Hospital Safety Protocols

Patient Identification

• MRN (Medical Record Number), UHID (Unique Health Identification Number), UID (Unique Identification Number), CR number, and IP number, are all acceptable data for patient identification.
• Bed number is insufficient for patient identification.

Hip Fracture

• A patient fall resulting in a hip fracture is classified as a sentinel event.

Code Pink

• Code pink indicates infant abduction.

Vulnerable Patients

• Vulnerable patients include those under 16 years and over 65 years.

NABH and QCI

• NABH (National Accreditation Board for Hospitals & Healthcare Providers) and QCI (Quality Council of India).

PPE (Personal Protective Equipment)

• Disposable gloves, caps, gowns, face masks, and eye wear are all forms of personal protective equipment (PPE).

Patient Rights

• Patient rights include confidentiality/privacy, dignity, and access to information.

Fire Emergency

• Code Red indicates Fire alert

Disinfection

• A 5% bleach solution needs to be left on a spill area for 20 minutes to properly disinfect.

Infection Control

• Hand-washing is the most important and frequently taken measure to control infection.

Emergency Codes

• Emergency event code dial number is for emergency events
• Cardiac arrest/patient collapse follows the emergency code
• Fire is an emergency code
• Security threat (fight) is an emergency code

RACE Acronym

• RACE stands for Rescue, Alarm, Confine and Extinguish/Evacuate.

Extinguishing Fire

• Fire can be extinguished by using a fire extinguisher, sprinkler system, or fire hydrant system.

Standard Precautions

• There is no alternative to standard precautions.

Surgical Site Infections (SSI)

• A surgical site infection occurring at the muscles of the patient is classified as a deep incisional SSI.

Documents for Access, Assessment, and Continuity of Care

• Documents related to access, assessment, and continuity of care include:
  • Uniform care policy
  • Handling of medico-legal cases
  • Triage of patients in emergency
  • Managing dead on arrival cases
  • Identification of likely community emergencies, epidemics, and disasters likely

Biosafety Levels

• Agents requiring the highest level of biosafety facilities and practices are extremely dangerous and pose a high risk of life-threatening disease.

Standard Precautions Components

• Components of standard precautions include:
  • Hand hygiene
  • Use of personal protective equipment (PPE) like cap, mask, gloves, aprons, gowns, whenever
  • Indicated during patient care
  • Immunization of health care worker against hepatitis B
  • Proper biomedical waste management
  • Proper handling and disposal of sharps

Observing Standard Precautions

• Standard precautions should be observed for all patients at all times.

WHO Five Moments of Hand Hygiene

• The WHO five moments of hand hygiene are:
  • Before touching a patient
  • Before clean/aseptic procedure
  • After body fluid exposure risk
  • After touching a patient
  • After touching patient surroundings

Hand Hygiene Steps

• Correct sequence of steps of hand hygiene:
  • Rub hands palm to palm (A)
  • Right palm over left dorsum with fingers interlaced and vice versa (B)
  • Palm to palm with fingers interlaced (C)
  • Back of fingers to opposing palm with fingers interlocked (D)
  • Rotational rubbing backwards and forwards with clasped fingers of right hand in left palm and vice versa (F)
  • Rotational rubbing of the left thumb clasped in right palm and vice versa (E)
  • Wrists (G)
• Correct Sequence is: A, B, D, C, F, G

Cleaning Methods

• Wet mopping is not recommended for cleaning in Wards and ICUs

Biosafety Levels

• Ebola virus, the Lassa virus, and any agent with unknown risks of pathogenicity and transmission falls under the highest biosafety level.

Medication Errors

• Medication errors include:
  • Prescribing errors
  • Omission errors
  • Wrong time errors
  • Unauthorized drug errors
  • Improper dose errors
  • Wrong dose prescription/wrong dose preparation errors

Needle Stick Injuries

• Common causes of needle stick injuries or exposure of mucous membranes to infectious material:
  • Recapping of needles
  • PPE not used wherever indicated
  • Improper disposal (wrong segregation) of biomedical waste in wrong color-coded bags

Actions After Needle Stick Injury

• In case of needle stick injury or exposure of mucous membrane to infectious material:
  • First aid: wash the site with lots of water and soap
  • Immediate reporting to the department
  • Post-exposure prophylaxis whenever required
  • Reporting of serological investigations to HIC (Hospital Infection Control) department

ISBAR Tool

• YES, ISBAR tool is used as a communication tool in healthcare organizations.

Steam Sterilization

• Geobacillus stearothermophilus biological spores are used in the steam sterilization process.

PDCA Process

• The PDCA (Plan, Do, Check, Act) process should be used when:
  • Exploring and testing multiple solutions in a small, controlled trial
  • Avoiding waste by catching and adapting ineffective solutions before rolling them out on a large scale
  • Implementing change and continuous improvement
  • Implementing total quality management or six Sigma initiatives
  • Developing or improving a process

Biomedical Waste Segregation

• Follow BMW policy for biomedical waste segregation (Red bag, yellow bag, sharp box)

Hospital Disinfectant

• Name one disinfectant mostly used in hospital:

Spillage Emergency Actions

• Action taken for spillage emergency:

Code Violet Indication

• Code violet indicates for:

Quality Indicators in Imaging Services

• Formula used for quality indicators in imaging services:

Compressions and Breaths in CPR

• How many compression___________ for breaths__________ / cycles