policies and procedure nursing

PATIENT SAFETY GOALSGOAL 1: IDENTIFY PATIENTS CORRECTLY

Introduction

The purpose of the Patient Safety Goals is to promote specific safety. The goals highlight problematic areas in health care and the policy is designed to address these issues and provide strategies to improve patient safety

GOAL 1- IDENTIFY PATIENTS CORRECTLY

1.0 Objectives1.1 To ensure patients safety by correctly identifying

every patient in all aspects of diagnosis, treatment and administrative process

2.0 Scope

2.1 All PMC healthcare facilities involving patient Care

3.0 Definition / Abbreviation

3.1 MRN - Medical Record Number3.2 Name – Full name of the patient as per NRIC /

Passport3.3 Patient – outpatients and inpatients3.4 Patients sticker – a label that is printed with

patient data1

3.5 Patient data – name, IC Number, MRN, age, gender, nationality, episode number, chief physician, payor and location of the department

4.0 Policies and Procedures

4.1 Every patient is given a unique MRN and this number is Permanent

4.2 Registration personnel must ensure that the patient data iscorrectly entered during registration

4.3 If a patients is brought in unconscious to the Emergency Department, the patients is registered and identified as ‘UNKNOWN’ and an MRN is given until full details are available

4.4 All patients admitted to the hospital are given the wristband. Wristbands are removed at discharge. If wristband is removed for various reasons, (e, g. surgical procedures) a new band is attached at alternate site or immediately after completion at the procedure

4.5 The admitting nurse must verify the patient’s particulars before sticking the name label on the patient’s wrist. The nursing staff must verify the information on the wrist band with the patient or PAP and ensure patient wears the wristband.

4.6 Before giving any medications, blood, and blood products, taking blood and other specimens for clinical testing, or providing any other treatment or procedure, every patient shall be identified by the two identifiers, i.e. name of patient and MRN.

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The doctors, nurses and allied health staff must read the wristband, if available, and whenever possible, ask the patient to state his/her full name and IC/ or birthdate. This information must be checked against the PMR.

4.7 In a conscious patients, identification is done by checking against the name and MRN on the patient’s wristband

4.8 In an unconscious patient, identification is done by checking against the name and MRN on the patient’s wristband

4.9 In patients who are unable to identify themselves (especially the young, elderly and mentally challenged) the care provider has to ask the parents or guardians for the name and double check with the MRN on the wristband

4.10 For outpatients, identification is done by checking against the name and MRN on the patient’s appointment card or name and identity card number as stated on the patient’s identity card.

5.0 Responsibility

5.1 Physicians5.2 Nurses5.3 Allied Health5.4 Administrative Personnel

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PATIENT SAFETY GOALSGOAL 2: IMPROVE EFFECTIVE COMMUNICATION

Introduction

The purpose of the Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and the policy is designed to address these issues and provide strategies to improve patient safety.

GOAL 2- IMPROVE EFFECTIVE COMMUNICATION4

1.0 Objectives

1.1 To improve the effectiveness of communication among

Caregivers

1.2 To reduce communication errors and improve patient

safety

2.0 Scope

2.1 This policy applies to all forms of communication; including

writen, verbal and telephone orders among all caregivers

2.2 It applies to all situations, including emergency situations


4.1 All verbal and telephone orders / test results shall be

Immediately recorded, dated and signed by the registered Nurse or allied health staff receiving the order4.2 The receiver should read back the order to the ordering

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physician or the test results to the person who gave the

verbal report.4.3 The person who gave the order or test results should

confirm after the read-back4.4 All order / test results shall be documented in the PMR by

the receiver and the person who instructed it.

4.4.1 The doctor, nursing and allied health staff must

verify the verbal and telephone orders per policy

( write,read back,confirmand witnessed by), and document it in PMR ( Doctor Clinical Notes)

PMC023 and PMC 266.4.4.2 The doctors must document the verbal

or telephone order and counter sign, as per hospital requirement within 24 hours.

4.5 In an emergency situation, the receiver will repeat the order

verbally or by telephone and must be witnessed by another staff. The instruction must be carried out stat and documentations should be done as soon as possible

4.0 Reference

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5.1 Private Healthcare Facilities and Services (Private Hospitals and Other Private Facilities)

Regulations2006

5.0 Responsibility

6.1 Physicians6.2 Nurses6.3 Allied Health

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PATIENT SAFETY GOALS

GOAL 3: IMPROVE THE SAFETY OF HIGH ALERT MEDICATION

Introduction

The purpose of the Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and the policy is designed to address these issues and provide strategies to improve patients safety.

GOAL 3 - IMPROVE THE SAFETY OF HIGH ALERT MEDICATION

1.0 Objectives

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1.1 To provide specific written procedures for the safe storage and handling of medications that has been designated as high-alert medications

1.2 To emphasize high-alert medications so that all healthcare providers involved in the prescribing, dispensing, and administration of these medications recognize potential risks

2.0 Scope

2.1 Patient care areas- Emergency Department, General Wards, Critical Care areas, Operating Theatre, Radiology Department and OPD


High – alert medications are medications that have a heightened risk of causing significant patient harm when used in error.

3.1 Concentrated electrolytes:

3.1.1 Potassium chloride 3.1.2 Potassium phosphate3.1.3 Sodium chloride greater than 0.9%

concentration3.1.4 Magnesium sulfate 3.1.5 Calcium gluconate

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4.0 Policies and ProceduresHigh – alert medications will be prescribed, dispensed, and administered using practices that are stated below in this policy

4.1 Concentrated electrolyte solutions are only stored in the Pharmacy Department and the locked cabinet / trolley

4.2 Name and strength of medication must be verified before administering to the patient

4.3 An independent verification of the medication name, strength, and amount to be administered is conducted by a second trained and qualified individual. Calculations used in determining the amount to be administered are also performed by this individual

4.4 The dose of medications to be administered is prepared just prior to administration as per doctor’s order

4.5 The medication, strength and dose to be administered are compared and confirmed with the patient’s record as per doctor’s order.

4.6 The pharmacist / physician is contacted if the dose to be administered exceeds the maximum permitted

4.7 The double checks are documented in the patient’s record.

5.0 Responsibility

6.4 Physicians6.5 Nurses6.6 Pharmacists, Dispenser

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GOAL 4: ENSURE CORRECT SITE, CORRECT PROCEDURE AND CORRECT PATIENT SURGERY

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Introduction

The purpose of the Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and the policy is designed to address these issues and provide strategies to improve patient safety

GOAL4- ENSURE CORRECT SITE, CORECT PROCEDURE AND CORRECT PATIENT SURGERY

1.0 Objectives

1.1 To establish a uniform process to verify and ensure the correct site, correct procedure and correct patient, including procedures done in settings other than the operating theatre

1.2 To ensure patient’s safety before any surgery or procedure.

2.0 Scope

2.1 Operating Theatre2.2 Endoscopy Department

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3.1 All the patients shall be informed of the location of their Surgical or procedure site in the ward especially when there

is more than one possible site. 3.2 The doctor in charge of the patient shall ensure that the

exact site of procedure is mentioned in the consent form

3.3 The exact site of procedure shall be recorded in the

operating schedule list. 3.4 Pre operative verification shall be done in the

ward and in OT using the standard OT checklist. The

checklist shall becompleted by the ward nurse who sends the

patient to OTand the receiving nurse In OT.

3.5 All relevant documents, x-ray films, equipment, instruments and / or implants are available and functional. Team members involved in the procedure are responsible to check the required equipments, instruments/implants.

4 Responsibility


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5 Related Document

5.1 Operation Theatre Department P & P5.2 Operation theatre Patient check list (PMC 029)


GOAL 5: REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION

Introduction


GOAL5 - REDUCE THE RISK OF HEALTHCARE ASSOCIATED INFECTIONS

2.0 Objectives

To reduce the risks of health care- associated infections in patients, staff and health workers

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To prevent and control the transfer of pathogenic micro-organisms between patients and healthcare

workers through hand contact.

3.0 Scope

2.1 All patient care patient support departments / services

2.2 All staff and visitor/visiting areas


3.1 WHO- World Health Organization3.2 CDC- Centers for Disease Control3.3 ICC- Infection Control Committee3.4 ICN- Infection Control Nurse


4.1 The department and ward incharge/manager, or designee,

or ICN shall instruct each employee in his or her role in the prevention of health care associated infection . The incharge/manager will incorporate infection control and prevention practices into departmental policies and procedures according to those formulated by the ICC.

4.2 Educational programs reviewing principles of infection

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control and prevention will be given to current and newly hired employees involved directly or indirectly in patient care.These programs will include the practical applicationof infection prevention techniques specific to

the natureof service of that department.

4.3 Each department incharge/manager or designee will

supervise employees in infection prevention practices, evaluate the need for further training and provide as needed in consultation with ICC.

4.4 The ICC incorporate Standard Precautions into the

Hospital – wide Infection Control policies.

Proper hand hygiene is the most important measurement for the prevention of spreading infection.

4.5 ICC shall be responsible for the setting up and implementation of hand hygiene guidelines and

monitoringcompliance for an effective hand hygiene

programs. Thisincludes basic hand hygiene instructions/poster in

all parts of the hospital including public areas.

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4.6 Indication for Hand hygiene

4.6.1 Before patient contact4.6.2 Before aseptic tasks4.6.3 After body fluid exposure risk4.6.4 After contact with patient4.6.5 After contact with patient’s surrounding

5. Responsibility

5.3 Infection Control Committee5.4 Healthcare workers

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GOAL 6: REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS

Introduction


GOAL6 - REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS

1.0 Objectives

1.1 To identify the patient who are at risk of falls

1.2 To reduce the risk of patient harm resulting from falls

2.0 Scope

2.1 All patient care areas – Emergency Department, General Wards, Critical Care areas, operating Theatre, Radiology Department, Physiotherapy

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Department, Laboratory and Blood Services and OPD


3.1 A fall – a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions

3.2 An un-witnessed fall- occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there.


4.1 All patients shall be assessed by the nurses for the risk of falls on admission using the Modified Morse Scale.

4.2 All patient categorized with high risk of falls, shall be Identified with a graphic label which is attached to the bed side, room door or PMR.

4.3 The patient and family shall be educated about

falls prevention

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4.4 The patient and family shall be accompanied by a hospitalstaff / family member whenever they are out of the bed / ward

4.5 Patient with high risk of falls shall be provided with Fall Preventive condition or medications

4.6 Reassessment of patient is required when indicated by a change in condition or medications

4.7 All falls shall be reported in accordance to the hospital requirements such as incident reporting

5.0 Responsibility


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ADMISSION TO THE ORGANIZATION

1.0 Objectives

1.1 This policy is established to provide effective screening methodfor patients who may require PMC’s clinical services as patient

2.0 Scope

2.1 All patients who are electively referred by their physicians forevaluation

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2.2 All patient who present at the PMC’s Emergency Department


3.1 All elective referrals shall be screened for elective outpatientappointment

3.2 All patients presenting to the Emergency Department shallbe screened.

3.3 Elective Referrals

3.3.1 Letter by referring physician

a)Patient with the relevant information (patient’s medical history, clinical examination, investigation results, medication and past treatment) shall be given an outpatient appointment.

b)When patient’s referring letter indicates the need for early appointment, the letter shall be given to the respective on-call consultants or base on patient request

3.3.2 Phone call by referring physician

a)The appointment counter staff (Front Office registration assistant) shall request clinical information and schedule an outpatient appointment. When there is a request from referring physician, the phone call shall be transferred to the consultant on-call

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3.4 Outpatient registration

3.4.1 There is a standardized procedure for outpatient registration

3.5 Outpatient Consultation

3.5.1 ECG, Chest X-Ray and necessary blood tests will be done if the patient does not have recent reports.

3.5.2 Clinical evaluation requires medical history, medication history, previous treatment and physical examination

3.5.3 All the results of diagnostic tests will be reviewed by the attending physician for determining if the patient is to be admitted, transferred, or referred

3.6 After the outpatient consultation, the patient will be referred for

3.6.1 Outpatient follow-up appointment3.6.2 Referral for elective surgery3.6.3 Non Elective Admission for

a)Patient from outstation who prefers one visit for consultation and treatment

3.6.4 The patient shall be discharged to the referring physician

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if he or she does not have follow up in PMC

3.7 Patient shall be informed when there will be a wait or

delay in care and treatment. The patient shall be informed the reasons for the delay or wait. This information will be documented.

4.0 Responsibility

4.1 Physicians4.2 Nurses4.3 Allied Health4.4 Front Office Registration Assistant

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2.0 PROCEDURES ADMISSION

ACTIVITIES RESPONSIBILITY

2.1

2.1.1

2.1.2

2.1.3

2.1.4

2.1.5

2.1.6

2.1.7

2.1.8

2.1.9

2.1.10

ADMISSION

All ambulance patients entering hospital should be provided with expedient attention and care as soon as possible.

Patients who are experiencing difficulty in breathing, have unstable vital signs, in severe pain or in a state of unconscious must be attended immediately.

The patient should be protected of his legal rights.

All patients must be given an identification band on admission. (In patient only)

Patients and relatives should be informed of hospital rules and regulation e.g. visiting hours and the hospital telephone number should they wish to phone and enquire about the patient.

All valuables and cash are referred to policy on care of property.

All medication brought from home and medic alert should be identified and noted to physician.

All admission should notify physician immediately.

Patients with no relatives or unconscious, next-of-kin should be notified via police.

On admission patient should be instructed

A & E Staff

A & E Staff

General

Ward staff

A+R Staff

Ward Staff

Ward Staff

A & E Admission Doctor / Ward

Staff

Sister / Administrator On

Call

Ward Staff

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not to leave the ward area without permission of ward sister or nursing staff on duty.


2.2

2.2.1

2.2.2

2.2.3

2.2.4

2.2.5

TRANSFER OF PATIENT TO OTHERHOSPITAL.

Obtain approval from respective consultant / medical officer on duty for all patients to be transferred.

For patient transfer out of the hospital, obtain referral letter from respective consultant and release it asbelow :-

a) To PAP / patient if by own transportb) To accompanying nurse if using

hospital ambulance facility.

Ensure that the referring consultant inform the consultant concerned of the hospital regarding the referral.

Explain and obtain consent from the patient / PAP regarding the reason of transfer.

a) Transfer of patient to another hospital is requested by PAP / patient, to issue PMC 037.

b) Either SRN / Ward aide must accompany the patient if using hospital facilities

E g: ambulance

Upon transfer of patient, to document and complete the PMC 021.

SRN / Nursing Supervisor

SRN

SRN & Consultant

Consultant

SRN

Nursing Supervisor /

Medical officer on duty.

SRN

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DISCHARGE

1.0 Objectives

1.1 To ensure a smooth discharge process including documentation,medication,subsequent management plan, follow up care and patient education.

2.0 Scope

2.1 General Wards2.2 Day Care2.3 Critical care areas


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3.1 Discharge planning is done early in the process of patient care depending on subsequent physician and nursing assessment

3.2 The discharge process is initiated after the daily physician’sward round and upon agreement from the patient’s response to treatment, clinical status and investigation results (e.g. CXR, ECG, echocardiography following cardiac surgery) allows for patient to be managed at home by the family.

3.3 Family members shall be included in the discharge planning. They shall be informed once the discharge decision/process is finalized.

3.4 The discharge process involves the following3.4.1 Medications3.4.2 Follow up appointment

a)Understandable follow up instructions are given to patient and family.

b)The instruction include any return for follow up care and when to obtain urgent care

c) MC when applicabled)Letter of discharge summary when required

by the patient or PAP.3.4.3 Subsequent management plan3.4.4 Diet Counseling3.4.5 Discharge summary / reply to referring

institution should be prepared by the attending

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or designated physician. The discharge summary includes the following information

a)Reason for admissionb)Diagnosis ( principal and secondary )c) Relevant physical findingsd)Procedures done and copies of operative

notese)Hospital course and complicationsf) Important investigation resultsg)Condition upon dischargeh)Medicationsi) Follow up instructions

3.5 Where possible, the discharge process must be completed by 11am.

3.6 The discharge summary / reply shall be prepared in 2 copies.3.6.1 A copy will be given to the patient at point of

discharge. If not completed at the time of discharge, it will be the responsibility of patient to collect it within 2 weeks.

3.6.2 A copy to be retained in the Patient Medical Record.

3.7 PMC will help to arrange for transportation , or to collect patient’s family or friends for transporting ,depending on the patient’s condition and status.

4.0 Responsibility

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4.1 Physicians4.2 Nurses4.3 Physiotherapists4.4 Dietitians4.5 Billing clerk.4.6 Pharmacist/Dispenser


2.3

2.3.1

2.3.2

DISCHARGE OF PATIENT

Obtain approval from respective consultant / medical officer on duty (with written evidence) for all patients to be discharged.

Inform all the secondary consultants regarding the patient been discharged

SRN

SRN

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2.3.3

2.3.4

2.3.5

2.3.6

Refer work instruction for nursing procedure, page 5-6 as a guideline for discharge

Refer nursing policies & procedure 16.1 till 16.1.7, page 28 for At Own Risk Discharge

Discharging of patient who is absconded(a) Notify the primary consultant as soon as the

patient found missing(b) To notify the next of kin / PAP/ police(c) Attempt to locate the patient within 1 hour. If

still fail to locate within 24 hours, the patient must be discharged by the consultant

(d) To notify the nursing supervisor on duty / administrator on call

Upon discharge of patient, to document and complete the PMC 021and click in I-Care system after alerted by billing staff

SRN/ward aids

SRN/Nursing Supervisor

SRN

SRN

2.4 PROCEDURES OF AT OWN RISK (AOR) DISHARGE AND LEAVE PROCEDURE

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FLOW CHART OF DISCHARGE PATIENT


2.4

2.4.1

2.4.2

2.4.3

2.4.4

2.4.5

2.4.6

2.4.7

2.4.8

2.4.9

2.4.10

2.4.11

2.4.12

2.4.13

At Own Risk Discharge

Confirm AOR discharge by doctor’s ordered.

Inform to Sister incharge and Public Relation Manager during working hours.

After working hours, inform to administrator on call and sister on duty.

To inform the other hospital doctor if requested by PAP / patient with written referral letter before discharge.

Explain regarding AOR.Get signature from PAP by using form PMC 037.

Refer flow chart of discharge patient.

Enter in AOR discharge / leave book.

At Own Risk Leave

Inform to consultant to obtain permission after requested by patient / PAP

Explain regarding AOR Leave procedure

Get signature from patient / PAP by using form PMC 037 and confirm with patient / PAP of time back to unit.

Inform to insurance counter in charge if patient admit under insurance

Supply indicated medication as prescribed in PMC 036

If the patient did not return to the ward according to the time granted;which should not be more than 24 hours otherwise, it will be considered as “ Absconded incident” and the respective consultant is compulsory to discharge the patient automatically.

Doctor

SN

SN

Consultant In Charge

Sister, SN

SN, Trained Nurse

SN

SN

SN

SN

SN

SNConsultant In Charge

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3.0 POLICIES AND PROCEDURES OF CARDIAC PULMONARY ARREST


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Receive order from doctor regarding

patient can discharge

Prepare as below: -

- TTA medication by consultant.- Medication chart, nursing & doctor notes

with tickets and medication, patient in ward.- TCA appointment card.- Record/enter in all admission book.

During office hours After office hours

Inform ward clerk Inform A & R

Once bill ready

Inform patient to collect TTA and settle bill.

Produce green chit to ward staff (Ward Aids / SRN)

Remove name tag and off IV line and vasocanSend patient by wheel chair to patient’s with patient’s property

3.1

3.1.1

3.1.2

3.1.3

3.1.4

3.1.5

3.1.6

3.1.7

3.1.8

3.1.9

Inform Doctor / Medical Officer Immediately

Push emergency trolley to the patient’s bedside.

Maintain airway and observe whether patient is breathing. Observe vital sign of patient.

Carry out manual bagging or defibrillator if indicated

Perform cardiac massage on the patient (CPR) while waiting for the arrival of the doctor if condition indicated. Administer drug ordered by doctor and record in PMC 175

Observe patient closely by monitoring the patient’s vital signs and general condition.

Prepare patient for intubations if condition deteriorates.

Inform family member by consultant when patient under DIL

Emergency case in A&E

Refer 2.1 Till 2.18

Refer Triage Accident & Emergency Department : 2.4

SRN / Trained Staff

SRN / Trained Staff

SRN / Trained Staff

SRN / Trained Staff

SRN / Trained Staff

SRN / Trained Staff

SRN / Trained Staff

Doctor

Doctor / Consultant

3.2 FLOW CHART OF CARDIAC PULMONARY ARREST

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Inform Doctor / MO immediately

Push emergency trolley to the patient’s bedside

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Carry out manual bagging / defibrillator

Initiate cardiac massage on the patient

Administer drugs ordered by doctor. Monitor the patient’s vital signs and general conditions.

Observe patient closely Put on ventilator if patient’s condition deteriorates.

Inform family member by consultant when patient under DIL

Critical cases / emergency brought in to Putra Medical Centre (PMC) by patient’s relatives using their own transport.

Bring in the patient to A&E Dept. and start resuscitation process.

Explain to the patient’s relatives.

Patient to send in ICU under the care

of the concern consultant. Regular patient ?

Old patient / simple cases

3.3 FLOW CHART FOR EMERGENCY CASES

If Not

3.4 Triage Accident & Emergency Department

1.0 POLICY

To ensure patients who arrive at the Accident & Emergency Department will be triaged and treated promptly according to their need for emergency treatment and evacuation.

2.0 IMPLEMENTATION2.1 All patients that arrive at the Accident & Emergency Department shall be triaged by a trained staff / medical officer on duty.2.2 The triage nurse shall determine the appropriate code of triage based on the trained personnel assessment of the patient.

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Medical officer will examine the patient inside the car to confirm whether the patient still alive or not.

Patient alive Patient dead

Survive

Yes No

Yes No

Issue the death certification & buried permit

Unknown cases

Ask patient’s relative to

make police report by

themselves

Call up the concern police and

inform the case and doctor

handover the post mortem letter to pathologist GH

Release the body to police when they arrive.

Body must dispose within 30 minutes to 1 hour. If not,

hospital will arrange undertaker to take away.

2.3 The triage nurse must consult the medical officer on duty when it is unclear as to which discipline the patient should be placed.2.4 Patient who have been triaged GREEN may be allowed to be consulted in the respective clinics or wait for consultation at the waiting area.2.5 Patient arriving by ambulance is to be triaged by the ambulance nurse.

3.0 PROCEDURES

There are 3 levels of triage:Critical: - RED (immediately)Semi-critical: YELLOW (5-15 mins)Non-critical: GREEN (16-30 mins)

Initially the triage nurse assesses the acuity level:- Stability of vital signs. Potential life, limb or organ threatened.

This is done based on the algorithm of BLS and ACLS.

Criteria for triage RED:

a) Cardiac arrest, respiratory arrest, severe respiratory distress SPO2<70%.b) Overdose with respiration of < 10 per minute.c) Severe brady/tachycardia with hypo perfusion.d) Polytraumae) Chest pain, pallor and diaphoretic.f) Anaphylactic shock.g) Epilepsy.h) Hypotension with hypo perfusion.i) Hypoglycemia with change in mental status.j) Baby or child that is flaccid.

Criteria for triage YELLOW:a) Chest pain with? Coronary syndrome but stable vital signs.b) Impending strokec) Ectopic pregnancy with stable haemodynamics.d) Neurological compromised eg: sudden onset of confusion, disorientated and child drowsy.e) Patient in severe pain with changes in vital signs changes eg: renal colic acute abdomen.f) Compound fracture.g) Closed fracture of femur.h) Pelvic fractures

Criteria for triage GREEN:a) Close fractures other than femur.b) Soft tissue injuries.c) Urinary tract infection and upper respiratory tract infection.d) Headache with no neurological changes.

Assessment also based on physiological changes and vital signs.

Adult Parameters:

Heart Rate(bpm)

SBP(mmHg)

DBP(mmHg)

GCS(per 15)

SpO2(%)

Respiration(per min)

Temperature( ۫۫C)

Green60-100 100-140 60-90 13-15 >90 15-25 36.5-37.5

40-59 70-99 40-59 8-12 70-90 10-14 37.6-40

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Yellow 101-120 141-200 91-120 26-30 34-36.4

Red<40

>120<70

>200<40

>1203-7 <70 <10

>30<34

>40

Pediatric Parameters:

DANGER ZONE VITALSAge Blood Pressure (SBP)

(mmHg)Heart Rate

(bpm)Respiration

(per min)Temperature

( ۫۫˚C)0-1 Month <50 _ >200

<100>60

>38.5˚ C

1 month – 1 year <60

>100180

>50

1 – 4 years <70 <80

>40

4 – 8 years <75150

8 – 12 years <80 >140

** Indication of Poor Circulation : Cold to touch ,peripheral cyanoses & capillary refill > 3 seconds

3.5 POLICIES AND PROCEDURES PROCESS OF DECEASED BODY


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3.5.1

3.5..2

3.5.3

3.5.4

3.5.5

3.5.6

3.5.7

3.5.8

3.5.9

3.5.10

3.5.11

3.5.12

3.5.13

3.5.14

Certified death.

Explain to family the time and cause of death to family members.

Complete document as belowa) Borang Pengakuan Pegawai Perubatan (JPN LM09)b) Borang Permit Menguburkan (AM138-

pin a/78)c) Daftar Kematian (JPN LM02)

Discharge procedure to be completed and send for billing process as soon as possible.

Arrange according to family request.

Perform last office in proper manner according to the culture and religion

Inform the family members to settle the bill.

After receiving inpatient discharge release form (PMC 097) from family members, call for transportation.

Inform family members the above documents (3.5..3) must be sent to the registration office within 3 working days.

Send the deceased body with the transport as arranged

PAP to sign the below document before releasing the deceased body.

a. X-Ray if available b. 3 document as stated above (3.5.3)c. Patient property.d. Panduan melapor kematian.

The deceased body should release by maximum of 2 hours.

Send the body to body holding area if PAP unable to collect within 1 hour.

Release body to next of kin with documentation ( maximum hours to clear the body is within 4 hours )

Medical Officer or Doctor In Charge

Doctor In Charge

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

A&E Staff Nurse

4.0 POLICIES AND PROCEDURES CARE FOR PATIENT’S PROPERTY


4.1 All patients admitted electively must be emphasized Admission Clerk

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4.2

4.3

not to bring valuable or excessive amount of cash to the hospital by the booking personnel.

The patient at the time of admission is notified that the hospital authorities cannot accept responsibility for money and personal property unless they are handed over to the authorities for safekeeping.

Record of patient’s properties

i) All properties received from the patient must be recorded in the patient’s property form, which must be kept locked.

ii) One SN and a witness are to receive and record patient’s properties.

iii) When listing down the patient properties, it must be witnessed by the patient and by another third party (it can be patient’ relative or another nurse).

iv) Below the signature of the nurse receiving of the properties, the patient and the witness, their full name and I/C Numbers must be clearly written for their purpose of identification.

v) Care is taken to ensure that descriptions of valuable are accurate e.g. metal will be described by color instead of diamond or gold.

Admission Clerk/

Ward Staff

SN

SN

SN

SN

SN


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4.4

4.5

4.6

4.6.1

4.6.1.1

4.6.1.2

4.6.1.3

Custody of patient’s properties.

i) Properties received must be wrapped and labeled clearly with the following

particular :-a) Name of patientb) R/N, I/C no.c) Date received

ii) Properties collected must be kept under lock and key at all time. The key must be kept by the medication SN of every shift.

iii) Properties must be checked and handed over from shift to shift.

Handling over patient propertiesi) All properties must be returned to the

patient upon request / dischargeii) The patient must sign in the patient’s

property form.iii) The handling over procedure must be

witnessed and acknowledged by a third party.

In case of death, the properties belonged to the deceased must be surrendered to the immediate relative and documented in similar manner.

LOSS OF PROPERTY

During office hours the nursing staff must inform the nursing in-charge who will inform the P.R. manager for further investigations.

After office hours, the nursing staff on ‘E’ shift must be informed and she should fill up the incidence reporting form PMC 140 and inform the sister on duty & the P.R. manager A.S.A.P.

If it is after 10 pm, to inform the administrator/A & R night supervisor on duty.

Advise patient to make a police report5.0 POLICIES AND PROCEDURES FOR CHECKING EMERGENCY TROLLEY

41


5.1

5.1.1

5.1.2

5.1.3

5.1.4

Check Emergency Trolley

Check emergency trolley every shift as listed in PMC049

Check for :-a) Stock level b) Expiry datec) Par level of items listedd) Working condition of each equipment

Check for presence of :-a) Cardiac boardb) Drip stand

The above checking needs to be documented completely and clearly.

SN, Trained Nurse

42


5.2

5.2.1

5.2.2

5.2.3

5.2.4

5.3

5.3.1

5.3.2

5.4

Replenish of Emergency Trolley

Replenish trolley immediately after each use.

Replace drugs or disposables 3 month prior to expiry

date.( Utilize color coding)

Report to unit head of any malfunction of equipment.

Restore cardiac board and drip stand after use.

Care of Emergency Trolley

Check wheels of the trolley are functioning well.

Damp dust and keep trolley clean and tidy always

Position emergency trolley back to its place and ready for

use

SN / Trained Staff

Ward Assistant

FLOW CHART FOR CHECKING OF EMERGENCY

43

TROLLEY

6.0 POLICY & PROCEDURE FOR INCIDENT REPORT

44

Daily Checking

Check items listed for :-a) Stock level b) Expiry date

Replenish Stock – PRNa) Replace expiring itemsb) Report malfunction of equipment

Check floor chart emergency trolley correspond to respective sections of the drawers

Document in Emergency Trolley Checklist for job done

Check for presence of cardiac board and drip stand

General cleanliness of trolley


6.0.1

6.0.2

6.0.3

6.0.4

6.0.5

6.0.6

6.0.7

6.0.8

6.0.9

Inform to the doctor or primary consultant to

review patient immediately upon incident

occur

Inform to the head of department (H.O.D) immediately or nursing supervisor on duty during absence of the H.O.D

Obtained and documented the immediate observation of patient involve as a baseline parameter in PMC 140

Continue monitor the patient accordingly to the need of Observation

Issue incident occurred according to PMC 140(Appendix Event Categories is attach as reference )

Make sure the attending Doctor complete the report after attended the patient

Make sure treatment been ordered is carry out accordingly

Alert the incident to the investigation team as soon as possible

Send the PMC 140 to Quality Assurance department within 24 hours

SRN / HOD

SRN / Staff on

Duty

SRN

SRN / HOD

HOD

SRN

SRN

SRN

HOD

45

INCIDENT REPORTING EVENT CATEGORIES

The following categories are reportable events and near misses;

A) CLINICAL

Anaesthesia Event : An event that occurred in the process of receiving anaesthesia that caused harm or had possibility of causing harm to a patient.

Surgical Event : An event that occurred in the process of any surgical procedure that caused harm or had the possibility of causing harm to a patient.

Cardiology Event (Adult and Paediatric) : An event that occurred in the process of receiving treatment and procedure that caused harm or had possibility of causing harm to a patient.

Blood Administration : An event that caused or had the possibility of causing inappropriate blood product administration. Such events may be related to professional practice, procedures and systems including, but not limited to, ordering, labelling, dispensing, storage, administration and education.

Fall Event : An event in which a patient or visitor is on the ground as a result of an unplanned occurrence.

Medical Device : An event that includes any unintended functioning of any product, device, instrument, or machine that is used to diagnose, treat, or prevent disease. This includes, but not limited to, implants, infusion pumps, catheters, monitors, scopes and gauze pads. If event involves malfunction of Medical Device, the Bio-Medical Engineering Department also must be informed.

Restrain / Seclusion : An event that caused or had the possibility of causing harm to a patient directly related to the use of restrains or seclusions.

Treatment Delay: An event that caused or had the possibility of causing a delay in treatment and/or a prolonged hospital stay. Such events may be related to procedures and systems including, but not limited to, patient transportation, availability and scheduling of diagnostic tests, and timely ordering and processing or orders.

Medical Records: An event that caused incomplete medical records such as missing specimen result, X-Rays, notes, procedures report, surgical report or other patient’s medical record was found in another patient’s medical record.

Nursing Care: An event that caused or had the possibility of causing harm to a patient directly related to nursing care

Medication : An event that cause or had the possibility of causing inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient , or consumer. Such event may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labelling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

Other: Miscellaneous event is an event that caused or had the possibility of causing harm to a patient / visitor / staff. But that does not fit into any of the other clinical categories.

B) NON CLINICAL

Building and Non Medical Equipmen t: An event that caused disruption in hospital operation due to malfunction of equipments such as interruption in telephone system/power supply, water leakage and others.

Interpersonal conflict: Conflicts between staff and patient / family, staff and staff.

Security Lapse: An event that occurred due to security lapse.

Administrative Error : An event that occurred as a result of mistake in clerical and administrative process.

Miscellaneous: Miscellaneous event is an event that caused or had the possibility of causing harm to a patient / visitor / staff. But that does not fit into any of the other event categories. Example; sexual harassment, absconded.

46

APPENDIX DEFINATION OF INCIDENTS REPORT

INCIDENT DEFINITION( For All Locations )

Fall from any place e.g.bed,stretcher,chair or anywhere e.g.toilet,bathroom or while

Fall ambulating wrong drug,dosage,formulation,route of administration,rate of administration,timing

Medication error of administration or diluting solution.Others include:omission or extra dosage of drug

wrong identification of investigation e.g.radiology,laboratory etc resulting in treatment

Investigation or procedure being carried out when it is not necessary or may even cause morbidity

error to the patient

Adverse outcome complication arising from a procedure resulting in morbidity or mortality

of procedure e.g.pneumothorax following Subclavian venous access,bleeding following liver biopsy

or OGDS,burn following defibrillation etc

Transfusion error wrong pack of blood or its products for the intended patient,expired blood

Needle stick injury caused by needle or sharp e.g.Scalpel blade.

injury contaminated with patient's blood

when a piece of equipment or instrument played a part in the morbidity or mortality

Equipment related e.g.ventilator failure causing hypoxic brain injury/death,electrocution,suction device

injury malfunction causing aspiration,cyclinder ran out of oxygen while transporting patient,

laser or diathermy burns etc.

Birth Injury caused by instruments e.g. forcep and mismanagement by health care team

( For OT use )

Cardiac / respiratory any cardiac or respiratory arrest that occur intra-operative or in recovery room

arrest

Wrong procedure procedure or surgery carried out which was different from what was intended

performed e.g.wrong limb being operated on,wrong space for laminectomy etc

Wrong patient operated

upon

Unplanned return to the e.g.relaporatomy to secure homeostasis following Cholecystectomy.Does not include

OT within 24 hours planned procedure e.g.removal of pack after laporatomy with abdominal packing done

surgery or staged procedure e.g.disloughing for burns

Incorrect surgical count e.g.gauze,sponge / instruments / needle

47

6.2 POLICIES AND PROCEDURES NEEDLE STICK INCIDENT


6.2

6.2.1

6.2.2

6.2.3

6.2.4

6.2.5

6.2.6

6.2.7

6.2.8

6.2.9

6.2.10

Needle Stick Incident

Staff pricked by sharp.

Perform first aid → squeeze the blood from puncture site immediately.

→ run under tap water. Staff involved to inform sister in charge / senior staff during sister’s absent

Inform the infection control nurse.

Staff involved to see medical officer immediately.

Fill up the incident reporting form together with staff involved and submit to QA.

Inform the infection control doctor regarding the incident.

Refer the case back to the infection control Doctor for further investigation and follow up.

The incident will take over by infection control Doctor for follow up.

Refer Putra Medical Centre Guidelines on the control of hospital acquired infection flow chart for needle stick incident page 43.

Staff involved

SN / Sister In charge

Infection Control Nurse / Sister In

Charge

Medical Officer

All employees

48

7.0 POLICIES AND PROCEDURES STOCK REQUISTION


1.

2.

3.

4.

5.

Check the stock in hand and balance.

Fill in the request form- Icare system

Send the request form to storekeeper as schedule

Receive the stock and check as ordered.

Keep stock in respective storage areas.

In Charge

In Charge

In Charge

SN

SN / WA

FLOW CHART OF STOCK REQUISITION

49

Check stock in hand and balance

Fill in request form/Icare

Send request form to storekeeper as schedule

Receive stock and check

Keep stock in respective storage areas

7.1 POLICIES AND PROCEDURES OF UNCONTROLLED DRUGS


7.1

7.1.1

7.1.2

7.1.3

7.2

7.2.1

7.2.2

7.2.3

7.3

7.3.1

7.3.2

7.4

7.4.1

7.4.2

7.4.3

Storage of Uncontrolled Drug

Store drugs as indicated by manufacturer

Store drugs in fridge, medication trolley / patient’s individual slot and lotion cupboard for all under external use only.

Keep storage place clean always

Replenish of Uncontrolled Drugs (stock)

Replenish daily

Check stock balance / par level before indenting.

Use uncontrolled drugs requisition form (PMC 082) for indenting.

Document of Drugs

Write drugs strength dosage of drugs in medication chart as per column provided.

Initial in respective frequency column upon administration to patient.

Unit Dose Drugs

Indent non – stock drugs from pharmacy using medication chart

Check number of drug supplied whether tally with number written in quantity column in medication chart.

Return all non – stock drugs to pharmacy on the same day when a patient is discharged.

SRN

Dispenser

SN

SN In Charge Medication

SN In Charge Medication

SN

SN

50

FLOW CHART FOR UNCONTROLLED DRUGS

7.5 POLICIES AND PROCEDURES OF CONTROLLED DRUGS

51

WARD

Storage :-a) Fridgeb) Medication Trolley – stock individual slotc) Lotion cupboard

Replenish – daily a) Stockb) Non – stock (unit dose)

Documentation – Medication Chart


7.5.1

7.5.2

7.5.3

7.5.4

7.5.5

7.5.6

7.5.7

7.5.8

7.5.9

Checking of Controlled Drugs(Injectables and Oral Drugs)

Check DDA drugs every shift for the balance of each drug as documented in DDA Record Book

Check drugs expiry date (if expiry date is 3 months before due date – send to Pharmacy for exchange).

Passing Over of Controlled DrugsPass over from shift to shift regarding drugs used and amount balance.

Check and receive the balance of all dangerous drugs and document in DDA Record Book.

Keeping And Storage of Dangerous and Psychotropic Drugs

Keep drugs in DDA cupboard with double lock at all times

Keep DDA par level at all times.

Keep empty ampoules for exchange.

Any broken / missing dangerous drug ampoules to be reported immediately to pharmacist in charge

SRN In Charge Medication / Trained

Staff


Staff

SN In Charge Medication / Trained

Staff

Sister, SN


52

7.5.10

7.5.11

7.5.12

7.5.13

7.5.14

7.5.15

7.5.16

7.5.17

Recording of Controlled Drugs

Immediately document any drugs used.

Document the following particulars :-

a) Name of patientb) Registration number of patientc) Date and time administeredd) Specify drugs and dosage given e) Stock balance of the drugf) Name and initial of SN who has given the

drugg) Name of consultant who ordered drugh) Two SN to counter check

Document drugs and dosage in patient’s medication chart. Document time given. For outpatient: record in patient’s case note.

Refer Centralized Psychotropic flow chart for overall handling

Replenishment of Controlled Drugs Indenting

Indent drugs in DDA indent book. Write in balance and the amount required.

Send the following items to Pharmacy when indenting :-

a) DDA indent bookb) DD Record Bookc) Empty ampoules of injectables

Follow indent schedule as given by the Pharmacist.

SN In Charge Medication / Trained

Staff


Staff

53


7.5.18

7.5.19

7.5.20

Collection of Drugs

Check the following when collecting drugs from Pharmacist:- (SRN to collect drugs)

a) Amount supplied tally with requisition note

b) Total of drugs supplied

Sign at the following columns to indicate receipt of correct amount

a) DDA indent Booksb) DDA Record Book

Keep and store drug in DD cupboard under double lock.


Staff

SRN In ChargeMedication / Trained

Staff

54

FLOW CHART FOR MANAGEMENT OF CONTROLLED DRUGS (CHECKING DRUGS)

55

Checking Of DD during the Passing Over

Check all DD balance tally with amount in DD Record Book

Lock DD & PD in cupboard

DD key kept by SN / trained staff

7.6 POLICIES AND PROCEDURES STORING LIVE VACCINE


7.6.1

7.6.1.1

7.6.1.2

7.6.2

7.6.2.1

7.6.2.2

7.6.2.3

7.6.2.4

7.6.2.5

Receiving Life Vaccine

Nursery staff will order in pharmacy requisition form for live vaccine.

Collect the live vaccine from pharmacy in the prepared cold chain bag

Storage of Live Vaccine

Store in compartment temperature of 2°c to 8°c.

To check temperature of the fridge two times a day and record it in the fridge temperature chart.

If any changes in temperatures, the sister in-charge must be notified immediately.

All live vaccine is to be disposed after use in a sharp bin.

Ensure the temperature of the fridge is maintained at 2°c to 8°c.

Trained Staff

Trained Staff

Trained Staff

Trained Staff

Trained Staff

Trained Staff / Sister In Charge

56

8.0 POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION


8.1

8.2

8.3

8.4

8.5

8.6

8.7

8.8

Diagnosed by the consultant in-charge with supporting investigation results (X-Ray, blood result) if available

Patient’s particulars in notification form to be filled up.

Notification form (Borang : Health 1 Rev 2001) must be completely filled up regarding the final diagnosis

Notification form must be stamped with the PMC chop and signed by the consultant on the lower left side corner of the form.

Notify the Public Health Inspector (PHI) on call through the nearby state health office by phone or fax stat, when indicated.

Dispatch the original copy to the nearby State Health Office (SHO). To notify online first.

Carbon copy must be kept in patient file / ticket.

Notification chop must be stamped in the admission card inside the patient’s file & PMC 022


Trained Nurse


SN

SN

Office Assistant/Sr. Incharge

SN

SN

57

FLOW CHART

9.0 POLICIES AND PROCEDURES RENTAL OXYGEN TANK

58

DIAGNOSIS

NOTIFICATION FORM

(COMPLETELY FILLED UP)

NOTIFY STATE HEALTH

OFFICE BY FAX OR PHONE

ORIGINAL COPY

(DESPATCH TO SHO)CARBON COPY (KEPT IN

PATIENT’S OFFICE)

NOTIFICATION CHOP STAMPED IN

PATIENT’S FILE / TICKET

(ADMISSION CARD)


9.1

9.1.1

9.1.2

9.1.3

9.1.4

9.1.5

9.1.6

9.1.7

9.1.8

Renting of Oxygen Cylinder

Received phone call regarding rental of oxygen cylinder.

Prepare the items as below :-i) Oxygen cylinder according to the request.ii) Flow meter.iii) Stand for oxygen cylinderiv) Precaution from for home oxygen use.

Explain the rental procedure to the person concerned.

Fill in rental oxygen form in double copy and confirm the size of oxygen tank before filling up.

Bring the person concerned to billing department to collect deposit as below.

i) Size E RM 1200.00 deposit and the usage is RM 280.00.

ii) Size F RM 1800.00 deposit and the usage is RM 490.00.

Send original copy to billing department and duplicate copy will keep in A&E.

After office hours the collection of deposit will be carry out by admission counter.

The person concerned to be reminded to keep the receipt of payment.

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Ward Aid / Staff Nurse

Ward Aid / Attendant

Admission Clerk


59

9.2

9.2.1

9.2.2

9.2.3

9.2.4

Returning of Oxygen Tank

Received phone call from admission counter regarding returning of oxygen tank.

Receive empty tank in proper condition and send to maintenance for refill.

Bring the person concerned to billing department to collect deposit with the duplicate form.

After office hours the deposit to be collected the next working day.

Staff Nurse

Staff Nurse / Ward Assistant

Ward Aid / Staff Nurse

Billing Clerk

60

10.0 POLICIES AND PROCEDURES IN MAINTENANCE REQUISITION


10.1

10.2

10.3

10.4

10.5

10.6

10.7

Confirm the faulty equipment.

Fill up the maintenance request form, PMC 051

Dispatch PMC 051 to the maintenance department.

Maintenance staff comes to the ward to check the equipment.

Repair is to be done stat if is possible.

If repair cannot be done in the ward, then the equipment has to be sent to the maintenance department.

Once the job is completed, the staff from maintenance department will fill up the last part of the form as evidence that job has been done.

Sister, Staff Nurse, Midwife

Sister, Staff Nurse, Midwife

Female Attendant

Maintenance Staff

Female Attendant

Maintenance Staff

61

11.0 POLICIES AND PROCEDURES CARE OF PATIENT UNDERGOING RADIOGAPHIC

AND OTHER IMAGING STUDIES


11.1

11.1.1

11.1.2

11.1.3

11.1.4

11.1.5

11.1.6

11.1.7

Preparation For The Examination

Patient must be informed of the Radiographic / Imaging Studies planned for him.

All requests for Radiographic and Imaging Studies must be ordered by the attending doctor and completed request form (PMC 058) with signature.

PMC 058 to be sent to X-Ray Department A.S.A.P

Ensure that all specific preparation and investigation (if any) are carried out accordingly.

All previous X-Ray films must accompany patient when going for subsequent Radiographic / Imaging Studies.

Ensure that all female patients are not pregnant before any radiographic examination. If a patient is suspected to be pregnant, it must be notified to the doctor for further instruction.

All female in-patients must change into hospital gown, have jewellery and bras removed if the radiographic examination is required on the upper part of the body.

Doctor

Doctor, SN

Ward Assistant / Female Attendant

Staff Nurse

Staff Nurse

Staff Nurse / Radiographic

Staff Nurse

62


11.2

11.2.1

11.2.2

11.2.3

11.3

11.3.1

11.3.2

11.3.3

Transportation Of Patient For Radiographic / Imaging Studies.

Assess the condition of patient to determine the type of transportation suitable for the patient.

All patients with intravenous therapy can be sent down to radiology department when call.

Decide if ill cases need a staff nurse or ward aid to accompany throughout the examination.

Patient Undergoing Radiographic Examination Using Radiopaque Contrast Medium.

Obtain history for any indication of allergies that might cause an adverse reaction to the contrast medium.

Obtain consent from patient if indicated

Be encouraged to take plenty of fluid (if there is no contraindication) following administration of radiopaque contrast medium.

Staff Nurse

SN, Sister

SN

Doctor

SN

63


11.4

11.4.1

11.4.2

11.4.3

11.5

11.5 .1

11.5.2

11.5.3

11.5.4

11.5.5

Ultra Sound Examination

Abdomen and liver, gall bladder and pancreas. Patient must be fasted from midnight or at least 4 hours before the examination. For afternoon appointment, breakfast is allowed then nothing by mouth thereafter. N. B. Infant – no preparation is required.

Kidney, thyroid glands and liver only. No preparation is required.

Organs in the pelvic cavity. A full urinary bladder is required. Patient is advised to take plenty of fluid if there is no contraindication.

Magnetic Resonance Imaging (MRI)

Send PMC 058 to X-Ray department as requestedConfirm with X-Ray coordinator regarding the appointment date and time.

Patient is advised to remove all metal items / jewellery from the body.

All patients are to change into MRI gown.

Nurse in charge is to do MRI checklist before sending patient down with MRI stretcher / wheel chair for MRI procedure.

N.B. For Infant, uncooperative children and restless patient, sedation may be necessary as ordered by the Doctor.

Ward Aid, Female Attendant

SN

SN, Trained Nurse

SN

SN

WA

SN

64

12.0 POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE


12.1

12.1.1

12.2

12.2.1

12.2.2

12.2.3

12.2.4

12.2.5

12.2.6

12.2.7

12.3

12.3.1

Types of Clinical Waste

Segregate clinical waste in appropriate groups :-a) Sharps and objects b) Clinical waste

Disposal of Sharps and Objects

Discard sharp instrument and objects e.g. syringes, needles cartridges and scalper blades into sharps container.

Do not re sheath or re-cap before discarding into sharp bins.

Do not leave used sharps lying around

Never fill sharp container more than two-third full.

Ensure that sharp containers are securely closed before disposal. Replace with new sharp container as soon as possible.

Place 2/3 full sharp container into clinical waste carriage

Disposal of Clinical Waste

Discard the bellow item listed clinical waste into yellow bag e.g. soiled surgical dressing, cotton wool, gloves, swabs material used to clean spillage.

SN

SN

H / Keeping Personnel


SN

SN

65


12.3.2

12.3.3

12.3.4

12.3.5

Never fill yellow bag more than ¾ full

Tie the bag with plastic seal

Tag with label and send to clinical waste carriage at holding area

Replace with new clinical waste bag into bin

SN




FLOW CHART OF CLINICAL WASTE

13. 0 POLICIES AND PROCEDURES MANAGEMENT OF BLOOD GROUP AND CROSS MATCH PROCEDURE

66

WARD

SHARPS

Discard into Sharp Bin

CLINICAL WASTEe.g. a) Dressings b) Drains

Dispose into Yellow Bag when ¾ full with the

sealerSeal Sharps Bin When 2/3 full

Discard sealed sharp bin by Housekeeping to clinical waste carriage at holding area

Replace sharp bin by Housekeeping

Seal Yellow Bag when ¾ full with the sealer

Dispose into clinical waste carriage (Yellow Bin) – as

supply by company at holding area by Housekeeping

Replace Yellow Bag by Housekeeping

Housekeeping Personnel to Dispose into Clinical Waste Carriage


15.1.

151.1.

151.2.

15.1.3

15.1.4

15.1.5

15.1.6

15.1.7

15.1.8

15.1.9

GXM ordered by the doctor.

Patient’s particular in GXM form (PMC 071) (original and CC) can be filled up by the trained Nurse (e.g. full name, 12 digit IC no / passport no, RN, etc).

Patient’s diagnosis and reason for request must be clearly stated and signed the PMC 071.

Inform the laboratory technician for requested test / procedure.

In any case that there’s no available supply in the center to be informed to ward staff stat

Inform the doctor stat

Send second set of PMC 071 for the doctor concern to sign.

To call the blood bank in-charge in General Hospital Alor Star (GHAS) to inform the needs and request of the supply urgently.

Document the exact date and time in PMC 071

The 2nd PMC 071must be sent to laboratory stat after the necessary requirements has be arranged

Doctor

Trained Nurse

Doctor

Laboratory Technician

SN

SN, Doctor

Doctor

Doctor

Doctor, SN

FLOW CHART

67

68

DOCTOR’S ORDER

GXM FORM

(COMPLETELY FILLED UP)

INFORM LABORATORY TECHNICIAN

SUPPLY AVAILABLEPROCEED WITH

TRANSFUSION AS DOCTOR’S ORDER

SUPPLY UNAVAILABLE- Send 2nd GXM form to the doctor

concern and arrange with blood bank GHAS in charge

- Write the exact date & time in PMC 071

SEND THE 2nd GXM FORM TO LAB

BLOOD SUPPLY AVAILABLE PROCEED TRANSFUSION AS

DOCTOR’S ORDER

policies and procedure nursing

Health & Medicine