Title Page

  • Conducted on

  • Prepared by : Mustafa QaraQei

  • Location

Critical Care Nursing Administration (CCNA) - Internal Cross Audit


  • BCA (Business Continuity Access) PC / BCWA (Business Continuity Web Access): access the PC/ aware of the process

1.1 Patient Safety_ Identify patients correctly

  • All patients’ bed sign are identified by clear MRN with maintaining the confidentiality of patient information.

  • All Patient wear clear ID band with 2 identifiers

  • Adhering to color codes ID band

1.2 Improve effective communication.

  • Verbal and telephone notification/orders are completely signed within 24 hours or immediately( check EPIC)

  • Communication with MDT, Patient, Family, Visitors ( Check EPIC )

1.3 Improve the safety of high-alert medications

  • All Administered high alert medications checked and signed by 2 nurses - show me the dual sign off in EPIC.

  • Patient’s medication labelled with HAM

1.4 Ensure safe surgery.

  • e - Consent form completed in EPIC

  • Pre and post-surgical bundle checklist for patient undergoing surgery

1.5 Reduce the risk of health care-associated infections.

  • Approved poster by Infection control (WHO) is visible in all water sink, soap and alcohol hand rub dispensers.

  • Staff performs proper hand hygiene before and after visiting patients

  • All line-traced and tubings are dated, valid and labeled such as oxygen Humidifiers, high-risk catheters, nebulization set and suction canister Enteral Tubings (Feeding Tube, pigtail, etc…) and Infusion tubes.

  • All patients’ beds are provided with 2 trash bin (green & Yellow).

  • Medical & domestic wastes are disposed properly.

  • Sharp containers are containing 3/4 capacity and not overfill.

  • Mounted sharp containers at or below eyes level

  • Opened medications/solutions labels are correct and legibly: dates, time and staff Initial, Id number

  • All opened Solutions are not expired as multi dose.

  • All trolleys and trays are clean, and not dusty.

  • Primary Staff are using proper PPE devices and evidence of N95 fit test.

  • Patients doors/beds are using correct and proper precautionary posters/signage as required.

  • Record and monitor of negative pressure room on daily basis for occupied by patient or weekly for not occupied

  • Daily equipment checklist: safe and clean

  •  Vacant/ Empty room maintained clean

  •  Vacant/ Empty room’s Medical devices/ equipment checked and documented on daily basis

1.6 Reduce the risk of patient harm resulting from falls.

  • Adult and pediatric patients identified at moderate risk and above are to wear a red patient identification band with 'Risk for Fall" written, 'Falls" alert attached to their file, and a sign placed by their bed, cot, and/or room door

  • Side rails are up and bed in the lowest level.

  • Call bell and patient needs are reachable to the patient

  • Patient room and toilets were clean and well arranged

  • Patient categorized as moderate to high risks for fall initiated or reviewed NCP’s are updated ( check EPIC )

2) Environmental Safety

  • No obstacles in the way of emergency exit and fire extinguisher

  • Posted KPIs is updated

  • Temperature and humidity checklist is updated

  • All items in the store labelled and correct expiration dates displayed

  • The store arranged, cleaned within minimum and maximum stock

  • The monthly inventory checklist is updated

  • No expiry items.

  • Cleaned and arranged equipment store

Crash Cart

  • Defibrillator connected to correct Electrical outlet

  • No expiration dates for medication in crash cart

  • Crash cart cleaned and not dusty

  • Proper utilization of energy during daily paddle test checking.

Material Safety Data Sheet (MSDS)

  • Hazard items labelled and record

Medication Room

  • All high alert medications stored in locked door and labeled as KFMC IPSG NO.3 Policy & procedure

  • No over stock items in medication room.

  • Cleaned, tidy and not dusty medication room.

  • All trays, trolleys are clean, and not dusty.

  • The list of high alert medications is visible and accessible to all nurses in medication room.

  • All LASA medications are stored and labeled

  • The list of LASA medications is updated, visible and accessible to all nurses in medication room

  • All nearly expired or short dated HAM and/or LASA including narcotic and controlled medications, reported to pharmacy.

  • Narcotics and Controlled Substance Medications count and checking done properly.

  • Medication appropriateness poster

  • Medication admixture list

Clean utility (LINEN)

  • Arranged & cleaned clean utility room.

  • Par level of clean utility room

  • All trays, trolleys are clean, and not dusty.

Staff Lounge

  • Staff lounge area cleaned and arranged

  • Labelled food in the staff refrigerator and table

  • Top of lockers are clear from dusts and clutter

Dirty Utility

  • No clean utility inside

  • Linen management/ Curtains

  • Infected linen inside red hamper bag

  • Used CSSD item are keeping in correct place

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