Title Page
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Conducted on
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Prepared by : Mustafa QaraQei
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Location
- GICU
- GICUD
- NCCU
- ACVICU
- PICU
- PCVICU
- NICI L3
- NICU L2
- MHNCCU(PICU)
Critical Care Nursing Administration (CCNA) - Internal Cross Audit
1 Patient Safety
1.1 Identify patients correctly
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All patients’ bed sign are identified by clear MRN with maintaining the confidentiality of patient information.
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All Patient wear clear ID band with 2 identifiers
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Adhering to color codes ID band
1.2 Improve effective communication.
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Verbal and telephone notification/orders are completely signed within 24 hours or immediately( check EPIC)
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Communication with MDT, Patient, Family, Visitors ( Check EPIC )
1.3 Improve the safety of high-alert medications
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All Administered high alert medications checked and signed by 2 nurses - show me the dual sign off in EPIC.
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Patient’s medication labelled with HAM
1.4 Ensure safe surgery.
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e - Consent form completed in EPIC
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Pre and post-surgical bundle checklist for patient undergoing surgery
1.5 Reduce the risk of health care-associated infections.
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Approved poster by Infection control (WHO) is visible in all water sink, soap and alcohol hand rub dispensers.
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Staff performs proper hand hygiene before and after visiting patients
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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.
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All patients’ beds are provided with 2 trash bin (green & Yellow).
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Medical & domestic wastes are disposed properly.
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Sharp containers are containing 3/4 capacity and not overfill.
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Mounted sharp containers at or below eyes level
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Opened medications/solutions labels are correct and legibly: dates, time and staff Initial, Id number
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All opened Solutions are not expired as multi dose.
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All trolleys and trays are clean, and not dusty.
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Primary Staff are using proper PPE devices and evidence of N95 fit test.
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Patients doors/beds are using correct and proper precautionary posters/signage as required.
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Record and monitor of negative pressure room on daily basis for occupied by patient or weekly for not occupied
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Daily equipment checklist: safe and clean
1.6 Reduce the risk of patient harm resulting from falls.
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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
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Side rails are up and bed in the lowest level.
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Call bell and patient needs are reachable to the patient
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Patient room and toilets were clean and well arranged
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Patient categorized as moderate to high risks for fall initiated or reviewed NCP’s are updated ( check EPIC )
2) Environmental Safety
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No obstacles in the way of emergency exit and fire extinguisher
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Posted KPIs is updated
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Temperature and humidity checklist is updated
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All items in the store labelled and correct expiration dates displayed
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The store arranged, cleaned within minimum and maximum stock
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The monthly inventory checklist is updated
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No expiry items.
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Cleaned and arranged equipment store
Crash Cart
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Defibrillator connected to correct Electrical outlet
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No expiration dates for medication in crash cart
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Crash cart cleaned and not dusty
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Proper utilization of energy during daily paddle test checking.
Material Safety Data Sheet (MSDS)
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Hazard items labelled and record
Medication Room
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All high alert medications stored in locked door and labeled as KFMC IPSG NO.3 Policy & procedure
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No over stock items in medication room.
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Cleaned, tidy and not dusty medication room.
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All trays, trolleys are clean, and not dusty.
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The list of high alert medications is visible and accessible to all nurses in medication room.
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All LASA medications are stored and labeled
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The list of LASA medications is updated, visible and accessible to all nurses in medication room
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All nearly expired or short dated HAM and/or LASA including narcotic and controlled medications, reported to pharmacy.
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Narcotics and Controlled Substance Medications count and checking done properly.
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Medication appropriateness poster
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Medication admixture list
Clean utility (LINEN)
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Arranged & cleaned clean utility room.
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Par level of clean utility room
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All trays, trolleys are clean, and not dusty.
Staff Lounge
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Staff lounge area cleaned and arranged
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Labelled food in the staff refrigerator and table
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Top of lockers are clear from dusts and clutter
Dirty Utility
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No clean utility inside
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Linen management/ Curtains
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Infected linen inside red hamper bag
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Used CSSD item are keeping in correct place
