HOSPITAL HAZARDS

INTRODUCTION
One of the duties of Hosp Administrator is to ensure
safety and protection of patients, staff and visitors who
come to visit the hospital.

Operational activities involve dealing with

Infectious materials
Dangerous drugs
High voltage electric eqpt
X Ray radiations
Explosive gases
 FUNCTIONS OF HOSPITAL

Diagnosis
Treatment
Rehabilitation
Education
Research
 Types of Hospital Hazard
Cross Infection.
Operation Theatre
Radiation Hazard
Blood Transfusion
Fire Hazard
 OTHER HAZARDS
Errors in Medication
Errors in Identification of New Born Baby.
Errors in Compounding & Dispensing Drugs in the
Pharmacy
Falls & Accidents
Accidents from Heavy Machinery
Food Poisoning
Collapse of Building
 CROSS INFECTION
Increase in Diagnostic & Therapeutic Procedures
requiring Instrumentation.
Prolonged & Increasing Number of Complicated
Surgical Interventions
Indiscriminate Use of Antibiotics Production of
Drug Resistant Strains
IV Invasion Increase in use of IV Route
Susceptibility of New Born Baby & Children to
Infection
 Prevalence of Hospital Acquired Infection - 1-
20% of all admitted patients
Half occurs in surgical patients and the rest in
paediatric, obstetric and other patients.
Hospital staff are potential links in the chain as
well as carriers of this infection
Most of the cross infection cases occur due to
Human indifference
Carelessness in adopting the well established
methods and techniques of antisepsis and asepsis
Poor sanitary environment in the hospitals
 OT : HAZARDS

Hazards of Explosion
Hazards of Infection
Cardiac Arrest
Fire Hazards
Infusion/Transfusions
 OT : Hazard of Explosion
Anaesthetic gases prone to accidental fires/ explosions
Heavier than air & sink down with max concentration
at 3-4 feet.
Source of Ignition
Heaters
Suction machines
Cautery
Window Airconditioner
Various Switches
Static Electricity
 OT - Safety Precautions
Conductive flooring - Copper / Aluminium strips.
Avoidance of nylon and wool use of cotton
blankets
Proper Grounding / earthing of all eqpt.
Effective Air Conditioning - 50% humidity and 16
- 18 air changes.
Safety Switches with no chance of spark.
Electric outlets at the height of 6 ft or above.
Proper maint of all electrical eqpt to avoid sparks.
 OT - Infection Hazards

Proper design with zoning

OT Discipline
Highest standard of Aseptic techniques &
Sterilisation
Periodic inspection & maint of Autoclaves
Proper & periodic fumigation
Sterility Tests Culture Swabs
 OT Hazard Cardiac Arrest

Cardiac Arrest Alarm system whereby senior Surgeon/

Anaesthetist rush to affected OT
Training of all Surgeons to do thorasic & cardiac
massage
Availability of Cardiac Arrest Tray with sterile eqpt
Availability of Cardiac Defibrillator in OT &
Recovery Room
 OT - Other Safety Precautions
Proper Identification of Patient, the Limb or the
Operation Site
Sponge & Instrument Count
Identification of Gas Cylinders
Oxygen - Black body white cap
Carbon Dioxide - Grey
Nitrous Oxide - Blue
Ethylene Magenta
Repainting of cylinders is prohibited
 Radiation Hazards
Proper design & construction as per AERB guidelines
Periodic inspection & check of all radiation eqpt
Edn & training of staff in use of machines & safety
precautions lead apron/ gloves
Film Badge Service (TLD Badges)
Periodic medical examination & blood counts
Regulation of working hours
Electric hazard precaution high voltage
 Blood Transfusion Hazards
Judicious use of blood as per Laid down policies
Existence of SOPs and adherence to the same
Reaction forms filled in after transfusion
Even minor reaction adequately investigated
All laid down procedures are followed as per SOP
No undue delay between issue & transfusion
Reaction forms are being filled regularly
Instruction regardingaction on occurrence of reaction being followed
Technicians are careful in grouping and cross matching
All mandatory safety tests (HIV, Hepatitis, STD,Blood Parasite) are
being carried out
 COP.5
Policies and procedures define rational use of
blood and blood products

Objective elements
a) Documented policies and procedures are used to
guide rational use of blood and blood products
b) The transfusion services are governed by the
applicable laws and regulations

16
 Cont

c) Informed consent is obtained for donation and

transfusion of blood and blood products
d) Informed consent also includes patient and family
education about donation
e) Staff is trained to implement the policies
f) Transfusion reactions are analyzed for preventive and
corrective actions

17
 Fire Hazard
Susceptible to fire
Multifarious activities
Use of Electric eqpt
Use of Gases
Storage of inflammable & combustible material
Restricting spread of fire
 Minimizing chances of fire.
Proper design & construction using fire proof
structures, fixtures & materials
Proper storage combustible material- X-ray
films, gases & chemicals
Regular maint of machines & electric eqpt.
Proper collection storage and disposal of waste.
General tidiness & cleanliness
Fire compartmentation
 Early Discovery of Fire
Smoke & fire detectors
Alarm system in all functional areas
Restricting Spread of Fire
Evacuation of the occupants
Closing all doors & windows
Isolation of rooms, wings & floors possible only if
designed that way
Use of transverse fire resistant partitions
Patient evac ambulatory, wheel chair & stretcher patients
Extinguishing the fire Adequate No. of Fire Points, regular
fire drill
 CAUSES OF FIRE

(a) INDISCRIMINATELY THROWING OILY RAGS,

CAUSING SPONTANEOUS COMBUSTION.

(b) CARELESS AND UNRESTRICTED SMOKING.

(c) NON-EXTINGUISHING OF NAKED LIGHTS.

(d) NOT TURNING OFF ELECTRICAL MAINS.

(e) ACCUMULATION OF RUBBISH

(f) STORING OF PACKING MATERIAL/SAW DUST

NEAR STORES HOUSES.
(g) IMPROPER COOK HOUSES.

(h) IMPROPER USE OF BUKHARIES,

STOVES OIL WICKLESS,
LAMPS INCANDESCENT.

(j) INCORRECT STORAGE OF FOL,

PAINT AND OILS.

(k) IMPROPER VENTILATION OF

STORE HOUSES.
 PREVENTIVE MEASURES
(a) NO OILY RAGS OR OTHER COMBUSTIBLE
MATERIAL IS LYING IN STORE HOUSES
OR AROUND IT.
(b)ALL DOORS, WINDOWS AND VENTILATORS OF
THE STORE HOUSES, OFFICES SHOULD BE
SECURELY CLOSED.
(c) LIGHTING CIGARETTES/BIDI ENDS SHOULD
NOT BE LYING AROUND.
(d)ALL NAKED LIGHTS SHOULD BE COMPLETELY
EXTINGUISHED.
(e) ALL ELECTRICAL SWITCHES INCLUDING MAIN
SWITCH SHOULD BE TURNED OFF.
(f) BUKHARIES, KEROSENE OIL OR WOOD
BURNING SHOULD NEVER BE LEFT
UNATTENDED.
(h)GRASS AND UNDERGROWTH SHOULD BE
CLEARED.
(j) PAINTS AND OILS MUST BE HANDLED WITH
CARE AND STORED PROPERLY IN PITS.
(k)SMOKING OR NAKED LIGHTS NEAR FOL
STORES SHOULD BE STRICTLY PROHIBITED.
(k)COMBUSTIBLE STORES LIKE PACKING
MATERIAL, RUBBER,CELLULOID SHEETS,
FILMS (NITRO-CELLULOSE) MUST BE STORED
CAREFULLY, SHOULD NOT BE MIXED.
 CAUSES OF FIRE

(a) INDISCRIMINATELY THROWING OILY RAGS,

CAUSING SPONTANEOUS COMBUSTION.

(b) CARELESS AND UNRESTRICTED SMOKING.

(c) NON-EXTINGUISHING OF NAKED LIGHTS.

(d) NOT TURNING OFF ELECTRICAL MAINS.

(e) ACCUMULATION OF RUBBISH

(f) STORING OF PACKING MATERIAL/SAW DUST

NEAR STORES HOUSES.
 PREVENTIVE MEASURES
(a) NO OILY RAGS OR OTHER COMBUSTIBLE
MATERIAL IS LYING IN STORE HOUSES
OR AROUND IT.
(b)ALL DOORS, WINDOWS AND VENTILATORS OF
THE STORE HOUSES, OFFICES SHOULD BE
SECURELY CLOSED.
(c) LIGHTING CIGARETTES/BIDI ENDS SHOULD
NOT BE LYING AROUND.
(d)ALL NAKED LIGHTS SHOULD BE COMPLETELY
EXTINGUISHED.
(e) ALL ELECTRICAL SWITCHES INCLUDING MAIN
SWITCH SHOULD BE TURNED OFF.
(f) BUKHARIES, KEROSENE OIL OR WOOD
BURNING SHOULD NEVER BE LEFT
UNATTENDED.
(h)GRASS AND UNDERGROWTH SHOULD BE
CLEARED.
(j) PAINTS AND OILS MUST BE HANDLED WITH
CARE AND STORED PROPERLY IN PITS.
(k)SMOKING OR NAKED LIGHTS NEAR FOL
STORES SHOULD BE STRICTLY PROHIBITED.
(k)COMBUSTIBLE STORES LIKE PACKING
MATERIAL, RUBBER,CELLULOID SHEETS,
FILMS (NITRO-CELLULOSE) MUST BE STORED
CAREFULLY, SHOULD NOT BE MIXED.
 CAT OF FIRE FIGHTING EQPT

(a) MAJOR FIRE FIGHTING FIGHTING EQPT

(i) EXTENSION LADDER 10.5 METER.

(ii) TRUCK FIRE FIGHTING LARGE MK II.
(iii) TRAILER FIRE PUMP LARGE.
(iv) FB 10X (NEW MODEL).
(v) FB 5X
(vi) FIRE ENTRY PROXIMITY SUIT.
(vii) COMPRESSED AIR TYPE BREATHING
APPARATUS.
(viii) FOAM PROPORTIONER.
(ix) ELECTRIC SIREN
(x) HOSE BUILDING MACHINE.
MINOR FIRE FIGHTING EQPT

(a) PORTABLE WATER CO2 EXTINGUISHER

OF 9 LTR CAPACITY WITH CO2 GAS CAT RIDGE.

(b) PORTABLE WATER STORED PRESSURE

TYPE EXTINGUISHER 8 LTR CAPACITY.

(c) CHEMICAL FOAM EXTINGUISHER OF

9 LTR CAPACITY.

(d) MECHANICAL FOAM EXTINGUISHER OF

9 LITRE CAPACITY, WITH CO2 GAS CAT RIDGE
COUPLED WITH HOSE AND FOAM

(e) BCF EXTINGUISHER OF 1.25 KG CAPACITY

(f) PORTABLE DRY POWDER EXTINGUISHER

(g) PORTABLE CO2 EXTINGUISHER

(h) BUCKETS SAND.

(j) BUCKETS WATER.

(k) SHOVEL GS.

(l) PICK AXE COMPLETE WITH HALVES.

(m) FIREMAN AXE COMPLETE WITH HALVES.

(n) AXE FELLING

 Other Hazards
Errors of medication.
Errors of identification of newborn
Errors of compounding and dispensing.
Fall and accidents wet floor, over waxing
Accidents from heavy machinery laundry,
autoclaves, boilers
Food poisoning
Collapse of building
 Patient Safety Solutions
Look Alike, Sound Alike Medications
Patient Identification
Communication during Patient hand Over
Performance of correct Procedure at Correct site
Control of Concentrated Electrolyte Solutions
Assuring Medication Accuracy at Transitions in Care
Avoiding catheter & Tubing Mis connections
Single use of Injection Devices
Improved Hand Hygiene to prevent Health care Associated
Infection
 Look Alike, Sound Alike Medications (LASA)
Contributing Factors
Illegible handwriting
Incomplete knowledge of drug names (new product)
Similar packaging or labelling
Similar Clinical use
Similar Strength, dosage, frequency of administration
Annual review of LASA medicine used
Implementing Clinical protocols
Minimise use of verbal/ tele orders
Read label each time medicine accessed & again prior to
administration
Use non proprietory & brand name
 Look Alike, Sound Alike Medications (LASA)
Using bold & Tallman lettering
Store problem medicines in separate locations or in non
alphabetical order
Provide patients/ attender with written medication info
Sight impaired coloured containers (DOTS)
Instruct patients to alert care giver where medicines
appear to be different than expected
Dispensing by qualified individuals
Seminars/ CMEs on LASA
Avoid frequent change of brand name
 Patient Identification
Lead to medication errors, transfusion/ testing errors,
wrong person procedure, infant discharge to wrong
families
Check pt identity & match it
Two identifiers used-name, date of birth, personal/
hosp No.
Standardise approach ID bands
Train health care workers procedure
Automated systems bar coding, biometrics
Communication during Patient hand Over
 Patient Safety Solutions
Look Alike, Sound Alike Medications
Patient Identification
Communication during Patient hand Over
Performance of correct Procedure at Correct site
Control of Concentrated Electrolyte Solutions
Assuring Medication Accuracy at Transitions in Care
Avoiding catheter & Tubing Mis connections
Single use of Injection Devices
Improved Hand Hygiene to prevent Health care Associated
Infection
HOSPITAL ACQUIRED
INFECTIONS
 Definition

HAI or Nosocomial infection is any infection acquired

in the hospital, manifestation of which may occur
during hospital stay or after discharge. Includes
patient, staff or visitor.
Nosocomial (nosokomeion - greek = hospital) infection
is also defined as the infection that develops in the
patients after more than 48 hrs of hospitalisation.
Infection which appears within 48 hrs of admission is
considered as community acquired
 HOSPITAL ACQUIRED INFECTION(HAI)
`Hospitals are intended to heal the sick, but they are also
sources of infection. Ironically, advances in medicine are
partly responsible for the fact that today hospital infections
are a leading cause of death in some parts of the world`
World Health report 1996
 HAI Rates
MAJOR PUBLIC HLTH PROBLEM - Problem is more in
Developing Countries
-5% of all Hospitalised Patients
CDC estimates
Hosp types/services Rates
Gen Hosp 3.6%
Surgical Services 5.1%
ICU 4-25%
NICU 24%
Other countries
USA 5%
Canada 5.1%
UK10%
Denmark 5-10%
Norway 11-18%
 HAI Rates(contd)
WHO Survey - 1988
28,861 patients
47 hosp of 14 countries in 4 continents
Prevalence rate
3 to 21 %
mean : 8.4%
 EFFECTS OF HAI
Morbidity & Mortality
ALS
Cost of treatment
Wastage of limited resources
Productivity-ineffective utilisation of beds
Psychological trauma
Image of the hosp
Legal implications
Manifestations: Majority during Hosp stay
- 25% post-op wound after discharge
Dynamics of HAI : New Challenges & Issues

Rapidly changing character of hosp

New varieties of microorganism
Increasing number and complexities of services
Emergence & growth of spl units -Greater No. &
variety of care givers
Organ transplant & implants of foreign bodies
Marked increase in invasive devices
Increase in HIV & blood borne pathogens
Ageing population
 Epidemiology
Agent :
Bacterium;
Virus;
Fungus;
Parasite;
Rickettsia;
 Epidemiology(contd)
Upto 1940 : Streptococci & Staphylococci

1950-1960 : Staphylococci

1960 onwards : Gm -ve bacilli; pseudomonas;

klebsiella; proteus; E.coli.

1965-1976 : Pseudomonas single imp agent

1980 onwards : HIV; HBV ; HCV & MRSA

 Epidemiology(contd)
Agent factors
Virulence e.g. staph A; gp A strep
Opportunism secondary to Antibiotic therapy
lower body resistance
Colonisation post instrumentation
Invasion secondary to viral infection
High infecting dose
 Epidemiology(contd)

Host factors
Extremes of age
Reduction in resistance
Therapeutic practices e.g. immunosuppressive
drugs
Complicated diagnostic/ therapeutic procedures
Engr services ( water, environment)
Prolonged surgical procedures
 Epidemiology(contd)
Environmental factors
Staff; patients; eqpt etc.
Hospital design & physical facilities
Housekeeping ; linen & laundry services
CSSD
Dietary services
Waste disposal
Pharmacy services
Humidity
Temp
IAQ (internal air quality)
 Source of Infection

Endogenous
(self infection)

skin nose throat mouth intestine tissues

infected lesion
 Source of Infection(contd)
Exogenous

Airborne Contact

Skin Direct Indirect

Scales
Droplets Hands Clinical Eqpt Nosocomial
Clothing e.g. Eqpt e.g.
Ventilator Bedpan,
Contaminated dressings Urinary catheter Bowls/ Jug
IV Line
Food, Milk, Water
 Types of HAI

UTI - 40%
Surgical wounds - 30%
Pneumonia - 20%
Bacteremia - 5%
Other HBV; HCV; HIV - 5%
 High Risk Areas in Hospital
ICU / NICU
Burn units
Nurseries
OTs
Post op wards
Dialysis units
Organ transplant units
Isolation wards
Lab
Onco wards
 PREVENTION & CONTROL
OF HOSPITAL ACQUIRED INFECTION
 CONTROL OF HAI

CAN NOT BE ERADICATED ENTIRELY

PLANNING CONTROL MEASURES
INVESTIGATION
SURVEILLANCE
DOCUMENTATION
ORGANISED MANAGEMENT SYSTEM
HICCO
 Prevent spread of infection
Isolation of patients
Barrier Nursing
Hand Washing
Antibiotic usage
Training & Monitoring
Administrative Set up
Hand hygiene is the simplest, most
effective measure for preventing
hospital-acquired infections.
 UNIVERSAL PRECAUTIONS

WEAR GLOVES
USE GOWNS, MASKS, PROTECTIVE EYE WEARS AND
FACE SHIELD
WASH HANDS AND SKIN CONTAMINATED WITH BLOOD
AND BODY FLUIDS
PREVENT SHARP OR NEEDLE STICK INJURY
HCW (Health Care Workers) WITH EXUDATIVE SKIN
LESIONS NOT TO BE INVOLVED IN DIRECT PATIENT
CARE /HANDLE PATIENT CARE EQPT
 CDC ISOLATION RECOMMENDATIONS - CONTD

REVISION OF CDC GUIDELINES 1994

2 TIER PRECAUTION
FIRST TIER
STANDARD PRECAUTION
COMBINES THE MAJOR FEATURES OF UNIVERSAL
PRECAUTIONS AND BODY SUBSTANCE ISOLATION
APPLY TO ALL PATIENTS REGARDLESS OF DIAGNOSIS/ KNOWN
INFECTIVE STATUS
SECOND TIER
CATEGORY SPECIFIC AND DISEASE SPECIFIC TRANSMISSION BASED
PRECAUTIONS
AIR BORNE
DROPLET
CONTACT
 CDC ISOLATION RECOMMENDATIONS (CONTD)

COMPONENTS
HAND WASHING
USE GLOVES, GOWN, MASK
EYE SHIELD/ FACE SHIELDS
PRIVATE ROOMS FOR HIGHLY INFECTIOUS PATIENTS
HOUSE KEEPING STAFF TO FOLLOW THE SAME
BARRIER PRECAUTIONS
 Why
Dont Staff Wash their Hands

(Compliance estimated at less than 50%)

 Why Not?
Working in high-risk areas
Lack of hand hygiene promotion
Lack of role model
Lack of institutional priority
Lack of sanction of non-compliers
 Successful Promotion
Education
Routine observation & feedback
Engineering controls
Location of hand basins
Possible, easy & convenient
Alcohol-based hand rubs available
Patient education
(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection
Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)
 Successful Promotion
Reminders in the workplace
Promote and facilitate skin care
Avoid understaffing and excessive
workload; Nursing shortages have caused
Areas Most Frequently Missed
 Hand Care
Nails
Rings
Hand creams
Cuts & abrasions
Chapping
Skin Problems
 HICCO

Multidisciplinary
Infection problem & control measures often
cross departmental lines
Effective Disease Mgt requires participation
of most department
Multidisciplinary representation bolster
authority of committee
 HICCO -Composition
Chairperson : Physician
Member secy : Micro / Path
Members :
Medical staff : Med; Surg; Paed; Obs & Gyn
Adm staff: Adm office rep
Nursing staff: Nursing services
Co-opted members
Blood bank; OT; housekeeping; laundry ; CSSD;
pharmacy; engrr services; dietician
 Functions of HICCO

Formulation of policies for HAI control

Decision & policy making on hosp infection
surveillance & control programme
Recommend infection control policies &
control measures to med staff
Decides policies on training pgme & evaluation
pgme for the staff
 Functions of HICCO(contd)

Implementation of policies
Disseminate data; knowledge; skill; policies &
pgmes to hosp staff
Review & evaluate policies; protocols & results
of surveillance pgme & maintain records
Set methods for assessing completeness &
effectiveness of implementation
 Functions of HICCO(contd)
Meets regularly
Once a month
Review of antibiogram of nosocomial blood
stream pathogens
Review significant features of monthly report of
ICO & ICN
Review one major control pgme or policy area
each month in the light of newest available info &
hosp current practices
 Functions of HICCO(contd)

HAI Control manual

An essential document
Tool for Wd level teaching & Edn
Provides uniformity & standardization of Pt care &
staff practices
Guide for all aspects of HAI :
surveillance
prevention
control measures
 Infection Control Team

Infection control officer/physician

Infection control nurse

Administrator
Functions of Infection Control Team (ICT)

SURVEILLANCE ACTIVITY
MEETS WEEKLY
ENVIRONMENTAL SURVEY
GUIDELINES
MONITORING STANDARD TECHNIQUES
Infection Control Officer/Physician

Main Responsibilities:-
Implementation of Infection Control Team
Administration of Infection Control Team
Runs the surveillance programe
Monitor the incidence of HAI
Investigate the source of HAI
Takes measures to control infection
 Infection Control Nurse

Key person in Infection surveillance &

control pgme
Responsibilities
Supervise the surveillance pgme
Day to day monitoring of Pt care practices
Spot investigation of cases of Hosp Infection
Counsels the nurses & paramedics
 HOSPITAL ADMINISTRATOR

To Ensure Implementation
Org Framework
Transalation of Decisions into Policy
Appropriation of Funds
Publicity
 Methods of Surveillance

Scrutiny of lab records

Routine visits to wards
Written report system
 Preventive & Control Measures
Policies
Principles of disinfection

Principles of sterilisation

Hospital Waste Management & disposal of

sharps
 Legal aspects of HAI
Compliance with legal rules
Reduction of infection
Appropriate procedure for surveillance &
early detection
Immunisation cover to medical pers
Informed consent
Reasonable level of care
Visitors policy
Staff training & placement evaluation
 CLEAN CARE IS SAFER CARE
Chapter 5
 HIC.1
Standard

The organization has a well-designed, comprehensive

and coordinated Hospital Infection Control (HIC)
programme aimed at reducing/ eliminating risks to
patients, visitors and providers of care.
Objective elements
a) The hospital infection control programme is documented
which aims at preventing and reducing risk of nosocomial
infections.
 cont
b) The hospital has a multi-disciplinary infection
control committee.
c) The hospital has an infection control team.
d) The hospital has designated and qualified
infection control nurse(s) for this activity.
 HIC.2
Standard
The hospital has an infection control manual, which is
periodically updated.
Objective elements
a) The manual identifies the various high-risk areas
and procedures.
b) It outlines methods of surveillance in the identified
high-risk areas.
 cont
c) It focuses on adherence to standard precautions at
all times.
d) Equipment cleaning and sterilisation practices are
included.
e) An appropriate antibiotic policy is established and
implemented.
f) Laundry and linen management processes are also
included.
 cont
g) Kitchen sanitation and food handling issues are
included in the manual.
h) Engineering controls to prevent infections are
included.
i) Mortuary practices and procedures are included as
appropriate to the organization.
j) The organization defines the periodicity of
updating the infection control manual.
 HIC.3
Standard
The infection control team is responsible for surveillance
activities in identified areas of the hospital.
Objective elements
a) Surveillance activities are appropriately directed
towards the identified high-risk areas.
b) Collection of surveillance data is an ongoing process.
c) Verification of data is done on regular basis by the
infection control team.
 cont

d) In cases of notifiable diseases, information (in

relevant format) is sent to appropriate authorities.
e) Scope of surveillance activities incorporates
tracking and analyzing of infection risks, rates and
trends.
f) Surveillance activities include monitoring the
effectiveness of housekeeping services.
 HIC.4
Standard
The hospital takes actions to prevent or reduce the risks
of Hospital Associated Infections (HAI) in patients
and employees
Objective elements
a) The organization monitors urinary tract infections.
b) The organization monitors respiratory tract
infections.
 cont
c) The organization monitors intra-vascular device
infections.
d) The organization monitors surgical site infections.
e) Appropriate feedback regarding HAI rates are
provided on a regular basis to medical and nursing
staff.
 HIC.5
Standard
Proper facilities and adequate resources are provided to
support the infection control programme
Objective elements
a) Hand washing facilities in all patient care areas are
accessible to health care providers.
b) Compliance with proper hand washing is
monitored regularly.
 cont
c) Isolation/ barrier nursing facilities are available.
d) Adequate gloves, masks, soaps, and
disinfectants are available and used correctly.
 HIC.6
Standard
The hospital takes appropriate action to control
outbreaks of infections.
Objective elements
a) Hospital has a documented procedure for handling
such outbreaks.
b) This procedure is implemented during outbreaks.
c) After the outbreak is over appropriate corrective
actions are taken to prevent recurrence.
 HIC.7
Standard
There are documented procedures for sterilisation
activities in the hospital.
Objective elements
a) There is adequate space available for sterilization
activities
b) Regular validation tests for sterilisation are carried
out and documented.
c) There is an established recall procedure when
breakdown in the sterilisation system is identified
 HIC.8
Standard
Statutory provisions with regard to Bio-medical Waste
(BMW) management are complied with
Objective elements
a) The hospital is authorised by prescribed authority
for the management and handling of Bio-medical
Waste.
b) Proper segregation and collection of Bio-medical
Waste from all patient care areas of the hospital is
implemented and monitored.
 cont
c) The organization ensures that Bio-medical Waste
is stored and transported to the site of treatment
and disposal in proper covered vehicles within
stipulated time limits in a secure manner.
d) Bio-medical Waste treatment facility is managed
as per statutory provisions (if in-house) or
outsourced to authorised contractor(s).
 cont
e) Requisite fees, documents and reports are
submitted to competent authorities on stipulated
dates.
f) Appropriate personal protective measures are
used by all categories of staff handling Bio-
medical Waste
 HIC.9
Standard
The infection control programme is supported by
hospital management and includes training of staff
and employee health
Objective elements
a) Hospital management makes available resources
required for the infection control programme
b) The hospital regularly earmarks adequate funds
from its annual budget in this regard.
 Cont..
c) It conducts regular pre-induction training for
appropriate categories of staff before joining
concerned department(s).
d) It also conducts regular in-service training
sessions for all concerned categories of staff at
least once in a year.
e) Appropriate pre and post exposure prophylaxis
is provided to all concerned staff members
THanK YoU fOr yoUr cOopeRatiO
and UnTiriNg sUPpoRt
 COP.5
Policies and procedures define rational use of
blood and blood products

Objective elements
a) Documented policies and procedures are used to
guide rational use of blood and blood products
b) The transfusion services are governed by the
applicable laws and regulations

105
 Cont

c) Informed consent is obtained for donation and

transfusion of blood and blood products
d) Informed consent also includes patient and family
education about donation
e) Staff is trained to implement the policies
f) Transfusion reactions are analyzed for preventive and
corrective actions

106
 MOM.1
Policies and procedures guide the organization
of pharmacy services and usage of medication
Objective elements
a) There is a documented policy and procedure for
pharmacy services and medication usage
b) These comply with the applicable laws and regulations
c) A multidisciplinary committee guides the formulation
and implementation of these policies and procedures

107
 MOM.2
There is a hospital formulary
Objective elements
a) A list of medication appropriate for the patients and
organizations resources is developed
b) The list is developed collaboratively by the
multidisciplinary committee
c) There is a defined process for acquisition of these
medications
d) There is a process to obtain medications not listed
in the formulary

108
 MOM.3
Policies and procedures exist for storage of
medication

Objective elements
a) Documented policies and procedures exist for
storage of medication
b) Medications are stored in a clean, well lit and
ventilated environment
c) Sound inventory control practices guide storage of
the medications

109
 Cont
d) Medications are protected from loss or theft
e) Sound alike and look alike medications are stored
separately
f) There is a method to obtain medication when the
pharmacy is closed
g) Emergency medications are available all the time
h) Emergency medications are replenished in a timely
manner when used

110
 MOM.4
Policies and procedures guide the prescription of
medications

Objective elements
a) Documented policies and procedures exist for
prescription of medications
b) The organization determines who can write orders
c) Orders are written in a uniform location in the
medical records

111
 MOM.4
Policies and procedures guide the safe dispensing
of medications
Objective elements
a) Documented policies and procedures guide the safe
dispensing of medications
b) The policies include a procedure for medication
recall
c) Expiry dates are checked prior to dispensing
d) Labeling requirements are documented and
implemented by the organization
112
 MOM.5
There are defined procedures for medication
administration
Objective elements
a) Medications are administered by those who are permitted
by law to do so
b) Prepared medication are labeled prior to preparation of a
second drug
c) Patient is identified prior to administration
d) Medication is verified from the order prior to
administration
e) Dosage is verified from the order prior to administration

113
 Cont
d) Route is verified from the order prior to administration
e) Timing is verified from the order prior to administration
h) Medication administration is documented
i) Polices and procedures govern patients self
administration of medications
j) Polices and procedures govern patients medications
brought from outside the organization

114
 MOM.7
Patients and family members are educated about
safe medication and food-drug interactions

Objective elements
a) Patient and family are educated about safe and
effective use of medication
b) Patient and family are educated about food-drug
interactions

115
 MOM.8
Patients are monitored after medication
administration
Objective elements
a) Patients are monitored after medication administration
and this is documented
b) Adverse drug events are defined
c) Adverse drug events are reported within a specified
time frame
d) Adverse drug events are collected and analysed
e) Policies are modified to reduce adverse drug events
when unacceptable trends occur
116
 MOM.9
Policies and procedures guide the use of
narcotic drugs and psychotropic substances
Objective elements
a) Documented policies and procedures guide the use of narcotic drugs and
psychotropic substances
b) These policies are in consonance with local and national regulations
c) A proper record is kept of the usage, administration and disposal of these
drugs
d) These drugs are handled by appropriate personnel in accordance with
policies

117
 MOM.10
Policies and procedures guide the usage of
chemotherapeutic agents
Objective elements
a) Documented policies and procedures guide the usage of
chemotherapeutic agents
b) Chemotherapy is prescribed by those who have the
knowledge to monitor and treat the adverse effect of
chemotherapy
c) Chemotherapy is prepared and administered by qualified
personnel
d) Chemotherapy drugs are disposed off in accordance with
legal requirements
118
 MOM.11
Policies and procedures govern usage of
radioactive drugs
Objective elements.
a) Documented policies and procedures govern usage of radioactive
drugs
b) These policies and procedures are in consonance with laws and
regulations
c) The policies and procedures include the safe storage, preparation,
handling, distribution and disposal of radioactive drugs
d) Staff, patients and visitors are educated on safety precautions

119
 MOM.12
Policies and procedures guide the use of
implantable prosthesis
Objective elements.
a) Documented policies and procedures govern procurement
and usage of implantable prosthesis
b) Selection of implantable prosthesis is based on scientific
criteria and national/internationally recognized approvals
c) The batch and serial number of the implantable prosthesis
are recorded in the patients medical record and the master
logbook

120
 MOM.13
Policies and procedures guide the use of
medical gases
Objective elements
a) Documented policies and procedures govern
procurement, handling, storage, distribution, usage
and replenishment of medical gases.
b) The policies and procedures address the safety issues
at all levels
c) Appropriate records are maintained in accordance
with the policies, procedures and legal requirements.

121