Frequently Asked NABH Questions and Answers
Q. What is NABH and what does it do?
NABH stands for National Accreditation Board for Hospitals and Healthcare Providers. It is a constituent board of the Quality Council of India (QCI), set up to establish and operate accreditation programs for healthcare organizations. The board is structured to cater to the much-desired needs of the consumers and to set benchmarks for the progress of the health industry. NABH also promotes quality and patient safety through various initiatives, education, training, recognition, and endorsement.
Q. What are the benefits of NABH accreditation?
NABH accreditation provides many benefits to the healthcare organizations, such as:
- It demonstrates their commitment to quality and patient safety.
- It enhances their credibility and reputation among the stakeholders, including patients, regulators, insurers, and employers.
- It improves operational efficiency and effectiveness by reducing errors, wastage, and risks.
- It enables them to benchmark their performance against national and international standards.
- It facilitates their participation in various government schemes and empanelment with insurance companies.
Q. What are the types of accreditation programs offered by NABH?
NABH offers various types of accreditation programs for different categories of healthcare organizations, such as:
- Hospitals: For general or specialty hospitals that provide inpatient and outpatient services.
- Small Healthcare Organizations: For clinics, nursing homes, or daycare centers that have less than 50 beds or provide only outpatient services.
- Blood Banks/Transfusion Services: For facilities that collect, process, store, or transfuse blood or blood components.
- Dental Facilities: For dental clinics or hospitals that provide dental care services.
- Eye Care Organizations: For eye clinics or hospitals that provide eye care services.
- Wellness Centers: For facilities that provide wellness or preventive health care services, such as spa, yoga, naturopathy, etc.
- Medical Imaging Services: For facilities that provide diagnostic imaging services, such as X-ray, ultrasound, CT scan, MRI, etc.
- Medical Laboratories: For facilities that provide diagnostic laboratory services, such as pathology, microbiology, biochemistry, etc.
- Primary Health Centers/Community Health Centers: For facilities that provide primary health care services in rural or urban areas.
- Allopathic Clinics: For facilities that provide allopathic consultation services in outpatient settings.
Q. What are the standards and criteria for NABH accreditation?
NABH has developed specific standards and criteria for each type of accreditation program based on national and international best practices. The standards cover various aspects of quality and patient safety, such as:
- Access, assessment, and continuity of care
- Care of patients
- Management of medication
- Patient Rights and Education
- Hospital infection control
- Continuous quality improvement
- Responsibilities of management
- Facility management and safety
- Human resource management
- Information management system
The criteria are based on objective evidence that can be verified during the assessment process.
Q. What is the process and duration of NABH accreditation?
The process and duration of NABH accreditation vary depending on the type of accreditation program. However, the general steps involved are:
- Application: The healthcare organization submits an online application along with the required documents and fees to NABH.
- Pre-assessment: NABH assigns a pre-assessment team to conduct a preliminary visit to the healthcare organization to verify its readiness for accreditation.
- Final assessment: NABH assigns a final assessment team to conduct a comprehensive visit to the healthcare organization to evaluate its compliance with the standards and criteria.
- Accreditation decision: NABH reviews the final assessment report and makes a decision on granting or denying accreditation to the healthcare organization.
- Surveillance visits: NABH conducts periodic surveillance visits to monitor the continued compliance of the accredited healthcare organization with the standards and criteria.
The duration of accreditation is usually three years for hospitals and small healthcare organizations, two years for blood banks/transfusion services, dental facilities, eye care organizations, wellness centers, medical imaging services, medical laboratories, primary health centers/community health centers, and allopathic clinics.
Q. What are the fees for NABH accreditation?
The fees for NABH accreditation depend on the type of accreditation program and the size or scope of the healthcare organization. The fees include application fee, pre-assessment fee, final assessment fee, annual fee (for hospitals and small healthcare organizations), surveillance fee (for other programs), travel expenses of assessors (if applicable), GST (18%), etc. The fees are subject to revision from time to time by NABH.
Q. How can a healthcare organization prepare for NABH accreditation?
A healthcare organization can prepare for NABH accreditation by following these steps:
- Obtain the relevant standards and criteria from the NABH website or office.
- Conduct a self-assessment or gap analysis to identify the areas of improvement and compliance.
- Develop and implement an action plan to address the gaps and comply with the standards and criteria.
- Provide training and orientation to the staff on the standards and criteria and their roles and responsibilities.
- Monitor and evaluate the progress and effectiveness of the action plan and make necessary adjustments.
- Seek guidance or assistance from NABH or external consultants if required.
Q. How can a patient or a stakeholder verify the NABH accreditation status of a healthcare organization?
A patient or a stakeholder can verify the NABH accreditation status of a healthcare organization by:
- Checking the NABH certificate displayed at the healthcare organization premises or website.
- Checking the NABH website for the list of accredited healthcare organizations.
- Contacting the NABH office (011-23323415/16/17) or email ([email protected]) for confirmation.
Q. How can a patient or a stakeholder provide feedback or complaint about a NABH-accredited healthcare organization?
A patient or a stakeholder can provide feedback or complaint about a NABH-accredited healthcare organization by:
- Contacting the healthcare organization directly and following its grievance redressal mechanism.
- Contacting the NABH office (011-23323415/16/17) or email ([email protected]) and providing the details of the feedback or complaint along with supporting evidence.
- Filling an online feedback or complaint form on the NABH website (https://nabh.co/feedback.aspx).
NABH will acknowledge the feedback or complaint and take appropriate action as per its policy and procedure.
Q. How can a healthcare professional become an assessor for NABH accreditation programs?
A healthcare professional can become an assessor for NABH accreditation programs by:
- Meeting the eligibility criteria for the specific accreditation program, such as qualification, experience, training, etc.
- Applying online on the NABH website along with the required documents and fees.
- Attending an orientation program conducted by NABH to familiarize with the standards, criteria, process, and expectations of assessment.
- Passing an online examination conducted by NABH to test the knowledge and skills of assessment.
- Undergoing a mentorship program conducted by NABH to gain practical exposure and experience in assessment under the guidance of senior assessors.
NABH will empanel the successful candidates as assessors and assign them assessment assignments as per their availability and suitability
What are Sound-alike and Look-alike Medicines
Sound-alike and look-alike medicines are drugs that have similar names or packaging, which can cause confusion and errors in medication administration. For example, Celebrex and Cerebyx, or Zantac and Xanax.
Expand PEP and PPE?
PEP stands for post-exposure prophylaxis, which is a preventive treatment given after exposure to a potential infection, such as HIV or rabies. PPE stands for personal protective equipment, which is a set of devices or clothing worn to protect oneself from exposure to hazards, such as infectious agents or chemicals.
What is Multi-dose Vial?
A multi-dose vial is a container of liquid medication that can be used for more than one patient or injection. Once the vial is opened for use, it can be stored for up to 28 days only. To use a multi-dose vial, one should follow these steps: check the expiration date and the label, clean the rubber stopper with alcohol, use a new sterile needle and syringe, insert the needle through the stopper, and withdraw the required amount of medication, remove the needle and syringe from the vial, label the syringe with the patient’s name and date, and store the vial in a designated area according to the manufacturer’s instructions.
What is DNR?
DNR stands for do not resuscitate, which is a medical order that instructs health care providers not to perform cardiopulmonary resuscitation (CPR) or other life-saving measures in case of cardiac arrest or respiratory failure.
Explain 5 Moments of Hand Washing.
The five moments of hand washing are: before touching a patient, before performing a clean or aseptic procedure, after exposure to body fluids or blood, after touching a patient, and after touching the patient’s surroundings.
Expand NSI and BBF
NSI stands for needle stick injury, which is a wound caused by a sharp object such as a needle or scalpel that has been contaminated with blood or body fluids. BBF stands for blood and Body Fluids, which are microorganisms that can cause infections through contact with blood or body fluids, such as HIV, hepatitis B, and hepatitis C.
How to do Immediate Care for NSI?
The immediate management of NSI are: wash the wound with soap and water, apply pressure to stop bleeding if necessary, cover the wound with a sterile dressing or bandage, report the incident to the supervisor or infection control officer, seek medical advice and treatment as soon as possible, and follow up with testing and counseling as recommended.
What is the meaning of Isolation?
Isolation is a measure taken to prevent the spread of infectious diseases by separating infected or potentially infected individuals from others. There are different types of isolation depending on the mode of transmission and the level of risk. Some examples are airborne isolation, droplet isolation, contact isolation, and protective isolation.
RCA stands for?
RCA stands for root cause analysis, which is a method of identifying and solving problems by tracing them back to their underlying causes. For example, if a patient falls in the hospital, an RCA would investigate what factors contributed to the fall, such as environmental hazards, medication errors, staff communication issues, etc., and propose corrective actions to prevent future falls.
What are the Emergency Codes
Emergency codes are standardized signals used in healthcare facilities to alert staff and responders about various situations that require immediate attention. Some common emergency codes are code blue (cardiac arrest), code red (fire), code black (bomb threat), code pink (infant abduction), etc.
What is RACE?
RACE is an acronym that stands for rescue, alarm, confine, and extinguish/evacuate. It is a mnemonic used to remember the steps to take in case of fire in a healthcare facility. Rescue means to move anyone in immediate danger away from the fire. The Alarm means to activate the fire alarm system and notify others. Confine means to close doors and windows to prevent the fire from spreading. Extinguish means to use a fire extinguisher if safe and possible. Evacuate means to leave the area following the emergency plan.
What are the diseases belongs to Notifiable Diseases Category?
Notifiable diseases are diseases that are required by law to be reported to public health authorities by health care providers or laboratories. The purpose of reporting notifiable diseases is to monitor their occurrence and trends, prevent their spread, and implement control measures. Some examples of notifiable diseases are: tuberculosis, measles, mumps, rubella, meningitis, cholera, dengue fever, anthrax, plague, etc.
SOP stands for standard operating procedure, which is a set of written instructions that describe how to perform a specific task or activity in a consistent and safe manner. SOPs are used in various fields and settings to ensure quality control, compliance with regulations, staff training, risk management, etc.
Major Spill Vs Minor Spill
The difference between major spill and minor spill is based on the amount and type of substance spilled, the potential for exposure or harm, and the resources needed for cleanup. A major spill is one that involves a large volume of substance, a hazardous or infectious material, a high risk of exposure or injury, or a complex or difficult cleanup. A minor spill is one that involves a small volume of substance, a non-hazardous or non-infectious material, a low risk of exposure or injury, or a simple or easy cleanup.
What is MRSA and VRE?
MRSA stands for methicillin-resistant Staphylococcus aureus, which is a type of bacteria that is resistant to many antibiotics and can cause serious infections in various parts of the body. VRE stands for vancomycin-resistant enterococci, which is another type of bacteria that is resistant to vancomycin and other antibiotics and can cause infections in the bloodstream, urinary tract, wounds, etc.
What is SAS Protocol?
SAS protocol stands for swab, alcohol, swab, which is a technique used to disinfect injection ports or vial stoppers before accessing them with a needle or syringe. The protocol involves wiping the port or stopper with a sterile swab, then applying alcohol with another sterile swab, and then wiping again with a third sterile swab.
What is CLABSI, CAUTI, SSI, and VAP?
CLABSI stands for central line-associated bloodstream infection, which is an infection that occurs when bacteria or fungi enter the bloodstream through a central venous catheter. CAUTI stands for catheter-associated urinary tract infection, which is an infection that occurs when bacteria or fungi enter the urinary tract through a urinary catheter. SSI stands for surgical site infection, which is an infection that occurs at the site of a surgical incision. VAP stands for ventilator-associated pneumonia, which is an infection that occurs in the lungs of patients who are on mechanical ventilation.
CLABSI bundle is a set of evidence-based practices that aim to prevent CLABSI by reducing the risk of contamination and colonization of central venous catheters. The bundle includes: hand hygiene before catheter insertion and manipulation; maximal barrier precautions during catheter insertion; chlorhexidine skin antisepsis; optimal catheter site selection; daily review of catheter necessity and prompt removal when no longer needed.
VAP bundle is a set of evidence-based practices that aim to prevent VAP by reducing the risk of aspiration and colonization of respiratory secretions. The bundle includes: elevation of the head of the bed to 30-45 degrees; daily sedation interruption and assessment of readiness to extubate; peptic ulcer disease prophylaxis; deep vein thrombosis prophylaxis; oral care with chlorhexidine.
Expand DVT and PUD
DVT stands for deep vein thrombosis, which is a condition where a blood clot forms in a deep vein, usually in the legs. PUD stands for peptic ulcer disease, which is a condition where sores develop in the lining of the stomach or duodenum due to acid erosion.
What are the monitoring criteria for the Patient with Blood Transfusion?
The monitoring criteria of patients with blood transfusion are: vital signs (temperature, pulse, blood pressure, respiratory rate) before, during, and after transfusion; signs and symptoms of transfusion reaction (fever, chills, rash, itching, dyspnea, chest pain, back pain, etc.); urine output and hemoglobin level after transfusion; documentation of transfusion details (type and amount of blood product, start and end time, patient’s name and identification number, donor’s name and identification number, etc.).
What are the adverse reactions associated with blood transfusion?
The signs and symptoms of blood transfusion reaction are: fever (>1°C increase from baseline), chills, rigors, rash, itching, hives, flushing, dyspnea, wheezes, cough, chest pain or tightness, tachycardia, hypotension or hypertension, back pain or flank pain, hemoglobinuria (red urine), jaundice (yellow skin or eyes), anaphylaxis (severe allergic reaction), shock (severe hypotension), disseminated intravascular coagulation (abnormal bleeding or clotting).
How to do effective Pain Assessment?
The criteria for pain assessment are: location (where the pain is felt), intensity (how severe the pain is on a scale from 0 to 10), quality (how the pain feels like such as sharp, dull, throbbing, burning, etc.), duration (how long the pain lasts), frequency (how often the pain occurs), aggravating factors (what makes the pain worse), relieving factors (what makes the pain better), impact (how the pain affects daily activities and quality of life).
How to Prepare 1 % Hypochlorite Solution from available 5 % Solution?
To prepare 1% hypochlorite solution from 5% hypochlorite solution container, one should use the following formula: C1V1 = C2V2. C1 is the initial concentration (5%), V1 is the initial volume (unknown), C2 is the final concentration (1%), V2 is
Q. What is a sentinel event with an example?
A. A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:
- Permanent harm
- Severe temporary harm and intervention required to sustain life
An event is also considered sentinel if it is one of the following:
- Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)
- Unanticipated death of a full-term infant
- Discharge of an infant to the wrong family
- Abduction of any patient receiving care, treatment, and services
- Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient
- Administration of blood or blood products having unintended ABO and non-ABO (Rh, Duffy, Kell, Lewis, and other clinically important blood groups) incompatibilities, hemolytic transfusion reactions, or transfusions resulting in severe temporary harm, permanent harm, or death
- Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care
- Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on-site at the hospital
- Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on-site at the hospital
- An invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure
- Unintended retention of a foreign object in a patient after an invasive procedure, including surgery
- Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
- Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose
Some examples of sentinel events are:
- A patient dies after receiving an overdose of insulin due to a medication error
- A patient undergoes surgery on the left knee instead of the right knee due to a communication failure
- A patient falls from the bed and suffers a head injury due to inadequate fall prevention measures
- A patient develops a severe infection after a surgical sponge is left inside the abdomen during surgery
- A patient commits suicide in the hospital bathroom due to inadequate suicide risk assessment and monitoring
Q. What is surrogate consent with an example?
A. Surrogate consent is a type of informed consent that is obtained from a person who is authorized to make decisions on behalf of another person who is unable to provide consent for themselves due to incapacity or incompetence. Surrogate consent is usually based on the best interests or the known preferences of the person who needs care.
Some examples of surrogate consent are:
- A spouse gives consent for their partner who is in a coma to undergo a life-saving surgery
- A parent gives consent for their minor child who is unconscious to receive a blood transfusion
- A legal guardian gives consent for their ward who has dementia to participate in a clinical trial
- A health care proxy gives consent for their friend who has a terminal illness to receive palliative care
- A court-appointed representative gives consent for their client who has a mental disorder to receive electroconvulsive therapy
Q. How to store and administer narcotic drugs?
A. Narcotic drugs are controlled substances that have a high potential for abuse and addiction. They are used for pain relief and anesthesia. They include opioids such as morphine, codeine, fentanyl, oxycodone, hydrocodone, etc.
To store and administer narcotic drugs safely and legally, one should follow these steps:
- Obtain a valid prescription from a licensed prescriber for each narcotic drug
- Store narcotic drugs in a secure and double-locked location that is accessible only to authorized personnel
- Maintain accurate and complete records of narcotic drugs inventory, dispensing, administration, disposal, and loss
- Follow the manufacturer’s instructions and expiration dates for narcotic drugs storage and handling
- Use appropriate labels and containers for narcotic drugs to prevent confusion and errors
- Verify the identity and dosage of narcotic drugs before administering them to patients
- Use proper techniques and equipment for narcotic drug administration such as oral syringes, intravenous pumps, patches, etc.
- Monitor patients for signs and symptoms of narcotic drug effects and adverse reactions such as pain relief, sedation, respiratory depression, nausea, constipation, etc.
- Educate patients and caregivers about the benefits, risks, and precautions of narcotic drug use such as addiction, dependence, tolerance, withdrawal, overdose, etc.
- Dispose of narcotic drugs waste and unused or expired narcotic drugs in accordance with the local and federal regulations and guidelines
Q. What are the drugs that belong to narcotic drugs?
A. Narcotic drugs are controlled substances that have a high potential for abuse and addiction. They are used for pain relief and anesthesia. They include opioids and their derivatives such as:
Narcotic drugs also include some synthetic substances that have similar effects to opioids such as:
Q. What are the international patient safety goals?
A. The international patient safety goals are a set of standards and guidelines developed by the World Health Organization (WHO) and the Joint Commission International (JCI) to improve patient safety and quality of care in healthcare settings. They are:
- Identify patients correctly: Use at least two ways to identify patients before providing care, treatment, or services to prevent errors such as wrong patient, wrong site, wrong procedure, etc.
- Improve effective communication: Communicate relevant and timely information clearly and accurately among health care providers and patients to prevent errors such as missed or delayed diagnosis, treatment, follow-up, etc.
- Improve the safety of high-alert medications: Label and store high-alert medications safely and correctly to prevent errors such as wrong medication, wrong dose, wrong route, wrong time, etc.
- Ensure safe surgery: Perform a preoperative verification process, mark the surgical site, and conduct a time-out before surgery to prevent errors such as wrong patient, wrong site, wrong procedure, etc.
- Reduce the risk of healthcare-associated infections: Follow hand hygiene guidelines and infection prevention and control practices to prevent infections such as surgical site infections, catheter-associated urinary tract infections, central line-associated bloodstream infections, ventilator-associated pneumonia, etc.
- Reduce the risk of patient harm resulting from falls: Assess patients for fall risk factors and implement fall prevention strategies to prevent injuries such as fractures, head trauma, bleeding, etc.
Q. Who are the vulnerable patients, with examples?
A. Vulnerable patients are those who have increased susceptibility or exposure to harm or adverse outcomes due to various factors such as age, disability, disease, social status, culture, language, etc. Vulnerable patients may have difficulty accessing or receiving appropriate healthcare services or expressing their needs and preferences. They may also face discrimination or exploitation from healthcare providers or others.
Some examples of vulnerable patients are:
- Children and adolescents who may have limited understanding or autonomy in health care decisions and may be subject to abuse or neglect
- Older adults who may have multiple chronic conditions or cognitive impairment and may be subject to abuse or neglect
- Pregnant women who may have specific health needs or complications and may be subject to discrimination or violence
- People with mental disorders who may have impaired judgment or communication and may be subject to stigma or coercion
- People with physical disabilities who may have mobility or sensory limitations and may be subject to discrimination or exclusion
- People with chronic diseases who may have complex care needs or poor prognoses and may be subject to the financial or emotional burden
- People with terminal illnesses who may have palliative care needs or end-of-life preferences and may be subject to suffering or abandonment
- People with low socioeconomic status who may have limited access to health care resources or social support and may be subject to poverty or marginalization
- People with minority ethnic or cultural backgrounds who may have different health beliefs or practices and may be subject to discrimination or misunderstanding
- People with limited language proficiency who may have difficulty communicating or understanding health information and may be subject to miscommunication or error
Q. What are the types of fire extinguishers and their uses?
A. Fire extinguishers are devices that contain a substance that can be sprayed or discharged to put out a fire. There are different types of fire extinguishers based on the type of substance they contain and the type of fire they can extinguish. The types of fire extinguishers are:
- Water extinguishers: These contain pressurized water that can cool down the fire by reducing its temperature. They are suitable for Class A fires involving ordinary combustible materials such as wood, paper, cloth, etc. They are not suitable for Class B fires involving flammable liquids such as gasoline, oil, paint, etc., Class C fires involving electrical equipment such as wires, appliances, computers, etc., Class D fires involving combustible metals such as magnesium, sodium, potassium,
- Foam extinguishers: These contain pressurized foam that can smother the fire by creating a barrier between the fuel and the oxygen. They are suitable for Class A and Class B fires. They are not suitable for Class C and Class D fires.
- Dry powder extinguishers: These contain a pressurized dry powder that can extinguish the fire by interrupting the chemical reaction. They are suitable for Class A, Class B, Class C, and Class D fires. However, they may not be very effective for Class A fires as they do not cool down the fire and may cause re-ignition. They may also create a lot of dust and reduce visibility.
- Carbon dioxide extinguishers: These contain pressurized carbon dioxide gas that can displace the oxygen and suffocate the fire. They are suitable for Class B and Class C fires. They are not suitable for Class A and Class D fires. They may also cause frostbite if sprayed on the skin or eyes.
- Wet chemical extinguishers: These contain a pressurized wet chemical solution that can create a layer of foam on the surface of the fire and prevent re-ignition. They are suitable for Class K fires involving cooking oils or fats such as in kitchens. They may also be used for Class A fires.
Q. What are the structures of the NABH?
A. NABH stands for National Accreditation Board for Hospitals and Healthcare Providers. It is a constituent board of the Quality Council of India (QCI), which is an autonomous body set up by the government of India to establish and operate accreditation programs for various sectors.
The structure of NABH consists of:
- The Governing Board: This is the apex body that provides strategic direction, policy guidance, and oversight to NABH. It consists of representatives from various stakeholders such as government, industry, consumers, academia, etc.
- The Technical Committee: This is the body that develops and reviews the standards and criteria for various accreditation programs. It consists of experts from various fields such as medicine, nursing, pharmacy, management, etc.
- The Secretariat: This is the body that implements and administers the accreditation programs. It consists of staff members who perform various functions such as processing applications, conducting assessments, granting accreditations, providing training, etc.
Q. What are the 10 chapters of NABH?
A. NABH has developed 10 chapters of standards and criteria for hospital accreditation programs based on national and international best practices. The 10 chapters are:
- Access, Assessment, and Continuity of Care (AAC): This chapter covers the standards related to the provision of timely, appropriate, and continuous care to patients from admission to discharge or transfer.
- Care of Patients (COP): This chapter covers the standards related to the delivery of safe, effective, and patient-centered care to patients according to their needs and preferences.
- Management of Medication (MOM): This chapter covers the standards related to the safe and rational use of medications in hospitals, including prescribing, dispensing, administering, monitoring, and disposing of medications.
- Patient Rights and Education (PRE): This chapter covers the standards related to the respect and protection of patient’s rights and dignity, as well as the provision of relevant information and education to patients and their families or caregivers.
- Hospital Infection Control (HIC): This chapter covers the standards related to the prevention and control of healthcare-associated infections in hospitals, including surveillance, isolation, hand hygiene, sterilization, waste management, etc.
- Continuous Quality Improvement (CQI): This chapter covers the standards related to the establishment and implementation of a quality management system in hospitals, including planning, monitoring, measuring, analyzing, improving, and sustaining quality and patient safety.
- Responsibilities of Management (ROM): This chapter covers the standards related to the leadership and governance of hospitals, including vision, mission, values, goals, policies, procedures, roles, responsibilities, accountability, communication, etc.
- Facility Management and Safety (FMS): This chapter covers the standards related to the maintenance and safety of hospital facilities, equipment, utilities, environment
- Human Resource Management (HRM): This chapter covers the standards related to the management of human resources in hospitals, including recruitment, orientation, training, performance appraisal, retention, etc.
- Information Management System (IMS): This chapter covers the standards related to the management of information in hospitals, including collection, storage, retrieval, analysis, dissemination, and security of data and records.
- Quality Indicators (QI): This chapter covers the standards related to the identification, measurement, and reporting of quality indicators in hospitals, including clinical outcomes, patient satisfaction, adverse events, etc.
Q. What is a quality indicator of a Hospital or healthcare center?
A. A quality indicator is a measurable element of quality that reflects the performance of a hospital or health care center in a specific area of care or service. Quality indicators can be used to monitor, evaluate, and improve the quality and patient safety of health care delivery. Quality indicators can be classified into four types:
- Structure indicators: These measure the characteristics of the health care setting, such as infrastructure, equipment, staff, policies, etc.
- Process indicators: These measure the activities or interventions that are performed in the health care setting, such as diagnosis, treatment, prevention, education, etc.
- Outcome indicators: These measure the results or effects of the health care delivery on patients or populations, such as mortality, morbidity, satisfaction, etc.
- Balancing indicators: These measure the unintended consequences or trade-offs of the health care delivery on other aspects of quality or patient safety, such as cost, access, equity, etc.
Q. What are the patient’s rights and responsibilities?
A. Patient rights and responsibilities are the principles that guide the relationship between patients and health care providers based on mutual respect and trust. Patients’ rights and responsibilities aim to protect the dignity, autonomy, and well-being of patients and to ensure the quality and safety of health care delivery.
Some examples of patient’s rights are:
- The right to receive respectful and compassionate care regardless of age, gender, race, religion, culture, language, disability, or socioeconomic status
- The right to receive accurate and complete information about their health condition, diagnosis, prognosis, treatment options, benefits, risks, alternatives, costs, etc., in a language and manner that they can understand
- The right to participate in decisions about their care and to give informed consent or refusal for any intervention or procedure
- The right to seek a second opinion or to change their health care provider if they wish
- The right to have access to their medical records and to request corrections or amendments if needed
- The right to have privacy and confidentiality of their personal and health information protected
- The right to have their complaints or grievances heard and addressed in a fair and timely manner
- The right to have an advance directive or a living will that expresses their preferences for end-of-life care
Some examples of a patient’s responsibilities are:
- The responsibility to follow the agreed-upon plan of care and to comply with the instructions and advice of their healthcare providers
- The responsibility to ask questions or seek clarification if they do not understand or are unsure about any aspect of their care
- The responsibility to inform their healthcare providers of any changes in their condition, symptoms, medication, or treatment
- The responsibility to respect the rights, privacy, and confidentiality of other patients and healthcare providers
- The responsibility to be courteous and cooperative with the staff and facilities of the healthcare setting
- The responsibility to accept the consequences of their decisions and actions if they refuse treatment or do not follow the plan of care
- The responsibility to fulfill their financial obligations for the health care services they receive
Q. What is SDS, and what does it contain?
A. SDS stands for Safety Data Sheet. It is a document that provides information about the hazards, properties, handling, storage, disposal, and emergency procedures of a chemical substance or product. SDS is intended to help workers, employers, and other users protect themselves and the environment from potential harm.
SDS contains 16 sections that cover the following information:
- Identification: This section provides the name, address, phone number, and emergency number of the manufacturer or supplier of the substance or product. It also provides the product identifier, such as trade name, CAS number, etc., and the recommended use and restrictions of the substance or product.
- Hazard(s) identification: This section provides the classification of the substance or product according to its physical, health, and environmental hazards. It also provides the signal word, hazard statements, precautionary statements, pictograms, and hazard codes that indicate the severity and nature of the hazards.
- Composition/information on ingredients: This section provides information on the ingredients of the substance or product, such as name, concentration, CAS number, etc. It also provides information on any impurities or additives that may affect its classification or hazards.
- First-aid measures: This section provides information on the first-aid measures for different routes of exposure, such as inhalation, ingestion, skin contact, eye contact, etc. It also provides information on the symptoms and effects of exposure and the indications for immediate medical attention or special treatment.
- Fire-fighting measures: This section provides information on the suitable and unsuitable extinguishing media for the substance or product. It also provides information on the specific hazards arising from the substance or product in case of fire, such as flammable gases, toxic fumes, etc., and the special protective equipment and precautions for firefighters.
- Accidental release measures: This section provides information on personal precautions, protective equipment, and emergency procedures for dealing with accidental spills or leaks of the substance or product. It also provides information on the methods and materials for containment and cleanup of the substance or product and its environmental precautions.
- Handling and storage: This section provides information on the safe handling practices and conditions for the safe storage of the substance or product. It also provides information on any incompatibilities or specific hazards that may arise from handling or storing the substance or product.
- Exposure controls/personal protection: This section provides information on the exposure limits and biological limit values for the substance or product, as well as the appropriate engineering controls and personal protective equipment to prevent or minimize exposure.
- Physical and chemical properties: This section provides information on the physical and chemical properties of the substance or product, such as appearance, odor, pH, melting point, boiling point, flash point, flammability, explosiveness, solubility, etc.
- Stability and reactivity: This section provides information on the stability and reactivity of the substance or product, such as its chemical stability, the possibility of hazardous reactions, conditions to avoid, incompatible materials, and hazardous decomposition products.
- Toxicological information: This section provides information on the toxicological effects of the substance or product, such as acute toxicity, chronic toxicity, carcinogenicity, mutagenicity, teratogenicity, etc. It also provides information on the routes of exposure, symptoms, and effects of exposure, and dose-response data.
- Ecological information: This section provides information on the ecological effects of the substance or product, such as its persistence and degradability, bioaccumulation potential, mobility in soil, aquatic toxicity, etc. It also provides information on the environmental fate and transport of the substance or product and its impact on the ozone layer or global warming.
- Disposal considerations: This section provides information on the safe and proper disposal methods for the substance or product and its contaminated packaging. It also provides information on any special precautions or regulations for waste disposal.
- Transport information: This section provides information on the transport classification and regulations for the substance or product according to different modes of transport, such as road, rail, sea, air, etc. It also provides information on any special handling or safety measures for transport.
- Regulatory information: This section provides information on the regulatory status and requirements for the substance or product according to different jurisdictions or regions, such as national, regional, or international laws or conventions. It also provides information on any safety or health labels or symbols for the substance or product.
- Other information: This section provides any other relevant information that is not covered in the previous sections, such as sources of data, references, abbreviations, acronyms, etc. It also provides information on the date of preparation or revision of the SDS.
Q. What is medication error, and how it is reported?
A. A medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication errors can occur at any stage of the medication process, such as prescribing, dispensing, administering, monitoring, or educating. Medication errors can result from various factors, such as human errors, system failures, communication breakdowns, knowledge gaps, etc.
- Medication errors should be reported as soon as possible to prevent or minimize harm to patients to learn from the errors and prevent their recurrence. Medication errors can be reported internally within the health care setting or externally to the relevant authorities or agencies.
- Internal reporting of medication errors involves notifying the immediate supervisor or manager, the patient, and their family or caregiver, the prescriber and other health care providers involved in the patient’s care, and the pharmacy or medication safety committee. Internal reporting of medication errors also involves documenting the error and its details, such as date, time, location, medication name, dose, route, frequency, etc., in the patient’s medical record and in the incident reporting system.
- External reporting of medication errors involves notifying the regulatory bodies or agencies that are responsible for monitoring and regulating medication safety and quality, such as the Food and Drug Administration (FDA), the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), the Institute for Safe Medication Practices (ISMP), etc. External reporting of medication errors also involves submitting the error and its details, such as date, time, location, medication name, dose, route, frequency, etc., in the online reporting system or form provided by the respective body or agency.
Q. What is drug recall?
A. A drug recall is a voluntary or mandatory action taken by a manufacturer or a regulatory authority to remove a drug from the market or to correct a defect or problem with a drug that may pose a risk to public health or safety. A drug recall can occur due to various reasons, such as:
- Contamination or adulteration of the drug with foreign substances or microorganisms
- Mislabeling or misbranding of the drug with incorrect or incomplete information
- Manufacturing or packaging defects that affect the quality, potency, purity, stability, or efficacy of the drug
- Discovery of new or serious adverse effects or interactions of the drug
- Violation of good manufacturing practices (GMP) or other regulations by the manufacturer
A drug recall can be classified into three categories according to the level of risk involved:
- Class I recall: This is the most serious type of recall that involves a situation where there is a reasonable probability that the use of or exposure to the drug will cause serious adverse health consequences or death.
- Class II recall: This is a less serious type of recall that involves a situation where the use of or exposure to the drug may cause temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote.
- Class III recall: This is the least serious type of recall that involves a situation where the use of or exposure to the drug is not likely to cause adverse health consequences.
Q. What are near-miss events with examples?
A. A near-miss event is an incident that could have resulted in harm but did not cause harm due to chance, prevention, or mitigation. A near-miss event is also known as a close call, a near hit,
- a good catch, or a potential adverse event. A near-miss event is an opportunity to identify and correct the underlying causes or factors that may lead to harm in the future.
- Some examples of near-miss events are:
- A nurse almost administers medication to the wrong patient but realizes the error before giving the medication
- A surgeon almost performs surgery on the wrong site but notices the discrepancy during the time-out procedure
- A pharmacist almost dispenses a medication with the wrong strength but catches the mistake during the final check
- A patient almost falls from the bed but is prevented by the side rails or the staff
- A laboratory technician almost reports a wrong test result but verifies the result with another method
Q. Which scale is used to assess fall risk, DVT, and bedsore?
A. There are different scales or tools that can be used to assess fall risk, deep vein thrombosis (DVT), and bedsore (also known as a pressure ulcer or decubitus ulcer) in patients. Some of the commonly used scales or tools are:
- Fall risk: The Morse Fall Scale (MFS) is a simple and quick tool that assesses six factors that are associated with fall risks, such as the history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. The MFS assigns a score to each factor and calculates a total score that ranges from 0 to 125. The higher the score, the higher the fall risk. The MFS categorizes patients into three levels of fall risk: low (0-24), moderate (25-50), and high (>50).
- DVT: The Caprini risk assessment model assigns 1 point for each general factor (except for age 41-60 years and minor surgery which are assigned 0.5 points each), 2 points for each mobility factor (except for medical patient at bed rest which is assigned 1 point), 3 points for each other present and past history factor (except for BMI >25 kg/m2 and other risk factors which are assigned 1 point each), and 5 points for each high-risk factor. The total score ranges from 0 to 53.
- The Caprini risk assessment model categorizes patients into four levels of VTE risk based on their total score:
- Low risk: 0 to 1 point
- Moderate risk: 2 points
- High risk: 3 to 4 points
- Highest risk: ≥5 points
The higher the score, the higher the VTE risk and the need for prophylaxis.
- Bedsore: The Braden Scale for Predicting Pressure Sore Risk is a tool that assesses six factors that are associated with bedsore risks, such as sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The Braden Scale assigns a score to each factor and calculates a total score that ranges from 6 to 23. The lower the score, the higher the bedsore risk. The Braden Scale categorizes patients into four levels of bedsore risk: very high (≤9), high (10-12), moderate (13-14), and mild (15-18).
Here, we have answered some common questions about various topics related to health care and patient safety, such as sentinel events, surrogate consent, narcotic drugs, international patient safety goals, vulnerable patients, fire extinguishers, NABH standards, quality indicators, patient rights and responsibilities, SDS, medication errors, drug recall, near miss events, and DVT assessment. We have used reliable sources and evidence-based information to provide informative and comprehensive answers. We hope that this blog post has helped you to learn more about these topics and to improve your knowledge and skills as a healthcare professional or a patient.
(1) National Accreditation Board for Hospitals & Healthcare Providers.
(2) National Accreditation Board for Hospitals & Healthcare Providers (NABH).
(3) Get Online National Accreditation Board for Hospitals and Health Care ….