ERNA Gemba Walkround

• Unit conducted

• Conducted on

  Date

• Prepared by

Patient Confidentiality

• No patient personal information in public; Station and Computer

  Met

  Not Met

  N/A

• Patient is covered during transportation

  Met

  Not Met

  N/A

Infection Control

• Regular and infectious waste disposed in appropriate containers. Not overfilled

  Met

  Not Met

  N/A

• Sharp containers should be tightly closed/sealed at 3/4 full

  Met

  Not Met

  N/A

• Sharps containers present in appropriate locations

  Met

  Not Met

  N/A

• Hand rub dispenser in every clinical room, patient waiting areas, near the elevators and at each sink available

  Met

  Not Met

  N/A

• Is there adequate PPE available?

  Met

  Not Met

  N/A

• Are people trained in the use of PPE?

  Met

  Not Met

  N/A

• Items for CSSD are clean and stacked

  Met

  Not Met

  N/A

• Treatment trolleys are clean and organized

  Met

  Not Met

  N/A

• All the used linens and hamper bags are stored in soiled utility room

  Met

  Not Met

  N/A

• Food is stored and eaten in designated places

  Met

  Not Met

  N/A

• Spill kit available and updated

  Met

  Not Met

  N/A

Facilities

• Patient bathrooms have non-slippery surface. Door can be accessed if locked

  Met

  Not Met

  N/A

• Is adequate lighting in toilet?

  Met

  Not Met

  N/A

• Is the floor/area free from water?

  Met

  Not Met

  N/A

• Are doors locks are working?

  Met

  Not Met

  N/A

• Female and male toilet signs are clear?

  Met

  Not Met

  N/A

• Waiting areas are separately identified with male and female and organized

  Met

  Not Met

  N/A

MSDS Checklist

• MSDS folder available in the area

  Met

  Not Met

  N/A

• List of staff who have competency checkoff

  Met

  Not Met

  N/A

• CPP: Emergency Hazardous Material Spill Management updated in the folder

  Met

  Not Met

  N/A

• PPE must be available in the MSDS area

  Met

  Not Met

  N/A

• HAZMAT area must be separated from other areas of the facility

  Met

  Not Met

  N/A

• Proper labeling according to hazard rating classification.(Diamond sticker)

  Met

  Not Met

  N/A

• Safety (officer) contact number visible for any suspected or witnessed release of a hazardous material to the environment

  Met

  Not Met

  N/A

Linen (DPP: 30501 /125/30 Ns Patient Linen Management – Nurses Role)

• A minimum/maximum level for linen requirement per unit is established and should be adhered to

  Met

  Not Met

  N/A

• Fresh/clean linen is to be stored separate from dirty/used linen

  Met

  Not Met

  N/A

• Clean linen store is to be secured and preferably locked

  Met

  Not Met

  N/A

• Problems with amounts, availability or quality are to be documented on a Linen Problem log and followed-up

  Met

  Not Met

  N/A

• Daily linen monitoring sheet updated and completed

  Met

  Not Met

  N/A

Medication (DPP: 30501-106-30 NS Medication Management – Ordering and Storage)

• Narcotic cupboard double locked

  Met

  Not Met

  N/A

• Expiry date of stock (included in medication fridge) noted every week

  Met

  Not Met

  N/A

• Medication room temperature and humidity are monitored and recorded

  Met

  Not Met

  N/A

• Medication refrigerator temperature maintained 2 to 8 degree °C and recorded

  Met

  Not Met

  N/A

• No food etc in medication fridge

  Met

  Not Met

  N/A

• Medication storage areas (room and cart) locked (except when in use)

  Met

  Not Met

  N/A

• Cassettes are properly labelled with the name of medication and expiry date

  Met

  Not Met

  N/A

• Medication preparation area is clean, good lighting and closed

  Met

  Not Met

  N/A

• Updated stock medication list

  Met

  Not Met

  N/A

• Drug Formulary

  Met

  Not Met

  N/A

• Approved Abbreviations list /Floor Stock medication policy available

  Met

  Not Met

  N/A

• Externally and internally used products separated

  Met

  Not Met

  N/A

• Any product used on patient (external/internal) to be labelled with date when opened

  Met

  Not Met

  N/A

• Proper removal of medication waste

  Met

  Not Met

  N/A

• LASA and HAM poster updated.

  Met

  Not Met

  N/A

Refrigerators (DPP:0501-034-1432 NS Food and Medication Storage In Unit/Ward Refrigerators)

• Food refrigerator temperatures per shift maintained 0-5 °C and recorded

  Met

  Not Met

  N/A

Medical Equipment

• Clinical Equipment (Biomed): Clean

  Met

  Not Met

  N/A

• All equipment has label

  Met

  Not Met

  N/A

• Last service date (PPM)

  Met

  Not Met

  N/A

• Next service date (PPM)

  Met

  Not Met

  N/A

• Tag if out of order equipment

  Met

  Not Met

  N/A

• Manufacturer's instructions available

  Met

  Not Met

  N/A

• List of biomedical equipment inventory is accessible

  Met

  Not Met

  N/A

• Oxygen tanks are stored in appropriate holders

  Met

  Not Met

  N/A

• Keep oxygen tank out of entrance ways and walkways

  Met

  Not Met

  N/A

• Empty cylinders separate from full

  Met

  Not Met

  N/A

• Daily room check list is updated and maintained

  Met

  Not Met

  N/A

POCT

• Control solutions labelled with date of opening and in date

  Met

  Not Met

  N/A

• POCT Consumables stored in accordance to PCLM recommendations

  Met

  Not Met

  N/A

• QC done and results recorded daily

  Met

  Not Met

  N/A

• POCT (Glucose, urine, pregnancy test, etc) competencies list is updated

  Met

  Not Met

  N/A

Emergency Contacts

• Station/telephones (either poster or label on phone): Emergency: X 22222

  Met

  Not Met

  N/A

• Color code emergencies posted

  Met

  Not Met

  N/A

• Radiation safety officer name and contact details

  Met

  Not Met

  N/A

• KFMC safety officer name and contact details

  Met

  Not Met

  N/A

Office/Computer

• Reference manuals;

  Met

  Not Met

  N/A

• Read and sign folder (Polices updated)

  Met

  Not Met

  N/A

• Infection control Manual

  Met

  Not Met

  N/A

• Disaster plans and manuals

  Met

  Not Met

  N/A

• Safety/Equipment manual

  Met

  Not Met

  N/A

• Lab guidelines

  Met

  Not Met

  N/A

• Quality Board – Location/Contents

  Met

  Not Met

  N/A

Staff Knowledge

• Awareness what is the meaning of JCI or CBAHI

  Met

  Not Met

  N/A

• Verbalized and performed correct Patient identification

  Met

  Not Met

  N/A

• Verbalized and performed correct Medication Administration (includes patient ID Scanning and BCMA Scanning)

  Met

  Not Met

  N/A

• Met

  Not Met

  N/A