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Essential Safety Requirements - ESR Standards for Saudi CBAHI Accreditation in Hospitals and PHCS.

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  1. 1. Joven Botin Bilbao, RN, MAN Deputy Chief Nurse Officer Clinical and Accreditation Educator
  2. 2. QM.17 The hospital has a process to ensure correct identification of patients.
  3. 3. “can you tell me your name and address” “are you Ahmed Saeed Saleh Alqahtani”,
  4. 4. Q.M. 18 The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure.
  5. 5. A Surgical Safety Checklist Should Be Done For At Least:  Procedures that investigate and/or treat diseases and disorders of the human body through cutting, removing, altering, or insertion of diagnostic /therapeutic scopes.  The Sign In, Sign Out, and Time Out applies to a location in the hospital where these procedures are performed, and it must be done just before starting the procedure which involves the entire operative team.
  6. 6. Protocol : Pre-operative verification process Marking of the precise site of procedure/surgery A time-out that is held immediately before the start of any procedure/Surgery.
  7. 7. Pre-operative Checklist Will be initiated the day before the surgery unless the procedure is an emergency.
  8. 8. Surgical Site Marking :  Involve the patient  Done with an instantly recognize mark “X”  Be consistent throughout the hospital  Be made by the person performing the procedure  Take place with the patient awake and aware, if possible.  Be visible after the patient is prepped and draped.  Marked in all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine)
  9. 9. Exemption of marking the surgical site:  Single organ  Interventional cases for which the catheter/instruments insertion site is not predetermined.  Teeth-But, indicate operative tooth name(s) on documentation.  Premature infants, for whom the mark may cause a permanent tattoo.
  10. 10. The Sign In process:  To verify the correct site, procedure, and patient  To confirm Informed Consent is obtained.  Identify site by marking.  Pre anesthesia assessment done  Pulse oximeter on patient and functioning.  Diagnostic and radiologic test result is available  Known allergy.  Difficult Airway/Aspiration risk.  Crossmatching done.
  11. 11. Time Out   
  12. 12. Sign out  The performed procedure have to be recorded.  Confirmed that the count complete  Specimen identified and labeled  Any equipment problems.  Post operative management in the recovery area.
  13. 13. PC.25 Policies And Procedures Guide The Handling, Use, and Administration Of Blood And Blood Products.
  14. 14. ”Transfusion without NAT testing".  Two staff members  
  15. 15. P.C. 26 Patients at risk for developing venous thromboembol ism are identified and managed.
  17. 17. ( Chemical and Mechanical)SHOULD
  18. 18. Thank You