ORANGE CITY HOSPITAL & RESEARCH INSTITUTE

Internal Assessment -ICU

Checklist: I.C.U ..
Date: - Time in:…….. Time out: …………
S No Checks Y/N/NA Remarks
Check awareness on Mission/vision/Quality Policy
1 and Values of the Hospital

Check For the Quality Indicators

2

Check awareness on No. of beds (Department &

3 Hospital)

Check awareness on scope of services

4

Check awareness on services which are not

5 available (RMO & Nursing stff)

6 Check for duty rosters of the employees

Check for handing over and takingover register/

7 Notes

Departmental policies and procedures are available.

8

9 Check Awareness on department manual

Check for process flow on emergency codes

10 anouncement (Disasters)
Departmental training register
11

Check for employee grievance process flow

12

Check whether the staff is aware of patient right and

13 responsibilities.
Check wheteher the staff is aware of the
14 (correct) process for handling patient complaints

Check family members are made aware of the same

15 (Display, Written information)

Staff is correctly aware of "what to do" in case of

16 accidental exposure to the blood or body fluid

Staff is aware about the colour codes of the

17 biomedical waste management rules and is using
that properly.
Handwash technique display is there at the wash
18 basin.Ask for demo.

Demo for the blood spill management correctly done

19 by staff.
Check whether that staff knows correctly about
20 "what to do" in the emergency situations (fire, bomb
threat) ?

Look for signages, fire exit are displayed. Fire exits

21 are free from obstruction.
 ORANGE CITY HOSPITAL & RESEARCH INSTITUTE

Internal Assessment -ICU

Checklist: I.C.U ..
Date: - Time in:…….. Time out: …………
S No Checks Y/N/NA Remarks
Fire fighting equipment are free from obstruction.
22

Check awareness on Adverse drug reaction

23

Training records of staff on CPR avilable and are

24 Staff aware about Code Blue .(All staff & RMO's to be
ACLS trained)

They know what to do in case of needle stick injury

25

26 check for use of PPE

They are aware of the adverse events, and Incident

27 reporting, Theft & Needle Stick Injury

Check staff is aware of external reporting

28 (Failure of equipment)
Check whether the staff is given Vaccination &
29
undergone Medical Check up.
Check Awareness on NABH ( No. of Standards,
30 Chapters, Objective elements)

Look-alike and sound alike medicines are store

31 separatly.(Apart from each other)
A list of High Risk Medicines is available?
32

The sterility /disinfection of thermometer is

33 maintained.
Temperature of the refrigerator is monitored
34 regularly

The crash cart is maintained properly.(1. Some

mechanism should be there to ensure that the
35 medicines in it are available in apt amount and are
not expired. 2. Defib is checked regularly. 3. Oxy
cylinder is checked regularly)

36 Staff is aware of occupation hazards

Check awareness on blood transfusion and reaction

37

A "plan of care" (consisting of the full treatment

38 pathway) is documented in medical record.

The patient is carried safely (safety belt etc) to and

39 from the dptt.
Patient are educated about their expected results of
40 treatment by both RMO's & Nurses
If the sample/specimen is collected at bedside, the
container is labelled properly after the sample is
41
collected and before moving to the next patient.
 ORANGE CITY HOSPITAL & RESEARCH INSTITUTE

Internal Assessment -ICU

Checklist: I.C.U ..
Date: - Time in:…….. Time out: …………
S No Checks Y/N/NA Remarks
All the equipment are calibrated on time periodically
42 and calibration records are maintained properly

Patients are explained about the risks, complications

involved in their treatment (blood
43 transfusion/surgery/other clinical intervention etc.)

Identity of the patient is verified before carrying him

44 for any procedure.
check whether the staff is immunised
45

There is no expired drug stored in the department.

46 (check randomly the drugs)

If the paient has to be restrained, does it happen

47 according to the policy? (reasons for restraint are
noted) Check consent & monitoring
Parenteral route Sedation is given to the patient by
the qualified staff.(no technician is qualified for this-
48 either nurse or doctor himself should sedate)

The admission/discharge criteria is followed in the

49 ICU. Staff is trained.
The situation of the bed shortage is handled as per
50 the policy. Ask Nurses & RMO's

Patients are educated about the pain management.

51

check for pain assessment and reassessment( as per

52 the hospital policy) done for all the patients (RMO &
Nurses)
The consent of the patient is taken and form is
53 complete. (RMO''s)

Does staff have list of treatment/Procedures where

54 consent to be taken.

Before administrating the drug to pateint she verifies

55 - patient id, name of drug, dose, route & time

Check awareness on self Administration of

56 medication
Check awareness on Medication bought from outside
57

Narcotics are stored in lock and proper records are

58 maintained. (Ask about policy & discard register)

check for temperature monitoring log

59

The equipment in the CPR kit are in working

60 condition. The kit is maintained properly. Ambu beg
ETO
 ORANGE CITY HOSPITAL & RESEARCH INSTITUTE

Internal Assessment -ICU

Checklist: I.C.U ..
Date: - Time in:…….. Time out: …………
S No Checks Y/N/NA Remarks
Check for awareness of colour codes of medical
61 gases.
The infection control nurse takes rounds and
62 educates the staff /patient for infection control.

Check for awareness on End of life care

63

Check Process flow on Handling death Cases

64

65 Check awareness on Isolation Room

The patients are issued wrist band for identification.

66 Ask vulnerable patient policy.

There are specially trained nurse for the ICU.

67

Nursing staff is aware of the high riks medicines &

68 Policy

Verbal orders are taken cautiously (minimising the

69 errors) Ask about policy.

Ask for the Procedure of How Endo Tracheal Tube

70 Intubation & Extubation is done

Awareness on hospital disinfectant policy

71

Awareness of all hospital forms

72

check the fumigation records

73

Ask for the Procedure for Feeding for Criticall Ill

74 Patients

Check whether device is dated (central line, urinary

75 catheter, ET tube)

Check whether suction apparatus is disinfected when

76 not in use and dated when in use

Check whether device care bundle is filled in

77 consonance with patient condition

AUDITEE NAME: AUDITOR NAME:

 ORANGE CITY HOSPITAL & RESEARCH INSTITUTE

Internal Assessment -ICU

Checklist: I.C.U ..
Date: - Time in:…….. Time out: …………
AUDITEE NAME: AUDITOR NAME:
S No Checks Y/N/NA Remarks
S No Checks Y/N/NA Remarks
Check awareness on
1 Mission/vision/Quality Policy and
Values of the Hospital
Check For the Quality Indicators
2

Check awareness on No. of beds

3
(Department & Hospital)
Check awareness on scope of
4
services
Check awareness on services
5 which are not
available (RMO & Nursing stff)
Check for duty rosters of the
6
employees
Check for handing over and
7
takingover register/ Notes
Departmental policies and
8
procedures are available.
Check Awareness on department
9 manual

Check for process flow on

10 emergency codes
anouncement (Disasters)
11 Departmental training register

Check for employee grievance

12
process flow
Check whether the staff is aware
13 of patient right and
responsibilities.
Check wheteher the staff is
aware of the
14
(correct) process for handling
patient complaints
Check family members are made
15 aware of the same
(Display, Written information)
Staff is correctly aware of "what
to do" in case of accidental
16
exposure to the blood or body
fluid
Staff is aware about the colour
codes of the biomedical waste
17 management rules and is using
that properly.

Handwash technique display is

18 there at the wash basin.Ask for
demo.
 Demo for the blood spill
19 management correctly done by
staff.
Check whether that staff knows
correctly about "what to do" in
20 the emergency situations (fire,
bomb threat) ?

Look for signages, fire exit are

21 displayed. Fire exits are free
from obstruction.
Fire fighting equipment are free
22
from obstruction.
Check awareness on Adverse
23
drug reaction
Training records of staff on CPR
avilable and are Staff aware
24 about Code Blue .(All staff &
RMO's to be ACLS trained)

They know what to do in case of

25
needle stick injury
26 check for use of PPE

They are aware of the adverse

events, and Incident reporting,
27
Theft & Needle Stick Injury

Check staff is aware of external

28 reporting
(Failure of equipment)
Check whether the staff is given
29 Vaccination & undergone Medical
Check up.
Check Awareness on NABH ( No.
30 of Standards, Chapters,
Objective elements)
Look-alike and sound alike
medicines are store separatly.
31
(Apart from each other)

A list of High Risk Medicines is

32
available?
The sterility /disinfection of
33
thermometer is maintained.
Temperature of the refrigerator
34 is monitored regularly
 The crash cart is maintained
properly.(1. Some mechanism
should be there to ensure that
the medicines in it are available
35 in apt amount and are not
expired. 2. Defib is checked
regularly. 3. Oxy cylinder is
checked regularly)

Staff is aware of occupation

36
hazards
Check awareness on blood
37
transfusion and reaction
A "plan of care" (consisting of
the full treatment pathway) is
38
documented in medical record.

The patient is carried safely

39 (safety belt etc) to and from the
dptt.
Patient are educated about their
expected results of treatment by
40
both RMO's & Nurses

If the sample/specimen is
collected at bedside, the
container is labelled properly
41
after the sample is collected and
before moving to the next
patient.
All the equipment are calibrated
on time periodically and
42
calibration records are
maintained properly
Patients are explained about the
risks, complications involved in
their treatment (blood
43
transfusion/surgery/other clinical
intervention etc.)

Identity of the patient is verified

44 before carrying him for any
procedure.
check whether the staff is
45
immunised
There is no expired drug stored
46 in the department. (check
randomly the drugs)
If the paient has to be
restrained, does it happen
according to the policy? (reasons
47
for restraint are noted) Check
consent & monitoring
 Parenteral route Sedation is
given to the patient by the
qualified staff.(no technician is
48
qualified for this-either nurse or
doctor himself should sedate)

The admission/discharge criteria

49 is followed in the ICU. Staff is
trained.
The situation of the bed
50 shortage is handled as per the
policy. Ask Nurses & RMO's
51 Patients are educated about the
pain management.
check for pain assessment and
reassessment( as per the
52
hospital policy) done for all the
patients (RMO & Nurses)
The consent of the patient is
53 taken and form is complete.
(RMO''s)
Does staff have list of
54 treatment/Procedures where
consent to be taken.
Before administrating the drug
to pateint she verifies - patient
55
id, name of drug, dose, route &
time
Check awareness on self
56
Administration of medication
Check awareness on Medication
57 bought from outside

Narcotics are stored in lock and

proper records are maintained.
58
(Ask about policy & discard
register)
check for temperature
59
monitoring log
The equipment in the CPR kit are
in working condition. The kit is
60
maintained properly. Ambu beg
ETO
Check for awareness of colour
61 codes of medical gases.

The infection control nurse takes

rounds and educates the staff
62
/patient for infection control.

Check for awareness on End of

63
life care
64 Check Process flow on Handling
death Cases
Check awareness on Isolation
65
Room
 The patients are issued wrist
66 band for identification. Ask
vulnerable patient policy.
There are specially trained nurse
67
for the ICU.
Nursing staff is aware of the
68
high riks medicines & Policy
Verbal orders are taken
69 cautiously (minimising the
errors) Ask about policy.
Ask for the Procedure of How
Endo Tracheal Tube Intubation &
70
Extubation is done

Awareness on hospital
71
disinfectant policy
Awareness of all hospital forms
72
73 check the fumigation records
Ask for the Procedure for
74 Feeding for Criticall Ill
Patients
Check whether device is dated
75 (central line, urinary catheter,
ET tube)
Check whether suction
apparatus is disinfected when
76
not in use and dated when in
use
Check whether device care
77 bundle is filled in consonance
with patient condition

AUDITEE NAME: AUDITOR NAME:

S No Checks Y/N/NA Remarks

Awarness

The initial assessment also includes the nutritional

1
assessment/screening by the dietician

A "plan of care" (consisting of the full treatment

2
pathway) is documented in medical record.

The patient is carried safely (safety belt etc) to and

3
from the dptt.

The staff is adequately qualified (chk the files in HR

4
dptt is required)

If the sample/specimen is collected at bedside, the

5 container is labelled properly after the sample is
collected and before moving to the next patient.

All the equipment are calibrated on time periodically

6
and calibration records are maintained properly
 Patient are educated about their expected results of
7
treatment

Patients are explained about the risks, complications

8 involved in their treatment (blood
transfusion/surgery/other clinical intervention etc.)

Identity of the patient is verified before carrying him

9
for any procedure.

The staff is well aware "what to do" if any person

10 (patient/patient relative/visitor) gets into a cardiac
arrest situation.

There is no expired drug stored in the department.

11
(check randomly the drugs)

12 check whether the staff is immunised

If the paient has to be restrained, does it happen

13 according to the policy? (reasons for restraint are
noted)

Parenteral route Sedation is given to the patient by

14 the qualified staff.(no technician is qualified for this-
either nurse or doctor himself should sedate)

The admission/discharge criteria is followed in the

15
ICU. Staff is trained.
 The situation of the bed shortage is handled as per the
16
policy.

17 Patients are educated about the pain management.

check for pain assessment and reassessment( as per

18
the hospital policy) done for all the patients

The consent of the patient is taken and form is

19
complete.

Staff knows how are the patients communicated about

20
their rights. (any display/brochure etc.)

The staff is aware of the (correct) process for handling

21 the patient complaints. (If not much they should at
least be able to directed the patient in such cases)

Look-alike and sound alike medicines are stored

22
separately.

Medicines are protected from lost of theft. (ensure the

23
mechanism is foolpoof)

A list of Medicines to be stored in the refrigerator is

24
available.
25 Temperature of the refrigerator is monitored regularly

Narcotics are stored in lock and proper records are

26
maintained.

27 check for temperature monitoring log

The crash cart is maintained properly. (1. some

mechanism should be there to ensure that the
28 medicines in it are available in apt amount and are not
expired, 2. Defib is checked regularly, 3. Oxy Cylinder
is checked regularly)

The equipment in the CPR kit are in working condition.

29
The kit is maintained properly.

30 Check for awareness of colour codes of medical gases.

The infection control nurse takes rounds and educates

31
the staff /patient for infection control.

Staff is correctly aware of "what to do" in case of

32 accidental exposure to the blood or body fluid (for
example sharp injury).
 Staff is aware about the colour codes of the
33 biomedical waste management rules and is using that
properly.

check for Handwash technique display near all the

34
wash basin area and ask for demo

Demo for the blood spill management correctly done

35
by staff.

36 Ask about quality/NABH/vision/mission.

37 Manual Awareness

Check whether that staff knows correctly about

38 "what to do" in the emergency situations (fire, bomb
threat) ?

39 Fire fighting equipment are free from obstruction.

40 Departmental policies and procedures are available.

The staff is aware of the grievance handling process

41
correctly (as in written HR policy of the hospital).
42 Check whether the staff is aware of their rights.

43 The staff is aware about the policy on patient abduction.

44 The visitors are allowed only when they have a valid pass

45 The patients are issued wrist band for identification.

46 There are specially trained nurse for the PICU/NICU.

47 Nursing staff is aware of the high riks medicines.

48 Verbal orders are taken cautiously (minimising the errors)

49 They know what to do in case of needle stick injury

Demo for the blood spill management correctly done by

50
staff.

51 check for use of PPE in ICU's

 They carry the samples to the lab safely as per Lab
52
protocol.

53 Awareness on BLS/ACLS

54 Awareness on hospital disinfectant policy

check for the maintenance of sterility of

55
thermometer

56 Awareness of all hospital forms

57 check the fumigation records

58 updated records and registers

Checklist: ICU
Date: ………………………. Time in: ……….………. Time out: ………………….
S. NO CHECKS Y/N/NA REMARKS
AAC.14 The organisation has a documented discharge process.
a.   The patient’s discharge process is planned in consultation with
    the patient and/ or family.
Policies and procedures exist for coordination of various
b.  
departments and agencies involved in the discharge process
  
(including medico-legal cases)
c.   Policies and procedures are in place for patients leaving against
    medical advice.
A discharge summary is given to all the patients leaving the
d.  
organization (including patients leaving against medical
  
advice).
AAC.15 Organisation define the content of the discharge summary.
a.   Discharge summary is provided to the patients at the time of
    discharge.
Discharge summary contains the reasons for admission,
b.  
significant findings and diagnosis and the patient’s condition at
  
the time of discharge.
Discharge summary contains information regarding
c.  
investigation results, any procedure performed, medication and
  
other treatment given.
d.   Discharge summary contains follow up advice, medication and
    other instructions in an understandable manner.
e.   Discharge summary incorporates instructions about when and
    how to obtain urgent care.
 f.    In case of death the summary of the case also includes the
  cause of death.
COP.1: Uniform care of patients is provided in all settings of the
organization and is guided by the applicable laws, regulations and
guidelines.
Care delivery is uniform when similar care is provided in more
a
than one setting.
Uniform care is guided by policies and procedures which
b
reflect applicable laws and regulations.
The care and treatment orders are signed, named, timed and
c
dated by the concerned doctor.
The care plan is countersigned by the clinician in-charge of the
d
patient within 24 hours.
Evidence based medicine and clinical practise guidelines are
e
adopted to guide patient care whenever possible.
COP.4: Policies and procedures guide the care of patients requiring
cardio-pulmonary resuscitation.
Documented policies and procedures guide the uniform use of
a
resuscitation throughout the organisation.
Staff providing direct patient care is trained and periodically
b
update in cardio pulmonary resuscitation.
The events during a cardio pulmonary resuscitation are
c
recorded.
A post-event analysis of all cardiac asserts is done by a
d
multidisciplinary committee.
Corrective and preventive measures are taken based on the
e
post-event analysis.
COP.5: Policies and procedures define rational use of blood and blood
products.
Documented policies and procedures are used to guide rational
a
use of blood and blood products.
 The transfusion services are governed by the applicable laws
b
and regulations.
Informed consent is obtained for donation and transfusion of
c
blood and blood products.
Informed consent also includes patient and family education
d
about donation.
e Staff is trained to implement the policies.
Transfusion reactions are analysed for preventive and
f
corrective actions.
COP.6: Policies and procedures guide the care of patients in the
intensive Care and High Dependency Units.
The organisation has documented admission and discharge
a
criteria for its intensive care and high dependency units.
b Staff is trained to apply these criteria.
c Adequate staff and equipment are available.
d Defined procedures for situation of bed shortages are followed.
e Infection control practices are followed.
f A quality assurance programme is implemented.
COP.7: Policies and procedures guide the care of vulnerable patients
(elderly, physically and/ or mentally challenged and children).
Policies and procedures are documented and are in accordance
a with the prevailing laws and the national and international
guidelines.
Care is organised and delivered in accordance with the policies
b
and procedures.
The organisation provides for a safe and secure environment
c
for this vulnerable group.
A documented procedure exists for obtaining informed consent
d
from the appropriate legal representative.
e Staff is trained to care for this vulnerable group.
COP.13: Policies and procedures guide the care of patients under
restraints (physical and/ or chemical).
Documented policies and procedures guide the care of patients
a
under restraints.
b These include both physical and chemical restraint measures.
c These include documentation of reasons for restraints.
d These patients are more frequently monitored.
Staff receive training and periodic updating in control and
e
restraint techniques.
COP.14: Policies and procedures guide appropriate pain
management.
Documented policies and procedures guide the management of
a
pain.
The organization respects and supports the appropriate
b
assessment and management of pain for all patients.
Patient and family are educated on various pain management
c
techniques.
COP.18: Policies and procedures guide the end of life care.
a Documented policies and procedures guide the end of life care.
These policies and procedures are in consonance with the legal
b
requirements.
These also address the identification of the unique needs of
c
such patient and family.
These also include sensitively addressing issues such as
d
autopsy and organ donation.
e Staff is educated and trained in end of life care.
MOM.5: Policies and procedures guide the safe dispensing of
medications.
Documented policies and procedures guide the safe dispensing
a
of medications.
b The policies include a procedure for medication recall.
 c Expiry dates are checked prior to dispensing.
Labeling requirements are documented and implemented by
d
the organization.

MOM.4: Policies and procedures exist for prescription of medications.

Documented policies and procedures exist for prescription of
a
medications.
b The organization determines who can write orders.
c Orders are written in a uniform location in the medical records.
Medication orders are clear, legible, dated, timed, named and
d
signed.
e Policy on verbal orders is documented and implemented.
f The organization defines a list of high risk medication.
g High risk medication orders are verified prior to dispensing.
MOM.6: There are defined procedures for medication administration.

Medications are administered by those who are permitted by

a
law to do so.
Prepared medication are labeled prior to preparation of a
b
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.
f Route is verified from the order prior to administration.
g Timing is verified from the order prior to administration.
h Medication administration is documented.
Polices and procedures govern patient’s self administration of
i
medications.
Polices and procedures govern patient’s medications brought
j
from outside the organization.
MOM.7: Patients and family members are educated about safe
medication and food-drug interactions.
Patient and family are educated about safe and effective use of
a
medication.
b Patient and family are educated about food-drug interactions.
MOM.10: Policies and procedures guide the usage of
chemotherapeutic agents.
Documented policies and procedures guide the usage of
a
chemotherapeutic agents.
Chemotherapy is prescribed by those who have the knowledge
b
to monitor and treat the adverse effect of chemotherapy.
Chemotherapy is prepared and administered by qualified
c
personnel.
Chemotherapy drugs are disposed off in accordance with legal
d
requirements.
PRE.2: Patient and family rights support individual beliefs, values
and involve the patient and family in decision-making processes.
Patient and family rights address any special preferences,
a
spiritual and cultural needs.
Patient and family rights include respect for personal dignity
b
and privacy during examination, procedures and treatment.
Patient and family rights include protection from physical
c
abuse and neglect.
Patient and family rights include treating patient information as
d
confidential.
e Patient and family rights include refusal of treatment.
Patient and family rights include informed consent before
f anaesthesia, blood and blood product transfusions and any
invasive/ high-risk procedures/ treatment.
 Patient and family right include information and consent before
g
any research protocol is initiated.
Patient and family rights include information on how to voice a
h
complaint.
Patient and family rights include information on the expected
i
cost of the treatment.
Patient and family have a right to have an access to his/ her
j
clinical records.
PRE.3: A documented process for obtaining patient and/ or family's
consent exists for informed decision making about their care.
General consent for treatment is obtained when the patient
a
enters the organisation.
Patient and / or his family members are informed of the scope
b
of such general consent.
The organisation has listed those situations where informed
c
consent is required.
Informed consent includes information on risks, benefits,
d alternatives and as to who will perform the requisite procedure
in a language that they can understand.
The policy describes who can give consent when patient is
e
incapable of independent decision-making.
PRE.4: Patient and families have a right to information and education
about their health care needs.

When appropriate, patient and families and are educated about

a the safe and effective use of medication and the potential side
effects of the medication.
b Patient and families are educated about diet and nutrition
c Patient and families are educated about immunisations.
Patient and families are educated about their specific disease
d
process, complications and prevention strategies.
e Patient and families are educated about preventing infections.
Patients and family are taught in a language and format that
f
they can understand.
ORANGE CITY HOSPITAL & RESEARCH INSTITUTE
Internal Assessment
Checklist: I.C.U ..
Date: - DEC-2018 Time in:…….. Time out: ……
S No Checks Y/N/NA
Remarks

Check awareness on
Mission/vision/Quality Policy and
Values of the Hospital

Check for department objectives

(awareness
and training record)

Check for Organisational Improvement

targets
(awareness, and training record)
4

Check For the Quality Indicators

5
Check awareness on No. of beds
(Department &
Hospital)
6 Check awareness on scope of services

7
Check awareness on services which are
not
available
8 Check for duty rosters of the employees
9 Check for handing over and takingover register

10

Departmental policies and procedures

are available.

11

Check Awareness on department manual,

Total No. of SOP

12

The departmental hierarchy is available

13

Check for List of records (Updates)

14 Check for job descriptions

15

Check for process flow on emergency

codes
anouncement (Disasters)

16

Check for Staff's soft skill

communication
(Training Record)

17

Check whether the staff is aware of their

rights.
18 Check for employee grievance process flow

19

Check whether the staff is aware of

patient right and responsibilities.
20

Check wheteher the staff is aware of the

(correct) process for handling patient
complaints

21

Check family members are made aware of

the same
(Display, Written information)

22

Staff is correctly aware of "what to do"

in case of accidental exposure to the
blood or body fluid (for example sharp
injury).
23

Staff is aware about the colour codes of

the biomedical waste management rules
and is using that properly.

24

Handwash technique display is there at

the wash basin.Ask for demo.

25

Demo for the blood spill management

correctly done by staff.

26

Check whether that staff knows

correctly about "what to do" in the
emergency situations (fire, bomb
threat) ?
27

Look for signages, fire exit are

displayed. Fire exits are free from
obstruction.

28

Fire fighting equipment are free from

obstruction.

29

Check awareness on Adverse drug

reaction

30

Training records of staff on CPR

avilable and are Staff aware about Code
Blue .

31

They know what to do in case of needle

stick injury

32
check for use of PPE
33

They are aware of the adverse events,

and Incident reporting, Theft & Needle
Stick Injury

34

Check staff is aware of external reporting

(Failure of equipment)

35

Check whether the staff is given

Vaccination & undergone Medical
Check up.

36

Check Awareness on NABH ( No. of

Standards, Chapters, Objective
elements) Training record.
37

Look-alike and sound alike medicines

are store separatly.

38

Medicines are protected from lost of

theft. (ensure the mechanism is
foolpoof)

39

A list of High Risk Medicines is

available?

40

The sterility /disinfection of

thermometer is maintained.

41

Temperature of the refrigerator is

monitored regularly
42

The crash cart is maintained properly.

(1. some mechanism should be there to
ensure that the medicines in it are
available in apt amount and are not
expired, 2. Defib is checked regularly, 3.
Oxy Cylinder is checked regularly)
43 Staff is aware of occupation hazards

44

Check awareness on 24 availability of

Medical
record dept
45 Check awareness on blood transfusion and reaction

The staff is adequately qualified (chk

46
the files in HR dptt is required)
 A "plan of care" (consisting of the full
47 treatment pathway) is documented in
medical record.

The patient is carried safely (safety belt

48
etc) to and from the dptt.

Patient are educated about their

49
expected results of treatment
 If the sample/specimen is collected at
bedside, the container is labelled
50
properly after the sample is collected
and before moving to the next patient.

All the equipment are calibrated on time

51 periodically and calibration records are
maintained properly
 Patients are explained about the risks,
complications involved in their
52 treatment (blood
transfusion/surgery/other clinical
intervention etc.)

Identity of the patient is verified before

53
carrying him for any procedure.

54 check whether the staff is immunised

There is no expired drug stored in the

55
department. (check randomly the drugs)
 If the paient has to be restrained, does it
56 happen according to the policy?
(reasons for restraint are noted)

Parenteral route Sedation is given to the

patient by the qualified staff.(no
57
technician is qualified for this-either
nurse or doctor himself should sedate)

The admission/discharge criteria is

58
followed in the ICU. Staff is trained.
 The situation of the bed shortage is
59
handled as per the policy.

Patients are educated about the pain

60
management.

check for pain assessment and

61 reassessment( as per the hospital policy)
done for all the patients

The consent of the patient is taken and

62
form is complete.
63

Does staff have list of treatment/Procedures

where consent to be taken.

64

Before administrating the drug to pateint

she verifies - patient id, name of drug, dose,
route & time

65

Check awareness on self Administration of

medication

66

Check awareness on Medication bought

from outside

Narcotics are stored in lock and proper

67
records are maintained.
68 check for temperature monitoring log

The crash cart is maintained properly.

(1. some mechanism should be there to
ensure that the medicines in it are
69
available in apt amount and are not
expired, 2. Defib is checked regularly, 3.
Oxy Cylinder is checked regularly)

The equipment in the CPR kit are in

70 working condition. The kit is maintained
properly.
 Check for awareness of colour codes of
71
medical gases.

The infection control nurse takes rounds

72 and educates the staff /patient for
infection control.

Staff is correctly aware of "what to do"

in case of accidental exposure to the
73
blood or body fluid (for example sharp
injury).
 Staff is aware about the colour codes of
74 the biomedical waste management rules
and is using that properly.

check for Handwash technique display

75 near all the wash basin area and ask for
demo

Demo for the blood spill management

76
correctly done by staff.

77

Check Awareness on General consent

( Patient Councelling)
78 Check for awareness on End of life care
79 Check Process flow on Handling death Cases
80 Check awareness on Isolation Room
 The patients are issued wrist band for
81
identification.

There are specially trained nurse for the

82
ICU.

Nursing staff is aware of the high riks

83
medicines.

Verbal orders are taken cautiously

84
(minimising the errors)

85 check for use of PPE in ICU's

86 They carry the samples to the lab safely as per Lab protocol.
87 Awareness on BLS/ACLS
88 Check weather the Staff is aware of End of Life Care

Ask for the Procedure of How Endo

89 Tracheal Tube
Intubation & Extubation is done
90 Awareness on hospital disinfectant policy
91 check for the maintenance of sterility of thermometer
92 Awareness of all hospital forms
93 check the fumigation records

94

Ask for the Procedure for Feeding for

Criticall Ill
Patients

95
Check for the awareness of Cleaning
Policy
in the ICU

AUDITEE NAME: AUDITOR

.. Time out: ……………….