NURSING DEPARTMENT

Quality and Patient Safety Rounds Checklist

Compliance ( tick as Remarks/action

STANDARDS/MEASURABLE ELEMENTS appropriate) needed
Yes No N.A
Scope of Service
Tell me about your ward , Staff should able to share the following:
 No. of beds in the ward/cubicle
 Are your wards usually full/ What the occupancy rate?
 Nurse to patient ratio in the ward
 How many units are you responsible for?
Staff doing the coordination is able to articulate
 No. Of working hours per shifts for nurses
 No. Of staff at each shifts in the wards
 Type of the delivery care system using in the unit.
 Specific core competency for professional staff to practice in
this ward
Could you tell me more about this patient? Staff should be able to share
the following ( Handover communication) :
 Situation
 background
 assessment
 Recommendation
Documentation - Completeness and Legibility
Legibility of patients clinical records is evidenced
 Every clinical record entry Identifies the data and name of person
who made the entry in the records
 Inpatients entries must also include date and time of entry
Doctors/nurses use the SOAP format in writing progress notes
Order forms and checklist are adequately filled in (e.g. Radiology
laboratory)
Standardizes symbols/abbreviations are used .No un approved
abbreviation used.
No parts of the patient form should be left blank "N.A" should be written in
those sections not deemed to be clinically relevant.
Identify patients correctly
 How do you identify patients
 How do you identify unknown /unconscious /uncommunicative
patients (e.g. comatose)?
 When do you use 2 patient's identifiers?
Verbal and Telephone orders -"Read Back"
 What is the procedure of taking down verbal/telephonic order for
the doctor or receiving &reporting critical test results?
 How do you do a verbal handover of your patients when you go for a
break? What do you inform the nurse.
Safety of High alert medications (HAM)
 Are there any high concentrated electrolyte her? Where should
they be kept?
 Why are the concentrated electrolytes kept in ICUs?
 For places that can store concentrated electrolytes, they are not
stored inpatient medication drawer or shelves
 What HAM do you have in the unit?
 Where is the list of High Alert Medication?
 Can high alert medications be stored with other drugs?
 Where are HAM placed/ stored &how do you ensure the safety of
HAM?
 Refrigerated drugs are
  Kept under lock and key
 Fridges should be located in secure areas allowing only
medical/nursing staff access.
How do you know how long you can keep the medications if near expired?
Do you have discard dates for medications and disinfectants once they are
opened?
What are the examples of measures used to improve the safety of high alert
medications
when do you serve PRN (pro re nata or "as needed") medication
Ensure Correct site/Procedure/Patient surgery
 When do you Time-out
 Do you document the completed time-out procedure? Where is it?
 What do you check before conducting the procedure?
 How is site making done?
 How do you involved patients during site making?
 When do you do site making?
Reduce risk of Healthcare Associated Infections(HAI)(IPSG5)
 When do you practice hand hygiene
 Staff practice correct hand washing and hand disinfection
techniques
 when do we hand wash and not hand rub?
 hand hygiene items are available /Alcohol hand rub at cubicles are
reasonably used
 What kind of training is there for staff on infection control
practices?
 What do you teach patient regarding infection control?
Reduce risk of patient Harm Reducing from Falls
 How do you determine the Score for falls risk?
 When is the initial falls risk assessment for all patients?
 When and how often do you do conduct the fall risk reassessment
for all patients?
 What interventions do you do those patients who are at fail risk?
 How do we know which patients here are at fall risk?
 How do you educate patients & families on falls prevention?
(Signage)
 What happens when a patient falls? How do you report falls?
Patients at risk for developing VTE are identified and managed.
 Patients are screened for the risk of developing VTE
 Patients at risk receive prophylaxis according to current evidence-
based practice.
 All acute patient undertake VTE Risk assessment at least twice
weekly by most responsible physician and nurse in charge to
review patient status and treatment.
Handling, use and administration of blood and blood products
 Only physicians order blood and blood products, No verbal and
telephone order should carried- out except emergency.
 The physician obtain informed consent for transfusion of blood
and blood of patient consent
 In dire emergencies, patient/family signs consent for
”Transfusion without NAT testing".
 Two staff members verify the patient’s identity prior to blood
drawing for cross match and prior to the administration of blood

 Patients receiving blood are closely monitored.

ASSESSMENT OF PATIENTS (AOP)
Initial Assessment/ Re-assessments
 What are the main factors in the Initial Assessment?
 How long do the doctor and nurses need to complete the initial
medical and nursing assessment of a patient?
 How often do you re -assess patient
Nutritional screening
 Do you do nutritional screening?
 What do you do when patient has nutritional risk?
  who can refer patient to the dietician?
Pain Assessment
 Do you screen for pain the initial assessment?
 How do you assess for pain /What do you measure?
 Pain score is documented
 What happens to the patient when significant pain is identified by
screening criteria?
 How often do you assess/re-assess for pain?
 Interventions and evaluation post pain interventions are
documented.
Discharge planning
 What's the time frame for discharge planning
PATIENTS &FAMILY EDUCATION(PFE)
 What are assessed and documented in the patient record?
 who initiates patient education
 What have you been communicating to the patient about
education?
 PFE form is adequately filled up
PATIENTS &FAMILY RIGHTS (PFR)
Consent Taking /Information Consent
 What is the process for obtaining consent
 Is the patient capable of give consent?
 Who do you obtain consent from if patient is incapable of giving
consent?
 What are some of the procedure and treatments that require
informed consent?
 Do you use family members as interpreters for consent?
 No medical abbreviations and symbols are used.
 No alterations made in the consent form.
Patient Privacy and confidentiality
 How do you ensure patient’s personal belongings are protected?
 How are patients protected from physical assault?
 How do you ensure patients privacy and confidentiality?
 Privacy is provided to patients during the care and
treatment(Observation)
 what if patient or family request for spirutual support?
Care of high Risk Patients/ High risk Services
 What is the timeframe to prepare patient's care plan?
 The patient's plan of care is documented in the medical record and
measurable goals are indicated, when appropriate.
 What are the High risk groups?
Do Not Resuscitate Orders (DNR) & Eternal of Care at the End of Life
 How is a DNR order made?
 Can the on call doctor (register and above ) make the DNR ?
 How often to you review the DNR?
 If Patient (on DNR) is not able to communicate , how do you assist
the family with decision on end of life case?
 If you are faced with unresolved ethical dilemmas, what do you do?
Use of Restraints
 Who can initiate restraint use for a patient?
 How often do you need to monitor patients on restraints?
 How long is each restraint order limited to?
ACCESS OF CARE AND CONTINUTY OF CARE (ACC)
Patient Transfer/Referral
 Patient transfer to ICU/ Specialized services is according to
criteria, and jointly agreed/ approved by primary team and ICU
doctor
 Who accompany patients during transfer
 when a patient is transferred to another healthcare organization,
What relevant documents are required to handover to the staff of
the receiving institution?
ANAESTHESIA AND SURGICAL CARE (ASC)
Sedation (Moderate sedation)
  What do you have to do before administering sedation?
 What minimum monitoring is provided when performing
sedation?
 How often do you monitor patient when performing sedation?
 What are the criteria for assessing the readiness for discharge to
ward from sedation monitoring?
 How do you know if the doctor has been to perform moderate
sedation is qualified?
Anesthesia
 Pre-anesthesia assessment performed
 Anesthesia care is planned and documented
 Patient is reassessed prior to induction of anesthesia by the
anesthesiology team?
 When do you monitor patient's physiological status?
 What tool do you use to monitor the physiological status?
 What are the criteria for patient to be discharge from PACU?
Surgery
 Before surgery, what assessment is needed?
 Patient is re-evaluated before surgery. Date and time documented
 Documentation of the following are completed in the surgical
reports and brief operative notes:
 Written operative report is completed and available before patient
leaves PACU
EMERGENCY RESUSCITATION
Emergency Medications
 Where can I find emergency medications?
 Emergency Medications are stored , maintained and protected
from loss o theft
 Emergency medications are available, monitored, and replaced
after use.
 How do you replace the medications In the crash cart?
 No expired items in the crash cart. Staff should know who checks
for the expiry dates.
Crash Cart
 Check that crash cart is locked &checking is documented daily.
 who checks the crash cart? How often do you check the items in
the crash cart? What do you checked for?
 Check defibrillator is complete with defibrillation pads.
 Staff able to demonstrate proficient testing of:
 Demonstrate fixing of a functioning laryngoscope.
 Demonstrate on how to do user test of defibrillator
 Demonstrate if the bi-Valve mask is working properly
Code blue activation
 Staff able to recognize and assess cardiac arrest to activate CPR
 Staff know the steps/ who to activate code blue
 What number to call during emergency resuscitation ?
MEDICATION MANAGEMENT AND USE (MMU)
Storage
 How are the medications stored?
 Medications are stored using First-in-first-out principle.
 How do you label look-alike and sound-alike medications?
 There is segregation of look-alike and sound-alike medications?
 Controlled drugs are checked each shift and kept locked in safe?
 The type of quality of controlled drugs physically available tallies
with the number recorded in the Narcotic Checklist
 Staff able to show log on drug wastage
 Staff able to show prescription for narcotics and controlled drugs?
 Drug fridge temperature maintained at 2°C-8°C.
 Staff interviewed can explain what he/she is supposed to do
o when the medication fridge temp is out of range.
 medications are properly and safely stored according to
recommended storage conditions as specified by manufacturers
 What is the procedure for inpatients who bring their own
 medication and for of patients own medication
 There is a procedure to stored and control sample medications.
Ordering and Transcribing
 Who or where can you look for where you have doubts/
clarification on the medications prescribed?
 Patients recorded contain a list of current medications taken prior
to admission and this information is made available to the
pharmacy and the patient's care providers.
 Initial medication orders are compared to the list of medications
taken prior to admission
 There are special precautions or procedure for ordering drugs
with look-alike and sound-alike names?
Preparing and Dispensing
 Injection trolleys are:
 Clean and tidy
 Assigned area for drug dilution
 Aseptic techniques observed during dilution
 Medication cart is clean and tidy
 Multi dose medication is dated upon opening.
 there are no expired medications/ tubes.
 How do you review medications prescriptions or orders for
appropriateness?
 Staff is able to articulate how to dispense the medication during
downtime
Administering Medications
 What is process of administering medications to patients?
 Drug allergies are identified and indicated
 What are the 10 rights of medication administration?
 Medication prescribed and administered is written in the patient's
record.
 What do you do with the leftover narcotics drug and consumable
used during administration of narcotics drugs?
 For medication prepared in a syringe or burette for continuous
infusion, is labeled :
Monitoring
 What do you do when adverse side effects are observed?
 What happens when there is a medication error/near misses?
 there is a medication recall system in place
 effect of medication documented
INFECTION CONTRO L
Equipment /disposables
Staff have knowledge of:
 Who is supposed to clean equipments
 Devices which are reused in the hospital (None)
Laundry and linen Management
 Soiled linen is appropriately disposed
 Linen is properly stored in covered cabinet
Waste Disposal
 Name some examples of waste
 How is general waste disposed?
 How do you dispose biohazard materials?
Sharps and needles
 Sharp boxes is less than ¾ filled
 What is the process of disposing the sharp box?
 No needle recapping in the unit
 Staff's knowledge of needle-stick injury protocol
Patients In Isolation
 What do you need to observe before entering an isolation room/
ward?
 Signage for isolation precaution are available and appropriate
 Personal protection Equipment (PPE) is available for use
 Staff educates patient's relatives to take precautions for patients in
isolation room
  What happens when isolation rooms are unavailable?
 Patients with known/ suspected diseases are isolated
appropriately
 Cases of MRSA infection are documented and reported
 What precautions do you have for MRSA patient?
Personal Protective Equipment
 Staff know which situations to use different levels of PPE
 Staff demonstrates correct techniques of Donning and doping of
PPE
FACILITY MANAGEMENT AND SAFETY
Safety and Security
 All staff and visitors are identified
Hazardous Materials
 How do you handle a chemical spill?
 Show your Materials Safety Datasheet(MSDS)
 Hazardous Chemical labeled with NFPA diamond sticker
 Give examples on the type of hazardous wastes.
 How do you dispose cytotoxic wastes?
Emergency Management
 Emergency phone numbers posted in the unit
 Evacuation route available
 Staff are oriented their role in case of emergency
 Staff has participated in Emergency Preparedness Exercise (at
least 1 per year)
Fire Safety
Staff is able to articulate procedures related to:
 Fire safety R.A.C.E. relating to fire
 Location of Fire Extinguishers
 P.A.S.S. relating to fire
 Location of Fire hose reel
 Contact number for fire safety reporting center
 Clear passage way for all fire exits
 Fire exit doors closed completely
 Location of fire assembly area
 Staff has participated in fire drills (at least 1 per yr)
Medical Equipment
 Preventive Maintenance of equipment is updated & documented
 Oxygen cylinders are stored properly in holder in a designated
area
 Point of Care Testing Equipment:
 Blood glucose testing machine
 show Quality records
 expiry date time frame
Utility Systems
 Show you uninterruptable power supply(UPS)
Utility Room-Clean
 Items are labeled and placed in correct containers
 Stock items are arranged in first in first out order
 No carton boxes on floor /All items are elevated from the floor
 No contaminated or dirty items in utility room
 No patient care items under the sink
 CSSD items are stored in a clean and dry area
 Check integrity of items
 Utility room door is kept closed
Utility Room-Dirty
 Room door is kept closed
 Separation of clean and dirty items
STAFF QUALIFICATIONS AND EDUCATION
Unit Staffing plan Staff schedule/roster in place
In the event of an emergency, what would your staffing response plan be?
Plan is in place for unexpected staff shortage
Job description are current and available for all staff
How do you ensure competency for your staff?
 Do all departments have a list of specific privileges for physician?
All staff wear name tags or identification badges
QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)
What are your quality data and measures / quality improvement projects?
What is a serious reportable event?
What is medication error?
What is a near miss?
What are steps to take in the event of a serious reportable event / near
miss?

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