Hospital Procedures and Policies

Hospital Information System (HIS) Documentation

• The primary documentation needed during a patient's initial clinical assessment includes vital signs and the care pathway aligned with clinical findings.

Patient Transfer Criteria

• A key criterion for determining if a patient is unstable for transfer involves the Glasgow Coma Scale (GCS) being less than 10/15.

Patient Transfer Policy

• Stable patients should be transferred within the hospital using wheelchairs or stretchers and with trained personnel.

Lab Specimen Collection

• Before drawing a lab sample from a patient, a written request from the treating doctor is required.

Outsourced Test Register

• An outsourced test register must maintain the external lab's name, test results, and the patient's Unique Health Identification (UHID).

CBCT Imaging for Pregnant Patients

• A mandatory precaution for pregnant patients undergoing CBCT imaging is the use of a lead apron to shield the abdomen.

Radiation Monitoring with TLD Badges

• Thermoluminescent dosimeter (TLD) badges must be processed quarterly for radiation monitoring.

Reducing Radiation Exposure

• The principle that reduces radiation exposure by increasing distance from the source is the inverse square law.

Protective Aprons During Imaging

• Protective aprons should have a minimum lead equivalence of 0.25 mm during imaging procedures.

Hospital Pharmacy Monitoring

• Monitoring of agreements with outsourced hospital pharmacies should focus on verifying compliance with service standards and scope.

Internal Quality Audits

• Internal Quality Audits should be conducted once every six months to check policy adherence.

Mobile X-Ray Unit Safety

• The minimum source-skin distance (SSD) for mobile X-ray units is 30 cm.

TLD Badge Readings

• If radiation exposure levels exceed permissible limits on TLD badge readings, a root cause analysis should be conducted, and equipment recalibrated.

Reporting Non-Compliance

• Employees should report any non-compliance event before the end of their scheduled duty shift.

Storing Look-Alike Medications

• Medications with similar packaging need to be stored physically apart and potentially with pink color coding to prevent errors.

WHO Surgical Safety Checklist

• The purpose of the WHO Surgical Safety Checklist is to confirm the patient's identity and surgical site.

Vulnerable Patients

• Elderly patients and children are considered a vulnerable group requiring special care.

Pharmacist Error Classification

• A pharmacist catching a prescribing error for a lethal dose before dispensing, with no harm reaching the patient, is classified as a Near Miss.

Safety Inspections

• Comprehensive safety inspections in patient care areas should be conducted twice a year

Hand Hygiene for Dental Exams

• Alcohol-based hand rub is preferred for routine dental exams when hands are not visibly soiled, according to standard precautions.

Mercury Spill Protocol

• After donning PPE and removing glass from a mercury spill, the next step is to aspirate the mercury beads with a syringe.

Needle Recapping

• The one-handed scoop technique is explicitly recommended for safely recapping a used dental anesthetic needle.

Power Outage Protocol

• During a power outage and backup generator failure, the duty electrician/maintenance team is primarily responsible for addressing the failure.

Tuberculosis Isolation Precautions

• For a patient with active pulmonary tuberculosis needing emergency dental treatment, ensuring negative pressure ventilation in the isolation room is crucial.

Electrical Fire Extinguisher Type

• A Carbon Dioxide (CO₂) extinguisher is the most appropriate type for an electrical fire in a dental chair's control panel.

Sterilization Monitoring Indicators

• Biological indicators (spore tests) should be used weekly to monitor the sterilization process.

Water Tank Maintenance

• Overhead water storage tanks should be cleaned and treated every 3 months according to the maintenance plan.

Local Anesthetic Administration

• Use a new sterile syringe-needle assembly for each cartridge when administering a second cartridge of local anesthetic to the same patient.

Disinfectant for Clostridium difficile

• After treating a patient with Clostridium difficile, sodium hypochlorite solution (bleach) is the recommended disinfectant for environmental surfaces.

High-Risk Patient Identification

• Patients identified as high-risk (e.g., HBV, HIV positive) are visually indicated on their records/UHID card using a red color coded signage label "SAFETY FIRST".

Amalgam Disposal

• An extracted tooth with an amalgam filling must be managed as hazardous chemical waste (due to mercury).

Code Orange

• Announce Code Orange when a major water pipe bursts and floods a clinical area.

Soiled Linen

• Used linen visibly soiled with blood should be placed in a red biohazard bag, clearly marked as soiled linen.

Dental Unit Waterlines

• To minimize microbial contamination in dental unit waterlines, waterlines should be flushed for 20-30 seconds between patients.

Instrument Processing Area

• Instrument processing should have distinct areas for receiving & cleaning, packaging, sterilization, and storage.

Formalin Disposal

• Expired formalin should be treated as chemical waste, labeled, and handed over to an authorized disposal agency.

Multi-Dose Vial Usage

• Opened multi-dose vials of medication can typically be used for 28 days unless specified otherwise by the manufacturer.

Cleaning

• Cleaning removes visible soil and debris but does not necessarily kill microorganisms

Maintenance Complaint Response

• The Facility Management and Safety policy tracks the time from reporting an inspection and to implement corrective actions for maintenance complaints.

Alginate Impression Handling

• Potentially contaminated alginate impressions should be rinsed thoroughly under running water and disinfected before sending it to the lab.

Infection Control Policy Review

• Hospital infection control policies and procedures should be reviewed and updated annually or as needed based on new guidelines/data.

Alcohol-Based Hand Rub

• The minimum duration for performing hand hygiene using an alcohol-based hand rub is 20-30 seconds.

Donning PPE

• The correct sequence for donning PPE is gown, mask, goggles, and gloves.

Needlestick Exposure

• Post-exposure prophylaxis for an unvaccinated healthcare worker with needlestick exposure from an HBsAg-positive patient with unknown HBeAg status includes HBIG x 1 dose + Hepatitis B vaccine series.

Infectious Spill Cleanup

• For a major infectious spill (>30ml), wait 10-20 minutes after covering with absorbent material and pouring 1% Sodium Hypochlorite before cleaning.

Code Pink Protocol

• During a Code Pink, a key immediate action is to lock down specific exits/areas as directed by security.

Critical Dental Instruments

• Dental instruments that penetrate soft tissue or bone are classified as critical and require sterilization.

Fire Escape Route Markings

• Fire escape routes and emergency exits should be marked with green signs.

Sentinel Event Definition

• A wrong-site extraction requiring future implant placement as a result of loss of a healthy tooth is labeled as a Sentinel Event.

Sharps Container Disposal

• A sharps container is considered full and ready for disposal when it is approximately 3/4 full.