JCIA BOOKLET

TOPIC
CEO Message
KSMC Mission, Vision, Core
Values
Me and My Job
Joint Commission International
Accreditation
International Patients Safety Goals
FOCUS PDCA

PAGE
NUMBER
3
5
5
6
8
12

Performance Improvement Projects

JCIA Chapters
Patient and Family Rights

13
13

Privacy and Confidentiality

Informed Consent
Patient and Family Education

18
19

Assessment and Care of Patient

Physicians` Documentation
Physical Restraint
Moderate And Deep Sedation
Medication Safety
Infection Prevention and Control
Sentinel Event and Root Cause
Analysis
Occurrence Variance Accidental
Report
Emergency Color Codes
Fire Safety
Safety and Security
KSMC web site

Prepared by:
Dr. Yousef Sharif
Ms Anhar Al Bousi
Mrs. Sujamol
Mathew

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Supervised by:
Dr. Saif Ibrahim
Director
Total Quality Management
Department

MESSAGE OF CEO
Dear KSMC family,
Patients Safety First: - is the shared commitment
in the King Saud Medical City and main goal of
Ministry of Health. The approach is strengthening
the organizations ability to achieve world class
outcomes in education and patient care through an
atmosphere of team work, trust, passion and
pursuit of excellence.
To reflect the implementation of our vision,
mission and values that in consistent with MOH
vision, mission and values and to implement royal
decision and MOH ministers instruction to
improve the quality of health care services. Based
on that, we are moving towards the continuous
quality improvement. We got CBAHI
accreditation, which is the first step of our system
improvement as national accreditation program.
Now we will move towards the JCIA program for
continuous quality improvement through the
implementation implementing all standards which
will maintaining and ensuring patient safety and
staff development.
Total Quality Management department team in
collaboration with other departments developed
this booklet in English and Arabic to outlines the
most important standards, safe practices as well as
pertinent policies and procedures. I have found
them most useful and I am sure you will also get
benefited from them.
I would like to thank you on behalf of all the
patients and their families for your excellent hard
work and congratulate you for your firm
commitment and loyalty to our organization in its
pursuit of excellence.
Sincerely,
DR. NABIL AL GOSAIBI
Chief Executive Officer, King Saud Medical City

MESSAGE OF TQM DIRECTOR

Dear colleagues,
Thanks to our staff members for their dedicated
service and commitment towards achieving
excellence. The achievements of KSMC are the
results of the combined efforts of all KSMC
members.
Our focus is now to continuously distinguish
ourselves as a regional health care leading
institution. Were committed to continuously
search for new ways to improve our quality and
make our hospital the best place for patients to
receive care, for physicians to practice and for
employees to work. I extend my sincere thanks for
all your support to our hospital.
The TQM department staff members are always
here for you as a consultant, facilitator, advisor
and also as educators for the patient safety
improvement initiatives.
As a part of our progress towards innovation and
the accreditation process TQM prepared the
educational material (JCIA booklet) for all KSMC
employees that I hope you will find this booklet
most useful.

Sincerely,
DR. SAIF IBRAHIM
TQM Director, King Saud Medical City

Quality is never an accident; it is always the result of high

intention, sincere effort, intelligent direction and skillful
execution; it represents the wise choice of many
alternatives.

KSMC Mission
We are committed to provide safe and distinct
health care for our patients through effective
management and qualified staff while seeking to
achieve good training and continuous development
with the optimal use of the available resources
KSMC Vision
King Saud Medical City will be the Pioneer Health
Organization in providing the best health care in
the Kingdom.
KSMC Core Values
Adhering to the rules of Islamic religion, laws
and regulations in KSA.
Respect of patients and their rights.
Transparency and mutual respect among
workers
Work with team spirit.
Adhering to medical ethics and professional
morale.
Me and My Job
KSMC needs qualified and skilled people to meet its
mission and exceed patient satisfaction needs. Our
staff is recruited as per the organizations staffing plan.
They are oriented to the organization and assigned a
specific job description. Each staff is provided an
opportunity to learn and develop both personally and
professionally.
Some of the questions that ALL staff must be able to
answer:
What is my role in KSMC? How does my job
contribute to or support those who provide
patient care of KSMC?
How was I oriented to the hospital and to my

job?
How am I being evaluated and supervised?
Do I keep all my license, registration and / or
certification current?
What are ongoing in-service education and
Training and Competition I participated in?
Does my HR file contain copies of my in-service
education attendance?
How do I identify my privileges as a clinician
before certain procedures?
What quality improvement projects I participated
in?

Joint Commission International

Accreditation
What is Accreditation?
Accreditation is a voluntary process in which an
entity (e.g. JCI), separate and distinct from health care
organization, usually non-governmental, assess the
health care organization to determine if it meets a set
of international standards to improve the quality of
care provided.
What to expect from JCI?
Surveyor will review the medical record with the
direct care provider (knowledge and practice) and ask
questions.
Sample questions:

Tell me about your patient? (History, reason for

admission, tests, current condition)
How do you assess your patients on admission?
Show me where you document this?
How do you assess patients for pain? Show
me..

What is your role in patient education?....where

do you document?

How do you prepare patients for discharge?

What skill do you need to work in this
area?....Surveyor may then review the staff file.
What to Do and What Not to Do?

Dont run away

Welcome the surveyor to your area

Introduce yourself; explain your position

and how long youve been here.

The surveyor wants to hear about your

everyday practice (safe and competent care)

Answer only what youre asked

Do not volunteer additional information

Ask for clarification if you do not

understand the question

If unsure of the answer, the safest response

is that youd check the policy or ask your
supervisor

Try to allocate appropriate space for the

tracer team to do the interviews

Dont show panic behaviors, or

inappropriate body language
Focus Areas

Environment- medical record charts,

computers, (clean organized unit) Fire
Safety (RACE, nearest fire exits,
extinguishers, alarms).

Patients and family rights

Assessments- nutritional, functional,

discharge planning, etc..

Pain assessment (scales, documentation &

reassessment)

Patient identification (using 2 unique

identifier)

Using read back with verbal/telephone

order and critical result

Falls assessment and reassessment

Procedural sedation

Orientation/competencies/training

Patient and family educationdocumentation

Quality improvement activities

Restraint management
Hand hygiene compliance

International Patient Safety Goals

Joint Commission introduced its 6 patient Safety
Goals in 2007 to highlight problematic areas in health
care and to describe evidence based-and expert based
solutions for these problems.
IPSG 1 Identify Patients
Correctly
APP-KSMC-028-(V2) Patient
Identification
1. Use at least two (2) ways to
identify a patient when:
1.1. Giving medications
1.2. Giving blood and blood
products
1.3. Taking blood samples
1.4. Taking other samples for clinical testing
1.5. Providing treatment or procedure
1.6. Also when food is served.
2.

The two unique identifiers are:

2.1. Patients medical record number (MRN)
2.2. Patients full name

3.

The patients Room Number or Bed Number

must never be used to identify patients.

IPSG 2 Improve Effective

Communication
APP-LB-007 Critical Result Reporting
Policy
Communication can be verbal, electronic or written
1. Staff must use read back to identify the
complete order or test result in the following
situation:
1.1. Verbal order

1.2. Telephone order

1.3. Reporting of critical result value

2.

The receiver of the information will write down

the complete order or test. A colleague will then
be requested to read back the written order or
test result to the individual who gave the order or
test result.

3.

The order or test result is confirmed by the

individual who gave the order or test result.

IPSG 3 Improve the Safety of High-Alert

Medications
APP-KSMC-137- (V1)
High Alert Medication
Management
1.

Concentrated
electrolytes are not
present in patient
care units unless
clinically necessary
and actions are taken
to prevent inadvertent administration in those
areas permitted by policy.

2.

Remove concentrated electrolytes from patient

care units, including, but not limited to the
following:
2.1. Potassium Chloride
2.2. Potassium Phosphate
2.3. Sodium Chloride > 0.9%

IPSG 4 Ensure Correct-Site, Correct- Procedure,

Correct-Patient Surgery
APP KSMC 045 Surgical and/or Procedural site
verification.
1.

Make sure it is the correct patient using two

patient identifiers.

2.

Verify the correct documents (medical records,

consent, radiological images, laboratory test
results, etc.)

3.

Mark the correct site, side, or level with the

patients and/or legal guardians involvement.

4.

Verify correct equipment and implants, if needed.

5.

Conduct the Time-Out process, just before the

surgery and/or invasive procedure, by way of final
verification of the correct patient, correct
procedure, correct site, and correct implants( if
applicable) through active communication among
all members of the surgical and/or procedure team).

IPSG 5 Reduce the Risk of

Health Care Associated
Infections
APP-KSMC-180Hand
Hygiene
1.

The hospital
implements an
effective hand
hygiene program.

2.

The hospital has

adopted or adapted
currently published
and generally accepted hand hygiene guidelines
(can be national or international).

3.

Need data to demonstrate effectiveness.

(Know your Units hand hygiene compliance)

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IPSG 6 Reduce the risk of Patient Harm Resulting

from Falls
APP- KSMC 216 Patient Falls
Prevention
1.

Assess and periodically

reassess each patients risk for
falling, including the potential
risk associated with the
patients medication regimen.

2.

Take action to decrease or eliminate any

identified risks.

3.

Document all the assessments.

International Patient Safety Goals (IPSG) Goals

Goal 1

Goal

Identify
Patients
Correctly

Improve
Effective
2 Commun
ication

Goal 4

Goal 5

Ensure
CorrectSite,
CorrectProcedure,
CorrectPatient
Surgery

Reduce the
Risk of
Health
Care
Associated
Infections
Reduce the

Improve the
Safety
of High-Alert
Medications

Goal 3

11

of
Goal 6 Risk
Patient
Harm
Resulting
from Falls

FOCUS-PDCA MODEL
F- Find a process to improve
O- Organize a team that knows the process
C- Clarify current knowledge
U- Understand variation
S- Select potential process improvement
-

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Plan
Do
Check
Act

Examples of Performance Improvement Projects

in KSMC:
1. Reduce the risk of improper patient identification
prior to surgical procedure.
2. Reduce the risk of ineffective communication
between staff (regarding to verbal orders).
3. Reduce the risk of patient harm resulting from
improper storage and identification of high alert
medications.
4. Increase the rate of documentation of surgery
safety check list.
5. Reduce the rate of CLABSI (Central line
associated blood stream infection).
6. Increate the rate of compliance to hand hygiene
guidelines.
7. Reduce the risk of patient falls and fall related
injuries.
8. Reduce the occurrence of pressure sore during
hospitalization.
9. Improve the employee health program.
10. Increase the patient satisfaction regarding to
cleaning services.
11. Establish an educational channel for patients.
Joint Commission International Accreditation
for Hospitals 2011
14 Chapters Summary:
Chapter1: International patient safety goals
chapter
IPSG.1 Identify Patients Correctly
IPSG.2 Improve Effective Communication
IPSG.3 Improve the Safety of High-Alert
Medications
IPSG.4 Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
IPSG.5 Reduce the Risk of Health CareAssociated
Infections

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IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls
Chapter 2: Access and Continuity of Care
Chapter (ACC)
Access and continuity of care chapter require from
health care organization to provide the care as part of
an integrated system of services, health care
professionals, and level of care to make up a
continuum of care.
Chapter 3: Patient and Family Rights Chapter
(PFR)
Patient and Family Rights chapter require from health
care organization to understand and protect each
patients cultural, psychosocial, and spiritual values.
Chapter 4: Assessment of Patients (AOP)
Assessment of patient chapter requires the healthcare
organization to have an effective patients
assessments process results in decisions about the
patients immediate and continuing treatment needs
for emergency, elective or planned care, even when
the patients condition changes.
Chapter 5: Care of Patient Chapter (COP)
Care of patient chapter require from health care
organization to provide the most appropriate care
from all discipline that care for the patient.
Chapter 6: Anesthesia and Surgical Care
(ASC)
This chapter focus on the use of anesthesia, sedation
in a health care organization, this require complete
and comprehensive patient assessment, integrated
care planning, continued patient monitoring.
Anesthesia and sedation are commonly viewed as a
continuum from minimal sedation to full anesthesia.

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Chapter 7: Medication Management and

Use(MMU)
Medication Management and Use Chapter require the
healthcare organization to manage medication
effectively in order to ensuring patient safety.
Chapter 8: Patient and Family Education
Chapter (PFE)
Patient and Family Education Chapter requires the
health care organization to provide patients and their
families with effective education according to their
needs.
Chapter 9: Quality Improvement and Patient
Safety (QPS)
Quality Improvement and Patient Safety (QPS)
Chapter describes a comprehensive approach to
quality improvement and patient safety. Integral the
overall improvement in quality is the ongoing
reduction in risks to patient and staff.
Chapter 10: Prevention and Control of Infection
Chapter (PCI)
Prevention and Control of Infection Chapter requires
the health care organization to determine infection
control program activities depending on institution
clinical activities and services, patient population,
geographic location, patient volume, and number of
employees.
Chapter 11: Governance, Leadership and
Direction Chapter (GLD)
The Governance, Leadership and Direction Chapter
requires the healthcare organization to identify
organizational leaders and others who hold positions
of leadership, responsibility, and trust and involve
them in dening its mission and ensuring that the
organization is an effective, efficient resource for the

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community and its patients. It consists of 26 standards

and a total of 91 measurable elements.
Chapter 12: Facility Management and Safety
(FMS)
Health care organization work to provide a safe,
functional and supportive facility for patient families,
staff and visitors. The physical facility medical and
other equipment and people must be effectively
managed.
Chapter 13: Staff Qualication & Education
(SQE)
This chapter will work on providing an appropriate
variety of skilled, qualied people to fulll the health
care organizations mission and meet the needs of the
patients it serves.
Chapter 14: Management of Communication
and Information (MCI)
Management of Communication and Information
(MCI) requires the healthcare organization to manage
information effectively in order to provide, coordinate
and integrate the services provided to patients.
Effective communication with the community,
patients and their families and to other health
professionals is an integral part of the patient care
process.

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Patients & Family

Rights
APP-KSMC-163 Patient
Rights &
Responsibilities
1. PRIVACY
The patient has the right to
refuse to talk to or meet anyone who is not officially
and directly involved in the healthcare provided to
him/her including visitors. Medical assessment and
examination are to be conducted in designated areas
out of the sight and hearing of others.

2.

CONFIDENTIALITY
Only direct health care providers have access to
patients files and details of their condition.

3.

REFUSAL OF TREATMENT
When a patient refuses care or chooses to
discontinue treatment/, he/she will be advised of
the consequences of his/her refusal and the
expected outcome of this decision.

4.

COMPLAINTS RESOLUTION

The Patient Relations Department and its

representatives at KSMC medical facilities
familiarize patients and their families with valid
rules and regulations and how to submit
proposals, opinions, and complaints and provide
them with the required feedback.
5.

INFORMED CONSENT
The patient (or his/her family) is entitled to have
a complete explanation of the medical procedure
required for his/her treatment, including risks
and benefits of the proposed procedure, its
complications, and alternative treatments.

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6.

PAIN MANAGEMENT
Patient has the right to have his/her pain assessed
and addressed as part of his treatment plan.

7.

SAFETY
The patient has the right to expect appropriate and
reasonable provision of personal safety insofar as
KSMC treating/healthcare facilities,
environment, and personnel practices are
concerned.

8.

RESPECT, DIGNITY AND

CONSIDERATION
Patients have the right to considerate and
respectful care at all times and under all
circumstances with due recognition of his/her
personal dignity

Privacy and Confidentiality

These are some best practices to maintain patient
privacy and confidentiality:
DOs

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Log-out after using the computers in patient

care areas.
Close doors and curtains during treatment
and examination.
Cover patients appropriately during treatment
and transport.
Modulate voice volume in areas where
privacy could be compromised.

Think about what you say and where you say it

DONTs

Do not share computer passwords.

Do not discuss patient-specific information
in public areas like elevators, food courts and
hallways.
Do not display patient-specific information
on notice boards accessible to the public.
Do not leave medical records in public areas
or unattended by staff.
Do not give treatment, or perform physical
examination or procedure if the patient
belongs to the opposite gender, without the
presence of a person/chaperone/care-provider
of the same (patients) gender present.

Informed Consent
APP-KSMC-093 Obtaining General Consent
APP-KSMC-027 Informed Consent
It is the policy of the King Saud Medical City (KSMC) to
administer consent for admission to hospital for general
treatment, and all invasive or special procedures, surgical
procedures and medical treatment.
Consent for general treatment will be obtained by the
Registration/Admissions clerk at the time of registration
or admission.
Informed Consent
1. It is the process whereby the attending physician
or designee, from the team performing the
surgery/procedure, provides the following
information to the patient, legal guardian,
custodian about specialized (non-routine)
procedure(s).
2.The patients condition
The proposed treatment
Potential benefits, risks, and complications of

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the procedure
Possible alternatives
The likelihood of success
Possible problems related to recovery
Possible risks of non-treatment

3. The legal age to give consent is 18 HEGIRA

years (17 years and 6 months by the Gregorian
calendar) for both males and females.
4. Consent must be obtained by the attending
physician or designee who is going to perform
the treatment procedure/intervention from the
patient, legal guardian.
5. The attending physician or designee will write in
full on the respective consent form (no
abbreviations will be accepted), the name of the
procedure, the site, side, and level (if applicable)
of the procedure to be performed.
6. The consent form shall be completed in English
for non-Arabic speaking patients and in both
English and Arabic for Arabic speaking patients.
7. Consent must be obtained from a patient or legal
representative on behalf of the Patient (should
the patient by unable to give consent) for all
treatments, procedures/interventions in one of
the following consent forms:
SL
#

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Type of Consent

General Consent

Surgery/Procedure
consent

Validity Period

Inpatient: On
admission for all
patient
Outpatient: All
follow up

14 Days only

Anesthesia/
Sedation consent
(includes

4.

Blood & Blood

Products
transfusion Consent
(used when only
blood transfusion
is the only
treatment needed)

14 Days only

14 Days only

8. It is the responsibility of the attending physician

or designee to ensure that the procedure is
explained fully to the patient or representative, or
legal guardian.
Surgical Procedure and Intervention Requiring
Consent
The following list is not an exhaustive one. It is
prudent upon the attending physician to include any
other similar ones that may in this list:

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All surgical procedures (that involve breaking

skin integrity) classical or minimal invasive.
All types of diagnostic or therapeutic
endoscopies.
All types of biopsies.
Central nervous system ventricular taps,
pressure monitoring probes.
Exchange transfusion.
Supra-pubic bladder aspiration/catheterization.
Temporary trans-venous pacing.
Pericardiocentesis, thoracocentesis, peritoneal
paracentesis.
Abscess drainage with or without incision.
Percutaneous nephrostomy.
Intra-uterine transfusion.
Other non-venous percutaneous invasive
procedure.
Lumbar puncture, myelography.
All angiographic diagnostic and therapeutic
procedure.

Hysterosalpingography, amniocentesis,
placenta.
Cordocentesis, aspiration of fetal fluid.
Any other similar procedures.

Patient and Family Education

APP-KSMC-159- (V1) Multidisciplinary Patient and
Family Education
Providing education to the patients and their families
about their health or medical problems enables them
to make informed decisions about their healthcare
needs. It is important for our patients and families to
assume a proactive role in the maintenance and/or
improvement of their own health.
What must you do before teaching patients and
their families?
Before conducting patient and family education, you
need to assess their:
Education level
Preferred language
Readiness to learn
Barriers to learning (psychological, financial,
mental)
Knowledge of the disease, treatment,
complications, and prevention
Assistance from their family
What can you teach?
You can teach patients
and their families:

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Their rights and

responsibilities
The disease
process
Pain Management
Falls prevention
Self-care needs
Medication (safe use of medication, food,

interaction, safe use of medical devices used

for consumption of medication)
Diet and Nutrition
The procedure they will be undergoing
The use of medical equipment
The rehabilitative techniques
The home environment and emergency care
Community resources

All teaching must be summarized & documented in

the interdisciplinary patient / family education
record form No. 569
Remember, all staff plays a role in patient and
family education.

Assessment & Care of Patients

APP-KSMC-135- Patient Assessment and
Reassessment
Assessment of patients
To consistently assess patients needs, the scope and
content of assessment performed by physicians,
nurses and other clinical disciplines as well as forms
to be used must be defined in writing. The new
Physician Admission Assessment form and the
Nursing Assessment Form contain information
required by the standards.
To ensure that patients are treated promptly,
assessments must be completed in a timely manner. A
physicians assessment must be completed within 24
hours. Nurses Admission assessment must be
completed within 4 to 24 hours.
When there is no time to record the complete history
and physical examination of an emergency patient
requiring urgent surgery, a note on the presenting
condition and a preoperative diagnosis is recorded
before surgery.

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Functional Screening**
APP- KSMC 216 Patient Falls Prevention
The most effective way to identify patients with
functional needs is through screening criteria.
Nurses Complete the fall Risk Assessment as part of
their initial assessment, and reassess at least each
shift, OT, PT and Clinical Pharmacist is auto referred
based on preset criteria.
Pain Screening and Assessment
APP-KSMC-085- (V1) Pain Assessment,
Reassessment Management
During the initial assessment and reassessment,
patients must be screened for pain. When pain is
identified, a more comprehensive assessment is
performed. This assessment is appropriate to the
patients age and measures pain intensity and quality
such as pain character, frequency, location, and
duration.
Reassessment of Patient
Reassessment by all of the patients care providers is
the key to understanding whether care decisions are
appropriate and effective. Reassessment by a
physician is integral to ongoing patient care. Hospital
policy requires a consultant physician to assess all
acute care patients daily, including weekends and
holidays.
Integration and Coordination of Patient Care
APP-KSMC-135- (V1) Patients Assessment &
Reassessment
Assessments must be integrated and the most urgent
care needs identified. To effectively integrate and
coordinate care activities, the organization has
implemented the Integrated Plan of Care Form. All
those who care for the patient must document a
summary of care planned with established goals and
timeframe for reassessment.

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Ensure consistent and appropriate care by using

clinical pathways and guidelines e.g. pediatric
bronchial asthma.
Discharge Summary Report
A summary of the patients care is prepared at
discharge and a copy is given to the patient, as
appropriate, the patients family. To ensure a smooth
flow of information, the organization has
implemented the In-patient Discharge summary
Report which must be completed and given to the
patient/family upon discharge.
** Physicians documentation must acknowledge
the results of the Nursing screening.

Physical Documentation
Write it Right

Write legibly
Use Black/Blue Ballpoint Pen
Gregorian date; (dd/mm/yy)
Time : Use 24 hr clock e.g. (1300 for 1pm)
The heading of all physician entries should
include the Date, Time, Physicians Name
and Title Intern, Resident, Consultant, etc..)

The tail of all Physician entries should

include signature, Name, Badge Number,
and Bleeper, Physicians should include their
stamp.
Cross It Right

Cross out wrong

entries with a single
horizontal line

Write Mischarted
or Error next to it
Put your initials beside it

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Do not Use

Prohibited and Unapproved abbreviations

NAD, instead Use Not Relevant
NIL
NA
O

Complete the History and Physical

Within 24 hours of admission

H & P by junior staff physicians reviewed,
validated and co-signed by the consultant
within 24 hours
H & P is legible
H & P is dated
H & P is timed
History And Physical Includes:

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Admission Date / time

Chief Complaint
History of Present Illness
Specialty Specific History
Medical and Surgical History
Family History
Nutritional and Functional
Psychosocial Status
Allergy
Medications
Review of Systems
Pain Assessment
Physical Exam
Investigations
Assessment / Impression
Plan of Care
Educational Needs
Discharge Planning
Consultant Notes

Physical Restraint
APP- KSMC 238 Uses of Restraints
Physical Restraint is an approved mechanical device
or devices which restrict the movement of the whole
or a portion of the patients body for the purposes of
preventing harm to self or others.
Points to Remember:
1. Initiation of Physical Restraint is by the
Physicians order only. Orders for the restraints
shall not exceed twenty-four (24) hours in
duration.
2. Recurrent use of Restraint: a registered Nurse or
Physician shall document in the patients record
the justification for recurrent use of restraints in
addition to the patients physical and behavioral
status.
3. Assessment of patients physical and
psychological well-being shall be made
throughout the restraint period with a maximum of
two (2) hours interval
a. Application of restraint devices- ensuring that
patients have as much freedom as possible.
b.Circulation and degree of movement in the
extremities are evaluated.
c. Each restrained limb is released from restraints
and examined from bruising or skin tears and
exercised (range motion) every two (2) hours.
4. Meals are provided at regular time and fluids are
offered every two (2) hours to ensure nutrition and
hydration.
5. Elimination needs are met at least every two (2)
hours or as requested. Hygiene is offered on a
daily basis.
Restraint should not be started before physician
assessment and order, patient are assessed every 2
hours, and restraint order evaluated every 24 hour

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Moderate and Deep Sedation

APP KSMC- 045 (V2) Moderate and Deep
Sedation Policy
Anesthesia and Surgical care
(ASC)
1.

2.

Hospital Sedation
committee is in-charge of
evaluating the ongoing
practices of sedation by
the non-anesthesiologist
throughout the hospital to
ensure the adherence to
standard of care.

The non Anesthesiologist and the assisting RN /

EMT must be appropriately qualified.
And competent in following:

Techniques of various modes of sedation

Appropriate monitoring
Response to complications
Use of reversal agents (Narcan Flumazenil)
At least Basic Life Support

3.

Pre-sedation Assessment (Risk assessment):

an appropriate evaluation of the patient shall be
undertaken prior to initiation of sedation.

4.

Informed Anesthesia / Sedation consent:

anesthesia must be obtained by physician
providing the sedation, to explain all the
benefits, risks and the alternatives to the patient,
parent and family.

5.

A qualified individual monitors the patient

during sedation (Intra sedation monitoring)
and during the period of recovery from sedation
(Post sedation monitoring) and documents the
finding.

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Document all sedation activity in the hospital in the

hospital sedation form.

Medication Safety
Medication is the leading cause of patient harm in
health care institutions the following strategies are
used to decrease the incident of medication error.
1.

Patients (6) |rights:

2.

Right patient
Right drug
Right time
Right dose
Right route
Right documentation

Prohibited abbreviations.

APP-KSMC-008-(V2) The Prohibited

Abbreviations and Symbols
In accordance with Prohibited abbreviations, the
use of certain abbreviations is prohibited. The list
includes fourteen (14) prohibited abbreviations that
include the eight (8) mandated by JCI.

29

Look Alike, Sound Alike and High Alert

Medications.

3.

APP-KSMC-137- (V1) High Alert Medication

Management.
Look Alike: drugs/medication which due to
their spelling, may look similar with other
drugs / medications names and the
distribution/ administration/ of this medication
may be prone to errors.
Sound-Alike: Drugs/ Medications which due to their
pronunciation may sound similar with other
drugs/medications names and the distribution
administration of these medications may be prone
to errors.
All Look- Alike &Sound -Alike drugs/medications
must be stored separately.
High Alert: Drugs medications that have increase risk
of causing significant harm to a patient when used
incorrectly i.e. insulin and heparin.

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All High Alert medication should have an

independent double check before administration.
4.

Medication Error
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 professional or patient. Errors can
occur during prescribing, dispensing /or
administration.

Medication error shall be reported immediately

through OVAR
PHASES OF MEDICATION ERROR
Phase 1- Ordering/Prescribing
Phase 2- Transcribing
Phase 3 Dispensing
Phase 4 Preparation
Phase 5 Administration
Phase 6 Documentation
Phase 7 Monitoring
5.

Adverse Drug Reaction

A detrimental response to medications,
excluding therapeutic failure, that in unexpected
unintended undesired or excessive response to a
drug. Adverse drug reaction includes
anaphylaxis, arrhythmias, convulsions,
hallucination, a shortness of breath rashes and
other reactions.

Adverse drug reaction shall be reported through the

Adverse Drug Reaction Report (ADR) available on
the intranet- Department of Pharmacy
One strategy to decrease ADR is to make sure the
patient allergy Status is documented in Physician
order sheet or pre-printed physician medication
admission form.

31

6.

Medication reconciliation
Medication reconciliation is a formal process
aimed at preventing of medication errors /
adverse occurrences.
It involves:
1. Obtaining an accurate and complete list
of patients home medications.
2. Comparing the physicians' medication
orders on admission to the list of home
medication.
3. Justifying any discrepancies between
home medications and admission orders.
4. Documenting any changes.
All Patients should have a medication
reconciliation done on admission.

Infection Prevention and Control

Infection Prevention and Control Manual
Standard precautions to prevent infection
transmission
Foundation for
preventing
transmission of
infectious agent during
interactions between
healthcare personnel
and patient are the
work practice having
basic level of infection
control to reduce the
risk of transmission. These infection control practice
should be applied to all blood & body fluids, non
intact skin and mucous membranes, and should be
used for all patients regardless of their diagnosis or
presumed infectious status and they includes:

32

1. Hand Hygiene
A 5 moments of Hand hygiene (When and Why)

1
BEFORE
TOUCHING
PATIENT
2
BEFORE AN
ASEPTIC TASK

AFTER BODY
FLUID
EXPOSURE RISK

4
AFTER
TOUCHING THE
PATIENT

AFTER
TOUCHING
PATIENT
SURROUNDINGS

33

When: Clean Your hands

before touching a patient
when approaching him/her
Why: To protect the patient
against harmful germs
carried on your hands
When: Clean Your hands
immediately before any
aseptic task.
Why: To protect the patient
against harmful germs,
including the patients own
from entering his/her body
When: Clean Your hands
immediately after an
exposure risk to body
fluids(and after glove
removal)
Why: To protect yourself
and the health care
environment from harmful
patient germs
When: Clean Your hands
after touching patient and
her/his immediate
surroundings when leaving
the patients side.
Why: To protect yourself
and the health- care
environment from harmful
patient germs
When: Clean Your hands
after touching any object or
furniture in the patients
immediate Surroundings,
when leaving-even if the
patient has not been
touched.
Why: To protect yourself
and the health- care
environment from harmful
patient germs

B- Hand hygiene (how)

How to hand wash?

WASH HANDS ONLY WHEN VISIBLY SOILED!
OTHERWISE USE HANDRUB

34

Limitation of alcohol based hand rub (ABHR):

ABHR is inactive when hands are visibly dirty and
when dealing with spore forming bacteria
(clostridium defficile)
2.

Use of Personal protective equipment (PPE)

a. Donning: (Hand hygiene), Gown, mask or
respirators, goggles/ face shield, gloves.
b. Removing: gloves, goggles or face shield,
Gown, mask, (hand hygiene)

3.

Use of aseptic techniques

4.

Patient care equipment

o Handle equipment soiled with blood and
body fluids, secretion and excretion in a
manner that prevents skin and mucous
membrane exposure, contamination or
clothing and transfer of pathogens to other
patients or the environment.

5.

Collection and handling of Lab specimens

(they are considered infectious at all times)

6.

Respiratory hygiene and cough Etiquette

(Cover the nose/mouth when coughing sneezing,
using tissue to maintain respiratory secretion and
dispose them in the nearest waste disposal and
then perform hand hygiene).

7.

Waste Disposal: Ensure safe waste management

o Safe handling and disposal of sharp
o Linen management
o Medical waste Management
o Use the appropriate color code
waste Bags:
-

35

Use yellow bag for: infectious

waste, container with blood/body
fluids cannot be emptied, all
specimens: Blood ( more than
20ml ), body fluids. Swab etc.,
items moderately or grossly

soaked in blood or body fluids,

chemotherapy waste.
Use Blue bag / Water Soluble Bag
for: Contaminated
Linen/gown/pillow.
Use red bag for: body parts,
organs, fetuses,and placenta.
Use Black bag for: general waste,
items not moderately or grossly
soiled in blood/body fluids.
Use water soluble bag for: linen
which is using in Isolation rooms.

Needle Stick/Sharp Injury

1. First Aid

Allow the site to bleed gently

Wash generously with soap and water

Cleanse with alcohol wipes

Cover with appropriate bandages

2.

Fill out OVAR (Occurrence/Variance /Accident

Report)
Report for medical assessment at employee
health clinic or ER (weekends)
Comply with follow up recommendations

Body Fluid Exposure

1. First Aid

Irrigate affected area with copious amount

of water
2.

Fill out OVAR

Report for medical assessment at Employee
health clinic or ER (weekends)
Comply with follow up recommendations

Infection control is everybodys business

Refer to the Infection Control Manual for more
details
For more information contact infection control
department ext3214, 3216,
1697,134 ,201

36

Sentinel Event &Root cause analysis RCA

APP-KSMC-006 Sentinel Event & RCA

A sentinel event: A sentinel event signals need for

immediate investigation and response. A sentinel
event is an unexpected occurrence involving death
or serious physical or psychological injury or the
risk thereof. Serious injury specifically includes
loss of limb or function. The phrase or the risk
thereof includes any process variation for which a
reoccurrence would carry a significant chance of a
serious adverse outcome.
Root Cause Analysis (RCA) -is a process for
identifying the basic or causal factor of an adverse
event. Root Cause Analysis primarily focuses on
system and processes, not individual performance.
Sentinel events are defined as the result or outcome of
the following occurrences:
1.

Any event that results in an unanticipated death

or major permanent loss of function, not related
to the natural cause of the patients illness or
underlying condition or;

2.

The event is one of the following (Even if the

outcome was not death or major permanent loss
of function:
a)

b)

c)
d)
e)
f)
g)

37

An unanticipated major permanent loss of

organ or function, not related to the natural
course of the patients illness or underlying
condition.
Death, paralysis, coma, or other major
permanent loss of function associated with a
medication error.
Suicide of any patient receiving inpatient
care.
Maternal Death.
An unanticipated death of a full-term infant.
Abduction of any patient receiving care,
treatment or services.
Patient fall resulting in death or permanent
loss of function.

h) Discharge of an infant to the wrong

family.
i) Hemolytic transfusion reaction involving
administration of blood or blood products
having major blood group
incompatibilities.
j) Surgery on the wrong patient or wrong
body part.
k) Unintended retention of a foreign object in
a patient after surgery or other procedure.
l) Rape
Team Formation- once a Sentinel Event has been
identified the sentinel event Committee will
immediately appoint members for RCA team to direct
the investigation. The team utilizes the root cause
analysis template and completes an action plan.
Sentinel Event Reporting Flow Chart

38

Occurrence Variance Accident Report (OVAR)

and Safety Reporting System
APP-KSMC-005 Occurrence Variance Accident
Reporting
An incident may be defined as any event that has
caused harm, or has the potential to harm a patient,
visitor or staff member, or any event which involves
malfunction, damage or loss of equipment or
property, and event which might lead to a complaint.
The policy on Occurrence/Variance /Accident Report
(OVAR) provides a mechanism for reporting risk
management/ safety variance or accident related to
practice, process or outcome.
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.

An OVAR report should be completed if any of

the following occur:
1.

An error o mistakes that injuries or could have

injured a patient, employee or visitor.

2.

Failure or shortage of direct patient care

equipment, utility or material had adverse impact
or could have adverse impact upon patient care
outcome.

3.

An incident that cause an angry reaction by a

patient or family member.

4.

An incident that inhibits a process or system and

has an adverse effect upon patient care.

PROCEDURE FOR COMPLETION

1.

39

The Quality Designee is responsible for

ensuring the report information is complete and
that applicable boxes are indicated. Where an
addressograph is not available, the name and ID

badge number or medical record number should

be written in the box provided.
2. In cases resulting in employee injury, the report
should be completed by the injured person when
possible or by the immediate supervisor if the
employee is physical unable to do so.
3. OVAR report is routed to the Quality
Management Department for further actions
according to the risk severity of the events.

40

Emergency Coding System

APP-KSMC-125 Emergency Codes (Code Blue,
Code Red, Code Yellow, Code White, Code Pink,
Code Orange, Code Green, Code Black, Mr. Strong

41

Hospital Fire Safety Program

When you discover a fire

Remember: Always use proper type extinguisher to

fight fire
FM 200 7DRY POWDER
CO2SUBSCRIPT
WATER

: CLASS B& C
: CLASS B&C
: CLASS A ONLY

CLASS A: Solid or ordinary combustible materials

(Paper, Wood, Rubber, Plastic)
CLASS B: Flammable liquids and gasses

CLASS C: Involving energized electrical

equipment

42

Observe effective fire safety and fire prevention

measures:
1.

2.
3.
4.
5.

6.
7.

Ensure that your department/ ward practice good

housekeeping. Dispose of all oily rags in left on
top of closed containers.
Report any faulty equipment.
Store flammable/ combustible items properly.
Ensure that staff is aware of the procedure for
safe handling of such items.
Ensure that staff are aware of the evacuation
routes and assembly points of the department /
ward.
Know where your fire extinguisher is and how to
operate them.
Familiarize yourself with the safety manual and
attend regularly fire safety drill & Fire safety inservice training.

8.

9.

In case of fire the nurse in charge of the

unit/area is responsible with the shutting off
of oxygen valve by breaking the glass or
removing the acrylic cover (pulling out)
In case of emergency, call the emergency
number of KSMC

Always treat a spilled substance as hazardous

unless identified as non-hazardous by proper
authority
Hazardous Material Spill Procedure (by code
orange Team/or fire department):

Management of Spills of Hazardous Material

43

Report immediately by calling 1970 or 555.

Isolate the area immediately.
Try to identify the spilled material and
inform the code orange Team/or fire
department.
Do not attempt to clear the spill unless
properly trained or wearing proper
protective equipment.
Meet the code orange Team/or fire
department and relay relevant information.

Important numbers

General Hospital

IN CASE OF FIRE

1970

ER HOT LINE

1234

SECURITY
EMERGENCY
MAINTENANCE
REQUEST
URGENT
MAINTENANCE
OPEARATOR
UTILITY
SYSTEM
FAILURE

Maternity
Hospital
and
Pediatric
Hospital

1888
1747/1364

555 / 188

1616
9
1747/1364/212

Safety and Security

KSMC has dedicated security team available around
the clock to ensure that the hospital environment is
safe for staff and patient.
For security assistance please calls security EXT:
1888 or Hospital administrator on duty EXT: 1230

General Guidelines:
Staff should were their ID badge, prominently
or left chest.
Be alert when you see visitors unidentified in
the staff and patient area.
Ensure that door; especially number-accessed
doors are closed properly.

44

Safety and Security System for Newborns

APP-KSMC-010 Infant/ Child Abduction
The purpose is to identify areas and conditions where
newborn and pediatric patients are exposed to the risk
of abduction, and implement security measures that
prevent abduction of new born and pediatric patients.
All staff in the clinical areas must be aware and
uphold the provisions for visitors by allowing no
more than two visitors at any given time.
All babies shall be transported in the hospital and
discharged accompanied by a nurse.
Code pink will be activated when an infant and/or
child is missing or is known to have been kidnapped.
Every one is responsible for safety.
Your safety is our concern
KSMC WEB SITE

Home Page

For Medical
Record Forms

45

http://www.ksmc.med.sa or
http://100.43.100.62/ksmcportal

http://100.43.100.62/ksm
cportal/system/applicatio
n/views/admin/upload/

Journey
is continuous

to get

JCIA

46