Adhiparasakthi Dental College Process Manual PDF

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 01...

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 01 Version: 03 Issue:01 APDH/NABH/MOM/01 03/05/2023 of 31 1.0 PURPOSE: To ensure the availability and proper management of dental materials and medications and to provide guidelines for developing, updating, and implementing the hospital formulary. 2.0 SCOPE 2.1 Purchase 2.2 Outpatient services 3.0 RESPONSIBILTY: 3.1 Correspondent 3.2 Consultants / Doctors 3.3 Principal 3.4 Purchase In-Charge 4.0 ABBREVIATION: 4.1 NABH ; National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH Accreditation Standards for Dental Health Care Service Provider, Third Edition, April l 2023/MOM 5.2 MOM 1 : The developing, updating, and implementing the hospital formulary. 6.0 DEFINITION: 6.1 Hospital Formulary: A list of medications and dental materials approved for use within the hospital. 6.2 DHSP (Dental Health Service Provider): The entity responsible for dental health services PREPARED in the hospital. BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 02 Version: 03 Issue:01 APDH/NABH/MOM/01 03/05/2023 of 31 7.0 POLICY: 7.1 DHSP creates a comprehensive hospital formulary listing approved medications, could be available in electronic form based on evidence and patient needs. 7.2 The formulary is reviewed and updated annually to reflect new medications, guidelines, and safety information. 7.3 The formulary is effectively implemented, with staff trained and the formulary accessible. 7.4 Input from dentists, pharmacists, and other professionals ensures a practical and effective formulary. 7.5 Adherence to the formulary is monitored, with a process for managing non-formulary medications. 7.6 DHSP adheres to the written guidance for the acquisition of formulary medications. 7.7 The policy emphasizes rational drug use and patient safety. 7.8 Updates to the formulary are communicated promptly to relevant staff. 7.9 Regular audits and reviews ensure the formulary's ongoing effectiveness. 8.0 PROCEDURE 8.1 Developing the Hospital Formulary  Formulary Committee: A Formulary Committee will be formed with dental specialists, pharmacists, nurses, and administrative staff.  Needs Assessment: A needs assessment will be conducted to identify essential dental materials and medications.  Usage Review: Current usage patterns and feedback from dental staff will be reviewed. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 03 Version: 03 Issue:01 APDH/NABH/MOM/01 03/05/2023 of 31  Selection Criteria: Selection criteria focusing on efficacy, safety, cost-effectiveness, and availability will be used.  Committee Review: The committee will review and approve the list of materials and medications (Drug formulary).  Final Approval: Final approval will be obtained from hospital management. 8.2 Updating the Hospital Formulary  Review Meetings: Regular review meetings will be held quarterly or as needed.  Monitor Developments: New developments in dental materials and medications will be monitored.  Adverse Events: Adverse event reports and clinical outcomes will be reviewed.  Amendments: Necessary amendments will be made based on reviews.  Communication: Changes will be communicated to all relevant departments. 8.3 Implementing the Hospital Formulary  Distribution: The updated formulary will be distributed to all departments.  Training: Training on formulary usage will be provided.  Audits: Regular audits will be conducted to monitor compliance.  Non-Compliance: Non-compliance issues will be addressed promptly. 9.0 Documentation  Drug Formulary Records: Records of the drug formulary will be maintained. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 04 Version: 03 Issue:01 APDH/NABH/MOM/01 03/05/2023 of 31  Formulary Committee Meetings: Records of formulary committee meetings will be maintained.  Approved List: An updated list of approved materials and medications will be kept.  Training and Audits: Documentation of training sessions and compliance audits will be maintained. 10.0 Monitoring and Evaluation  Effectiveness Evaluation: The effectiveness of the formulary will be regularly evaluated.  Feedback and Improvements: Feedback from dental staff and patient outcomes will be used to make improvements.  Reporting: Findings will be reported to hospital management. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 05 Version:03 Issue:01 APDH/NABH/MOM/02 03/05/2023 of 31 1.0 PURPOSE: 1.1 To provide guidelines on storage of dental materials and medications. 2.0 SCOPE: 2.1 Central Store 3.0 RESPONSIBILTY: 3.1 Correspondent 3.2 Principal 3.3 Store In Charge 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 /MOM 5.2 MOM.2: Policies and procedures guiding the storage of dental materials and medications. 6.0 POLICY: 6.1 All Dental materials and medications must be stored as per manufacturer’s instructions. 6.2 Medications shall be stored in a clean, well lit, and ventilated environment. 6.3 Sound Inventory control practices (like first in and first out (FIFO, ABC) shall be followed while issuing inventory. 6.4 The DHSP defines a list of high-risk medications, including those with a low therapeutic window, controlled substances, look-alike/sound-alike drugs and concentrated electrolytes due to their heightened risk for serious adverse outcomes. 6.5 Emergency medication, High risk medication and dental materials should be available all time in the clinical area. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 06 Version:03 Issue:01 APDH/NABH/MOM/02 03/05/2023 of 31 6.6 High risk medication list ( Red color coded) including look-alike ( pink color coded) sound-alike ( yellow color coded) and different concentration of same medication are stored physically apart from each other. 6.7 Emergency medication list shall be prepared and documented. 6.8 Emergency medication and dental materials should be available all time. 6.9 Organization shall conduct audits at regular intervals every quarter. 6.10 Overstocking is not allowed since it costs money and increases waste. 6.11 Materials shall be stored as per the storage requirement specified by the manufacturers, (these should address issues pertaining to temperature (refrigeration), light, ventilation, preventing entry of pests / rodents and vermin’s) at all location of storage. 6.12 The storage of medications is done in alphabetical order of their generic names in all the areas. 6.13 Refrigerator storage temperature shall be recorded at least 4 times a day in the stores, whereas in other storage areas, it shall be recorded 4 times a day and the same shall be verified and counter signed by the in-charge staff. 6.14 Materials shall be protected from loss and theft. 6.15 Organization shall conduct audits at regular intervals every quarter. 7.0 PROCEDURE: 7.1 Vendor Registration and Selection The Purchase manager shall maintain a database of registered suppliers. This database shall be organized as per the various Inventory heads. The hospital shall strive to maintain at least two registered suppliers for each items used by the hospital. The registration of each supplier shall be based on Criteria for Approval of Suppliers. The final selections and approval of suppliers; and awarding of tenders / contracts shall be done in consultation with the Correspondent and Principal. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 07 Version:03 Issue:01 APDH/NABH/MOM/02 03/05/2023 of 31 7.1.1 Procuring materials from unauthorized dealers or sources is strictly prohibited. 7.1.2 The supplier will issue credit note and the same is send to accounts department daily for payment to the supplier on the end of the month. 7.1.3 Outsiders, other hospital staff or other unauthorized people are not allowed inside the Stores 7.1.4 The emergency materials should be regularly replenished so as to maintain the stock at all times. 7.2 Storage of Materials: Materials are stored in the store\floor according to the manufacturer's recommendation and as per government recommendations. Sound inventory control practices (first expiry and first out) guide storage of the material Inventory shall be as directed by department head. Expired, Short expiry & damaged materials shall be stored in a separate designated area. All drugs storage container/racks shall be clearly & legibly labeled. Dental material requiring cold chain shall be stored in refrigerator within temperature range of 2 to 8 degree C and rest shall be stored at room temperature. Medicine requiring maintenance of cold chain, such as vaccines and sera are stored in refrigerators and maintained in low temperature. Monitoring of all refrigerated items will be done once in a day & a record will be maintained. A daily record log of temperature readings will be maintained on the outside door of the refrigerator.In case the variation is found repetitively, it will be notified to Maintenance / Engineering department. 7.3 Expired: Dental materials shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. The materials nearing expiry are returned to stores 3 months prior to their date of expiry. The mechanism for destruction and disposal will be as per laid down norms and regulations. In case of non supervision, all materials shall be stored under Lock & Key. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Issue Date: Page 08 Doc No : Version: 03 Issue: 01 APDH/NABH/MOM/03 03/05/2023 of 31 1.0 PURPOSE: To provide guidelines on the procedures and guidelines for the safe and rational prescription of medications. 2.0 SCOPE: Dental practitioners 3.0 RESPONSIBILTY: 3.1 Correspondent 3.2 Principal 3.3 Head of pharmacy, dental practitioners 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 / MOM 5.2 MOM.3: Policies and procedures guiding the safe and rational prescription of medication. 6.0 POLICY:  Medication prescription is in consonant with good practices.  The prescription shall have the name of the patient; unique number; name of the drug patient's electronic medical records.  Dental practitioners assess the patient's medical history, dental condition, and any allergies before prescribing medications. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Issue Date: Page 09 Doc No : Version: 03 Issue: 01 APDH/NABH/MOM/03 03/05/2023 of 31  Schedule follow-up appointments to monitor the patient's response to medication and adjust treatment as necessary.  Advised Stop the suspected medication, stabilize the patient, and provide necessary treatment.  Record the ADR details in the patient's medical record using standardized forms  Regularly train staff on ADR identification, management, and reporting protocols.  DHSP has mechanism to assists the clinician in prescribing appropriate medication to help identify drug interactions, food drug interactions in physical form or electronic form.  Based on the assessment, the appropriate medication is selected, considering efficacy, safety, and patient-specific factors.  Prescribe the correct dosage and frequency based on standard guidelines and patient factors such as age, weight, and medical condition.  Record the prescribed medication, dosage, frequency, and rationale in the patient's electronic medical records.  Minimize the use of multiple medications unless necessary to reduce the risk of adverse drug interactions and complications.  Educate patients about the prescribed medications, including dosage, frequency, potential side effects, and the importance of compliance.  Audit of medication orders is carried out to check for safe prescription of medications.  Corrective and preventive actions based on audit.  Reconciliation of medication occurs transition point in patient care.  Document and investigate any incidents or adverse drug reactions related to medication use, implementing corrective actions to prevent recurrence. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Issue Date: Page 10 Doc No : Version: 03 Issue: 01 APDH/NABH/MOM/03 03/05/2023 of 31  Regularly review medication management protocols and update them in response to changes in clinical guidelines, regulations, or best practices. 7.0 PROCEDURE: 7.1 Patient Assessment  A thorough assessment of the patient's medical history, allergies, and current medications is conducted.  All findings are documented in the patient’s electronic medical record (HIS – SOFTWARE ). 7.2 Generating Prescription  Standardized prescription is generated by using HIS- SOFTWARE.  Patient’s full name, age, and contact details on the prescription are clearly mentioned.  Medication prescription is in consonant with good practices.  Medication name, dosage, route, frequency, and duration of treatment are specified.  It may include any special instructions for use or precautions. 7.3 Approval  Once the prescription is generated , it is verified by the assigned doctor and approved using HIS- SOFTWARE.  The approved prescription is then sent to Pharmacy and medications are dispensed to the corresponding patients after verification by pharmacists. 7.4 Verification  The prescribed medication is double checked for accuracy.  Cross-reference with the patient’s medical history to avoid contraindications. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Issue Date: Page 11 Doc No : Version: 03 Issue: 01 APDH/NABH/MOM/03 03/05/2023 of 31  Pharmacists verify and confirm the prescription before dispensing.  Audit of medication orders is carried out to check for safe prescription of medications.  Corrective and preventive actions based on audit.  Reconciliation of medication occurs transition point in patient care. 7.5 Patient Education  Patient is educated about the prescribed medication on how to take it.  Written instructions are provided if necessary. 7.6 Documentation  All the prescribed medications are recorded in the patient’s medical record.  Any changes in medication or adverse reactions reported by the patient are entered in patient’s medical record in HIS –SOFTWARE.  Record the ADR details in the patient's medical record using standardized forms.  Regularly train staff on ADR identification, management, and reporting protocols. 7.7 Monitoring and Follow-Up  Follow-up appointments are scheduled to monitor the patient’s response to the medication.  Prescription is adjusted if necessary, based on the patient’s progress and any side effects. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 12 Version: 03 Issue:01 APDH/NABH/MOM/04 03/05/2023 of 31 1.0 PURPOSE: To ensure that all medication orders are written in a uniform and standardized manner when utilizing HIS - SOFTWARE (Electronic medical record system). This policy aims to promote patient safety, improve medication administration efficiency, and enhance communication among healthcare providers. 2.0 SCOPE: 2.1 Central Store 2.2 Dentists, pharmacists 3.0 RESPONSIBILTY: 3.1 All healthcare providers, including dentists, physicians, nurses, and other staff involved in prescribing and administering medications 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 / MOM 5.2 MOM.4: Policies and procedures ensuring medications orders are in a uniform manner 6.0 POLICY: 6.1 Medication orders shall be written by a dental surgeon who at a minimum, holds a BDS qualification. 6.2 All medication orders entered into the electronic medical record system must follow a standardized format. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 13 Version: 03 Issue:01 APDH/NABH/MOM/04 03/05/2023 of 31 6.3 The format should include fields for essential information such as patient name, date of birth, medical record number, medication name, dosage, route of administration, frequency, start date, prescriber's name, and signature. 6.4 Medication order should be clear, legible, timed and signed. 6.5 Follow established guidelines for abbreviations and symbols as per institutional policies and industry standards. 7.0 PROCEDURE: 7.1 Patient Assessment  A thorough assessment of the patient's medical history, allergies, and current medications is conducted.  All findings are documented in the patient’s medical record using HIS-SOFTWARE. 7.2 Generating Prescription  Prescription is generated using HIS-SOFTWARE.  Patient’s full name, age, and contact details on the prescription are clearly mentioned.  Medications are prescribed in a uniform manner which specifies the medication name, dosage, route, frequency, and duration of treatment.  It may include any special instructions for use or precautions. 7.3 Approval  Once the prescription is generated , it is verified by the assigned doctor and approved using HIS-SOFTWARE.  The approved prescription is then sent to Pharmacy and drugs are dispensed to the corresponding patients after verification by pharmacists. 7.4 Verification  Pharmacists double-check the prescribed medication for accuracy. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 14 Version: 03 Issue:01 APDH/NABH/MOM/04 03/05/2023 of 31  Cross-reference with the patient’s medical history to avoid contraindications.  Pharmacist verify and confirm the prescription before dispensing. 7.5 Patient Education  Patient is educated about the prescribed medication and on how to take it.  Written instructions are provided if necessary. 7.6 Documentation  Prescribed medications are recorded in the patient’s medical record using HIS- SOFTWARE.  Any changes in medication or adverse reactions reported by the patient are entered in patient’s medical record in HIS-SOFTWARE. 7.7 Monitoring and Follow-Up  Follow-up appointments are scheduled to monitor the patient’s response to the medication.  Prescription is adjusted if necessary, based on the patient’s progress and any side effects. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 15 Version: 03 Issue:01 APDH/NABH/MOM/05 03/05/2023 of 31 1.0 PURPOSE: To ensure that all medication are dispensed in a safe manner. 2.0 SCOPE: 2.1 Central Store 2.2 Pharmacist 2.3 DHSP 3.0 RESPONSIBILTY: 3.1 Principal 3.2 Pharmacist 3.3 Dental Health care service providers 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 / MOM 5.2 MOM.5: Policies and procedures ensuring medications are dispensed in a safe manner 6.0 POLICY: 6.1 Medication is checked before dispensing for generic composition, formulation, expiry date, and strength. 6.2 Medication recalls may be initiated based on regulatory communication, manufacturer alerts, or internal feedback. 6.3 A mechanism ensures that near-expiry drugs (3 months before the expiry date) are withdrawn. 6.4 Dispensed medications are labelled. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 16 Version: 03 Issue:01 APDH/NABH/MOM/05 03/05/2023 of 31 6.5 High-risk medications are dispensed only with verified written orders and verification by staff is required before dispensing. 7.0 PROCEDURE: 7.1 Prescription Verification:  The prescription is verified for completeness: patient's name, age, weight (if required), diagnosis, prescribed medication, dosage, route of administration, frequency, and duration.  Prescription is ensured that it is approved by a dental practitioner. 7.2 Medication Storage:  Medications are stored in a secure, temperature-controlled environment.  Medications are separate and clearly labelled in boxes and are arranged in an orderly manner. 7.3 Medication Dispensing:  Medications are dispensed only after receiving the concerned doctor approved prescription.  The medication is double-checked for name, dosage, and expiry date before dispensing.  Labelled medications with patient’s name, date of dispensing, name of medication, dosage, route of administration, frequency, and any special instructions are dispensed.  Clearly specify when to take the medication (e.g., morning, evening, before or after meals).  Medication recalls may be initiated based on regulatory communication, manufacturer alerts, or internal feedback. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 17 Version: 03 Issue:01 APDH/NABH/MOM/05 03/05/2023 of 31  Recall policy  Recall announcement : The company will be making a recall announcement regarding the defective products.  Establish Procedure: A recall procedure will be documented, specifying roles and responsibilities.  Identification & Notification: Recalls will be identified through alerts, and relevant departments will be notified.  Segregation & Quarantine: Recalled items will be removed and quarantined to prevent use.  Patient Communication: Affected patients will be informed about the recall and necessary follow-up actions.  Return/Disposal: Instructions for returning or safely disposing of recalled items will be followed.  Documentation: All actions taken during the recall process will be recorded.  Review & Analysis: The recall impact will be analyzed, and corrective actions will be implemented.  Staff Training: Staff will be trained on recall procedures regularly.  Near expiry medications are checked properly.  High risk medication orders are verified before dispensing. 7.4 Patient Counseling:  Clear instructions are provided to the patient or caregiver on how to take the medication, including the importance of adherence to the prescribed regimen.  Patient is informed about possible side effects and what to do in case of adverse reactions. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 18 Version: 03 Issue:01 APDH/NABH/MOM/06 03/05/2023 of 31 1.0 PURPOSE: To ensure that all medication is administered in a defined procedures. 2.0 SCOPE: 2.1 DHSP 3.0 RESPONSIBILTY: 3.1 Principal 3.2 Pharmacist 3.3 Dental Health care service providers 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board for Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 / MOM 5.2 MOM.6: Policies and procedures ensuring defined procedures for medication administration 6.0 POLICY: 6.1 Medications are administrated by registered nurse or dentists. 6.2 Label each medication before preparing the next, especially when multiple drugs are loaded. 6.3 Medications verified from the order and medication administration is documented. 6.4 Patient is identified by their unique ID number and name before administering medication. 6.5 Verify the medication from the prescription and inspect it physically. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 19 Version: 03 Issue:01 APDH/NABH/MOM/06 03/05/2023 of 31 6.6 Document each administration in a uniform location, including the medication name, strength, route, timing, and details of the administering staff. 6.7 Document each dose separately for every medication administered. 7.0 PROCEDURE: 7.1 Prescription Verification:  Medication order/prescription is verified for completeness and accuracy.  It is ensured that the prescription includes the patient’s name, age, weight (if applicable), diagnosis, medication name, dosage, route, frequency, and duration. 7.2 Patient Identification:  Patient's identity is confirmed using at least two identifiers (e.g., name and date of birth).  Checked for any allergies or previous adverse reactions to medications. 7.3 Preparation of Medication:  Hands are washed and aseptic techniques are used during the preparation of medication.  The medication is prepared in a clean and well-lit area.  Medication name, dosage, and expiration date are double-checked against the prescription. 7.4 Administration:  Procedure and medication are explained to the patient, including potential side effects.  The medication is administered using the correct route (oral, topical, injection, etc.) as prescribed.  Proper positioning of the patient is ensured for the type of medication administration. 7.5 Documentation:  Medication administered are recorded in patient’s medical record, including the name, dosage, route, time, and any observations.  Any adverse reactions or side effects are noted and reported immediately. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 20 Version: 03 Issue:01 APDH/NABH/MOM/06 03/05/2023 of 31 7.6 Post-Administration Monitoring:  The patient is observed for any immediate adverse reactions or side effects.  Post-administration instructions are provided to the patient, if applicable (e.g., dietary restrictions, activity limitations). 7.7 Storage and Disposal:  Medications are stored according to manufacturer’s instructions and regulatory requirements.  Dispose of expired or unused medications safely, following the clinic's waste management policy. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 21 Version: 03 Issue: 01 APDH/NABH/MOM/07 03/05/2023 of 31 1.0 PURPOSE:  To ensure early detection of adverse reactions and ensure patient safety post-medication. 2.0 SCOPE: 2.1 DHSP 2.2 Nurses 3.0 RESPONSIBILTY: 3.1 Dental Health care service providers 3.2 Nursing staffs 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of Dental material & Medication. 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Provider, third Edition, April 2023 / MOM 5.2 MOM.7: Policies and procedures ensuring procedures after medication administration 6.0 POLICY: 6.1 Patients are monitored after medication administration to observe effects and ensure safety. 6.2 Medications are adjusted as necessary based on patient monitoring results.The DHSP records all near misses, medication errors, and adverse drug reactions. 6.3 Near misses, medication errors, and adverse drug reactions are reported within a specified time frame. 6.4 Incidents of near misses, medication errors, and adverse drug reactions are collected and analyzed. 6.5 Corrective and preventive actions are taken based on the analysis. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 22 Version: 03 Issue: 01 APDH/NABH/MOM/07 03/05/2023 of 31 7.0 PROCEDURE 7.1 Dental Team Responsibilities:  Responsible for prescribing medications based on patient's condition and history.  Ensures proper documentation of medication administration and patient responses.  Administers medications according to prescribed dosage and route.  Monitors patients closely post-medication and records vital signs.  Assists in patient positioning and comfort during monitoring.  Supports nursing staff in documentation and reporting. 7.2 Patient Responsibilities:  Cooperates with dental staff during medication administration.  Reports any discomfort or adverse reactions immediately.  Follows post-medication instructions provided by dental staff. 7.3 Preparing for Medication Administration  Review patient's medical history, allergies, and current medications.  Confirm prescription details and obtain informed consent.  Ensure availability of monitoring equipment (e.g., blood pressure cuff, pulse oximeter). 7.4 Post-Medication Administration Monitoring Protocol Immediate Post-Administration:  Monitor vital signs (e.g., blood pressure, heart rate, respiratory rate) immediately after medication administration.  Observe for any signs of immediate adverse reactions (e.g., allergic reactions, dizziness).  Document findings promptly in the patient's medical record.  Medications are changed where appropriate based on monitoring. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 23 Version: 03 Issue: 01 APDH/NABH/MOM/07 03/05/2023 of 31 Short-Term Monitoring:  Continue monitoring vital signs at regular intervals as per protocol (e.g., every 15 minutes for the first hour post-administration).  Document observations, including any changes in patient condition or responses to medication.  Inform the dentist promptly of any concerning findings. Long-Term Monitoring (if applicable):  Provide patient education on potential delayed reactions or side effects of medications.  Instruct patients on self-monitoring at home, if necessary.  Schedule follow-up appointments as needed to assess long-term effects. 7.5 Documentation and Reporting  Reporting System: A system will be established to report medication errors and near misses.  Immediate Action: Corrective actions will be taken to ensure patient safety.  Documentation: Error details, causes, and actions taken will be recorded.  Root Cause Analysis: Errors will be investigated to identify contributing factors.  Communication: Patients and staff will be informed about the error and corrective measures.  Preventive Measures: Strategies to prevent future errors will be implemented.  Staff Training: Staff will be trained on error prevention and reporting.  Monitoring and Review: Errors will be monitored, trends will be reviewed, and policies will be updated.  Continuous Quality Improvement PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 24 Version: 03 Issue: 01 APDH/NABH/MOM/07 03/05/2023 of 31  Audits: Regular audits of medication administration and monitoring practices will be conducted.  Review: Monitoring protocols will be reviewed based on feedback, incidents, and updated guidelines.  Corrective Actions: Corrective actions and improvements will be implemented as identified through audit findings. 7.6 Training and Education:  Ongoing training will be provided to dental staff on medication administration procedures and monitoring techniques.  Staff will be educated on recognizing and managing adverse drug reactions effectively.  Patient education materials on medication effects and monitoring procedures will be offered. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 25 Version: 03 Issue: 01 APDH/NABH/MOM/08 03/05/2023 of 31 1.0 PURPOSE: 1.1 To provide guidelines on the procurement and usage of dental implant prosthesis and dental devices. 2.0 SCOPE: 2.1 Purchase 3.0 RESPONSIBILTY: 3.1 Consultants / Doctors – prosthodontist, Implantologist, Oral Surgeon, Periodontologist 3.2 Principal 3.3 Implantologist 3.4 Purchase In-Charge 3.5 Biomedical Engineer 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 MOM : Management of dental material and Medication 5.0 REFERENCE: 5.1 NABH : Accreditation Standards for Dental Health Care Service Provider, Third Edition, April 2023 / MOM 5.2 MOM 8 : Policies and procedures guide for the use of implant prosthesis. 6.0 POLICY: 6.1 The usage of implantable prostheses and dental devices is guided by scientific criteria specific to each item. 6.2 A mechanism is in place for the usage of implantable prostheses and dental devices. 6.3 Patients and their families are counseled on the usage of implantable prostheses and dental devices. 6.4 The batch and serial numbers of implantable prostheses are recorded in the patient’s medical record and the master logbook. 6.5 Recalls of implantable prostheses and dental devices are managed effectively. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & DENTAL EQUIPMENTS Doc No : Issue Date: Page 26 Version: 03 Issue: 01 APDH/NABH/MOM/08 03/05/2023 of 31 7.0 PROCEDURE: 7.1 Implant Procurement: It is our endeavor to see to the utmost safety of patients undergoing implant based procedures. We follow strict guidelines while purchasing the implants. The indent is formulated keeping the following points: 1) The retailer of the implant supply should be well experienced in the field. 2) The implants should be pre gamma irradiated with no damage to the package at the time of delivery. 3) Implants should be free from scratches and transported in a hygienic environment. 4) Additional instrumentation required for the implant procedure should be supplied by the retailer. The implants are strictly purchased from the companies complying with these guidelines and ensuring global quality standards with scientific evidences for their products. At any given time an adequate stock of implant is maintained by bulk indenting from the above said companies. 7.2 Implant Maintenance: All the implants are already gamma irradiated and packed in a sterile container by the manufacturer. 7.3 Implant sterilization: All implants are pre sterilized gamma irradiated implants and are checked for damages in packing. 7.4 Implant disposal: In view of the patient’s health and well-being we do counseling regarding the implants and various merits and demerits using different types of implants, which includes post op care, maintenance and survival rate. All implants recovered from the patients are returned to the concern implant company. 7.5 Documentation: The batch no, and serial no of the implantable prosthesis are recorded in the patient’s medical record.The batch stickers are also applied in the respective areas 7.6 Patient education: Every patient undergoing surgery for instillation of an implant or device shall be educated and oriented towards the safe usage and precautions to be taken by the concerned treating and operating doctors. The precautions shall include the aspects of non-usage of specific drugs, diet and reporting to the hospital in case certain specific symptoms are noticed. 7.7 The patients are educated regarding dental implants through in their own convenient language. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 27 Version: 03 Issue: 01 APDH/NABH/MOM/09 03/05/2023 of 31 1.0 PURPOSE: 1.1 To provide guidelines on the procurement, usage and storage of dental supplies and consumables. 2.0 SCOPE: 2.1 Purchase 2.2 Outpatient services 3.0 RESPONSIBILTY: 3.1 Correspondent 3.2 Consultants / Doctors 3.3 Principal 3.4 Purchase In-Charge 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 5.0 DEFINITION: 5.1 Consumable: The term consumable covers a broad range of products used in the everyday healthcare setting; and can be defined as any instrument, apparatus, appliance, material or healthcare product, excluding drugs, used for a patient or client that is used only once after which it is disposed of and not reused. 6.0 REFERENCE: 6.1 NABH: Accreditation Standards for Dental Health Care Service Provider, Third Edition, April 2023 / MOM 6.2 MOM.9: Policies and procedures guide the DHSP procurement and storage of dental supplies and consumables. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 28 Version: 03 Issue: 01 APDH/NABH/MOM/09 03/05/2023 of 31 7.0 POLICY: 7.1 The organization follows the established procedures for acquiring medical supplies and consumables. 7.2 The process for acquisition of medical supplies and consumables shall be addressed with respect to: 7.2.1 Vendor selection 7.2.2 Vendor evaluation 7.2.3 Indenting process 7.2.4 Generation of purchase order 7.2.5 Receipt of goods 7.3 All medical supplies and consumables are used in safe manner wherever applicable. 7.4 All medical supplies and consumables shall be stored in clean, safe, secure environment in accordance with the manufacturer specification. 7.5 Sound inventory practices shall be utilized to guide the storage and usage of all medical supplies and consumables. 7.6 All hazardous material shall be identified and Material safety data sheet shall be prepared to prevent health hazards. 7.7 Sound inventory control shall be done as per VED (Vital essential desirable), FIFO (First in First out), ABC analysis etc. 7.8 A mechanism is in place to ensure that medical supplies and consumables are in a condition suitable for safe use, with checks for factors such as opened packages, damp cotton rolls, physical damage, and unwanted discoloration before dispensing and use. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 29 Version: 03 Issue: 01 APDH/NABH/MOM/09 03/05/2023 of 31 8.0 PROCEDURE: 8.1 Vendor Registration and Selection The Purchase manager shall maintain a database of registered suppliers. This database shall be organized as per the various Inventory heads. The hospital shall strive to maintain at least two registered suppliers for each items used by the hospital. The registration of each supplier shall be based on Criteria for Approval of Suppliers. The final selections and approval of suppliers; and awarding of tenders / contracts shall be done in consultation with the Correspondent and concerned functional heads in the respective areas. 8.2 Tender / Quotation Process Tenders / Quotations should be obtained for all items. Tenders can be called for through advertisements or directly from registered firms. There should be at least three bidders for a tender /quotation process to be valid. In case of proprietary items of special nature where a single or few suppliers are available a single bidder may be requested for tender / quotation; after obtaining approval of the Correspondent. The Coordinator Materials Management shall prepare a comparative statement of the bidders short-listed for final negotiation and final discussion is based on quality with comparable rate. The comparative statement shall cover the following details about the bids short-listed; Name & Details of Bidder, Make / Model, Price per Unit, Quantity offered, Delivery Period, Terms of delivery, Past Performance of the supplier; etc. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 30 Version: 03 Issue: 01 APDH/NABH/MOM/09 03/05/2023 of 31 8.3 Purchase Orders No goods / items, except cases of emergency purchases’ shall be obtained without a purchase order issued and signed by the competent authority. For regular purchase orders for items agreed upon by rate contracts, Purchase committee shall have the authority to approve and issue the purchase orders. The Purchase Assistant shall be responsible for preparation of the purchase orders. All purchase orders shall contain the following relevant information; Order Number, Date, Full Name and Address of the Supplier, Consignees’ Name and Address, GST of suppliers, Terms & Conditions, Description of goods, Quantity, Supplier Quotation / Tender / Contract reference, Price terms, Payment Terms, Payment Mode, Delivery date and Schedule, Packing / Transport Instructions, Freight Payment terms, Insurance details, Inspection Details, Penalties, Special Terms and Conditions if any. In case of amendments to the purchase orders, the same shall be incorporated and shall follow the same procedure before approval and issue. 8.4 Rating of Suppliers The Coordinator Materials Management/ Purchase manager shall be responsible for the rating of the key suppliers at least once in a year. The evaluation for rating shall be based on assessment of quality by both the Central Stores in-charge at the time of receipt and by the user department; separately for each items evaluated. These ratings and details any violations of terms of the purchase order by any supplier shall be presented to the Principal on a periodic basis. He shall take appropriate actions based on this feedback. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – MANAGEMENT OF DENTAL MATERIAL & MEDICATION Doc No : Issue Date: Page 31 Version: 03 Issue: 01 APDH/NABH/MOM/09 03/05/2023 of 31 A Supplier Evaluation Sheets shall be used to record these feedback and these shall be maintained for all key supplier item wise. 8.5 Storage of Materials: Materials are stored in the store\floor according to the manufacturer's recommendation and as per government recommendations. Sound inventory control practices (first expiry and first out) guide storage of the material Inventory shall be as directed by department head. Expired, Short expiry & damaged materials shall be stored in a separate designated area. All drugs storage container/racks shall be clearly & legibly labeled. Dental material requiring cold chain shall be stored in refrigerator within temperature range of 2 to 8 degree C and rest shall be stored at room temperature. Medicine requiring maintenance of cold chain, such as vaccines and sera are stored in refrigerators and maintained in low temperature. Monitoring of all refrigerated items will be done once in a day & a record will be maintained. A daily record log of temperature readings will be maintained on the outside door of the refrigerator.In case the variation is found repetitively, it will be notified to Maintenance / Engineering department. 8.6 Expired: Dental materials shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. The materials nearing expiry are returned to stores 3 months prior to their date of expiry. The mechanism for destruction and disposal will be as per laid down norms and regulations. In case of non supervision, all materials shall be stored under Lock & Key. PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 01 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 1.0 PURPOSE: 1.1 To describe the Rights of Patients & Family members. 1.2 To describe the Responsibilities of patients and family members. 2.0 SCOPE 2.1 Outpatient services 3.0 RESPONSIBILTY: 3.1 Hospital wide – All staff 4.0 ABBREVIATION: 4.1 NABH : National Accreditation for Hospitals and Healthcare Providers 4.2 PRE : Patient Rights and Education 5.0 REFERENCE: 5.1 Accreditation Standards for Dental Health Care Provider, Third Edition, April 2023 5.2 PRE.1: The organization protects patient and family rights and informs them about their responsibilities during care 5.3 PRE.2: Patient and family rights support individual beliefs, values and involve the patient and family in decision making process 6.0 POLICY: 6.1 Patient and family rights are as given in document. These rights shall be respected and protected by entire staff of the hospital. Following shall be done to comply with fulfillment of patient rights and education. Display of patients’ rights and responsibilities at convenient places in the hospital. Information of rights of patients shall be communicated to them and their families, if asked, in a format and language that they understand. Staff shall be made aware of their responsibility towards protecting of patients and family rights. Violation of patient rights is recorded, reviewed and corrective / preventive measures taken by the designated official in accordance with Indian medical council code of conduct. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 02 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 7.0 PROCEDURE: 7.1.1 Rights of patient: The Rights of Patients in APDCH are as follows: 7.1.2 Right to Medical care: Every patient is entitled without discrimination to appropriate dental care. Every patient has the right to be cared for by the physician whom he/she knows to be free to make clinical and ethical judgments without any outside interference. Patient shall be treated in accordance with his/ her best interests. The treatment applied shall be in accordance with generally approved principles. 7.1.3 Privacy: You have the right to every consideration of privacy, including personal needs. This also means that case discussion; consultation, examination and treatment should be conducted so as to protect your privacy. You have the right to expect that all written communications and records about your treatment be treated as strictly confidential, except in cases permitted or required by law, such as suspected abuse or public health hazards. 7.1.4 Decision making: You have the right to know the details of your condition, diagnosis, various treatment options, prognosis, and cost. One of our most important jobs is keeping you informed. You have the right to participate in the decisions regarding your care, including refusing of the treatment. You have right of choice of doctor for treatment, right to change the doctor in mid of treatment. 7.1.5 Access to Medical Records: You have the right to review all records pertaining to your dental care and to have the information fully explained to you, except when such disclosure is restricted by law. 7.1.6 Knowledge of staff Information: You have the right to know the names of everyone involved in your care, education and relationship with the hospital center. You have the right to know of relationships between APDCH and educational institutions and other health care providers. 7.1.7 Right for dignity: Every patient has the right to have dignity; hospital shall protect this right and provide dignity to the patients. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER CORRESPONDENT PRINCIPAL  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 03 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 7.1.8 Right for refusal: In any point of time during his/her course of treatment he/she can or his/her family can refuse the treatment from the hospital. Hospital has no right to force them taking treatment from their hospital. Hospital shall discuss about the negative points only for the refusal what could happen. Though they want to leave they can but before leaving hospital shall get filled the LAMA (Leaving against medical advice) consent and the same shall be kept with medical record file of the patient. 7.1.9 Right for Complaint: Patient and their relatives have the right to lodge a complaint against the staff of the hospital. Hospital shall display the process to lodge a complaint. 7.1.10 Confidentiality: Patient has the right to have confidentiality of his/her diseases related information like, diagnosis, report of investigation etc. 7.1.11 Freedom to participate in Research: You have the right to consent, to participate in proposed studies or human experimentation affecting care and treatment. You have the right to have studies explained to you prior to your consent. You have the right to be given a description of alternative services that might also prove advantageous to you. If you decide not to participate in research, you are still entitled to the most effective care the hospital center can otherwise provide. 7.1.12 Patient Grievance: We strive to treat all patients with compassion and dignity. Sometimes, despite our finest intentions, problems arise. If that happens, we encourage you to first discuss them with your doctor or ask to speak with the manager of that area. Also, Complaint forms and Suggestion boxes are located inside hospital premises. If a problem is not resolved to your satisfaction, the hospital has a Grievance Committee. To file an appeal, you should contact by calling or write the Head of the Institution. 7.1.13 Unless you withdraw your appeal or otherwise indicate that your appeal has been addressed to your satisfaction, the grievance Committee will respond in writing within a reasonable time (but not to exceed thirty (30) days). The response will describe the steps taken to investigate your appeal, the results of the investigation and when the review was completed. The response will also give you the name, telephone number and address of a person to contact if you remain dissatisfied. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 04 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 7.1.14 Safety: You have the right to receive care in a safe setting and the right to be free from abuse or Harassment. 7.2 Patient and Family Responsibility: The patients at APDCH shall be responsible for the following, 7.2.1 Every Patient Shall Respect the rights and treat all healthcare workers and other patients and visitors with dignity. Comply by medications and other matters relating to your health. Comply with all hospital policies and guidelines as informed or displayed. Be available for any appointments made or notify the hospital as early as possible if you are unable to do so. Acknowledge that some other patients’ medical condition may be more urgent than yours and accept that your doctor may need to attend them first. Kindly cooperate in such situations. Regardless of the type of insurance coverage you have, pay your bill promptly or make consent from manual on arrangements with our financial services department before entering the hospital. Provide us with comprehensive and accurate details about your past medical records and be complaint as regard to taking medication or following any other prescribed treatment. Follow the prescribed and agreed treatment plan and carefully comply with the instructions given. Accept responsibility for decisions you make regarding the treatment. Do not take medication independent of medical advice. Do not ask us to provide incorrect information, receipts or certificates. Do not waste medical resources and time unnecessarily. Accept, where applicable, adaptations to the environment to ensure a safe and secure in hospital with a full explanation from our staff. Accept the measures taken by the hospital to ensure personal privacy and confidentiality of medical records. Provide correct information regarding identity and financial status. Strictly observe the Hospitals Visitors Policy as displayed. To protect the environment. To utilize the health care system appropriately and do not abuse it. To maintain cleanliness & hygiene of APDCH. To follow hospital safety rules. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 05 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 1.0 PURPOSE: 1.1 To guide and formulate a policy where patients are made aware about his/her health status and other preventive measures (risk, benefits, alternatives and doctor who performs the procedure) and are involved in the decision making about their care. 2.0 SCOPE: 2.1 Outpatient services 3.0 RESPONSIBILTY: 3.1 Doctors, staff nurse, paramedical staff and other technicians. 4.0 ABBREVIATION: 4.1 NABH : National Accreditation for Hospitals and Healthcare Providers 4.2 PRE : Patient Rights and Education 5.0 REFERENCE: 5.1 Accreditation Standards for Dental Health Care Service Provider, Third Edition – April-2023/ PRE 5.2 PRE.3: The patient and /or family members are educated to make informed decision's and are involved in the care planning and delivery process. 6.0 POLICY: 6.1 Patient and / or family education: 6.1.1 The patient / relative shall be explained about the proposed care plan by the treating doctor / consultant including the risks, alternatives and benefits. The plan shall be discussed with the patient and / or family members in the language that they can understand. The information shall be documented and countersigned by the concerned doctor. 6.1.2 The patient and / or family members shall be explained the possible outcomes, complications and benefits of the care plan. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 06 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 6.1.3 The care plan shall incorporate the religious, cultural and spiritual views of the patient and / or family members wherever possible. 6.1.4 The care plan shall have the possibility of modification in consultation with the patient and / or family members. 6.1.5 The results of the diagnostic tests and the diagnosis shall be communicated to the patient and / or family members. 6.1.6 Any change in the condition of the patient shall be communicated to the patient and / or family members. 6.2 General Guidelines for Informed Consent: 6.2.1 The hospital has the following list of situation where the informed consent shall be necessary: 6.2.1.1 Before any minor surgery 6.2.1.2 Before any procedure 6.2.1.3 Administration local anesthesia 6.2.2 The scope of the consent shall be communicated to the patient and / or family members in the language that they can understand. 6.2.3 All informed consent for procedures shall include the following information: 6.2.3.1 Information regarding the procedure 6.2.3.2 The risks involved 6.2.3.3 The benefits involved 6.2.3.4 The alternatives 6.2.3.5 Who will be performing the requisite procedure 6.2.3.6 It is necessary for what 6.2.4 The informed consent shall be obtained by the concerned doctor performing the procedure. 6.2.5 The informed consent shall adhere to the following statutory norms: 6.2.5.1 The consent shall be taken on consent form which shall contain: PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 07 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 6.2.5.1.1 Name, Signature/thumb impression of the patient; 6.2.5.1.2 Name, Signature/ thumb impression of the witness; 6.2.5.1.3 (In case patient incapable of independent decision making) Signature / thumb impression of guardian (as per policy) with name and relationship with patient; 6.2.5.1.4 Name and Signature of doctor in- charge 6.2.5.1.5 Date and time of signing the consent 6.2.5.2 The consent shall be taken prior to the procedure 6.2.5.3 There shall be atleast one independent witness signing the consent. 6.2.5.4 Fresh consent shall be sought in case the procedure has to be changed mid-way. 6.2.5.5 Staff shall be made aware of the informed consent procedures. 6.3 Patient and / or family informed consents: 6.3.1 General Consent: General consent is obtained for all out patients visiting the hospital. The scope of general consent shall include awareness about patient rights and responsibilities, intake of medications, dental health related, photography/ ideography documentation for academic purpose etc. 6.3.2 Informed Consent: Informed consent is obtained by the person who is performing the procedure explaining the benefits and alternatives and the risk involved in the procedure in an understandable language. For Adult patients: His/her signature or thumb impression is obtained in the consent form along with the witness signature, name, date and time. For Paediatric cases: The signature is obtained from the parents.. For unconscious person consent shall be given by the attendant with the reason for why the patient could not give the consent has to be documented by the consultant. On life saving conditions, treating Doctor shall be authorized for decision making. Consent for minor surgery and other related procedure shall be obtained by the surgeon prior to surgery explaining about the procedure, outcome and expected duration of recovery and the consent is obtained from PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 08 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 patient / attending relative. Consent for local anesthesia is obtained from patients after explaining the risks, benefits and alternatives, person performing the procedure by the concern personnel. 6.3.3 Exclusions of informed consent: 6.3.3.1 Medical Emergency: A procedure which may otherwise require informed consent may be performed without obtaining prior informed consent in an emergency when the patient is incapable and cannot make an informed decision, and the patient has a life-threatening situation requiring immediate treatment such that any delay in treatment would likely result in death, deterioration, or serious permanent impairment. In such circumstances treating doctor shall consent the patient, with proper reasoning and the same shall be documented in the medical record. And if the patient is unconscious or not in a state to give consent, the treating physician shall seek the consent from attending relative or next of kin. 6.3.4 Minor: If the patient is under 18 years of age, consent should be obtained from legal guardian with the specific facts and reasons the exception applies must be documented in detail in the medical record. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 09 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 PROCEDURES: S.no Consent Name Procedure Who can give Responsibility Valid consent Period 1 General Consent Out patient Patient or Doctor or Till leave primary only if concerned treating from the major. doctor hospital In case of minor - Parents / guardian/Next of kin 2 Consent for Any k i n d of Patient or Surgeon who is Till leave minor dental or oral primary performing the from the surgery surgery relatives procedure hospital 3 Consent for Any kind of Patient or Doctors or Till leave local dental or oral primary concerned treating from the anesthesia procedure which relatives. doctor hospital requires local anesthesia 4 Consent for Any type of Patient or Consultant who Till they high risk invasive primary is performing the leave from procedures procedures relative procedure the hospital 5. Consent for Any kind of dental Patient or Consultant who is Till they Procedure or oral procedure primary performing the leave from relatives procedure the hospital PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 10 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 1.0 PURPOSE: 1.1 To ensure that patients and families have the right to information regarding their healthcare needs and the expected costs involved. 2.0 SCOPE: 2.1 Outpatient Service. 3.0 RESPONSIBILTY: 3.1 Admission desk, front office, all dental, nursing and paramedical staff involved in direct patient care. 4.0 ABBREVIATION: 4.1 NABH : National Accreditation for Hospitals and Healthcare Providers 4.2 PRE : Patient Rights and Education 5.0 REFERENCE: 5.1 Accreditation Standards for Dental Health Care Service Providers, Third edition, April 2023 5.2 PRE.4: Informed consent is obtained from the patient or family about their care. 5.3 PRE.5: Patient and families have a right to information and education about their healthcare needs. 5.4 PRE.6: Patient and families have a right to information on expected costs. 6.0 POLICY: 6.1 RIGHT TO INFORMATION ON HEALTHCARE NEEDS: 6.1.1 Safe medication: Patient and their family should be informed and educated for safe medication and potential side effect of the medicines he/she is taking. They should be educated about the dose related side effects to prevent any adverse situation and better patient care. All sustained released (SR), Controlled released (CR), Metered released (MR) medicines to be taken at a given interval otherwise adverse situation may appear like drug overdose; PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 11 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 6.1.2 Food and drug interaction: All patient and their relatives should be educated about the food and drug interaction. Some food or fruits inhibits the result of some medicines, some food increase the efficacy of some medicines. 6.1.3 Diet and Nutrition: Patient and their families are educated about the diet and nutrition. 6.1.4 Disease and Prevention: Patient and their relatives are being educated on some specific diseases and their preventive measures, like oral cancer and its prevention etc. Pamphlets is available to educate them on disease and prevention. 6.1.5 Prevention of HAI: Patients and attendants are educated on prevention of HAIs, as and when they come to visit they instructed to maintain hand hygiene, use of barrier devices and not to bring or eat food inside the hospital. To use dust bins according to color coding. 6.1.6 All the pamphlets and awareness giving them in local language which is understandable by them. 6.2 RIGHT TO INFORMATION ON EXPECTED COSTS: 6.2.1 There shall be a uniform billing policy defining the charges to be levied for various services at all levels of care. 6.2.2 The patients and families shall be informed about the costs on the basis of the treatment plan by the OPD / Front Office Staff in consultation with the treating doctor. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 12 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 1.2 PURPOSE: 1.3 To ensure that patients and families have the right to information regarding their healthcare needs and the expected costs involved. 2.2 SCOPE: 2.3 Outpatient Service. 3.2 RESPONSIBILTY: 3.3 Admission desk, front office, all dental, nursing and paramedical staff involved in direct patient care. 4.3 ABBREVIATION: 4.4 NABH : National Accreditation for Hospitals and Healthcare Providers 4.5 PRE : Patient Rights and Education 5.5 REFERENCE: 5.6 Accreditation Standards for Dental Health Care Service Providers, Third edition, Feb 2023 5.7 PRE.7: The organization has a mechanism to capture patient's feedback and to redress complaints. 5.8 PRE.8: The organization has a system for effective communication with patients and /or families. 6.3 POLICY: 6.4 PATIENTS FEED BACK AND REDRESS OF COMPLAINTS 6.4.1 Feed Back from Patients: Patients are informed and educated for providing feedback on treatment he/she is taking. They are educated about the values of the feedback and subsequent better patient care in future. The feedback comprise of Good and adverse so that continual growth is ensured and confident level of the patients on the system is improved. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENTS RIGHTS AND EDUCATION Doc No : Issue Date: Page 13 APDH/NABH/PRE/01/ Version: 03 Issue:01 03/05/2023 of 13 02/03/04/05/06/07/08 6.4.2 Good Feedback: All patients are asked to submit their feedback at the end of the treatment. The positive feedbacks are taken for encouraging the staff concerned and suitably rewarded in suitable occasion. 6.4.3 Bad feedback: Patient's critical comments and their untoward comments are taken and redressed suitably. The feedback on treatment issues are taken to the department concerned and reviewed with the head and addressed to the satisfaction of the patients. 6.5 ORGANISATION HAS A SYSTEM FOR EFFECTIVE COMMUNICATION WITH PATIENTS AND/OR FAMILIES. 6.5.1 The registration of patients is being made with contact phone numbers of the individual and one more number of the relatives are obtained as contact on emergencies. The repeated treatment protocol if any to be adopted it is informed by sms and direct to the registered number of the patient. The general information on free camp, special camps etc are well informed by sms and WhatsApp regularly. PREPARED BY VERIFIED BY APPROVED BY ADMINISTRATIVE OFFICER PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENT SAFETY AND QUALITY IMPROVEMENT Doc No : Issue Date: Page 01 APDH/NABH/PSQ/01 Version: 03 Issue:01 03/05/2023 of 23 /02/03 1.0 PURPOSE: 1.1 To define the policy and procedure for patient safety and quality improvement programme of APDCH hospital. 1.2 To fix key indicators for the processes. 1.3 To organize the measurement process to assess the performance index on such key indicators. 1.4 Scheduling of periodical measurement of performance index of key indicators explained above. 1.5 Based on periodic measurements data to carry out trend analysis. 1.6 Based on trend analysis to implement corrective action when desired for continual improvement 1.7 To establish a defined system for hospital-wide Nonconformance, incident related events management to improve continuously the performance. 1.8 To provide a confidential mechanism of identification, tracking, analyzing and to pursue and implement corrective/preventive actions of all incidences that poses an actual or potential safety risk to patients, families, visitors and staff. 2.0 SCOPE: 2.1 Outpatient Service 2.2 Applicable to all employees of the hospital 3.0 RESPONSIBILITY: 3.1 Doctors 3.2 All hospital staff 3.3 Internal Quality Assurance Committee 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 PSQ : Patient Safety and Quality Improvement PREPARED BY VERIFIED BY APPROVED BY NABH COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – PATIENT SAFETY AND QUALITY IMPROVEMENT Doc No : Issue Date: Page 02 APDH/NABH/PSQ/01 Version: 03 Issue:01 03/05/2023 of 23 /02/03 5.0 DEFINITION: 5.1 Non Conformance: Defined as any event or circumstance not consistent with the standard routine operations or not having compliance to defined processes of the hospital in staff functions on support activities to internal/external customers or on care processes to patients. 5.2 Sentinel Events: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof to a patient, visitor, or an employee. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof”, includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. 5.3 Near Miss: Any process variation which did not affect the outcome but for which a recurrence carries a significant chance of a serious adverse outcome. 5.4 Hazardous conditions: Refer to any set of circumstances (exclusive of disease or condition for which the patient is being treated), which significantly increases the likelihood of a serious adverse outcome. 5.5 Lapse in compliance to statutory safety norms resulting in near miss harms the patients/ staff /visitors or to infrastructure. 5.6 Quality improvements: It is an ongoing response to quality assessment data about a service in ways that improve the process by which services are provided to the patients. 5.7 Risk management: Clinical and administrative activities to identify evaluate and reduce the risk of injury. 6.0 REFERENCE: 6.1 NABH: Accreditation for Dental Health Care Service Provider, Third Edition, Apr 2023 / PSQ 6.2 PSQ.1: There is a structured quality assurance and continuous monitoring programme in the DHSP 6.3 PSQ.2: The DHSP identifies key indicators to monitor the structures, processes and outcomes, which are used as tools for continual improvement. 6.4 PSQ.3: The quality improvement progr