Patient Safety

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BATANES GENERAL HOSPITAL

NURSING SERVICE
AUDIT CHECKLIST
AREA: _________________________________ DATE:
________________________________
Factor PATIENT SAFETY GOALS (PSG) YES NO N.A. REMARKS
#2
I IDENTIFY PATIENT’S CORRECTLY
Patient identified
 Wrist band (Pink for female and blue for
male)
 Bed tag
Laboratory specimens properly labelled
Diagnostic results with correct patient's data

II PROPER AND EFFECTIVE COMMUNICATION YES NO N.A. REMARKS


Observed right procedure in taking down
verbal / telephone order of doctor
Observed information privacy and
confidentiality
Proper communication with:
 Patient
 Co-staff
Plan of care explained to patient and family
Physician’s orders documented clearly, timed,
signed and carried out
Uses standard abbreviations, acronym and
symbols
Prompt referral of critical diagnostic test result
s

III SAFETY ON MEDICATIONS YES NO N.A. REMARKS


Physician’s orders documented clearly, timed,
signed and carried out
Medication prescription complete
Medications written legibly on medication
cards, medication record and Kardex
Emergency medications complete, available,
monitored (expiration dates checked), labelled
and stored safely (E-cart)
Drug allergies identified
IVF and Side drip properly labelled (with IV tag)
Observed the 10 medication rights
1. Right patient
2. Right drug
3. Right dose
4. Right route
5. Right time
6. Right documentation
7. Right patient education
8. Right assessment
9. Right to refuse
10.Right evaluation
IV SURGICAL CARE / ENSURE CORRECT SITE, YES NO N.A. REMARKS
CORRECT PROCEDURE, CORRECT PATIENT
SURGERY
Accomplish the pre-operative checklist before
surgical procedure
Re-evaluation of patient and medical record
done by the doctor and nurse before surgery
Pre-anesthesia assessment performed prior to
induction of anesthesia by the anesthetist
Verification process for the site, procedure and
position done before the induction
OR nurse accomplishes the surgical safety
checklist after the procedure

V REDUCE RISK OF HEALTHCARE YES NO N.A. REMARKS


ASSOCIATED INFECTIONS (HAI)
Practice proper hand hygiene
Hand hygiene items available (Alcohol,
Antibacterial liquid or bar soap, hand sanitizer)
Health education to patient and relatives
regarding infection control
HAI precautions observed:
 Pneumonia precaution
 Pressure sore precaution
 Foley catheter associated infection
precaution
Wound treatment done as ordered

VI REDUCE RISK OF PATIENT HARM YES NO N.A. REMARKS


RESULTING FROM FALLS
Side rails of stretchers/bed up during transport
Patient's bed functional (can be adjusted /
positioned) and with functional side rails and
up when occupied
Physician’s order on use of restraint to patient
Restraints or protective devices applied in safe
and comfortable manner to applicable patients
and with consent
Functional stretchers with side rails and
wheelchairs (wheels tight, and wheel chairs
with footrest and functional break)
(Concurrent)
Patient’s articles within reach (Concurrent)
24-hour watcher for suicidal, depressed,
withdrawal and psychiatric patients
Floors free of debris, spilled liquids and
hazardous equipment (Concurrent)

VII AMBULANCE CONDUCTION YES NO N.A. REMARKS


Equipment and emergency medicines inside
the ambulance complete
Ambulance conduction form properly
accomplished

VIII TRANSFUSION OF BLOOD AND BLOOD YES NO N.A. REMARKS


COMPONENTS
Physician’s orders documented clearly, timed,
signed and carried out
Consent form for transfusion of blood and
blood components secured prior to the
procedure
Checks availability of the cross matching form
Observed therapeutic measures for adverse
reaction and nursing considerations before,
during and after the transfusion
Proper documentation

IX IV CANNULATION YES NO N.A. REMARKS


Physician’s orders documented clearly, timed,
signed and carried out
Materials (iv tubing, size of iv cannula)
appropriate with patient's age and condition
Site of insertion and vein selection considered
Proper documentation

X INFECTION CONTROL YES NO N.A. REMARKS


Practice proper hand hygiene at all times
All PPEs are available for use
Perform proper cleaning and disinfection of
instruments, equipment and room
Soiled linens properly segregated in a clean
covered bin
Linens undergo proper cleaning and
disinfection
Proper waste segregation / disposal
Proper disposal of sharps and needles
Aware of needle stick injury protocol
Signage for isolation precaution outside the
isolation room /ward
Orientation to patient's relatives regarding
precautions for patients in isolation room
All patients with known / suspected diseases
isolated appropriately

XI TIMELINESS OF SERVICE DELIVERY YES NO N.A. REMARKS


Assessed and re-assessed at appropriate time
intervals to determine response and to plan for
continued treatment for discharge
All diagnostic results available in a timely way
Are the following administered /done properly
and on time?
1. Medication
2. Feeding per NGT
3. Wound dressing
4. Transport of patient
5. Admission and discharge process
6. Pharmacy medication dispensing
7. Request for repair of equipment

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