal)

  • General measures are used to reduce risk of pressure ulcer such as pressure relieving devices and mattresses

  • Recognition of and response to clinical deterioration are recorded in the patient’s medical record.

  • Medication reconciliation occurs on admission, during the transition of care and upon discharge within a defined timeframe.

Medication Management and Use (MMU)

  • Medication Administration five rights (Right patient, Medication, Dose, Duration, Route)

  • Double check on medication before administration is documented

  • No medication beside patient

Anesthesia and Surgical Care

  • Pre and post anesthesia/ procedure checklist (Complete, accurate)

  • Discharge criteria (Complete, accurate)

  • Post Surgical Plan (Complete, accurate)

  • Monitoring patient in recovery (Complete, accurate)

  • A preoperative medical assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, psychological, social, economic, and discharge needs

  • Implantable device is documented in medical record and there is process for Recall

Staff Interview

  • The hospital has a process for the management and follow-up of patients who notify hospital staff that they intend to leave against medical advice(LAMA)

  • The hospital has a process for the management of patients who leave the hospital against medical advice without notifying hospital staff (DAMA)

  • Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities

  • Staff aware of using tubes and catheters policy

  • Staff are trained in the strategies and tactics used for planned and unplanned downtime of data systems.

  • Competent individuals are responsible for the management and use of critical alarms

  • All staff who records in the patient’s medical record are aware of approved and prohibited abbreviations

  • The hospital provides education for fire response and evacuation to all staff at least once annually.

  • Staff are aware of safety measure pertinent to their job.

  • Staff aware about (RACE-PASS)

  • Hospital Vision and Mission

  • What is the process of reporting errors in your hospital?

  • What is the meaning of near miss, sentinel event, adverse event and no- harm event?

  • Anyone blamed you when reporting any error?

  • What are the KPIs for your departments?

Unit Requirements

  • The complete Critical result is documented and read back process confirmed by witness (Signature physician with 24hr )?

  • The complete verbal order is documented and read back process confirmed by witness (Physician Signature within 24hr and pharmacist signature on form) ?

  • Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access and promotes safe use and there is a process that prevents inadvertent administration?

  • POCT quality control is done as planned (daily for blood sugar, weekly for hemoglobin and urine strip)

  • POCT critical results are reported and documented according to policy

  • For radiation safety (Radiology, Radiotherapy, Nuclear Medicine); all personnel are wearing TLD, Lead aprons stored upright on specified hangers and numbered

  • In ICU /SICU /recovery /Operating room unit (check clinical alarm)

  • Crash cart (checked ,complete and closed with serial number)

  •   In O.R and dental clinic if use laser (check precaution, sign and ventilation )

  • Medications are safely and securely stored in stores, pharmacies, and patient care areas according to laws and regulations

  • Material safety data sheet (MSDS) available and includes information such as physical data, hazardous material type, safe storage, handling, spill management and exposures, first aid, and disposal.

  • Appropriate segregation, labeling, handling, storage, transportation, and disposal of all categories of hazardous waste.

  • Availability of required protective equipment and spill kits.

  • Records are maintained for Biomedical devices, testing, periodic preventive maintenance

  • Records are maintained for utility systems inventory, testing, periodic preventive maintenance and malfunction history.

  • Medication Room (Locked, Secured)

  • Are medications in the medication cart valid(check expiry date)?

  • check all medications are appropriately labeled and not masking information (HAM , LASA or conc.electro sign.)

  • Are thermo-sensitive / opened medications kept in the refrigerator in place ? (according to pharmacy list)

  • Are medications and IV fluids valid at stock? (Check expiry date)?

  • Do refrigerators have working thermometers & place ? Checklists are fulfilled regularly?

  • Hospital Lists (High alert ,LASA ,Concentrated electrolytes ,Critical Results ,Refrigerated medications ,Beyond use date )( available , complete , clear , right position , communicated )

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