NABH

EMPLOYEE
HAND BOOK
NABH: OVERVIEW

Our Vision-

Our Mission-

Our Core Values-

Scope of Services-

Why this Handbook ?

The handbook has been made to prepare you for the NABH Accreditation Process. It informs
You about JJIMS vision, mission, core values, policies & health care practices. We request you to
read this Handbook carefully; you may also refer to your departmental manual, which will give
you details of policies and procedures relevant to your functional area.

You are a part of our team:

 You are a part of organization which is in process of establishing an outstanding reputation for
itself in medical care and quality services.
To achieve this goal, we at JJIMS have decided to be in
The NABH programme which will improve our services and patient care.

1. What do you mean by Mission?

A written expression that sets forth the purpose of the organization. It usually precedes the
formation of goals and objectives.

2. What does NABH stand for?

NABH: National Accreditation Board for Hospitals and Health Care Providers.

3. When was it set up?

It was set up in 2005 by QCI.

4. What is NABH and its aim and objective?

NABH is a constituent board of QCI- Quality Council of India. It sets standards and operates
accreditation programmes for health care organization.
o Medical Excellence.
o Ensure ‘Quality Assurance’ system.
o Risk Management System w.r.t. patient care and treatment.
o Patient/Organization need.
o Helps Standardization.

The NABH standards touch all those areas where we face difficulties in day to day issues, risk to
us or our patients, and there is a strong focus on patient requirements i.e. Care satisfaction,
Education and information safety.

5. What is QCI?
(QCI) Quality Council of India is an autonomous body set up jointly by Govt. of India and industry
to establish and operate accreditation structure for assessment conformity bodies offering
certification, inspection, testing and registration services etc. in the field of health, environment,
food safety, information security, occupational health and safety and quality management.

6. What is Accreditation?
a.) It is a process of external review of quality of the health care being provided by a health care
organization. This is generally carried out by a non-governmental organization.
b.) It also represents the outcome of review and decision that and eligible organization meets
an applicable set of standards.
7. Accreditation survey?
The evaluation process for assessing the compliance of an organization with the applicable
standards for determining its accreditation status.

NABH survey includes the following:

a. Documentation review.
b. Facility tour.
c. Interview with staff, patient and visitors.
d. On site observation by surveyors.
e. Education about standards compliance.

8. Structure of NABH Standards?

. 10 chapters
. 105 Standards
.683 Objective elements

9. What are the 10 chapters of NABH?

.Patient centered standards:-
• Chapter-1 (AAC) Access, Assessment and continuity of care
• Chapter-2 (COP) Care of Patient
• Chapter-3 (MOM) Management of Medication
• Chapter-4 (PRE) Patient Right and Education
• Chapter-5 (HIC) Hospital Infection Control

.Organization centered Standards:-

• Chaper-6 (CQI) Continuous Quality Improvement
• Chapter-7 (ROM) Responsibility of Management
• Chapter-8 (FMS) Facility Management and Safety
• Chapter-9 (HRM) Human Resource Management
• Chapter-10 (IMS) Information Management System

10. What is a Standard?

It is a statement of experience that defines the structures and process that must be
substantially in place in an organization to enhance the quality of care.

11. What is an Objective element?

It is the component of the standards which can be measured objectively on a rating scale. The
acceptable compliance with the measurable elements will determine overall compliance with
the standards.

12. What is the process to move patients in and out of various units?
a. Doctors’ written order with date, time, diagnosis and reason for transfer.
b. Prior to transfer ensure receiving area is ready to provide appropriate care.
c. Escort the patient according to the patient’s condition.
 d. Before shifting-dress the patient, update the nursing summary, document, and recent
treatment, check IV fluids, drugs, Cannula site, if chest tube and ryles tube ensure close
system maintained.
e. Intra transfer form & transfer slip from admission counter to be attached.

13. What is “end of life care”?

When the doctors and patient representatives decide to withhold or withdraw the life support
measures, it is documented in the patient’s file with consent of the next kin of the patient.
Nurses carry out the orders and also ensure that the patient and family are taken care with
utmost respect and compassion/palliative care.

14. How often should a patient have written order to be revised?

12 hourly

15. What is patient’s complaint policy?

A formal, written or verbal grievance is filed by a patient/kin when there is dissatisfaction with
hospital services & is reported to grievance officer (Medical Superintendent).

16. What is the attire code?

It is the attire protocol which is to be followed in to prevent infection.

➢ ICUs Gowns, face mask, head cover, shoe cover or slipper.

➢ OT scrub suit, face mask, head cover, OT slippers.
➢ Other: patient handling with mask & gloves.
➢ ICU- patient dress- Pyjama & top.

17. Check-list for patient care documentation :-

All papers in patient’s file should have patient information/label on each sheet. This includes-
IP No., Name, Age/Sex, Room No., Consultant, and Date & Time of admission.

18. Check-list of key aspects of prescription :-

➢ Date, name of the patient at top and signature & time at bottom.
➢ Clear legible prescription in capital letters.
➢ Dose, route & duration of administration.
Note: Also check for allergies and note down.

19. What are the aspects of patient transportation?

Wheels of stretchers, wheelchairs, and beds are locked when a patient is lifted from or assisted
on to them. Side rails are raised on stretchers, when present. Where no side rails exist, safety
belts are fastened. Patient must be accompanied by nurse/doctor if critically ill.

20. What is Sentinel Event?

An unexpected incidence, related to system or process deficiencies, which leads to death or
major and enduring loss of function for a recipient of health care services. They include:-
 A. SURGICAL EVENTS

➢ Surgery performed on the wrong body part.

➢ Surgery performed on the wrong patient.
➢ Wrong surgical procedure performed on the wrong patient.
➢ Retained instruments in patient discovered after surgery/procedure.
➢ Patient death during or immediately post surgical procedure.
➢ Anesthesia related event.
B. DEVICE OR PROCEDURE EVENTS
Patient death or serious disability associated with:-
➢ The use of contaminated drugs, devices, products supplied by the organization.
➢ The use or function of a device in a manner other than the device’s intended use.
➢ The failure or breakdown of a device or medical equipment.
➢ Intravascular air embolism.

C. PATIENT PROTECTION EVENTS

➢ Discharge of an infant to the wrong person.

➢ Patient death or serious disability associated with elopement from health care facility.
➢ Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability.
➢ Intentional injury to a patient by a staff member, another patient, visitor, others.
➢ Any incident in which a line designated for oxygen contains the wrong gas or is contaminated by
toxic substances.
➢ Nosocomial infection or disease causing patient death or serious disability.

D. CRIMINAL EVENTS

➢ Any instance of care ordered by or provided by an individual

Impersonating a clinical member of staff.
➢ Abduction of a patient.
➢ Sexual assault on a patient within or on the grounds of the health care facilities.
➢ Death or significant injury of a patient or staff member resulting from a physical assault or other
crime that occurs within or on the ground of the health care facility.

ANY SENTINAL EVENT MUST BE REPORTED

21. What is Medical audit?

A peer review carried out by analysis of medical record with a view to improve the quality of the
patient care.

22. What is an “Adverse Drug Event” and “Adverse drug Reaction”?

➢ Adverse Drug Event: Any untoward medical occurrence that may present during
treatment with a pharmaceutical product but which does not necessarily have a causal
relationship with this treatment.
➢ Adverse Drug Reaction: A response to a drug which is noxious and unintended and
which occurs at doses normally used in man for prophylaxis, diagnosis or therapy of
disease or for the modification of physiologic function.
Therefore ADR = adverse event with a causal link to a drug.

➢ Adverse Event: The FDA recognizes the term adverse drug event to be synonym for
adverse event. In the patient safety literature the teams adverse drug event and adverse
event usually denote casual association between the drug and the event, but there is a
wide spectrum of definition for these terms including harm caused by a-
➢ Drug
➢ Harm caused by drug use, and
➢ A medication error with or without harm.
Institute of Medicine: “An injury from medical intervention related to a drug” which has
been simplified to “An injury resulting from the use of drug”.

Adverse drug event extend beyond adverse drug reactions to include harm from overdoses
and under doses usually related to medication errors.

Minorities of adverse drug events are medication errors,

And medication error rarely results in adverse drug event.

➢ 10 Rights of Drug Administration

Follow 10 Rights (10 R) before giving Medication:-
1. Right Drugs.
2. Right Patient.
3. Right Dose.
4. Right Route.
5. Right Time and Frequency.
6. Right Documentation.
7. Right History and Assessment.
8. Right to Refuse.
9. Right Drug Interaction and Evaluation.
10. Right Education and Information.
1. Right Drug.

Check and verify if it’s the right name and form. Beware of look-alike and sound-alike medication
names. Misreading medication names that look similar is a common mistake. These look-alike medication names
may also sound alike and can lead to errors associated with verbal prescriptions. Check out The Joint
Commission’s list of look-alike/sound-alike drugs.

2. Right Patient.

Ask the name of the client and check his/her ID band before giving the medication. Even if you know that
patient’s name, you still need to ask just to verify.

3. Right Dose.

Check the medication sheet and the doctor’s order before medicating. Be aware of the difference of an adult and a
pediatric dose.

4. Right Route.

Check the order if it’s oral, IV, SQ, IM, etc..

5. Right Time and Frequency.

Check the order for when it would be given and when was the last time it was given.

6. Right Documentation.

Make sure to right the time and any remarks on the chart correctly.

7. Right History and Assessment.

Secure a copy of the client’s history to drug interactions and allergies.

8. Drug approach and Right to Refuse.

Give the client enough autonomy to refuse to the medication after thoroughly explaining the effects.

9. Right Drug-Drug Interaction and Evaluation.

Review any medications previously given or the diet of the patient that can yield a bad interaction to the drug to
be given. Check also the expiry date of the medication being given.

10. Right Education and Information.

Provide enough knowledge to the patient of what drug he/she would be taking and what are the expected
therapeutic and side effects.

Two nurses administer the high risk medicine after cross checking especially Narcotic &
psychotropic drugs.

Never leave medicines unattended in the open. Lock them in beside cabinets, label all open, in
use vials.

23. Who is vulnerable patient?

“Those patient who are prone to injury and disease by virtue of their age, Sex, Physical,
mental and immunological status.”

e.g.:-
➢ Children < 12 yrs.
➢ People > 65 yrs. of age.
➢ Patient on immunosuppressive or chemotherapeutic agents
➢ Pregnant patients
➢ Physically and mentally challenged
➢ Rape/suicide victims
➢ Patient in ICU
➢ Patient who cannot perform activity of daily living. (ADL)

For Vulnerable patient, precautions taken are-

 ➢ Side rails on bed+ appropriate bed of safe height+ mattress/overlay.
➢ Must be attended by family attendant/nurse.
➢ Provided scheduled toileting + scheduled turning and positioning.
➢ Urine and / or feces cleaned promptly.
➢ Skin care and hygiene.
➢ Provide timely nutrition /feeds
➢ Attended for physical interventions i.e. bathing, toilet by appropriate gender
➢ Restraints if required comfort assessment and emotional care by psychologist.

ANY ABUSE MUST BE REPORTED TO CONCERNED DEPARTMENT

24. What is assessment?

All activities including history taking, physical examination, laboratory investigation that
contributes towards determining the prevailing clinical status of the patient.

25. What are Quality Indicators?

Quality Indicators are a set of functional parameters which have been selected across different
area of the hospital. Data for these is collected by the respective departments every month and
analyzed by the Quality Committee, which looks into gross deviations in any of this data.

26. What is a patient Rights and Responsibility?

Patient & Family Rights :-
➢ Right to information of his/her disease, treatment and prognosis and other related
information.
➢ Right to have Privacy during examination.
➢ Right to know estimated cost of & treatment.
➢ Right to treating patient information as confidential.
➢ Right to Refusal of treatment.
➢ Right to have second opinion.
➢ Right to Information on how to voice a complaint and grievances.
➢ Right to complete information alternatives in case of transfer to another facility.
➢ Right to obtain a copy of medical record.
➢ Right to informed consent before anesthesia, blood and blood product transfusions and
any invasive/high risk procedure/treatment.
 Patient responsibilities :-

➢ To provide complete and accurate information about medical complaint, past illness,
hospitalizations, medications, pain and other matters relating to their health.
➢ To follow the treatment plan recommended by those responsible for their care.
➢ To be responsible for their actions if they refuse treatment or do not follow the health
care team’s instructions.
➢ To see that their bills are paid as promptly as possible; following hospital rules and
regulations.
➢ To be considerate of the right of other patients and hospital personnel.
➢ To seek information, and questions, asking them.

27.What is an Employee Rights and Responsibility?

1. Safe environment: The duty of the employer is to provide a healthy and safe environment to the
employees. They are required to install safe and healthy plants, systems and machineries. The
employees should make sure that they carry out their work in a way which is safe for others too.
Workplace exits are to be made sure that they aren’t blocked. 2. Arrangements: Any factory should
possess safe arrangements for making use of harmful substances, dangerous products or chemicals.
There are specific regulations for the usage and storing of such substances which should be followed.

3. Basic necessities for employers and employees: The employer should also make sure that the
employees has all the basic facilities such as clean toilets, tidy eating areas, clean workplace, and good
drinking water.

4. Information for the employees: All details such as training, information about safety should be
updated to the employees at time. The employers should also abide by the government conditions in
purchasing new equipments and machines. And also the work place should follow certain rules about
temperature control.

5. Inequalities at workplace: In a work environment the rights of the employees is to work in a place
which is free from discrimination, harassment, and abuse. In almost all work places these are major
issues and hence it is the right of every employee.
6. Dressing and activity: Way of dressing for any individual varies and so it is the freedom and right for
any employee to dress and work according to their belief and tradition. Dressing cannot be ruled in any
work place.

7. Payments: Every employee or employer has a fixed payment and allowances if present. Hence it is the
right for every employee to get paid fairly and correctly. There cannot be any discrimination in payments
for workers.

8. Equal opportunity: Every individual joins the organisation based on their skill set and experience.
When its promotion or hike, the actual and eligible employees should get it based on their expert work
and skills, regardless of their caste, age, colour etc.

9. Holidays: The employee and employers have the rights to access the appropriate holidays assigned
for them. Public holidays, family, personal and other holidays present.

10. Main responsibility: Apart from the rights there are various responsibilities that are for both the
employer and employee. Irrespective of any position, the employee’s main responsibility is to arrive to
the work place at time. Once arrived at time, they should have the intention to work.

11. Uniform: There are certain workplaces which have specific uniforms and dresses for their workplace.
If so, it is the duty of the employee to wear the uniform and start to work. In case the organisation has a
dress code, then it should be followed.

12. Respect: This is one main responsibility which enhances the relationship amongst employees.
Respecting one another employees, customers and co-workers is the key responsibility which makes
your work place lively.

13. Performing: Apart from all the rights and responsibilities, carrying out your assigned task in the right
manner with enthusiasm to work is another responsibility of every employee. Your work enthusiasm
should be presented in your performance.

14. Right to ask: With number of rights and responsibilities for employer and employees, while in an
organisation the employer has the right to question about the mental health condition of the employee.
By this way the employer makes sure that the employee can work and satisfy the company
requirements.

15. About work environment: The employer can pick out if there are any adjustments to be made. If
there are changes to be made in the selection or recruitment process and also in the role or work
situation, the employer has the complete rights to clarify and bring out changes.

16. Entitlements: The main claims required for the job position such as superannuation, sick leave,
available insurances and compensation are clarified by the employee at any situation in the organisation
as it is his right to ask.

17. Adjustments for disabled: For people who possess a slight mental health condition, can work well
when slight changes are made in the organisation. These small changes offer them the chance and equal
opportunity to work like other employees. According to the disability discrimination act of 1992, an
employer is to make adjustments for the employee so that he performs the required job. The
adjustments here would include variation in hours of work, leave and also the facilities and equipments
in work place may vary.

18. Prevention of harassment: An organisation would have people from all groups, the disability
discrimination act 1992 states that harassment, verbal abuse and physical abuse against mental health
conditioned employees are to be averted. In the same manner the equality act works towards
employees to be treated fairly and nine characteristics fall under it. Unfair act and discrimination should
be averted against age, sex, gender, disability, sexual orientation, marriage and civil partnership, religion
and belief, gender reassignment, pregnancy and race.

19. Equal and right work: When discoursing about rights and responsibilities the employers should
provide a equal and fair work environment. The employer should not be partial and unfair during
advertising work positions. They cannot be in favour of any specific group of people for any job opening;
all jobs should be treated in the same manner.

20. Main facilities: It is the responsibility of the employer to the necessary adjustments for the
employees wherever required. The work place should be accessible where it should possess the
appropriate requirements such as lifts, stairs and other necessities for the work place. This would be
comfortable for disabled employees too.

21. Flexible hours: It is the right of the employee to choose his or her flexible working hours. The
employee can pick his appropriate shift, can share his work load, and can work for par time or also from
home. All these factors relate to the hours of work. In the same manner an employee cannot be forced
to work for more than 48 hours a week. This is because they bring it to an average of about 17 weeks.
When average over 17 weeks is calculated then it should be less than 48 hours.

22. Detailed claims: The rights for employees also include for them to look into the claims available for
them. Sick leave are provided and salary are also allotted as per it. There are fixed sick leave that can be
taken each year and so employees can take a deep look into it.

23. About pension: The national insurance payment is something that comes out of your monthly salary.
The employer also pays the same. The employee is to pay the national insurance payment, for his
complete career. He as the chance to receive pension and hence an employee can look forward for such
options as his right.

24. The HR department: The HR department in any organisation should be available to the employees
to settle them in case of disputes and also to educate them about their rights and responsibilities in
each stage.

25. Policies at work place: There are few workplace policies which should be followed by the
employees. Abiding to the principles and approach it is mandatory to open up a fair practice to all the
employees. Privacy is something which should be respected in the work environment; a privacy matter
is to be maintained privately and not to be gossiped around.

26. Trade unions: Trade unions are another session present in a work environment. A trade union is
present in order to move the employee’s requirements to the higher authority in case of hike or any
other facility needed or to set right any disputes prevailing amongst employees. There are many trade
unions present within an organisation.
It is mandatory for both the employers and employees to understand their rights and responsibilities at
work place. The employees are also advised to make a thorough reading on their contracts which they
sign during the initial stage of joining as it would have the complete details regarding the right,
responsibilities, rules and regulations. Also hovering over the company site could be helpful to gather
more details. They would know what is to be done and what not to be done. Hence educating
themselves about company procedures, rules, regulations and other work related responsibilities are
important

28. Name the patient identifier?

1. UHID
2. Patient name.

29. How do you know that your patient/family/others understand the information they
Received?
➢ Asking them to verbalize their understanding.
➢ Asking them to give a demonstration.

30. Which department deals with patient complaints/grievances?

➢ Front Office
➢ Chief Manager Operations

31. What is ADL?

Acts of daily living.

32. What is MSDS?

Material safety data sheet (It contains a list of all hazardous material).

33. What is drug formulary?

A drug formulary is a list of prescription drugs (“preferred list”). Only these drugs are available
for sale in JJIMS.
The purpose of drug formulary is to steer least costly medications of renowned companies that
are sufficiently effective for treating health condition.
34. Who choose the drugs on formulary?
The drug formulary is developed by a committee comprising Pharmacist, therapeutics,
physicians from various medical specialties and & the request comes from physician.

35. How do you indent for new formulary drug?

Request comes from doctors on basis of:-
➢ Urgent- Approved by Chairperson of P & T (Pharmacy & Therapeutic).
➢ Non-urgent- discussed in the next meeting.

36. What is colour coding of patient?

Wrist bands are used to designate patient risks in the acute care setting, and the care provider
use the different colours sets by the JJIMS.
➢ Allergy- Red
➢ Vulnerable Patient- Yellow
➢ IPD patient (for all)- Green

37. What is consent when it should it be taken?

A willingness of a patient to undergo examination/procedure/treatment by a health care
provider. It may be implied/expressed and may be written or verbal. Informed consent is a type
of consent in which the health care provider has a duty to inform his/her patient about the
procedures, its potential risks and benefits so as to enable the patient to take an informed
decision of his/her health care.

38. Who obtains informed consent?

The Doctors.

39. What is the validity of a signed consent?

30 days.

40. What do you mean by patient safety?

➢ Patients are identified correctly before procedures.
➢ Patients are protected against falls by safety belts on wheel chairs, trolleys etc.
➢ Vulnerable patients are identified and taken care of specialty.
➢ To improve the effectiveness of communication amongst givers.
➢ Vigorous hand hygiene practices to prevent hospital acquired infection in patients.
 41. What are the Emergency code and whom to contact?
Kindly go through the emergency code mentioned below. It is the duty to every employee at
JJIMS to attend training session on how to handle emergency situations.

CODES SITUATIONS RESPONSE TEAM DIAL RESPONSE TIME

Red Fire disaster (Security)Security Officer/Supervisor, 20/21 90 seconds
(Major/Minor) Admin, MS, NS, Engineering Team
(Front Office)
Blue Individual disaster, CPR ER Doctor, Critical Care Team, 20/21 90 seconds
Cardiologist, Anesthesiologist,
Physician (Front Office)
Pink Child Abduction/Person (Security)Sister In-charge, Security 20/21 90 seconds
Missing Officer/Supervisor, MS, NS, PRO
Purple Physical Fights (Security)Security Officer/Supervisor, 20/21 60 seconds
MS, Admin, NS, PRO (Front Office)
Yellow Community threats & (Emergency)ER team, Admin, Security 20/21 N.A.
need immediate medical officer/supervisor, MS,NS (Front
assistance Office)
White Patient Deceased (Emergency)ER team, Security, Admin 20/21 N.A.
Black Bomb Threat (Security)Security Officer/Supervisor, 20/21 60 seconds
Admin, MS, NS, (Front Office)
Green All clear (after disastrous (Emergency), (Front Office) 20/21 N.A.
situation)

Colour coding in Triage:-

RED : Most Urgent

Yellow : Urgent

Green : Non Urgent

Black : Dead

42. What could you do in case of fire? What is the number of fire alarm?
➢ Orient yourself about fire & know fire exits in the Hospital.
➢ Does not use water to extinguish fire due to electric short-circuit?
➢ Inform security room immediately at 33.
➢ Participate in all fire and safety training initiatives.

FIRE SAFETY:-
In case of fire dial- 20/21/33

RACE
R: Rescue
A: Alarm
C: Confine
E: Extinguish/Evacuate

PASS
P: Pull the pins between the handle
A: Aim the nozzle at the base of the fire
S: Squeeze the handle
S: Sweep from side to side

Dial- 9/Reception and Emergency Number

Fire Extinguisher- Multipurpose

43. What is Code Blue & CPR?

Code Blue means Cardiac Arrest
It is a situation when there is need for cardio-pulmonary resuscitation (CPR): It is a procedure, a
support and maintains breathing and circulation for a person who has stopped breathing
(respiratory arrest) and/or whose heart has stopped (cardiac arrest).

44. Is soiled infected linen segregated from other linen and how?
Yes, soiled linen is soaked in 1% sodium hypochlorite for 1/2 hour and then sent to laundry.

45. What is the life of Autoclaved Pack and ETO (Ethylene oxide) pack?
➢ Autoclaving is a process of steam sterilization e.g. surgical sets.
➢ Shelf life of autoclaved pack is 1 week for instruments sets. The packed set has indicator
tape outside which indicated black color stripes.
➢ ETO sets have shelf life of 3 months.
➢ Open IV fluids life is 24 hours.
➢ Open vials life is 1 month.
➢ Open bottles life is 3 months.

46. What is Bio-Medical Waste & how should it be disposed ?

 Bio-Medical waste is the waste that is generated during the diagnosis, treatment or
immunization of human beings or animals, or in research activities pertaining thereto, or in the
production or testing of biological matter. It must be disposed within 48 hours of collection and
must be segregated as per hospital policy.

47. What are occupational hazards?

➢ Biological hazards (blood, body fluids)
➢ Chemical hazards (formalin, cidex, mercury)
➢ Physical hazards (fall, back ache etc.)
➢ Safety hazards (electric hazard, broken equipment)
➢ Psychological hazards (work related stress)
 What is JJIMS policy on smoking?
➢ No smoking zone.
➢ Smoking being a punishable act, staff/Patient/Attendants caught smoking in hospital areas
will be fined Rs. 200/-.

48. What should be temperature of refrigerator (medicine)?

➢ 2-8 degree Celsius
➢ (Exception is Polio Vaccine which is stored in ice box below 0 degree Celsius).

49. How do you report ADR?

By filling ADR Sheet. This is available on all Nursing Stations.

50. What is drug recall?

It is an action taken by Pharmaceutical firm or drug regulatory authorities to remove a drug
product from JJIMS formulary.

51. How long it takes to disinfect your hands?

➢ Alcohol base hand rubs- 20 seconds.
➢ Anti microbial soap and water- 1minute

52. How many steps are there to disinfect hand?

8 steps.

53. What is PPE?

Personal Protective Equipment’s (PPE) refers to self-protection designed to protect the wearer’s
body from job-related occupational injuries occurring by electrical hazards, heat, chemicals,
infections, etc.
54. Name few PPE?
➢ Filter mask/gas masks (respiratory protection)
➢ Helmets/head guard/cap (head protection)
➢ Goggles/eye protector (eye protection)
➢ Ear plugs/muffs (ear protection)
➢ Gloves (hand protection)
 ➢ Apron (body protection)
➢ Gum boots/ shoe covers

55. Name two hospital wide indicators for infection control?

➢ Hand hygiene
➢ Proper segregation and safe disposal of Bio-medical waste.

56. How should dirty linen be transported?

Through linen hampers

57. Name to radiation safety devices?

➢ TLD badges
➢ Lead aprons

58. What is the composition of Code Blue Team?

➢ Anesthesia specialist on duty
➢ Medicine specialist on duty
➢ Staff nurse on duty in emergency
➢ Nursing head on duty form ICU
➢ Consultant anesthesiologist (should be present at course as far as to ensure quality)
➢ EMO & ICU Doctor on duty

59. What is time frame in which Record of patient should reach MRD?
48 hrs.

60. What is retention period of MLC file?

10 yrs. or till the decision of court.

61. What is the retention period of Normal file?

5 yrs.
62. What is needle stick injury & what should be done in case of needle stick injury?
Needle stick injuries are wounds caused by needle/sharps that accidentally puncture the skin.
Steps to be followed in case of needle stick injury are:-
➢ Do not panic.
➢ Do not put injured part in mouth as a reflex.
➢ Wash the area with soap and running water or alcoholic hand rub.
➢ Report to the infection control nurse/infection control officer.
➢ Record details of exposure and source,
➢ Complete and submit needle stick injury form.
➢ Follow the needle stick injury policy in management of sharp injuries.
➢ Contact the infection control nurse/officer for any information on the same.

63. What are standard precautions?

Standard precautions are a combination of both universal precautions & body substance
isolation precautions. All patient receiving care in hospital, irrespective of their diagnosis or
presumed infection status, should be treated in a manner as to reduce the risk of transmission
of microorganisms from HCW to patient.

Cardinal rules of standard precautions:-

Consider all patients as potentially infectious. Assume all blood & body fluids & tissues covered
by standard precautions as contaminated with blood borne pathogens. Assume all unsterile
Needles & other sharps as similarly contaminated.

Protocol for Standard Precaution:-

Hand washing for decontamination:
With soap & water
Hand disinfection: with chlorhexidine alcohol hand rubs or povidine lodine hand scrub.
Personal protective equipment- use of-
- Gloves
- Caps
- Shoe cover/boots
Handling needles & other sharps.

64. What is disinfection, decontamination and sterilization?

Disinfection:- It is as process by which vegetative i.e. growing forms of pathogenic organism are
killed. This is done by using sodium, hypochlorite, alcohol, Lysol, baccilocid etc.

Decontamination:- It is a process by which vegetative micro-organisms are killed. Before

cleaning such processing may be required to make solid instruments or material safe by using:-
- Detergent with enzyme for scopes.
- Chlorthxidine with alcohol for preparation & disinfection of hands.
- Baccilocid for high risk area.
 Steilization :- It is the destruction of all micro-organism including bacterial pores. This is
achieved by physical or chemical means e.g. saturated steam, ETO it is complete elimination or
destruction of all forms of microbial life and is accomplished in health care facility by either
physical or chemical process e.g. Autoclave/ETO.

65. What is Barrier Nursing & Reverse Barrier Nursing?

Barrier Nursing :- In addition to standard precaution, these are special precautions to be taken
for patients suffering from certain infections, based on mode of transmission of these infection
e.g. respiration precaution for droplet infections & isolation of patients in a negative pressure
room, contact precautions for gastrointestinal, respiratory, skin, wound, conjunctival infections
or colonization with MDR bacteria.

Reverse Barrier Nursing:- This includes precautions which need to be followed by HCWS, taking
care of Immune compromised patients to prevent such patients from getting infections. in
addition to standard precautions, it includes isolation in a positive pressure room.

66. What do you do in case of blood spill on patient file?

Contaminated file is put in a yellow colour bag, scaled, labeled, and sent to MRD. There they
photocopy the entire file and send the Xeroxed file back to the ward with authorized signature
by the Medical Superintendent.

67. How would you handle mercury spills?

➢ Do not touch mercury.
➢ Remove any jewelry/watch.
➢ Wear gloves, masks & eye shield.
➢ Use a flashlight to locate the mercury.
➢ Collection-
o Use cardboard sheets to push beads of mercury together.
o Use syringes to push beads of mercury.
o Place it in a container with water.
o Pick up remaining beads with stick tape.
o Place contaminated tape, in a bag with used syringe, cardboard & gloves.
➢ Label the bags as mercury waste.
➢ Place this sealed container in a second bin and send it to the Biomedical Engineer.
➢ Document the incident & inform MS.

68. What are Do’s and Don’ts while handling sharps?

Do’s-
- Pass syringe & needles in a tray.
- Remove cap of needle near the site of use.
- Pick up open needles from tray with forceps.
- Use puncture proof containers near site of usage to collect & dispose needle & the
sharp/broken ampoules.
 Don’ts-
- Never pass syringe & needles directly to next person.
- Do not bend/break used needle with hands.
- Never test fineness of needle/ pick up open needle by hand
- Never dispose it off by breaking with hammer/stone.

69. What do you mean by facility safety?

➢ All equipments are periodically inspected & maintained.
➢ Potable water and electricity is available.
➢ The corridor & wards are clean.
➢ Equipment & trained personnel are available.
➢ “No Smoking” policy is in place & formed.

70. What are 10 safety tips?

1. Wash your hands.
2. Use 10Rs right patient, right drug, right dose, right time, and right route. Right
documentation.
3. Place the light switch within reach of the patient.
4. Write down verbal order and read back.
5. Repeat vital verbal communication.
6. Listen to the patient to your full attention.
7. Utilize safety devices- raise bed rail, wear mask, wear gloves, use safety strap, and use
aseptic technique.
8. Write legibly, read back in front of the writer.
9. Never guess.
10. Be the patient advocate.

71. What are the 6 international Patients safety goals?

1. Identify patient correctly.
2. Improve effective communication.
3. Improve safety to high risk medications.
4. Eliminate wrong site, wrong patient, and wrong procedure surgery.
5. Reduce the risk of health care-acquired infection.
6. Reduce the risk of patient harm resulting from fall.

72. What are the Ten Commandments for Doctor?

1. Write Medication Order in Capital Letters.
2. Document your visit with notes duly signed with the date, time, and name.
3. Avoid verbal orders.
4. Use alcohol hand rub before and after each patient examination.
5. Make a habit of patient and family education as part of care.
 6. Ensure informed consent for all procedures.
7. Assess and re-assess patient as per hospital policy.
8. Prepare/counter sign discharge summaries and talk to patient regarding discharge
instruction, follow-up and care at home.
9. Prescribe as per hospital formulary.
10. Have formal meeting/ briefings with other specialist when more than one doctor is treating
the patient.

73. What are the Ten Commandments for Nurses?

1. Always ask your senior- ASK ME, ASK HER, ASK- DOCTOR, ASK THEM. If you are not confident in
any procedure, do not do it.
2. Wash your hand before and after each procedure.
3. You must know the hospital waste management system before you start your work.
4. Be polite and well behaved to your seniors, colleagues, patient and attendants.
5. Check your patient physically and chart untoward event in file.
6. Call bell should be attended immediately.
7. Immediately report any error.
8. Take care of hospital property- it’s your second home.
9. Do not use crash cart items for routine use.

THIS IS ONLY FOR EMERGENCY

Incomplete crash cart may cost patient his/her life.
You are here to save them.
10. Do not use any items of one patient for another.

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