QUESTIONS FOR

NURSING
DR EMAD KOTB
QUALITY MANAGEMENT DIRECTOR
NR.54.EC5 There is compliance with patient
restraint
policy.
Observation
2. MS.24.EC2 Crash carts which contain
intubation
equipment.
Observation
3. MS.24.EC3 Crash carts contain venous
access equipment. Observation
4. MS.24.EC5 There is crash cart
adequately equipped &
available in all the critical areas , that are age
specific (e.g. neonate, infant, child, adult).
5. MS.24.EC6 Defibrillator that are in
good working order. Observation
6. MS.24.EC7 Availability of oxygen
cylinder in all the critical
areas.
Observation
7. MS.24.EC8 Availability of portable
suction machine in all
the critical areas.
Observation
8. MS.87.EC2 Availability of fully
equipped Ambulance. Observation
9. NR.3.EC2 Nursing staff can state the
nursing
department mission, vision, values and goals.
Interview
10. NR.5.EC2 Operational plan is prepared
with nursing
leaders (head nurses) participation.
Interview
11. NR.14.EC2 Implementation of patient
care delivery
system functional team, total care.
Observation
12. NR.18.EC2 Allocating staff is according to
patient type
and acuity on unit.
Interview
QM.18.EC1 Observation in the patient care areas (ICU,
ER, OR, L&D etc.) of IV free-flow protection.
Interview
14. NR.21.EC1 Delegation to non-nursing staff
assignments
under supervision of registered nurse.
Interview
15. NR.29.EC1 Availability of all adequate basic
supplies and
equipment of unit stock (patient scales,
stretchers with safety straps,vital sign
equipment,wheelchairs with safety straps,
sharp box, foot stools, lifting device, soft
restraint, bed rails, devices equipment to
prevent skin breakdown, patient call bells,
oxygen and suction, emergency call).
Observation
16. NR.31.EC1 Availability of all reference manual
and/or
policies in each nursing unit (policy ad
procedure manual, current nursing practice
books, infection control, safety manual,
operating manuals for equipment, lab
information, dietary).
Observation
17. NR.33.EC1 Nursing staff adhere patient and family
rights
policies (informed consent, communication of
patient/family concern and documentation in
the medical record).
Interview
18. NR.34.EC1 Availability of patient spaces to ensure
patients privacy with male and female rooms
identified.
Observation
19. NR.36.EC1 Nurse are aware of and implement
the OVR
system (able to complete the report/form).
Interview
20. AN.34.EC2 Availability of one registered nurse
who is
certified with BCLS and preferably ACLS /
PALS is at the patient side constantly and
continuously monitors the patient.
Observation
21. NR.37.EC1 Nurse are aware of and implement
the
sentinel event system (able to complete the
report/form, nurses must know sentinel
event definition, who to contact for sentinel
event).
Interview
NR.39.EC2 Nurses are aware of and implement
patients
protection process (vulnerable children,
disabled individuals, and the elderly
populations).
Observation
23. NICU.14.EC1 NICU staff encourages
mother-infant bonding
(e.g. breast feeding).
Interview
24. NR.40.EC1 Nurses orientation of
medical equipment use,
trouble shooting and report of malefunctioning.
Interview
25. NR.45.EC2 Implementation of
preoperative preparation
policy.
Observation
26. L&D.10.EC2 The Midwives are
allowed to deal with only
uncomplicated deliveries, and physician back
up is immediately available.
Interview
27. NR.46.EC2 Implementation of
medication administration
policies.
Observation
28. NR.47.EC1 Implementation of
medication administration
policies emphasizing the 7 rules of medication
administration.
Interview
29. NR.53.EC2 There is proper patient
identification process
(two identifiers - medical record number and
patients name).
Observation
30. NR.53.EC3 There is verification of
patient identity by two
hospital staff prior to blood drawing for cross
match and prior to administration of blood.
Observation
31. NR.55.EC2 There is compliance with
newborn
identification policy.
Observation
32. NR.56.EC2 Keeping the patient
covered when attending
to his/her physical needs.
Observation
33. NR.59.EC1 Nursing awareness of end of
life care and
assessment and documentation in the
response to the psychological, emotional,
spiritual and cultural concerns of the patient
and family.
Interview
34. NR.66.EC2 There is awareness of nursing
staff about
safety, security and medical equipment
operation and maintenance.
Interview
35. NR.67.EC2 There is awareness of nursing
staff on their
role during mock event.
Interview
36. QM.15.EC1 Observations of lab
specimens and
medications to be administered (have two
patient identifiers).
Interview
37. QM.15.EC2 Hospital staff are aware about
the two
patient identifiers and when to be used.
Interview
38. PFE.1.EC1 The education department has
adequate
resources to carry out its mandate (enough
space, office equipment, computers, health
publications, educational pamphlets and
adequate staff [diabetic educator, patient
educator]).
Observation
39. PFE.2.EC2 Medical and nursing staff
interviewed can
state their role in patient education.
Interview
40. PFE.5.EC1 Patient can state the name
of his/her
attending physician.
Interview
41. AN.15.EC1 Recovery room equipment
(pulse oximetry,
automated blood pressure monitor, EGG
machine, crash cart with defibrillator, wall
suction or suction equipment, oxygen).
Observation
42. AN.21.EC1 Written criteria on patient
discharge from the
Recovery room.
Interview
43. AN.22.EC1 Effective emergency call
system in Recovery
room.
Observation
44. ICU.11.EC1 Availability of all ICU
essential equipment and
supplies (ventilators, tracheostomy set,
defilbrillators, pulse oximetry, vital signs
monitor, transfusion pumps).
Observation
45. ICU.12.EC2 Regular inspection of
intubations, ventilation
tools and equipments.
Observation
46. ICU.12.EC1 Availability of functional
tools and equipment
for intubation and ventilation.
Observation
47. ICU.13.EC2 Implementation of
infection control
guidelines.
Observation
48. ICU.13.EC1 Availability of ICU
isolation room for patients
with infectious or communicable diseases.
Observation
49. CCU.6.EC1 Availability of all CCU
essential equipment
(ventilators, tracheostomy set, defibrillator,
pulse oximetry, transfusion pumps).
Observation
50. CCU.11.EC1 Availability of functional
tools and equipment
for intubation and ventilation.
Observation
51. CCU.12.EC2 Implementation of
infection control
guidelines in CCU.
Observation
52. CCU.12.EC1 Availability of CCU isolation room for
patients
with communicable diseases or infections.
Observation
53. CCU.15.EC1 Availability of equipped and accessible
crash
cart.
Observation
54. NICU.11.EC1 Availability of all essential NICU
equipment
and supplies (Ventilators, Pulse oximetry,
Infant resuscitator, Incubators, Portable
incubators with portable ventilators, Infusion
pump/syringe pumps, Trach sets).
Observation
55. NICU.12.EC1 Availability of functional tools and
equipment
of intubation and ventilation in NICU.
Observation
NICU.12.EC2 Regular inspection of NICU tools
and
equipment of intubation and ventilation.
Observation
57. NICU.13.EC1 Availability of NICU
isolation area for
neonates with communicable diseases or
infections.
Observation
58. NICU.13.EC2 Implementation of
infection control
guidelines.
Observation
59. OR.5.EC2 The patient is accepted into
the OR only after
proper identification, checking consent form
for completion, checking operation
procedures and surgeon name, surgery site,
x-ray jacket, lab results, pre-anesthesia
sheet,
history and physical exam, and reserved
blood.
Interview
60. OR.9.EC2 Strict implementation of
sponge count
(sponge count log sheet or form to check).
Observation
61. OR.9.EC3 There is an instrument count
(instrument log
sheet or form to check).
Observation
62. L&D.12.EC1 Availability of all L&D necessary
equipment
"Vital signs monitor, Pulse oximetry, Infusion
pump, Glucometer, CTG monitor/CTg for
twins, Amnihook, Assist delivery instruments ,
Forceps and ventose, Infant resuscitator".
Observation
63. ER.18.EC1 Availability of all essential
Emergency Room
equipments (Crash cart with defibrillator, and
emergency drugs, pulse oximetry, intubation
equipment and chest tubing).
Observation
64. ER.19.EC1 Availability of all essential
Emergency Room
equipment (portable x-ray, abdominal lavage
set, infusion pumps, oxygen, suction,
immobilization device, delivery set, IV access
set, poison antidotes and thrombolytics).
Observation
65. ER.25.EC1 Daily check of essential
ambulance
equipment including oxygen, intubation set,
C-spine cuff, spinal board, and suction
machine (log book).
Observation
72. DT.5.EC2 There is staff compliance
with the manual
guidelines.
Observation
93. NR.49.EC2 Compliance with narcotics
and
controlled substances
management policy.
Interview
94. NR.49.EC3 Availability of narcotic
safe box
/storage spaces, secure with double /doors
locks.
Observation
22 ER.13.EC1 ER staff are able to receive
STAT lab results
within 30 minutes for critical cases.
Log sheet STAT lab results within 30
minutes for critical cases.
ER.13.EC2 ER staff are able to receive
Lab results within
one hour for urgent cases.
23 LB.22.EC1 Accessible and approved,
current or reviewed
(every 2 year) lab procedure manual.
Procedure manuals e.g. sectional
policies
NR.53.EC1 Availability of written
multidisciplinary policy
and procedure on Blood and Blood Products
(handling,
use, administration, 2 patient identifiers, 2
nurses verify patient identity prior to blood
drawing and
administration).
Issuing and administration of Blood
and Blood Products multidisciplinary policy
and procedure