IMCH Employee Handbook PDF

NABH EM PLOYEE HANDBOOK  CONTENTS 1. DETAILS OF MANAGEMENT................................................................................................. 4 2. BOARD OF DIRECTORS.........................................................

NABH EM PLOYEE HANDBOOK  CONTENTS 1. DETAILS OF MANAGEMENT................................................................................................. 4 2. BOARD OF DIRECTORS.......................................................................................................... 4 3. DIRECTORS.................................................................................. Error! Bookmark not defined. 4. VISION........................................................................................................................................... 4 5. MISSION........................................................................................................................................ 5 6. QUALITY POLICY........................................................................................................................ 5 7. QUALITY OBJECTIVES............................................................................................................... 5 8. DEPARTMENTS............................................................................................................................ 6 9. SCOPE OF SERVICE..................................................................................................................... 7 10. EMPLOYEE RIGHTS & RESPONSIBILITIES........................................................................... 8 11. ANTI-SEXUAL HARASSMENT COMMITTEE (CASH).......................................................... 9 12. GRIEVANCE REDRESSAL COMMITTEE................................................................................ 9 13. PATIENT RIGHTS:.................................................................................................................. 11 14. PATIENT’S RESPONSIBILITIES:........................................................................................... 11 15. NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS( NABH).......................................................................................................................... 11 16. COMMITTEES......................................................................................................................... 13 18. What are standard precautions?.................................................................................................. 14 19. INTERNATIONAL PATIENT SAFTY GOALS....................................................................... 16 20. What is the difference between barrier nursing & reverse barrier nursing?.................................. 17 21. What is airborne infection & Isolation?...................................................................................... 17 22. What do you mean by Notifiable disease?................................................................................... 18 23. What is “End of Life Care Policy in our hospital”?..................................................................... 18 24. What is a Near Miss in Medicine?.............................................................................................. 18 25. What is a Sentinel event?........................................................................................................... 19 26. What is Adverse Drug Reaction?................................................................................................ 19 27. What is Adverse Drug Event(ADE)?.......................................................................................... 20 28. What are Narcotic Drugs & Examples........................................................................................ 20 29. What is High Risk-Medicines?................................................................................................... 20 30. What is the protocol for Look-alike and Sound alike Medications?............................................. 21 31. What is the Hospital Policy for Sample Rejection in Laboratory?................................................ 21 32. Name two Radiation Safety devices?.......................................................................................... 21 33. What is the Medical Records Retention Policy in our hospital?................................................... 22 34. What is the Restraint Policy in our hospital?............................................................................... 22 2 35. What are the types of Medical Gas Cylinders used in the hospital and what are the Colors of the cylinder/ pipe those carry them?............................................................................................................ 23 36. EMERGENCY CODES....................................................................................................... 23 37. BIOMEDICAL WASTE MANAGEMENT............................................................................... 24 38. FIRE & SAFETY...................................................................................................................... 26 39. What is Disaster?....................................................................................................................... 28 40. What is Occupational Health Hazard?........................................................................................ 29 41. What is Needle Stick Injury and how to prevent this?................................................................. 29 42. What is all type of Spillage?....................................................................................................... 30 43. How will you dispose blood or body fluids?............................................................................... 30 44. How will you disinfect articles?................................................................................................. 31 3 1. DETAILS OF MANAGEMENT Imbichibava Memorial Co-operative Hospital and Research Centre Society Ltd No M841 professionally known as IMCH is a monumental co-operative organization named after the great leader of communist party of India (Marxist) Shri: E. K Imbichibava popularly known as Imbichibava. IMCH functions on the philosophy that the modern medicine practice should be an aid to life for anyone who seeks medical attention. IMCH is registered as 100 bedded hospital. IMCH has formed a 13 member board of directors to provide clear direction and guidance. The board of directors is the supreme authority of IMCH. This authority is universally recognized as Team IMCH among the public. 2. BOARD OF DIRECTORS Mr. Sivadasan - Chairman Mr. V. Abdu Rahiman MLA - Vice Chairman Mr. A. P. Sudevan - Executive Director Dr. Santhosh kumari - Medical director Mr. P.T. Narayanan - Finance Director Dr. K. T. Jaleel MLA Dr. S. D. Vanaja Mr. P. Mohamed Ali Mr. P.V Azeez Abdulh Ayyub Adv. K. M. Moosa Kutty Mr. C. P. Bavakutty Ms. P. Indira Dr. V. P. Sasidharan 3. ADMINISTRATION Mr. Shuaib Ali. K- Managing Director Mr. Renju Alappatt- Deputy General Manager 4. VISION IMCH will provide an unparalleled experience as the most trusted partner for healthcare. 4 5. MISSION The center of excellence for public healthcare, medical research, and academics with the help of public participation. To provide high-quality healthcare at an affordable cost to all who seek care and to provide this care with compassion, grace, and love. 6. QUALITY POLICY  IMCH is committed to providing high quality, affordable, and accessible preventive, curative, primitive, and comprehensive health care services to the community and assure the best outcome by:  Focusing on quality patient care to facilitate uncompromised patient safety.  Facilitating optimal utilization of available resources for effective and speedy patient recovery.  Fostering a working environment that caters to employee efficiency and performance and Initiating, standardizing, and propagating cost-effective patient care strategies. 7. QUALITY OBJECTIVES  To focus on quality of patient care.  To improve the performance of all professionals.  To monitor, measure, assess, and improve performance and to enhance patient satisfaction.  To guard, measure, and improve patient safety.  To inculcate an excellent hygienic treatment process.  To involve all employees in improving quality.  To search for patterns of non-compliance with goals, objectives, and standards through:  Problem identification  Problem assessment  Find the root cause  Solution generation  Plan for the solution implementation  Implementation of corrective action  Monitoring 5 8. DEPARTMENTS SL No. NON MEDICAL MEDICAL 1. Administration Nursing 2. Human Resource (HR) Pharmacy 3. Finance/Accounts Laboratory/Hematology/Microbiology 4. Front Office/OPD Diagnostic Imaging 5. PRD (Public Relation) Central Sterilization Supply Department (CSSD) 6. Information Technology Biomedical Engineering 7. Medical Record (MRD)& Hospital Infection Control Hospital Information System (HIS) 8. Purchase Clinical Nutrition & Dietetics 9. Facilities: - Physiotherapy 1) Security 2) Transportation 3) Attenders 10. Engineering Dialysis 11. Quality 12. Marketing 13. In patient Department (IPD) 14. Laundry (OS) 15. Maintenance (OS) 16 Housekeeping (OS) 17 Insurance 6 9. SCOPE OF SERVICE CLINICAL SERVICES  General Medicine  General Surgery  Orthopedics  Pediatrics  Cardiology  ENT  Anesthesiology  Pulmonology  Obstetrics and Gynecology  Dermatology  Psychology  Casualty/ ED  Dental  Pain and Regenerative care  Oncology  Diabetology  Family Medicine  Dietetics  Physiotherapy  Dialysis DIAGNOSTIC SERVICES  Laboratory  Radiology  CT scan  X-ray  Ultra Sound Scan ICU- INTENSIVE CARE UNIT  MICU- Medical Intensive Care Unit  SICU- Surgical Intensive Care Unit  CCU- Cardiac/Coronary Care Unit  NICU- Neonatal Intensive Care Unit OPERATION THEATRES - 4 7 10. EMPLOYEE RIGHTS & RESPONSIBILITIES Rights  To be aware of the hospital policies.  To have a safe and healthful workplace.  To have equal opportunities for employment and promotion regardless of age, gender, caste, creed, and economic strata.  To be aware of the terms and conditions of his/her employment before joining the organization.  Right to have all training and orientation as per job specification. Clarity regarding the roles/responsibilities associated with the task to be performed.  Right to be treated with respect and dignity.  Right to get leave as per hospital policy.  Right to have grievance redressal.  Open door policy: Any employee has the right to voice his/her opinion to any higher authority within the organization through the prescribed channel.  Right to know details of performance appraisal regarding weaknesses and improvements required.  Right to be appraised for growth and development within the organization based strictly on merit.  Right to information regarding key performance indicators and key deliverables to enable understanding of role. Responsibilities  To report duty on time, scan the finger in the punching machine, and sign the attendance register at the time of in and out.  Employees are expected to work during their duty hours to support the hospital’s 24/7 operations and are also required to work overtime when the workload necessitates.  Employees shall devote their time exclusively to the work assigned to them and not engage in unwanted activities.  To avail leave after sanctioning from HOD.  To follow the dress code policy of the organization.  Employees are expected to maintain proper discipline and professional ethics.  Employees shall be responsible for the equipment allocated to them and maintain it in accordance with the standard operating procedures.  To adhere to professional practices as per hospital’s rules, regulations, and practices.  To understand and adhere to patients' rights and responsibilities.  To treat clients, co-workers, and patients with respect and dignity. Employees should not share any valued information gained during employment with any other individual or 8  organization while in service or even after leaving the service.  Not to interfere with or misuse any material resource provided by the hospital.  To ensure a safe and secure environment in the hospital for self, colleagues, patients, and others.  To report immediately to HR or hospital management about any untoward incident, dangerous unsafe practice, or any type of harassment.  To provide complete and accurate information to the organization during the employment process. If there is any change in the permanent/local address or contact number, then inform the HR department within seven days in writing. 11. ANTI-SEXUAL HARASSMENT COMMITTEE (CASH) Purpose: This committee is a legal requirement under the ‘Prevention of Sexual Harassment’ law. The purpose of this committee is to investigate and take action against any complaint received that has a nature of sexual harassment. Roles & Responsibilities:  To receive complaints related to sexual harassment at the workplace.  To investigate each and every complaint in light of evidence and following the principles of natural justice.  To decide appropriate actions in each case in accordance with the legal guidelines under the act.  To ensure that the rights of the complainant and compliance are protected.  To issue guidelines from time to time regarding the prevention of sexual harassment.  To prevent discrimination and sexual harassment in the organization.  To deal with cases of discrimination and sexual harassment against women in a time-bound manner, aiming at ensuring support services to the victimized and termination of the harassment.  To recommend appropriate punitive action against the guilty party. 12. GRIEVANCE REDRESSAL COMMITTEE Purpose: To handle grievances of hospital staff based on the principles of natural justice and prevailing law. Activities:  Taking proper measures to ensure that all employees are aware of the existence of this committee, contact persons, and the process of filing a complaint—at the time of induction 9  training itself  The committee meets on a half-yearly basis or when an incident happens.  Grievances may be personal or service-related. In both cases, employees can approach the Grievance Redressal Committee by submitting a written request/complaint.  Employees are expected to follow the statutory laws, service rules, and code of conduct. Any violation of these by a single employee or group of employees that hurts another employee(s) can be reported to this committee.  The committee will look into the incident/situation, conduct an enquiry, and submit its report with recommendations.  The committee can appoint an enquiry commission also to investigate the incident to gather details for preparing the report.  The minutes of the committee meeting—including the formation of the commission—shall be circulated to the members within five days of the meeting for corrections, if any.  No grievance report shall be ignored without enquiry, final report, and intimation to the applicant, irrespective of its importance.  The enquiry should follow the principles of natural justice by giving an opportunity to both parties to provide evidence.  If the grievance is interdepartmental in nature, the committee shall organize an interdepartmental meeting to resolve it with the consent and presence of Management.  Normally, the enquiry and final report should be prepared within two weeks of the committee meeting. If the process takes more time, the applicant should be informed of the progress. However, the committee shall never intimate any decisions of their own to the candidate without getting consent from Hospital Management.  Depending on the severity of the incident/situation or act detected through the analysis of the investigation report, the committee can suggest actions like—fine, warning, cutting increment, demotion, transfer (to another unit or section), suspension, dismissal, etc.— against the convicted employee.  The decision of the committee will be taken by a majority vote and shall be finalized for suggestion to management for proper action.  The finalized report shall be submitted to the hospital management for approval within seven days of the meeting.  After getting approval from Hospital Management, the final decision will be implemented by the Secretary through the HR Manager within seven days, and the same will be intimated to both the grievance petitioner and the convict.  The convict can appeal to the head of the institution within three days of receiving the final decision.  A copy of the approved meeting minutes of every meeting shall be sent to the Quality Coordinator by the Committee Secretary. 10 13. PATIENT RIGHTS:  Respect for personal dignity and privacy.  Confidentiality of patient’s information.  Knowledge about disease.  Details of the consultant’s treatment plan.  Cost and expected duration of stay/treatment.  Consent for any treatment, surgeries, procedures, anesthesia, and blood transfusion.  Complaint redressal mechanism available.  The right to request a second opinion about the diagnosis or treatment plan and to know about alternate treatment methods.  As and when appropriate, to be educated about the medications, diet, immunization, preventive measures, and other aspects of the disease, including anticipated outcomes and preventing healthcare-associated infections. 14. PATIENT’S RESPONSIBILITIES:  Follow hospital rules.  Maintain peace.  Provide accurate information about healthcare problems.  Follow the treatment plan.  Pay the bills on time.  Keep the hospital clean.  Not to smoke in the hospital premises. 15. NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS( NABH)  The NABH is a constituent board of the Quality Council of India (QCI), set up to establish and operate an accreditation program for healthcare organizations.  NABH Accreditation is a process of external review of the quality of healthcare service/patient care being provided by a healthcare organization, ensuring compliance with set benchmarks. It is used to accurately assess their level of performance in relation to the established standards and to continuously improve the healthcare system.  Composition of NABH (5th Edition):  10 Chapters  100 Standards  651 Objective Elements  32 Quality Indicators 11  NABH CHAPTERS Patient Centered:  Access, Assessment, and Continuity of Care (AAC)  Care of Patients (COP)  Management of Medication (MOM)  Patient Rights and Education (PRE)  Hospital Infection Control (HIC) Organization-Centered:  Patient Safety & Quality Improvement (PSQ)/Continuous Quality Improvement (CQI)  Responsibilities of Management (ROM)  Facility Management and Safety (FMS)  Human Resource Management (HRM)  Information Management System (IMS) 12 16. COMMITTEES Total 18 committees: 01 INFECTION CONTROL COMMITTEE 02 QUALITY ASSURANCE COMMITTEE MONTHLY 03 MANAGEMENT REVIEW COMMITTEE (CORECOMMITTEE) 04 ANTI BIOTIC COMMITTEE 05 CLINICAL AUDIT COMMITTEE 06 MEDICAL AUDIT COMMITTEE BIANNUALLY 07 CONDEMNATION COMMITTEE 08 BLOOD TRANSFUSION COMMITTEE 09 ETHICS COMMITTEE 10 CPR & CODE BLUE COMMITTEE 11 PHARMACY AND THERAPEUTICS COMMITTEE 12 SAFETY COMMITTEE 13 MORTALITY REVIEW COMMITTEE QUARTERLY 14 PURCHASE COMMITTEE 15 HR COMMITTEE 16 CREDENTIALING & PRIVILAGING COMMITTEE 17 ANTI – SEXUAL HARRASSEMENT COMMITTEE ON NEED BASIS 18 STAFF GREIVANCE REDDRESSAL COMMITTEE 17. What are Hospital Acquired/ nosocomial Infection (hai)? Hospital acquired infection is infections that are as a result of treatment in a hospital or a healthcare unit. Infection is considered as hospital acquired if they first appear 48 hours or more after hospital admission. Infections occur within 3 days after discharge. Examples : o UTI (Urinary Tract Infection) o VAP (Ventilator Associated Pneumonia o SSI (Surgical Site Infection) o BSI (Blood Stream Infection) 13 18. What are standard precautions? Standard precautions are the minimum infection prevention practices that should be used in the care of all patients all of the time. These practices are designed to both protect the healthcare worker and to prevent the healthcare worker from spreading infections among patients. Standard precautions include: 1) Hand hygiene. 2) Use of personal protective equipment (e.g., gloves, gowns, masks). 3) Safe injection practices. 4) Safe infusion practices. 5) Safe handling of potentially contaminated equipment or surfaces in the patient environment 6) Respiratory hygiene / cough etiquette. 1) Hand hygiene technique 14 Make sure to complete all the steps below properly to ensure safe and clean hands. Step 1: Rub palm together Step 2: Rub the back of both hands Step 3: Interlace finger and rub hands together Step 4: Interlock finger and rub the back of finger of both hands Step 5: Rub thumb in a rotating manner followed by the area between index finger and thumb for both hands Step 6: Rub fingertips on palm for both hands  Five Moments of Hand Hygiene The Five Moments of Hand Hygiene?  Moment 1 - Before touching a patient.  Moment 2 - Before a procedure.  Moment 3 - After a procedure or body fluid exposure risk.  Moment 4 - After touching a patient.  Moment 5 - After touching a patient's surroundings. 15 2) What is PPE? Name few components? Personal Protective Equipment (PPE): o Cap o Mask o Goggles o Gloves o Apron o Gum boots (shoe cover) 19. INTERNATIONAL PATIENT SAFTY GOALS Goal – 1 Identify patients correctly  Patient full name and UHD No  Additional identifier – Age of Patient  Check for id band on Patient  Do not use room no / location for identification Goal – 2 Improve effective communication  Verbal order– write down, readback and confirm(read back of verbal order with confirmation)  Ensure proper handover among all care givers  Use ISBAR Tool for all patient related communications  Critical value intimation within 10 minutes to the treating / duty doctor  Critical value to be documented in patient file on intimation by the doctor Goal – 3 Improve the safety of high alert medication  Look Alike & Sound Alike – separate storage & re-check drug name  High risk – check and verification by a second staff before administration  Concentrated electrolytes – Strict control & check for dilution Goal – 4 Ensure correct –site, correct –procedure, correct patient surgery  Surgical site marking with active patient involvement throughout the hospital  Time out for all invasive procedures throughout the hospital  Inside OT, Follow sign in, time out and sign out using surgical safety check list. 16 Goal – 5 Reduce risk of Healthcare associated infections  6 Steps of hand hygiene  Use hand rub (20 – 30 sec) or Hand wash (40 – 60 sec)  Appropriate PPE To be used  Care bundles to prevent HAI Goal – 6 Reduce risk of patient harm resulting from falls  Daily fall risk assessment and Re-assessment as and when required  Side rails should be up always  Safety belt while transport  Identify slip and trip areas, and take necessary action 20. What is the difference between barrier nursing & reverse barrier nursing? The aim of barrier nursing is to protect medical staff against infection by patients particularly those with highly infectious diseases. Reverse barrier nursing is similar, but concentrates on the reverse: protecting vulnerable patients, such as those with weakened immune systems, against infection by medical staff. Terminal disinfection of isolation rooms  All surfaces and walls must be washed thoroughly with warm water and detergent and drie(wipe over with a disinfectant if indicated)  All bed linen, curtains etc. that is sent to the laundry should be clearly marked "infected"  The bed mattress and pillow should be wipe with warm water and detergent and dried thoroughly. Occasionally, a disinfectant may be indicated.  All autoclavable items should be sent to the CSSD.  All disposable items should be discarded in containers for clinical waste and the room should be aired and open for admission after 24 hours.  If the isolation area is a bed on an open ward, then the entire surrounding area up to the next ward, including curtains, should be treated as above. 21. What is airborne infection & Isolation? E.g. Tuberculosis, Chicken pox, measles. These are the infections that spread through the droplet nuclei. Certain organisms are very light and remain suspended in air along with dust particles for a very long time. These organisms can spread through the agency of air from one place to another. Therefore it is important to separate these patients and ensure that the air surrounding them is not mixed with air that other people are 17 breathing.  Patient is placed in a Negative pressure isolation room (The air in this room is at negative pressure to the surrounding air. As a result air cannot move from this room to outside, while the outside air can move into this room).  The air from this room is exhausted by special exhaust fans & ducts, high up in the atmosphere and is not mixed with general air.  When you enter this room, you need to wear mask.  When you move the patient out for some procedure, give the mask to the patient.  After discharge, let the exhaust run for 1 hour to exhaust the room air, before you take any other patient. 22. What do you mean by Notifiable disease? Diseases where stern steps are needed to be taken to prevent them from taking the form of an epidemic or spreading from one person to another, thereby increasing the levels Shall be characterized as Notifiable diseases (or we can say as disease or condition which Is Notifiable to State as per regulation?) E.g.: Cholera, Plague, Dengue What is Code Blue & CPR ?  Code Blue: It is the situation when there is a cardio-pulmonary arrest within the hospital premises.  Cardio Pulmonary resuscitation (CPR): It is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and / or whose heart has stopped (cardiac arrest). 23. What is “End of Life Care Policy in our hospital”? When the doctors and patient’s representatives are decide to withhold or withdraw the life supportive measures, it is documented in the patient’s file with the consent of the next kin of the patient. Nurses carry out the orders and also ensure that the patient and family are taken care of with utmost respect and compassionate care. End of Life care Policy provides practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improving the quality care of the dying, with compassionate palliative care and appropriate (Physical, social, emotional & spiritual) support to the family, within an ethical frame work and through a professional and family consensus process. 24. What is a Near Miss in Medicine? A Near miss is an unplanned event that did not result in injury, illness or damage. But had the 18 potential to do so. E.g.: The patient received a contraindicated drug but did not experience an adverse drug reaction. prevention (a potentially lethal overdose was prescribed, but the nurse identified the error before administering the medication) or mitigation (a lethal overdose was administered but countered with an antidote). Incident form can be filled for the record. Disciplinary action have to be taken to stop such activities. 25. What is a Sentinel event? A sentinel event is an unexpected occurrence involving death or permanent harm or serious physical or psychological injury to a patient. Serious injury specifically includes loss of limb or function. Such events are called sentinel event because they signal the need for immediate investigation and response. Management core committee will address this issue without any delay and will document the proceedings. E.g.: Wrong Surgery on wrong Part Here’s a revised list of potential medical errors and incidents with gaps added for clarity:  Unintended Retention of a Foreign Body in the Patient's Body.  Wrong Patient, Wrong Site, Wrong Procedure.  Mismatched Blood Transfusion.  Fall from Bed.  Patient Suicide.  Displacement of Joint Due to Mal positioning by the Staff.  Delay in Treatment which resulted harm to the patient  Any Preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare staff. Reasons:  Prescribing Errors (Not legible, Dose/Route/Concentration etc. mentioned, others)  Dispensing Errors (Wrong patient, Similar Medicines)  Administration Errors (Dose/Route/Concentration/administration/recording etc ) Follow the 6 “R” (Right) every time to prevent Medication error; Right Drug - Right Dose - Right Patient -Right Route - Right Time - Right Documentation 26. What is Adverse Drug Reaction? An Adverse drug reaction is a response to a drug which is noxious and unintended and which occurs at doses normally used in patient for prophylaxis, diagnosis or therapy. E.g.: Rashes 19 Reasons: Patient Nature, Combination of two or more drugs, dosage, etc. 27. What is Adverse Drug Event(ADE)? Adverse Drug Event is an injury resulting from the use of a drug. This includes Medication Error, Adverse Drug Reaction, Allergic reaction and over dose. Reasons:  Drug overdose  Drug abuse  Drug withdrawal  Any significant failure of expected pharmacological action.  Drug Interaction. E.g.: Jaundice, Anemia, Kidney Damage, Nerve injury that may cause vision/hearing etc  If the ADE occurs, what is the protocol?  Stop administering the medicine.  Identify the reaction that has occurred and inform the treating doctor immediately.  In the meantime administer any standard anti-allergy / antidote /Prophylaxis which will be kept for the emergency as per the instruction of the doctor.  Observe the patient for further complication and deterioration.  The Adverse Drug Event form is filled and signed by the treating doctor.  Inform the pharmacy to provide details of incident raised.  The Nursing superintend shall submit the filled ADE form to Quality department.  Present the ADE forms in the coming quality assurance committee meeting. 28. What are Narcotic Drugs & Examples The term Narcotic originally referred medically to any “psychoactive” compound with sleep- inducing properties and euphoric properties as well. E.g.: Fentanyl 10ml Inj, Morphine 1ml, Pethidine, etc. These drugs are stored in double locker at OT. 29. What is High Risk-Medicines? High Risk Medicines are those medicines that have a high risk of causing significant patient harm/ death when used in error. E.g.: Inj: Adrenaline, Inj: Atropine, Inj: Calcium Gluconate, Insulin  Use separate rack (Rack color should be different from normal) with red color individual container.  Display (High Risk Medicines)  Separate Register has to be maintained. 20 30. What is the protocol for Look-alike and Sound alike Medications?  Storing products with look-alike or sound-alike names in different locations.  Employing double checks in the dispensing process.  Minimize the use of verbal and telephone orders.  Affixing “name alert” stickers to areas where look-alike or sound-alike products are stored.  Changing the appearance of look-alike product names on pharmacy labels, computer screens, shelf labels and bins, and medication records by highlighting, through bold face, colour, and/or tall man letters, the parts of the names that are different (e.g. hydroxyzine, hydralazine).  Having physicians write prescriptions using both the brand and generic names (E prescription will help to use Tallman letters)  Encouraging patients and direct care staff to question pharmacists and nurses about medications that are unfamiliar or look or sound different than expected. 31. What is the Hospital Policy for Sample Rejection in Laboratory? Criteria are followed for sample rejection, Reasons for not accepting such samples include;  Sample without request form  Sample without label  Name on form/ sample do not match  Test request/s on form/sample does not match  Hospital numbers on form/ sample do not match  No diagnosis, clinical history or requesting doctor’s name on request form  Clotted (For EDTA tube/ Sodium citrate tube for coagulation studies)  Sample sent in wrong/inappropriate container –  Contaminated sample  Broken or leaking container or spilt sample  Insufficient sample 32. Name two Radiation Safety devices?  TLD badges (Thermo Luminescent Dosimeter)  Lead aprons  How lead aprons are handled? Inspected? How often? Lead aprons are never folded they are hung on hangers; they are put under fluoroscopy test once every year to test for any leakage, also subjected to any crack on the apron. 21 33. What is the Medical Records Retention Policy in our hospital? Patient’s Complete Medical Information (Registration - discharge) It is the responsibility of the Medical Records Department to keep Medical Records under safe custody and make it readily available as and when required. In - Patient Record : Five (5) Years. Out- Patient Record : Three (3) Years. Medico Legal Case Records : Life time. Death Records : Life time 34. What is the Restraint Policy in our hospital?  The uses of restraint are primarily to protect the patient and others against injury because of:- Patient’s emotional or behavioral disorder or any other reason that threatens the patient’s safety. The restrain may be physical or chemical- the policy applies to both.  Restraint use within the hospital is limited to situations with adequate, appropriate clinical justifications. Restraint may be considered appropriate in the following conditions: -  When the patient’s condition or behavior indicates an immediate & ongoing high risk of self- harm (either deliberate or unintentional)  When patient’s behavior poses immediate & ongoing serious risk to others  When he/she seriously compromises the therapeutic environment e.g. by damaging property  When it is necessary to give essential clinical treatment to the individual who is refusing the treatment  When there is legal support to carry out the prescribed treatment against the person’s will.  Types of Restraint 1) Physical Physical restraints are used when patients are to be restrained to stay in a chair or bed to limit their movement. 2) Chemical Chemical restraints are medicine used to help the patients calm down and relax when the behavior of the patient can cause harm to himself and others 22  35. What are the types of Medical Gas Cylinders used in the hospital and what are the Colors of the cylinder/ pipe those carry them? MEDICAL GAS COLOR CODES USED PURPOSE Used for anesthesia in these areas OTs Nitrous Oxide (N2O) The pipelines are colored in Blue & minor OT Used in wards and all other patient care Oxygen pipelines are colored in White areas where requires air support Used for suction in these areas Vacuum / Suction Pipelines are colored in Yellow ICU, OT, NICU, LABOUR ROOM, WARD, ROOMS, CASUALTY, OPDs Air 4 (Compressed Air Used in ventilators in these areas ICU, Pipelines are colored in Black & White in 4 bar pressure) OT, CASUALTY Used for LAPROSCOPIC surgeries in CO2 - Carbon Dioxide Pipeline colored Grey. OT Used for autoclave and equipment Air 7 - (Compressed Pipelines are colored in Black & White drying purpose in these areas Air in 7 bar pressure) CSSD & OT 36. EMERGENCY CODES CODE EVENT DEFINITION CODE RED Fire CODE RED should be announced when there is an indication of a fire. Signs of a fire may include observation of smoke and/or flames; smelling smoke or other burning material; feeling unusual heat on a wall, door or other surface. CODE BLUE Cardiopulmonary CODE BLUE should be announced Arrest/Emergency casualty when a patient or any person is found to be in a cardiac or respiratory arrest situation in the hospital or its premises. CODE ORANGE Hazardous /Body fluid CODE ORANGE should be announced spillage when there is a release or spill of any hazardous material in the hospital/body fluid spillage. CODE PURPLE Internal/External violence to CODE PURPLE should be announced the hospital staff when an internal violence or external violence occurs towards the hospital, 23  staff or patients and is threatening the safety of others. CODE PINK Infant/Child Abduction CODE PINK should be announced when an infant or child is missing or is known or suspected to have been kidnapped. CODE BROWN External Emergencies CODE BROWN announced to inform (Mass casualty/Disaster) about Mass casualties or external disasters like earthquake, flood, land sliding etc. CODE YELLOW Patient Missing CODE YELLOW is to alert the team about the incidents of patient (adult) missing. CODE BLACK Bomb/Nuclear CODE BLACK is used to alert Attack employees of a potential on-site Bomb threat or nuclear attack. 37. BIOMEDICAL WASTE MANAGEMENT Biomedical waste management consists of solids, liquids, sharps, and laboratory waste that are potentially infectious or dangerous. It must be properly managed to protect the public, specifically healthcare and sanitation workers who are regularly exposed to biomedical waste as occupational hazards. Objective of Waste Management To prevent infection by maintaining good hygiene and sanitation. To prevent environmental pollution. To manage waste in a clean and safe manner. Waste Categories and Color Coding  Yellow All infected non-plastic waste, human-animal anatomical waste. Postoperative body parts, placenta, Plaster of Paris (POP). Cotton waste, chemical liquids, blood & body fluids, contaminated paper & cloths, dressing materials, bedding, bandages.  Red: All infected plastic waste. Gloves, blood bags, syringes without needles, catheters, urine bags, IV bottles & tubing’s, infected IV cannula, ET tubes.  Blue: Glass, broken glasses, ampoules, vials, laboratory slides, metals, metallic body implants, dentures. 24  White: Needles, syringes with fixed needles, scalpels, blades and razors, contaminated metallic objects, lancets, and nails.  Green: All uninfected biodegradable wastes. Food wastes, paper wastes.  Black: All clean plastic. Plastic covers, bottles. BMW Segregation chart 25 38. FIRE & SAFETY In a building premise, there should be a fire fighting system to prevent, protect, and escape from fire accidents and emergency situations. The following systems are used in our building;  Manual Call Point & Fire Alarm: A manual call point is a device used for the manual initiation of an alarm.  Smoke Detectors: Smoke detectors catch and analyze smoke before it turns into fire and initiate the fire alarm.  Fire Extinguishers: A fire extinguisher is an active fire protection device used to extinguish or control small fires.  Fire Hydrants & Cabinet Accessories: Fire hydrants and cabinet accessories are used to provide adequate water supply to the building during emergency situations.  Fire Sprinkler: A fire sprinkler system is an active fire protection method consisting of a water supply system that discharges water when the effects of fire have been detected.  Talkback System: A two-way communication system used to communicate properly between the fire safety officer and the person in a fire zone during an emergency.  Fire Exit: An emergency exit in a structure is a special exit for emergencies such as a fire.  Fire Assembly Area: An area where staff, patients, visitors, and others can gather in the event of a fire or other emergencies to ensure everyone is in a designated safe area.  PASS & RACE Fire Extinguisher Sign:  PASS: P – Pull the pin A – Aim at the base of the fire S – Squeeze the handle S – Sweep side to side 26   RACE: R – Rescue A – Alarm C – Confine/Contain E – Extinguish/Evacuate  Procedure to be followed to Activate Emergency Codes  All the employees are requested dial 8030 to activate the Emergency codes by informing the telephone operator by mentioning the Emergency Code (Code Blue, Code Red, etc.) & Location with respect to ward, floor and bed number  Telephone operator will announce the Emergency Code & location with respect to ward, floor and bed number through public announcement system (PAS) thrice.  On hearing the Emergency Code announcement over the PA system, respective team responsible for the particular code needs to rush to the location immediately.  Factors Influencing fire accident To prevent incidents of fire by implementing appropriate measures;  No smoking zone  Smoke detection devices are placed in different parts of the hospital.  Fire extinguisher providing of fire extinguisher and checking of working condition.  Do not accumulate combustible materials like cotton.  No work involving fire or spark.  Do not leave any electrical wiring open/naked  Fire hydrant wherever located should be in working condition at all time.  All fire exit routes are properly makes and free from obstruction.  Staff should know how to use the fire extinguisher and its location.  Ensure high standards of housekeeping.  Do not avoid any burning smell/ smoke coming from any place. Try to ascertain the cause and take corrective action.  In case of fire active the CODE RED by dialing 8030 and tell the location.  Emergency Evacuation  Systematic method to minimize the effect of fire accidents.  What is the protocol to evacuate patients in case of fire? Patients in category 4 are usually moved first followed by 3, 2, and 1.  Category 1 – Bed ridden patients including babies.  Category 2 – Patients who are able to move with the aids.  Category 3 – Patients that need staff help in moving.  Category 4 – Able to move on their own. 27 39. What is Disaster? It is an event where there is a reason to expect more number of injured of/ ill persons to be Emergency Room at same time.  What are the all the types of disasters? 1) External Disaster – (Example) Mass RTA, 2) Internal Disaster – (Example) Fire  What is the list of potential Emergencies identified in our hospital for as per Disaster Management Policy in our hospital? 1) Earthquakes 2) Floods 3) Train/ bus accidents which may bring in mass casualties 4) Civil unrest outside the organization’s premises 5) Major fire  Who will confirm the Disaster? Medical Superintendent  Disaster triage protocol  What is triage and what are the codes used in Triage? The purpose of triage is to properly identify patients and provide the care as per needs in mass casualty or during any disasters. Emergency Department patients will receive prompt initial assessment by a registered nurse and will have emergency care initiated according to their level of acuity, triaging will be done by doctor. The desired outcome of the triage process is that all Emergency Department patients will receive expedient treatment according to established priorities. Emergency patients requiring immediate intervention are transferred to the appropriate beds in EW to initiate the patient assessment & care process o TRIAGE COLOR CODES 1) Red tags: (Immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival. 2) Yellow tags: (Observation) for those who require observation (and possible later re- triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances. 3) Green tags: (Wait) are reserved for the “walking wounded” who will need medical 28  care at some point, after more critical injuries have been treated. 4) Black tags: Dead 40. What is Occupational Health Hazard? The hazards to which an individual is exposed during the course of performance of his job. This includes physical, chemical, biological, mechanical and psychological health hazards. 1) Physical: (Heat, Cold, Light, Noise etc.) 2) Chemical: (Gases, Phenol, others) 3) Biological: (Bacteria, Virus, fungi etc.,) 4) Mechanical: (Injuries, falls, Cuts etc.) 5) Psychological: (Work Pressure, Insecurity, Depression etc.) 41. What is Needle Stick Injury and how to prevent this? The accidental puncture of the skin by a needle during medical intervention. Steps to follow:  Do not suck the site  Flush the site with running water for 20 -30 seconds  Wash with soap and water  If needed cover with a dressing  Report the incident to the Nurse in charge, Infection Control Nurse and to the Medical superintendent  Identify what caused the problem  Take corrective action to solve the problem and prevent future accidental exposure  Provide appropriate care for the case  Lab tests for baseline studies - HBV, HIV, HCV  Fill the Performa of Needle stick injury Avoiding needle stick injuries  Avoid recapping of needle  Use a rigid puncture proof container for used needles  Make sure the container is always at hand.  Every hospital employee or any healthcare personal should be vaccinated against  Hepatitis B  Use PPE as required When do you discard the Sharp containers? When they are 3/4th full, sealed and sent for disposal. Needles and sharps should be completely inside the containers and not jutting out. Needles should not be recapped before discarding 29 The sharp container should be conveniently placed near the site of sharp generation. Sharp containers are not to be re-used. And should not be emptied into any other bag or container. Needles and sharps should never be disposed in plastic bags. 42. What is all type of Spillage?  Chemical spill  Mercury spill  Other chemical spill  Biological spill  Blood  Body fluids  What are all articles there in spill kit?  PPE (Gloves, mask, goggles)  500 ml container contains 1% sodium hypochlorite  Small containers  Biomedical waste cover  Zip lock cover  Syringe, cardboards  Forceps, Paper towel, torch light.  How do you manage spills? Spills of blood and body fluids or hazardous material spills should be cleaned Properly and the surface decontaminated in such a manner as to minimize the Possibility of workers becoming exposed to infectious or hazardous agents. There are two types of spills: 1) Major spill: (It is any fluids or blood more than 30ml)-Spill Kit 2) Minor spill: (It is any fluids or blood less than 30ml) Hazmat Kit Note: spills are managed with 1% hypochlorite solution for 30 mins. 43. How will you dispose blood or body fluids? Whenever any blood or body fluids is to be discarded, add equal amount of 5% sodium hypochlorite to the fluids and keep it for 15 to 20 minutes and discard it.  What is the available form of sodium hypochlorite? Available form of sodium hypochlorite is 5%, 1 % of sodium hypochlorite can be prepared by adding 100ml of solution in 400ml of water (i.e.; 1: 4 ratio) 30 44. How will you disinfect articles?  Digital Thermometer- Clean with Alcohol swab;  Before- Bulb to stem  After- Stem to bulb  BP cuff - Wash with Detergent, If rexin BP cuff is present clean with Aerosept solution  Stethoscope- Wipe the diaphragm and ear piece with alcohol swab.  Suction jar- Immerse in 1% sodium hypochlorite for 20 minutes  Humidifiers- Warm water and detergent  Biomedical Equipments- Aerosept solution 31 32 33 34 35