Title Page
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Unit conducted
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Conducted on
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Prepared by
ERNA Gemba Walkround
Patient Confidentiality
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No patient personal information in public; Station and Computer
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Patient is covered during transportation
Infection Control
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Regular and infectious waste disposed in appropriate containers. Not overfilled
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Sharp containers should be tightly closed/sealed at 3/4 full
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Sharps containers present in appropriate locations
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Hand rub dispenser in every clinical room, patient waiting areas, near the elevators and at each sink available
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Is there adequate PPE available?
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Are people trained in the use of PPE?
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Treatment trolleys are clean and organized
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All the used linens and hamper bags are stored in soiled utility room
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Food is stored and eaten in designated places
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Spill kit available and updated
Facilities
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Patient bathrooms have non-slippery surface. Door can be accessed if locked
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Is adequate lighting in toilet?
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Is the floor/area free from water?
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Are doors locks are working?
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Female and male toilet signs are clear?
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Waiting areas are separately identified with male and female and organized
MSDS Checklist
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MSDS folder available in the area
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List of staff who have competency checkoff
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CPP: Emergency Hazardous Material Spill Management updated in the folder
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PPE must be available in the MSDS area
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HAZMAT area must be separated from other areas of the facility
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Proper labeling according to hazard rating classification.(Diamond sticker)
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Safety (officer) contact number visible for any suspected or witnessed release of a hazardous material to the environment
Linen (DPP: 30501 /125/30 Ns Patient Linen Management – Nurses Role)
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A minimum/maximum level for linen requirement per unit is established and should be adhered to
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Fresh/clean linen is to be stored separate from dirty/used linen
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Clean linen store is to be secured and preferably locked
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Problems with amounts, availability or quality are to be documented on a Linen Problem log and followed-up
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Daily linen monitoring sheet updated and completed
Medication (DPP: 30501-106-30 NS Medication Management – Ordering and Storage)
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Narcotic cupboard double locked
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Expiry date of stock (included in medication fridge) noted every week
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Medication room temperature and humidity are monitored and recorded
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Medication refrigerator temperature maintained 2 to 8 degree °C and recorded
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No food etc in medication fridge
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Medication storage areas (room and cart) locked (except when in use)
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Cassettes are properly labelled with the patient's name of medication and expiry date
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Medication preparation area is clean, good lighting and closed
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Updated stock medication list
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Drug Formulary
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Approved Abbreviations list /Floor Stock medication policy available
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Externally and internally used products separated
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Any product used on patient (external/internal) to be labelled with date when opened
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Proper removal of medication waste
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LASA and HAM poster updated.
Refrigerators (DPP:0501-034-1432 NS Food and Medication Storage In Unit/Ward Refrigerators)
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Food refrigerator temperatures per shift maintained 0-5 °C and recorded
Medical Equipment
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Clinical Equipment (Biomed): Clean
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All equipment has label
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Last service date (PPM)
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Next service date (PPM)
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Tag if out of order equipment
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Manufacturer's instructions available
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List of biomedical equipment inventory is accessible
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Oxygen tanks are stored in appropriate holders
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Keep oxygen tank out of entrance ways and walkways
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Empty cylinders separate from full
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Daily room check list is updated and maintained
POCT
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Control solutions labelled with date of opening and in date
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POCT Consumables stored in accordance to PCLM recommendations
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QC done and results recorded daily
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POCT (Glucose, urine, pregnancy test, etc) competencies list is updated
Emergency Contacts
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Station/telephones (either poster or label on phone): Emergency: X 22222
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Color code emergencies posted
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Radiation safety officer name and contact details
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KFMC safety officer name and contact details
Office/Computer
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Reference manuals;
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Read and sign folder (Polices updated)
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Infection control Manual
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Disaster plans and manuals
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Safety/Equipment manual
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Lab guidelines
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Quality Board – Location/Contents
Staff Knowledge
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Verbalized and performed correct Patient identification
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Verbalized and performed correct Medication Administration (includes patient ID Scanning and BCMA Scanning)
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Verbalized and performed correct blood and blood product administrations as per policy
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Verbalized the Department - Nursing Performance Indicators
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Verbalized correct procedures for the patient procedural without sedation
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Other related questions (please write the questions)
