Security Forces Hospital Program Makkah ESR Guide

ESSENTIAL SAFETY REQUIREMENTS

ORIENTATION HANDBOOK
Security Forces Hospital Program Makkah ESR Guide

SECURITY FORCES HOSPITAL PROGRAM MAKKAH

VISION
To be recognized as a role model hospital and to be the first
choice healthcare provider for our clients.

MISSION
To augment clients’ quality of life by providing high quality healthcare services to
Ministry of interior employees and their dependents, By implementing a client centered
system which integrates updated technologies, with staff competencies development,
and copes with Makkah’s unique condition by adopting continuous readiness strategies.

VALUES
TRUST, Teamwork, Responsibility, Unique service, Sustainability, Transparency

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Contents:
Intent Statement.......................................................................................................................................................................................................................................... 3
What are Essential Safety Requirements (ESR)? ......................................................................................................................................................................................... 3
How are Essential Safety Requirements scored? ........................................................................................................................................................................................ 3
Frequently Asked Questions ........................................................................................................................................................................................................................ 4
HR.05 Credentialing Process.................................................................................................................................................................................................................... 4
MS.07 Clinical Privileges .......................................................................................................................................................................................................................... 5
PC.25 Handling, Use and Administration of Blood and Blood Products .................................................................................................................................................. 6
PC.26 Venous Thromboembolism ........................................................................................................................................................................................................... 7
QM.17 Patient Identification ................................................................................................................................................................................................................... 8
QM.18 Sign-in, Time-out and Sign-out .................................................................................................................................................................................................... 9
AN.02 Anesthesia Staff Qualifications ................................................................................................................................................................................................... 10
AN.15 Moderate and Deep Sedation..................................................................................................................................................................................................... 10
IPC.04 Infection Control Committee ...................................................................................................................................................................................................... 12
IPC.15 Isolation Practices ....................................................................................................................................................................................................................... 13
MM.05 High-Alert Medications ............................................................................................................................................................................................................. 14
MM.06 Look-a-Like, Sound-a-Like Medications .................................................................................................................................................................................... 15
MM.41 MEDICATION ERROR ................................................................................................................................................................................................................. 16
LB.51 Blood/Platelet Transfusion Disease Transmission ....................................................................................................................................................................... 17
FMS.09 Radiation Safety ........................................................................................................................................................................................................................ 18
FMS.21 Fire Alarm ................................................................................................................................................................................................................................. 19
FMS.22 Fire Suppression ....................................................................................................................................................................................................................... 19
FMS.23 Fire Exits.................................................................................................................................................................................................................................... 20
FMS.24 Fire and Smoke ......................................................................................................................................................................................................................... 20
FMS.32 Medical Gas System .................................................................................................................................................................................................................. 21
List of Related Policies for Review ............................................................................................................................................................................................................. 21
How to Access Hospital Intranet? .............................................................................................................................................................................................................. 23

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Intent Statement
This guide is intended to provide oversight and general orientation about ESRs identified by CBAHI and included general concepts. It is not intended to be an all-
inclusive resource. Further information about procedures standardizing each ESR can be found in related policies (a list of related policies is included at the end of this
handbook and can be accessed through the hospital intranet.

What are Essential Safety Requirements (ESR)?

Essential Safety Requirements are defined as essential structures and practices that the hospitals undergoing CBAHI accreditation must have in place and be in full
compliance with, to minimize the risk of serious harm and/or death of a patient or a staff member. The list was not meant to be all-inclusive of essential safety
requirements but rather, a focus on some areas that are relevant to our national context.

How are Essential Safety Requirements scored?

ESRs are scored similar to the old physiological principle ; the “ All or None Law “ , meaning that a standard that represents an Essential Safety Requirement is
scored during the on-site survey as a full rate or zero, depending on the level of compliance as evidenced by documentation/interview/or observation of the surveyor.
Partial compliance will not be acceptable for any ESR and accreditation award will not be granted unless all ESRs are in full compliance.

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Q3: What are the documents to be presented for verifications of credentials?

Frequently Asked Questions
A3: All candidates applying for hire shall submit a complete set of documents for
HR.05 Credentialing Process credentialing process that shall contain the following documents:

Standard HR.5: The hospital has a process for proper credentialing of staff o Professional resume containing professional history
members licensed to provide patient care. o Copies of qualifying education and training certificates, courses/
workshops/seminars attended.
HR.5.1 The hospital has a written policy describing the process used for the verification of
o Experience credentials.
credentials.
o Published research - if any.
HR.5.2 The hospital gathers, verifies, and evaluates the credentials (license, education,
training, certification and experience) of those medical staff, nursing staff, and other health o Evidence of current Malpractice coverage (if not available should be done
professionals licensed to provide patient care. after hiring).
HR.5.3 Credentials are verified from the original source. o Copy of Saudi Commission for Health Specialties registration (if not available
HR.5.4 Job responsibilities and clinical work assignments/ privileges are based on the should be done upon hiring).
evaluation of the verified credentials. o Essential courses such as BLS/ACLS/ATLS/ PALS/NRP as appropriate.
HR.5.5 The hospital ensures the registration of all healthcare professionals with the Saudi o List of three references with mailing address, contact telephone numbers and
Commission for Health Specialties. email address.
HR.5.6 Staff licensed to provide patient care must always have and maintain a valid license
o Valid license form SCFHS or license of country of origin if applicable.
to practice only within their profession.
o Copy of previous privileges from other hospital if available.
HR.5.7 The hospital maintains an updated record of the current professional license,
certificate, or registration, when required by laws, regulations, or by the hospital for every o Written statement including but not limited to:
medical staff, nursing staff and other healthcare professionals.
HR.5.8 When verification of credentials is conducted through a third party, the hospital  Conviction of any offence
must request for a confirmatory documentation.  Denial of any license, certification, hospital appointment.
HR.5.9 Verification process applies to all clinical staff categories (full time, part time, visitor,  Hospital appointment or privileges withdrawn, cancelled, challenged,
and locum). reduced, limited, not renewed or relinquished, whether voluntary or
involuntary.
Q1: What Is a Credentialing Processes?
o A routine security screening will be done and criminal background checked.
A1: Credentialing is the process of obtaining, verifying and assessing the
qualifications of a healthcare professional to determine if that individual can
provide patient care services in or for a healthcare organization.

Q2: Why is credentialing important?

A2: To ensure that all SFHPM medical staff members are performing care within
limits of their license, education, and training and that a credentials are verified
from their primary source of origin.

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MS.07 Clinical Privileges o Ability to perform clinical privileges requested

o Professional references and peer recommendations that include written
Standard MS.7 Medical staff members have current delineated clinical privileges. information about the applicant’s medical/clinical knowledge, technical and
clinical skills, clinical judgment, interpersonal skills, communication skills,
MS.7.1 Medical staff members are allowed to practice only within the privileges granted by professionalism, and health status.
the credentialing and privileging committee. o Information from current or past facility affiliations regarding membership
MS.7.2 Clinical privileges are reviewed and updated every two years and as needed. status and current competence, professional liability experience and
MS.7.3 The hospital identifies the circumstances under which temporary or emergency insurance coverage, and other relevant information.
privileges are granted. o Evaluation of their credentials (license, education, training, and experience).
MS.7.4 Temporary or emergency privileges are not granted for more than 90 days and are o Evaluation of the mental and physical health and capabilities.
not renewable. o Category of the medical staff as stated in the professional registration with the
MS.7.5 When a new privilege is requested by a medical staff member, the relevant
Saudi Commission for Health Specialties (e.g., consultant, specialist).
credentials are verified and evaluated prior to approval.
o Clinical privileges that are granted, renewed, or revised shall be appropriate to
scope of services and service capabilities of the Hospital.
Q1: What is the difference between credentialing and privileging?
Q4: Are there different types of granted privileges?
A1: Credentialing is the process of obtaining, verifying and assessing the
qualifications of a healthcare professional to determine if that individual can A4: Privileges can be:
provide patient care services in or for a healthcare organization.
o Initial privileges: granted to practitioners applying for the first time to be
Privileging is the process of reviewing an individual’s credentials through evaluated during a 90 day probationary period.
credentials body to determine the authority and responsibility to be granted to a o Final privileges: granted after evaluation of practitioners performance during
practitioner for making independent decisions to diagnose, initiate, alter, or probationary period.
terminate a regimen of medical or dental care. Privileging determines the o Temporary privileges: granted locum, part time or visiting medical staff.
practitioner’s scope of practice in the organization determined by his/her o Emergency Privileges: granted in emergency situation where serious harm or
competencies. aggravation of injury or disease is imminent, or where the life of a patient is in
immediate danger, and any treatment delay could add to that danger.
Q2: Who are the staff members who are required to acquire privileges? o Disaster privileges: granted only when the emergency management plan has
been activated and the Hospital is unable to meet immediate patient needs.
A2: Medical staff including physicians, surgeons and dentists only.
Q5: Can a practitioner appeal against committee decisions?
Q3: How are medical staff granted privileges?
A5: Medical staff can file an appeal against credentialing or privileging decisions
A3: Medical staff are granted initial privileges based on: within five work days after notification. Appeal requests shall be sent to Executive
Director of Medical Administration for re-evaluation and modification as required.
o Initial recommendation of related HOD. Requester shall be provided written feedback as regards of appeal request.
o Applicant’s education, training, current competence

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PC.25 Handling, Use and Administration of Q2: What are elements of blood informed consent?

Blood and Blood Products A2: Blood informed consent consists of:

Standard PC.25: Policies and procedures guide the handling, use, and o Description of the transfusion process.
administration of blood and blood products. o Identification of the risks and benefits of the transfusion.
o Identification of alternatives including consequences of refusing treatment.
PC.25.01 There are policies and procedures that are developed collaboratively by the blood o Giving the opportunity to ask questions.
utilization committee, guiding the handling, use, and administration of blood and blood
o Giving the right to accept or refuse the transfusion.
products.
PC.25.02 Only physicians order blood and in accordance with a policy clarifying when blood
and blood products may be ordered. Q3: When can we skip the NAT testing?
PC.25.03 The physician obtain informed consent for transfusion of blood and blood
products. Elements of patient consent include: A3: In emergencies, patient/family signs consent for transfusion without NAT
PC.25.03.01 Description of the transfusion process. testing.
PC.25.03.02 Identification of the risks and benefits of the transfusion.
PC.25.03.03 Identification of alternatives including the consequences of refusing the Q4: If a side effect or complication occurs, to whom should it be reported?
treatment.
PC.25.03.04 Giving the opportunity to ask questions.
A4: Side effects or complications are immediately reported to MRP or designee and
PC.25.03.05 Giving the right to accept or refuse the transfusion.
blood bank and transfused unit is sent to blood bank for further investigations.
PC.25.04 Two staff members verify the patient’s identity prior to blood drawing for cross
match and prior to the administration of blood.
PC.25.05 In dire emergencies, patient/family signs consent for transfusion without NAT Q5: When should Blood or blood components be returned to blood bank?
testing.
PC.25.06 Blood is transfused according to accepted transfusion practices from recognized A5: If not used within 30 minutes and kept in ice box, or otherwise kept in
professional organizations. temperature-monitored refrigerator or freezer in the department.
PC.25.07 Policies and procedures guide the administration of blood transfusions.
PC.25.08 Patients receiving blood are closely monitored. Q6: When could ABO incompatible plasma be issued?
PC.25.09 Transfusion reactions are reported and analyzed for preventive and corrective
actions.
A6: In emergency situation when a patient requiring large numbers of plasma units
PC.25.10 Side effects or complications are immediately reported to the medical staff and
blood bank and the transfused unit is sent to the blood bank for further investigations. and blood bank has shortage of same ABO plasma. To cure the deficiency of
multiple clotting factors. e.g.: DIC, Liver disease, Septicemia, Massive transfusion,
Q1: Who should order blood transfusions? replacement of single factor deficiency where specific or combined factor
concentrate is not available and for reversal of warfarin effect.
A1: Only physicians order blood.

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PC.26 Venous Thromboembolism Q4: Who are the patients with an increased risk of bleeding with anticoagulation
prophylaxis?
Standard PC.26 Patients at risk for developing venous thromboembolism are
identified and managed. A4: Patients at increased-risk include:

PC.26.01 Patients are screened for the risk of developing venous thromboembolism. o Inherited or acquired bleeding disorders
PC.26.02 Patients at risk receive prophylaxis according to current evidence-based practice. o Renal failure
o Extreme elderly
Q1: Who should be assessed for VTE? o Antiplatelet therapy
o Recent bleeding event (e.g. GI bleed, hemorrhagic stroke)
A1: All in-patients, whose length of stay may exceed 24 hours, should have a o Primary hemostasis not achieved
documented risk assessment upon hospital admission, change in level of care and o Platelet count < 50,000/cc.
discharge, leading to a clinical decision regarding appropriate measures to prevent o Hepatic failure.
venous thromboembolism (VTE). o Patient already on anticoagulants, thrombolysis.
o Acute stroke.
Q2: Who should identify VTE prophylaxis exclusions? o Uncontrolled hypertension.

A2: Physician will identify any VTE prophylaxis exclusions and/or contraindications. Q5: Who should be educated regarding VTE?
If none, physician is to complete the risk assessment, score, and signature. If
exclusions and/or contraindications are identified, the remaining risk assessment A5: All patients should have proper education regarding venous thromboembolism,
does not need to be completed. They must complete signature, date, and time. prophylaxis methods available. All patients should be encouraged to ambulate as
Exclusions include: early as possible, and as frequently as possible.

o Patients who are less than 18 years of age. Q6: How shall implementation be evaluated?
o Patients who stayed less than or equal to 24hours post-operative.
o Patients who are on Warfarin prior to admission A6: A VTE Safety Zone Team is responsible to monitor and evaluate results of
o Patients who undergo Emergency C/S ( To follow C/S pathway ) implementation. Full cooperation of all clinical staff is mandated to ensure the
team performs all required functions accordingly.
Q3: What are the adverse effects of anticoagulation prophylaxis that may occur
and should be monitored?

A3: Anticoagulation prophylaxis adverse effects include:

o Bleeding complications
o Heparin induced thrombocytopenia
o Wound hematomas
o Peri-spinal hematoma

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QM.17 Patient Identification Q4: How and when are emergency patients identified?

Standard QM.17: The hospital has a process to ensure correct identification of A4: All emergency room patients must wear an ID band whether they are actively
patients. receiving emergency medical care, scheduled for treatment/procedures, or
admitted for observation.
QM.17.01 At least two patient identifiers (e.g., patient full name and medical record
number) are required whenever taking blood samples, administering medications or blood o In extreme emergencies (life threatening situations), clinical care may take
products, or performing procedures. priority over affixing ID Band to patients.
QM.17.02 The hospital has a standardized approach to patient identification (e.g., use of ID o If the patient is unidentifiable, patient shall be identified as "UNKNOWN
bands with standardized information). MALE/FEMALE" and a Medical Record Number (MRN) given on a white ID
QM.17.03 Patients are actively involved in the process of patient identification. band. In event of multiple unknown patients, sequential numbering based on
gender shall be used (e.g. "UNKNOWN MALE 001", etc.).
Q1: What is an identification band and what are approved patient identifiers? o If patient's condition does not permit application of an ID band to the
upper/lower extremities (such as in burn cases, or other medical conditions),
A1: It is a bracelet containing individual identification information. SFHPM uses two it can be securely attached to their clothes.
main identifiers to identify patients, which are; the patient’s full name (up to
fourth name) and Medical Record Number (MRN). Dental and Outpatients, an ID Q5: What is the followed procedure in case of patient refusal to wear ID band?
band shall be issued when invasive procedures are required, otherwise Outpatient
Slip shall be considered as patient identification during regular visit. A5: Patient Relations department shall be contacted to communicate the
importance of wearing an ID band to patients/caregivers.
Q2: How should registration office identify the patient?
Q6: In case of patient death or discharge, how shall the ID band be processed?
A2: On arrival, Patient Registration Clerks should check the patient’s full name
against his/her ID card (for Saudi Nationals) or Passport/Iqama (for all other A6: In case of patient death, ID band must remain on the patient’s body until
nationalities). For children who do not have an identification card, birth certificates endorsed to family members or responsible authorities. While in case of patient
(or family card) shall be accepted. discharge, ID band shall be removed upon discharge and disposed as
CONFIDENTIAL WASTE (i.e.: either shredded or cut into small pieces).
Q3: What are the colors of ID bracelet and their use?
Q7: What about Specimens and Samples Identification:
A3: The following four colors of ID bracelets are utilized in SFHPM:
A7: Minimum information required on specimen/sample label include:
o White for all patients.
o Red for allergic patients (including allergen name). o Patient’s identifiers;
o Orange for aggressive patients. o Collection date and time;
o Yellow for moderate or high fall risk. o Collector’s initials and ID number;
o Patient location.

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QM.18 Sign-in, Time-out and Sign-out Q2: Who is responsible to mark surgical site?

Standard QM.18: The hospital has a process to prevent wrong patient, wrong site, A2: Surgeon performing the procedure/operation marks their initials at the site
and wrong surgery/procedure. with an indelible marker. The patient will concurrently participate in marking the
site with the person performing the procedure (if possible).
QM.18.01 There is a process implemented to prevent wrong patient, wrong site, and wrong
surgery/procedure during all invasive interventions performed in operating rooms or other Q6: What is the function of time-out procedure?
locations.
QM.18.02 The process consists of three phases: verification, site marking, and time out. A6: Time-out is an active communication among members of the surgical/
QM.18.03 A pre-procedure verification of the patient information is carried out including procedure team to verify correct site/ side, correct procedure, correct patient,
the patient’s identity, consent, full details of the procedure, laboratory tests and images, conducted in a ‘fail-safe’ mode (i.e.: permits any unanswered questions or
and any implant or prosthesis. confusion to be resolved). It should be performed before skin incision where all
QM.18.04 The surgical/procedural site is marked before conducting the surgery/procedure.
the procedures teams should be actively involved.
QM.18.04.01 The site is marked especially in bilateral organs and multiple structures (e.g.
fingers, toes, and spine).
QM.18.04.02 The site is marked by the individual who will perform the procedure. Q7: What is the function of sign-out procedure?
QM.18.04.03 The patient is involved in the marking process.
QM.18.04.04 The marking method is consistent throughout the hospital. A7: Sign-out should be conducted before the patient leaves the operating room
QM.18.04.05 The mark is visible after the patient is prepped and draped. after exudation with the anesthetist permission to discuss any concerns for
QM.18.05 A final check (time-out) is conducted before the procedure is initiated. recovery and management of the patient.
QM.18.05.01 The time-out is conducted in the location where the procedure will be done,
just before starting.
QM.18.05.02 The time-out is initiated by a designated member of the team and involves the
members of the team, including the individual performing the procedure, the anesthesia
providers, and the nurse(s) involved.
QM.18.05.03 The entire procedure team uses active communication during the time out.
QM.18.05.04 During the time-out, the team members agree on the correct patient identity,
the correct procedure to be performed, the correct site, and when applicable, the
availability of the correct implant or equipment.
QM.18.06 The hospital documents its processes for preventing wrong patient, wrong site,
and wrong surgery/procedure.

Q1: What is the function of sign-in procedure?

A1: Sign-in process (verification process) is done before induction of anesthesia in

pre-holding area, it’s performed by circulating nurse and anesthesia. If a
discrepancy is identified during sign-in; notify clinicians involved in the procedure,
stop the procedure, and reconcile the discrepancy.

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AN.02 Anesthesia Staff Qualifications AN.15 Moderate and Deep Sedation

Standard AN.2 Anesthesia staff members have the appropriate qualifications. Standard AN.15 Qualified staff perform moderate and deep sedation/analgesia.

AN.2.1 Qualified anesthesiologists provide anesthesia services. AN.15.1 Physicians who perform moderate and deep sedation/analgesia have competency-
AN.2.2 Qualified anesthesiologist is present inside the operating room throughout the based privileges granted to perform moderate and deep sedation/analgesia.
operation. AN.15.2 Clinical staff who participate in caring for patients receiving moderate or deep
AN.2.3 Anesthesia consultant administers and supervises anesthesia for major/specialized sedation are certified in advanced life support as appropriate to the age of the patients
operations or high risk patients, including: served.
AN.2.3.1 Pediatric operations. AN.15.3 Clinical staff who participate in conducting sedation must successfully complete a
AN.2.3.2 Cardio-pulmonary operations. proper education/training on moderate and deep sedation.
AN.2.3.3 Neurosurgery operations.
AN.2.3.4 Transplant operations. Q1: What is anesthesia means?
AN.2.4 Anesthesia staff are certified in advanced life support as appropriate to the patient’s
age. A1: It consists of general anesthesia and spinal or major regional anesthesia. It
does not include local anesthesia. General anesthesia is a drug-induced loss of
Code Statement Evidence consciousness during which patients are not arousable, even by painful
AN.2.1 Qualified anesthesiologists provide Anesthesia Job stimulation.
anesthesia services Descriptions
AN.2.2 Qualified anesthesiologist is present Roster - A list, especially Q2: What is moderate sedation means?
inside the operating room throughout of the physician names
the operation from Anesthesia team A2: It is a drug-induced depression of consciousness during which patients respond
AN.2.3 Anesthesia consultant administers and Provision of Anesthesia purposefully to verbal commands, either alone or accompanied by light tactile
supervises anesthesia for Care – Classifications of stimulation.
major/specialized operations or high risk patients
risk patients, including: Q3: What is deep sedation means?
AN.2.3.1 Pediatric operations Pediatric/Neonatal
Advance Life Support A3: It is drug-induced depression of consciousness during which patients cannot be
AN.2.3.2 Cardio-pulmonary operations. Not Applicable easily aroused, but respond purposefully following repeated or painful stimulation.
AN.2.3.3 Neurosurgery operations. Not Applicable
Q4: What are the common procedures requiring moderate and deep sedation?
AN.2.3.4 Transplant operations. Not Applicable
A4: The following list includes, but does not limit, the procedures which may
AN.2.4 Anesthesia staff are certified in Personnel File require moderate and deep sedation/analgesia: Diagnostic and Invasive G.I
advanced life support as appropriate to procedures, Renal biopsy, Cardio-version, Orthopedic procedures, Insertion of
the patient’s age. invasive hemodynamic monitoring lines, Trans-esophageal Echocardiography,

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Bronchoscopy, Surgical procedures under local anesthesia, CT Scans and MRI  Administer medication per physician order and titrate to patient
scanning. response.
 Continually monitor the patient and document the monitoring
Q5: What are the responsibilities of the physician and nursing staff? parameters.

A5: Physicians responsibilities include: o Post-procedure: Ensure the patient meets discharge criteria and verify the
patient is discharged with responsible person.
o Perform a History and Physical examination on the patient along with relevant
lab work.
o Obtain informed consent
o Oversee the sedation of the patient
o Oversee the recovery of the patient, and are responsible for the patient until a
discharge order is written and/or discharge criteria are met. The physician
must remain in the facility (or sign the patient out to another physician) until
the patient leaves the recovery area.

Nurses responsibilities include:

o Ensure completion of nursing pre-procedure assessment, pre-sedation

evaluation, related nursing care plan, and evaluation to include:

 Confirm documented consent for the procedure and moderate and deep
sedation and analgesia.
 Check patient’s compliance with NPO status.
 Verify the presence of a responsible adult for transportation home.
 Review and document post-procedural instructions with the patient
and/or caregiver prior to patient receiving sedation.
 Obtain and document baseline vital signs, oxygen saturation, EKG rhythm,
level of consciousness and pain level.

o During the procedure the nursing staff will:

 Establish and maintain an intravenous line until the patient is stable in

recovery phase. The IV catheter must be of adequate size to allow fluid
and resuscitation medications to be easily given.

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IPC.04 Infection Control Committee o Each member of the committee acts as an advocate of IPC practices in his
department, trying to promote its principles.
Standard IPC.4 There is a designated multidisciplinary committee that provides
oversight of the infection prevention and control program. Q2: How frequent does the IPC committee meet?

IPC.4.1 The infection prevention and control committee is chaired by the hospital director A2: The infection prevention and control committee meets on a regular basis of
or the medical director. once per month (at least quarterly).
IPC.4.2 The membership of the infection prevention and control committee includes
representatives from the medical staff, nursing staff, microbiology, operating room, central Q3: Who is the chairperson of IPC committee?
sterilization service, pharmaceutical care, dietary services, housekeeping, infection
prevention and control staff, and other departments as needed. A3: IPC committee is chaired by Executive Director of Medical Administration.
IPC.4.3 The infection prevention and control committee meets on a regular basis (at least
quarterly).
Q4: Who are the members of the IPC committee?
IPC.4.4 Functions of the infection prevention and control committee include, but are not
limited to, the following:
IPC.4.4.1 Review of the hospital infection prevention and control policies and procedures. A4: It includes representatives from the medical staff, nursing staff, microbiology,
IPC.4.4.2 Review of the reports of healthcare-associated infections surveillance submitted operating room, central sterilization service, pharmaceutical care, dietary services,
regularly by the infection prevention and control team and suggestion of appropriate housekeeping, infection prevention and control staff, and other departments as
actions. needed.
IPC.4.4.3 Revision of the yearly plan submitted by infection prevention and control team
and suggestion of additions/changes if necessary.
IPC.4.4.4 Evaluates and revises on a continuous basis the procedures & the mechanisms
developed by the infection prevention & control team to serve established standards and
goals.
IPC.4.4.5 Brings to the attention of the infection prevention & control team new infection
control issues arising in different departments of the hospital & suggests solutions.
IPC.4.4.6 Each member of the committee acts as an advocate of infection prevention &
control in his department, trying to promote its principles, and ensures application of its
rules.

Q1: What are the functions of the infection prevention and control committee?

A1: IPC committee functions include:

o Review of the IPC policies and procedures.
o Review of the reports of healthcare-associated infections.
o Revision of the IPC annual plan.
o Any new infection control related issues arising in different departments of
the hospital and suggested solutions.

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IPC.15 Isolation Practices Q1: What are contact precautions? and what are the required PPEs?

Standard IPC.15 Facility design and available supplies support isolation practices. A1: Contact precautions for patients infected or suspected to have
Multidrug Resistant Microorganisms (e.g.: Acienetobacter, MRSA, etc.).
IPC.15.1 There is at least one negative pressure airborne isolation room in the emergency Required PPEs include; isolation gown, gloves and surgical mask. In case a
room and one in patient care areas (one negative pressure room for every 25-30 beds in patient have MDRO infection in sputum and is coughing or under
general hospitals). suctioning, the illustrative poster color code is green.
IPC.15.2 The infection prevention and control team decides the need for more airborne
isolation rooms depending on the volume of patients in need for airborne isolation
admitted to the hospital. Q2: What are droplet precautions? and what are the required PPEs?
IPC.15.3 The ventilation system serving airborne isolation facilities provides pressure
patterns that prevent airborne pathogens from being distributed to other areas of the A2: Droplet precautions for patients infected or suspected to have
hospital. infections transmitted through droplets (e.g.: meningitis). Required PPEs
IPC.15.3.1 Rooms designed for airborne isolation patients are under negative pressure.
include; surgical mask. Illustrative poster color code is red.
IPC.15.3.2 Air is exhausted to the outside and is not re-circulated unless it is filtered through
High-Efficiency Particulate Air (HEPA) Filter.
IPC.15.3.3 There is evidence of daily air exchange monitoring (12 air changes per hour) Q3: What are airborne isolation precautions? And what are the required PPEs?
when a patient is isolated. Weekly monitoring of the air exchange is needed when no
patient is isolated. A3: Airborne precautions are for patients infected or suspected to have
IPC.15.4 The entry of the isolation room is through a work area or ante-room that serves as
a site for hand washing, gowning and storage of protective clothing (gloves, aprons, masks).
disease that can be transmitted through air (e.g.: pulmonary TB). Required
IPC.15.5 Toilet, shower, or tub and hand washing facilities are provided for each isolation PPE is N95 mask. Poster color code is blue and the patient have to be
room. isolated in negative pressure room.
IPC.15.6 Transmission-based precaution cards (isolation signs) are consistent with the
patient diagnosis and are posted in Arabic and English and indicate the type of precautions Q4: What are the criteria of airborne isolation room?
required.
IPC.15.6.1 Transmission-based precaution cards (isolation signs) are color coded for
isolation of different categories (e.g., contact: green, airborne: blue, droplet: pink or red). A4: Rooms designed for airborne isolation patients are under negative
IPC.15.6.2 Transmission-based precaution cards (isolation signs) should contain short pressure. The entry of the isolation room is through a work area or ante-
statements and supported with the required figures. room that serves as a site for hand washing, gowning and storage of
IPC.15.6.3 Isolation instructions must highlight the transmission-based precaution cards protective clothing (gloves, aprons, masks).
(isolation signs) needed while transporting the patients under transmission-based
precautions to other department (e.g., radiology).
IPC.15.7 Respirator (high filtration) masks (N-95, N-99) are used by staff during direct care
of patients on airborne precautions and are available on all units likely to admit patients on
airborne precautions.
IPC.15.8 Respirator (high filtration) masks (N95, N-99) can be reused by the same patient
care giver as per the period specified by the manufacturer.

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MM.05 High-Alert Medications

o For routine medication, prescribed HAMs shall be stored in admitted patients’
Standard MM.05 The hospital has a system for the safety of high-alert medication cassette and labeled with ‘HAMs label’ or ‘red dot’;
medications. o Discontinued, expired, damaged and contaminated HAMs are segregated and
isolated until removal.
MM.05.01 There is a written multidisciplinary plan for managing high-alert medications and
hazardous pharmaceutical chemicals. It includes identification, location, labeling, storage, Q2: How are HAMs labeled?
dispensing, and administration of high-alert medications.
MM.05.02 The hospital identifies an annually updated list of high-alert medications and A2: All HAMs shall be clearly labeled with ‘HAMs label’ or ‘red dot’ for vials;
hazardous pharmaceutical chemicals based on its own data and national and international Where possible, multi-dose vials are reduced or eliminated. Once a multi-dose vial
recognized organizations (e.g., Institute of Safe Medication Practice, World Health is opened, it must be labeled with opening date, opening time, expiry date, and
Organization). The list contains, but is not limited to, the following:
initials.
MM.05.02.01 Controlled and narcotics medications.
MM.05.02.02 Neuromuscular blockers.
MM.05.02.03 Chemotherapeutic agents. Q3: what are the precautions for HAMs administration?
MM.05.02.04 Concentrated electrolytes (e.g., hypertonic sodium chloride, concentrated
potassium salts). A3: For initial dose or initiation of a new infusion healthcare provider preparing
MM.05.02.05 Antithrombotic medications (e.g., heparin, warfarin). medication shall retain the following items for double-check by a second provider:
MM.05.02.06 Insulins.
MM.05.02.07 Anesthetic medications (e.g., propofol, ketamine). o Original medication package (with labeling intact), or vial.
MM.05.02.08 Investigational (research) drugs, as applicable. o ‘Medication Administration Record (MAR)’ or ‘Physician’s Order’
MM.05.02.09 Other medications as identified by the hospital.
o Prepared medication ready for administration with labeling intact.
MM.05.03 The hospital plan for managing high-alert medications and hazardous
pharmaceutical chemicals is implemented. This includes, but is not limited to, the following:
MM.05.03.01 Improving access to information about high-alert medications. For second provider performing double-check shall ensure:
MM.05.03.02 Limiting access to high-alert medications.
MM.05.03.03 Using auxiliary labels or computerized alerts if available. o Double-check is conducted PRIOR to administration;
MM.05.03.04 Standardizing the ordering, transcribing, preparation, dispensing, o Medication preparation according to order (compared against MAR or
administration, and monitoring of high-alert medications. Physician’s Order);
MM.05.03.05 Employing independent double checks. o Prepared medication matches the seven rights by reading the label clearly to
MM.05.04 The hospital develops and implements standard concentrations for all the administering healthcare provider to verify seven rights;
medications administered by intravenous infusion.
o Medication packaging or empty vial matches ordered medication.
Q1: How should HAMs be stored? Q4: How are HAMs monitored?
A1: In pharmacy and pharmacy store, HAMs are segregated from other A4: Infusion pump settings (i.e. dose and rate) are visually checked hourly and
medications. Outside the pharmacy, floor stock shall be in limited quantity volume charted at the bedside on the appropriate fluid balance record.
according to 'HAMs Distribution List’, locked separately in a single-door closed
cabinet and labeled with ‘HAMs label’ or ‘red dot’.

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MM.06 Look-a-Like, Sound-a-Like Medications

medications where tall man lettering is not applicable, proprietary (brand or
Standard MM.06 The hospital has a system for the safety of look-alike and sound- trademarked) names may be added to distinguish between the medications.
alike (LASA) medications. Also yellow warning labels are used for look-alike medicines.

MM.06.01 There is a multidisciplinary policy and procedure on handling look- alike/sound- Q3: How are LASA medications prescribed?
alike (LASA) medications.
MM.06.02 The hospital reviews and revises annually its list of confusing drug names, which A3: Using both brand and generic names.
include LASA medication name pairs that the hospital stores, dispenses, and administers.
MM.06.03 The hospital takes actions to prevent errors involving LASA medications including
Q4: How are LASA medications dispensed/supplied?
the following, as applicable:
MM.06.03.01 Providing education on LASA medications to healthcare professionals at
orientation and as part of continuing education. A4: LASA medications are dispensed by:
MM.06.03.02 Using both the brand and generic names for prescribing LASA medications.
MM.06.03.03 Writing the diagnosis/ indication of the LASA medication on the prescription. o Medicines are identified by name and strength not by appearance or location.
MM.06.03.04 Changing the appearance of look-alike product package. o Appropriateness is checked for medicines dose dispensed.
MM.06.03.05 Reading carefully the label each time a medication is accessed, and/or prior to o Medication labels are read carefully at all dispensing stages.
administration. o Double-checking is conducted during dispensing and supply process.
MM.06.03.06 Minimizing the use of verbal and telephone orders.
o On counseling Highlight changes in medication appearances to patients upon
MM.06.03.07 Checking the purpose/indication of the medication on the prescription prior
dispensing.
to dispensing and administering.
MM.06.03.08 Placing LASA medications in locations separate from each other or in non-
alphabetical order. Q5: How are LASA medications administrated?

Q1: What are LASA medications? A5: Read medication label carefully during administration process and perform
double-check. Emphasize the need to read labels rather than relying on visual
A1: Look‐Alike Drugs/Medication: This refer to names, shape, color and package of recognition or location.
drugs/medications that may look similar with other drugs/medications’. Sound‐
Alike Drugs/Medications: These refer to names of drugs/medications which, due to Q6: How are LASA medications monitored?
their pronunciation and/or spelling, may sound similar to other drugs/medications.
A6: The LASA list needs to be reviewed, monitored and updated periodically at
least every 6 months. Implement feedback mechanism to inform on look-alike
medications. Evaluate medication errors related to LASA medications.
Q2: How are LASA medications stored?

A2: LASA medications are separately stored from their LASA pair and TALL-Man
lettering are used to emphasize differences in medications. For sound-a-like

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MM.41 MEDICATION ERROR Q2: What are the categories of medication error?

Standard MM.41 The hospital has a process for monitoring, identifying, and A2: Medication Error Categories:
reporting significant medication errors, including near misses, hazardous
Category A: Circumstances or events that have the capacity to cause error.
conditions, and at-risk behaviors that have the potential to cause patient harm.
Category B: An error occurred but the error did not reach the patient
Category C: An error occurred that reached the patient but did not cause patient harm
MM.41.1 There is a multidisciplinary policy and procedure on handling medication errors, (includes errors of omission)
near misses, and hazardous situations (e.g., confusion over look-alike/sound-alike drugs or Category D: An error occurred that reached the patient and required monitoring to
similar packaging). confirm that it resulted in no harm to the patient and /or required
MM.41.2 The policy has a clear and acceptable definition of significant medication error, intervention to prevent harm.
near misses, and hazardous situations. Category E: An error occurred that may have contributed to or resulted in temporary
MM.41.3 The treating physician is notified of the medication error at the appropriate time. harm to the patient and required intervention.
MM.41.4 Medication error reporting is completed within the specified time frame after Category F: An error occurred that may have contributed to or resulted in temporary
discovery of the error. harm to the patient and required initial or prolonged hospitalization.
MM.41.5 The hospital has a standard format for reporting medication errors. Category G: An error occurred that may have contributed to or resulted in permanent
MM.41.6 Staff are educated on the process and importance of medication error reporting. patient harm
MM.41.7 There is active reporting of medication errors, near misses, and hazardous Category H: An error occurred that required intervention necessary to sustain life.
situations. Category I: An error occurred that may have contributed to resulted in patient death.
MM.41.8 The hospital conducts intensive root-cause analysis for all significant or potentially
significant medication errors.
Q3: Who should fulfill a medication error report?
MM.41.9 Medication errors, near misses, and hazardous situations are documented in the
patient’s medical record.
MM.41.10 The hospital utilizes reported data to improve the medication use process, A3: Medication errors reports should be documented by physicians, pharmacists,
prevent medication errors, and improve patient safety. nurses, or any other member of the healthcare team who discovers the error.
MM.41.11 Healthcare professionals are provided with feedback on reported medication
errors, near misses, and hazardous situations. Q4: When should I fulfill the medication error report?
MM.41.12 The hospital reports sentinel events related to serious medication errors to the
relevant authorities. A4: Medication Error Form should be completed and sent to Pharmacy Department
within 24 hours. If it is a sentinel event related to medication error; please do not
Q1: What is a medication error? waste time and directly inform Quality and Patient Safety Director through his
extension number: 8313, or On-Duty Manager by calling Hospital Operator
A1: It is any preventable event that may cause or lead to inappropriate medication extension number: 0, or personally.
use or patient harm while the medication is in the control of the health care
professional or patient. Such events may be related to professional practice, Q5: When will MRP fulfill his/her feedback regarding a medication error?
health care products and systems, including: prescribing, order communication,
product labeling, packaging and nomenclature, compounding, dispensing, A5: MRP shall be asked to fulfill his/her feedback regarding a medication error if
distribution, administration, education, monitoring and use. the error reached the patient.

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LB.51 Blood/Platelet Transfusion Disease Transmission o HBV DNA

o Serological test for syphilis
Standard LB.51 The blood bank develops a process to prevent disease o Other additional or supplemental tests as mandated by relevant health
transmission by blood/platelet transfusion. authorities

LB.51.01 There are policies and procedures mandating that a sample of blood obtained Q2: How to limit bacterial contamination in platelets
from the donor during blood/ blood component collection is subjected to the following
infectious diseases testing: A2: Before venipuncture a phlebotomist should:
LB.51.01.01 HBsAg
LB.51.01.02 Anti-HBc o Disinfect the phlebotomy site properly with alcohol swab in center to outward
LB.51.01.03 Anti-HCV circular manner.
LB.51.01.04 Anti-HIV-1/2 o Swab the same area with iodine solution for 30 seconds. Refer to Blood
LB.51.01.05 Anti-HTLV-I/II
Collection and Care for the Donors Policy and Procedure (SFHM-LBB-BB-007)
LB.51.01.06 HIV-1 RNA
for further instructions.
LB.51.01.07 HCV RNA
LB.51.01.08 HBV DNA o The first flow of blood after insertion should be collected in Blood Bag sample
LB.51.01.09 Serological test for syphilis pouch, since the first few ml of blood are most likely contaminated.

LB.51.01.10 Other additional or supplemental tests as mandated by relevant health Q3: What are the procedures for releasing blood with incomplete testing?
authorities.
LB.51.02 The blood bank has a process to limit and detect bacterial contamination in A3: Treating Doctor must send a written request to blood bank properly filled.
platelet components. The process: Blood bank Staff must issue the desired amount and components as per
LB.51.02.01 Describes the blood bank approach to limit bacterial contamination and the
availability. Blood Bank Staff should verify consent is obtained for transfusions
investigations of positive cases.
requiring blood components with incomplete pre-transfusion testing if possible.
LB.51.02.02 Ensures the employed detection method is sensitive enough to detect
significant bacterial contamination.
Q4: What are the levels of urgent blood components requests?
Q1: What infectious diseases tests should be done for donated blood?
A4: Levels include:
A1: Infectious diseases tests include:
o Lifesaving 5 min
o HBsAg o Emergency or Immediate 20 min
o Anti-HBc o Urgent 1 Hour
o Anti-HCV
o Anti-HIV-1/2
o Anti-HTLV-I/II
o HIV-1 RNA
o HCV RNA

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FMS.09 Radiation Safety Q4: What is the max. dose and rule of a pregnant radiographer?

Standard FMS.9 The hospital ensures that all its occupants are safe from radiation A4: During pregnancy the external dose will be < 2 mSv; 1msv for the mom and
hazards. 1msv for the fetus. A pregnant radiographer shall:

FMS.9.1 The hospital has a radiation safety policy and procedure and it is implemented. o Declare her pregnancy to her supervisor at an early stage.
FMS.9.2 All radio-active materials are clearly labeled and safely and securely stored. o Be informed of potential risks, local policies, and recommended dose limits.
FMS.9.3 The hospital has the relevant valid license(s) from King Abdulaziz City for Science o The supervisor must examine the most recent dose record and assess the
and Technology. dose incurred during the pregnant employee’s work over the previous year. If
FMS.9.4 Staff handling nuclear materials are qualified and certified by King Abdul-Aziz City this dose is 1 mSv or less, no change in assigned working duties is required to
for Science and Technology. address the radiation risk.
FMS.9.5 There is a valid shielding certificate of the x-ray room(s) including regular test to o If the dose is greater than 1 mSv, following procedure the supervisor and the
ensure permissible radiation levels.
pregnant employee will work together to limit the radiation exposure to the
FMS.9.6 Lead aprons and gonad/thyroid shields are available to cover patients and staff
unborn child using the following methods:
needs and are annually tested according to a hospital-wide inventory.
FMS.9.7 Personal radiation dosimeters (TLD cards) are available, tested every 3 months, and
actions taken when test results exceed permissible levels.  Reduce the time spent in the radiation area, if possible, by working out a
schedule to modify the duties during the time of pregnancy or to an area
Q1: What is the function of Thermo-Luminescent Dosimeter (TLD)? in the department where there is less scattered radiation.
 Stand in a shielded area during all radiographs; keep an extra distance
A1: To protect staff exposed to radiation by measuring the dose of radiation (greater than 3 m) from the radiation source whenever possible.
reaching their bodies. They are placed anywhere between the collar and belt and  The pregnant radiation worker continues to faithfully wear her personal
during using a lead gown, it is placed inside the lead gown, to know the dose dosimeter on her abdomen.
reaching the body not the gown.  The exposure record at the end of each wearing period is to be examined
and further action taken if required on the basis of the dose accumulated.
Q2: How to keep your TLD badge safe?  What is length of each quarter for the TLD badges?
 3 months after that it will be replaced.
A2: Do not expose to high temperature, direct sunlight, water and store in a
holder, low radiation area when not in use.

Q3: How can you receive information regarding your TLD readings?

A3: Staff members can contact the in-charge RSO.

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FMS.21 Fire Alarm FMS.22 Fire Suppression

Standard FMS.21 The hospital has an effective fire alarm system. FMS.22 The hospital has a fire suppression system available in the required area(s).

FMS.21.1 There is a fire alarm system that is functioning and regularly inspected as per civil FMS.22.1 The hospital has a functional sprinkler system.
defense guidelines. FMS.22.2 The hospital has clean agent suppression system.
FMS.21.2 The fire alarm system testing results are documented. FMS.22.3 The hospital has wet chemical system.
FMS.21.3 The fire alarm system has preventive maintenance. FMS.22.4 The hospital has stand pipes and hose system.
FMS.21.4 The elevators are connected to the fire alarm system.

Q1: How to activate the alarm system?

A1: In SFHPM, 3 types of alarms are used; of which 2 are automatically operated
and 1 that requires manual activation:

o Smoke Detector (Automatic): automatically activated if it senses the presence

of smoke in the designated location.
o Heat Detector (Automatic): automatically activated if it senses increase in
temperature more than the pre-set value (which might be different from one
location to another).
o Break Glass Alarm (Manual): manually activated by the user in case of
presence of fire or smoke.

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FMS.24.5 Fire rated doors are available according to the hospital zones with no separation
FMS.23 Fire Exits between walls and ceiling to prevent smoke spread between rooms and areas.
FMS.23 There are fire exits that are properly located in the hospital.

FMS.23.1 Fire exits are available and are properly located in the hospital.
FMS.23.2 Fire exits are not locked.
FMS.23.3 Fire exits are not obstructed.
FMS.23.4 Fire exits have panic hard ware.
FMS.23.5 Fire exits are fire resistant.
FMS.23.6 Fire exits are clearly marked with illuminated exit sign.

Q1: How to identify the nearest exit?

A1: Follow the green ‘fire exit’ to the nearest exit.

FMS.24 Fire and Smoke

FMS.24 The hospital and its occupants are safe from fire and smoke.

FMS.24.1 The hospital implements a strict “No Smoking” policy.

FMS.24.2 There are no obstructions to exits, fire extinguishers, fire alarm boxes, emergency
blankets, safety showers, and eye wash stations.
FMS.24.3 Emergency lighting is adequate for safe evacuation of the hospital.
FMS.24.4 Storage areas are properly and safely organized:
FMS.24.4.1 Shelves and racks are sturdy and in good condition.
FMS.24.4.2 No items stored directly on the floor (a minimum of ten centimeters is left to
manage spills).
FMS.24.4.3 Items should be stacked on a flat base.
FMS.24.4.4 Heavier objects are close to the floor and lighter/smaller objects are higher.
FMS.24.4.5 Items are not stacked so high to block sprinklers or come in contact with
overhead lights or pipes (a minimum distance of fifty centimeters from ceiling level).

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FMS.32 Medical Gas System

Q1: How to isolate the medical gas service in case of any malfunctioning?

A1: By breaking the medical gas isolation valve plastic cover and switching off the
affected system.

Q2: Who is the responsible person to isolate the medical gas service in case of any
malfunctioning?

A2: The area nurse manager or the in-charge deputy.

Q3: What is the emergency maintenance call room extension number for any
medical gas system issue?

A3: Emergency maintenance call room extension number: 8709.

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List of Related Policies for Review 11 Blood Collection and Care for the Donors SFHM-LBB-BB-007

SN Document Title Code 12 Collection of Donor Blood Specimen SFHM-LBB-BB-009

1 Credentialing, Promotion and Privileging SFHM-MED-POL-030

13 Prevention of Disease Transmission by SFHM-LBB-BB-019
Policy
Blood and Platelet Transfusion Policy and
2 Infection Control Annual Plan Procedure
14 Selection of Blood and Blood Product for SFHM-LBB-BB-030
Transfusion Policy and Procedure
3 Standard Precautions Policy SFHM-IPC-POL-001
15 Release of Incompletely Tested Blood and SFHM-LBB-BB-POL-022
Blood Components Policy
4 Droplet Precautions Policy SFHM-IPC-POL-003
16 Emergency Release of Incompletely or SFHM-LBB-BB-POL-034
Uncross-Matched Blood Policy
5 Airborne Isolation Precaution Policy SFHM-IPC-POL-008
17 Management of Adverse or Suspected SFHM-LBB-BB-POL-035
Transfusion Events Policy
6 Contact Precautions Policy SFHM-IPC-POL-017
18 Radiation Safety Manual Protocol SFHM-RS-PTL-001

7 Personal Protective Equipment Policy SFHM-IPC-POL-032

19 No Smoking Policy SFHM-SAF-POL-002

8 High Alert Medications Policy SFHM-PS-POL-003

20 Policy and Procedure on Effective Use of
Medical Gas System
9 Look-a-like, Sound-a-like Medications SFHM-PS-POL-008
Policy

10 Medication Error Policy SFHM-PHR-POL-022

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How to Access Hospital Intranet?

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