PATIENT SAFETY GOALS

GOAL 1: IDENTIFY PATIENTS

CORRECTLY

Introduction

The purpose of the Patient Safety Goals is to promote

specific safety. The goals highlight problematic areas in
health care and the policy is designed to address these
issues and provide strategies to improve patient safety

GOAL 1- IDENTIFY PATIENTS CORRECTLY

1.0 Objectives
1.1 To ensure patients safety by correctly identifying
every patient in all aspects of diagnosis,
treatment and administrative process

2.0 Scope

2.1 All PMC healthcare facilities involving patient

Care

3.0 Definition / Abbreviation

3.1 MRN - Medical Record Number

3.2 Name Full name of the patient as per NRIC /
Passport
3.3 Patient outpatients and inpatients
3.4 Patients sticker a label that is printed with
patient data

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 3.5 Patient data name, IC Number, MRN, age,
gender, nationality, episode number, chief
physician, payor and location of the department

4.0 Policies and Procedures

4.1 Every patient is given a unique MRN and this

number is
Permanent
4.2 Registration personnel must ensure that the
patient data is
correctly entered during registration
4.3 If a patients is brought in unconscious to the
Emergency
Department, the patients is registered and
identified as UNKNOWN and an MRN is given
until full details are available
4.4 All patients admitted to the hospital are given the
wristband.
Wristbands are removed at discharge. If
wristband is removed for various reasons, (e, g.
surgical procedures) a new band is attached at
alternate site or immediately after completion at
the procedure
4.5 The admitting nurse must verify the patients
particulars before sticking the name label on the
patients wrist. The nursing staff must verify the
information on the wrist band with the patient or
PAP and ensure patient wears the wristband.
4.6 Before giving any medications, blood, and blood
products, taking blood and other specimens for
clinical testing, or providing any other treatment
or procedure, every patient shall be identified by
the two identifiers, i.e. name of patient and MRN.
2
 The doctors, nurses and allied health staff must
read the wristband, if available, and whenever
possible, ask the patient to state his/her full name
and IC/ or birthdate. This information must be
checked against the PMR.
4.7 In a conscious patients, identification is done by
checking against the name and MRN on the
patients wristband
4.8 In an unconscious patient, identification is done
by checking against the name and MRN on the
patients wristband
4.9 In patients who are unable to identify themselves
(especially the young, elderly and mentally
challenged) the care provider has to ask the
parents or guardians for the name and double
check with the MRN on the wristband
4.10 For outpatients, identification is done by checking
against the name and MRN on the patients
appointment card or name and identity card
number as stated on the patients identity card.

5.0 Responsibility

5.1 Physicians
5.2 Nurses
5.3 Allied Health
5.4 Administrative Personnel

3
 PATIENT SAFETY GOALS
GOAL 2: IMPROVE EFFECTIVE
COMMUNICATION

Introduction
The purpose of the Patient Safety Goals is to promote
specific improvements in patient safety. The goals highlight
problematic areas in health care and the policy is designed
to address these issues and provide strategies to improve
patient safety.

GOAL 2- IMPROVE EFFECTIVE COMMUNICATION

4
1.0 Objectives

1.1 To improve the effectiveness of communication

among
Caregivers

1.2 To reduce communication errors and improve

patient
safety

2.0 Scope

2.1 This policy applies to all forms of communication;

including
writen, verbal and telephone orders among all
caregivers

2.2 It applies to all situations, including emergency

situations

3.0 Policies and Procedures

4.1 All verbal and telephone orders / test results shall

be
Immediately recorded, dated and signed by the
registered
Nurse or allied health staff receiving the order
4.2 The receiver should read back the order to the
ordering
physician or the test results to the person who
gave the
5
 verbal report.
4.3 The person who gave the order or test results
should
confirm after the read-back
4.4 All order / test results shall be documented in the
PMR by
the receiver and the person who instructed it.

4.4.1 The doctor, nursing and allied health

staff must
verify the verbal and telephone orders
per policy
( write,read back,confirmand witnessed
by), and
document it in PMR ( Doctor Clinical
Notes)
PMC023 and PMC 266.
4.4.2 The doctors must document the verbal
or
telephone order and counter sign,
as per
hospital requirement within 24
hours.
4.5 In an emergency situation, the receiver will
repeat the order
verbally or by telephone and must be witnessed
by another
staff. The instruction must be carried out stat
and
documentations should be done as soon as
possible

4.0 Reference

5.1 Private Healthcare Facilities and Services

6
 (Private Hospitals and Other Private Facilities)
Regulations
2006

5.0 Responsibility

6.1 Physicians
6.2 Nurses
6.3 Allied Health

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 PATIENT SAFETY GOALS
GOAL 3: IMPROVE THE SAFETY OF
HIGH ALERT
MEDICATION

Introduction
The purpose of the Patient Safety Goals is to promote
specific improvements in patient safety. The goals highlight
problematic areas in health care and the policy is designed
to address these issues and provide strategies to improve
patients safety.

GOAL 3 - IMPROVE THE SAFETY OF HIGH ALERT

MEDICATION

1.0 Objectives

1.1 To provide specific written procedures for the safe

storage and handling of medications that has
been designated as high-alert medications
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 1.2 To emphasize high-alert medications so that all
health
care providers involved in the prescribing,
dispensing, and administration of these
medications recognize potential risks

2.0 Scope

2.1 Patient care areas- Emergency Department,

General
Wards, Critical Care areas, Operating Theatre,
Radiology Department and OPD

3.0 Definition / Abbreviation

High alert medications are medications that have a

heightened risk of causing significant patient harm
when used in error.

3.1 Concentrated electrolytes:

3.1.1 Potassium chloride

3.1.2 Potassium phosphate
3.1.3 Sodium chloride greater than 0.9%
concentration
3.1.4 Magnesium sulfate
3.1.5 Calcium gluconate

4.0 Policies and Procedures

High alert medications will be prescribed, dispensed,
and administered using practices that are stated
below in this policy
9
 4.1 Concentrated electrolyte solutions are only stored
in the Pharmacy Department and the locked
cabinet / trolley
4.2 Name and strength of medication must be
verified before administering to the patient
4.3 An independent verification of the medication
name, strength, and amount to be administered
is conducted by a second trained and qualified
individual. Calculations used in determining the
amount to be administered are also performed by
this individual
4.4 The dose of medications to be administered is
prepared just prior to administration as per
doctors order
4.5 The medication, strength and dose to be
administered are compared and confirmed with
the patients record as per doctors order.
4.6 The pharmacist / physician is contacted if the
dose to be administered exceeds the maximum
permitted
4.7 The double checks are documented in the
patients record.

5.0 Responsibility

6.4 Physicians
6.5 Nurses
6.6 Pharmacists, Dispenser

10
 PATIENT SAFETY GOALS
GOAL 4: ENSURE CORRECT SITE,
CORRECT PROCEDURE AND CORRECT
PATIENT SURGERY

Introduction

11
The purpose of the Patient Safety Goals is to promote
specific improvements in patient safety. The goals highlight
problematic areas in health care and the policy is designed
to address these issues and provide strategies to improve
patient safety

GOAL4- ENSURE CORRECT SITE, CORECT

PROCEDURE AND
CORRECT PATIENT SURGERY

1.0 Objectives

1.1 To establish a uniform process to verify and

ensure the
correct site, correct procedure and correct
patient, including procedures done in settings
other than the operating theatre
1.2 To ensure patients safety before any surgery or
procedure.

2.0 Scope

2.1 Operating Theatre

2.2 Endoscopy Department

3.0 Policies and Procedures

3.1 All the patients shall be informed of the location

of their

12
 Surgical or procedure site in the ward especially
when there
is more than one possible site.
3.2 The doctor in charge of the patient shall ensure
that the
exact site of procedure is mentioned in the
consent form
3.3 The exact site of procedure shall be recorded in
the
operating schedule list.
3.4 Pre operative verification shall be done in the
ward and in
OT using the standard OT checklist. The
checklist shall be
completed by the ward nurse who sends the
patient to OT
and the receiving nurse In OT.
3.5 All relevant documents, x-ray films, equipment,
instruments and / or implants are available and
functional. Team members involved in the
procedure are responsible to check the required
equipments, instruments/implants.

4 Responsibility

4.1 Physicians
4.2 Nurses
4.3 Allied Health

5 Related Document

5.1 Operation Theatre Department P & P

5.2 Operation theatre Patient check list (PMC 029)

13
 PATIENT SAFETY GOALS
GOAL 5: REDUCE THE RISK OF HEALTH
CARE ASSOCIATED INFECTION
Introduction
The purpose of the Patient Safety Goals is to promote
specific improvements in patient safety. The goals highlight
problematic areas in health care and the policy is designed
to address these issues and provide strategies to improve
patient safety

GOAL5 - REDUCE THE RISK OF HEALTHCARE

ASSOCIATED INFECTIONS
2.0 Objectives

To reduce the risks of health care- associated

infections in
patients, staff and health workers

To prevent and control the transfer of pathogenic

micro-organisms between patients and healthcare
workers
through hand contact.

3.0 Scope

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 2.1 All patient care patient support departments /
services
2.2 All staff and visitor/visiting areas

4.0 Definition / Abbreviation

3.1 WHO- World Health Organization

3.2 CDC- Centers for Disease Control
3.3 ICC- Infection Control Committee
3.4 ICN- Infection Control Nurse

4.0 Policies and Procedures

4.1 The department and ward incharge/manager, or

designee,
or ICN shall instruct each employee in his or
her role in the
prevention of health care associated infection
. The
incharge/manager will incorporate infection
control and
prevention practices into departmental
policies and
procedures according to those formulated by
the ICC.

4.2 Educational programs reviewing principles of

infection
control and prevention will be given to current
and newly hired employees involved directly or
indirectly in patient care.These programs will
include the practical application
of infection prevention techniques specific to
the nature
of service of that department.

15
 4.3 Each department incharge/manager or designee
will
supervise employees in infection prevention
practices,
evaluate the need for further training and
provide as
needed in consultation with ICC.

4.4 The ICC incorporate Standard Precautions into

the
Hospital wide Infection Control policies.

Proper hand hygiene is the most important

measurement
for the prevention of spreading infection.

4.5 ICC shall be responsible for the setting up and

implementation of hand hygiene guidelines and
monitoring
compliance for an effective hand hygiene
programs. This
includes basic hand hygiene instructions/poster in
all parts
of the hospital including public areas.

4.6 Indication for Hand hygiene

4.6.1 Before patient contact

4.6.2 Before aseptic tasks
4.6.3 After body fluid exposure risk
4.6.4 After contact with patient
4.6.5 After contact with patients surrounding
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5. Responsibility

5.3 Infection Control Committee

5.4 Healthcare workers

PATIENT SAFETY GOALS

GOAL 6: REDUCE THE RISK OF PATIENT
HARM RESULTING FROM FALLS

17
Introduction
The purpose of the Patient Safety Goals is to promote
specific improvements in patient safety. The goals highlight
problematic areas in health care and the policy is designed
to address these issues and provide strategies to improve
patient safety

GOAL6 - REDUCE THE RISK OF PATIENT HARM

RESULTING FROM FALLS

1.0 Objectives

1.1 To identify the patient who are at risk of

falls
1.2 To reduce the risk of patient harm resulting
from falls

2.0 Scope

2.1 All patient care areas Emergency Department,

General
Wards, Critical Care areas, operating Theatre,
Radiology Department, Physiotherapy
Department, Laboratory and Blood Services and
OPD

3.0 Definition / Abbreviation

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 3.1 A fall a sudden, uncontrolled, unintentional,
downward
displacement of the body to the ground or other
object, excluding falls resulting from violent blows
or other purposeful actions

3.2 An un-witnessed fall- occurs when a patient is

found on the
floor and neither the patient nor anyone else
knows how he or she got there.

4.0 Policies and Procedures

4.1 All patients shall be assessed by the nurses for

the risk of
falls on admission using the Modified Morse
Scale.

4.2 All patient categorized with high risk of falls, shall

be
Identified with a graphic label which is attached
to the bed side, room door or PMR.

4.3 The patient and family shall be educated about

falls
prevention

4.4 The patient and family shall be accompanied by a

hospital
staff / family member whenever they are out of
the bed / ward

4.5 Patient with high risk of falls shall be provided

with Fall
Preventive condition or medications

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 4.6 Reassessment of patient is required when
indicated by a
change in condition or medications

4.7 All falls shall be reported in accordance to the

hospital
requirements such as incident reporting

5.0 Responsibility

5.1 Physicians
5.2 Nurses
5.3 Allied Health

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 ADMISSION TO THE ORGANIZATION

1.0 Objectives

1.1 This policy is established to provide effective

screening method
for patients who may require PMCs clinical services
as patient

2.0 Scope

2.1 All patients who are electively referred by their

physicians for
evaluation

2.2 All patient who present at the PMCs Emergency

Department

3.0 Policies and Procedures

3.1 All elective referrals shall be screened for elective

outpatient
appointment

3.2 All patients presenting to the Emergency Department

shall
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 be screened.

3.3 Elective Referrals

3.3.1 Letter by referring physician

a) Patient with the relevant information

(patients medical history, clinical
examination, investigation results,
medication and past treatment) shall be
given an outpatient appointment.
b)When patients referring letter indicates the
need for early appointment, the letter shall
be given to the respective on-call consultants
or base on patient request

3.3.2 Phone call by referring physician

a) The appointment counter staff (Front Office

registration assistant) shall request clinical
information and schedule an outpatient
appointment. When there is a request from
referring physician, the phone call shall be
transferred to the consultant on-call

3.4 Outpatient registration

3.4.1 There is a standardized procedure for

outpatient
registration

3.5 Outpatient Consultation

3.5.1 ECG, Chest X-Ray and necessary blood tests

will be
22
 done if the patient does not have recent
reports.

3.5.2 Clinical evaluation requires medical history,

medication history, previous treatment and
physical examination
3.5.3 All the results of diagnostic tests will be
reviewed by the attending physician for
determining if the patient is to be admitted,
transferred, or referred

3.6 After the outpatient consultation, the patient will be

referred for

3.6.1 Outpatient follow-up appointment

3.6.2 Referral for elective surgery
3.6.3 Non Elective Admission for
a) Patient from outstation who prefers one visit
for consultation and treatment

3.6.4 The patient shall be discharged to the referring

physician
if he or she does not have follow up in PMC

3.7 Patient shall be informed when there will be a wait or

delay in
care and treatment. The patient shall be informed the
reasons for the delay or wait. This information will be
documented.

4.0 Responsibility
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 4.1 Physicians
4.2 Nurses
4.3 Allied Health
4.4 Front Office Registration Assistant

2.0 PROCEDURES ADMISSION

ACTIVITIES RESPONSIBILITY

2.1 ADMISSION

2.1.1 All ambulance patients entering hospital A & E Staff

should be provided with expedient attention
and care as soon as possible.

2.1.2 Patients who are experiencing difficulty in A & E Staff

24
 breathing, have unstable vital signs, in
severe pain or in a state of unconscious
must be attended immediately.
2.1.3 General
The patient should be protected of his legal
2.1.4 rights. Ward staff

All patients must be given an identification

2.1.5 band on admission. (In patient only) A+R Staff

Patients and relatives should be informed of

hospital rules and regulation e.g. visiting
hours and the hospital telephone number
2.1.6 should they wish to phone and enquire Ward Staff
about the patient.

2.1.7 All valuables and cash are referred to policy Ward Staff
on care of property.

2.1.8 All medication brought from home and A & E Admission

medic alert should be identified and noted Doctor / Ward
to physician. Staff
2.1.9
All admission should notify physician Sister /
immediately. Administrator On
2.1.1 Call
0
Patients with no relatives or unconscious, Ward Staff
next-of-kin should be notified via police.

On admission patient should be instructed

not to leave the ward area without
permission of ward sister or nursing staff
on duty.

ACTIVITIES RESPONSIBILITY
SRN / Nursing
2.2 TRANSFER OF PATIENT TO OTHER Supervisor
HOSPITAL.

25
2.2.1 Obtain approval from respective
consultant / medical officer on duty for all
patients to be transferred.

2.2.2 For patient transfer out of the hospital,

obtain referral letter from respective
consultant and release it as
below :-
a) To PAP / patient if by own transport
b) To accompanying nurse if using SRN
hospital ambulance facility.

2.2.3 Ensure that the referring consultant inform

the consultant concerned of the hospital
regarding the referral. SRN & Consultant

2.2.4 Explain and obtain consent from the patient

/ PAP regarding the reason of transfer.
Consultant
a) Transfer of patient to another hospital
is requested by PAP / patient, to issue
PMC 037. SRN

b) Either SRN / Ward aide must

accompany the patient if using Nursing
hospital facilities Supervisor /
E g: ambulance Medical officer on
2.2.5 duty.
Upon transfer of patient, to document and
complete the PMC 021. SRN

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DISCHARGE

1.0 Objectives

1.1 To ensure a smooth discharge process including

documentation,
medication,subsequent management plan, follow up
care and patient education.

2.0 Scope

2.1 General Wards

2.2 Day Care
2.3 Critical care areas

3.0 Policies and Procedures

3.1 Discharge planning is done early in the process of

patient
care depending on subsequent physician and nursing
assessment

3.2 The discharge process is initiated after the daily

physicians
ward round and upon agreement from the patients
response to treatment, clinical status and
investigation results (e.g. CXR, ECG,
echocardiography following cardiac surgery) allows
for patient to be managed at home by the family.

27
3.3 Family members shall be included in the discharge
planning.
They shall be informed once the discharge
decision/process is finalized.

3.4 The discharge process involves the following

3.4.1 Medications
3.4.2 Follow up appointment
a) Understandable follow up instructions are
given to patient and family.
b)The instruction include any return for follow
up care and when to obtain urgent care
c) MC when applicable
d)Letter of discharge summary when required
by the patient or PAP.
3.4.3 Subsequent management plan
3.4.4 Diet Counseling
3.4.5 Discharge summary / reply to referring
institution should be prepared by the attending
or designated physician. The discharge
summary includes the following information

a) Reason for admission

b)Diagnosis ( principal and secondary )
c) Relevant physical findings
d)Procedures done and copies of operative
notes
e) Hospital course and complications
f) Important investigation results
g)Condition upon discharge
h) Medications
i) Follow up instructions

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 3.5 Where possible, the discharge process must be
completed by 11am.
3.6 The discharge summary / reply shall be prepared in 2
copies.
3.6.1 A copy will be given to the patient at point of
discharge. If not completed at the time of
discharge, it will be the responsibility of patient
to collect it within 2 weeks.
3.6.2 A copy to be retained in the Patient Medical
Record.

3.7 PMC will help to arrange for transportation , or to

collect patients family or friends for transporting
,depending on the patients condition and status.

4.0 Responsibility

4.1 Physicians
4.2 Nurses
4.3 Physiotherapists
4.4 Dietitians
4.5 Billing clerk.
4.6 Pharmacist/Dispenser

29
 ACTIVITIES RESPONSIBILITY

2.3 DISCHARGE OF PATIENT

2.3.1 Obtain approval from respective consultant / medical SRN

officer on duty (with written evidence) for all patients
to be discharged.

2.3.2 Inform all the secondary consultants regarding the SRN

patient been discharged

2.3.3 Refer work instruction for nursing procedure, page 5-6 SRN/ward aids
as a guideline for discharge

2.3.4 Refer nursing policies & procedure 16.1 till 16.1.7, SRN/Nursing
page 28 for At Own Risk Discharge Supervisor

2.3.5 Discharging of patient who is absconded SRN

(a) Notify the primary consultant as soon as the
patient found missing
(b) To notify the next of kin / PAP/ police
(c) Attempt to locate the patient within 1 hour. If
still fail to locate within 24 hours, the patient
must be discharged by the consultant
(d) To notify the nursing supervisor on duty /
administrator on call

2.3.6 Upon discharge of patient, to document and complete SRN

30
 the PMC 021and click in I-Care system after alerted
by billing staff

2.4 PROCEDURES OF AT OWN RISK (AOR) DISHARGE

AND LEAVE PROCEDURE

31
 ACTIVITIES RESPONSIBILITY

2.4 At Own Risk Discharge

2.4.1 Confirm AOR discharge by doctors ordered. Doctor

2.4.2 Inform to Sister incharge and Public Relation Manager SN

during working hours.

2.4.3 After working hours, inform to administrator on call and SN

sister on duty.

2.4.4 To inform the other hospital doctor if requested by PAP / Consultant In Charge
patient with written referral letter before discharge.

2.4.5 Explain regarding AOR. Sister, SN

Get signature from PAP by using form PMC 037.

2.4.6 Refer flow chart of discharge patient.

2.4.7 Enter in AOR discharge / leave book. SN, Trained Nurse

At Own Risk Leave

2.4.8 Inform to consultant to obtain permission after requested SN

by patient / PAP

2.4.9 Explain regarding AOR Leave procedure SN

2.4.10 Get signature from patient / PAP by using form PMC SN

037 and confirm with patient / PAP of time back to unit.

2.4.11 Inform to insurance counter in charge if patient admit SN

under insurance

2.4.12 Supply indicated medication as prescribed in PMC 036 SN

2.4.13 If the patient did not return to the ward according to the SN
time granted;which should not be more than 24 hours Consultant In Charge
otherwise, it will be considered as Absconded
incident and the respective consultant is compulsory to
discharge the patient automatically.

FLOW CHART OF DISCHARGE PATIENT

32
 Receive order from doctor regarding
patient can discharge

Prepare as below: -

- TTA medication by consultant.

- Medication chart, nursing & doctor notes
with tickets and medication, patient in ward.
- TCA appointment card.
- Record/enter in all admission book.

During office hours After office hours

Inform ward clerk Inform A & R

Once bill ready

Inform patient to collect TTA and settle bill.

Produce green chit to ward staff (Ward Aids / SRN)

Remove name tag and off IV line and vasocan

Send patient by wheel chair to patients with patients property

3.0 POLICIES AND PROCEDURES OF CARDIAC PULMONARY ARREST

ACTIVITIES RESPONSIBILITY

33
3.1 Inform Doctor / Medical Officer Immediately SRN / Trained Staff

3.1.1 Push emergency trolley to the patients bedside. SRN / Trained Staff

3.1.2 Maintain airway and observe whether patient is SRN / Trained Staff
breathing. Observe vital sign of patient.

3.1.3 Carry out manual bagging or defibrillator if SRN / Trained Staff

indicated

3.1.4 Perform cardiac massage on the patient (CPR) SRN / Trained Staff
while waiting for the arrival of the doctor if
condition indicated.

3.1.5 Administer drug ordered by doctor and record in SRN / Trained Staff
PMC 175

3.1.6 Observe patient closely by monitoring the patients SRN / Trained Staff
vital signs and general condition.

3.1.7 Prepare patient for intubations if condition Doctor

deteriorates.

3.1.8 Inform family member by consultant when patient Doctor / Consultant

under DIL

3.1.9 Emergency case in A&E

Refer 2.1 Till 2.18

Refer Triage Accident & Emergency

Department : 2.4

3.2 FLOW CHART OF CARDIAC PULMONARY ARREST

Inform Doctor / MO immediately

34
Push emergency trolley to the patients bedside
 Carry out manual bagging / defibrillator

Initiate cardiac massage on the patient

Administer drugs ordered by doctor. Monitor the patients vital signs

and general conditions.

Observe patient closely Put on ventilator if patients

condition deteriorates.

Inform family member by consultant when patient under DIL

3.3 FLOW CHART FOR EMERGENCY CASES

Critical cases / emergency brought in to Putra Medical Centre

(PMC) by patients relatives using their own transport.

Patient to send in
ICUBring
underinthe Old
thecare
patient to 35 patient /
ofA&E
the concern
Dept. and start
consultant. process. simple Explain to the
resuscitation Regular patientcases
? patients
If Not relatives.
 Medical officer will examine the patient inside the car to
confirm whether the patient still alive or not.

Patient alive Patient dead

Survive

Yes No

Yes No

Issue the death Unknown

certification & cases
buried permit

Call up the
Ask patients
concern police and
relative to
inform the case
make police
and doctor
report by
handover the post
themselves
mortem letter to
pathologist GH
Body must dispose within 30
minutes to 1 hour. If not, Release the body to police
hospital will arrange undertaker when they arrive.
to take away.

3.4 Triage Accident & Emergency Department

1.0 POLICY

To ensure patients who arrive at the Accident & Emergency Department will be triaged and treated
promptly according to their need for emergency treatment and evacuation.

2.0 IMPLEMENTATION

36
 2.1 All patients that arrive at the Accident & Emergency Department shall be triaged by a
trained staff / medical officer on duty.
2.2 The triage nurse shall determine the appropriate code of triage based on the trained
personnel assessment of the patient.
2.3 The triage nurse must consult the medical officer on duty when it is unclear as to which
discipline the patient should be placed.
2.4 Patient who have been triaged GREEN may be allowed to be consulted in the respective
clinics or wait for consultation at the waiting area.
2.5 Patient arriving by ambulance is to be triaged by the ambulance nurse.

3.0 PROCEDURES

There are 3 levels of triage:

Critical: - RED (immediately)
Semi-critical: YELLOW (5-15 mins)
Non-critical: GREEN (16-30 mins)

Initially the triage nurse assesses the acuity level:-

Stability of vital signs.
Potential life, limb or organ threatened.
This is done based on the algorithm of BLS and ACLS.

Criteria for triage RED:

a) Cardiac arrest, respiratory arrest, severe respiratory distress SPO2<70%.

b) Overdose with respiration of < 10 per minute.
c) Severe brady/tachycardia with hypo perfusion.
d) Polytrauma
e) Chest pain, pallor and diaphoretic.
f) Anaphylactic shock.
g) Epilepsy.
h) Hypotension with hypo perfusion.
i) Hypoglycemia with change in mental status.
j) Baby or child that is flaccid.

Criteria for triage YELLOW:

a) Chest pain with? Coronary syndrome but stable vital signs.
b) Impending stroke
c) Ectopic pregnancy with stable haemodynamics.
d) Neurological compromised eg: sudden onset of confusion, disorientated and child drowsy.
e) Patient in severe pain with changes in vital signs changes eg: renal colic acute abdomen.
f) Compound fracture.
g) Closed fracture of femur.
h) Pelvic fractures

Criteria for triage GREEN:

a) Close fractures other than femur.

37
 b) Soft tissue injuries.
c) Urinary tract infection and upper respiratory tract infection.
d) Headache with no neurological changes.

Assessment also based on physiological changes and vital signs.

Adult Parameters:

Heart Rate SBP DBP GCS SpO2 Respiration Temperature

(bpm) (mmHg) (mmHg) (per 15) (%) (per min) (C)
60-100 100-140 60-90 13-15 >90 15-25 36.5-37.5
Green

40-59 70-99 40-59 8-12 70-90 10-14 37.6-40

Yellow 101-120 141-200 91-120 26-30 34-36.4

<40 <70 <40 3-7 <70 <10 <34

Red >120 >200 >120 >30 >40

Pediatric Parameters:

DANGER ZONE VITALS

Age Blood Pressure (SBP) Heart Rate Respiration Temperature
(mmHg) (bpm) (per min) (C)
0.1 Month <50 _ >200 >60
<100
1 month 1 year <60 >50
180
1 4 years <70 >100
<80 >40 >38.5 C
4 8 years <75
150
8 12 years <80 >140

** Indication of Poor Circulation : Cold to touch ,peripheral cyanoses & capillary refill > 3 seconds

38
3.5 POLICIES AND PROCEDURES PROCESS OF DECEASED BODY

ACTIVITIES RESPONSIBILITY

39
3.5.1 Certified death. Medical Officer or
Doctor In Charge

3.5..2 Explain to family the time and cause of death to family Doctor In Charge
members.

3.5.3 Complete document as below Staff Nurse

a) Borang Pengakuan Pegawai Perubatan
(JPN LM09)
b) Borang Permit Menguburkan (AM138-
pin a/78)
c) Daftar Kematian (JPN LM02)

3.5.4 Discharge procedure to be completed and send for billing Staff Nurse
process as soon as possible.

3.5.5 Arrange according to family request.

3.5.6 Perform last office in proper manner according to the culture Staff Nurse
and religion

3.5.7 Inform the family members to settle the bill. Staff Nurse

3.5.8 After receiving inpatient discharge release form (PMC 097) Staff Nurse
from family members, call for transportation.

3.5.9 Inform family members the above documents (3.5..3) must Staff Nurse
be sent to the registration office within 3 working days.

3.5.10 Send the deceased body with the transport as arranged

3.5.11 PAP to sign the below document before releasing the Staff Nurse
deceased body.
a. X-Ray if available
b. 3 document as stated above (3.5.3)
c. Patient property.
d. Panduan melapor kematian.

3.5.12 The deceased body should release by maximum of 2 hours. Staff Nurse

3.5.13 Send the body to body holding area if PAP unable to collect Staff Nurse
within 1 hour.

3.5.14 Release body to next of kin with documentation ( maximum A&E Staff Nurse
hours to clear the body is within 4 hours )

4.0 POLICIES AND PROCEDURES CARE FOR PATIENTS PROPERTY

ACTIVITIES RESPONSIBILITY

4.1 All patients admitted electively must be emphasized Admission Clerk

40
 not to bring valuable or excessive amount of cash to the
hospital by the booking personnel.

4.2 The patient at the time of admission is notified that the Admission Clerk/
hospital authorities cannot accept responsibility for
money and personal property unless they are handed Ward Staff
over to the authorities for safekeeping.

4.3 Record of patients properties

i) All properties received from the

patient must be recorded in the
patients property form, which must SN
be kept locked.

ii) One SN and a witness are to receive SN

and record patients properties.

iii) When listing down the patient SN

properties, it must be witnessed by
the patient and by another third party
(it can be patient relative or another
nurse).

iv) Below the signature of the nurse

receiving of the properties, the
patient and the witness, their full SN
name and I/C Numbers must be
clearly written for their purpose of
identification.

v) Care is taken to ensure that

descriptions of valuable are accurate SN
e.g. metal will be described by color
instead of diamond or gold.

ACTIVITIES RESPONSIBILITY

41
 4.4 Custody of patients properties.

i) Properties received must be wrapped

and labeled clearly with the following
particular :-
a) Name of patient
b) R/N, I/C no.
c) Date received

ii) Properties collected must be kept under

lock and key at all time. The key must
be kept by the medication SN of every
shift.

iii) Properties must be checked and handed

over from shift to shift.

4.5 Handling over patient properties

i) All properties must be returned to the
patient upon request / discharge
ii) The patient must sign in the patients
property form.
iii) The handling over procedure must be
witnessed and acknowledged by a third
party.

In case of death, the properties belonged to

the deceased must be surrendered to the
immediate relative and documented in
similar manner.

4.6 LOSS OF PROPERTY

4.6.1 During office hours the nursing staff must inform the
nursing in-charge who will inform the P.R. manager
for further investigations.

After office hours, the nursing staff on E shift must be

4.6.1.1 informed and she should fill up the incidence reporting
form PMC 140 and inform the sister on duty & the P.R.
manager A.S.A.P.

4.6.1.2 If it is after 10 pm, to inform the administrator/A & R

night supervisor on duty.

4.6.1.3 Advise patient to make a police report

5.0 POLICIES AND PROCEDURES FOR CHECKING EMERGENCY
TROLLEY
42
 ACTIVITIES RESPONSIBILITY

5.1
Check Emergency Trolley

Check emergency trolley every shift as listed in PMC049

5.1.1

Check for :-
5.1.2
a) Stock level
b) Expiry date
c) Par level of items listed SN, Trained Nurse
d) Working condition of each equipment
5.1.3
Check for presence of :-
a) Cardiac board
b) Drip stand

The above checking needs to be documented completely

5.1.4
and clearly.

43
 ACTIVITIES RESPONSIBILITY

5.2 Replenish of Emergency Trolley

5.2.1 Replenish trolley immediately after each use.

5.2.2 Replace drugs or disposables 3 month prior to expiry

date.( Utilize color coding)
SN / Trained Staff
5.2.3 Report to unit head of any malfunction of equipment.

5.2.4 Restore cardiac board and drip stand after use.

5.3 Care of Emergency Trolley

5.3.1 Check wheels of the trolley are functioning well.

Ward Assistant
5.3.2 Damp dust and keep trolley clean and tidy always

5.4 Position emergency trolley back to its place and ready for
use

FLOW CHART FOR CHECKING OF EMERGENCY

TROLLEY

44
 Daily Checking

Check items listed for :-

a) Stock level
b) Expiry date

Replenish Stock PRN

a) Replace expiring items
b) Report malfunction of equipment

Check floor chart emergency trolley correspond to

respective sections of the drawers

Document in Emergency Trolley Checklist for job done

Check for presence of cardiac board and drip stand

General cleanliness of trolley

6.0 POLICY & PROCEDURE FOR INCIDENT REPORT

ACTIVITIES RESPONSIBILITY

45
6.0.1 Inform to the doctor or primary consultant to SRN / HOD
review patient immediately upon incident
occur
6.0.2 SRN / Staff on
Inform to the head of department (H.O.D)
Duty
immediately or nursing supervisor on duty
during absence of the H.O.D
6.0.3
Obtained and documented the immediate
observation of patient involve as a baseline SRN
6.0.4
parameter in PMC 140
SRN / HOD
Continue monitor the patient accordingly to
6.0.5
the need of Observation

Issue incident occurred according to PMC 140 HOD

6.0.6
(Appendix Event Categories is attach as
reference )
SRN
6.0.7
Make sure the attending Doctor complete the
report after attended the patient
SRN
6.0.8
Make sure treatment been ordered is carry
out accordingly
SRN
6.0.9
Alert the incident to the investigation team
as soon as possible
HOD
Send the PMC 140 to Quality Assurance
department within 24 hours

INCIDENT REPORTING EVENT CATEGORIES

46
 The following categories are reportable events and near misses;

A) CLINICAL

Anaesthesia Event: An event that occurred in the process of receiving anaesthesia that caused harm or
had possibility of causing harm to a patient.
Surgical Event: An event that occurred in the process of any surgical procedure that caused harm or had
the possibility of causing harm to a patient.
Cardiology Event (Adult and Paediatric): An event that occurred in the process of receiving treatment
and procedure that caused harm or had possibility of causing harm to a patient.
Blood Administration: An event that caused or had the possibility of causing inappropriate blood product
administration. Such events may be related to professional practice, procedures and systems including, but
not limited to, ordering, labelling, dispensing, storage, administration and education.
Fall Event: An event in which a patient or visitor is on the ground as a result of an unplanned occurrence.
Medical Device: An event that includes any unintended functioning of any product, device, instrument, or
machine that is used to diagnose, treat, or prevent disease. This includes, but not limited to, implants,
infusion pumps, catheters, monitors, scopes and gauze pads. If event involves malfunction of Medical
Device, the Bio-Medical Engineering Department also must be informed.
Restrain / Seclusion: An event that caused or had the possibility of causing harm to a patient directly
related to the use of restrains or seclusions.
Treatment Delay: An event that caused or had the possibility of causing a delay in treatment and/or a
prolonged hospital stay. Such events may be related to procedures and systems including, but not limited
to, patient transportation, availability and scheduling of diagnostic tests, and timely ordering and processing
or orders.
Medical Records: An event that caused incomplete medical records such as missing specimen result, X-
Rays, notes, procedures report, surgical report or other patients medical record was found in another
patients medical record.
Nursing Care: An event that caused or had the possibility of causing harm to a patient directly related to
nursing care
Medication: An event that cause or had the possibility of causing inappropriate medication use or patient
harm while the medication is in the control of the healthcare professional, patient , or consumer. Such
event may be related to professional practice, healthcare products, procedures, and systems, including
prescribing, order communication, product labelling, packaging and nomenclature; compounding;
dispensing; distribution; administration; education; monitoring; and use.
Other: Miscellaneous event is an event that caused or had the possibility of causing harm to a patient /
visitor / staff. But that does not fit into any of the other clinical categories.

B) NON CLINICAL

Building and Non Medical Equipment: An event that caused disruption in hospital operation due to
malfunction of equipments such as interruption in telephone system/power supply, water leakage and
others.
Interpersonal conflict: Conflicts between staff and patient / family, staff and staff.
Security Lapse: An event that occurred due to security lapse.
Administrative Error: An event that occurred as a result of mistake in clerical and administrative process.
Miscellaneous: Miscellaneous event is an event that caused or had the possibility of causing harm to a
patient / visitor / staff. But that does not fit into any of the other event categories. Example; sexual
harassment, absconded.

47
 APPENDIX DEFINATION OF INCIDENTS REPORT

INCIDENT DEFINITION
( For All Locations )
Fall from any place e.g.bed,stretcher,chair or anywhere e.g.toilet,bathroom or while
Fall ambulating

wrong drug,dosage,formulation,route of administration,rate of administration,timing

Medication error of administration or diluting solution.Others include:omission or extra dosage of drug

wrong identification of investigation e.g.radiology,laboratory etc resulting in treatment

Investigation or procedure being carried out when it is not necessary or may even cause morbidity
error to the patient

Adverse outcome complication arising from a procedure resulting in morbidity or mortality

of procedure e.g.pneumothorax following Subclavian venous access,bleeding following liver biopsy
or OGDS,burn following defibrillation etc

Transfusion error wrong pack of blood or its products for the intended patient,expired blood

Needle stick injury caused by needle or sharp e.g.Scalpel blade.

injury contaminated with patient's blood

when a piece of equipment or instrument played a part in the morbidity or mortality

Equipment related e.g.ventilator failure causing hypoxic brain injury/death,electrocution,suction device
injury malfunction causing aspiration,cyclinder ran out of oxygen while transporting patient,
laser or diathermy burns etc.

Birth Injury caused by instruments e.g. forcep and mismanagement by health care team

( For OT use )
Cardiac / respiratory any cardiac or respiratory arrest that occur intra-operative or in recovery room
arrest

Wrong procedure procedure or surgery carried out which was different from what was intended
performed e.g.wrong limb being operated on,wrong space for laminectomy etc

Wrong patient operated

upon
Unplanned return to the e.g.relaporatomy to secure homeostasis following Cholecystectomy.Does not include
OT within 24 hours planned procedure e.g.removal of pack after laporatomy with abdominal packing done
surgery or staged procedure e.g.disloughing for burns

Incorrect surgical count e.g.gauze,sponge / instruments / needle

48
6.2 POLICIES AND PROCEDURES NEEDLE STICK INCIDENT

ACTIVITIES RESPONSIBILITY

6.2 Needle Stick Incident

6.2.1 Staff pricked by sharp.

Staff involved
6.2.2 Perform first aid squeeze the blood from puncture
site immediately.

run under tap water.

6.2.3 Staff involved to inform sister in charge / senior staff

during sisters absent

6.2.4 Inform the infection control nurse. SN / Sister In charge

6.2.5 Staff involved to see medical officer immediately. Infection Control

Nurse / Sister In
Charge

6.2.6 Fill up the incident reporting form together with staff

involved and submit to QA.

6.2.7 Inform the infection control doctor regarding the Medical Officer
incident.

6.2.8 Refer the case back to the infection control Doctor for
further investigation and follow up.

6.2.9 The incident will take over by infection control Doctor

for follow up.

6.2.10 Refer Putra Medical Centre Guidelines on the control All employees
of hospital acquired infection flow chart for needle
stick incident page 43.

49
7.0 POLICIES AND PROCEDURES STOCK REQUISTION

ACTIVITIES RESPONSIBILITY

1. Check the stock in hand and balance. In Charge

2. Fill in the request form- Icare system In Charge

3. Send the request form to storekeeper as schedule In Charge

4. Receive the stock and check as ordered. SN

5. Keep stock in respective storage areas. SN / WA

FLOW CHART OF STOCK REQUISITION

Check stock in hand and balance

Fill in request form/Icare

Send request form to storekeeper as schedule

Receive stock and check

Keep stock in respective storage areas

50
7.1 POLICIES AND PROCEDURES OF UNCONTROLLED DRUGS

ACTIVITIES RESPONSIBILITY

7.1 Storage of Uncontrolled Drug

7.1.1 Store drugs as indicated by manufacturer SRN

7.1.2 Store drugs in fridge, medication trolley / patients

individual slot and lotion cupboard for all under
external use only.

7.1.3 Keep storage place clean always

7.2 Replenish of Uncontrolled Drugs (stock)

7.2.1 Replenish daily Dispenser

7.2.2 Check stock balance / par level before indenting.

7.2.3 Use uncontrolled drugs requisition form (PMC 082) for SN

indenting.

7.3 Document of Drugs

7.3.1 Write drugs strength dosage of drugs in medication SN In Charge

chart as per column provided. Medication

7.3.2 Initial in respective frequency column upon SN In Charge

administration to patient. Medication

7.4 Unit Dose Drugs

7.4.1 Indent non stock drugs from pharmacy using SN

medication chart

7.4.2 Check number of drug supplied whether tally with SN

number written in quantity column in medication chart.

7.4.3 Return all non stock drugs to pharmacy on the same

day when a patient is discharged.

51
 FLOW CHART FOR UNCONTROLLED DRUGS

WARD

Storage :-
a) Fridge
b) Medication Trolley stock individual slot
c) Lotion cupboard

Replenish daily
a) Stock
b) Non stock (unit dose)

Documentation Medication Chart

7.5 POLICIES AND PROCEDURES OF CONTROLLED DRUGS

52
 ACTIVITIES RESPONSIBILITY

7.5.1 Checking of Controlled Drugs

(Injectables and Oral Drugs)
SRN In Charge
7.5.2 Check DDA drugs every shift for the balance of each Medication / Trained
drug as documented in DDA Record Book Staff

7.5.3 Check drugs expiry date (if expiry date is 3 months

before due date send to Pharmacy for exchange).

7.5.4 Passing Over of Controlled Drugs

Pass over from shift to shift regarding drugs used and
amount balance.
SRN In Charge
7.5.5 Check and receive the balance of all dangerous drugs Medication / Trained
and document in DDA Record Book. Staff

Keeping And Storage of Dangerous and

Psychotropic Drugs

7.5.6 Keep drugs in DDA cupboard with double lock at all

times

7.5.7 Keep DDA par level at all times. SN In Charge

Medication / Trained
7.5.8 Keep empty ampoules for exchange. Staff

7.5.9 Any broken / missing dangerous drug ampoules to be

reported immediately to pharmacist in charge Sister, SN

ACTIVITIES RESPONSIBILITY
53
 Recording of Controlled Drugs

7.5.10 Immediately document any drugs used. SN In Charge

Medication / Trained
7.5.11 Document the following particulars :- Staff

a) Name of patient
b) Registration number of patient
c) Date and time administered
d) Specify drugs and dosage given
e) Stock balance of the drug
f) Name and initial of SN who has given the
drug
g) Name of consultant who ordered drug
h) Two SN to counter check

7.5.12 Document drugs and dosage in patients medication

chart. Document time given. For outpatient: record
in patients case note.

7.5.13 Refer Centralized Psychotropic flow chart for

overall handling

7.5.14 Replenishment of Controlled Drugs Indenting SRN In Charge

Medication / Trained
7.5.15 Indent drugs in DDA indent book. Write in balance Staff
and the amount required.

7.5.16 Send the following items to Pharmacy when

indenting :-

a) DDA indent book

b) DD Record Book
c) Empty ampoules of injectables

7.5.17 Follow indent schedule as given by the Pharmacist.

54
 ACTIVITIES RESPONSIBILITY

Collection of Drugs

7.5.18 Check the following when collecting drugs from SRN In Charge
Pharmacist:- (SRN to collect drugs) Medication / Trained
Staff
a) Amount supplied tally with requisition
note
b) Total of drugs supplied

7.5.19 Sign at the following columns to indicate receipt SRN In Charge

of correct amount Medication / Trained
Staff
a) DDA indent Books
b) DDA Record Book

Keep and store drug in DD cupboard under double

7.5.20 lock.

55
FLOW CHART FOR MANAGEMENT OF CONTROLLED DRUGS (CHECKING DRUGS)

Checking Of DD during the Passing Over

Check all DD balance tally with amount in DD Record

Book

Lock DD & PD in cupboard

DD key kept by SN / trained staff

56
7.6 POLICIES AND PROCEDURES STORING LIVE VACCINE

ACTIVITIES RESPONSIBILITY

7.6.1 Receiving Life Vaccine

7.6.1.1 Nursery staff will order in pharmacy requisition form Trained Staff
for live vaccine.

7.6.1.2 Collect the live vaccine from pharmacy in the prepared Trained Staff
cold chain bag

7.6.2 Storage of Live Vaccine

7.6.2.1 Store in compartment temperature of 2c to 8c.

7.6.2.2 To check temperature of the fridge two times a day and Trained Staff
record it in the fridge temperature chart.

7.6.2.3 If any changes in temperatures, the sister in-charge Trained Staff

must be notified immediately.

7.6.2.4 All live vaccine is to be disposed after use in a sharp Trained Staff
bin.

7.6.2.5 Ensure the temperature of the fridge is maintained at Trained Staff / Sister
2c to 8c. In Charge

57
8.0 POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION

ACTIVITIES RESPONSIBILITY

8.1 Diagnosed by the consultant in-charge with Consultant In Charge

supporting investigation results (X-Ray, blood result)
if available

8.2 Patients particulars in notification form to be filled Trained Nurse

up.

8.3 Notification form (Borang : Health 1 Rev 2001) must Consultant In Charge
be completely filled up regarding the final diagnosis

8.4 Notification form must be stamped with the PMC SN

chop and signed by the consultant on the lower left
side corner of the form.

8.5 Notify the Public Health Inspector (PHI) on call SN

through the nearby state health office by phone or fax
stat, when indicated.

8.6 Dispatch the original copy to the nearby State Health Office Assistant/Sr.
Office (SHO). To notify online first. Incharge

8.7 Carbon copy must be kept in patient file / ticket.

SN
8.8 Notification chop must be stamped in the admission
card inside the patients file & PMC 022 SN

58
 FLOW CHART

DIAGNOSIS

NOTIFICATION FORM
(COMPLETELY FILLED UP)

NOTIFY STATE HEALTH

OFFICE BY FAX OR PHONE

ORIGINAL COPY CARBON COPY (KEPT IN

(DESPATCH TO SHO) PATIENTS OFFICE)

NOTIFICATION CHOP STAMPED IN

PATIENTS FILE / TICKET (ADMISSION
CARD)

9.0 POLICIES AND PROCEDURES RENTAL OXYGEN TANK

59
 ACTIVITIES RESPONSIBILITY

9.1 Renting of Oxygen Cylinder

9.1.1 Received phone call regarding rental of oxygen Staff Nurse

cylinder.

9.1.2 Prepare the items as below :- Staff Nurse

i) Oxygen cylinder according to the request.
ii) Flow meter.
iii) Stand for oxygen cylinder
iv) Precaution from for home oxygen use.

9.1.3 Explain the rental procedure to the person concerned. Staff Nurse

9.1.4 Fill in rental oxygen form in double copy and confirm Staff Nurse
the size of oxygen tank before filling up.

9.1.5 Bring the person concerned to billing department to Ward Aid / Staff Nurse
collect deposit as below.
i) Size E RM 1200.00 deposit and the usage is
RM 280.00.
ii) Size F RM 1800.00 deposit and the usage is
RM 490.00.

9.1.6 Send original copy to billing department and duplicate Ward Aid / Attendant
copy will keep in A&E.

9.1.7 After office hours the collection of deposit will be Admission Clerk
carry out by admission counter.

9.1.8 The person concerned to be reminded to keep the

receipt of payment.

ACTIVITIES RESPONSIBILITY
60
9.2 Returning of Oxygen Tank

9.2.1 Received phone call from admission counter regarding Staff Nurse
returning of oxygen tank.

9.2.2 Receive empty tank in proper condition and send to Staff Nurse / Ward
maintenance for refill. Assistant

9.2.3 Bring the person concerned to billing department to Ward Aid / Staff Nurse
collect deposit with the duplicate form.

9.2.4 After office hours the deposit to be collected the next Billing Clerk
working day.

61
10.0 POLICIES AND PROCEDURES IN MAINTENANCE REQUISITION

ACTIVITIES RESPONSIBILITY

10.1 Confirm the faulty equipment. Sister, Staff Nurse,

Midwife

10.2 Fill up the maintenance request form, PMC 051 Sister, Staff Nurse,
Midwife

10.3 Dispatch PMC 051 to the maintenance department. Female Attendant

10.4 Maintenance staff comes to the ward to check the

equipment.

10.5 Repair is to be done stat if is possible. Maintenance Staff

10.6 If repair cannot be done in the ward, then the Female Attendant
equipment has to be sent to the maintenance
department.

10.7 Once the job is completed, the staff from maintenance Maintenance Staff
department will fill up the last part of the form as
evidence that job has been done.

62
11.0POLICIES AND PROCEDURES CARE OF PATIENT UNDERGOING RADIOGAPHIC AND
OTHER IMAGING STUDIES

ACTIVITIES RESPONSIBILITY

11.1 Preparation For The Examination

11.1.1 Patient must be informed of the Radiographic / Doctor

Imaging Studies planned for him.

11.1.2 All requests for Radiographic and Imaging Studies Doctor, SN

must be ordered by the attending doctor and completed
request form (PMC 058) with signature.

11.1.3 PMC 058 to be sent to X-Ray Department A.S.A.P Ward Assistant /

Female Attendant

11.1.4 Ensure that all specific preparation and investigation Staff Nurse
(if any) are carried out accordingly.

11.1.5 All previous X-Ray films must accompany patient Staff Nurse
when going for subsequent Radiographic / Imaging
Studies.

11.1.6 Ensure that all female patients are not pregnant before Staff Nurse /
any radiographic examination. If a patient is suspected Radiographic
to be pregnant, it must be notified to the doctor for
further instruction.

11.1.7 All female in-patients must change into hospital gown, Staff Nurse
have jewellery and bras removed if the radiographic
examination is required on the upper part of the body.

63
 ACTIVITIES RESPONSIBILITY

11.2 Transportation Of Patient For Radiographic /

Imaging Studies.

11.2.1 Assess the condition of patient to determine the type of Staff Nurse
transportation suitable for the patient.

11.2.2 All patients with intravenous therapy can be sent down

to radiology department when call.

11.2.3 Decide if ill cases need a staff nurse or ward aid to SN, Sister
accompany throughout the examination.

11.3 Patient Undergoing Radiographic Examination

Using Radiopaque Contrast Medium.

11.3.1 Obtain history for any indication of allergies that might SN

cause an adverse reaction to the contrast medium.

11.3.2 Obtain consent from patient if indicated Doctor

11.3.3 Be encouraged to take plenty of fluid (if there is no SN

contraindication) following administration of
radiopaque contrast medium.

64
 ACTIVITIES RESPONSIBILITY

11.4 Ultra Sound Examination

11.4.1 Abdomen and liver, gall bladder and pancreas. Ward Aid, Female
Patient must be fasted from midnight or at least 4 Attendant
hours before the examination. For afternoon
appointment, breakfast is allowed then nothing by
mouth thereafter. N. B. Infant no preparation is
required.

11.4.2 Kidney, thyroid glands and liver only. No preparation SN

is required.

11.4.3 Organs in the pelvic cavity. A full urinary bladder is SN, Trained Nurse
required. Patient is advised to take plenty of fluid if
there is no contraindication.

11.5 Magnetic Resonance Imaging (MRI)

11.5 .1 Send PMC 058 to X-Ray department as requested SN

Confirm with X-Ray coordinator regarding the
appointment date and time.

11.5.2 Patient is advised to remove all metal items / SN

jewellery from the body.

11.5.3 All patients are to change into MRI gown. WA

11.5.4 Nurse in charge is to do MRI checklist before SN

sending patient down with MRI stretcher / wheel
chair for MRI procedure.

11.5.5 N.B. For Infant, uncooperative children and restless

patient, sedation may be necessary as ordered by the
Doctor.

65
12.0 POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE

ACTIVITIES RESPONSIBILITY

12.1 Types of Clinical Waste

12.1.1 Segregate clinical waste in appropriate groups :- SN

a) Sharps and objects
b) Clinical waste

12.2 Disposal of Sharps and Objects

12.2.1 Discard sharp instrument and objects e.g. syringes, SN

needles cartridges and scalper blades into sharps
container.

12.2.2 Do not re sheath or re-cap before discarding into

sharp bins.

12.2.3 Do not leave used sharps lying around

12.2.4 Never fill sharp container more than two-third full.

12.2.5 Ensure that sharp containers are securely closed

before disposal.

12.2.6 Replace with new sharp container as soon as

possible. H / Keeping Personnel

12.2.7 Place 2/3 full sharp container into clinical waste

carriage H / Keeping Personnel

12.3 Disposal of Clinical Waste

SN
12.3.1 Discard the bellow item listed clinical waste into
yellow bag e.g. soiled surgical dressing, cotton SN
wool, gloves, swabs material used to clean spillage.

66
 ACTIVITIES RESPONSIBILITY

12.3.2 Never fill yellow bag more than full SN

12.3.3 Tie the bag with plastic seal H / Keeping Personnel

12.3.4 Tag with label and send to clinical waste carriage at H / Keeping Personnel
holding area

12.3.5 Replace with new clinical waste bag into bin H / Keeping Personnel

FLOW CHART OF CLINICAL WASTE

WARD

SHARPS CLINICAL WASTE

e.g. a) Dressings
b) Drains
Discard into Sharp Bin
Dispose into Yellow Bag
Seal Sharps Bin When 2/3 full when full with the
sealer

Discard sealed sharp bin by Housekeeping

to clinical waste carriage at holding area Seal Yellow Bag when
full with the sealer

Replace sharp bin by Housekeeping

Dispose into clinical waste
carriage (Yellow Bin) as
supply by company at holding
area by Housekeeping

Replace Yellow Bag by Housekeeping

Housekeeping Personnel to Dispose into Clinical

Waste Carriage

13. 0 POLICIES AND PROCEDURES MANAGEMENT OF BLOOD GROUP AND

CROSS MATCH PROCEDURE
67
 ACTIVITIES RESPONSIBILITY

15.1. GXM ordered by the doctor. Doctor

151.1. Patients particular in GXM form (PMC 071) Trained Nurse

(original and CC) can be filled up by the trained
Nurse (e.g. full name, 12 digit IC no / passport no,
RN, etc).

151.2. Patients diagnosis and reason for request must be Doctor

clearly stated and signed the PMC 071.

15.1.3 Inform the laboratory technician for requested test /

procedure.

15.1.4 In any case that theres no available supply in the Laboratory Technician
center to be informed to ward staff stat

15.1.5 Inform the doctor stat SN

15.1.6 Send second set of PMC 071 for the doctor concern SN, Doctor
to sign.

15.1.7 To call the blood bank in-charge in General Doctor

Hospital Alor Star (GHAS) to inform the needs and
request of the supply urgently.

15.1.8 Document the exact date and time in PMC 071 Doctor

15.1.9 The 2nd PMC 071must be sent to laboratory stat Doctor, SN

after the necessary requirements has be arranged

FLOW CHART

68
 DOCTORS ORDER

GXM FORM
(COMPLETELY FILLED UP)

INFORM LABORATORY TECHNICIAN

SUPPLY AVAILABLE SUPPLY UNAVAILABLE

PROCEED WITH - Send 2nd GXM form to the doctor
TRANSFUSION AS DOCTORS concern and arrange with blood bank
ORDER GHAS in charge
- Write the exact date & time in PMC
071

SEND THE 2nd GXM FORM TO LAB

BLOOD SUPPLY AVAILABLE

PROCEED TRANSFUSION AS
DOCTORS ORDER

69