Critical Patient Safety Areas Of MSDS PHC .PPT

Critical Patient Safety Areas Of MSDS PHC CPSA

1. In the name of Allah, the most gracious, the most merciful.

2. Critical Patients Safety Areas ( CPSAs) WHY CPSA ? Impact Of CPSA How To Respond CPSA ?

3. WHY CPSA In order to ensure patient safety at PL stage, implementation of a set of Critical Patients Safety Areas (CPSA) for PL has been made mandatory for hospitals. 3

4. IMPACT of CPSA Living Document Almost Covering 50% overall concept and set up of Minimum Service Delivery Standards in Hospital for Patient Safety 4

5. HOW To RESPOND CPSA ACCESS to Portal for HCE 5

6. 1.Qualified Human Resource as per Declared Scope of Services

7. Required Qualification of MS/Administrator Medical graduate/Management Qualification JD of Administrator/MS Appointment letter 1(a) : Documentary evidence that appropriately qualified individual is heading the hospital

8. Mark Service list in accordance with the available consultants 1(b): List of services provided on given format .

9. Provide the list of appropriately qualified consultants and specialists duly registered with the Pakistan Medical Commission (PMC) to provide the services declared by the hospital in the services list 1(c): List of qualified consultants/ specialists providing the services mentioned in the services list

10. Provide the list of qualified doctors duly registered with PMC, providing 24/7 medical coverage at the hospital as per below format: 1(d): List of doctors providing 24/7 Coverage, on given format

11. Provide the list of nurses duly registered with PNC, providing 24/7 medical coverage at the hospital as per below format 1(e): List of Nursing Staff Providing 24/7 coverage, on given format

12. 2.Emergency Services

13. Beds HR (number of MO, Staff) SOP's (Admission, Notes, Discharge, Death) MLC Policy Triage Referral Equipment list Services list 2(a): Emergency SOPs are available, staff trained and implemented

14. Emergency services log book Check disposal (Admission, Discharge or referral) Relevant slips 2(b): Evidence of admission & disposal record of patients from emergency department .

15. Emergency Department Check list Hospital Emergency Departments Operational Model 2(c): Emergency management guidelines issued by PHC are available and implemented .

16. List of Emergency Department Equipment 2(d): List of Emergency Department Equipment on given format .

17. 3.Safe Blood Transfusion Services

18. SOPs must include Donor screening Processing of blood Storage of blood Administration of blood Use of blood product Identification and analysis of real and suspect transfusion Disposal of blood and related products Office order Training report Pictorial evidence 3(a): SOPs for Blood Transfusion Services available, staff trained and implemented .

19. Reactions are analyzed Check staff member awareness of reporting process 3(b): : Updated record of Blood Transfusion reaction analysis available

20. 1. Upload PBTA license of your hospital OR 2. If PBTA license is expired then upload evidence that the HCE has applied for renewal of license OR 3. Upload MOU with PBTA licensed blood bank duly vetted by PBTA OR 4. Upload evidence that the hospital has applied to PBTA for vetted MOU i.e. upload copy of application to PBTA along with fee challan , copy of MOU with PBTA licensed blood bank and valid PBTA license of that blood bank and 5. Registration with PBTA or applied for PBTA registration is not enough to comply the requirement 3(c): PBTA Registration/ License / MOU Vet by PBTA available

21. 4.Hospital Infection Control

22. Hospital infection control plan which includes: Surveillance activities Hand hygiene procedures Isolation procedures Responsibilities and authorities of committee Orientation of plan 4(a): Hospital Infection Control Plan available, staff trained and implemented .

23. Notification of Infection Control Committee : Wide representation from the relevant departments Infection Control Nurse / Infection Control Officer Responsibilities of ICO/ICN 4(b): Notification of HIC Committee with TORs and minutes of meeting available

24. Notification of Infection control committee Medical specialist Surgical specialist OT Incharge Lab Technician IC Nurse Minutes of meeting Notification of IC Nurse Training of IC Nurse JD of IC Nurse 4(c): Notification of HIC Committee with TORs and minutes of meeting available .

25. Notification of Infection control committee 4(d): Notification of HIC team with TORs and evidence of daily activity available .

26. Notification of IC Nurse Training of IC Nurse JD of IC Nurse 4(e): Notification of Infection Control Nurse/Officer with JD available

27. REGULAR VALIDATION TESTS FOR STERILIZATION ARE CARRIED OUT AND DOCUMENTED STERILIZATION CONTROLS LOT CONTROL STICKER EVENT RELATED DATING STORAGE 4(f): Record of sterilization validation available

28. 5.Operation Theatre Surveillance

29. Quality assurance (QA) in quality services is an integrate part of the overall QA program of the organization. It focuses on post-operative complication, e.g. bleeding, post-operative infection, rational use of antibiotics etc Salient features of the QA program Inventory management Equipment maintenance Staffing schedules Policies to ensure quality Process prior to procedure Regulation OT Surveillance Surgical Site Infection 5(a): OT SOPs available, staff trained and implemented

30. Culture reports from 7 different places at 37C and 72hrs Reports must not be older than 6 months 5(b): External OT Swab Culture Reports (within last 6 months) from seven sites available

31. Breakdown Recall The HCE shall ensure that the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items. The Autoclave register provides the record of sterilization activities with batch no., items sterilized, and date of sterilization, expiry and where these are sent. It also documents the sterilization validation tests and thus helps in retrieving the items in case of any sterilization breakdown. Whenever a breakdown in the sterilization system is noted, all packs sterilized by the faulty machine should immediately be called back from the respective area where the sterile packs has been supplied. The packs called back should be sent for re-sterilization using a proper machine/technique. 5(c): Policy for sterilization breakdown recall with record available .

32. List of OT Equipment 5(d): List of OT Equipment on given format available .

33. 6.Fire & Non Fire Emergencies  

34. 6(a): Fire & Non Fire Emergency Plan available, staff trained and implemented Fire and non fire emergency plan Early Detection Containment Abatement Office order Training

35. Emergency evacuation drill (at least once in a year) Evacuation drill report Pictorial evidence 6(b): Evidence of MOCK fire drill within last twelve months available

36. Exit maps should be visible at different places 6(c): Documented Safe Exit Plan available

37. 7.Hospital Waste Management

38. 7(a): Hospital Waste Management Plan available, staff trained and implemented Number of Waste Points Risk/Non-Risk Location of Risk/Non-Risk central storage facility Estimated cost of bags, containers Number of Staff Onsite/Offsite treatment facility Waste management team Duties and responsibilities of staff Training on waste management

39. 7(b): Notification of HWM Committee available Notification of HWM Committee

40. 7(c): MOU for Hospital Waste Disposal or Documented in-house arrangements Incinerator/ MOU Validity of MOU Signatures of both parties

41. 8.Surgical Services

42. SOPs of Pre-operative assessment Informed consent of surgery TIME OUT Protocol Operation Notes Post-Operative plan of care Procedures for pre-operative and post operative handover of the patients Approved by MS 8(a): Documented SOPs for Surgical Procedures available, staff trained and implemented

43. Marking of surgical site when there is a possibility of bilateral confusion Pre-operative checklist (ALL documents X-ray, medical record and needed equipment is available) Time out protocol prior to the induction of anesthesia Marking of site for surgery Verifying the correct operative site is the responsibility of the surgical t eam members. 8(b): Documented SOPs address the prevention of adverse events like wrong site, wrong patient and wrong surgery.

44. 8(c): Evidence of recording of surgical site infection rate is available . Total Infected Surgeries / Total Surgeries * 100 = Percentage of Infected Surgeries Total Infected Surgeries of Surgeon (Dr. ABC) / Total Surgeries of Surgeon (Dr. ABC) * 100 = Percentage of Infected Surgeries of Specific Doctor Total Infected Surgeries of (Procedure Name) / Total Surgeries (Procedure Name) * 100 = Percentage of Infected Surgeries Specific Procedure Total Infected Surgeries of (OT1) / Total Surgeries of (OT1) * 100 = Percentage of Infected Surgeries OT1 Specific

45. 9.Anesthesia Services

46. Pre-anesthesia evaluation Assignment of an anesthesia risk scoring Documentation requirements during anesthesia Recording of any complications Post-anesthesia monitoring requirement Discharge from Post Anesthesia/Post-Operative Care (Recovery Room): 9(a): Documented SOPs for Administration of Anesthesia are available, staff trained and implemented

47. Register 9(b): : ALL adverse anaesthesia events are recorded and monitored.

48. 10.Management of Medication

49. Policy/SOPs Who will prescribe How prescriptions must be written Which staff can prescribe and which staff can administer What done when the order is not accepted because of confusion about order 10(a): Documented SOPs for Prescription, dispensation and administration are available, staff trained and implemented .

50. Verbal order policy Observe staff receiving verbal orders Option of sending SMS/Voice message may also be considered 10(b): Documented policy on verbal orders is available, staff trained and implemented .

51. Safe storage practices Matching the order with the correct patient and medication Confirming look alike drugs Labeling 10(c): Documented SOPs guide the safe storage and dispensing of medication.

52. Policy of medicine recall Review documents in case of recall 10(d): Medication recall policy with ADR reporting system is available, staff trained and implemented .

53. Staff members aware who can w rite the orders Supported by the evidence in medical record 10(e): Evidence of staff authorization for prescription of medication, administration/dispensing of medication and entry in medical records

54. At ABC Hospital XYZ self-administration of medication by the patients is not allowed. 10(f): SOPs regarding patient’s self-administration of medication are defined.

55. Right Patient : Staff member administering the drug should identify the patient prior to administration By comparing medication orders in treatment chart with the label of the drug and patient name and other data Verbally asking the prescriber before administration: Check the patient name & hospital number against the chart & I.D. band. Ask the patient to state her name with Husband/Father name. 10(g): Policy of patient identification prior to administration of medicine

56. Right Drug: Identify the drug from the order. Clarify with the doctor if in doubt. Check the drug three times: Before removing it from the trolley or shelf When the drug is removed from the container Before the container is returned to storage BEST PRACTICE INDICATES USING GENERIC NAMES OF MEDICATIONS WHENEVER POSSIBLE Check the expiry date of the drug 10(h): Policy of medication verification from the order prior to administration .

57. Right Dose : Check the dose, read the container label, calculate the dose & check with a prescriber if necessary. Use proper measuring devices for liquids, do not crush tablets or open capsules unless directed by the pharmacist. (do not crush enteric coated tablets). If a drug is required in another form you may get it from the pharmacy. Know the abbreviations for different dosing schedules like: OD (once daily), BD (twice daily), TDS (thrice daily), QID (four times daily) 10( i ): Policy of dosage verification from the order prior to administration .

58. Right Route: Make sure the Prescriber’s order is clear & only give the medications by the route designated. Know the abbreviations for the different routes like IV (intravenous), SC (sub cutaneous), IM (intramuscular), PO (per oral) etc. 10(j): Policy of route verification from the order prior to administration .

59. Right Time: Check the time interval ordered & give the medication at the prescribed time. Drugs should be given within 20 minutes of orders. 10(k): Policy of timing verification from the order prior to administration .

60. Medications brought from outside the hospital are not allowed during hospital stay except those medications which are included in the prescription by attending physician 10(l): Policies and procedures govern patients medications brought from outside the organization are available, staff trained and implemented .

61. Definition of High Risk Medication   High Risk Medicines must be re-verified from the doctor prior to administration. List of high risk medicines Must include Conc. electrolytes (like KCl ) Chemotherapy Very high cost drugs LASA Biogenic products Psychotropics 10(m): Documented process for safety of high risk medications is available, staff trained and implemented .

62. 11.Continuous Quality Improvement  

63. CQI Plan must contains CQI committee TORs Responsibilities of committee Authorities Methodology KPIs Reporting Structure Minutes of meeting format CQI coordinator Responsibilities 11(a ): : CQI Program is available, staff trained and implemented

64. CQI Coordinator Notification 11(b): : The Quality improvement plan is communicated to ALL employees of the HCE through a proper orientation mechanism

65. Sentinel event definition List of events Reporting system Register that must contain: Date Event Corrective action Prevention 11(c): The hospital has defined sentinel events and are intensively analysed when they occur.

66. 12.Medical Record

67. 12(a ): Documented process for patient unique identification & evidence of implementation is available, staff trained and implemented. Unique MR Number for Emergency is: YYYY/MM/ER/PCN e.g. (2022/03/ER/001) Unique MR Number for Indoor is: YYYY/MM/ID/PCN e.g. ( 2022/03/ID/001) Unique MR Number for OPD is: YYYY/MM/OPD/PCN e.g. (2022/03/OPD/001 )

68. 12(b): Medical record review policy is available, staff trained and implemented Medical record Review Policy Process of periodic review Review contains both active and discharged patients Set sample size standard Identify deficiencies Corrective n preventive measures Make report Review focuses on timeliness legibility completeness Medical Record Review Committee + Notification

69. Document must include Identification of deficiencies Corrective and preventive measures 12(c): Evidence of last medical Record Review report

70. 13.Complaint Management System

71. Inform complainant about complaint status PROCESS FOR REDRESS COMPLAINTS 13(a ): Documented Complaint Management System is available, staff trained and implemented .

72. 13(b): Evidence that standee prescribed by PHC displayed .

73. Display Charts 13(c): Evidence that Patients’ Rights & Responsibility Displayed

74. 14.Diagnostic Services  

75. Laboratory SOPs Handling of Specimens Laboratory Safety Procedures HISTOLOGY & CYTOLOGY LABORATORY SAFETY PROCEDURES INFECTIOUS WASTE 14(a ): Lab Policy Manual (SOPs) is available, staff trained and implemented .

76. Identification Client’s/Patient’s name Identification number Examination requested Relevant history Information relating to the gestational status in women of childbearing age Identity of the requesting physician Safe Transportation Transferring Patients to and from the Exam Table 14(b): SOPs for patient identification and safe transportation regarding imaging services are available, staff trained and implemented .

77. 14(c): Laboratory services are available within a defined time frame.

78. Defined critical values and its Reporting List of Radiology Critical Results (Findings) General : Retained sponge or other clinically significant foreign body, new/unexpected and clinically significant mass/ tumour or arterial dissection/occlusion. Acute Abdomen: Life-threatening obstruction; previously undiagnosed abscess, acute thrombotic or embolic event, including DVT; unexpected or previously undiagnosed free air or active leakage; previously undiagnosed, clinically significant haemorrhage or vascular disruption, ectopic pregnancy and intestinal ischemia. Acute Chest: New, unexpected, clinically significant collapse of lung, pneumothorax and pulmonary artery embolus. Acute Skeletal: Impending pathologic fracture and new, unexpected, clinically significant fracture. Foreign Body The critical findings are conveyed to the doctor immediately. 14(d): Critical results are reported immediately to the concerned personnel.

79. PNRA License, MOU having validity, sign of both parties PNRA and PHC registration of institute who signed the MOU 14(f): PNRA License .

80. MOU having validity, sign of both parties PNRA and PHC registration of institute who signed the MOU 14(g): Evidence of list of in-house and outsourced tests / investigations along with evidence of outsourcing .

81. Evidence that Backup Power Supply plan for all patient areas, OTs and Life Support Systems is available 15: Backup Power supply .

82. Medical gas supply 16: Proper medical gas supply system .

83. Applicable Only CAT 1 Hospitals 17: Performance Assessment System .

84. Take into consideration the requirements of CPSA Reflect services of hospital in visuals from main board, main gate to final roof. Ensure to add visuals from within OT/s, labour room, emergency, sterilization area, internal ramp/lift, reception, waiting area, equipment, lab, hygienic condition etc. Video must not be more than 3 minutes 18: VIDEO Of HCE .

85. Upload/Display 19: Geographical Location .

86. Check all sections are filled with Y/Yes Required declaration must be filled and signed MS & Owner as per prescribed format and attached 20: Declaration Submission .