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Nursing Policies and Procedures' Committee 2011 ..... It is the policy of the organization, that in order to protect the personal welfare ..... 8.2 CBAHI standards.
Ministry Of Health, General Directorate Of Nursing

nd

2 Edition

NURSING ADMINISTRATION

anual of ursing olicies and rocedures Prepared by: Nursing Policies and Procedures’ Committee 2011

Supervised by: Dr. Munira Al Oseimy General Director of Nursing-MOH

Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures

______________________________________________ NURSING ADMINISTRATION

TABLE OF CONTENTS

S.N

INDEX NUMBER

POLICY TITLE

.1 PATIENT RIGHTS AND RESPONSIBILITIES .2 .3 .4 .5 .6 .7 .8 .9 .10 .11 .12 .13 .14 .15 .16 .17 .18 .19 .20 .21 .22 .23 .24 .25 .26 .27 .28 .29 .30 .31 .32 .33 .34 .35

PEDIATRIC RIGHTS AND RESPONSIBILITIES OF PARENTS / GUARDIANS NURSING PERFORMNCE APPERISIAL PERFORMANCE APPRAISAL AND PEER PERFORMANCE REVIEW RETENTION PLAN CHAINE OF COMAND & REPORTING VACATION SCHEDULE SCHEDULING CHANGE OF DUTY ON CALL GUIDELINES FOR INTERNAL SWAPPING / TRANSFER FLOATING & CROSS TRAINING DRESS CODE FOR NURSING STAFF NURSING CODE OF ETHICS OPD STAFFING PLAN STAFF PLAN IN ORTHOPEDIC DEPARTMENT. STAFFING PLAN IN OPERATING ROOM STAFFING PLAN MEDICAL WARD STAFFING PLAN IN SURGICAL DEPARTMENT NURSING RESPONSIBILITIES IN QUALITY IMPROVEMENT SENTINEL EVENT – ROOT CAUSE ANALYSIS NURSE’S ROLE IN INFORMED CONSENT NURSES ROLE ON PROTECTING PATIENT'S PRIVACY AND CONFIDENTIALITY PREVENTION OF INFANT \CHILD ABDUCTION ( CODE PINK ) DISASTER CODE BLUE POLICY CODE RED CODE CRISIS VIOLENT PATIENT (code violet) VIOLENT SITUATION IN OPD EMERGENCY CALL PATIENT FALLS POLICE HOLD POLICY MAINTENANCE OF MEDICAL EQUIPMENT BCLS/ACLS CERTIFICATE NURSING ESCORT DUTY

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Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures ______________________________________________ NURSING ADMINISTRATION

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.36 .37 .38 .39 .40 .41 .42 .43 44 45 46

INDEX NUMBER

POLICY TITLE OCCURRENCE VARIANCE REPORTING SYSTEM NURSING CARE OF PATIENT AT END OF LIFE NURSING MEETINGS General Environment Observations Overtime (Backtime) Physical Assault On Staff Dirty Utility Room Clean Util ilit it ity yR Ro oom

SUPPLIES SUPPLIES AND EQUIPMENTS MOI CASES

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1.0 DEFINITION Patient rights and responsibilities- the doctrine of informed consent is that competent adult patients have a right of self-determination which include the right to refuse treatment.

2.0 PURPOSE To assist patients to know their basic rights and responsibilities as patients, to themselves, the health care team and the institution.

3.0 POLICY 1. It is the responsibility of every members of the health care team to identify and adhere to patients’ rights and responsibilities that would promote trust and respect as part of the dimensions of patient care. 2. It is the policy of the organization, that in order to protect the personal welfare and safeguard the dignity of every patients as human being, the hospital and medical staff have adopted the following rights and responsibilities of patients.

4.0 RESPONSIBILITIES Nurses must respect clients’ right’s and abide by the Patient’s Bill of Rights.

5.0 MATERIALS & EQUIPMENT 1. Informed Consent IPP 2. Discharged Against Medical Advise IPP

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6.0 PROCEDURES GUIDELINES 1. Patient Rights: 1.1 The right to considerate care, with full respect of patient’s dignity, regardless of nationality, color, age, sex, religion, and disability (if any). 1.2 The right to know them by name the physician, nurses, and staff members involved in the treatment. 1.3 The right to be seen by the consultant within twenty four hours from admission and on a regular basis after that during the episode of admission. 1.4 The right to know the physician in a language that patient understands all the information about the case, diagnosis, and the treatment plan any other instructions about the follow-up care. 1.5 Convenient atmosphere should be provided where patient can discuss openly and in full confidentiality about his illness.

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1.6 To know the reason for any test or diagnostic procedures that will be done, and who is going to do them and the right to know the treatment and who is going to deliver it. 1.7 The right to know the nature and inherent risks of any procedure to which the patient has given consent. 1.8 The right to refuse signing the consent form for any test that he feels does not have information about. 1.9 The right to change his mind and to refuse the test that has been agreed upon. 1.10The right to limit those persons who would visit or call during admission, in accordance with the hospital policy and procedure. 1.11The right to refuse treatment after knowing and being aware of the consequence. 1.12The right to expect his personal privacy to be respected to the fullest extent consistent with the care prescribed for. 1.13 The right to expect that all communications and other records pertaining to, be kept confidential. 1.14 The right to obtain any information or documents, such as medical reports, sick leave, etc. as documented in the medical chart 1.15 The right to request consultation or second opinion from another physician(s) through the treating consultant guided by the Hospital’s administrative policy.

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1.16The right to request for a change of physician as per hospital policy. 1.17The right to change or transfer to other hospital as per hospital policy. 1.18The right to refuse to participate in Medical Training Program and Research Projects. And he / she also has the right to withdraw at any stage, from an on-going research in which the patient has been participating, without the consequences that affect the care given to him. 1.19The right to be discharged from the hospital, against the physician’s advice. 1.20The right to choose the person who would represent him in signing the hospital documents including release of information. 1.21When discharged from the hospital, have the right to have medicine prescriptions, follow-up appointments and all the information and the training needed to be able to take care of themselves at home (if case requires). 2. Patient Responsibilities: 2.1 To know and follow the law of the Kingdom of Saudi Arabia and the hospital rules and regulations as explained by the hospital staff. 2.2 To provide accurate and Complete information concerning the present complaints, past illnesses and hospitalizations, and other matters relating to his / her illness.

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6.0 PROCEDURES 2.3 To make it known whether he / she clearly comprehend the course of the medical treatment. 2.4 To follow the treatment plan established by the physician,including the instructions of nurses and other health professionals as they carry out the doctor’s orders. 2.5 Is responsible for the actions should he refused treatment or no to follow the physician’s order.

2.6 To notify the physician, the Head Nurse or the Social Worker representative of any dissatisfaction to the care at the hospital. 2.7 Be considerate of the rights of other patients and hospital personnel, and assist in the control of noise, smoking, and other possible sources of unnecessary disturbance and / or discomfort. 2.8 Show respect and consideration of other patients, visitors and hospital priorities. 2.9 Sign the informed consent for surgery, medical or interventional procedures that may be needed during admission or in case he insisted to be discharged against medical advice, and other forms requested by the hospital. 1.10 Be aware that the hospital is committed to high standards of care and hospitality for patients and their families.

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7.0 ATTACHMENTS Patient’s Bill of rights

8.0

REFERENCES

Kingdom Saudi Arabia- Ministry Of Health Policy

PREPARED BY: 

NAME:

DATE

Kingdom Saudi Arabia- Ministry Of Health

2010

Saleh Ziad Al-Juaid - RN, BSN, MSN. KFH-TAIF Michelle R.Anapi - RN, BSN, MSN. KFH-TAIF

REVIEWED BY:



APPROVED BY:

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

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1.0 DEFINITION Patient’s Rights – are ethical legal principles and privileges in which patients are entitled to be upheld and observed by the health care procedure. Beneficence – affirms the inherent professional aspiration and duty to help promote the well-being of others. Non maleficence - complements beneficence and obligates the professional nurse not to harm the patient directly or with intent.

2.0 PURPOSE To assist parents / guardians on their rights and responsibilities in belief of patient whose rights / responsibilities are dependent from others.

3.0 POLICY 1. In addition to the rights of adult patients, the needs of children / adolescent and / or handicapped patient and they, with their parents / guardian, shall have the following rights; Respect for: Each child, adolescent and / or handicapped patients as a unique individual. The care-taking role and individual response of the parent. 2. Provides for normal physical and physiological needs include nutrition, rest, sleep, warmth, activity and freedom to move and explore.

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3. Consistent, supportive and nurturing care which meets the emotional and psychosocial needs of patients, and fosters open communication. 4. Provision for self esteem which will be met by attempts to give; The reassuring presence of a caring person, especially a parent / family member. Freedom to express feeling of fears with appropriate reaction, if possible, To maintain control as possible over self and situation; Opportunities to work through experience before and after they occur, verbally, in play or in other appropriate ways; Recognize and reward the coping well doing difficult situations. 5. Provision for varied and normal stimuli of life which contributes to cognitive, social, emotional and physical development needs; Play, educational and social activities essential to all children and adolescents. 6. Information about what to expect prior to, during and following procedure / treatment and support in coping with it. 7. Participation of children / families in decision affecting their own medical treatment. 8. Minimization of the hospital stay duration by planning patient’s discharge needs.

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4.0 RESPONSIBILITIES All Medical And Non Medical Staff

8.0

REFERENCES

Kingdom Saudi Arabia- Ministry Of Health Policy

NAME: PREPARED BY: REVIEWED BY: APPROVED BY:

Kingdom Saudi Arabia- Ministry Of Health  

Saleh Ziad Al-Juaid - RN, BSN, MSN. KFH-TAIF Michelle R.Anapi - RN, BSN, MSN. KFH-TAIF

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

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1.0 PURPOSE : 1.1.

To assess the professional skill & implementation ability.

1.2.

To determine the success of Nursing Care.

1.3.

To identify the areas of improvement that needs to be made in the nursing practice.

2.0 DEFINITION : 2.1. Performance Evaluation refers to appraisal/monitoring of staff performance according to goals or available resources within a period of time to determine efficiency in delivery of care as required by the standards of Nursing education and practice. 2.2. Probationary Evaluation: (FIRST 3-6 months of orientation period for new staff). 3.0 RESPONSIBILITIES Head Nurse/ Supervisors/ Nursing Director.

4.0 POLICY 4.1. The Head Nurse is responsible for performance appraisal of his/ her personnel.

4.2.

4.3.

Probationary evaluations must be completed and sent to Nursing Department within the required time .

During the probationary period, a verbal report is given to the employee from time to time.

4.4. Progress notes are to be signed by Head Nurse and employee. Head Nurse to place reports in employee’s file. 4.5.

The Assistant Director of Nursing must be kept informed on an-going basis of any

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unresolved problems. 4.6.

Annual Evaluation: 4.6.1. Annual evaluations must be completed and sent to Personnel through the Nursing Department, at least 2 months (as per hospital / MOH policy) 4.6.2. prior to the end of the employee’s service year. It must be signed by the Head Nurse and employee before submission.

4.7.

Written anecdotal notes, conferences/ counseling session are to be kept by the Head Nurse on all employees throughout the contract year.

4.8.

The Assistant Director of Nursing must be informed on an on-going basis of any unresolved problems.

4.9.

Staff Nurse is expected to complete self-evaluation as required.

4.10.

All employees must be notified at least 90 days prior to end of service date, if a further contract will or will not be offered.

4.11.

Probationary Period (3-6 months)

4.12. Head Nurse is responsible for making initial contact with employee when he / she arrived on the unit.

4.13. Head Nurse to review skills check list, expectations and job description with new employee. 4.14. Introduce the assigned preceptor and outline his / her responsibilities in the presence of new employee. 4.15. Head Nurse is responsible to have the employee checked off any unfamiliar procedure prior to end of three (3) to six (6) months probationary period. 4.16. Head Nurse to make a notation in employee’s file, regarding discussion and any planned

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follow-up. 4.17. On at least two (2) weekly basis, the Head Nurse assess employee’s

performance in the following manner : 4.17.1. Review documentation on the medical record. 4.17.2. Evaluates care given to assigned patients i.e. observe employee at bedside, ascertain knowledge of patient diagnosis, medical and nursing management. 4.17.3. Evaluate written care of plan 4.17.4. Listen to shift report. 4.17.5. Obtain feedback from other staff/ preceptor (if applicable) 4.18.

For any problem identified and still not resolved during the first three (3) months of employment, employee should be told specifically that he/she is not meeting expectations and may not be retained beyond the 90 day probationary period; have the employee sign and give him / her a copy.

4.20Goals with target date for the next six (6) – nine (9) months should be discussed with the employee. Itshould be emphasized that these goals must be met, otherwise may result in employee not being re-contracted at the end of the year, or a less satisfactory performance rating. 4.21. Head Nurse must document each session and employee should also sign. 4.22. Head Nurse is expected to keep accurate and current files on employees. CRITERIA FOR EVALUATION 1.0 Experience 1.1. Experience & work performance 1.2. Interest and ability to learn 1.3. Efficiency to handle emergencies

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1.4. Interest in work 2.0 Personal 2.1. Appearance 2.2. Accepts correction or not 2.3. General behavior 3.0 Relation with a. b. c.

NURSING

3.1. Head of Department 3.2. Colleagues 3.3. Patients

5.0 PROCEDURES

RATIONALE

6.0 MATERIALS & EQUIPMENT 6.1. Pen, blue or black

7.0 ATTACHMENTS 7.1. Performance Appraisal Form 7.2. Performance Standard Indicators 7.3. Employee Unit File / Documentation 7.4. Completion of Employee Performance Appraisal

8.0 REFERENCES 8.1 Ministry Of Health policy & procedure CD 8.2 CBAHI standards

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NAME:

DATE

PREPARED BY:

Kingdom Saudi Arabia- Ministry Of Health

2010

REVIEWED By:

Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital jedsdah

2010

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

2010

APPROVED BY:

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1.0DEFINITION 1.1 Performance evaluation is a constructive process to acknowledge the employee performance of a non probationary career employee. 1.2 Peer is an employee’s co-workers or individuals other than the employee’s

supervisors who are familiar with the employees’ performance work products and / services

2.0 PURPOSE 2.1To ensure that that the quality and quantity of work performed by staff member. 2.2. To allow for continuous communication between manager /leaders and employee about job performance. 2.3 To offer the manager / leader and employee the opportunity to develop a set of expectation for future performance. 2.4 To used the opportunity for the manager /leader and employee to assess the employee’s best performance. 2.5 To use for future development plan of the employee. 2.6 To provide supporting documentation for pay increment, decisions, promotions, grievances, complaints, disciplinary actions and termination.

3.0 POLICY 3.1 Performance Appraisal 3.1.1 Performance appraisal shall be done for all staff yearly. 3.1.2 New staff nurses shall be evaluated after the 3 months probationary period, if the result

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fair or poor educational plan must be done by head nurse and nursing supervisor and to be re evaluated by the end of the year. Annually this should focus on employee’s ability to perform the duties listed in the job description. 3.1.3

All performance appraisals should be done according to the staff job description.

3.1.4

The evaluator should be capable of evaluating performance in an effective manner

3.1.5

Performance appraisal should reflect the performance of the staff

3.1.6

Result of the evaluation process will be the identification of individual development needs and the creation of a plan by which that development will be achieved.

3.1.7

Development plan should include the area most in need of improvement, action and strategies to improve performance. The criteria on which performance is evaluated must be clearly communicated to the individual prior to the commencement of the evaluation process. The evaluator should set up private meeting with the staff to discuss the evaluation. Leader / manager and the staff must sign the evaluation form.

3.1.8

3.1.9

3.1.10 In case unsatisfied staff with his / her evaluation after discussion with evaluator appointment should be arranged with Assistant Nursing Director or Director of Nursing to discuss the issue. 3.2 Peer Performance Review

3.2.1 Peer performance review shall be done for all staff yearly. 3.2.2 Peer input should be captured independent of the evaluation being conducted by the supervisor.

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3.3 Peer Performance scale.

Strongly agree Agree Neutral Disagree Strongly Disagree

3.4 Name and Signature of the Appraiser

4.0 RESPONSIBILITIES 4.1 Head Nurse for regular nursing staff 4.2 Supervisor for head nurses 4.3 Asst. Nursing Director for Supervisor 4.4 Nursing Director for Asst. Nursing Director and the staff who are directly under her supervision.

5.0 MATERIALS & EQUIPMENT N\A

6.0 PROCEDURES NA

7.0 ATTACHMENTS Performance scale form

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REFERENCES

8.1 Ministry of Health Nursing Policy And Procedures 2006 8.2 INTERNAL NURSING POLICY AND PROCEDURES KFH-J NRS-IPP-ADM-001E (2 8.3 Columbia university HR, nursing practice 8.4 Canadian clay and Glass Gallery performance appraisal policy 8.5 Staff performance appraisal policy UPPSN. 04 & 20 issue no. 7 effective date 03/3/2007 8.6 Agency for workforce performance evaluation system.

NAME:

DATE

PREPARED BY:

Kingdom Saudi Arabia- Ministry Of Health

2010

REVIEWED By:

Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital -jedsdah

2010

APPROVED BY:

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

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1.0 PURPOSE To retain staff in order for them to work in the hospital setting with satisfaction.

2.0 DEFINITION Retention Plan is the process of keeping staff currently employed for longer period of time with satisfaction on their job.

3.0 RESPONSIBILITIES Director of Nursing

4.0 POLICY It is the policy Rehabilitation Hospital to retain staff who are currently employed, with comfort and satisfaction, to function in their full capacity, providing good nursing services and quality nursing care to the patients.

5.0 PROCEDURES 5.1 Assess the current situation. 5.2 Develop a satisfaction survey or hold various meetings to determine how to make the work environment better for nurses. 5.3 Assess the leadership’s interest and support for a program. 5.4 Assess your current turnover rate because the program is aimed at reducing nurse

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turnover which should reduce costs and also assist in creating a safer patient care environment. 5.5 Hold meetings with the nurses. 5.6 Provide good working environment. 5.7 Assign staff in their area of specialty. 5.8 Provide support and the feeling of cooperation with every staff. 5.9 Provide training and education programs. 5.10 Avoid pressure to the staff particularly at time of work. 5.11 Follow contract agreements: 5.11.1 Benefits 5.11.2 Leave 5.11.3 Medical Care 5.11.4 Transportation 5.11.5 Days Off 5.11.6 Uniform

6.0 ATTACHMENTS

7.0 MATERIALS & EQUIPMENT

8.0 REFERENCES KSA- MOH- GENERAL DIRECTORATE OF NURSING POLICY2010

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NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 PURPOSE 1.1 To outline a reporting format on each level of the Nursing Services Department. 1.2 To ensure effective communication to all relevant personnel at all times. 1.3 To facilitate quality nursing service.

2.0 DEFINITION This policy outlines the reporting relationship of each level of the nursing department.

3.0 RESPONSIBILITIES Nursing Staff in all levels

4.0 POLICY 4.1 Staff nurse / in-charge shall inform the Head Nurse of any change in any patient’s status (i.e. medication treatment, physical or behavior status). 4.2 Medical nurses must immediately inform the Head Nurse / In-charge and the appropriate medical officer(s) of all significant changes in a patient’s vital signs. 4.3 Nurses monitoring any patient on special observation status must immediately inform the Head Nurse / In-charge of any significant issues during their period of observation. 4.4 Head Nurse / In-charge must immediately inform the Nursing Supervisor on duty on all significant patient and non- patient related incidents, ICU admissions, seclusion or physical aggression by or against staff members. 4.4.1 A written report will be written at the end of each nursing shift. This will include a current census figure, number of admissions, discharges, home passes, and transfers in and out and other returns to the unit. The report shall also contain brief details of critical / unusual occurrences, admissions, ICU cases and any other patient related issue that is significant. A copy is to be maintained on the unit and a copy sent to Nursing Administration at the end of the shift.

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The Head Nurse / In-charge shall sit with all members of the nursing staff for the oncoming shift and give a verbal report of the status of each patient on the ward. This is to include medication change, physical status, restraints and seclusion, behavioral patterns, etc. The staff nurses on duty shall continue to monitor the ward until the completion of the report and the oncoming duty nurses are physically present on the ward.

4.5 Supervisor Level: 4.5.1 Shift Supervisors shall use the written unit reports and critical / unusual occurrences reports as a basis for providing a detailed report to the oncoming supervisor. Any other relevant information gained on their shift through rounds of the units and hospital environment should be included in this hand over. 4.5.2 All shift supervisors shall report directly to the Deputy Director of Nursing concerning significant management / clinical issues that occur during their period of duty. 4.5.3 Deputy Director of Nursing will also read all unit reports and critical / unusual occurrence reports. 4.5.4 The Nursing Administrator on-call and the Director of Nursing must be informed of all critical / unusual occurrences and other events of significance that occur during a supervisor’s shift. 4.5.5 All unit reports and critical / unusual occurrence reports from the previous day are to be forwarded to the Director of Nursing on the following morning.

5.0 PROCEDURES

RATIONALE

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6.0 ATTACHMENTS

7.0 MATERIALS & EQUIPMENT 8.0 REFERENCES 1. General Directorate Of Nursing NPP Manual Of 2007 2. Al Amal Hospital, Jeddah MOH-NPP 2010

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GND- MOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

2010

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1.0 PURPOSE 1.1 To have an organized leave for staff. 1.2 To manage each unit with sufficient number of staff. 1.3 To control the leave of staff

2.0 DEFINITION Vacation schedule is the arrangement / scheduling of leave for the members of the Nursing Department without affecting the number of staff thereby rendering continuity of care to the patient with sufficient staff

3.0 RESPONSIBILITIES Head Nurses, Staff Nurses

4.0 POLICY 4.1 The Head Nurses receives and organize the schedules of vacation for the staff. 4.2 Maximum of 45 days is allowed for each staff, minimum of five (5) days for annual leave. 4.3 Maximum of 4 staff can be scheduled for leave each month if the requests indicates. 4.4 There should be an overlapping of 1 week between the leaves, last week of the staff on vacation overlapping with the first week of leave of the staff leaving for vacation.

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5.0 PROCEDURES 5.1

5.2 5.3 5.4 5.5

5.6

Nursing staff submits request (leave form with supporting papers) to the Head Nurse of the unit, the HN then list the name of the staff in the Schedule of Vacation Board. If the staff wants to swap their leave from time to time, they must arrange with colleagues and the Head Nurse of the unit. Staff should commit in day-out / day-in for good management of leave of other staff schedule. Vacation leave form must be submitted one (1) month prior to the schedule for leave for processing. In case of emergency while staff is on leave, and he cannot come back from vacation on time, he must send message through fax in the hospital with enough time for arrangement of schedule. Local vacation (compensation- annual leave, emergency leave) 5.6.1

Compensation must be filled and send to personnel before 24 hour at least for processing. 5.6.2 Local annual leave must be filled and send to personnel before one (1) week at least for processing Emergency leave could be the same day of leave but staff must arrange evidence or a valid reason for the leave.

6.0 ATTACHMENTS

7.0

MATERIALS & EQUIPMENT

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8.0 REFERENCES Kingdom Of Saudi Arabia – MOH - Policy

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0DEFINITION 1.1 Cyclic Scheduling is the staffing requirement based on equitable distribution of hours of work and time off for staff and the basic time pattern for a certain number of weeks is established and repeated in cycle.

2.0 PURPOSE 2.1 The purpose of the nursing schedule is to enhance the availability of nursing staffs, and thereby ensure patient’s safety.

3.0 POLICY 3.1 Nursing schedule is made for a period of one month ( monthly schedule) by the head nurse which includes productive and non productive time such as day off, owing day off, education, training, committee meeting and etc. The area supervisor in charge to counterchecks and approves the schedule before submission to the nursing office. Schedule must be submitted two weeks before the ongoing schedule ends. Three copies must bemade, one of which will be forwarded to the Nursing Service office and one will be kept in the unit where it is accessible to the staffs and the 3rd copy must be send to Dormitory matron with the mobile numbers written under each name.

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Official duty time for 3 shifts are as follows: Morning Shift Evening Shift

0700H – 1600H 1500H – 2400H

Night Shift

2300H – 0800H

Morning Shift Night Shift

For 12 HOURS SHIFT 0700H – 1900H

1900H – 0700H OPD From 7:30 AM to 12:30 PM – 1:30 PM to 5:00 PM Operating Room Morning Shift 0730H – 1630H Evening Shift Night Shift

1530H – 2400H 2330H – 0800H Rotation Nursing Supervisor SATURDAY - WEDNESDAY

Evening Shift

1500H – 2300H

Night Shift

2300H – 0700H WEEKENDS

First Shift

0700H – 1900H

Second Shift Lunch

1900H – 0700H Break Time ½ hour

Anytime between 11 am – 2 pm

Dinner

½ hour

Anytime between 4 -7 pm

Supper

½ hour

Anytime after 1 am.

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3.2 Schedule Request Before the Head Nurse/ CN makes the schedule staff nurses are being asked to submit their request for off duty or any other request which is schedule related. The HN/ CN will decide if the request will be granted or not depending on the need of the unit, or the requests will not affect the manpower, thereby affecting the delivery of patient care.

3.3 Changes in schedules Once the schedule has been finalized, approved and submitted changes must be made under the discretion of the head nurse/charge nurse, depending on the needs of the unit. In the event that the staff needs a change of duty a request must be made and submitted to the HN for approval. In the event that a nurse who is scheduled for duty is absent, or on sick leave or emergency leave, a reliever must be arranged by the HN or area supervisor during morning shift and charge nurse or rotation nursing supervisor for evening and night shift. Nurses who are going for sick leave must inform the head nurse or supervisor 2 hours before her or his duty hours. In cases wherein, the staff is absent without notifying the HN/ Supervisor, the head nurse or supervisor should make an attempt to contact the staff to clarify the reason. Absent for duty is subject to disciplinary action. Three incidents will result to investigation and dismissal. On call nurses are scheduled and the schedule available in nursing office. In case of any need arise they can be contacted easily through the nursing supervisor on duty. A. GENERALUNIT: 1.

Upon notification to the head nurse that the staff nurse is on sick leave, emergency leave or absent, nursing supervisor on duty should be informed to arrange a staff nurse to cover the area.

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During evening duty, night duty and weekend the charge nurse will coordinate with the rotating nursing supervisor to arrange scheduling depending on the ward situation,

or to be call off duty staff from the dormitory through the matron on duty. 3.

Head nurse/ charge Nurse must arrange the next duty schedule for the nurse who is on call.

4.

Nursing Supervisor endorse to the Rotating Supervisor on duty in cases of sick leave, emergency leave or absent or vice versa.

B. ON CALL NURSES A. Endoscopy 1.

On call duty nurse start from 1630 H until 0730 Hthe next morning.

2.

Thursday and Friday 24 hours covered by on call duty nurse.

3.

First or second on call duty nurse to be called by the rotating supervisor on duty through dormitory matron.

4.

Overtime hours will be paid back to the on call nurse according to the work situation in the unit.

B. DIALYSIS UNIT: (JEDDAH KIDNEY CENTER) 1.

Friday duty starts from 0700 hours to 1530 hours for morning shift, 1500 hours 2330 hours evening shift and 2300 hours to 0730 hours night shift.

2.

On Friday there is one nurse in morning and afternoon shift and 2 nurses for night duty.

3.

Friday duty nurse will have Saturday off or Thursday off or other days depending on the ward situation.

C. OPERATING ROOM:

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1.

Regular on call schedule is provided according to monthly schedule.

2.

On call duty starts at 1800 H to 0730 H from Saturday to Thursday.

3.

On call duty on Friday will be called anytime according to the work needs.

4.

2 nurses are assigned from morning and afternoon at 0800H to 2000H ours in order to cover and help the work and emergency operation, sick leave, emergency leave or absent.

5.

In case on call nurses are still extending his/ her duty and they need additional staff nurse, the charge nurse will inform the rotating nursing supervisor on duty to call the previous day first on call through the dormitory matron on duty.

6.

Nurses who attended the call still have to report on regular duty according to their schedule.

7.

Overtime hours will be replaced to on call nurse according to the work situation in the unit

Overtime Guidelines 1. Overtime is any time worked in a week which exceeds the schedules 48 hours. 2. Overtime will be closely monitored and controlled. It must be approved by the Director of Nursing or the Deputy Director of Nursing, the Nursing Supervisor and Head of the unit. In case of severe shortage of manpower, overtime must be approved by the appropriate hospital leaders according to hospital protocol (According to MOH and the hospital internal policy). 3. Overtime may be paid back in terms of extra days off in case financial remunerations is not applicable / approved. (According to MOH and / or hospital internal policy). 4. Staff may not work more than five overtime shifts (4 hours per day x 5 days a week or 20 hours of the Hijjra month (payroll period) or work more than five (5) consecutive days without authorization of the Director of Nursing / Assistant Chief of Nursing. 5. Advancement Planning / Approval.

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5.1 Assistant Chief of Nursing are responsible for the monitoring and control of overtime within their clinical service by. 

Requesting administrative approval for the required number of overtime hours.



Ensuring that the department does not exceed the amount of overtime authorized.

Nursing Personnel Vacation Policy & Other Leave Benefits PURPOSE: To provide guidelines on annual vacation for MOH- Saudi Staff- MOH, non Saudi staff and PIO staff and other leave benefits. Application policy and procedure (vacation/emergency leave) for Saudi staff MOH a) Application for annual vacation should be applied 5 days prior to the date of vacation and follow vacation plan in the unit. b) The annual vacation is 36 days per annum. The vacation can be taken with minimum of 5 days, and maximum of 3 months in one year. c) Vacation application form issued by the personnel department should be approved / signed by the:   

Unit Head Nurse Nursing Supervisor Nursing Administration after verification by the vacation allocation in –charge.

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Chief Nurse

d) Approved vacation request form should be returned back to the personnel department. 2) Maternity Leave Policy As per Ministry of Health Maternity leave is 60 days . 3) Emergency Leave

a) Emergency leave is granted to the staff with valid reason and is subject to approval by the Nurse Supervisor who is authorized by the Director of Nursing and Nursing Administration. b) The nurse is entitled for a maximum of 5 days emergency leave per application. Emergency leave is not allowed to save for next year contract. 4) Sick Leave Policy a) First 6 months with full salary b) Next 6 months with 1/2 salary c) Next 6 months with 1/4 salary d) If extended no salary shall be paid till he /she comes back for duty. e) Otherwise he /she will be referred to Medical Assembly. 5) Education / training activities – if any staff attends education or training activities out of duty owing hours will be refunded. 6) Attending meetings, committees and quality management activities. The assigned members must be attend committees, meetings and quality management activities as per schedule

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Vacation Application Policy & Procedure MOH Nursing Personnel Non Saudi Entitled for 45 days a) Application for annual vacation should be applied 2 months prior to the due date of vacation, to give enough time for clearance ticket and visa processing by the administrative personnel. b) Personnel Department will not entertain any vacation application earlier than the allowed 2 months period before the DDV c) Maximum period of extending vacation is- 5 months from the date of contract. d) Vacation application form issued by the personnel department should be approved / signed by the : 

Unit Head Nurse



Nursing Supervisor



Nursing Administration – after verification by the vacation allocation in-charge

e) Approved vacation request form should be returned back to Personnel Department for processing of clearance paper. Vacation Clearance Processing Procedure: MOH Nursing Personnel Non Saudi a. Personnel Department will issue the Vacation Clearance Form. b. Clearance Form has to be approved and signed by the following department / personnel in the following order.

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1. Head Nurse with Narcotic Clearance Form 2. Supervisor 3. Vacation allocation In-charge 4. Nursing Service Office 5. Pharmacy 6. Computer / 1D Department 7. General Store 8. Stock control committee(for Head Nurse & Charge Nurse) 9. Dietary 10. PRO 11. Cashier 12. Dormitory Matron ( not for live-out) 13. Personnel Department 14. Hospital Director / Administrative Director For the Head Nurse and the charge Nurse, three additional forms need to be accomplished as follows: 1. Clearance Certificate 2. Change of Authority Form 3. Pharmacy Form from chief Nurse to Head of Pharmacy

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After clearance has been made with the above mentioned department, return the clearance form to the Administration Department for completion and approval. One (1) copy for visa processing and one copy for ticketing / voucher processing.

Maternity Leave Policy: As per Ministry of Health Policy on Maternity Leave. a) During the first 3 years of contract – not entitled on maternity leave. b) On the 4th year contract period – entitled 25 days maternity leave. c) Upon completion of 4 years of contract – entitled for 45 days maternity leave and can attach 45 days annual vacation at the same time. d) Gap of 4 years between pregnancies also entitled for 45 days maternity leave. e) Gap of 3 years between pregnancies also entitled for 25days maternity leave. Legend: Due date of vacation -

D.D.V.

Requested vacation date

-

R.V.D.

Maternity Leave vacation

_

M.L.V

Emergency Leave

-

E.L.

Partial Leave

-

P.L.

Application Policy & Procedure PIO Nursing Personnel)

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Vacation & Emergency Leave 1)

Vacation Application Policy Procedure: Entitled for 30 days a.

Application for annual vacation should be applied 2 months prior to the due date of vacation, to give enough time for clearance, ticket and visa processing by the administrative personnel.

b.

Personnel Department will not entertain any vacation application earlier than the allowed 2 months period before the D.D.V.

c.

Maximum period for extending vacation is six months from the date of contract.

d.

Vacation application form issued by the personnel department should be approved / signed by the:

e.

2)

-

Unit Head Nurse

-

Nursing Supervisor

-

Nursing Administration – after verification by the Vacation Allocation InCharge.

Approved Vacation Request should be returned back to the Personnel Department of PIO.

Application for Ticket: a.

Send request to personnel department of PIO for signature and follow-up ticket.

Emergency Leave 1) 10 days per year, it can be taken anytime within the contract year with the coordination of the unit.

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2) Take request from PIO personnel department to be signed by Head Nurse, Supervisor and Nursing Administration. 3) Send back request to personnel department . 4) Then give it back to Nursing Office Secretary. 5) When the staff comes back from emergency leave head nurse or supervisor must inform the secretary. 6) Nursing Administration must sign the back to work on the same form then send it back to PIO office. Maternity Leave Policy Entitled for 30 days Maternity Leave per annum. Legend: Due Date of Vacation

-

D.D.V.

Requested Vacation Date

_

R.V.D.

Maternity Leave Vacation

-

M.L.V.

Emergency Leave

-

E.L.

Partial Leave

-

P.L.

Forms: 

Nurse monthly schedule form KFH -40



Vacation form KFH – 103

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Emergency Leave Form -

4.0 RESPONSIBILITIES 4.1 Unit schedule are being made by the respective head nurses ( HN) or charge nurses (CN) in the absence of the head nurse of the unit.

5.0 MATERIALS & EQUIPMENT

6

PROCEDURES 6.1 Have the master plan for 3 to 4 months (night duty only) and posted on the bulletin board for the nurses to know their night duty schedule so that they can plan their activities earlier. 6.2 Place all nurses on night duty and their day off according to cyclic scheduling. Meaning all the nurses should take turn to do night duty. Only 2 nights per person at one time. 6.3 Count on each day how may staff left and record on the bottom of the format. Circle those days where you have less number of staff to remind you that the request cannot be granted on those days. 6.4 Enter the staff requests if request can be approved ( to approve as much as you can ) by using the guideline for the number of staff you have. Any owing day/time off can also be given back accordingly. 6.5 Then the reminder of the staff sill be distributed sufficiently between AM & PM duty and according to the requirement of the unit setting. 6.6 New staff going for first time night duty should be placed as tagging (T). 6.7 Staff coming back from vacation, maternity leave and long sick leave should not

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be immediately placed on night duty. 6.8 Staffs who are pregnant should not be placed on night duty after 7 months pregnancy. 6.9 Write the number of staff accordingly on the side of the format. 6.10Complete the format by writing the number of staff on AM, PM and night duty and the total number of staff including the head nurse and other relevant information at the bottom of the format. 6.11Before sending to nursing office the area supervisor is responsible to double check the schedule. 6.12The completed staff scheduling sent to nursing office should show the relevant information that are required when doing the scheduling. 6.13To update all the changing of staff duty in nursing office.

6.0 PROCEDURES NA

7.0 ATTACHMENTS 8

REFERENCES

8.1 Ministry of Health Nursing Policy And Procedures 2006 8.2 King Fahd General Hospital NRS-IPP-ADM-003E (2)

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DATE 2010

REVIEWED BY:

Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital -jedsdah

2010

APPROVED BY:

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

2010

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1.0 PURPOSE 1.1. To give opportunity for staff to change duty with another staff, with valid reason. 1.2. To provide opportunity for Head Nurses to rearrange the schedule based on the need of the unit 1.3. To limit staff request for permission or incurring absence.

2.0 DEFINITION Changing of schedule of staff according to the need of the concerned staff, or according to the need of the unit, either with another staff or change of individual schedule.

3.0 RESPONSIBILITIES Head Nurses, Staff Nurses

4.0 POLICY 4.1 Give chance for staff to finish any activity with ease without affecting his work. 4.2 Allow change of duty between staff with similar work classification. 4.3 Change of duty must not affect the balance in the number of staff.

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5.0 PROCEDURES 5.1 Utilized the official form in changing of schedule between staff. 5.2 Concerned staff affixed their signatures as sign of acknowledgement of the change. 5.3 Form shall be approved by the Head Nurse and submitted to Nursing Office for approval. 5.4 Concerned staff will be notified of the approval. Change of individual schedule will be determined by the Head Nurse

6.0 ATTACHMENTS

7.0 MATERIALS & EQUIPMENT

8.0 REFERENCES

NAME Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

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1.0PURPOSE 1.1 To identify the need for staff. 1.2 To provide coverage in time of need for staff. 1.3 To provide nursing care.

2.0 DEFINITION On call is the duty of any staff out of regular duty hours. Where staff is required to appear in the hospital as per the need

3.0 RESPONSIBILITIES 4.0 POLICY On call only on cases of emergency.

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RATIONALE

5.1 Staff to be scheduled must provide the following information: 5.1.1 Telephone number (mobile and/or landline number) 5.1.2. Location of place of residency 5.2 Prepare the schedule. 5.3 If on call emergency has emerged, oncall must be covered by colleagues . 5.4 Notify the staff concerned. 5.5 Schedule must be posted, each of the staff on schedule will be provided with a copy of the schedule

6.0 ATTACHMENTS None

7.0

MATERIALS & EQUIPMENT None

8.0 REFERENCES General Directorate Of Nursing- MOH.KSA-2010

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION 1.1 Swapping - transferring or changing from the unit.

2.0 PURPOSE 2.1 To provide guidelines for policy of swapping staff.

3.0 POLICY 3.1 The Nursing Director will consider the internal transfer(swapping of staff)depending on the request of the staff. 3.2 Transfer form to be filled which is available in the nursing office and to be sent to the nursing department. 3.3 Staff shall be transferred if no replacement required otherwise it can only be considered with the arrival of new nurses.

4.0 RESPONSIBILITIES All nursing staff

5.0 MATERIALS & EQUIPMENT N\A

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6.0 PROCEDURES 6.1 The Staff initiated the swapping must put into writing his/ her request for swapping, which include not limited to the following; 6.1.1 Name and position 6.1.2 Area/ward of assignment 6.1.3 The reason/ purpose of sapping 6.1.4 Urgency of the requests 6.1.5 Area/ward to be preferred to be assigned. 6.2 The signed request must be submitted to the Head Nurse, Nurse Supervisor of the unit. 6.3 The Head Nurse and the Nurse Supervisor must discuss with the staff about his/her request for swapping to determine the underlying reason for the request, not necessarily to discourage but to allow the staff to reconsider his request or enough time to recognize the possible impact of his intent for swapping. 6.4 Head Nurse and Nurse Supervisor should decide together the decision for approval/disapproval of the request ,decision making must be made on which the welfare of the ward in the top priority to consider. 6.5 The Nursing Assistant Director responsible to the area must be informed once the decision has been finalized between the head nurse and the nurse supervisor. 6.6 Incase of conflict with the decision between head nurse and nurse supervisor ,the issue must be discuss with the Assistant Nursing Director responsible to the area. 6.7 Request must be submitted to the Director of Nursing or Assistant Nursing Director responsible to the area for final decision. 6.8 Decision for approval or disapproval must be clearly stated and understood by the

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requesting staff. 6.9 Requesting staff received the final decision as soon as possible ,at least 24-48 hours of the final decision. 6.10 Staff for swapping must be fully free of accountability at the ward of origin before release to the other ward. 6.11 A copy of the request with the decision must be keep in the unit for reference purposes.

7.0 ATTACHMENTS N\A

8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J

NRS-IPP-ADM-009E (2)2009

NAME: PREPARED BY:

Mrs.Ashwag Shibah Head of Nursing Education Unit At KFH_J

REVIEWED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

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1.0DEFINITION 1.1 Float Assignment – is a short term reassignment of a nursing staff member to a unit or the unit he / she permanently

assigned for few hours to one shift .

1.1.1 Float Staff . 1.1.1.1 General Float Nurse (GFH) – is assigned to work with a staff nurse assigned to the unit he / she is floated to ,and is not expected to assume a patent assignment alone . 1.1.1.2 Cross- Trained is prepared to assume full responsibilities in another unit with a different patient population than the nurse's regular unit . 1.1.1.3 Cross-Training is a competency –based , in – depth , organized preparation for a different role full patient care or management responsibilities on a unit with a patient population different from that on the nurse's regular unit of assignment .

2.0 PURPOSE 2.1 To provide a mechanism for provision of safe patient care by nurses when working outside their usual area of assignment or responsibility

3.0 POLICY 3.1 Nursing Staff members are not eligible to float until they have satisfactorily complete competency-based orientation and the 90-day probationary period on their own unit . 3.2 The float nurse must be cross-trained in advance of a float assignment , complete the competencies referred to administering nursing care on an assignment unit when she is going to assume the full responsibility in the new assigned unit (to be assigned patient care, even in charge ) . 3.3 Cross training criteria must be applied, refer to nursing education policy and procedure

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3.4 Floating between sister units requires an environmental orientation and any complete the competencies that are required to ensure safe patient care for any difference in set up with unit specific orientation . 3.5 Each unit will have its own cross-training criteria, and will state the minimum period required to cross- train to that area ..

3.6 Cross trained nurses list should be available in nursing office to facilitate the floating assignment.

4.0 RESPONSIBILITIES 4.1 Nursing Supervisor : 4.1.1 Maintain a competency based orientation and cross- training program within each /area to meet anticipated needs for short term staffing flexibility . 4.1.2 Maintains a current list of cross- trained staff before making float assignments . 4.1.3 Checks the list of approved cross-trained staff before making float assignments . 4.1.4 Notes the name and badge number of the floated staff member on the assignment worksheet and documents on the schedule which unit the nurse is assigned to . 4.2 Float training : 4.3.1.1 Appoints a preceptor or trainer for staff assigned for cross-training . 4.3.1.2 Determines eligibility of unit staff cross – training . 4.3.1.3 Develops and maintains a competency – based cross-training checklist ,to include

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Environment Orientation , Internal and External Emergency action , Environment of Care Program – location of crash cart, special safety concerns ( e.g. hazardous materials and equipment ) . 4.3.1.4 Assists in float preparation and orientation as necessary . 4.3.1.5.Upon completion of cross- training , documents and maintains completed crosstraining record in the employees unit file . 4.3 Float Supervisor and Assignments : 4.3.1 Receiving unit makes the float nurse feel welcome and appreciated . 4.3.2 Assigns permanent staff nurse to support and work with the GFN, and specifies the role on the patient assignment record . 4.3.3 Makes a patient / work assignment that is based on competency and needs. 4.3.4 Notes the name and badge number of each staff member floated in or out on the unit schedule . 4.3.5 Should the float nurse be given an assignment or task for which he/she/ does not feel competent, he/she must inform the charge nurse/ supervisor and the work in question discussed . 4.4 Cross-trained Nurse : 4.4.1 Receives patient assignment report 4.4.2 Requests assistance from a staff nurse assigned to the unit when unfamiliar procedures / equipment are encountered . 4.5 Float Nurse:

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4.5.1 Is Assigned with a staff nurse assigned to the unit where he/she is floated . 4.6.2 Performs basic, routine nursing care , and only procedures for which the float nurse is qualified .

5.0 MATERIALS & EQUIPMENT N\A

6.0 PROCEDURES N\A 6.0 PROCEDURES NA

7.0 ATTACHMENTS 7.2 Floating table 7.3 Cross training evaluation form

8.0

REFERENCES

8.1 New York State Nursing Association.(2005) NYSNA position treatment. RN staffing effectiveness and nursing shortage, Latham, NY Author . 8.2 New York State Nursing Association (2006) Nursing right and responsibilities. What to do in outside patient care situations, Latham, NY Author. 8.3 Mustard, LW.(2002) Perspectives. The paradigm shift in RN staffing in hospitals, corporate responsibility and institutional, Journal of Nursing low, 8(2), 31-4 8.4 Floating & Cross Training NRS-IPP-ADM-0010E(2)

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NAME:

DATE

PREPARED BY:

Kingdom Saudi Arabia- Ministry Of Health

2010

REVIEWED BY:

Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital -jedsdah

2010

Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

2010

APPROVED BY:

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DRESS CODE FOR NURSING STAFF

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1.0 DEFINITION Dress code is an established guideline for all nursing / hospital staff which requires uniformity, appropriateness and professionalism on nursing attire which reflect the customs of Islamic Religion in the Kingdom of Saudi Arabia.

2.0 PURPOSE 1. Uniforms presents an image of high standard and professionalism within a hospital, staff dressed appropriately in clean uniform forms part of that image. 2. Maintain professional levels of appearance and cleanliness. 3. A uniform gives confidence to the patients and their visitors. 4. Traditionally, the public expects to identify staff by the uniform they wear.

3.0 POLICY 1. In addition to the approved Hospital Dress Code, all nursing department staff will adhere to the following guidelines. 1.1 All nursing personnel who come into patient contact are to wear the approved uniform which has been issued by the hospital and according to the rules of the MOH. Personalized alterations are not acceptable. 1.2

Uniforms are to be worn on the hospital premises only.

1.3

At the end of each duty uniforms must be changed.

1.4

It is the responsibility of the Nursing Supervisor and the Head Nurse to ensure that the staff are wearing a clean and correct uniform prior to

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commencing of duty. 1.5 The uniform will be loose fitting and not body hugging or in other ways revealing. 1.6 Sleeve should be of a suitable, but practical length. 1.7. Hair should be covered for female. Long hair must be pinned up. 1.8 The hair of both male and female should be kept off the collar. 1.9 Fingernails should be short and uncolored. Ladies may use only clean nail polish. 1.10 Jewelry with exception of smooth wedding ring and watch, must not be worn. 1.11 Heavy make-up, and bright colored nail polish are NOT PERMITTED. 1.12 Strong perfumes must not be used by either male or female nurses. Antiperspirants is a must. 1.13 Nurses who are pregnant are permitted to wear a suitable white maternity top and trouser. 1.14 Uniform will be clean and ironed. 1.15 Undergarments must be plain white or fresh colored so as not to be noticeable through uniform fabric. 2. Foot Wear: 2.1 All nurses must wear suitable footwear all times for duty.

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Should be plain white, flat or low heeled, and low quiet rubber or leather heel / sole. High and noisy heels will not be worn. No heel or closed shoe must be worn. White or fresh colored socks or lose must be worn Frilly or colored socks will not be worn. Clogs are not acceptable except in certain specialty areas i.e. OR/Delivery Room 3. Ornamentation 3.1 Nurses watch

4.0 RESPONSIBILITIES Nursing leaders , supervisors, staff

5.0

REFERENCES

KSA- MOH- GENERAL DIRECTORATE OF NURSING POLICY2010

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION Code of Ethics is a branch of philosophy dealing with standard of conduct and moral judgments.

2.0 PURPOSE To provide basis for interpreting and analyzing clinical situations in decision making.

3.0 POLICY 1. Nurses are obligated to provide ethical and legal patient care that demonstrate respect for other. 2. Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. 3. Inherent in nursing is respect for human rights, including the right to life, dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, color, creed, culture, disability or illness, gender, nationality, politics, race or social status. 4. Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups. International Code of Ethics for Nurses: 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the name of health problems.

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2. The Nurse’s primary commitment is to the patient, whether an individual, family, group or community.

3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patients. 4. The nurse is responsible and accountable for individual nursing practice and determine the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining and improving healthcare environment and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 8. A nurse treats clients with respect for their individual needs and values. 9. Based on respect for clients and regard for their right to control their own care, nursing care reflects respect for the right of choice held by clients. 10.The nurse holds confidential all information about a client learned in the healthcare setting.

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11. The nurse is guided by consideration for the dignity of clients. 12. The nurse provides competent care to clients. 13. The nurse maintains trust in nurses and nursing. 14.The nurse recognition the contribution and expertise of colleagues from nursing and other discipline as essential to excellent healthcare. 15. The nurse takes steps to ensure that the client receives competent and ethical care. 16. The nurse advocates the interests of clients. 17. The nurse represents the values and ethics of nursing before colleagues and others. 18. Professional nurses organizations are responsible for clarifying, securing, and sustaining ethical nursing conduct. The fulfillment of these tasks requires that professional nurses organizations remains responsive to the rights, needs, and legitimate interests of clients and nurses.

4.0 RESPONSIBILITIES All staff nurses

8.0

REFERENCES

MOH.KSA – standard Policy

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION It is the distribution of competent registered nurses in accordance with their experience, skill and knowledge to deliver twenty four hours patient care.

2.0 PURPOSE To ensure that an adequate supply of manpower is available to run the unit and that the services delivered will meet optimum level of care.

3.0 POLICY 3.1 The head nurse ensures that the staff has completed the hospital general orientation program, the nursing department orientation program being conducted by the education department and the unit orientation before the staff will be exposed to the clinic. 3.2 The head nurse assigns one nurse to each clinic and ensures that other areas under his jurisdiction have adequate man power. Nurse's assignment is being based on their credentials and skills. 3.3 All nurses must be registered from their country of origin as well as with the Saudi Health Council. 3.4 All nurses must be BCLS certified. 3.5 An educational program for nurses must be developed and carried out and nurses are sent to attend continuous educational activities conducted by the nursing education department. 3.6 Competency test must be conducted periodically to ensure appropriate competency level for the delivery of care. 3.7 Nurses vacation schedule is being guided by the vacation plan .10% of the total number of staff in the unit can be scheduled for vacation at the same time. 3.8 A monthly schedule is being made and submitted a week before the previous schedule ends. 3.9 A head nurse with three years or more experience is assigned to handle administrative and clinical issues.

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3.10 There is a qualified registered nurse assigned as charge nurse who handle the unit at all times 3.11 Staff rotation in other clinics is considered to promote professional growth. 3.12 There is a disaster plan and the nurses will be assigned accordingly and must be aware of their role during disaster basing on the different action card formulated by the Disaster Planning Committee. 3.13 Nurses must adhere to the infection control policy as well as the policy and procedure of different departments needed for the delivery of patient care. 3.14 Nurses must be aware on what to do during injury and a statistics must be made and kept in the unit so as to monitor the occurrence as well as an action plan can be made to prevent future occurrences. 3.15 Staff performance evaluation is being made every year or if the need arises. 3.16 A monthly unit meeting is being conducted to update the staff of the recent nursing issues and to identify the problems so as to address them promptly. Attendance is compulsory, in the event that the staff apologized or is absent she or he will be made to read the minutes of the meeting. Three consecutive absences will be subject foe a disciplinary action. 3.17 Nurses going for emergency leave must adhere to the hospital policy. 3.18 A mandatory course is being conducted by the education department and nurses are scheduled to attend. 3.19 An organizational chart is available in the unit so as the staff will be guided on the proper chain of command.

4.0 RESPONSIBILITIES Head nurse / Charge nurse

5.0 MATERIALS & EQUIPMENT

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6.0 PROCEDURES

7.0 ATTACHMENTS 8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J NRS-IPP-ADM-018E (1)2009

NAME: PREPARED BY:

Mrs.Ashwag Shibah Head of Nursing Education Unit At KFH_J

REVIEWED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

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1.0 DEFINITION

2.0 PURPOSE To organize Orthopedic Nursing Service that provides 24-hour nursing services

3.0 POLICY 3.1. All staff nurses will have training experience and documented current competence in the care and management of patient in orthopedic department. 3.2 .As required by MOH all nurses are to be registered with the Saudi Health Council and is licensed from the country of origins. 3.3. Cyclic Schedule shall be done monthly and disaster schedule copy should be given to female dormitory. 3.4. Nursing staff will be scheduled on a rotation for 9 hours duty either morning, evening or night, and 4month master plan should be available in the area. 3.5. All new nurses shall attend hospital orientation program, nursing department orientation conduct by Nursing Education and Training Department, and unit orientation. 3.6 All Staff nurses will be expected to attend mandatory course and continuous educational program. 3.7. Staff nurses will be expected to accept temporary reassignment to other units as instructed when ever necessary.

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3.8 All student and orientee staff will be supervised by nursing staff. 3..9 Head nurse with 3 years experience is assigned at unit level to handle administrative and clinical issues. 3.10 A qualified registered nurse is assigned to be in charge of the unit at all times. 3.11 There is a charge nurse with 2 years clinical experience assigned to be in charge of the nursing unit at all times.

3.12 There is a Disaster Plan and the nurses shall be assigned accordingly. 3.13 There is an on going cross training for the nurses to ensure that when they are assigned out of the normal working area they have appropriate competency level to care for patient safety. 3.14 Ensure that assignments of nurses based according to his/her skill level with appropriate qualifications and their scope of current practice and the number, types and acuity of patients in the unit. 3.15 All nurses working in orthopedic department shall be BCLS certified. 3.16 There is a performance appraisal for all nursing staff conducted on a regular basis to assess staff performance and to promote professional growth. New comers, skill assessment during the first 3 months follows by evaluation. Current staff – evaluation is being done once a year. 3.17 Internal and external educational opportunity for nursing personnel to up date their knowledge and skills. 3.18 There is a vacation plan that allows 10%from nurses in each area to go vacation at the same

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time 5.19 Staff meeting shall be done monthly or as needed and all nurses have to attend, for those who did not attend they have to read and sign the minutes of meeting. 3.20 Any nursing staff will go for emergency leave should follow the hospital policy.

4.0 RESPONSIBILITIES Head nurse / Charge nurse

5.0 MATERIALS & EQUIPMENT

6.0 PROCEDURES 7.0 ATTACHMENTS 8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J NRS-IPP-ADM-017E (1)2009

NAME: PREPARED BY:

Mrs.Ashwag Shibah Head of Nursing Education Unit At KFH_J

REVIEWED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

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1.0 DEFINITION 1.1 Distribution of competent nurses for all aspect of operating room procedures.

2.0 PURPOSE 2.1 To provide a significant number of permanently assigned nurses to cover the operating room on 24 hours basis.

competent staff

3.0 POLICY 3.1. All staff nurses working in OR are qualified and competent with good knowledge & experience. 3.2. All staff nurses working in OR shall be BCLS certified, ACLS preferred. 3.3. All staff nurses working in OR must be registered with Saudi Health Council. 3.4. All staff nurses working in OR shall be on 9 hours duty & rotated as required. 3.5. All new nurses shall attend general hospital orientation, nursing department orientation, unit orientation and pass the required unit competency test. 3.6. A monthly schedule / daily assignment should be drawn up to ensure equal distribution of the staff according to availability, knowledge, experience & the need of the procedure. 3.7. A minimum of one circulating nurse & one scrub nurse to a procedure is to be maintained. 3.8. A registered nurse with post operative care unit experience must be assigned in recovery room. 3.9. Monthly on call schedule to all nurses staying in the dormitory on a daily / weekly basis to maintain the work need. 3.10. Attending on call & overtime shall be when ever necessary. 3.11. All nurses to attend & participate in unit regular meeting. 3.12. All nurses are encouraged to attend educational program & on going cross training to ensure that when they are assigned out of the usual working area they have appropriate

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competency level for patient care. 3.13. All staff working in OR will be encouraged to attend internal & external activities including nursing mandatory course to update their knowledge. 3.14. Preceptor & Head nurse in OR will supervise all nursing students / intern and orient staff. 5.15. All staff goes for annual vacation as scheduled in the unit vacation plan not more than 10% of the total number of staff at a time.

4.0 RESPONSIBILITIES Head nurse / Charge nurse

5.0 MATERIALS & EQUIPMENT 6.0 PROCEDURES

6.0 PROCEDURES 7.0 ATTACHMENTS 8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J

NRS-IPP-ADM-0021E(1))2009

NAME

DATE

PREPARED BY:

Mrs.Ashwag Shibah RN,BSN Head of Nursing Education Unit At KFH_J

2010

REVIEWED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

2010

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1.0 DEFINITION 1.1 To meet the patient's needs based on those needs and the specialized qualifications and competencies of the hospital nursing staff available.

2.0 PURPOSE 2.1 To provide significant competent skilled nurses to meet patients needs

3.0 POLICY 3.1 All nursing staff must be BCLS and registered with Saudi Health Council and is license from the country of origin. 3.2 All new nurses should attend Hospital Orientation, Nursing Department Orientation and Unit Orientation. 3.3 All nurses must attend Mandatory Course conducted by Nursing Education & Training Department. 3.4 All new staff nurses must continue 3 months morning shift duty and can be rotated according to her evaluation. 3.5 All staff nurses must read and sign their respective job description. 3.6 All staff nurses should have their own staff file in the unit with all completed requirements. 3.7 There is an adequate registered nurse to provide safe nursing care to patient and staff assignment will be based on acuity, needs of patients and staff credentials & skills. 3.8 There is a monthly unit schedule to ensure adequate manpower in the unit with 3 shifts of 9 hours duty using the cyclic format schedule.

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3.9 There should have a master plan schedule for the unit at least 3 to 4 months and display to the staff so that they can plan their activities in advance. 3.10 All staff nurses are required to have Unit Specific Skills Competency & Orientation Base Competency. 3.11 There is a head nurse with 3 years experience is assigned at unit level to handle administrative & clinical issues. 3.12 There is a Charge nurse with 2 year clinical experience to be assigned to handle administrative and clinical issues in the absence of the head nurse. 3.13 There is a monthly unit meeting to with attendance & all staff gets the opportunity for open discussion. Attendance is a must & excuses only accepted with valid reason. Three consecutive absences will consider for strict action. Those who did not attend must read the minutes of meeting with their signature. 3.14 There is Continuous Education Program scheduled twice a month in the unit where in each staff is given a topic to be discussed. 3.15 There is an External & Internal Education Program & staffs are encouraged to attend. 3.16 There is an going cross training for nurses to ensure that when they are assigned out of their unit they have appropriate competency level to care for patient safety. 3.17 There is available Policy procedure Manual which is accessible for all the staff to read. 3.18 There is Disaster Plan Schedule & the nurses shall be assigned accordingly. One copy submitted to matron office.

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3.19 The staff will be recalled to report for duty whenever necessary. 3.20 There is a performance appraisal for all staff conducted on a regular basis to assess staff performance end to promote professional growth. New staff, skill assessment done after 3 months follows by evaluation.Current staff evaluation is being done twice a year. 3.21 There is an annual vacation plan where in 10 % of the total number of staff in medical unit will be allowed to go for vacation at the same time. Emergency Leave and Maternity leave will be allowed for all staff according to hospital rules and regulation. 3.22 The staff should follow the proper channel of communication.

4.0 RESPONSIBILITIES Head nurse / Charge nurse

5.0 MATERIALS & EQUIPMENT N\A

6.0 PROCEDURES NA

7.0 ATTACHMENTS 8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J

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1.0 DEFINITION N/A

2.0 PURPOSE To organize Surgical Nursing Service that provides 24- hour nursing services.

3.0 POLICY 3.1 All staff nurses have training experience and documented current competence in the care and management of patient in surgical department. 3.2 As required by MOH all nurses are to be registered with the Saudi Health Council and is licensed form the country of origin. 3.3 Cyclic schedule shall be done monthly and disaster schedule copy should be given to female dormitory. 3.5 Nursing staff will be schedule on a rotation for 9 hours duty either morning, evening or night and 4 month master plan should be available in the area. 3.6 All new nurses shall attend hospital orientation program, nursing department orientation conducted by Nursing Education and Training Department and unit orientation. 3.7 All staff nurses will be expected to attend mandatory course and continuous educational program. 3.8 Staff nurses will be expected to accept temporary reassignment to other units as instructed whenever necessary.

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3.9 All student and orienteer staff will be supervised by nursing staff. 3.10 Head nurse with 3 years experience is assigned at unit level to handle administrative and clinical issues. 3.11 A qualified registered nurse is assignee to be in charge of the units at all times. 3.12 There is a charge nurse with 2 years clinical experience assigned to be in charge of the nursing unit at all times. 3.13 There is a Disaster Plan and the nurses shall be assigned accordingly. 3.14 There is an on going cross training for the nurses to ensure that when they are assigned out of the normal working area they have appropriate competency level to care for patient safety. 3.15 Ensure that assignments of nurses based according to his/her skill level with appropriate qualifications and their scope of current practice and the number, types and acuity of patients in the unit. 3.16 All nurses working in surgical department shall be BCLS certified. 3.17 There is performance appraisal for all nursing staff conducted on a regular basis to assess staff performance and to promote professional growth. New comers, skill assessment during the first 3 months follows by evaluation. Current staff- evaluation is being done once a year. 3.18 Internal and external educational opportunity for nursing personnel to update their knowledge and skills.

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3.19 There is a vacation plan that allows 10 % from nurses in each area to go vacation at the same time. 3.20 Staff meeting shall be done monthly or as needed and all nurses have to attend, for those who did attend they have to read and sign the minutes of meeting. 3.21 Any nursing staff will go for emergency leave should follow the hospital policy.

4.0 RESPONSIBILITIES Head nurse / Charge nurse

5.0 MATERIALS & EQUIPMENT N\A

6.0 PROCEDURES NA

7.0 ATTACHMENTS NA

8.0

REFERENCES

8.2 Internal Nursing Policy and Procedures KFH-J

NRS-IPP-ADM-0162009

NAME

DATE

PREPARED BY:

Mrs.Ashwag Shibah RN,BSN Head of Nursing Education Unit At KFH_J

2010

REVIEWED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

2010

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1.0 DEFINITION Quality Improvement Program allows for a systematic, deliberate, and on-going mechanisms for the evaluation and monitoring of professional nursing practice in terms of the quality patient care and organizational management.

2.0 PURPOSE To provide guidelines on the responsibilities of the nursing staff / leadership towards quality management department.

3.0 POLICY Nursing Responsibilities towards Quality Improvement Activities / Program. 1. QUALITY NURSING CARE 1.1 Quality management / performance improvement activities in hospital – based Nursing Services are guided by the MOH functional and nursing standards. 1.2 Quality management / performance improvement activities in accordance with all performance improvement standards. 1.3 Infection control activities to promote and improve patient safety. 1.4 Focus on patient care needs assessment (physical, psychological, and social). 1.5 Involvement of patient and significant others. 1.6 Interdisciplinary patient care and collaboration with physicians and other clinical disciplines. 1.7 Patient’s rights and education.

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1.8 Need for continuing care and coordination. 1.9 Nursing Documentation: 1.9.1 Initial assessment 1.9.2 Nursing diagnoses / patient care need 1.9.3 Interventions 1.9.4 Patient’s response to and outcomes of care provided. 1.10 Nursing care data integrated into the clinical information system. 1.11 Assessment of nurse competency including performance expectations and learning needs. 1.12 Development of policy and procedures, nursing standards of patient care (patient expectations), and standards of nursing practice (nurse expectations). 1.13 Provision for orientation, in-service training, and continuing education. 1.14 Defined mechanism for addressing ethical issues. 1.15 Determination of number, qualifications, and competence of nursing staff . 2.

NURSING LEADERSHIP RESPONSIBILITIES:

The participation of nursing leaders with leaders from governing body, management, medical staff, and other clinical areas in:  

Policy decisions affecting patient care services Developing and communicating the organization’s mission, strategic plans, budgets, resource allocation, operational plans, and policies.

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Planning, promoting and conducting organization –wide performance activities. Evaluating current nursing practice and patient care processes to improve the quality and efficiency of patient care. Promoting collaboration between nursing, medical staff, other clinical practitioners, and other departments. Recruitment, retention, development, and continuing education of nursing staff. Evaluating, selecting, and integrating technology and information management system. Collaborating with nursing educators to influence curricula, if applicable.

4.0 RESPONSIBILITIES All Nursing Staff

5.0 MATERIALS & EQUIPMENT MOH / Nursing Standards

7.0 ATTACHMENTS View NTQM attachments

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REFERENCES

1. Aspden P, Corrigan J, Wolcott J, et al., eds. Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004. 2. Adler M, Goman W. Quality. In: Adler M, Goman W, eds. The great ideas: a syntopicon of great books of the Western world. Chicago: Encyclopedia Britannica; 1952:p. 513-6. 3. Harteloh PPM. The meaning of quality in health care: a conceptual analysis. Health Care Analysis 2003; 11(3):259-67. 4. Lohr K, Committee to Design a Strategy for Quality Review and Assurance in Medicare, eds. Medicare: a strategy for quality assurance, Vol. 1. Washington, DC: National Academy Press; 1990.

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION Sentinel Events is defined as unexpected occurrences that involve deaths or serious physical injury or psychological injury or the risk event.

2.0 PURPOSE develop guidelines for root cause analysis of Sentinel Events.

3.0 POLICY 1. All sentinel events shall have a root cause analysis performed within 10 working days of discovery and an appropriate action plan. 2. A Root Cause Analysis Team shall be formed from a multi-disciplinary members, the term and membership of which depends on the nature of the incident involved. 3. The Quality Management Department will serve as the coordinator / facilitator of the team.

4.0 RESPONSIBILITIES Quality Management,coordenators,staff

5.0 MATERIALS & EQUIPMENT See attachments chapter

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RATIONAL

1. A Root Cause Analysis will be 1. As per hospital internal policy. performed by a multi-disciplinary root cause analysis team, after an incident has been identified as a Sentinel Event, within 24 – 48 hours of occurrences. 2. To provide tools / for better understanding 2. Brainstorming, Flow Charting and of the incident. other related QM tools shall be utilized to determine potential cause(s) of the incident. 2. Collection of data concerning the 3. Data gathering phase process would verify the potential cause(s) of variations. 3. The actual causes(s) of the 4. Identifying the c\actual cause of variation or at least the most variation. probable cause will be made, after collection of date, and analysis of the results. 4. The Quality Management will initiate the activity by coordinating with the concern department about the intent and purpose of the planned monitoring activity.

5. QM will serve as the facilitator for all QM related activity.

5. Criteria for monitoring shall be established accordingly.

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6. Responsible person for data collection and data entry, shall be identified for each activities. 7. Findings and analysis of the monitoring activities shall be a coordinated effort of the concern department and the QMD. 8. Final reports of the monitoring activities shall be received by Department concern, Quality Management Committee, Hospital General Director, Hospital Assistant Directors, Chief of Medical Staff, Chief of Medical Support Services for approval, comments, recommendation & action to be done and for general information.

9 . For reporting and documentation.

9. Action to be taken and it’s implementation shall be based on the finding’s, and recommendation of the Quality Management Committee, or the Hospital Director or any of the Deputies, Chief of Staff, Chief of the Medical Service; or Head of the Quality Management Department in the absence of the QM Committee.

10. Implementation stage of the planned action.

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10. Evaluation of the effectivity of action taken shall be done at least within 3-6 months of it’s implementation but not more than (1) year.

11. Evaluation stage – to evaluate the action taken.

11. Regular feedback shall be received by all concern departments and as identified at Step # 5.

12. To update concern departments of the issues involved.

12. Frequency of subsequent monitoring depends on the outcome of the follow-up evaluation activities, unless previously determined according to established criteria for monitoring and evaluation.

13. Monitoring depends upon the activity and the subsequent action taken findings of the previous.

7.0 ATTACHMENTS See NTQM tools attached

8.0

REFERENCES

1. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academy Press; 2004. 2. Reason JT. Human error. Cambridge, UK: Cambridge University Press; 1990. 3. Mick JM, Wood GL, Massey RL. The good catchprogram: increasing potential error reporting. J Nurs Adm 2007;37(11):499503. 4. Reason J. Human error: models and management. BMJ 2000;320:768-70. 5. Reason J. Managing the risks of organizational accidents. Aldershot, UK: Ashgate; 1997.

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Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

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2010

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1.0 PURPOSE 1.1 To define obligations in obtaining and documenting informed consent by physicians and nursing staff. 1.2 To ensure that informed consent is obtained from patients in accordance with patient right policy. 1.3 To obtain patients informed consent for medical and surgical procedure. 1.4 To out line procedures for refusal of treatment. 2.0 DEFINITION 2.1 Attending Physician – the Physician with primary responsibility for a patient’s treatment and case management. 2.2 Adult Patient - a person 18 years of age or older or a person under 18 years of age who has had the disabilities of minor removed. 2.3 Minor - is a person under eighteen (18) years of age and has not been legally emancipated by a court and is: - Not legally or previously married - Not at least 16 years old and living away from home managing his own financial affairs. 2.4 Informed Consent - Consent for treatment/procedure from a competent patient or authorize person not acting under duress, fraud or undue pressure, who is adequately informed by the healthcare worker of the following information concerning the contemplated procedure/treatment: 2.4.1 Patient’s diagnosis. 2.4.2 General nature of the contemplated procedure, its purpose, whether it is experimental, and the name (s) of the person(s)who will perform the procedure or administer the direct treatment. 2.4.3 The benefits, risks, discomforts and complications associated with the procedure, treatment and potential problems related to recuperation that may reasonably be expected, including all risks of the procedure or treatment. 2.4.4 The likelihood of success. 2.4.5 The patient’s prognosis if procedure is not performed. 2.4.6 Reasonable alternatives to medical treatment, if any. 2.5 Expressed Consent - Either oral/written consent given by a competent person or authorized representative for incapacitated patient. 1. Oral Consent – conveyed through speech. 2. Written Consent – conveyed though written document for diagnosis and treatment or specific

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treatment or procedure. 2.6 Emergency Consent - Medical Emergency is defined as a situation, where in competent medical judgment, the proposed surgical or medical treatment or procedures are immediately or imminently necessary and any delay caused by an attempt to obtain consent would jeopardize the life, health or safety of the person affected or would result in disfigurement or impaired faculties. This is a medical decision.

3.0 RESPONSIBILITIES Registered Nurse. Physician

4.0 POLICY 4.1 The underlying principle of informed consent is that patients have the right to be told what to expect and to determine what will be done with and to their bodies. 4.2 Except in emergencies, medical or surgical treatment or procedures shall not be administered to any patient until informed consent has been obtained from the patient or one legally authorized to act on behalf of the patient. 4.3 All adult patients have the right to make decisions regarding their treatment and to be provided sufficient information in order to make informed decisions regarding their healthcare. 4.4 The physician performing the medical and/or surgical procedure on patients is generally responsible for obtaining the patient’s informed consent prior to the treatment or procedure. 4.5 Inform Consent shall be obtained and placed in the patient’s medical record for all surgical procedures, emergency service treatment, administration of blood and/or blood products, ambulatory care treatment and other services including treatment of minors, mentally challenged, radiographic procedures, all surgical and endoscopic procedures including but not limited to: 4.5.1 General anesthesia 4.5.2 Local anesthesia. 4.5.3 Spinal anesthesia. 4.5.4 Minor surgical interventions. 4.5.5 Major surgical interventions. 4.5.6 Any other procedure that requires a specific explanation to the patient.

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5.1 It is the legal responsibility of the attending physician responsible for performing the medical or surgical treatment or procedure to: 5.1.1 Disclose all medical information that he/she believes is relevant to making an informed in a language the patient can understand. 5.1.2 Obtain an informed consent from the patient or one authorized, and capable of consenting on behalf of the patient.

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To insure that patient understand the nature of the treatment, including potential complications. To protect the patient against unauthorized procedures and to insure that the procedure is performed on the correct body. To protect the surgeon and hospital against legal action by patient who claims that an unauthorized procedure was performed.

The patient's signature on the Informed Consent Form is witnessed by a . medical/nursing staff not involved in the procedure. The witness' signature on the consent form signifies only that the patient's signature is indeed his own. Witnessing the signature implies nothing about the Witness’s knowledge of the patient's ability to give consent or completeness of the information shared by the physician with the patient.

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INFORMED CONSENT.

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Because of the distance involved or because of an extreme emergency situation, verbal or phone permission from any of the persons authorized to give consent on behalf of the patient may be obtained in the presence of two (2) witnesses by the use of extension phones (the physician and a hospital employee), and signed by both. The person giving the consent should be asked to sign as soon as possible. It is not necessary for the hospital employee to witness the information provided by the physician, merely the person's consent.

6.0 ATTACHMENTS Informed Consent Form

7.0 MATERIALS & EQUIPMENT None

8.0 REFERENCES Kingdom Saudi Arabia- Ministry Of Health Policy

NAME: PREPARED BY:

Kingdom Saudi Arabia- Ministry Of Health Policy

REVIEWED BY:

Mss.Lina AL-Harbi - Clinical Instructor GS Unit King Fahad Hospital-Jeddah

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NURSING

NURSES ROLE ON PROTECTING PATIENT'S PRIVACY AND CONFIDENTIALITY

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1.0DEFINITION 1.1 Privacy : Patient privacy is essential part of ethical and professional medical care. All reasonable measures based on the situation must be taken to ensure that each patient is assessed and treated with privacy of environment as possible. 1.2 Confidentiality : Patient confidentiality is strictly regulated by law . All reasonable measures, based on the situation must be taken to protect any identifying or medically revealing patient information .

2.0 PURPOSE 2.4

1.1 To set guidelines on how patient's privacy and confidentiality can be protected .

3.0 POLICY 5.1 Be sure to knock before entering patient's rooms. 5.1.1 Patient should be informed prior to doctor's rounds 5.1.2 If in a female ward a male entry must be limited and the nurse on duty must be informed so that The patients will be informed as well. Thus, visiting hours must be strictly observed. 5.2 Greet the patient upon entering the room. 5.3 In a room where more than one patient is admitted curtains must be drawn while the patient is being Examined or a special procedure is being performed where private parts have to be exposed. 5.4 The doctors must be assisted by a nurse while examining the patient. 5.4.1 In the clinic the nurse should not leave the male doctor alone with a female patient. A relative or companion must be with the patient if the nurse has to leave the clinic for a short period of time . 5.5 Patient must be properly covered while being transported be it on wheelchair or in a

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stretcher. 5.6 Female patients must be provided with a head cover all the time. 5.7 Confidentiality must be maintained as below : 5.7.1 The nurse must know when is it appropriate to breach confidentiality and should be aware of it's Legal implications. 5.7.2 Patient's file must remain confidential. 5.7.3 Confidential issues regarding the patient must not be discussed in public and to those who are not a member of the health team .

4.0 RESPONSIBILITIES 4.1 All nursing staff.

5.0 MATERIALS & EQUIPMENT NA

6

PROCEDURES

NA

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6.0 PROCEDURES NA

7.0 ATTACHMENTS 8

REFERENCES

8.1 Ministry of Health Nursing Policy And Procedures 2006 8.2 INTERNAL NURSING POLICY AND PROCEDURES KFH-J NRS-IPP-ADM-006E (2) 8.3 http://www,indiana.edu/~iuems/Pages/Members/privacy%20and%20 confidentiality 8.4 Policy Protecting Patient Privacy and Confidentiality KFHJ NR-1816 year 1428.

DATE NAME: PREPARED BY: REVIEWED BY: APPROVED BY:

Central Committee Of NPP 2007 General Directorate Of Nurs-ing- MOH.KSA Mrs. Mrs.Ashwag O. Shibah – RN,BSN King Fahd hospital -jedsdah Central Committee Of NPP 2010 General Directorate Of Nurs-ing- MOH.KSA

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2007

2010 2010

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Pediatrics, NICU, Nursery ,L&DL , MAT, Security staff

PREVENTION OF INFANT ABDUCTION ( CODE PINK ) DISASTER

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1.0 PURPOSE 1.1 To establish Infant Security Program in __________________. 1.2 To provide a rapid, organized and thorough response to a suspected or actual infant/child abduction. 2.0 DEFINITION Code Pink - when an infant between birth and six months of age is taken from the hospital by an unauthorized individual.

3.0 RESPONSIBILITIES Responsible to Staff Nurse/ Security guard. Other in-house Security Department personnel when available shall : 1.1 Respond to exits to secure the entire hospital. 1.2 Director of Security will direct available personnel to the appropriate exits to the shut and lock all doors. 2. Director of Security shall: 2.1 Notify the floor involved (Charge Nurse, Nurse Supervisor) 2.2 Call law enforcement and transit office. Have an operator notify all cab companies, airline terminals, bus depots, etc, if needed. 2.3 Assist is managing the respective search teams in the hospital . 2.4 Assist in formal documentation with the Hospital Risk Manager.

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4.0 POLICY STATEMENT It is the policy of _________________ to provide a process for the response to suspected or actual infant/child abductions. _____________ are open to the public for the specific purpose of providing health care and other associated services to patients. Visitor access to the medical facilities for incidental purposes associated with health care services is acceptable provided that patient care is not disrupted. To ensure a secure patient care environment for infants, the Security Management Program establishes Pregnancy and Newborn Services as 'security sensitive' areas. The Pregnancy and Newborn Services areas include Labor & Delivery, Maternity , Well Baby Nursery, Neonatal Intensive Care Unit (NICU) and Intermediate Intensive Care Nursery (IICN). In addition, security procedures are implemented throughout the facility to safeguard children as well. There are no guarantees that an abduction will not occur, but by preventative measures such as parental and staff awareness, 'security sensitive' area training and use of security systems minimizes such an occurrence.

5.0 PROCEDURES Measures that will Assist in Infant Abduction Prevention and Enhance Recovery 1. All staff will be required to wear proper hospital identification at all times. 2. Hospital scrubs and lab coats will be kept in an access - controlled area and are not to be loaned to unauthorized personnel. 3. Staff will ensure that infants are always in the direct line-of –sight or parents or hospital staff. 4. Parents will be informed of security measures at earliest opportunity after the birth of the infant. 5. Parents will be instructed to tell family members to use the Visitor’s Elevators, not the Staff Elevators or stairs(According to hospital settings). 6. Only hospital authorized staff members are allowed to transport an infant while in the healthcare facility. 8. Parents or staff members are NOT allowed to carry the infant outside of the mother’s room or within the facility at any time.

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9. NICU staff will transport the infant within the healthcare facility via wheeled bassinet, incubator or cart. 10. NICU staff will escort the family at the time of discharge to the admission/discharge office. 11. Staff will immediately report any unidentified individuals, suspicious activity or behavior or unfamiliar persons to the charge nurse. The Charge Nurse will in turn contact hospital Security Department. 12. Staff will require every one entering the department to identify themselves and reason for their visit. Suspected or Actual Infant Abduction 1. The staff member suspecting an infant abduction will conduct a brief search of the immediate vicinity (e.g. patient’s room and nearby hallway). 3. If the staff member continues to suspect an infant abduction, the charge nurse is notified immediately. 4. The charge nurse or his/her designee announces “Code Pink in progress”. 5. The charge nurse shall immediately CALL to notify Communications of the emergency. 6. Upon notification that CODE PINK has been called, the Communications Operator will announce CODE PINK on the public address system 5. The staff members will immediately check to see that each baby in their care is present and accounted for. Staff must immediately search the entire unit and adjacent areas: Nursery and a. b. c. d. e. f.

Maternity staff as Primary Responders will within their areas: Post staff at all entrances and exits of unit. Close all patient doors. Begin search of all vacant rooms. Search all equipment, linen and break rooms. Be prepared to be questioned by Security Services and Police. Report any suspicious activity to Security Services.

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7.

If there is reason to suspect that a baby may be in another vicinity on the Floor (e.g. Treatment room, or mother’s room, those rooms are quickly checked before calling the hospital Security Department. 8. It is important to remember to search in unlikely places such as closets, beneath beds, behind curtains, in offices, in call rooms, in locker rooms, in dumpsters, etc. 9. If there is little or no reason suspect that a baby may be in another vicinity on the Floor, the Hospital Security Department are called immediately. 10. The SOP Director/Muraqib or Medical Director on Duty shall and/or his designee will conduct with the Security Department and responding law enforcement agencies and will be responsible for the direction. 11. Once the abduction has been confirmed, the attending physician should notify the parents. 11. The Security Department will block all of the exits. 12. All persons are detained from leaving the unit until cleared by the Charge Nurse and / or the search of the unit has been finished and authorities completed proper questioning. 13. When the search is concluded, the Director of Security will notify the Communications Operator to announce CODE GREEN using the public address system. Care of the Family Experiencing an Infant Abduction 1. Move the parents of the abducted infant to a private room. 2. Have the nurse assigned to the infant remain with the parents at all times. Other Specific Administrative Duties of the Charge Nurse 1. Locate and secure the infant’s medical record. 2. Page the Unit Head/Director and the Nursing Office Supervisor. 3. Nurse manager or Charge Nurse briefs all staff on the unit. 4. Nurses should then explain the situation to each mother on the unit while the mother and their infant(s) are together.

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5. Conduct mandatory group debriefing sessions for personnel. 6. Document the incident from the discovery of the abduction until infant is located. Incident report/Occurrence Variance Report should be accomplished. 6.0 ATTACHEMENTS 6.1 Occurrence Variance Report Form 7.0 MATERIALS & EQUIPMENT None 8.0 REFERENCES 8.1 Security Management Program, King Faisal Specialist Hospital And Research Center - Jeddah 8.2 JCI & CBAHI Standard Code Pink Policy Nr-39 8.3 Hera General Hospital - Holy Makkah - Policy No- Sec-007 8.4 Photo Guide of Nursing Skills 2004, by Smith, Duell, Martin 8.5 Lippincott Manual of Nursing Practice, 7th editon by Nettina 8.6 Ministry of Health Policy and Procedure SNR-NICU-035

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GND- MOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 To outline the role of each responding code blue member. 1.2 To identify the steps to take for an organized, efficient and effective response to a medical emergency. 1.3 To prevent overcrowding the affected area with unnecessary staff.

2.0 DEFINITION Code Blue – code for medical emergencies. Defines the roles and responsibilities of each nursing code blue team in case of medical emergencies

3.0 RESPONSIBILITIES Head Nurse, Staff Nurses

4.0POLICY 4.1 Head nurse in each unit shall designate a treatment room nurse and assistant in each duty shift. 4.2 The treatment room nurse and assistant / Internist nurse in each unit shall be the nursing members of the code blue team. 4.3 Only the code blue members of each unit shall respond to the code blue situation. 4.4 Staff nurse discovering a patient in a cardiopulmonary arrest or other medical emergency must not leave the patient while summoning help. 4.5 Nurse on office duties or nurse in-charge shall notify the operator by dialing 333 and must mention the location clearly. 4.6 Details of the event must be documented in the patient's file and in the code blue flow sheet in a chronological order.

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5.0 PROCEDURES 5.1 Staff nurse discovering the patient (if not the Treatment Room nurse): 5.1.1 Stay with the patient. 5.1.2 Summon help by whatever means available. 5.1.3 Indicate that a code blue needs to be called. 5.1.4 Immediately commence CPR or required emergency first aid. 5.2 Nurse on office duties: 5.2.1 Notify the operator of the code blue by dialing (_ _ _) and clearly stating name, position and the exact location of the code blue. 5.2.2 Secure confirmation from the operator by asking the operator to repeat the information given 5.2.3 Label appropriate documents with the patient’s name and medical record number 5.3 Treatment Room Nurse and assistant (internist nurse): 5.3.1 Rush to the area. 5.3.2 Establish EKG monitoring and run strip as soon as possible. 5.3.3 Connect patient to vital signs monitor, if available. 5.3.4 Prepare defibrillator for use. 5.3.5 Establish an IV line and administer IV solutions as directed by the physician. 5.3.5.1 If physician has not yet arrived, commence 500ml of dextrose 5% in normal saline. 5.3.6 Connect Ambu bag to oxygen supply. 5.3.7 Prepare all medications as directed by the physician. 5.3.8 When time permits, Label all prepared medications including name and dosage or tape empty ampoules to syringe ensuring that drug name, dosage and expiration date are visible. And / or put each separate medication order in a separate plastic container. This should include the syringe and needle, empty medication vial and swabs. 5.3.9 Verbal medication orders given by the physician must be repeated by the nurse. 5.3.10 Check prepared medications and hand to physician for his administration.

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5.3.11 Nurse will hand prepared medication to the physician / internist for his administration. 5.3.12 Repeat aloud medication that is being handed to the physician. 5.3.13 Use additive labels for all medications added to IV solutions. 5.3.14 Carry out other physician orders 5.3.15 Check and record vital signs and pupillary response every 15 minutes. 5.4 Head Nurse or Charge Nurse 5.4.1 Take in-charge of the Code Blue until supervisor / physician arrives on the code blue scene. 5.4.2 Make the decision whether to: 5.4.2.1 Rush patient to Treatment Room, or 5.4.2.2 Deliver code cart and contents to scene of the code. 5.4.3 If patient is not in an ICU bed, place CPR board under the patient. 5.4.4 Establish code blue baseline observations for pulse, B/P, respiration and papillary response. Notify Nursing Supervisor of same or record directly. 5.4.5 Check and record pulse, B/P, respiration, and papillary response every 15 minutes until cardiac monitor and B/P monitor machine is hooked up. 5.5 Nursing Supervisor; 5.5.1 Note the time Code Blue was called. 5.5.2

Clear the room of unnecessary equipment and people.

5.5.3

Ensures that initial baseline observations are taken and recorded.

5.5.4

Coordinates all nursing activities and ensures that all designated code blue nursing activities are being performed as specified.

5.5.5

Records code events in chronological order on the special form provided.

5.5.6

Assists with CPR, if necessary, until the arrival of physician.

5.5.7

Complete the critique of the code blue and submit to Medical Director for review by Code Blue Committee.

5.5.8

Assist Head Nurse / Charge Nurse with documenting the incident in nursing progress notes.

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6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT Patient’s file, Code Blue Sheet

8.0 REFERENCES 1- Sarasota Memorial Hospital Policy. (2007) Code Blue Management

and Responsibilities (01.PAT.03). Sarasota Memorial Hospital: Author 2- Schilling-McCann, Judith A., RN Critical Care Nursing Made Incredibly Easy.

Lippincott Williams and Wilkins 2008 Code Master XL and Defibrillator/Monitor Users Guide.

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 To outline the role of each responding code red team. 1.2 To facilitate an efficient and effective response to a code red situation. 1.3 To ensure safety of patients, staff and important documents.

2.0DEFINITION 2.1 Code Red – code for fire emergencies. 2.2 Defines the roles of nursing during Code Red

3.0 RESPONSIBILITIES Staff Nurses

3.0 POLICY 3.1 There shall be a prompt and professional response to potentially dangerous situation. 3.2 All nurses to be alert to the RISK OF FIRE breaking out. 3.3 It is the responsibility of all nurses to be aware of the location of fire hoses and fire extinguishers on their units. 3.4 If a known fire is discovered and is small enough to be dealt with e.g. litterbin fire, the fire should be extinguished and a critical / unusual occurrence report shall be completed. 3.5 If the fire cannot be extinguished, the nearest fire alarm should be sounded and Code Red be instigated. 3.6 If a CODE RED is heard, 2 nurse from each unit to report to the affected area immediately.

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RATIONALE

5.1 ACTION IN THE EVENT OF FIRE IN WARDS 5.1.1 Nurse discovering fire to put it out if small. Report incident to the Head Nurse. 5.1.2 Nurses discovering fire, out of control or suspected of being large: 5.1.2.1 If smoke is detected from under door, do not open the door. 5.1.2.2 If door to affected room is open, closed the door immediately (to cut off spread). 5.1.3 In both situations, raise alarms. 5.1.4 Evacuation of patients / Staff of the affected Ward. 5.1.5 Follow fire and safety policy. 5.2 DESIGNATED NURSING ROLES: 5.2.1 Head Nurse / In-charge role 5.2.2 Role of checking the number of patients on the affected unit. Carried out by the nurse on office duties. 5.2.3 Role of safeguarding patients files Carried out by the nurse assigned on Store /Laundry Duties.

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Role of searching/ evacuation of the unit Carried out by the remaining nurses available in the unit. These nurses to report to the nurses’ office and awaits instructions from the head nurse. 5.3 HEAD NURSE / IN-CHARGE PERSON ROLE 5.3.1 Check alarm raised to get help. 5.3.2 Take possession of : 5.3.2.1 fire exit keys 5.3.2.2 key to safe area in the unit.

5.3.4

5.3.5 5.3.6

5.3.7

NURSING

CODE RED

5.2.4

5.3.3

APPLIES TO:

Designate the area to evacuate (reassess with Hospital Fire Officer when he arrives). Divide nurse without specific roles into two Search / Evacuation groups. Ensure each group has a master key. Assign a nurse to safeguard patients’ files if fire occurs during night duty. Coordinate all nursing roles during code red. Prepare to hand over, with brief verbal report of situation, to HOSPITAL FIRE OFFICER when he arrives. Coordinate with Hospital Fire Officer throughout the code red.

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CONTROLLING THE FLOW OF PERSONNEL ENTERING THE AFFECTED UNIT IN CODE RED SITUATION 5.4.1 The security personnel on door duty performs this role when a code red is called. 5.4.2 In Unit A, Head Nurse will assign a specific nurse to liaise with MOI guard. In Unit B/C, the security personnel should coordinate with the charge/head nurse of the unit. 5.4.3 Part of door duties should include, maintaining at all times a current record of patients off unit. 5.4.4 During a code red, only the following personnel should be allowed into the affected unit. 5.4.4.1 Unit nursing / medical staff, housekeeping supervisor. 5.4.4.2 Two (2) nurses from each of the other units (i.e. 8 nurses) 5.4.4.3 Engineering Personnel 5.4.4.4 Nursing / medical / hospital administration personnel 5.4.4.5 MOI personnel 5.4.4.6 HospitalFire Officer

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5.4.4.7 Other personnel as specifiedby Hospital Fire Officer. 5.4.4.8 Nopatients currently on off unit should not be allowed to re – enter the unit during a code red. 5.4.4.9 Nursing staff with patients off unit should remain off unit with those patients. 5.5 CHECKING THE NUMBER OF PATIENTS ON THE AFFECTED UNIT This role is always performed by the nurse assigned to office duties. 5.5.1 The most current patients’ list, (supplied by the medical records department) should be utilized as a basis for checking patients by: 5.5.1.1 Adding transfers-in to the unit. 5.5.1.2 Admissions to the unit. 5.5.1.3 Deleting transfersout from the unit 5.5.1.4 Deleting discharges

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from the unit 5.5.1.5 Acknowledging those gone for home pass 5.5.1.6 Re-registering home pass returns 5.5.2

Established from Head Nurse, where designated safe areas are and go to entry of same – if on unit. 5.5.3 Go to exit being used to evacuate patients – if safe area is off unit. 5.5.4 As each patient enters the safe area / leaves the unit, check his name off the current list of patients. 5.5.5 Do not allow patients that are evacuated / in safe area to reenter the unit. 5.5.6 Remain at this point until receiving further instructions from the Head Nurse, Hospital Fire Officer. 5.6 SAFEGUARDING PATIENTS FILES This role is always performed by the nurse assigned to Store / Laundry duties. 5.6.1 All files should be gathered and carried, in most

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5.6.2

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convenient container available, to the designated safe area if possible. Remain with and safeguard files until further instructions are received from Head Nurse / Hospital Fire Officer.

5.7 SEARCHING / EVACUATION OF THE UNIT This role is always carried out by: a. Nurses from code red unit without any other assignment in code red. b. Nurses from other units who responded to code red. 5.7.1 Nurses should assemble at Nurses Office and await instructions from the Head Nurse. 5.7.2 Each group should remove patients from the immediate vicinity of fire area. 5.7.3 Each group should then proceed in opposite directions away from the fire area and search in consecutive sequence all rooms / spaces until they reach the safe area /

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emergency exit being used. 5.7.4 Search procedure should consist of the following: 5.7.4.1 At least 2 nurses to remain outside the area being searched, 5.7.4.2 To ensure patients/others do not return to areas already searched 5.7.4.3 To direct patients who come out of area being searched, towards safe area. 5.7.4.4 Remaining nurses will search the area and calmly ask occupants to proceed towards the safe area. Assistance will be given to any patient requiring help. 5.7.5 Once the room is safely evacuated, the room will be locked and put a mark on it. 5.7.6 Once safe area is reached, the group will remain in

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5.7.7

the hallway to prevent personnel re – entering the searched area. Await further instructions from the Head Nurse or Hospital Fire officer.

5.8 STAFF WITH OFFICES IN THE UNIT All staffs are expected to take responsibility for their own areas by: 5.8.1

5.8.2

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Directing patients/others who may be in their offices towards the safe area. Taking medical files in their office to the safe area; or making designate nurse aware of same – if too many files. Once the office is safely evacuated of personalities, it should be locked.

5.9 DURING NIGHT DUTY 5.9.1 Head nurse – Night to report to affected area immediately and follow steps as per daytime 5.9.2 You are unlikely to receive help externally for some

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time, but: Ring

Switchboard to alert re: emergency Duty Nursing Administration Hospital Administration

AS SOON AS PRACTICABLE, All other nursing roles remain as during the day.

6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT None

8.0 REFERENCES -

-

Noji EK.the public health consequences of disaster .pre-hospital and disaster med.2000,15:147-157. Abbott D. disaster public health considerations. pre-hospital and disaster med. 2000,15:158-166 Alamal Hospital –Jeddah – Ksa-Code Red Policy 2010.

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 1.2 1.3 1.4

To outline the role of each responding code crises team. To facilitate an efficient and effective response to a code crises situation. To put potentially dangerous situations under control. . To ensure safety of patients and staff.

2.0 DEFINITION 1.2 Code crises – code for any potentially dangerous and violent situation. 1.3 Defines the role of each nursing member of the team responding in a potentially dangerous situation (Code Crisis ). 1.4 Silent code crises = A moderate or partially dangerous situation (lesser code Crisis situation) Operator will not be inform anymore, instead the Head Nurse / Charge Nurse will only inform the Nursing Management that in turn will arranged to send needed staff from other units to control the situation.

3.0 RESPONSIBILITIES Head Nurse, Charge Nurse, Staff Nurses

4.0POLICY 4.1 There shall be a prompt and professional response to potentially dangerous situation. 4.2 In the event of potentially dangerous situation within the ward environment, the Head Nurse or his designate may initiate Code crises . 4.3 To summon the code crises team, dial ______ and notify the switchboard operator or the code crises location three times at 10 seconds interval. 4.4 Code crises team should attend ward immediately. 4.5 Code crises Team will consist of 2 designated nurses from each unit and the Head Nurse / In-charge of the units.

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4.6 The head nurse or nurse- in charge in each unit shall designate two (2) staff nurses in each shift as members of the code crises team. This will be documented in the daily job allocation sheet. 4.7 Head Nurse or designate will be in-charge of code crises team. 4.8 Personnel on entry door duties will admit: 4.8.1 code crises team 4.8.2 unit clinical team members 4.8.3 members of nursing and medical administration 4.8.4 other personnel as indicated by nursing administration 4.8.5 members of security department, except in unit A (MOI unit).

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RATIONALE

5.1 Code crises team will take full control of crisis situation, and in case the team is unable to handle the crisis, personnel from MOI should be called immediately to help control the situation. 5.2 Unit pharmacy nurse will coordinate with unit specialist / resident / doctoron-duty for any emergency medication orders and to administer any such orders. 5.3 All other clinical staff present will channel the remaining unit population away from the immediate crisis area. 5.4 Unit Head nurse or designate will complete a critical / unusual occurrence report and submit to Nursing Administration. 5.5 Unit Head Nurse or designate will ensure that the incident is reviewed by the Unit Clinical Team as soon as possible. 5.6 In case of crisis situation is not potentially dangerous enough, Head Nurse / In-charge could initiate by calling Nursing Administration as a Silent Code crises

6.0 ATTACHMENTS None

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7.0 MATERIALS & EQUIPMENT Critical or unusual occurrence report

8.0 REFERENCES  



Fundamentals of disaster management – a handbook for medchal professionals,second edition 2008 Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the Nonviolent Crisis Intervention® training program. Brookfield,WI: Author Internal Nursing Policy And Procedures Alamal Hospital Jeddah

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 To bring the violent behavior under control. 1.2 To ensure safety of patients and staff.

2.0 DEFINITION A patient expressing feelings of anger, dissatisfaction, fear or hopelessness through aggressive behavior.

3.0 RESPONSIBILITIES Unit Head Nurses, Charge Nurses, Staff Nurses

4.0 POLICY 4.1 Whenever a violent situation involving patient(s) arises, the Head Nurse or designate should contain the situation with the assistance of other nurses in the unit. 4.1.1 Nurse must not attempt to control a violent patient alone. 4.1.2 If the nurses on the unit are unable to contain the situation, the Head Nurse or designee should call upon the assistance of the nurses from other units or when necessary, a code violet should be instigated, and physician must be informed. 4.2 All efforts must be done to protect patient and staff from harm during the crisis. 4.3 Any occurrence of violent situation should be documented (incident report, documentation on patient's file), for reference purposes. 4.4 The head Nurse / in-charge must ensure that a full review of the incident by the clinical treatment team takes place as soon as possible.

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Assess the situation.

5.1.1 Determine how many patients are involved and identify. 5.1.2 Determine the reason causing the violent behavior. 5.1.3 Check for the presence of weapon. 5.1.4 Inform the physician. Give details of the situation 5.2 Help patient bring violence under control. 5.2.1 Initiate conversation in the presence of the attending physician. 5.2.2 Give the patient space. Do not make any sudden movement. 5.2.3 Avoid touching an agitated patient or stand too close to him. 5.2.4 Adopt a calm, nonconfrontational approach. 5.3 Talk and listen to the patient. Acknowledge his state of agitation and give him opportunity to ventilate anger verbally. 5.3.1 Keep other patients away from

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the crisis area. 5.4

If the situation cannot be controlled by the nurses in the unit charge nurse may initiate a Code Violet.

5.5

Call for help of police or Ministry of Interior (MOI) staff if violent patient has weapon and refuses to surrender it to the nurses.

5.6

With doctor's order, bring patient to the seclusion room (follow the policy & procedure in secluding patient).

5.7

Administer prescribed tranquilizer.

5.8

Let doctor examine the patient for any possible injury. Administer first aid if deemed necessary.

5.9

Write incident report and document in the nursing progress notes.

6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT 7.1 Gloves 7.2 Critical/unusual occurrence form

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8.0 REFERENCES -

Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the Nonviolent Crisis Intervention® training program. Brookfield,WI: Author. Jambunathan, J., & Bellaire, K. (1996). Evaluating staff use of crisis prevention intervention techniques: A pilot study. Issues in Mental Health Nursing, 17, 541–558. Jonikas, J., Cook, J., Rosen, C., Laris, A., & Kia, J.(2004). A program to reduce use of physicalrestraint in psychiatric inpatient facilities.Psychiatric Services, 55, 818–820.

NAME

DATE

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2010

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2010

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1.0PURPOSE 1.1 To ensure safety of patient and hospital staff. 1.2 To prevent damage to any hospital properties. 1.3 To contain any violent situation.

2.0 DEFINITION A situation involving an aggressive patient that is posing danger to himself, other patient, hospital staff or other personnel while in OPD.

3.0 RESPONSIBILITIES Head Nurse/ Charge Nurse, Staff nurses, Security personnel

4.0 POLICY 4.1 Whenever a violent situation involving patient arises, it must be contained immediately. 4.2 There is a warning sign bell / light with switches placed at physicians' offices, nursing counter, and security office that can be operated, seen or heard at both ends. 4.3 Once the warning sign bell rings or warning light lit up, the concerned (nurses & security) personnel must rush to the site immediately to evaluate and control the situation. 4.4 Nursing staff should not put themselves at high risk by attempting to control a violent or aggressive patient on their own. The security personnel will be available to help in controlling the situation. 4.4.1 MOI personnel's help shall be sought whenever deemed necessary to control the situation.

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4.5 Head / nurse in charge shall coordinate the procedure. 4.6 All precaution must be taken to avoid injury to the patient who is being restrained and to the staff performing the restrain. Note: Details should be documented in the patient medical file including the reason that leads to the incident and intervention rendered.

5.0 PROCEDURES

RATIONALE

5.1 Determine the location and the extent of the situation. 5.2 With other nurses and security staff, rush to the area immediately and try to restrain the violent patient. 5.3 Seek the help of the MOI if deemed necessary. 5.4 Inform physician on duty and should see the patient ( if wasn't seen so far). 5.5 Move the involved patient in a safe area most likely to the observation room. 5.6 Apply physical restraints as ordered. 5.7 Immediately administer medication ordered.( if there is any order ) . 5.8 Notify nursing administration ASAP, complete an unusual occurrence report and send to nursing administration. 5.9 Keep the involved patient closely observed through out the time he

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stays in OPD. 5.10 Document the details in the patient's medical file including the reason that leads to the incident and interventions rendered.

6.0 ATTACHMENTS None

7.0

MATERIALS & EQUIPMENT 7.1 Gloves. 7.2 Critical/unusual occurrence form

8.0 REFERENCES -

Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the Nonviolent Crisis Intervention® training program. Brookfield,WI: Author. Jambunathan, J., & Bellaire, K. (1996). Evaluating staff use of crisis prevention intervention techniques: A pilot study. Issues in Mental Health Nursing, 17, 541–558.

NAME

DATE

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Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 PURPOSE To Ensure The Safety And The Welfare Of Patient Employee And Visitors

2.0 DEFINITION Call for help during emergency when there is risk for patients or staff

3.0 RESPONSIBILITIES Staff Nurses

4.0 POLICY 4.1 To call for more staff to aid or to assist in the control of emergency situation. 4.2 Establish a systematic role of nursing in emergency. 4.3 Provide guideline for evacuation of the patients and identify the location of the emergency. 4.4 To provide or established a process or procedure for call during emergency . 4.5 To provide guidance for staff on how to evaluate the situation and whom to call.

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5.1 The Head Nurse or the Charge Nurse will evaluate the situation and to decide whether to call for help or just to control the situation. 5.2 Calling for emergency situation: 5.2.1 Dial Hot Line( _ _ _) — in emergency 5.2.2 Identify yourself 5.2.3 Identify the type of emergency clearly 5.2.4 Identify your location clearly. 5.2.5 Operator should repeat the message back to the caller for confirmation, 5.2.6 Operator air the request clearly, at least twice 5.3 Head Nurse should allocate two (2) staff daily for emergency call. 5.4 Staff should be controlled and supervise well. 5.5 Patient should be controlled well. 5.6 Staff should serve as a guide for patients in time of evacuation. 5.7 Review the policy and procedure for the different codes. 5.8 In case of disaster, all areas should be notified immediately 5.9 Request transport to have an emergency car ready at all times. 5.10 Incident report to be filled and send to Nursing administration

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6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT None

8.0 REFERENCES -

The University Of Connecticut Health Center - John Dempsey Hospital - Dministrative Manual

-

Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the Nonviolent Crisis Intervention® training program. Brookfield,WI: Author.

NAME

DATE

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Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 1.2 1.3 1.4 1.5

To prevent trauma. To improve balance To prevent disuse atrophy and retard progressive bone For patient safety To avoid and alerting patient from falls.

2.0 DEFINITION Prevention of patient from falling down and guideline to patient safety and protection from harm and how to act in case of occurrence of patient falling down.

3.0 RESPONSIBILITIES Staff nurses

4.0 POLICY 4.1 SUSPECTED CASES OF PATIENT'S FALL: 4.1.1 4.1.2 4.1.3 4.1.3 4.1.4 4.1.5

Patient with psychiatric disorder Geriatric patient Hemiplegics patient Epileptic patient Diabetic patient Post – operative patient

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5.0 PROCEDURES

RATIONALE

5.1 Upon admission, orient the patient with the environment – room, bed, toilet, doctor's room, meeting room, etc 5.2 Demonstrate to patient ways to obtain help when needed. 5.3 Placed bed in low position with brakes locked if possible, or placed the mattress on the floor (particularly for patients who are prone to falls, history of frequent fall, or patient at high risks of falling. 5.4 If patient is alone, instruct the patient to utilize the help of the nearest person around. 5.5 Make sure that footwear is fitted and not slippery and is used properly. 5.6 Utilized night light. 5.7 Keep floor surface clean and dry. 5.8 Make sure that patient knows where personal belongings are, and that he can safely and easily access them. 5.9 Ensure adequate hand rails in the bathroom. 5.10 Evaluate effects of medication that increases the risk of patient fall. 5.11 Monitor patients regularly and encourage safe activities. 5.12 In case of occurrence of patient falling down:

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5.12.1 Call for assistance and inform the charge or the head nurse. 5.12.2 At least two members of the nursing staff in the unit must care for the patient. 5.12.3 Assess patient for any injuries, especially cervical and spinal injury, and patients level of consciousness (LOC). 5.12.4 Move patient as a whole (log roll), supporting the neck and spine. 5.12.5 Place wooden board under the patient. 5.12.6 Turn patient back over the wooden board in supine position. 5.12.7 Carry patient to treatment room using the wooden board moving in synchronized manner. 5.12.8 Transfer the patient to the treatment room bed lifting the patient from the wooden board to the bed (moving as one). 5.12.9 Check for vital signs 5.12.10 Call for the internist 5.12.11 Carry out Doctors order. 5.12.12 Document in the file.

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6.0 ATTACHMENTS View attached forms(attachment capter)

7.0 MATERIALS & EQUIPMENT Wooden board, Patient's file, BP apparatus

8.0 REFERENCES -

-

Clinical Protocol Nursing Practice Manual John Dempsey - ospital The University of Connecticut Health Center- Falls: Risk Identification, Prevention Management, and Treatment- REVISION DATES:8/06, 10/06, 8/07, 9/07, 8/09, 9/10 Morse JM, Morse RM, Tylko, SJ. Development of a scale to identify the fallprone patient. Canadian Journal on Aging. 8 (4): 366-367, 1989.

NAME

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2010

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Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION

2.0 PURPOSE 1. To cooperate with local law enforcement agencies in managing patients whom the police have their custody.

3.0 POLICY 1. The Hospital will notify the police of our intent to discharge a patient on whom a police department has placed a "Police Hold". 2. The Emergency Department or Nursing Unit will make the Police Department aware of patients who have been admitted on Police Hold. 3. The Hospital has no responsibility in retaining patients who want to leave Against Medical Advice. 4. Hospital personnel should not engage in any business or personal negotiations with the patient or police department. 5. Local police will provide personnel coverage for those patients who are under arrest and deemed dangerous. This will be in conjunction with Health Center Police Department and coordinated through Public Safety Administration. 6. All questions are to be directed to the Police Department.

4.0 RESPONSIBILITIES As clarified in policy

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5.0 MATERIALS & EQUIPMENT

6.0 PROCEDURES 1. Patients are classified as being on "Police Hold" are: A. Those who are under arrest. B. Those who are not under arrest but who are to be retained for questioning after discharge. 2. The police officer who accompanies a patient under arrest will state to the admitting interviewer that the individual is to be held for the police upon discharge. 3. The interviewer and Emergency Department nurse, or the primary nurse should indicate "Police Hold" on the hospital record, on permission to treat form and on the records that accompany the patient to the unit. 4. The nurse or clerk who transcribes orders and places charts in order on the unit should indicate this clearly on the Kardex. "Police Hold Upon Discharge." 5. In addition to completion of routine discharge planning, the following additional steps should be implemented: A. Notify the Police Department of discharge ahead of time so they can in turn notify the local police on time. B. Plan for the patient on "Police Hold" to be ready when the police come for him/her.

7.0 ATTACHMENTS NA

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REFERENCES

NPP 2010 - General Directorate Of Nursing- MOH.KSA

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 DEFINITION Maintenance of medical equipment is a process provides for the safe and proper use of medical equipments used in patient care. 2.0 PURPOSE 2.1 To assess and control the physical and clinical risks of all equipment used in the diagnosis, treatment, monitoring, and care of patients. 2.2 To ensure safe and effecv e us e of m e di cal devi ce. equipment from Biomedical department. 3.0 POLICY 3.1 All medical devices shall be rigidly inspected and tested by biomedical staff prior to use. for use of the specific medical device. 3.3 Any medical department should not accept and use any medical devices unless inspected and registered (BME Number) by biomedical department. 3.4 Emergency work order request for any medical equipment failure. 3.5 Medical equipment /devices are defective and out of order should be labeled by red stickers and not to be used. 3.6 Prevenv e m a i nt enance of the equi pme nt is car ri ed out accor di ng to ri gi d schedul e prepared by Biomedical department: White Sticker on the equipment indicates the next due date for the preventive maintenance. 3.7 Record all problems ,repairs and PPM done in the cardex of each device

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4.0 RESPONSIBILITIES 4.1 Head nurse/Charge nurse: 4.1.1 Orientation of new staff for basic operating, special procedures and safety procedures of medical equipments. 4.1.2 Identification of any equipment problems and reporting procedures 4.1.3 Initiation of the emergency work order request for any medical devices failures 4.1.4 Checking of tags (White Stickers / red stickers) on all medical devices in the ward 4.2 Staff Nurse: 4.2.1 Safe use procedures of medical equipments 4.2.2 Initiation of the emergency work order request for any medical devices failures 4.2.3 Report to the Head nurses/charge nurses any equipment problems 4.2.4 Cleanliness, appropriate arrangement and storage of medical equipments

5.0 5.1 5.2 5.3

MATERIALS & EQUIPMENT Job order book Disinfectants according user manual of each medical device Log book

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6.0 PROCEDURES 6.1 Receive of the new medical device from property control department

6.2 Call the biomedical dept for the installation of the medical device and tagging of the medical device; BME Number and PPM Sticker 6.3 Record the medical device and the BME Number of the in the log book 6.4 Organize a training sessions for the ward staffs with collaboration of biomedical dept 6.5 Reporting of any problem or inconvenient of the medical device to biomedical dept Medical device out of order 6.6 Call the biomedical dept to initiate a work order 6.7 Record in the job order book : the name and the BME Number of the medical device, date &time of the request and the work order number 6.8 Record the date and the time of the completion of the work order in the job order book 6.9 Assist the biomedical engineer to

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RATIONALE 6.1 All medical equipments and non medical equipments should be received through property control department 6.2 All medical devices should have BME number and PPM tag for the follow up of the device: date of next PPM and work orders.

6.4 For the safe use of the device

6.5 To evaluate the performance of the device

6.6 For urgent repair 6.7 For the follow up of the work order

6.9 To follow up the history of the device

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record the problem of the device and the kind of the repair done with date and time in the Kardex of the device 7.0 ATTACHMENTS Non

8.0 



REFERENCES MOH policy King fahad hospital Jeddah -ksa

NAME: PREPARED BY REVIEWED BY APPROVED BY

Ahmed Sallami- RN- KAASH Mrs.Ashwag o. Shibah,RN BSN-Head Of nursing Education Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

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1.0 DEFINITION BCLS/ACLS Certificate – is acquiring of certificate after underwent training for BCLS/ACLS.

2.0 PURPOSE To establish the sufficiency of the nursing staff to respond during emergency situation and related nursing situations requiring the practice of CP Resuscitation that is current and according standard of patient care.

3.0 RESPONSIBILITIES All registered nurses and nursing Aid

4.0 POLICY 1. All Nursing Personnel, who have direct patient contact, will maintain CPR skills as evidence by an annual update review or recertification class. All new nursing personnel, who have direct patient contact are required to present verification of a current BCLS certification card upon hiring. 1.1.1 Nurses hwo work in critical care unit must be cirtified by BLS AND BLS 1.1.2 A copy of the certification will be kept in the employee’s file and will be updated according to policy and procedure.

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4.0 POLICY 1.1.3 It is the responsibility of the employee to maintain a current BCLS/ACLS certification and provide evidence of recertification, according to policy and procedure. 1.2 Existing Employee 1.2.1

It is the responsibility of the employee to maintain a current BCLS/ACLS certification and to provide evidence of certification, according to policy and procedure.

1.2.2 A copy of the card will be kept in each nursing employee’s file, current and updated according to policy and procedure.

5.0 PROCEDURES

RATIONALE 1. As per MOH Standards requirement.

1. BCLS Initial Certification 1.1 All nursing staff having direct patient contract is required to be BCLS certified. 1.2 If the employee has never been certified, then the employee attends an 8 hour initial certification class 2. BCLS Re-certification 2.1 Each direct patient contact staff will recertify his/her BCLS card every 2 years at least 30 days before expiration.

2.1 As per hospital internal policy

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1.2 Recertification can be satisfied by any one of the following methods.

1.2.2 1.2.3

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Attend a four (4) hour BCLS recertification class. Complete the CPR recertification class. Participate in mock CPR drill and verify certification on the sign in sheet.

2. ACLS Certification 3.1 All nursing staff assigned at high risk areas (ICU, Burn, Coronary Care, OR/ER) will be required for ACLS certificate. 3. ACLS Re-certification 4.1 All nursing staff recertifies their ACLS card every two (2) years, at least 30 days before expiration.

6.0 ATTACHMENTS None

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7.0 MATERIALS & EQUIPMENT 1. BCLS \ ACLS course training set

8.0

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MOH.KSA PP

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NAME:

DATE

Central Committee Of NPP 2007 General Directorate Of Nursing- MOH.KSA

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Saleh Ziad Al-Juaid - Rn, Bsn, Msn. KFH-Taif  Michelle R.Anapi - Rn, Bsn, Msn. KFH-Taif

2010

Central Committee Of NPP 2010 General Directorate Of Nursing- MOH.KSA

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DEFINITION

A Nursing escort is assigned Nursing staff that accompanies patient to another facility or institution. 2.0 PURPOSE To ensure continuity of any nursing care of escorted patients from the ward/unit concerned to transferred destination e.g. hospital, airport or medical lift or vice versa. 3.0 POLICY The Nursing Supervisor will select the Nursing staff that will escort the patient and will be the one to arrange all documentation e.g. permit and ambulance papers. Female nurse will be accompanied by female health care provider for both male and female patient while male nurse will escort male patient alone unless circumstances dictate otherwise. When patient transferred from outside city to the city, a completed transfer attendance form should be secured from receiving hospital or institution for submission to the administration for claim of travel allowance. 4.0 RESPONSIBILITIES Nursing Supervisor Escort Nursing staff 5.0 MATERIALS & EQUIPMENT 5.1 Portable suction available from Neonatal or Pediatric Department ICU, General Nursing Supervisor 5.2 Oxygen cylinder with adequate oxygen supply and oxygen tubing’s 5.3 Airway 5.4 Intravenous fluids 5.5 Medications

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5.6 Ivac machine battery operated 5.7 Portable cardiac monitor 5.8 SPO2 machine 5.9 Emergency kit 6.0 PROCEDURES Before patient’s transfer:

RATIONALE

6.1 Report to the department concerned at least thirty minutes before the planned departure and be informed of the diagnosis, medication and reason for the referral.

To prepare the patient and know all the necessary information about the patient.

6.2 Secure any medical or nursing reports, transferrable letter or acceptance letter, X-rays or any radiological reports and keep record of medications. 6.3 Prepare items or equipments as required for transfer according to Patient’s condition.

To keep and bring during transfer for handover to receiving institution.

To have available equipment on hand when needed especially in case of emergency. To ensure the patient for safe keeping of belongings.

6.4 Assume responsibility of patient belongings or positions endorsed by the nurse in absence of Accompanying relatives.

To maximize patient dignity.

6.5 Keep patient well covered or dressed

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To ensure patient’s safety and make him or her relax. 6.6 Assist the patient on the trolley and place safety belts. Put him or her in a comfortable position inside the transport. During patient transfer:

To know immediately in any change of patient’s health condition.

6.7 Observe end monitor the patient continuously and maintain an open communication.

To continue nursing care required by the patient.

6.8 Perform nursing intervention as necessary such as:

To maintain IV fluid infusion and correct IV fluid rate.

6.8.1 Ensure the patency of IV lines maintain the rate of intravenous fluids as ordered by the doctor.

To prevent aspiration. To ensure accurate monitoring of patient.

6.8.2 Suction patient as necessary. 6.8.3 Check connection or machine or equipment functions tubings if properly attached.

To treat the patient.

6.8.4 Prepare and administer medications as required.

Arrival to the receiving institution:

To ensure immediate transfer of patient to the required area.

6.9 Ask for assistance if needed for the pick up point and assist the patient to the trolley, wheel chair or and

To ensure patient’s safety.

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incubator for a baby if required. In the airport, transfer of the patient in the departure lounge and don’t leave the patient at any time until taken over by the airport authorities and formalities proceed. 6.10 Ensure that the patient, photo copy of all papers works if needed and medications are handed over to receiving staff including and up to date summary of care needs. Patient belongings should be endorsed and appropriate signature will be obtained.

6.11 If there is an accompanying relative with the patient, don’t fail to introduce him or her to the receiving staff. 6.12 Ensure that the patient is safe in the new area before leaving e.g. transferred to new bed with side rails up. 6.13 Collect patient’s file if brought during transfer and medical equipment for return. Also collect the completed transfer attendance form.

To give appropriate information about the patient for the continuity of care and to transfer responsibility and accountability of patient belongings.

To make the receiving staff aware that relatives is around whenever in need of any assistance and information about the patient. To ensure patient’s safety.

To endorse patient’s file to medical records and to complete the inventory of equipments brought. To endorse the transfer attendance form to the administration for claim of travel allowance. To go back immediately to the point of origin.

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6.14 Return directly to the transport after endorsement is finished.

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To keep the nursing supervisor well informed.

Upon return to the point of origin: 6.15 Report immediately to the duty nursing supervisor and inform any problem encountered during the transfer.

To prepare the equipment for the next use.

6.16 Return and clean the medical equipment used. Return the medications to the ward stock or Pharmacy.

7.0 ATTACHMENTS 7.1 Transferrable or Acceptable Form 7.2 Transfer Attendance Form 7.3 Laboratory results 7.4 Permit or ambulance forms

8.0 REFERENCES 8.1 http://www.guysandstthomas.nhs.uk/resources/patient info/cardiothoracic/transfer_patients_policy.pdf 8.2 http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_031.pdf 8.3 http:/www.tamesidehospital.nhs.uk/Documents/Transfer PolicyAdultTamesideAcute.pdf.

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DATE NAME: PREPARED BY:

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2010

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1.0 PURPOSE 1.1. To provide a systematic hospital wide problem identification mechanism as quality improvement tool for early detection and prevention of problems which have (or may have) an adverse patient outcome and represent a potential hazard to patients, visitors, volunteer, trainee or employees. 1.2. To define the responsibilities and authorities of all individuals involved in the occurrence reporting activity. 1.3.To plan and implement corrective measures through identification by root cause analysis. 2.0 DEFINITION 2.1. Occurrence : It is an event which is not consistent with routine patient care or with the routine operation of the facility and which adversely affects or threatens the health or life of patient, visitor, employee, student or volunteer which involves loss or damage to personal or hospital property. An occurrence also includes any event that might other wise result in any other adverse situation or a claim against the organization. 2.2. Occurrence Variance Report (OVR): It is an internal form which is issued to document the details of the occurrence/ event and the investigation of an occurrence and the corrective actions taken. 2.3. Sentinel Event : An unexpected occurrence involving death, serious physical or psychological injury or the risk thereof, and any event that might cause embarrassment or risk to the hospital with potential legal implications and/or media inquiries or coverage. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. 2.4. Near Miss : An event or situation that could have resulted in an adverse event but did not either by chance or through timely intervention . 2.5. Malpractice: It is improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, nursing to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is an action for which

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damage is allowed. 2.6. Adverse Event ; Are unexpected incidents, misadventure , iatrogenic injuries or other adverse occurrences directly associated with care or services provided .adverse events can be categorized as either sentinel event or near miss that result from commission or omission . 2.7. Variation : the differences in results obtained in measuring the same event more than once .too much variation often leads to waste and loss ,such as the occurrence of undesirable patient health outcomes and increased coast of health services .

3.0 RESPONSIBILITIES 3.1 The employee who witnesses or discovers an occurrence has the professional obligation and the responsibility for: 3.1.1. Immediate notification to: 3.1.1.1. The Physician on call if the occurrence involves patient or employee injury or harm 3.1.1.2. The Immediate Supervisor. 3.1.2.Initiating the OVR form before the end of the current shift . 3.1.3.Submitting the OVR Form to the Immediate Supervisor/head of department for completion. 3.2. .The area Supervisor /Head of department is responsible for: 3.2.1.Ensuring that all employees are aware of Occurrence Variance Reporting System and how to report and process OVR Form. 3.2.2. Conducting immediate follow-up of the occurrence by initiating and documenting on the OVR form the actions taken 3.2.3. Indicate the category & contributing factors of the occurrence.. 3.2.4. The head of department responsible to complete the occurrence with their recommendations 3.2.5. Conducting any further investigation and documenting findings of the reported occurrence upon request of the Hospital Administration, the Quality Management or the Safety

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Committee. 3.2.6. Submit the original copy of his department OVR log sheet to TQM . 3.2.7. Forwarding the completed OVR Form to the Total Quality Management office within 72 hours of the occurrence. 3.3.The Physician: the physician who attends to patient / employee involved in occurrence is responsible for : 3.3.1. Examination & management of affected person . 3.3.2. Documenting a brief statement of his /her actions on the OVR form 3.4.The Total Quality Management Department is responsible for: 3.4.1.Monitoring all OVR for follow up with concerned departments/hospital administration so that necessary steps may be taken by those in charge to resolve the situation if necessary. 3.4.2.Trending and preparing a monthly summary of all reported OVR . 3.4.3.Submitting a quarterly report to the Quality Management patient safety council for discussion and further action if deemed necessary by the QMPS council . 3.4.4.Maintaining a file of all OVR submitted to the TQM office for three (3) years. 3.5.The Safety Officer is responsible for: 3.5.1.Investigating all safety related occurrences referred for investigation by initiating department and/or Head, TQM . 3.5.2.Activating a review team of selected Safety Committee Members to investigate critical safety related occurrences. 3.5.3.Documenting the results of investigation and corrective action taken on the OVR form. 3.5.4.Returning the completed form to the TQM office.

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4.0 POLICY 5.1. It is the responsibility of all staff to immediately report the details of any occurrence, which negatively impacts the care of a patient. 5.2.The Occurrence Variance Report Form will be initiated immediately following the occurrence and submitted to the immediate supervisor/head of department within the current work shift. 5.3. This report is to be used to identify the facts surrounding the occurrence and will not be used to criticize or speculate on actions of the staff involved. 5.4. Corrective actions shall be taken to minimize and eliminate the risk of injury and adverse outcomes. 5.5. Corrective action(s) shall be documented. 5.6. The Occurrence report shall not be placed in the medical record. The terms “incident” and “ error” shall not be used in the medical record when making an entry regarding an occurrence or the results of an occurrence. 5.7. Confidentiality: 5.7.1. All Occurrence Variance Reports shall be handled and maintained in a confidential manner, with access to such documentation restricted only to authorized individuals. 5.7.2. Occurrence Variance Reports shall not be duplicated with exception of the TQM department, when deemed necessary. 5.7.3. The information contained in the OVR form cannot and shall not be used against any individual as the sole basis for disciplinary action except in extreme situations e.g patient harm. 5.7.4. Hospital staffs are not at liberty to discuss the contents of an Occurrence Variance Report or the events and circumstances related to the occurrence either with patient, visitor or other members of the staff, unless clarifying facts under investigation with the proper authorities. 5.7.5. Discussion of general issues on OVR for instructional or educational purposes with view to improving patient care is, however strongly encourage 5.7.6. Names of involved/concerned person should not be used, instead use the ID number.

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6.1. Write in clear legible handwriting using blue or black ink, avoid using pencils. 6.2. The Occurrence Variance Report Form consists of the following sections: 6.2.1. Occurrence details filled by the employee who witness or discover an occurrence 6.2.1.1.Event Details. 6.2.1.2.Person(s) Affected. 6.2.1.3.Brief Description of Occurrence. 6.2.2. filled by immediate supervisor /head of involved department. 6.2.2.1. Immediate action taken . 6.2.2.2. Evaluate the occurrence if it is sentinel event or not according to sentinel event criteria . 6.2.2.3. If the occurrence is sentinel event follow the sentinel event procedure . 6.2.2.4. Document if the occurrence needs physician evaluation . 6.2.2.5. The immediate

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supervisor /head of department indicate the occurrence category and contributing factors in the OVR form 6.2.2.6. If a physician was notified and actually attended the patient, the physician is responsible for recording a brief statement 6.2.3. Action Taken (by involved/concerned department for follow up; this includes corrective action taken and recommendations to prevent recurrence of the incident. 6.2.3.1. To be filled by TQM. 6.2.3.2. TQM will return back the OVR form to concerned department if it is not completed . 6.2.3.3. The supervisor /head of department will verify & return the OVR form within the

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same day . 6.2.3.4. TQM will record the occurrence in hospital OVR log sheet . 6.3. If the occurrence happened in various departments after working hours : 6.3.1. Area supervisor /hospital director on duty 6.3.2. Area supervisor submit OVR form to the head of the department next day . 6.3.3. The hospital director on duty submit the OVR form every day Moring to TQM for redistribution to the head of concerned department. 6.4. Departmental OVR log sheet should be used during the transfer of the form from one employee to anther to indicate the date ,time name and signature . 6.5. The original copy of all monthly departmental OVR log sheet should be delivered by the departmental head to TQM department at the end of each month to be kept their .

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6.0. MATERIALS & EQUIPMENT N/A

7.0 ATTACHMENTS OVR FORME 8.0 REFERENCES 8.2. King Fahad General Hospital 8.2. Hera General Hospital . 8.3 JEDDAH EYE HOSPITAL TQM-APP-003 E/A(2)

DATE NAME: PREPARED BY:

Central Committee Of NPP 2007 -General Directorate Of Nursing- MOH.KSA

2007

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Mrs. Ashwag Omar Shibah , RN,BSN-Head of Nursing Education

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1.0 DEFINITION Palliative Care - The active total care of patient whose disease is not responsive to curative treatment. It also focuses on opportunities for growth at the end of life. Control of pain and other symptoms and providing psychological, social and spiritual support of utmost importance.

2.0 PURPOSE 2.1To provide the best quality of compassion to care for patient at the end of life ١٫ .and to provide relief of suffering when disease cannot be cured 2.2

To improve professional preparation for end of life care among registered nurses.

3.0 POLICY 1. The components of end of life care include communication, physical comfort, social needs, spiritual needs, patient centered decision making, age-related considerations, and legal ethical indications.

4.0 RESPONSIBILITIES All registered nurses involve in caring for patients requiring end of life care.

5.0 MATERIALS & EQUIPMENT 1. Informed Consent IPP 2. Discharged Against Medical Advise IPP

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6.0 PROCEDURES

RATIONALE

6.1 The responsible registered nurse providing care for patient requiring end of life care is competent to provide following care. 6.1.1 Promote the provision of comfort care to the dying as an active, desirable, and important skill and an integral component of nursing care. 6.1.2 Communicate effectively and compassionately with the patient family and health care team about the end of life care. 6.1.3 Facilitate participation in religious or spiritual activities. 6.1.4 Encourage families to minimize social isolation. 6.1.5Provide private time for relationships , 6.1.6 Discuss end of life issues early in patient's treatment plan. 6.1.6.1 Advance directions such as a living will. 6.1.6.2Durable power of attorney. 6.1.6.3Allow for the refusal of further treatment or authorize a family member or friend to make decision for the patient.

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6.1.6.4 After discussion with the patient and family. The physician will write a “Do not Resuscitate (DNR) order on his progress notes, physician order sheet, and DNR form (KFH-737). 6.1.7 Asses and treat multiple dimensions including physical, psychological, social and spiritual needs to improve quality at the end of life. 6.1.8Assist the patient, family, colleagues and one self to cope with suffering, grief, loss and in a cute state of sadness in end of life. 6.19 Demonstrate skill at implanting a plan for improved end of life care within a dynamic and complex health care delivery system. . 6.2 Providing Physical Comfort 6.2.1 Provides comfortable environments, nourishments hydration and symptoms relief. 6.2.2 Provide pain relief and symptoms control care ( hunger, nausea constipation , anxiety, agitation and prevention of constipation( 6 .٣

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Psychological Comfort.

6.٣٫١ Provide emotional support not only to the patient but also to family and friends.

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Establish trust with the patient

6.٣٫١٫٢ Allow the patient and family to express fears and concern. 6.٣٫١٫٣ Promote open non-judgmental environment. 6.٣٫١٫٤ Making referrals as indicated (e.g. counseling, social services and support from the religious group. 6.3.1.5 Accepting one’s own feeling about death and being able ٤.6 Social Needs 6.٤٫١ Facilitating social needs by: 6.٤٫١٫١ Providing privacy anytime the patient wishes 6.٤٫١٫٢ Maintaining dignity and value through respect caring comfort and communication. 6.٤٫١٫٣ Maintaining the patient’s personal independence and self determination. 6.5

Spiritual Needs

6.٥٫١ To provide more positive attitudes

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6.3.1.5 to therapeutically provide for the needs of the others.

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towards end of life. 6.٥٫٢ Facilitate participation in religious or spiritual activities. 6.٥٫٣ For Muslim dying patient the health care giver should have access to a Muslim (sheikh) who can read the Quran and make special prayers in consultation with the patient or family, Islamic Relation Office 6.٥٫٤ As the patient’s death approaches, give them emotional support. 6.٥٫٥ Turn those who are near to death to the kiblah side. 6.٥٫٦ Turn off channel where dying people lie down on the floor. 6.٥٫٧ Turn on the Holy Quran channel. 6.5.8 Show the importance of keeping the privacy of dying people the private parts.

٦.6.

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Documentation

6.٦٫١ Record changes in the patient vital signs, intake and output, and local of consciousness. 6.6.2 Note the time of cardiac arrest at the end of respiration and notify the physician when these occur.

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7.0 ATTACHMENTS Patient’s Bill of right

8.0

REFERENCES

8.1 Daaliman, T, & Van de Creck, L (200) Placing Religion and Li Spirituality in End of life care Jame. 284(19): 8.2 World Helath Organization (2004) who Definition of palliative care. Retrieved June 1,2004 from http:/www.who int/dsa/justpub/cpl.htm 8.3King Fahd Policy and Procedures NRS-IPP-PRC-033E (2)

NAME:

DATE

PREPARED BY:

Central Committee Of NPP 2007 -General Directorate Of Nursing- MOH.KSA

2007

REVIEWED BY:

Mrs. Ashwag Omar Shibah , RN,BSN-Head of Nursing Education

2010

APPROVED BY:

Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

2010

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1.0 PURPOSE 1.

To Clearly defined procedures for such events.

2.

To Accommodating and giving a voice to all staff members .

3.

To Fostering collaborative decision making

4.

To plan, effectively for routines of organization.

5.

To allow for a sense of staff through appropriate delegation.

6.

To involve all staff in the decision making process

2.0 DEFINITION NA

3.0 RESPONSIBILITIES All staff had a role in the implementation of this policy

4.0 POLICY

4.1 Staff meetings should be regular and provide an opportunity for all staff to have input into planning and decision making on centre issues, offer feedback on policies and procedures, formulate goals and strategies, network and share ideas with each other (this is especially beneficial if staff are working in different centres) and develop a co-operative approach to the management of day to day

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issues. 4.2 staff meetings should be well prepared, organized and kept on pathway ، 4.3 Staff should have a clear understanding of the expectation of staff meeting attendance. 4.4 ensure that staff have written documentation (i.e. in their job descriptions) explaining that out-ofhours staff meetings are an expectation. 4.5 Staff meetings should be compulsory for staff – this means they must attend and therefore must get reimbursed 4.6 staff will Give adequate advance notice of meeting dates and times and rotate the day to ensure that all staff have the opportunity to attend. Some staff teams like the meeting schedule ( agenda)to be set for the year so they can plan around the dates. 4.7 staff will Involve in deciding upon the agenda items ،then prepare and distribute the agenda prior to the meeting . 4.8 Every staff meeting should have a purpose with agenda items that are relevant and useful. 4.9 The minute taker records any discussion and summarizes as the meeting progresses . 4.9.1 The minute taker ensures that the minutes clearly document any decisions made and includes a clear list of actions, with timelines and who is responsible for each action . 4.9.2 The minute taker ensures that the minutes are distributed soon after the meeting while the topics are still fresh in

everyone’s mind.

4.10 The Environment ( venue)

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4.10.1 The meeting facilities should be comfortable and adequate (i.e .no baby chairs if possible .( 4.10.2 Ensure that everyone has an opportunity to present their views in an environment where they are listened too and no one tends to dominate the discussion . 4.10.3 Vary locations for staff meetings as appropriate, Include a meal or nibbles for staff 4.11 Staff will Accept responsibility for agreed action points and respect colleagues contributions to the meeting

5.0 PROCEDURES 5.1 Invite staff to consider items for the agenda 5.2 Draw up and distribute the agenda in advance of the meeting 5.3Chair the meeting as appropriate 5.4Ensure minutes and action points are recorded

RATIONALE 5.1This helps to avoid over-domination of any one issue or individual

5.5 Monitor and follow-up on action points 5.6 for time management .

5.6 The meetings should begin and end on time (negotiate with staff appropriate times. 5.7 Put aside time at each meeting for both business and socializing .

5.8 Include opportunities for small group work which is useful, relevant and deals with

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important issues/problems. 5.9Small groups can break off to brainstorm ideas then come back to the whole groups to share their thoughts .

6.0. MATERIALS & EQUIPMENT N/A

7.0 ATTACHMENTS

8.0 REFERENCES 8.2 EAST DUNBARTONSHIRE COUNCIL ©2008 Griffith Barracks Multi–Denominational School - site by lib-lab

PREPARED BY: APPROVED BY:

NAME Mrs. Ashwag Omar Shibah , Head of Nursing Education Central Committee Of NPP 2010 - General Directorate Of Nursing- MOH.KSA

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DATE 2010 2010

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1.0PURPOSE 1.1 To monitor the unit environment and patient activities. 1.2 To maintain a safe, secure and therapeutic environment.

2.0 DEFINITION Observation and inspection of all areas of the unit with open access to patients by the assigned nurse.

3.0 RESPONSIBILITIES Nursing staff

4.0 POLICY 4.1 Head Nurse / In-Charge of shift is to assign a nurse for routine unit rounds for a period of 2 hours, divided into fraction of 20 minutes each documentation It is permissible to assign a nurse for more than one 2-hour period during a shift. However, no one is to be assigned for 2 consecutive periods. Unit rounds to be carried out correctly. 4.2 Appropriate action should be taken whenever anything unusual is reported by the assigned nurse. Cases which are directly related to patients must be documented in their progress notes.

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5.1 IN-CHARGE OF THE SHIFT /HEAD NURSE 5.1.1 Head Nurse / nurse in-charged of the shift has to assign a nurse to routine unit rounds for a period of two hours. It is permissible to assign a nurse for more than one two-hour period during a shift. However, no one is to be assigned for routine rounds on two consecutive periods. 5.1.2 Appropriate action should be taken whenever anything unusual is reported by the assigned nurse. 5.1.3 Ensure that anything unusual which is directly related to the patients should be documented in the progress notes. 5.1.4 Ensure that the job allocation is signed by the nurse assigned. 5.1.5 Ensure that the routine round is carried out correctly. 5.2 ASSIGNED NURSE 5.2.1 5.2.2

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A round is to be made at all areas accessible to patients: 5.2.3.1 Patients’ rooms including their comfort rooms 5.2.3.2 Games room 5.2.3.3 TV room 5.2.3.4 Prayer room 5.2.3.5 Garden 5.2.3.6 Other areas accessible to patients 5.2.4 Check for: 5.2.4.1 Contrabands 5.2.4.1 Items or situations that are hazardous to patients and staff. 5.2.5 Observe condition and status of patients 5.2.6 Observe patients’ behaviours and activities. 5.2.7 Report to the charge nurse an unusual observations. 5.2.8 Use flash light when entering patients’ rooms (for night duties). 5.2.9 At the end of the two hour period, hand over directly to the next assigned nurse.

6.0 ATTACHMENTS None

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7.0 MATERIALS & EQUIPMENT None

8.0 REFERENCES  



Psychiatric Services, 55, 818–820. McCue, R., Urcuyo, L., Lilu, Y., Tobias, T., &Chambers, M. (2004). Reducing restraint use in a public psychiatric inpatient service. Journal of Behavioral Health Services &Research, 31(2), 217–224. Al Amal Hospital, Jeddah MOH-NPP 2010

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE 1.1 To provide sufficient staff at a specified time 1.2 To provide continuity of nursing care. 1.3 To provide quality nursing care. 1.4 To established guideline for staff duty during off hours.

2.0 DEFINITION Overtime is the working hours of the staff outside the regular duty hours, providing staff to give necessary nursing care to patient’s at a specified time.

3.0 RESPONSIBILITIES Director of Nursing, Nursing Supervisors, Head Nurses

4.0 POLICY There must be sufficient number of staff to cover a certain period of time, outside the regular duty time so as to provide the necessary care to the patients.

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5.1 The Nursing department determines the need for additional staff. 5.2 The Nursing Department coordinates with the Hospital administration regarding the need for additional staff. 5.3 The Nursing Department will organized the schedule for staff for extra duty hours. 5.4 Nursing Department should inform the concerned staff regarding the schedule. 5.5 The staff will report on the specified time and should continue on if needed. 5.6 Nursing Department will record the number of hours the staff went on duty. 5.7 The extra hours the staff went on duty will be compensated by giving the staff the chance to take back the time on another day as “back time.” 5.8 The Head Nurse of the unit will determine the appropriate time for the staff to take back the time, without affecting the number of staff on duty.

6.0 ATTACHMENTS None

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8.0 REFERENCES

NAME

DATE

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Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 PURPOSE 1.1 To ensure that all nursing staff receive appropriate attention and support following a physical assault during the course of their duty. 1.2 To investigate the incident and render appropriate disciplinary action.

2.0 DEFINITION An unlawful threat of bodily violence or harm to staff by patient or other personnel in the hospital.

3.0 RESPONSIBILITIES Nursing staff

4.0 POLICY 4.1 All physical assault on nursing staff by patients or fellow staff must be reported to Nursing Administration immediately. 4.2 The physically assaulted staff must be seen at the staff health clinic during office hours, and by the internist on duty if incident occurred at night time. 4.3 When a patient is involved, the primary physician must be notified immediately of the patient’s behavior. 4.4 Any occurrence of physical assault to staff should be documented (incident report, documentation on the staff's file), as reference for future review by the Nursing Administration and QA Department.

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5.1 Determine the presence of assault and identify the individuals involved. 5.2 Let the physically assaulted nursing staff proceed to the Staff Health Clinic and be evaluated by the staff physician for any injuries and treatments required. 5.3 A full description of the incident must be documented in the staff's file and in the patient's file (if patient is involved). This must include details of: 5.3.1 Time of assault 5.3.2 Events leading up to the assault 5.3.3 Interventions taken 5.3.4 Medical officer notification ( if patient is Involved) 5.3.5 Medical officer interventions 5.3.6 Details of staff injuries sustained 5.4 Complete a critical / unusual occurrence report

6.0 ATTACHMENTS Use the incident report form in your hospital for employees

7.0 MATERIALS & EQUIPMENT Employee’s Incident Report Form

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8.0 REFERENCES  



Smalls Y. (2004). Utility of the implementation of programmatic systems to reduce and eliminate restraint use for the treatment of problem behaviors with individuals with mental retardation. Unpublished dissertation. Retrieved February 20, 2006 from http://etd.lsu.edu/docs/submitted/etd-01282004145119/unrestricted/Smalls_dis.pdf. Al Amal Hospital, Jeddah MOH-NPP 2010

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0 PURPOSE To provide area for dirty / used items from the patients.

2.0 DEFINITION An area in the unit where dirty / soiled items used by patients are stored/kept for safekeeping before taken by the personnel from the laundry department for cleaning process.

3.0 RESPONSIBILITIES Staff Nurses, Laundry Staff

4.0 POLICY 4.1 4.2 4.3 4.4

Only dirty / used items from the patients should be in the hamper for the laundry. Never mix soiled items with the clean ones. Maintain tidiness in the hamper, not to let the soiled items to be scattered in the floor. Laundry personnel's taking the soiled items be provided with necessary protection while handling the items – gloves 4.5 The room should only be accessible to the store nurse. 4.6 Key to the room should always be with the store nurse 4.7 The hamper for the dirty items should never be used for clean items

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5.1 Provide protection for the laundry worker by giving gloves and mask, possibly apron if available. 5.2 The laundry worker should check all soiled or dirty items for any patient's belongings. 5.3 Put all soiled items in a hamper provided for transporting the items to the laundry, and close the hamper with cover 5.4 Keep the dirty utility room always closed. 5.5 Any item aside from the thobe, blanket, linens, underwear's, towels and other clothing's should be removed from the room and put in a garbage bin. 5.6 Give instructions to the patients to put all soiled items inside the hamper and not to scatter in the floor. 5.7 Put the hamper in an area easily accessible to the patients.

6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT Dirty patient care items, hampers for dirty linens

8.0 REFERENCES Standard policy

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NAME

DATE

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Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

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Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

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1.0PURPOSE To provide area for clean unused items for patients.

2.0 DEFINITION An area in the unit where clean items for patients are stored / kept for safekeeping before distribution to patients for use.

3.0 RESPONSIBILITIES Staff Nurses

4.0 POLICY 4.1 4.2 4.3 4.4 4.5

Only new, clean, unused items to be kept in the clean utility room. Never mix soiled items with the clean ones. Maintain an updated record of items in the room. Items to be separated from each other, marked with identification of the item. The room should only be accessible to the store nurse

5.0 PROCEDURES

RATIONALE

5.1 Separate items according to category ( towels, underwear, footwear, etc. ). 5.2 Arrange them in a manner providing the store nurse adequate space when taking any of the items. 5.3 Shelves containing the clean items should always be covered with clean linen, to avoid exposure of the clean items to dust in the air.

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6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT Clean and unused items for patients

8.0 REFERENCES Standard policy

NAME

DATE

Prepared By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

2010

Approved By:

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010

ADMIN-181

Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures ______________________________________________ GENERAL NURSING: NURSING ADMINISTRATION ADMINISTRATIVE POLICY AND PROCEDURE POLICY NUMBER:

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1.0 DEFINITION 1.0PURPOSE 1.1 To provide request for items needed in the work. 1.2 To provide what patient needs as well as the needs of the staff. 1.3 The care provider functions well if the needed supplies are available.

2.0 DEFINITION Items used by the patients, and the care providers in the performance of their duties/functions in providing quality nursing care to patients.

3.0 RESPONSIBILITIES

Head Nurse, Charge Nurse

4.0 POLICY 4.1 4.2 4.3 4.4

The Head Nurse or the Charge Nurse determines the supplies needed. Supplies should be requested according to need. There should be enough supply in the unit to provide continuous care to the patients. Don't make request only when items are all consumed. Anticipate the need to request for supplies. 4.5 The request is approved and signed by the Head Nurse before forwarding to the Department head for approval. 4.6 Request to be approved and signed by the Department head.

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5.0 PROCEDURES 5.1 Head Nurse or Charge Nurse will do the round in the unit to determine the items needed. Items should be listed accordingly. 5.2 Head Nurse coordinates with store nurse with regards to the stock of items and furnished the Head Nurse with the items or supplies needed. 5.3 The Head Nurse brings the signed request to the Nursing Office for approval and signing, then to the Central Store for submission and approval by the Head of the central store. 5.4 Supply Department to notify the requestor regarding unavailable items, that needed special request. 5.5 Special request to buy item from outside to be filled and approved by the Department Head and the Hospital Manager. 5.6 Items received from central store to be kept in special area. 5.7 Disposable item to be used under control for one use only. 5.8 Items received from CSR, should be checked for expiration date before receiving the items. 5.9 Items receive should be endorsed to the store Nurse .

7.0 ATTACHMENTS NA

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th

Manual Of Nursing Practice - 8 Edition – 2001 th Fundamentals Of Nursing Practice - 5 Edition – 2001 th Niraj Ahuja, Textbook Of Psychiatry (6 Edition) Al Amal Hospital – Jeddah-Drug Rehabilitation Hospital- Nursing Department

NAME Prepared By: Approved By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

DATE

2010 2010

Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures ______________________________________________ GENERAL NURSING: NURSING ADMINISTRATION ADMINISTRATIVE POLICY AND PROCEDURE POLICY NUMBER:

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1.0 PURPOSE To check for proper functioning of supplies and equipments to be used in the unit/area.

2.0 DEFINITION List of equipment and supplies that must be available and functioning in all the units.

3.0 RESPONSIBILITIES Staff Nurses

4.0 POLICY 4.1 There must be a checklist of equipments and supplies in the units. 4.2 Nurses have to check the equipments for functioning in every shift during endorsement. 4.3 Any malfunction should be labeled properly and reported to biomedical technicians. 4.4 Head nurses or charge nurses should be notified.

5.0 PROCEDURES 5.1 Checked equipment and supplies every shift during endorsement. 5.2 Follow the checking procedure for machinery and equipments.

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6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9

Scales appropriate to the age group and mobility of the patients Stretchers with safety straps Equipment for taking vital signs (thermometer, stethoscope, sphygmomanometer) Wheelchairs Sharp Box Foot stools Soft restraints Bed rails Oxygen and suction

8.0 REFERENCES -

Manual Of Nursing Practice - 8th Edition – 2001 Fundamentals Of Nursing Practice - 5th Edition – 2001

Al Amal Hospital – Jeddah-Drug Rehabilitation Hospital- Nursing Department

NAME Prepared By: Approved By:

Khalid A. Alharthi – Nursing Total Quality Coordinator – GNDMOH - KSA

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

DATE

2010 2010

Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures ______________________________________________ NURSING ADMINISTRATION

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1.0 PURPOSE 1.1 To render effective and efficient services to the patient. 1.2 To provide guideline in dealing with MOI patients.

2.0 DEFINITION Any patient referred to the hospital and accompanied by Ministry of interior (MOI) officer for management and treatment of substance–related problem.

3.0 RESPONSIBILITIES Nursing staff, MOI officer, Doctors

4.0 POLICY 4.1 All MOI patients shall be given priority to have him seen by physician as soon as possible. 4.2 MOI patients with leg chains must stay in separate room (MOI office at OPD) away from general waiting area and should be moved via wheel chair within the hospital confines, under any circumstances should never let the patient walk around with shackled leg. 4.3 An employee from patient's affair department shall take the required personal information in opening a file inside the MOI office. 4.4 Any information obtained from the patient that sounds not reliable, the patient's affair employee may ask the MOI officer to have clear patient data. 4.5 Accompanying MOI officer must stay with the patient all the time. 4.5.1 If patient is for admission, the accompanying officer shall stay with the patient until being brought to the unit.

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5.0 PROCEDURES 5.1 Check for the MOI referral letter. 5.2 Provide patient with wheel chair and white linen to cover the patient's lower extremities, if the patient is with leg chain. 5.3 Perform nursing assessment including vital signs. 5.4 Prepare patient file and attach all documents brought either by MOI or the patient. 5.5 Once patient file is ready it should be hand over to the nurse in charge of OPD. 5.6 Refer the patient to the physician on duty and remain with him until finish. 5.7 Get the patient to specimen collection room to obtain the required specimen as order by the physician. 5.8 Check the physician order care fully and make sure that all required specimen is taken before allowing the patient to leave the hospital (if for OPD treatment only). 5.9 Carry out other physician orders. 5.10 Head nurse or the nurse in charge should then follow up the case for sending a medical

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report if needed. 5.11 Put a copy of the MOI referral letter in the patient's file and in the OPD file.

6.0 ATTACHMENTS None

7.0 MATERIALS & EQUIPMENT MOI Referral letter, Patient’s file

8.0 REFERENCES -

Manual Of Nursing Practice - 8th Edition – 2001 Fundamentals Of Nursing Practice - 5th Edition – 2001 Niraj Ahuja, Textbook Of Psychiatry (6th Edition) ANN Isaac's Mental Health And Psychiatric Nursing (2nd Edition – 1992) Textbook Of Substance Abuse Treatment (2 nd Edition 1994) Gallantar And Klebber , American Psychiatric Press

NAME

DATE

Prepared By:

Al Amal Hospital – Jeddah-Drug Rehabilitation Hospital- Nursing Department

2010

Reviewed & Approved By

Central Committee Of NPP 2010 - General Directorate Of NursingMOH.KSA

2010