NABH 2025 - REFERENCE GUIDE

NABH 2025 - REFERENCE GUIDE

INDEX

Sl. No Topic Page No

1. Do’s And Don’ts 5

2. Vision Of The Hospital 5

3. Mission Of The Hospital 5

4. Core Values Of The Hospital 6

5. Quality Policy Of The Hospital 6

6. Quality Objectives Of The Hospital 6

7. Clinical Departments Not Available 6

8. Service Standards 6

9. Employee Rights And Responsibilities 7

10 List Of Committees 7

11 International Patient Safety Goals 9

12. Incident Reporting Systems 14

13 Patient Rights &Responsibility 14

14 Patient Identification Band 15

15 Vulnerable Policy 15

16. Emergency Codes 17

17 Hazmat ( Hazardous Material) Spillage & BBF ( Blood & Body 19

Fluid )Spillage Management

18 Biomedical Waste Management Rule 2016 20

19 Needle Stick & Sharp Injury, Injury Management Protocol 23

20 Sentinel Event Management 24

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21 Hazardous Material (Hazmat) 25

22 HIRA - Hazard Identification And Risk Assessment 26

23 Activities & Learning Opportunities 28

24 Patient And Family Interview 28

25 Key Performance Indicators 29

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DIRECTOR’S MESSAGE

Dear Colleague,

As part of the journey to provide the best care to our patients and their families, the Lourdes hospital made the
decision to pursue the NABH accreditation and successfully achieved the initial assessment in 2015 and re-
accreditation in March 2018 and 2021.

This achievement was a product of the collective work of each and every one of us and once again the opportunity
calls on us as members of this great organization to improve the safety and quality of care that we provide by
implementing and complying with the organizational and NABH standards.

The NABH reaccreditation of our hospital is due by March 2025, and in order to increase the awareness of the
NABH standards, colleagues in the Department of Quality System in collaboration with other departments developed
this pocket guide for your quick reference. I have found it most useful and I am sure you would too.

Good is not good when better is expected. It is a responsibility we take upon ourselves with pleasure as we know that
we would emerge successful in this endeavor of ours with the whole hearted participation of every single member of
our team.

Good luck my team,

Rev. Fr. George Sequeira

Director

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DURING THE HOSPITAL SURVEY
DO’s
1. Welcome the assessor to your area.
2. Allocate appropriate space for the assessor team to do the interviews if applicable. If you need the help of a
translator please ask for it.
3. Be truthful, describe your regular practice.
4. Be professional in your attitude and appearance.
5. Reply to assessors’ questions directly and concisely.
6. If unsure of the answer, the safest response is that you would check the policy or ask your supervisor.
7. Answer with confidence
8. If you don’t understand questions, ask the assessor to clarify or explain.

DON’Ts

1. Argue with the assessor.

2. Mislead the assessor.
3. Volunteer unnecessary information.
4. Provide non requested documents.
5. Use phrases such as, “most of the time”, “we usually”, “well, sometimes we do”.
6. Talk about past surveys or the future plan of the department.
7. Prompt the staff during the interview

1. VISION OF THE HOSPITAL

 Excellence in the health care, Manifesting Jesus' Love in Service, Giving His Life to humanity

2. MISSION OF THE HOSPITAL

 Develop affordable &holistic healthcare.
 Contribute to Better Quality of Life in the society.
 Equip the health professionals with knowledge, skills and values.
 Provide measurable benefits to all regardless of caste, creed and color.
 Adopt state-of-the-art technology with an Echo friendly environment.
 Emphasize Research & Development initiatives.

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3. CORE VALUES OF THE HOSPITAL
 Love in Service
 Organized Structure
 Unity in Action
 Respect for one another
 Devoted Zeal
 Empathetic Approach
 Safe Atmosphere

4. QUALITY POLICY OF THE HOSPITAL

We, at Lourdes Hospital, are committed to Excellence in Healthcare at an Affordable cost in a Safe and Eco-
friendly Environment with State-of-the art Technology, Well-defined Quality Systems and Competent
Professionals manifesting Jesus' Love in Service.

5. QUALITY OBJECTIVES OF LOURDES HOSPITAL

 To ensure safety of patients, visitors, employees and other service providers.
 To monitor, measure, assess and improve our performance to achieve service excellence and patient delight.
 To empower and involve all employees in continuous quality improvement.

6. SERVICESNOT AVAILABLE
 Radiation Oncology
 Neonatal Cardiac Surgery
 Artificial Reproductive Technology (ART)

7. SERVICE STANDARDS
a. Prayer – The Beginning of the Care (Culture of Dedication)
b. In-charge’s Department Introduction & Hierarchy (Culture of Respect)
c. Patient Greetings Protocol (Culture of Trust)
d. Training on Culture & Culture on Training (Culture of Learning)
e. Official Rounds by the Management Staff (Culture of Support)
f. Staff Self Introduction (Culture of Confidence & Help)

8. Employee Rights and Responsibilities

Rights
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 Right to receive appropriate standards, rules and regulations at the work place.
 Right to be covered under statutory requirements like P.F. and E.S.I.
 To be aware of the terms and conditions of his/her employment before joining the organization.
 To seek clarify on the job to be performed and the roles/responsibilities associated with the task to be
performed with Job Description.
 Right to receive salary on time.
 Right to be treated considerably and respectfully, and not discriminately on the basis of the caste, religion,
sex or socio-economic background.
 Right to get orientation programme.
 Right to be covered under ESI/ Mediclaim policy exists in the hospital.
 Right to take up your grievance at your workplace to the Grievance Committee.
 Right to take up your grievance on sexual harassment complaint to the internal committee
 Right to obtain information on safety and health standards from Hospital authorities.

Responsibility
 Every employee has to be at all times being courteous and considerate to patients, visitors, public, superiors and
coworkers.
 Every employee has to maintain a high standard of work culture.
 Every employee loyal to the hospital and observe all the rules and regulations and HRM Policy of the Hospital
 Every employee carries out the work assigned to him with utmost sincerity and dedication as per the instructions
of his superiors.
 Every employee maintains discipline at all times in the department, workplace.
 Every employee accepts any work allotted apart from his routine job.
 Every employee always neatly dressed in clean clothes while on duty and shall keep the premises clean.
 Every employee takes proper care of all hospital property.
 Every employee promptly reports any injury sustained at the work place to the concerned authorities
 Every employee should take care of their own health and safety, complying with safety and health standards and
reporting unsafe work incidents to employee safety committee through in charge.

9. LIST OF COMMITTEES
1. Internal Management Committee
The Internal Management Committee shall frequently review hospital performance in terms of policies,
objectives, plans and appropriate action to correct deviation from planned and desired standards of
performance.

2. Blood transfusion committee

The committee shall review aspects of transfusion services includes eligibility of donors, bleeding
process, storage, component separation, delivery issues, transfusion reaction if any with root cause
analysis and calibration of equipment.

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3. Patient safety committee
The role of patient safety committee is to establish and maintain a progressive patient safety program to
provide safe environment to the patient, visitors and employees. The committee shall review the patient
safety measures adopted and effectiveness of the programs across the hospital. Also perform proactive
risk analysis and implementation of its corrective & preventive actions.

4. Continuous Quality Improvement committee

The committee shall facilitate, oversee and monitor training and education of the staff about Quality
Assurance and Improvement and /or initiatives in QI and transformation associated with it.

5. Hospital infection control committee

The Committee is responsible for establishing and maintaining infection prevention and control, its
monitoring, surveillance, reporting, research and education.

6. Medical audit committee

The committee shall review the discrepancies, errors, or deficiencies in documentation or practices that
could impact patient care and thereby helping the healthcare organization to maintain accurate and
appropriate documentation.

7. Facility Management committee

The committee shall manage the statutory compliances and streamline routine operations. The
committee shall oversee, guide and ensures safe and efficient environment to patients, staff, and visitors.
Routine inspections are one of the hospital facility management’s key activities that are performed to
find and address any problem areas inside and outside of healthcare facilities

8. Employee safety committee

Employee safety committee is responsible for promoting workplace safety ,identify and reduce the
potential risk of work place hazards.
Members are:
 Director/Associate director (Chairman)
 Medical Superintendent
 Nursing Superintendent/Nursing Supervisor
 Clinical Safety officer
 AO-Human resource (Convener)

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 Engineering co-coordinator
 Infection Control Doctor
 Quality Systems Officer

9. Internal committee
Internal committee is responsible to create a non-discriminatory, non-hostile and harassment free healthy
working environment that enables all its women employees to work without fear of prejudice, gender
bias or sexual harassment.

Members:
 Dr.Preethi Peter (Chairman)
 Dr. Sr. Romia Rodriguez (Medical Person)
 Ms.Valerine Abro (NGO Woman Representative)
 Ms.Anna Sigi George (Member)
 Ms. Lidia Maria Tom (Member)
 Sr.Rufeena (Member)
 Sr.Alice C O (Member)
 Adv. Ainer Myloth (Legal Person)

10. Pharmacy & therapeutic committee

Pharmacy & therapeutic committee is responsible to ensure high-quality drug therapy for hospital
patients, provide liaison between the medical staff and the department of pharmacy services.PTC shall
review policies of purchase of drugs and consumables, prescription patterns and the issues related to
pharmacy.

11. Code blue committee

Code Blue Committee is a multidisciplinary committee established to review and monitor Code Blue
response procedures. Monitor the training and education needs of the staff

12. Ethics committee

Ethics committee is primarily responsible to ensure that ethical principles and guideline are upheld
within the studies involving human subjects.

13. Grievance committee

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The Grievance Redressal Committee shall consider all grievances submitted in writing by staff and take
necessary steps immediately. The Committee shall provide employees with an easy and trustworthy way
of raising any workplace grievances that they may have.

Medical staff grievance committee

MEMBERS:
 Dr. Santhosh John Abraham (Medical Superintendent)
 Dr. Anusha Varghese (Deputy Medical Superintendent)
 Dr. Mary Celine Stella (General Medicine)

General staff grievance committee

MEMBERS:
 Sr. Goldin peter (Nursing Superintendent)
 Ms. Anna Sigi George (Administrative officer - HR Manager )
 Mr. John Wilson (Medical Imaging Technologist)

14. Critical care management committee

The Critical Care Committee develops clinical practice guidelines related to critical care, analyze the
process in ICU’s and review its outcome.

10. INTERNATIONAL PATIENT SAFETY GOALS

ISBAR

 IPSG 1: Identify Patients Correctly

FIRST, to reliably identify the individual as the person for whom the service or treatment is intended.
SECOND, to match the service or treatment to that individual
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ALWAYS ask the patient/guardian/parent to verbalize patient’s name if possible.

1. Patients must be identified using “two unique identifiers” i.e. FULL NAME and MEDICAL RECORD NUMBER
(Hospital Number) throughout the organization
2. NEVER use patient’s room or location to identify patient.
3. Patients are identified before providing treatments and procedures (Such as administering medications, blood, or
blood products; serving a restricted diet tray; or taking blood and other specimens for clinical testing).
4. Patients are identified before any diagnostic procedures (performing a cardiac catheterization or diagnostic radiology
procedure)

 IPSG 2: Improve Effective Communication.

Improve the effectiveness of verbal and/or telephone communication among caregivers.

Verbal Orders/ telephonic orders: Verbal orders are reserved for emergency situations ONLY, and must be
documented in the clinical record which should be counter signed by clinician within 24 hours. Refer the permitted
verbal order list for details. (Medicine store manual)

Implements a process for reporting critical results of diagnostic tests.

Read back procedure for the receipt of laboratory or radiology results. ALWAYS REMEMBER: Physicians
MUST ALWAYS respond to critical result notification. Document the results in the patient chart, and the
corresponding action needed based on the patient’s clinical condition.

Implements a process for handover communication.

The standardized approach to patient care handover, namely ISBAR, must be used by all healthcare workers
(Physicians, Pharmacists, Residents and all other Healthcare Professionals) in all situations without fail.

{I: Identity S : Situation B : background A : Assessment R : recommendation }

Situations where ISBAR is applicable:

 Between health care providers and during shift changes;

 Between different levels of care in the same hospital (General ward to Critical care);
 From inpatient units to diagnostic units (endoscopy, physiotherapy, Cath Lab, etc.);
 When referring any abnormal values or change in patient’s condition to the Physician or another Colleague.

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UNACCEPTABLE COMMUNICATION & RELATED POLICY

Unacceptable communications/ behaviors: Behavior that is below the level expected from Lourdeans.
List of unacceptable communications/behavior
 Any communications /behavior that violates a patient’s rights.
 Any communications /behavior that causes or increases the risk to patient or employee.
 Any communications /behavior that does not uphold the dignity and confidentiality of a patient.
 Any aggressive behavior displayed towards visitors or colleagues
 Any communications /behavior violating the law of the land and medical ethics

 IPSG 3 : Improve the Safety of High-Alert Medications

 An independent double check procedure& documentation must be completed without distractions or
interruptions.
 Always use the Rights of medication before administration
 Segregate them to reduce the risk of error.
 Never store the high alert drugs at the patient bedside.
 Concentrated electrolytes shall l be: Labeled and kept in a locked cabinet
 Look-Alike and Sound-Alike Medications are kept physically apart.

 IPSG 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery.

The essential processes found in the Universal Protocol are: marking the surgical site; a preoperative verification
process; and a time-out that is held immediately before the start of a procedure.

Surgical and invasive procedure site marking should:

 Be done by the person performing the procedure with a permanent skin marker.
 Take place with the patient AWAKE and AWARE, if possible.
 Be done in all cases involving laterality (right, left), multiple structures (fingers, toes, lesions) or multiple levels
(spine).
 Be done using an instantly recognizable mark (X asper policy) that is consistent throughout the hospital.

Preoperative verification: it can be completed before the patient arrives at the preoperative area:
 Ensure that documents, imaging and test results, vital signs and paperwork are properly labeled and readily available.
 Informed consents are completed and signed by the Physician, Patient/Guardian or Parent and the witness.
 Proper handover is done in the preoperative area and all discrepancies should be corrected before sending the patient
into the Operating Theatre.

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Time out
 Time Out should be performed in a "fail-safe" mode, i.e., the procedure is not started until all questions or concerns
are resolved.
 The responsibility for the "Time Out" process lies with the Physician performing the surgery/ procedure on that
patient.

 IPSG 5 : Reduce the Risk of Health Care–Associated Infections

Five Moments for Hand Hygiene: Hand washing (40–60 sec). Hand rub: (20-30 seconds)
Wash hands with soap and water when hands are visibly soiled.
Limitation of alcohol-based hand rub (ABHR): ABHR is inactive when hands are visibly dirty and when
dealing with spore forming bacteria, i.e., clostridium difficile patients.
Use alcohol-based hand rub when hands are NOT visibly soiled.
Note: Always be AWARE of your unit’s hand hygiene compliance rate
MOMENTS OF HANDWASHING

HAND WASHING STEPS

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 IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls

STAFF RESPONSIBILITIES ON FALL PREVENTION

 The nurse shall assess all inpatients for any high fall risk factors immediately & upon admission and /or their
condition or level of care changes/ during the shift change. Nurse shall educate the patient/family as required.
Implement an age sensitive Nursing Plan of Care aimed at managing the risk of the patient falling.
 Execute the fall prevention/ control measures as required. Eg: side rail, caution board, safety belts for wheel
chair & trolley transportation

11. INCIDENT REPORTING SYSTEMS

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The All incidents, accidents, or occurrences that cause or could cause harm to an employee, patient or visitor
in Lourdes Hospital must be reported.

TYPES OF EVENTS
• Adverse event is a patient safety event that resulted in harm to a patient.
• No-harm event is a patient safety event that reaches the patient but does not cause harm.
• Near miss is a patient safety event that did not reach the patient.

INCIDENT REPORTING PROCEDURE

 Download incident report form from web master
 Complete the incident report form
 Send it to [email protected]
 Follow up

12. PATIENT RIGHTS &RESPONSIBILITY

PATIENT RIGHTS
1. Right to respect one's culture, values, and beliefs, as well as any cultural preferences and spiritual needs.
2. Right to privacy and respect for one's dignity when undergoing examination, treatments, and procedures:
Medical assessments and examinations are to be conducted in designated areas out of the sight and hearing of
others.
3. Right to protection against abuse or neglect
4. Right to treat patient information as confidential: Only direct healthcare providers have access to patients’ files
and details of their condition. These are some best practices to maintain patient privacy & confidentiality:

DO’s DON’Ts
Log-out after using the computers in patient care areas Do not share computer passwords
Knock before entering a room. Do not discuss patient-specific information in public
areas like elevators, food courts and hallways
Close doors and curtains during treatment and Do not display patient-specific information on notice
examination boards accessible to the public.
Cover patients appropriately during treatment and Do not leave medical records in public areas or
transport unattended by staff.

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Modulate voice volume in areas where privacy could be Do not give treatment, or perform physical examination
compromised. or procedures if the patient belongs to the opposite
gender, without the presence of a person of the same
(patient’s) gender present

5. Right to refuse treatment: The patient has the right to refuse to talk to or meet anyone who is not officially and
directly involved in the healthcare provided to him/her including visitors. When a patient refuses care or chooses
to discontinue treatment, he/she will be advised of the consequences of his/her refusal and the expected outcome
of this decision.
6. Right to obtain informed consent prior to surgeries and invasive treatments, including anesthesia and
transfusion of blood and blood products.: The patient (or his/her family) is entitled to have a complete
explanation of the medical procedure required for his/her treatment, including risks and benefits of the proposed
procedure, its complications, and alternative treatments.
Informed Consent is required for:
 Surgery/invasive Procedure
 Anesthesia and Sedation
 Blood and Blood Products
 Instrumental delivery & Elective Cesarean Section
 Dialysis
7. Right to information and consent before any research protocol is initiated.
8. Right to complain and right to information on how to voice a complaint.
9. Right to information on the expected cost of the treatment.
10. Right to access clinical records.
11. Right to seek an additional opinion regarding clinical care.
12. Right to get information on the name of the treating doctor, care plan, progress, and information on one's
healthcare needs.
13. Right to determine what information regarding the care should be provided to self and family.

PATIENT RESPONSIBILITY

1. Clearly and completely describe all health-related matters including past medical illnesses, surgeries,
hospitalizations and medications.
2. Adhere to the advice of the people in charge of the medical care regarding the treatment plan and other
instructions.
3. If disregarding the advice of the medical staff and refusing treatment, take responsibility for such
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conduct.
4. Follow the prescribed therapy exactly.
5. Follow doctor's advice when it comes to taking essential precautions in the event of an infectious
condition.
6. Recognize that medical experts are fallible human beings who might make mistakes and omissions.
7. Be respectful of the medical professionals' autonomy, take hospital staff members' rights into account,
and treat them with consideration.
8. Arrive at the hospital on time and be prompt for hospital appointments.
9. Keep and produce all medical documents.
10. Inform doctor if the patient wants to change hospital or doctor.
11. Inform doctor or nurse of any changes in the patient's health or symptoms, including pain.
12. Be cooperative and considerate of other patients' rights and comforts. Respect the property of the
hospital and others.
13. Adhere to all hospital policies including visiting hours, bill settlement, prohibition of alcohol, smoking
and drugs.
14. Provide insightful feedback on the services provided
15. Assume responsibility for protecting personal belongings.

13. PATIENT IDENTIFICATION BAND

Red Colour Band Patients with history of Allergy towards drugs

Blue Colour Band General Patients

Green Colour Band Vulnerable Group

Pink Colour Band Newborn Girl

Light Blue Colour Band Newborn Boy

14. VULNERABLE POLICY

Vulnerable Patients
Children below 5yrs
Patients above 75 yrs
Physically/mentally challenged
All patients admitted in intensive care units
Full term pregnant woman

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Patients on Dialysis
Patients on chemotherapy
Patient with seizure disorders

Patient first programmes

V” green sticker is pasted on the Nurses physical assessment form and displayed on the black board at nurses’
station.

15. GRIEVANCE POLICY

 In case of grievance the employee has to approach the In-charge at first.
 Aggrieved employees shall discuss his grievance with his immediate supervisor, within three working days
of its occurrence.
 If the grievance is unresolved at Step 1, the grievance shall be written by the aggrieved employees and
forward to the Grievance committee.
 The grievance shall be reduced to writing and presented for discussion in a meeting and the report and/or
recommendations may go to the Director for deliberations and necessary action which should be taken
within a month of the occurrence of the grievance.

16. EMERGENCY CODES

All the codes are usually announced over the hospital public announcement system along with exact location where
emergency has taken place. When emergency no longer exits, an ‘ALL CLEAR’ announcement is made & it is
repeated 3 times over PA system.

cardiac arrest / patient

Code Blue Code Blue + Location Call 1999
collapse

Paediatric Code Paediatric cardiac arrest / Paediatric Code Blue + Location Call 1999

Blue patient collapse

Code Pink child abduction Code Pink + Age + Gender + Location Call 1999

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Security threats/ physical
Code White Code White + Location Call 1999
assault

Code Red Fire emergency Code Red + Location Call 1001

Code Orange Mass casualty Code Orange + Location Call 1999

CodeTwenty
Twenty Work place accident/ injuries Code Twenty Twenty + Location Call 1999
Code Ten Obstetrical Emergencies Code Ten Call 1999
Stroke code 1&2 Neurological emergencies Stroke code 1 Call 1999
Stroke code 2

FIRE SAFETY
Remember RACE Classification of fire Operation of the fire extinguisher
Category A : Solid fire: Paper , Linen DCP :( dry chemical powder) :remember
R: RESCUE Category B : Liquid Fire /: oils, Paint PASS
A: ALARM Category C: Gas fire: LPG. P :Pull the pin
C : CONFINE the fire Category D : Metal Fire : Mg, Titanium A :Aim At the base of the fire
E : EXTINGUSH & Category E: Electrical Fire: short S :Squeeze the knob
EVACUATE circuit, fan, switch board, transformer S :Sweep from side to side
Co2 :Rotate the knob anti- clockwise , aim
the hose in the base of the fire & release the
content

17. HAZMAT ( hazardous material)Spillage & BBF ( Blood & Body fluid )Spillage MANAGEMENT
Minor spill (< 30 cc):to be cleaned by department itself with the help of BBF spill kit
 Put on PPE (mask & gloves).

 Place paper /cloth over the spill

 Pour 1% sodium hypochlorite solution over the towels. Leave it for 20 minutes.

 Clean the area in a unidirectional manner using towel & dispose it in yellow bag.

 Dispose the PPE as per the disposal as per policy

 Alert the housekeeping staff for further cleaning. The bucket and mop should be thoroughly cleaned after use

and stored dry.

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Major spill (> 30 cc)

 Isolate the area by placing caution board.

 Put on PPE(apron, mask, goggles & gloves).

 The area should be decontaminated by using blood spill kit as mentioned above using all barrier precautions.

 Alert the housekeeping staff for further cleaning. The bucket and mop should be thoroughly cleaned after use

and stored dry.

CYTOTOXIC SPILL MANAGEMENT

 Alert nearby persons about the spill.

 In case of spillage to skin, eyes or clothing:

 Remove contaminated gloves or clothing (if applicable) immediately.

 Wash the affected skin area with plain soap (avoid germicidal cleaner) and lukewarm water. For exposure to

eyes, immediately flush the affected eye with water or isotonic eyewash (or normal saline) for at least 15

minutes.

 For direct skin or eye contact, obtain medical attention as soon as possible.

 Prevent risk of additional skin contact with the spilled drug.

 Obtain chemotherapy/hazardous drugs spill kit.

 Put on safety goggles and double gloves from the kit. If spill involves more than 5 ml or covers more than one

square foot, put on gown and shoe covers (or coveralls) from the kit.

 If there are broken glass fragments, use the detachable scrapers to carefully "sweep" these or other sharps into

the scoop. Place these sharps in the bucket provided to discard cytotoxic waste.

 Use soil to gently cover and wipe up the spilled material. Place used soil in the yellow bag (with Cytotoxic

and biohazard symbol) from the spill kit.

 Clean the area thoroughly with water using rag pieces. Rag pieces used in this step should go into the yellow

bag (with Cytotoxic and biohazard symbol) from the spill kit.

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 Clean the area three times using a detergent solution, then rinse. (Housekeeping can be called for this

purpose).

 Place any contaminated hospital linen in a yellow bag (with Cytotoxic and biohazard symbol) and label

appropriately as “Cytotoxic linen” and send to laundry. If it is to be laundered, use double bag for transport,

then wash twice before combining with other laundry.

 Remove the shoe covers (if used) and discard in yellow bag (with Cytotoxic and biohazard symbol).

 Remove outer pair of gloves and discard into yellow bag from the spill kit.

 Remove the goggles and place into the yellow bag (with Cytotoxic and biohazard symbol).if disposable.

(Alternatively place goggles in Ziploc bag if reusable for washing).

 Close the yellow bag (with Cytotoxic and biohazard symbol) by knotting or using twist tie or tape, then place

it into the second yellow bag (with Cytotoxic and biohazard symbol) from the spill kit.

 Remove the gown and dispose into yellow bag (with Cytotoxic and biohazard symbol) from the spill kit.

 Remove the inner gloves. Place these into the yellow bag (with Cytotoxic and biohazard symbol) from the

spill kit. Close the outer bag.

 Wash hands thoroughly.

 Send the Cytotoxic spill management wastes for disposal as per policy.

MERCURY SPILL MANAGEMENT

 Put on gloves and mask

 Immediately after the spillage, the staff in the concerned area should collect the mercury using a conical

shaped paper & an index card.

 Transfer the mercury into a glass bottle from the conical shaped paper& secure the container with the lid.

 If there are any broken pieces of glass or sharp objects, gather them up with index card. Dispose all broken

objects into blue bucket.

 The collected mercury should be send to BME department.

 In case of contact to skin, mucous membranes including eyes, wash liberally with plenty of water.

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18. BIOMEDICAL WASTE MANAGEMENT RULE 2016

No CATEGORY TYPE OF WASTE

Human tissue, Infectious non plastic wastes, mask,

1 Yellow with biohazard symbol
cap, gauze. cotton

Cytotoxic, Chemical waste, expired and discarded

2 Yellow with biohazard and Cytotoxic symbol
medicines

3 Red with biohazard symbol Infected Plastics

4 White (Translucent) with biohazard symbol Needles, Blades, Scalpels

5 Blue with biohazard symbol Glassware

6 Blue with biohazard symbol Metals, Metallic body implants, Scissors

19. NEEDLE STICK&SHARP INJURY, INJURY MANAGEMENT PROTOCOL

1) Wash the Site with plenty of water and antiseptic soap solution immediately

2) Report to in-charge and fill up NSI form (available at Emergency Department)&Inform Infection Control Nurse.

3) Report to Infection control doctor with filled NSI form

20. SENTINEL EVENT MANGEMENT

A sentinel event is an unanticipated occurrence involving death or serious physical or psychological injury. Serious

physical injury specifically includes loss of limb or function. Such events are called sentinel because they signal the

need for immediate investigation and response.

Department Heads and In-charges are responsible for reporting the event.

Sentinel Events includes any occurrences that meet the following criteria:

1. SURGICAL EVENTS

 Surgery performed on the wrong body part, wrong patient.

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 Retained instruments in patient discovered after surgery/procedure.

 Patient death during or immediately postsurgical procedure, Anesthesia-related sentinel event.

2. DEVICE OR PRODUCT EVENTS PATIENT DEATH OR SERIOUS DISABILITY ASSOCIATED WITH:

 The use of contaminated drugs, devices, products supplied by the organization.

 The failure or breakdown of a device or medical equipment, Air embolism.

3. PATIENT PROTECTION EVENTS

 Discharge of an infant to the wrong person.

 Patient suicide, attempted suicide or deliberate self- harm resulting in serious disability.

 Intentional injury to a patient by a staff member, another patient, visitor, or other.

4. ENVIRONMENTAL EVENTS

 A burn incurred from any source, An electric shock.

5. CARE MANAGEMENT EVENTS

 Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO

incompatible blood or blood products.

 Maternal death or serious disability associated with labour or delivery in a low risk pregnancy.

 Medication error leading to the death

 Patient death or serious disability associated with an avoidable delay in treatment or response to abnormal

test results.

6. CRIMINAL EVENTS

 Any instance of care ordered by or provided by an individual impersonating a clinical member of staff.

 Abduction of a patient

 Sexual assault on a patient within or on the grounds of the healthcare facility

 Death or significant injury of a patient or staff member resulting from a physical assault

21. HAZARDOUS MATERIAL (HAZMAT)

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 Any substance or agents (chemicals, biological or radiological), if released or misused, can pose a threat to
the environment, life or health.

 Eg: biomedical waste, O2, mercury, chemotherapy agents etc.

 Should ensure the display of Material Safety Data Sheets(MSDS)

 MSDS is a document that lists information relating to occupational safety and health for the use of various
substances and products. SDSs are a widely used system for cataloging information on chemicals, chemical
compounds, and chemical mixtures..

 Should have a plan for managing spills of hazardous materials.

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22. HIRA- HAZARD IDENTIFICATION AND RISK ASSESSMENT

It is a systematic risk assessment tool that can be used to assess the risks of various hazards

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SL Activities & learning opportunities
NO
1 Training registers & its updation
2 Quality assurance program: OR, ICU, ED, RADIOLOGY, LAB.
3 Radiation safety, material safety data sheet – HIRA training, HAZMAT stickers, HAZMAT spill kit
4 Patient Safety manual & fire safety manual
5 HICC manual
6 BLS/ ACLS
7 Committee meeting & minutes with implementation report

1. PATIENT AND FAMILY INTERVIEW

1.  Information on next follow up in OPD where appropriate
2.  Consultation on planned discharge
3.  Education about nutrition, immunization and safe parenting
4.  Pain management techniques
5.  Diet limitations
6.  Counseling for the usage of implantable prosthesis and medical device
7.  Awareness of patient and family rights and responsibilities
8.  Patient and family rights include :
o Respecting any special preferences , spiritual and cultural needs
o Respect for personal dignity and privacy during examination
o Protection from physical abuse or neglect
o Treating patient information as confidential
o Refusing of treatment
o Informed consent
o Right to complaint and information on how to voice a complaint
o Information on the expected cost of the treatment
o Assess to his / her clinical records
o Information on plan of care , progress , etc .
o Information on name of treating doctor, care plan, progress and
information on their healthcare needs.
9.  Education / Explanation on :
o Proposed care including the risks , alternatives and benefits

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o Expected results
o Disease process , complications and prevention strategies
o Results of diagnostic tests and the diagnosis
o Any change in the patient’s condition/ home care management.
10.  Information on scope of general consent
 Information on informed consent regarding the procedure ,risks benefits,
alternatives and as to who will performed the requisite procedure in
understandable language
11.  Information and Education on:
o Proposed care including the risks alternatives and benefits
o Safe and effective use of medication and the potential side effects
o Food –drug interactions
o Diet and nutrition
o Immunizations
o Organ donation, when appropriate
o Specific disease process ,complications and prevention strategies
o Prevention of healthcare associated infections
12.  Estimated costs of treatment
 Financial implications when there is changing condition /treatment setting
13.  Procedure for lodging complaints
 Compliant redressal procedure
2. STAFF INTERVIEW-CARE OF PATIENTS
14.  Information sharing about patients from shift to shift

15.  CPR
16.  Rational use of blood and blood products
17.  Vulnerable group
18.  Moderate sedation
19.  Organ transplant
20.  Restraint control and restraint techniques
21.  Pain screening, assessment & reassessment; management
22.  End of life care
23.  List of high risk medications; drug reconciliation

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24.  Labeling prior to making a secondary medicine
 Patient identification before administering medication
25.  Monitoring after medication administration
26.  Awareness of adverse drug events and reporting mechanisms
27.  Awareness on patient rights and responsibilities
28.  Healthcare communications techniques
29.  Infection control programme
30.  Quality improvement programme
31.  Admission / discharge criteria in ICU

32.  Induction training

o Mission ,goals and service standards of organization ,employee rights
and responsibilities, patients rights, service standards
o Hospital and department policies and procedures
33.  Performance appraisal
34.  Pre-employment health check , annual health check
 Occupational health hazards
 Pre and post exposure prophylaxis
4. Safety education
35.  Lab safety
36.  Radiation safety
37.  Disaster management plan
38.  Segregation of BMW
39.  Safety education
40.  Fire and non fire emergencies
41.  Handling spills
42.  Child / neonate abduction
43.  Risk management. Incident reporting system
44.  Occupational safety – code twenty twenty

KEY PERFORMANCE INDICATORS

SL.NO STANDARDS INDICATOR

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1 PSQ3a Time taken for initial assessments indoor patients by doctor
2 PSQ3a No of reporting error per 1000 investigations-lab
PSQ3a No of reporting error per 1000 investigations-radiology
PSQ3a Percentage of adherence to safety precautions by staff working in
3 diagnostics-lab
PSQ3a Percentage of adherence to safety precautions by staff working in
diagnostics-radiology
PSQ3a Medication errors rate
4
5 PSQ3a Percentage of medication chart with error prone abbreviations
6 PSQ3a Percentage of in-patients develops adverse drug reactions
7 PSQ3a Percentage of unplanned return to OT

8 PSQ3a Percentage of surgeries where the organization’s procedure to

prevent adverse event like wrong site, wrong patient and wrong
surgery have been adhered to
9 PSQ3a Percentage of transfusion reactions

PSQ3a Standardized mortality ratio for ICU

10
11 PSQ3a Return to the emergency department within 72 hrs with similar
presenting complaints
12 PSQ3a Incidence of hospital associated pressure ulcers after
admission(bedsore per 1000 patient days)
13 PSQ3b Catheter associated urinary tract infection rate
14 PSQ3b Ventilator associated pneumonia rate

15 PSQ3b Central line associated blood stream infection rate

16 PSQ3b Surgical site infection rate

17 PSQ3b Hand hygiene compliance rate

PSQ3b Percentage of cases who received appropriate prophylactic

18 antibiotics within the specified time frame

19 PSQ3c Percentage of rescheduling of surgeries

20 PSQ3c Turnaround time for issue of blood and blood components

21 PSQ3c Nurse - patient ratio for ICU, ward

22 PSQ3c Waiting time for outpatient consultation

23 PSQ4c Waiting time for diagnostics-radiology

PSQ4c Waiting time for diagnostics-lab
24 PSQ4c Time taken for discharge

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25 PSQ4c Percentage of medical records having incomplete and/ or improper
consent
26 PSQ4c Number of stock out of emergency medications

27 PSQ4d Number of variations observed in the mock drills

28 PSQ4d Patient fall rate(falls per 1000 patient days)
29 PSQ4d Percentage of near misses
30 PSQ3d Rate of NSI-IP

31 PSQ3d Appropriate handover during shift change - Doctor, Nurses

32 PSQ3d Compliance rate to medication prescription in capitals

33 PSQ3a Return to ICU within 48hrs

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