Download What is CBAHI

WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
.What is the Performance Improvement
Approach Or FOCUS – PDCA?
F – Find a process to improve.
O – Organize the team that knows the process.
C – Clarify current knowledge of the process.
What is Accreditation?
Accreditation is a self assessment and external U – Understand causes of process variation.
peer review process used by healthcare S – Select the process improvement.
organizations to accurately assess their level of
performance in relation to established standards P – Plan the improvement and continue data
and to implement ways to continuously improve collection.
D – Do the improvement, data collection, and
the health care system.
analysis.
What are the objectives of Accreditation? C – Check the results and lesson learned from the
team effort.
Why we need to be accredited?
1. To ensure the quality of healthcare A – Act to hold the gain and to continue to improve
through the application of quality the process.
What do you understand by Patient’s rights?
concepts.
These are ethical legal principles/privileges in
2. To foster a culture of patient safety and
which patients are entitled.
minimize the risks of medical errors.
3. To achieve optimum organizational
What are the patient/family rights?
results with the available resources.
1. Right to get equal treatment regardless of age,
What is the Vision of WDGH?
To be the best healthcare provider in our gender, religion, race and disability at all times.
2. Right to be informed prior to obtaining consent
region.
in all the procedure and treatment to be performed.
What is the Mission of WDGH?
To achieve the quality requirements of 3. Right to information.
 To know the identity and professional
(CBAHI) to assure a safe and high quality
status of all individual providing service to
healthcare.
him/her.
What are the values of WDGH?
- Patient care is honor for us.
 To know which physician is primarily
- Team work is our feature.
responsible for his/her care.
- Respect of patients and their rights.
4. Right to privacy and confidentiality.
- Continuous improvement of performance and
 Have his/her medical record read only by
total quality achievement.
individual directly involved in his/her care.
- Continuous medical education to improve the
 Not to discuss patient information in
quality of hospital staff.
public.
- Adherence to religious ethics of our Islam.
 Not to post patient information in view.
What is CBAHI?
Central Board of Accreditation for Healthcare
Institution.

Not to be physically exposed when
not necessary for treatment.
5. Right to personal safety, security and
protection.
6. Right to refuse participation in any medical
research.
7. Right to be provided with proper means to
contact his family.
8. Right to obtain continuous care and referral
to different treatment levels.
9. Right to be provided with interpreters to
communicate if necessary.
10. Right to be transferred to another room if
another patient or visitor is unreasonably
disturbing.
What is Informed Consent?
A consent whereby the attending physician or
designee provides information to the patient/
legal guardian about specialize procedure
which include:
 The patient condition
 The proposed treatment
 The potential benefits and drawbacks
 Possible problems related to recovery
 Possible results of non treatment
What do you understand by patient
confidentiality?
 Not allowing unauthorized person to
have access to patient’s medical
record.
 Not discussing patient information in
public.
 Not posting patient information in
views.
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
practitioner in the presence of the charge nurse or
When do you obtain General Consent?
Upon admission and for all diagnostic another nurse who will verbally confirm that the
procedures.
“read back order” is correct.
-Telephone orders will be accepted in situations
that require actions that will facilitate care of the
What are Verbal/Telephone orders?
Verbal orders – are orders from a licensed patient.
practitioner, within the practitioner’s scope of
practice and hospital privileges directly given What would you do if a Doctor prescribes the
”verbal” to another practitioner whose scope of wrong dose of medication?
practice includes the authorization to receive
Hold the medication and inform the
and document such orders.
physician/prescriber.
Telephone orders – are orders from a
licensed practitioner, within the practitioner’s How will you transcribe a Physicians’ order?
scope of practice and hospital privileges, given
A clear specific physician’s order is transcribed
“over the telephone” to another practitioner to the patient’s Kardex and medication sheet by the
whose scope of practice includes the RN with legible name and signature, date and time,
authorization to receive and document such verified parallel to the order.
orders.
The nurse who prepares the medication is
responsible of administering the drug evident with
How long after a Verbal/Telephone orders the legible signature immediately after the
procedure observing the seven rules of medication
should a Doctor sign the order?
 Doctor must sign the “verbal orders” administration.
before leaving the area.
 Doctor must sign “telephone orders” What are the 10 Rights/Rules of Medication
Administration to minimize the risk of
within 24 hours.
medication error?
What will you do if a Doctor gave a telephone Right patient
Right drug
order?
Right dose
“WDRB”
Right frequency
 W – Write
Right route
 D – Down
Right time
 R – Read
Right documentation
 B – Back
- The receiving nurse will document the order to Right to know the action and reaction of the drug
be carried out in the physician’s order sheet, and Right to refuse
Right to privacy
then read the written order back to the ordering
What are the two (2) Patient Identifiers?
 Patient three names
 Medical Record Number
How are patients selected for admission to
ICU?
According to the severity and complexity
of care, assessment and recommendation of
the admitting consultant.
What is Discharge Against Medical
Advice?
It is the patient’s own desire to go home
holding his/her responsible and the hospital
has no legal responsibilities.
What do you understand by Discharge
Planning?
It is an interdisciplinary, systematic process
which aids patients and families to develop a
plan of care after hospitalization and a plan of
care 24 hours before physical discharge.
It involves the medical instructions that the
patient will need to fully recover.
What precautions will you observe before
starting blood transfusion?
Check the patient’s identifiers (three names
and medical record number), ID band,
prescribed blood product, number of unit,
blood type and cross-matching, blood tag
number, expiration date, ward/unit.
Check together with charge nurse or another
RN before administration.
Verify signed consent for blood/blood product
if present in patient’s file.
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
What is an OCCURRENCE?
These are inconsistencies which would result in
injury or loss to a patient or which might
otherwise give rise to a claim against the
hospital and/or employee that must be resolved
and reported to QMD within 24 hours of
occurrence.
What is an Incident Report/Occurrence
Variance Report
An internal form used to document the details of
the occurrence/ event and the investigation of an
occurrence and the corrective action taken.
Who is the responsible person to report an
Occurrence or incident?
What is sentinel event?
What are the 3 basic elements of Fire?
An unexpected occurrence involving death or
 heat
serious physical or psychological injury, or the risk
 fuel
thereof, not related to the course of patient’s illness
 oxygen
or underlying condition.
Enumerate the types of Fire:
What are the types of sentinel event?
Type A – combustible materials
 Homicide
Type B – flammable liquids oil and grease
 Surgery on the wrong patient or body part
Type C – involves electricity
 Impairment ( major/permanent loss of
Type D – K for kitchen
bodily function)
 Any unexpected death that is not the result What do you understand by “RACE”?
R – Rescue the nearest patient in the disaster
of the patient’s underlying condition
area
 Rape
 Child Abduction or discharge to the wrong A – Activate the nearest fire alarm
C - Confine the fire
family
E – Extinguish
 Significant Hemolytic Blood Transfusion
 Suicidal Attempt
What do you understand by “PASS”?
 Significant Medication Error (overdose
P – Pull the pin
causing death).
A – Aim the hose at the base of the fire
S – Squeeze the lever
What are other reportable occurrences?
S – Sweep the hose from side to side
 Medication Error
The Employee who witness or discover an
occurrence has the professional obligations and
responsibility for:
1. Immediately notifying:
 The physician on call if the occurrence
involves any question of patient or
employee injury or harm.
 Patient fall
 The Nursing Supervisor on duty.
 Wrong procedure
2. Initiating the completion of OVR form before
 Needle stick injury
the end of the occurrence shift.
3. Submitting the original of the OVR form to
What is Root Cause Analysis?
the supervisor on duty.
 It is an in-depth investigation; a process for
identifying the basic causal factors of an
What do you understand by near miss?
adverse event and analyze them.
An event or a situation that could have

Collecting,
analyzing,
integrating
resulted in an accident, injury or illness, but did
evidences
and
establish
causes,
make
not either by chance or timely intervention.
recommendations
and
drawing
conclusions.
How do you call for help during a Fire?
Activate the fire alarm.
Dial- 0- Central Paging System or 1111
State your name, ward, room, or bed number
of the disaster area.
Who has the ultimate responsibility for
calling “Code Yellow”?
The Hospital Director or his deputy during
working hours or
The Director-On-Duty after normal working
hours.
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
What are the different CODES of WDGH?
Code Red – FIRE
Code Blue – Adult CPR
Code Green – Pediatric CPR
Code Yellow – External Disaster
Code Orange – Hazardous Materials
Code White – Bomb Threat
Code Pink – Infant//Child Abduction
Mr. Strong – Agitated or Aggressive Person
What will you do before you turn off the
oxygen in the ward during the Fire?
 Transfer the patient to portable oxygen.
 Mobilize the patient to safe area (follow
the RACE procedure, move patient
horizontally, if smoke or flame blocks
your way proceed vertically).
 Evacuate ambulatory patient first.
 Stay calm.
What will you do in case of “Child
Abduction” in your ward/unit?
 Conduct a brief search of the unit and
inform the Charge Nurse/Head nurse.
 Activate “Code Pink” Dial – 0 (Central
Paging System) or 1111.
 State your name, ward room and bed
number.
 If the time permits before calling the
code, the charge/head nurse and/or
supervisor calls each of the other unit to
notify them of the “Code Pink in
progress.”
Guidelines for preventing “Falls and Fall Who is responsible for checking the crash
related Injuries”?
cart and replace items used every after
C – Create a safe environment
code and for expiring equipment?
A – Assess a patient’s risks
 Charge nurse/Head nurse
R - Reduce a patient’s risks
E – Evaluate interventions
Procedure of sterilization of Laryngoscope
blades and ambu bag?
How to activate CODE BLUE?
 Laryngoscope blades should be
 Dial – 0- (Central Paging system) or 1111
soaked in the prescribed disinfectant
 State nurse name, ward/unit, room and bed
every after use.
Make sure that no
number of the coded patient.
residues sticks on each equipment,
use brush if indicated.
Who are the members of the Code Blue Team?
 Rinse properly with running water
 Anesthesiologist on call
after soaking from disinfectant.
 Anesthesia technician on duty/call
 Dry and wrap with sterile gauze, then
attach to the handle of the
 Medical Specialist on call
laryngoscope.
 Medical resident on duty
 The handle must be wiped with 70%
 Nursing Supervisor on duty
alcohol.
 Charge Nurse/Head nurse on duty

Ambu bag must be dismantled every
 Staff nurse in the unit
after use for disinfection, properly
 Pediatric specialist
rinse, dry, reassemble and cover with
 Pediatric resident
CSSD paper including face mask .
What do you understand by External Disaster?
Emergency situation/events that occur in the Who is responsible in keeping the narcotic
community, when there is a disproportionate key?
The Charge Nurse on duty every shift.
amount of hospital staff to care for the incoming
emergency room patients or victims.
What is the procedure of narcotic
endorsement?
What do you understand by Internal Disaster?
Both the incoming and outgoing charge
 Any situation within the hospital premises
nurses
are responsible in checking the
that may jeopardize patient and staff safety
narcotic ampoules with signatures of the
and security.
receiver and endorser in the endorsement
 An event of fire, explosion or similar
book.
incident which necessitates the evaluation
of patient to relocate them in safe area.
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
What is the evidence of checking the crash
 Remove concentrated electrolytes from
cart in the ward/unit?
crash cart (potassium chloride)
 The crash cart checklist which is evident
 Identify look alike/sound alike drugs and
with legible signature of the charge/staff
avoid mix up.
nurse every shift.
 Label all meds, containers, and solutions
 The quantity of the crash cart drugs
on and off sterile areas
floor stock varies from each unit/ward
 Do not draw up, transfer more than one
depending on the bed capacity and
med/solution at a time.
needs of the unit with list provided by 4. Ensure correct site, correct procedure,
the Pharmacist.
correct patient-surgery.
 Marking the surgical site
What are the International Patient Safety
 Verification process prior to patient
Goals?
moving to procedural areas
1. Identify patient correctly(use 2 identifiers)
 Correct patient ,site, procedure, required
 When giving medications, blood and
document, functional equipment/device
blood products
 A Time Out conducted prior to procedure
 When collecting and sending specimen
when all activities are suspended
for clinical testing
interactive communication among other
 When performing any treatment or
team members for verification.
procedure
5. Reduce the risk of Health care Acquired
2. Improve effective communication
Infection (HAI).
 Implement correct procedure for taking
 Comply with Hand Hygiene.
verbal/telephone orders, date/time and
 Implement practices to prevent MDR
signature
organism infections
 Give concise hand off communications
 Practice to prevent central-line associated
(clear, legible handwriting with
blood stream infections.
date/time and signature for each entry of
 Practices to prevent surgical site infections
nurse’s documentation)
6. Reduce the risk of harm from falls.
 Be familiar with the “do not use”
 Education of patient and relative to fall
abbreviations.
prevention
 Document referrals for altered lab
 Reassess fall risk daily
results with date/time of notification and
 Use bed alarm/side rails as needed.
reason if no action.
Where will you dispose sharps/needle?
3. Improve the safety of high alert Yellow thick bucket with cover to be changed
medication.
when ¾ full.
Policies
and
Procedures
regarding
Restraints:
 Obtain written doctor’s order, if
urgent an order will be written within
24 hours
 Assess the skin of the site to be
restrained
 Check the site hourly for circulatory
suppression
 Release every 2 hours
 Provide and assist for personal needs
 Reassess for the reduction of the
restraint and document as necessary
What is Nosocomial Infection?
Hospital Acquired Infection (HAI) can be
prevented or minimize if there is staff
adherence to the following:
 Comply with Hand Hygiene
 Practices to prevent central-line
associated blood stream infections
 Practices to prevent surgical site
infections
What Standard Precaution appropriate for
MRSA?
 Contact precaution.
What is PPE?
Personal protective equipment consisting of:
 Gloves,
 Gown,
 Face shield/mask
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
Hepatitis Screening for Employees:
 All new staff will undergo hepatitis
screening prior to the application of
residency identification (Iqama)
 Senior nurses had screening for hepatitis
virus
 In the event of accidental exposure of
the staff, OVR form shall be
accomplished and referred to employee
clinic for treatment and management.
Hand washing Technique (40-60 seconds)
1. Remove all jewelries
2. Roll the sleeves
3. Wet hands with water
4. Apply enough soap to cover all hand surfaces
5. Rub hands from palm to palm
6. Right palm over the left dorsum with
interlaced fingers and vice versa
7. Palm to palm with fingers interlaced
8. Back of fingers to opposing palms with
fingers interlocked
9. Rotational rubbing of left thumb clasped in
right palm and vice versa
10. Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa
11. Rinse hands with water
12 Dry hands thoroughly with a single use towel
13. Use towel to turn off the faucet
When? 5 moments of Hand Hygiene
 Before patient contact
 Before aseptic task
 After body fluid exposure risks
 After patient contact
 After contact with patient surrounding
What do you understand by Standard
Precaution?
A procedure where in concerned staff or significant
others must wear appropriate personal protective
equipment to prevent the transmission of blood
borne pathogens or any other body substance
except sweat.
What is Job Description?
It is a summary of primary duties
performed by the holder of the job, prepared
By the employer.
What is Nursing Process?
It is a systematic approach to meet the
patients needs in health care setting, enabling
the nurse to identify and understand, explain
How do you manage “chemical spill” on the and analyze the problems and needs
presented.
floor? (less than 50 ml)
 Put on double latex gloves, gown and face
5 Steps of Nursing Process:
shield
 Confine and contain spill, cover with 1. Assessment – a comprehensive gathering
appropriate absorbent material, acid and of information using our senses.
a. Subjective – verbalized by the patient
base spills should be neutralized prior to
b. Objective – nurse observation based on
clean up.
 Use only one hand to directly clean spill clinical manifestation
2. Nursing Diagnosis – analyses of the data
and exposed surface.
 Wipe area with alcohol dampened non- collected that leads to the areas of concerns or
sterile 4x4 gauze and dispose gauze to red needs.
3. Plan – objectives or direct outcomes we
bag
want to achieve for the patients
 Allow area to dry for 15 minutes.
How do you manage “infectious spill” on the 4. Intervention/Implementation – appropriate
actions taken to achieve the desired outcome
floor?
based on the concerns or needs identified by
 Wear appropriate PPE
 Cover the spills completely with paper the clients, nurses, physician
5. Evaluation/Reassessment – the desired
towels
outcome on the nursing care delivered
 Gently pour chlorox 5.25% (1:10 dilution)
whether it has a positive or negative response
over the towel from the outer to the center
to the patient.
 Wait for 10 minutes, then remove the
disinfectant paper towels.
When opening a door, do it slowly or look
What are the different color bins used in
through the window to avoid hitting the
hospital?
person on the other side.
RED – human body parts
YELLOW – infectious/hazardous med. waste
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)
Nursing Process will be implemented to:
 Provide direction and continuity of care
by facilitating communication through
documentation among nurses and other
discipline in the health care setting.
 Provide
guidelines
for
accurate
documentation and evaluate the delivery
of patient care.
What are the patient’s care plan upon
admission and OPD follow up:
 Nursing Process Care Plan
 Medication Reconciliation and Hands
Off communication
 Patient/significant
others
health
education
 24 hours discharge plan
What is Medication Reconciliation?
 The process where the current
medications are reviewed and compared
to any new medication being ordered to
prevent medication errors that could
have a harmful effect on the patient.
What is the Nursing Operational Plan
 Measurement of staff competencies
level based on knowledge, skills, and
aptitude.
 Conduct monthly supervisors/head
nurse’s meeting with the Nursing
Director
 Nursing process implementation to all
the units of the organization.
 Nurse’s Case Presentation 2x a month
 Nursing Procedural Demonstration
 Mandatory BLS course
 Orientation Program for new staff nurse
BLACK – ordinary waste
 Lectures on Policies and Procedures 2-3x a
week
How are the nurses oriented on the use of
medical equipment?
 Orientation is conducted by the
charge/head nurse
 The functional status will be used prior to
use
 In case of malfunction the Biomedical
Department will be informed.
 The machine will be segregated and
properly labeled.
 The Biomedical request form is filed as an
evidence in the unit.
What is the evidence of the staff implementation
on the internal transfer policy or transfer within
the facility?
 The availability of transfer notes, and reorder of the patient transfer and care plan
upon receipt is evident with signature of
both endorser and receiver.
 The time the receiver signs the
acceptance/transfer sheet will start the full
responsibility of the patient.
What are some of the general safety procedure?
 Asking for help if realistically you can’t
lift or move a patient or an object.
 Putting the bed and wheelchair in a locked
position if not transporting a patient.
 Putting the stethoscope in the pocket of
uniform instead of putting around the neck.
 Use flat shoes with non-skid sole.
 Use of side rails.
 Locked bed/trolley/wheelchair unless
during transport.
What safety precautions will prevent the
incidents of back strains and injury?
 Proper body mechanics
 Correct
handling
and
lifting
techniques.
 Proper positioning at work place.
What is the procedure of staff allocation
based on the patient category and unit
acuity?
 The staffing plan identifies the patient
category and acuity based on the care
hours or activity level points in the
patient care areas.
 The categorization of general and sub
nursing care into activity level points
ranging from 1,2,3,4 depending on
the complexity of care, is sum up
utilizing the therapeutic intervention
scoring system (TISS) that will
classify the activity level points into
patient acuity level.
 The time required for each patient’s
nursing procedure and the sum for all
patients in the unit is calculated to
predict the nursing care hours needed,
divided by the number of productive
work hours on a shift equals the
personnel needed.
Productivity – is defined as the output
divided by the input related both to how
efficiently clinical nurses deliver nursing care
and how effective that care is relative to its
quality and appropriateness.
WADI AL DAWASER GENERAL HOSPITAL
Nursing Department (CBAHI Orientation)