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

1. Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer
Clinical and Accreditation Educator

2. QM.17
The hospital
has a process
to ensure
correct
identification
of patients.

4. “can you tell me your name and
address” “are you Ahmed Saeed Saleh
Alqahtani”,

5. Q.M. 18
The hospital has a
process to prevent
wrong patient,
wrong site,
and wrong
surgery/procedure.

6. 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.

7. 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.

8. Pre-operative Checklist
Will be initiated the day before the
surgery unless the procedure is an
emergency.

9. 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)

10. 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.

11. 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.

12. Time Out




13. 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.

14. PC.25
Policies And
Procedures
Guide The
Handling,
Use, and
Administration Of
Blood And Blood
Products.

16. ”Transfusion without NAT testing".
 Two staff members



17. P.C. 26
Patients at
risk for
developing
venous
thromboembol
ism are
identified and
managed.

18. ADULT VENOUS
THROMBOEMBOLISM RISK ASSESSMENT TOOL.


19. ( Chemical and
Mechanical)SHOULD

21. Thank You