essential safety requirements for CBAHI accreditation

1. ESR Standards
To be presented by:
Dr. Asmaa Fayez
Quality Specialist

2. Objectives:
Identify how many ESR standards
How to implement the ESR Standards
Involved departments and required standards for
them
Why each standard is chosen as an ESR?
Raise awareness by ESR importance
Offer knowledge about ESR intents and how to
comply?
Promote excellence in patient care

3. ‫ا‬ً‫ع‬‫ي‬ِ‫م‬َ‫ج‬ َ
‫اس‬َّ‫ن‬‫ال‬ ‫ا‬َ‫ي‬ْ‫ح‬َ‫أ‬ ‫ا‬َ‫م‬َّ‫ن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫َا‬‫ه‬‫ا‬َ‫ي‬ْ‫ح‬َ‫أ‬ ْ‫ن‬َ‫م‬ َ‫و‬
And whoever saves one- It is as if he had saved mankind entirely.

4. ‫مقدمة‬
• The central board for accreditation of
health care institutions has set the
basic national requirements for
patient safety in a list of 20 national
hospital standards as key
requirements that must be fully
adhered to, to ensure patient safety
from healthcare errors.
• In the current phase, the ministry has
focused on these criteria for it’s
importance .
• These standards included 9 different
sections as follows:
‫الصحي‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬ ‫وضع‬
‫ة‬
,
‫ف‬ ‫المرضي‬ ‫لسالمة‬ ‫األساسية‬ ‫الوطنية‬ ‫المتطلبات‬
‫ي‬
‫من‬ ‫قائمة‬
20
‫الوطنية‬ ‫المعايير‬ ‫من‬ ً‫ا‬‫معيار‬
‫للمستشفيات‬
,
‫ي‬ ‫أساسية‬ ‫اشتراطات‬ ‫واعتباره‬
‫جب‬
‫م‬ ‫المرضي‬ ‫سالمة‬ ‫لضمان‬ ‫كامل‬ ‫بشكل‬ ‫بها‬ ‫االلتزام‬
‫ن‬
‫الصحية‬ ‫بالرعاية‬ ‫المتعلقة‬ ‫األخطاء‬
.
‫هذه‬ ‫علي‬ ‫الحالية‬ ‫المرحلة‬ ‫في‬ ‫الوزارة‬ ‫ركزت‬
‫و‬ ‫الراهنة‬ ‫المرحلة‬ ‫في‬ ‫البالغة‬ ‫ألهميتها‬ ‫المعايير‬
‫شملت‬
‫المعايير‬ ‫هذه‬
9
‫التالي‬ ‫النحو‬ ‫علي‬ ‫مختلفة‬ ‫أقسام‬
:

5. ‫البشرية‬ ‫الموارد‬
Human
Resources(HR)
‫الطبية‬ ‫اإلدارة‬
Medical Staff
(MS)
‫الرعاية‬ ‫توفير‬
Provision of
Care (PC)
‫الجودة‬ ‫إدارة‬
Quality
Management
(QM)
‫التخدير‬
Anesthesia
Care (AN)
‫العدوي‬ ‫من‬ ‫الوقاية‬
‫ومكافحتها‬
Infection
prevention
and control
(IPC)
‫األدوية‬ ‫إدارة‬
Medication
Management
(MM)
‫المختبر‬
Laboratory
(LB)
‫المرافق‬ ‫إدارة‬
‫والسالمة‬
Facility
Management
and Safety
(FMS)
Involved departments
1 2 3 4 5
6 7 8 9

6. Essential Safety Requirements
• ESR are essential practices-
represented by a selected group
of standards that the hospitals
must fully met, to minimize the
risk of adverse/ sentinal events&
near miss.
• There are 20 ESR standards for
hospitals.
‫األساسية‬ ‫الممارسات‬ ‫هي‬
-
‫بمجموعة‬ ‫ممثلة‬
‫علي‬ ‫يجب‬ ‫التي‬ ‫المعايير‬ ‫من‬ ‫مختارة‬
‫تماما‬ ‫بها‬ ‫االلتزام‬ ‫المستشفيات‬
,
‫م‬ ‫للحد‬
‫ن‬
‫المخاطر‬
‫الحدوث‬ ‫وشيكة‬ ‫الجسيمة‬ ‫األحداث‬
.
‫هناك‬
20
‫معيار‬
ESR
‫للمستشفيات‬

7. ESR scoring system for each standard:
•Hospital passed if overall score ≥ 85%

8. Total ESR Standards : 20
Total ESR Sub-Standards: 113

10. HR.5
1

11. HR.5
‫للمرضي‬ ‫الصحية‬ ‫الرعاية‬ ‫لتقديم‬ ‫المؤهلين‬ ‫الصحيين‬ ‫الممارسين‬ ‫العتماد‬ ‫مناسبة‬ ‫الية‬ ‫المستشفى‬ ‫لدي‬
The hospital has a process for proper credentialing of staff members licensed to
provide patient care
1. The hospital has a written policy
describing the process used to verify
credentials.
2. The hospital collects, reviews and
evaluates accreditation
documents(license, education, training,
certification and experience) for
medical staff, training staff and other
health professionals licensed to
provide patient health care.
3. The credentials are verified from the
original source.
4. Work responsibilities and clinical work
assignments are based on the
assessment of credentials.
.1
‫العملي‬ ‫تصف‬ ‫مكتوبة‬ ‫سياسة‬ ‫المستشفى‬ ‫لدي‬
‫ة‬
‫االعتماد‬ ‫بيانات‬ ‫من‬ ‫للتحقق‬ ‫المستخدمة‬
.
.2
‫االعت‬ ‫وثائق‬ ‫ويقيم‬ ‫ويراجع‬ ‫المستشفى‬ ‫يجمع‬
‫ماد‬
(
‫والخبر‬ ‫والشهادة‬ ‫والتدريب‬ ‫والتعليم‬ ‫الرخصة‬
‫ات‬
)
‫المه‬ ‫من‬ ‫وغيرهم‬ ‫التدريب‬ ‫وطاقم‬ ‫الطبية‬ ‫للكوادر‬
‫نيين‬
‫الصحي‬ ‫الرعاية‬ ‫لتقديم‬ ‫لهم‬ ‫المرخص‬ ‫الصحيين‬
‫ة‬
‫للمرضي‬
.
.3
‫المصدر‬ ‫من‬ ‫االعتماد‬ ‫بيانات‬ ‫من‬ ‫التحقق‬ ‫يتم‬
‫األصلي‬
.
.4
‫السريرية‬ ‫العمل‬ ‫ومهام‬ ‫العمل‬ ‫مسئوليات‬
(
‫االمتيا‬
‫زات‬
)
‫االعتماد‬ ‫بيانات‬ ‫تقييم‬ ‫علي‬ ً‫ء‬‫بنا‬ ‫تتم‬

12. 5. Registeration of all health care
professionals in the saudi commission
for health specialties.
6. All employees licensed to provide
health care must have a valid work
permition in their specialties.
7. The hospital shall keep an updated
copy of the license of the authority and
the certificate of classification and
registeration for all health care workers
for reference if requested by an internal
or external entity.
8. When the credentials are verified
through a third party, the hospital must
request documents for confirmation
9. The verification process applies to all
categories of clinical staff(full or part
time, visitors or locum)
5
.
‫ال‬ ‫الرعاية‬ ‫في‬ ‫المتخصصين‬ ‫جميع‬ ‫تسجيل‬
‫صحية‬
‫في‬
‫الصحية‬ ‫للتخصصات‬ ‫السعودية‬ ‫الهيئة‬
.
6
.
‫الرعاي‬ ‫بتقديم‬ ‫لهم‬ ‫المرخص‬ ‫الموظفين‬ ‫جميع‬
‫ة‬
‫لديهم‬ ‫يكون‬ ‫أن‬ ‫يجب‬ ‫الصحية‬
‫سارية‬ ‫عمل‬ ‫رخصة‬
‫تخصصاتهم‬ ‫في‬ ‫المفعول‬
.
7
.
‫من‬ ‫محدثة‬ ‫بنسخة‬ ‫المستشفى‬ ‫يحتفظ‬
‫رخص‬
‫الهيئة‬ ‫ة‬
‫والتسجيل‬ ‫التصنيف‬ ‫وشهادة‬
‫العاملين‬ ‫لجميع‬
‫في‬
‫ط‬ ‫حال‬ ‫في‬ ‫اليها‬ ‫للرجوع‬ ‫الصحية‬ ‫الرعاية‬ ‫تقديم‬
‫لبها‬
‫خارجية‬ ‫او‬ ‫داخلية‬ ‫جهة‬ ‫من‬
.
8
.
‫خالل‬ ‫من‬ ‫االعتماد‬ ‫أوراق‬ ‫من‬ ‫التحقق‬ ‫يتم‬ ‫عندما‬
‫وثائق‬ ‫طلب‬ ‫المستشفى‬ ‫علي‬ ‫يجب‬ ‫ثالث‬ ‫طرف‬
‫للتأكيد‬
.
9
.
‫الم‬ ‫فئات‬ ‫جميع‬ ‫علي‬ ‫التحقق‬ ‫عملية‬ ‫تنطبق‬
‫وظفين‬
‫اإلكلينيكية‬
(
‫او‬ ‫زوار‬ ‫او‬ ‫جزئي‬ ‫او‬ ‫كامل‬ ‫دوام‬
locum
)

13. Why it is an ESR
• This is standard aims to improve
the safety of the services
provided to patients by holding
the hospital accountable for
ensuring that all staff members
who provide patient care have
the required qualifications that
enable them to provide safe and
effective patient care. Staff
qualifications are believed to
influence personal, professional,
and practice characteristics, and
consequently, can significantly
impact the provision of high-
quality patient care.
•
‫الي‬ ‫المعيار‬ ‫هذا‬ ‫يهدف‬
‫سالمة‬ ‫تحسين‬
‫للمرضي‬ ‫المقدمة‬ ‫الخدمات‬
‫تحمل‬ ‫خالل‬ ‫من‬
‫جميع‬ ‫أن‬ ‫ضمان‬ ‫مسؤولية‬ ‫المستشفى‬
‫للمرض‬ ‫الرعاية‬ ‫يقدمون‬ ‫الذين‬ ‫الموظفين‬
‫ي‬
‫م‬ ‫تمكنهم‬ ‫التي‬ ‫المطلوبة‬ ‫المؤهالت‬ ‫لديهم‬
‫ن‬
‫للمرضي‬ ‫وفعالة‬ ‫امنة‬ ‫رعاية‬ ‫توفير‬
.
•
‫عل‬ ‫تؤثر‬ ‫الموظفين‬ ‫مؤهالت‬ ‫ان‬ ‫ويعتقد‬
‫ي‬
‫والمهنية‬ ‫الشخصية‬ ‫الخصائص‬
,
‫والممارسة‬
,
‫وبالتالي‬
,
‫ب‬ ‫تؤثر‬ ‫أن‬ ‫يمكن‬
‫شكل‬
‫الجودة‬ ‫عالية‬ ‫رعاية‬ ‫توفير‬ ‫علي‬ ‫كبير‬
‫للمرضي‬
.

14. MS.7
2

15. MS.7
‫وسارية‬ ‫محددة‬ ‫سريرية‬ ‫امتيازات‬ ‫جميعا‬ ‫يمتلكون‬ ‫الطبي‬ ‫الطاقم‬ ‫أعضاء‬
Clinical Delinated Privileges
1. Medical staff members are allowed to
practice only within the limits granted
by the commission.
2. Clinical privileges are reviewed and
updated every two years as needed.
3. The hospital determines the
circumstanses in which emergency or
temporary benefits are granted.
4. Temporary or temporary privileges are
not granted for more than 90 days and
are non-renewable.
5. When a new license is requested by a
medical staff, the relevent credentials
are verified and evaluated prior to
approval.
.1
‫ف‬ ‫فقط‬ ‫بالممارسة‬ ‫الطبي‬ ‫الطاقم‬ ‫ألعضاء‬ ‫يسمح‬
‫ي‬
‫اللجنة‬ ‫تمنحها‬ ‫التي‬ ‫االمتيازات‬ ‫حدود‬
.
.2
‫ك‬ ‫وتحديثها‬ ‫السريرية‬ ‫االمتيازات‬ ‫مراجعة‬ ‫تتم‬
‫ل‬
‫الحاجة‬ ‫وحسب‬ ‫سنتين‬
.
.3
‫تمنح‬ ‫التي‬ ‫الظروف‬ ‫بتحديد‬ ‫المستشفى‬ ‫يقوم‬
‫فيها‬
‫مؤقتة‬ ‫او‬ ‫طارئة‬ ‫امتيازات‬
.
.4
‫م‬ ‫ألكثر‬ ‫تمنح‬ ‫ال‬ ‫المؤقتة‬ ‫او‬ ‫الطارئة‬ ‫االمتيازات‬
‫ن‬
90
‫للتجديد‬ ‫قابلة‬ ‫غير‬ ‫وهي‬ ‫يوما‬
.
.5
‫الطاقم‬ ‫أفراد‬ ‫أحد‬ ‫قبل‬ ‫من‬ ‫جديد‬ ‫امتياز‬ ‫طلب‬ ‫عند‬
‫الص‬ ‫ذات‬ ‫االعتماد‬ ‫أوراق‬ ‫من‬ ‫التحقق‬ ‫يتم‬ ‫الطبي‬
‫لة‬
‫الموافقة‬ ‫قبل‬ ‫وتقييمها‬
.

16. PC.25
3

17. PC.25
Policies and procedures guide the handling, use,
and adminstration of blood and blood products.
1. Availability of policy in the units/wards
2. Blood order is only made by physician
3. Full consent process by physician (elements of consent)
4. Two staff members verification (prior to blood drawing for cross
match and prior to the administration of blood)
5. Consent for transfusion without NAT testing in emergencies.
6. Applying accepted transfusion practices
7. Close monitoring during transfusion(monitoring intervals)
8. Related events reporting& corrective action
9. Side effects& complications reporting to staff & the blood
bank(with return of blood bag for investigation)

18. PC.26
4

19. PC.26
Patients at risk for developing venous
thromboembolism are identified and managed.
1- Screening for risk of developing VTE
2- Patient receive prophylaxis accordingly
3- Availability of mechanical prophylaxis

20. QM.17
5

21. QM.17
‫المرضي‬ ‫علي‬ ‫الصحيح‬ ‫التعرف‬ ‫لضمان‬ ‫مناسبة‬ ‫الية‬ ‫المستشفى‬ ‫لدي‬
The hospital has a process to ensure correct identification of
patients.
1. At least two ways of identifying
the patient (such as the patient’s
full name and medical file
number) are used when taking
blood samples, giving medicines
or blood derivatives, or
performing operations.
2. The hospital has a standard
approach and method to ensure
proper identification of patients (
such as using wrist band with
uniform information)
3. Patients actively participate in
the identification process.
.1
‫علي‬ ‫للتعرف‬ ‫معرفين‬ ‫هناك‬ ‫األقل‬ ‫علي‬
‫المريض‬
(
‫ورقم‬ ‫كامال‬ ‫المريض‬ ‫اسم‬ ‫مثل‬
‫الطبي‬ ‫الملف‬
)
‫ا‬ ‫عينات‬ ‫اخذ‬ ‫عند‬ ‫تستخدم‬
‫لدم‬
‫عند‬ ‫او‬ ‫الدم‬ ‫مشتقات‬ ‫او‬ ‫االدوية‬ ‫اعطاء‬ ‫او‬
‫العمليات‬ ‫اجراء‬
.
.2
‫موحدة‬ ‫وطريقة‬ ‫منهج‬ ‫لديه‬ ‫المستشفى‬
‫المرضي‬ ‫علي‬ ‫الصحيح‬ ‫التعرف‬ ‫لضمان‬
(
‫استخدام‬ ‫مثل‬
‫المعصم‬ ‫سوار‬
‫معلومات‬ ‫مع‬
‫موحدة‬
)
.3
‫ت‬ ‫عملية‬ ‫في‬ ‫بفعالية‬ ‫المرضي‬ ‫يشارك‬
‫حديد‬
‫المريض‬ ‫هوية‬
.

22. QM. 17
The hospital has a process to ensure correct
identification of patients.
1. Two patients identifiers (patient full name&
medical record number)
2. Standardized approach(when to identify
patients)
3. Room number is not used to identify
patients
4. Patients/ Family involvement
5. Availability of policy in the units/wards

23. Why it is an ESR
• Identifying patients correctly is vital for patient safety.
• The healthcare services are of a multidisciplinary nature, where in
many professionals provide care to each patient.
• Therefore, there is increased chance for misidentifying patient that
can result in harm to patient throughout the healthcare organization
including medications errors, blood transfusion errors, testing
errors, wrong person procedures, and the discharge of infants to the
wrong families.
• Misidentifying patients is identified as a common root cause of many
incidents and near misses.

24. QM.18
6

25. QM.18
The hospital has a process to prevent wrong patient,
wrong site, and wrong surgery/ procedure.
1. Process for prevention of wrong surgery (related Policy& procedure)
2. Include invasive procedures(intraoperative and outside OR)
3. Three phases: Verification, Site marking& Time out
4. Pre-operative verification ( correct spelling of name, correct MRN, correct
procedure)
5. Site marking (arrow marking to be done in the ward by the surgeon
who will perform the procedure)
6. When to site mark( laterality/ multiple structures e.g fingers, toes,
lesion/ multiple levels e.g spine/simultanous bilateral procedures.
7. Final check by Time out- active communication by the entire team
8. Documentation- Surgical Safety Checklist/ Non- OR procedural checklist

28. QM. 18
The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/ procedure.
‫الخطأ‬ ‫للمريض‬ ‫جراحة‬ ‫اجراء‬ ‫لمنع‬ ‫الية‬ ‫المستشفى‬ ‫لدي‬
,
‫الخطأ‬ ‫بالموقع‬
,
‫الخطأ‬ ‫الجراحة‬ ‫أو‬
• Surgeries on the wrong patient or body part such as removing a
kidney from the wrong patient or amputating the wrong limb are rare
but extremly unacceptable.
• Such errors are classified as “ Never Events” because they should
never occur.
• “ However, such mishaps can be prevented by adopting certain
strategies and procedures that improve communication among staff
and between staff& patient, support patient involvement, improve
patient assessment, and improve legibility of information in medical
records.

30. Time out forms

31. AN.2
7

32. AN.2
Anesthesia staff members have the appropriate
qualifications
1. Qualified anesthesiologists ( Qualification& Privilege)
2. Qualified anesthetist in OR during surgeries
3. Anesthesia consultant for major operations (Pediatric
operations, cardio-pulmonary operations, neurosurgery
operations, and transplant operations)
4. ACLS/PALS certification (PALS is anesthesiologist participating
in pediatric operations)

33. AN.15
8

34. AN.15
Qualified staff perform moderate and deep
sedation/ analgesia
1- Competency- based privileges of physicians (non-
anesthesiologists)
2- ACLS/ PALS certification (PALS if clinical staff is participating
in pediatric group)
3- Proper education/ training

35. IPC.4
9

36. IPC.4
There is a designated multidisciplinary committee
that provides oversight of the IPC program
1. IPC committee (TOR-Terms of
refernce)
2. Membership (Multidisciplinary
involvement)
3. Regular meetings (quarterly)-
documented minutes of the
meetings
4. Detailed functions & documental
record

37. IPC.4
There is a designated multidisciplinary committee that provides oversight of the
infection prevention and control program.
‫ومراقبتها‬ ‫العدوي‬ ‫مكافحة‬ ‫برنامج‬ ‫علي‬ ‫لألشراف‬ ‫معينة‬ ‫التخصصات‬ ‫متعددة‬ ‫لجنة‬ ‫المستشفى‬ ‫لدي‬
.
•
4
.
‫علي‬ ‫تقتصر‬ ‫وال‬ ‫تتضمن‬ ‫اللجنة‬ ‫مهام‬
:
(1
‫العدوى‬ ‫مكافحة‬ ‫قسم‬ ‫وإجراءات‬ ‫سياسات‬ ‫مراجعة‬
‫ومراقبتها‬
(2
‫ومراقبتها‬ ‫العدوى‬ ‫مكافحة‬ ‫قسم‬ ‫تقارير‬ ‫استعراض‬
‫المناسبة‬ ‫اإلجراءات‬ ‫واقتراح‬ ‫ومراجعتها‬
(3
‫او‬ ‫اإلضافات‬ ‫واقتراح‬ ‫للقسم‬ ‫السنوية‬ ‫الخطة‬ ‫مراجعة‬
‫االمر‬ ‫لزم‬ ‫اذا‬ ‫التغييرات‬
(4
‫ال‬ ‫وإجراءات‬ ‫لسياسات‬ ‫المستمر‬ ‫والتنقيح‬ ‫التقييم‬
‫لخدمة‬ ‫قسم‬
‫بها‬ ‫المعمول‬ ‫والمعايير‬ ‫األهداف‬
.
(5
‫وم‬ ‫ومراقبتها‬ ‫العدوي‬ ‫مكافحة‬ ‫لقضايا‬ ‫االنتباه‬ ‫لفت‬
‫ما‬ ‫تابعة‬
‫األقس‬ ‫في‬ ‫ومكافحتها‬ ‫العدوي‬ ‫مراقبة‬ ‫أمور‬ ‫من‬ ‫يستجد‬
‫ام‬
‫الحلول‬ ‫وتقديم‬
(6
‫فيم‬ ‫صحي‬ ‫كمثقف‬ ‫يعمل‬ ‫اللجنة‬ ‫أعضاء‬ ‫من‬ ‫عضو‬ ‫كل‬
‫ا‬
‫ادارته‬ ‫او‬ ‫قسمه‬ ‫في‬ ‫ومكافحتها‬ ‫العدوي‬ ‫مراقبة‬ ‫يخص‬
‫الصحيح‬ ‫بالشكل‬ ‫تطبيقها‬ ‫وضمان‬
.
.1
‫الطبي‬ ‫المدير‬ ‫اللجنة‬ ‫يرأس‬
.2
‫العامل‬ ‫عن‬ ‫ممثال‬ ‫تشمل‬ ‫اللجنة‬ ‫عضوية‬
‫ين‬
‫التمريض‬ ‫وطاقم‬ ‫الطبي‬ ‫المجال‬ ‫في‬
‫والتعقي‬ ‫العمليات‬ ‫وغرفة‬ ‫والمختبر‬
‫م‬
‫وخدمات‬ ‫الصيدالنية‬ ‫والرعاية‬ ‫المركزي‬
‫بأ‬ ‫القائمة‬ ‫الشركة‬ ‫من‬ ‫وممثل‬ ‫التغذية‬
‫عمال‬
‫الع‬ ‫مكافحة‬ ‫قسم‬ ‫من‬ ‫وممثلين‬ ‫النظافة‬
‫دوي‬
‫الحاجة‬ ‫حسب‬ ‫أخر‬ ‫قسم‬ ‫وأي‬ ‫ومراقبتها‬
.3
‫ومحدد‬ ‫منتظمة‬ ‫بصورة‬ ‫اللجنة‬ ‫تجتمع‬
‫ة‬
‫سابقا‬
(
‫كل‬
3
‫األقل‬ ‫علي‬ ‫أشهر‬
.)

38. IPC.15
10

39. IPC.15
Facility design and available supplies support
isolation practices
1. Negative pressure airborne isolation room (at least one in ER& one in patient care areas/ and one in every
25-30 beds in general hospitals)
2. Ventilation system & pressure maintenance (Negative pressure/Air exhaust / High efficiency / Particular air
{HEPA} filter / Daily validation if pt. & weekly if no pt./ 12 air change per hr./ record)
3. Ante-room (standardized) equibed with PPEs
4. Extra facilities (all required amenities)
5. Transmission based precaution cards(isolation instructions {bilingual}/ color coding/ isolation sign/
highlighting while transporting the patients)
6. Respirator masks( usage& availability)
7. Respirator masks(re-usage specifications)

42. IPC.15
Facility design and available supplies support isolation
practices
‫الحاجة‬ ‫عند‬ ‫المرضي‬ ‫عزل‬ ‫ممارسات‬ ‫االمدادات‬ ‫وتوفر‬ ‫المنشأة‬ ‫تصميم‬ ‫يدعم‬
1. The hospital has isolation rooms with
negative pressure in emergency and in
patient care areas(sections)
2. Infection warning cards (isolation
signals) are consistent with patient
diagnosis and are in both arabic and
english and indicate the type of
precautions required.
3. (N-95/N-99) Masks are used by staff
when providing direct patient care and
are available in all sections masks can
be reused by the same
person(healthcare provider) according
to the manufacturer’s specified
duration.
.1
‫المستشفى‬ ‫في‬ ‫يوجد‬
‫سلب‬ ‫ضغط‬ ‫ذات‬ ‫عزل‬ ‫غرف‬
‫ي‬
‫المرضي‬ ‫رعاية‬ ‫مناطق‬ ‫وفي‬ ‫الطوارئ‬ ‫في‬
(
‫األقس‬
‫ام‬
)
.2
‫التهوية‬ ‫نظام‬
‫يضمن‬ ‫العزل‬ ‫غرف‬ ‫في‬ ‫المستخدم‬
‫المستش‬ ‫من‬ ‫اخري‬ ‫مناطق‬ ‫الي‬ ‫العدوي‬ ‫انتقال‬ ‫عدم‬
‫فى‬
.3
‫العدوي‬ ‫من‬ ‫التحذير‬ ‫بطاقات‬
(
‫العزل‬ ‫إشارات‬
)
‫تت‬
‫فق‬
‫العرب‬ ‫باللغتين‬ ‫وتكون‬ ‫المريض‬ ‫تشخيص‬ ‫مع‬
‫ية‬
‫الال‬ ‫االحتياطات‬ ‫نوع‬ ‫الي‬ ‫وتشير‬ ‫واالنجليزية‬
‫زمة‬
.4
‫التنفس‬ ‫أقنعة‬ ‫تستخدم‬
(
N-95/ N-99
)
‫قبل‬ ‫من‬
‫للمري‬ ‫المباشرة‬ ‫الرعاية‬ ‫تقديم‬ ‫عند‬ ‫الموظفين‬
‫ض‬
‫األقسام‬ ‫جميع‬ ‫في‬ ‫متوفرة‬ ‫وتكون‬
.
.5
‫الشخ‬ ‫نفس‬ ‫قبل‬ ‫من‬ ‫األقنعة‬ ‫استخدام‬ ‫إعادة‬ ‫يمكن‬
‫ص‬
(
‫الصحية‬ ‫الرعاية‬ ‫مقدم‬
)
‫من‬ ‫المحددة‬ ‫المدة‬ ‫حسب‬
‫المصنعة‬ ‫الشركة‬
.

43. MM.5
11

44. MM.5
High alert medications
‫الخطرة‬ ‫االدوية‬ ‫لسالمة‬ ‫نظام‬ ‫المستشفى‬ ‫لدي‬
1. There is a multidisciplinary written policy for
the management of high-risk drugs and
hazardous pharmaceutical chemicals
2. The hospital makes an annual list of high-risk
drugs and hazardous pharmaceutical
chemicals.
3. The hospital carries out a plan for the
management of high-risk drugs and
hazardous pharmaceutical chemicals,
including but not limited to:
1. Improve access to information on high-risk
drugs
2. Reduce access to high-risk drugs
3. Use cards and computing as they become
available
4. Standardization of writing, preparation,
drainage, management and control of high-risk
drugs.
5. Double check by Two employees
.1
‫هناك‬
‫االختصاصات‬ ‫متعددة‬ ‫مكتوبة‬ ‫خطة‬
‫إلدارة‬
‫الخط‬ ‫الدوائية‬ ‫والكيماويات‬ ‫الخطورة‬ ‫عالية‬ ‫االدوية‬
‫رة‬
.2
‫بعمل‬ ‫المستشفى‬ ‫يقوم‬
‫لألد‬ ‫سنويا‬ ‫تحدث‬ ‫قائمة‬
‫وية‬
‫الخطرة‬ ‫الدوائية‬ ‫والكيماويات‬ ‫الخطورة‬ ‫عالية‬
.3
‫الخطو‬ ‫عالية‬ ‫االدوية‬ ‫إلدارة‬ ‫خطة‬ ‫المستشفى‬ ‫ينفذ‬
‫رة‬
‫تقتص‬ ‫وال‬ ‫تشتمل‬ ‫الخطرة‬ ‫الدوائية‬ ‫والكيماويات‬
‫علي‬ ‫ر‬
:
.1
‫فرص‬ ‫تحسين‬
‫المعلومات‬ ‫علي‬ ‫الحصول‬
‫حول‬
‫الخطورة‬ ‫عالية‬ ‫االدوية‬
.2
‫الخطورة‬ ‫عالية‬ ‫االدوية‬ ‫الي‬ ‫الوصول‬ ‫من‬ ‫الحد‬
.3
‫توفرها‬ ‫حال‬ ‫والحوسبة‬ ‫البطاقات‬ ‫استخدام‬
.4
‫واإلدارة‬ ‫والصرف‬ ‫واالعداد‬ ‫الكتابة‬ ‫توحيد‬
‫الخطورة‬ ‫عالية‬ ‫لألدوية‬ ‫والمراقبة‬
.5
‫اثنين‬ ‫موظفين‬ ‫قبل‬ ‫من‬ ‫التحقق‬ ‫يتم‬

45. MM.5
The hospital has a system for the safety of high-
alert medications(HAM).
1. Written multidisciplinary plan for HAM&
hazardous pharmaceutical chemicals(P&P)
2. Annually updated list
3. Awarness /Access/Labeling/Storage /Usage /
Standard Precautions / Independent Double
checking
4. Standard concentration for IV fluids

46. MM.6
12

47. MM.6
‫متش‬ ‫تبدو‬ ‫التي‬ ‫االدوية‬ ‫من‬ ‫للسالمة‬ ‫نظام‬ ‫المستشفى‬ ‫لدي‬
‫الشكل‬ ‫ابهة‬
‫واالسم‬
(LASA)
1. The hospital has policies and
procedures for dealing with
drugs that look similar in
shape and name(LASA)
2. The hospital will review and
revise the list of drugs that
appear to be similar in shape
and Name (LASA) annually in
storage, drainage and
distribution sites.
.1
‫المستشفى‬ ‫لدي‬
‫سياسات‬
‫وإجرا‬
‫ءات‬
‫تبدو‬ ‫التي‬ ‫االدوية‬ ‫مع‬ ‫للتعامل‬
‫واالسم‬ ‫الشكل‬ ‫متشابهة‬
(
LASA
)
.2
‫وتراجع‬ ‫المستشفى‬ ‫تستعرض‬
‫وتعدل‬
‫االدوية‬ ‫قائمة‬
‫تبدو‬ ‫التي‬
‫واالسم‬ ‫الشكل‬ ‫متشابهة‬
LASA)
)
‫التخز‬ ‫أماكن‬ ‫في‬ ‫سنوية‬ ‫بصورة‬
‫ين‬
‫والتوزيع‬ ‫الصرف‬ ‫وأماكن‬

48. •
3
.
‫باأل‬ ‫المعلقة‬ ‫األخطاء‬ ‫لمنع‬ ‫إجراءات‬ ‫باتخاذ‬ ‫المستشفى‬ ‫تقوم‬
‫دوية‬
‫يلي‬ ‫ما‬ ‫ذلك‬ ‫في‬ ‫بما‬ ‫واالسم‬ ‫الشكل‬ ‫متشابهة‬ ‫تبدو‬ ‫التي‬
:
(1
‫ا‬ ‫لمقدمي‬ ‫االدوية‬ ‫هذه‬ ‫يخص‬ ‫فيما‬ ‫والتدريب‬ ‫التعليم‬ ‫تقديم‬
‫لرعاية‬
‫المستمر‬ ‫الطبي‬ ‫والتعليم‬ ‫التعريف‬ ‫من‬ ‫كجزء‬ ‫الصحية‬
(2
‫لألدوية‬ ‫التجاري‬ ‫واالسم‬ ‫العلمي‬ ‫االسم‬ ‫استخدام‬
(3
‫األدوية‬ ‫وصف‬ ‫عند‬ ‫التشخيص‬ ‫كتابة‬
(4
‫الشكل‬ ‫متشابهة‬ ‫لألدوية‬ ‫الخارجي‬ ‫المظهر‬ ‫تغيير‬
(5
‫الص‬ ‫وعند‬ ‫العالج‬ ‫الي‬ ‫الوصول‬ ‫عند‬ ‫بعناية‬ ‫التسمية‬ ‫قراءة‬
‫رف‬
(6
‫الهاتفية‬ ‫واالوامر‬ ‫اللفظية‬ ‫األوامر‬ ‫استخدام‬ ‫تقليل‬
(7
‫الدواء‬ ‫صرف‬ ‫قبل‬ ‫التشخيص‬ ‫من‬ ‫التحقق‬
(8
‫أما‬ ‫في‬ ‫واالسم‬ ‫الشكل‬ ‫متشابهة‬ ‫تبدو‬ ‫التي‬ ‫االدوية‬ ‫ترتيب‬
‫كن‬
‫الهجائي‬ ‫الترتيب‬ ‫علي‬ ‫تعتمد‬ ‫ال‬ ‫بطريقة‬ ‫منفصلة‬

50. MM.6
12

51. MM.6
The hospital had a system for the safety of Look-
Alike and Sound-Alike(LASA) medications.
1. Multidisciplinary policy on handling LASA
2. Annual review of list
3. Error prevention related to LASA
medicines by available error prevention
strategies (Awareness/ usage of both generic
&brand names/ indication on prescription/
changing appearance/ careful reading
/minimizing verbal/ telephone orders/
double check/ Labeling/ Placing)

52. List of Top 10 Sound-Alike and Look-Alike Drugs

53. Why it is an ESR?
• Look-alike, Sound-alike (LASA) medications account for an estimated
25-30% of medications errors.
• Look-alike medications: Names of medications, which due to their
spelling, may look similar to other medications’ names, and the
distribution/ administration of these medications may be prone to
errors. Also refer to product labeling/ packaging.
• Example: Prozac and Proscar
• Sound-alike medications: Names of medications, which due to their
prononciation, may sound similar to other medications’ names, and
the distribution/ administration of these medications may be prone
to errors. Example: Ceftazidime and Ceftizoxime

54. MM.41
13

55. MM.41
The hospital has a process for monitoring, identifying, and reporting significant
medication errors, including near misses, hazardous conditions, and at- risk
behaviours that have the potential to cause patient harm.
1. Multidisciplinary policy
2. Definition of significant medication error, near misses, and
hazardous situations.
3. Physician is notified
4. Specified time frame of reporting
5. Standard format for reporting
6. Staff education
7. Active reporting (OVR)
8. Root-cause analysis
9. Documented in patient file
10. Data usage for prevention &improvement
11. Feedback to staff
12. Related Sentinal events reporting

57. Right medication .
6
Right dose .
2
Right route
3
Right time and frequency
4
1
10
9
8
7
5
Right patient
Right reason/assessment Right education Right to refuse Right evaluation Right documentation
The 10 Rights of Medication Administration are:

60. MM.41
‫الجسيمة‬ ‫الخطرة‬ ‫والحاالت‬ ‫الطبية‬ ‫األخطاء‬ ‫عن‬ ‫والتبليغ‬ ‫علي‬ ‫والتعرف‬ ‫للرصد‬ ‫مناسبة‬ ‫الية‬ ‫المستشفى‬ ‫لدى‬
‫بما‬
‫الحدوث‬ ‫القريبة‬ ‫األخطاء‬ ‫ذلك‬ ‫في‬
‫المريض‬ ‫يضر‬ ‫ان‬ ‫يحتمل‬ ‫الذي‬ ‫للمخاطر‬ ‫المعرض‬ ‫والسلوك‬
( near missess,senttinal events, at-risk behaviour, hazardous condition)
1. There are multidisciplinary policies and
procedures to deal with drug errors,
near misses, and hazardous situations.
2. The policy contains an acceptable and
clear definition of drug errors and near
missess, hazardous situation
3. The doctor is notified when medication
error occur in time
4. The report of drug errors is completed
within the specified timeframe after the
error has been detected
5. The hospital has a standard form for
reporting drug errors
.1
‫للتع‬ ‫التخصصات‬ ‫متعددة‬ ‫وإجراءات‬ ‫سياسات‬ ‫هناك‬
‫امل‬
‫الحدوث‬ ‫القريبة‬ ‫واالخطاء‬ ‫الدوائية‬ ‫األخطاء‬ ‫مع‬
‫الخطرة‬ ‫والحاالت‬
.2
‫لأل‬ ‫وواضح‬ ‫مقبول‬ ‫تعريف‬ ‫علي‬ ‫السياسة‬ ‫تحتوي‬
‫خطاء‬
‫الحدوث‬ ‫القريبة‬ ‫واألخطاء‬ ‫الدوائية‬
,
‫الخطر‬ ‫الحاالت‬
‫ة‬
.3
‫األخطاء‬ ‫حدوث‬ ‫عند‬ ‫المعالج‬ ‫الطبيب‬ ‫اخطار‬ ‫يتم‬
‫الوقت‬ ‫في‬ ‫الدوائية‬
.4
‫االطار‬ ‫ضمن‬ ‫الدوائية‬ ‫األخطاء‬ ‫عن‬ ‫التقرير‬ ‫اكتمال‬
‫الخطأ‬ ‫اكتشاف‬ ‫بعد‬ ‫المحدد‬ ‫الزمني‬
.5
‫األخطاء‬ ‫عن‬ ‫لإلبالغ‬ ‫موحد‬ ‫نموذج‬ ‫المستشفى‬ ‫لدي‬
‫الدوائية‬

61. •
6
.
‫العمل‬ ‫طاقم‬ ‫توعية‬
‫الدوائية‬ ‫األخطاء‬ ‫عن‬ ‫التبليغ‬ ‫عملية‬ ‫بأهمية‬
•
7
.
‫وجود‬
‫الدوائية‬ ‫األخطاء‬ ‫عن‬ ‫نشطة‬ ‫تقارير‬
‫الخط‬ ‫والحاالت‬ ‫الحدوث‬ ‫القريبة‬ ‫واألخطاء‬
‫رة‬
•
8
.
‫بأجراء‬ ‫المستشفى‬ ‫تقوم‬
‫الجذرية‬ ‫لألسباب‬ ‫مكثفة‬ ‫تحاليل‬
(
RCA
)
‫الدوائية‬ ‫األخطاء‬ ‫لجميع‬
‫الحدوث‬ ‫متكررة‬ ‫او‬ ‫الكبيرة‬
•
9
.
‫يتم‬
‫الدوائية‬ ‫األخطاء‬ ‫توثيق‬
‫السج‬ ‫في‬ ‫الخطرة‬ ‫والحاالت‬ ‫الحدوث‬ ‫قريبة‬ ‫واألخطاء‬
‫ل‬
‫للمريض‬ ‫الطبي‬
•
10
.
‫البيانات‬ ‫هذه‬ ‫المستشفى‬ ‫تستخدم‬
‫الدواء‬ ‫استخدام‬ ‫عملية‬ ‫لتحسين‬
‫األخط‬ ‫ومنع‬
‫الدوائية‬ ‫اء‬
‫المرضي‬ ‫سالمة‬ ‫وتحسين‬
•
11
.
‫الخ‬ ‫والحاالت‬ ‫الحدوث‬ ‫قريبة‬ ‫واألخطاء‬ ‫الدوائية‬ ‫األخطاء‬ ‫لتقارير‬ ‫مراجعة‬ ‫عمل‬ ‫يتم‬
‫طرة‬
‫الصحية‬ ‫الرعاية‬ ‫مقدمي‬ ‫الي‬
•
12
.
‫المعنية‬ ‫الجهات‬ ‫الي‬ ‫الجسيمة‬ ‫الدوائية‬ ‫األخطاء‬ ‫تقارير‬ ‫المستشفى‬ ‫ترفع‬

62. • Medications errors compromise patient confidence in the health-
care system and increase health- care costs.
• Many medication errors are probably undetected.
• The outcome(s) or clinical significance of many medication errors may
be minimal, with few or no consequences that adversely affect a
patient.
• TRAGICALLY, however, some medication eroors result in serious
patient morbidity or mortality.
• A medication error is defined as any preventable event that may
cause or lead to inappropriate medication use or patient harm while
the medication is in the control of the health care professional,
patient, or consumer.

63. • Such events may be related to professional practice, health care
products, procedures, systems, including prescribing , order
communication, product labelling, packaging, and nomenclature,
compounding, dispensing, distribution, administration, education,
monitoring and use.

65. LB.51
14

66. LB.51
The blood bank develops a process to prevent disease
transmission by blood/platelet transfusion.
1. Policy & procedures for infectious diseases’s tests
2. Limiting & detection of contamination (investigation of
+ve cases/ reliable methods) provision of required
equipment.

68. FMS.9
15

69. FMS.9
The hospital ensures that all it’s occupants are safe from
radiation hazards
‫االشعاعات‬ ‫أخطار‬ ‫من‬ ‫امنين‬ ‫شاغليها‬ ‫كل‬ ‫ان‬ ‫المستشفى‬ ‫تضمن‬
.1
‫التنفيذ‬ ‫قيد‬ ‫وهي‬ ‫االشعاع‬ ‫من‬ ‫السالمة‬ ‫سياسة‬ ‫لديه‬ ‫المستشفى‬
.2
‫االش‬ ‫مستويات‬ ‫لضمان‬ ‫بانتظام‬ ‫وتختبر‬ ‫السينية‬ ‫االشعة‬ ‫لغرف‬ ‫التدريع‬ ‫شهادة‬
‫المسموح‬ ‫عاع‬
‫بها‬
.3
‫التناسلية‬ ‫الغدد‬ ‫دروع‬
/
‫و‬ ‫الموظفين‬ ‫واحتياجات‬ ‫المرضي‬ ‫لتغطية‬ ‫متاحة‬ ‫الدرقية‬ ‫الغدة‬
‫يتم‬
‫وجردها‬ ‫سنويا‬ ‫اختبارها‬
.4
‫التشخيصية‬ ‫االشعاع‬ ‫جرعات‬ ‫مقاييس‬ ‫تتوفر‬
(TLD cards)
‫كل‬ ‫وتختبر‬
3
‫أشهر‬
‫يتم‬ ‫ومن‬
‫االختبار‬ ‫تتجاوز‬ ‫عندما‬ ‫اإلجراءات‬ ‫اخذ‬

70. FMS.9
The hospital ensures that all its occupants are safe from
radiation hazards.
1. Radiation safety policy
2. Clear labeling &safe storage of all radioactive
material
3. License from KAACST for hospital
4. Qualification and certificates by KAACST, for the
handling staff
5. Valid shielding certificates& regular testing for
permitted radiation level
6. Lead aprons and glands shields & their regular
testing
7. Personal radiation dosimeters(TLD cards)

71. FMS.21
16

72. FMS.21
The hospital has an effective fire alarm system
1. Fire alarms/ Civil Defense Certificates
2. Documentation of regular inspection
3. Preventive maintenance
4. Connection of system in elevators

73. FMS.21
The hospital has an effective fire alarm system
‫فعال‬ ‫نظام‬ ‫المستشفى‬ ‫لدي‬
‫لألنذار‬
‫الحريق‬ ‫ضد‬
• A fire alarm system operates
and is regularly inspected
according to Civil defense
instructions
• The results of the fire alarm
system test are documented
• There is preventive
maintenance of the fire
alarm system.
.1
‫وي‬ ‫يعمل‬ ‫للحريق‬ ‫انذار‬ ‫نظام‬ ‫هناك‬
‫تم‬
‫تعليمات‬ ‫حسب‬ ‫بانتظام‬ ‫فحصه‬
‫المدني‬ ‫الدفاع‬
.2
‫نظا‬ ‫اختبار‬ ‫نتائج‬ ‫توثيق‬ ‫يتم‬
‫انذار‬ ‫م‬
‫الحريق‬
.3
‫اإلنذا‬ ‫لنظام‬ ‫وقائية‬ ‫صيانة‬ ‫يوجد‬
‫ر‬
‫الحريق‬ ‫ضد‬

74. FMS.22
17

75. FMS.22
The hospital has a fire suppression system available in
the required area(s).
1. Functional Sprinkler System
2.Clean agent suppression system
3. Wet chemical system
4. Stand pipes and hose system

76. FMS.22
The hospital has a fire suppression system available in the required
area(s).
‫المطلوبة‬ ‫المناطق‬ ‫في‬ ‫فعال‬ ‫حريق‬ ‫اخماد‬ ‫نظام‬ ‫المستشفى‬ ‫لدي‬
1. Sprinkling system
2. Clean agent suppression
system
3. Wet chemical system
4. There is a fire extinguishing
system based on pipes and
hoses
.1
‫الذاتي‬ ‫الرش‬ ‫نظام‬
.2
‫النظيف‬ ‫الرش‬ ‫نظام‬
(Clean agent
suppression system)
.3
‫الرطبة‬ ‫الكيميائية‬ ‫البودرة‬ ‫نظام‬
(
wet
chemical system )
.4
‫االنابيب‬ ‫علي‬ ‫معتمد‬ ‫إطفاء‬ ‫نظام‬ ‫يوجد‬
‫والخراطيم‬

77. FMS.23
18

78. FMS.23
There are fire exits that are properly located in
the hospital
1. Availability & locations
2. Not locked
3. Not Obstructed
4. With panic hard ware
5. Fire resistant
6. Marked with illuminated sign

79. FMS.23
There are fire exits that are properly located in the hospital
‫المستشفى‬ ‫أنحاء‬ ‫في‬ ‫صحيح‬ ‫بشكل‬ ‫وموزعة‬ ‫متوفرة‬ ‫الطوارئ‬ ‫مخارج‬
• Fire outlets are
available and located
correctly in the
hospital
• The doors are not
locked
• There is no
impediment to
access
• Panic hard ware
• Fire resistant
• Clearly marked by
installing a panel of
luminous exits
.1
‫وت‬ ‫الحريق‬ ‫مخارج‬ ‫تتوفر‬
‫قع‬
‫المست‬ ‫في‬ ‫صحيح‬ ‫بشكل‬
‫شفى‬
.2
‫مقفلة‬ ‫ليست‬ ‫األبواب‬
.3
‫الوصول‬ ‫يعيق‬ ‫ما‬ ‫يوجد‬ ‫ال‬
‫اليها‬
.4
‫دفع‬ ‫قضيب‬ ‫عليها‬
(panic
hard ware)
.5
‫للحريق‬ ‫مقاومة‬
.6
‫بتث‬ ‫وذلك‬ ‫بوضوح‬ ‫تكون‬
‫بيت‬
‫مضيئة‬ ‫مخارج‬ ‫لوحة‬

80. FMS.24
19

81. FMS.24
The hospital and it’s occupants are safe from fire and
smoke
1. No smoking policy
2. No obstruction (to fire extinguishers/ fire alarm boxes/
emergency blankets/ safety showers/ eye wash station)
3. Emergency lighting
4. Safe & well organized storage areas(P&P)
5. Fire rated doors (without gap between walla & ceilings)

82. FMS.24
The hospital and its occupants are safe from fire and smoke
‫الحريق‬ ‫من‬ ‫مأمن‬ ‫في‬ ‫وشاغلوه‬ ‫المستشفى‬ ‫مبني‬
1. Hospital applies a “no smoking” policy
strictly.
2. There are no barriers to fire extinguishers,
fire alarm boxes, emergency blankets,
safety showers, and eye wash stations.
3. Emergency lighting is sufficient for safe
evacuation of the hospital.
4. Storage areas are organized correctly &
safely
1. The shelves are strong and in good condition.
2. There are no items stored directly on the
floor( leaving at least 10 cm for floor
cleaning)
3. The items should be placed on a flat base
4. Heavy objects are close to the ground, lighter
or smaller at the top
.1
‫سياسة‬ ‫يطبق‬ ‫المستشفى‬
"
‫التدخين‬ ‫ممنوع‬
"
‫بصر‬
‫امة‬
.2
‫الحريق‬ ‫طفايات‬ ‫علي‬ ‫عوائق‬ ‫أية‬ ‫توجد‬ ‫ال‬
,
‫ا‬ ‫وصناديق‬
‫نذار‬
‫الطوارئ‬ ‫وبطانيات‬ ‫الحريق‬
,
‫السالمة‬ ‫ودش‬
,
‫ومحطات‬
‫العين‬ ‫غسل‬
.3
‫األمن‬ ‫لألخالء‬ ‫كافية‬ ‫الطوارئ‬ ‫حاالت‬ ‫في‬ ‫اإلضاءة‬
‫للمستشفى‬
.4
‫وامن‬ ‫صحيح‬ ‫بشكل‬ ‫التخزين‬ ‫مناطق‬ ‫تنظيم‬ ‫يتم‬
.1
‫جيدة‬ ‫حالة‬ ‫وفي‬ ‫قوية‬ ‫الرفوف‬
.2
‫األرض‬ ‫علي‬ ‫مباشرة‬ ‫تخزن‬ ‫سلع‬ ‫يوجد‬ ‫ال‬
(
‫يقل‬ ‫ال‬ ‫ما‬ ‫ترك‬
‫االرضيات‬ ‫لتنظيف‬ ‫سنتيمترات‬ ‫عشرة‬ ‫عن‬
)
.3
‫مسطحة‬ ‫قاعدة‬ ‫علي‬ ‫العناصر‬ ‫توضع‬ ‫ان‬ ‫يجب‬
.4
‫األرض‬ ‫من‬ ‫قريبة‬ ‫الثقيلة‬ ‫األشياء‬
,
‫األص‬ ‫او‬ ‫وزنا‬ ‫واألخف‬
‫غر‬
‫األعلى‬ ‫في‬

83. FMS.32
20

84. FMS.32
The hospital ensures proper maintenance of the medical gas
system
‫الطبية‬ ‫الغازات‬ ‫لنظام‬ ‫المناسبة‬ ‫الصيانة‬ ‫يضمن‬ ‫المستشفى‬
• The medical gas system is regularly
tested for pressure leakage
• Working valves, alarm, pressure
gauge and switches.
• Central medical gas station in a
safe place.
• The hospital provides backup
oxygen cylinders for 48 h. Of
average consumption.
• Gas cylinders are regularly tested
to determine the type of gas, the
quantity and the absence of
leaking.
.1
‫م‬ ‫بانتظام‬ ‫يختبر‬ ‫الطبية‬ ‫الغازات‬ ‫نظام‬
‫أجل‬ ‫ن‬
‫الضغط‬ ‫تسرب‬
.2
‫الضغط‬ ‫وعداد‬ ‫واالنذار‬ ‫الصمامات‬ ‫عمل‬
‫والمفاتيح‬
.3
‫مكان‬ ‫في‬ ‫المركزية‬ ‫الطبية‬ ‫الغازات‬ ‫محطة‬
‫امن‬
.4
‫االوكسجي‬ ‫أسطوانات‬ ‫يوفر‬ ‫المستشفى‬
‫ن‬
‫س‬ ‫وأربعين‬ ‫لثمان‬ ‫يكفي‬ ‫لما‬ ‫االحتياطية‬
‫اعة‬
‫االستهالك‬ ‫متوسط‬ ‫من‬
.5
‫لم‬ ‫بانتظام‬ ‫الغاز‬ ‫أسطوانات‬ ‫اختبار‬ ‫يتم‬
‫عرفة‬
‫تسريب‬ ‫وجود‬ ‫وعدم‬ ‫والكمية‬ ‫الغاز‬ ‫نوع‬
.

85. FMS.32
The hospital ensures proper maintenance of the
medical gas system.
1. Regular testing & maintenance for pressure& leaks and functionally
( of all components- valves, alarms, pressure gauge & switches)
2. Policy for effective use& all documents
3. Compressed medical air regular testing for humidity & purity.
4. Safety & Security of central medical gas station.
5. Clearly marked outlets
6. Clearly marked pipes(content / flow direction)
7. Standardized fixing & maintenance of pipes
8. Standby Oxygen and medical air cylinders
9. Regular testing (type / amount/ any leakage)
10. Emergency shut off valves
11. Shut off valve closed by well trained staff
12. Standardized & adequate outlets

87. ‫الكريم‬ ‫لحضوركم‬ ‫شكرا‬