Fms the fire alarm system has preventive maintenance

ESR Standards

	Only physicians order blood and in accordance with a policy clarifying when blood and blood products may be ordered. The physician obtain informed consent for transfusion of blood and blood products. PC.25.3.5 Giving the right to accept or refuse the transfusion. Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to the administration of blood. Transfusion reactions are reported and analyzed for preventive and corrective actions. Side effects or complications are immediately reported to the medical staff and blood bank and the transfused unit is sent to the blood bank for further investigations.
PC.26

QM.17
QM.17.1 QM.17.2
QM.18	The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure.

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IPC.4	There is a designated multidisciplinary committee that provides oversight of the infection prevention and control program.
IPC.4.1 IPC.4.2	Functions of the infection prevention and control committee include, but are not limited to, the following: IPC.4.4.1 Review of the hospital infection prevention and control policies and procedures. IPC.4.4.2 Review of the reports of healthcare-associated infections surveillance submitted regularly by the infection prevention and control team and suggestion of appropriate actions.
IPC.15	Facility design and available supplies support isolation practices.
IPC.15.1

ESR Standards

MM.5.2.5 Antithrombotic medications (e.g., heparin, warfarin). MM.5.2.6 Insulins.

MM.5.2.7 Anesthetic medications (e.g., propofol, ketamine).

	MM.5.3.3 Using auxiliary labels or computerized alerts if available. MM.5.3.4 Standardizing the ordering, transcribing, preparation, dispensing, administration, and monitoring of high-alert medications.
MM.6
	There is a multidisciplinary policy and procedure on handling look- alike/sound-alike (LASA) medications. The hospital reviews and revises annually its list of confusing drug names, which include LASA medication name pairs that the hospital stores, dispenses, and administers. MM.6.3.5 Reading carefully the label each time a medication is accessed, and/or prior to administration. MM.6.3.6 Minimizing the use of verbal and telephone orders.
MM.41

ESR Standards

MM.41.5 The hospital has a standard format for reporting medication errors.

MM.41.6 Staff are educated on the process and importance of medication error reporting.

MM.41.11 Healthcare professionals are provided with feedback on reported medication errors, near misses, and hazardous situations.

MM.41.12 The hospital reports sentinel events related to serious medication errors to the relevant authorities.

ESR Standards

LB.51.2.1 Describes the blood bank approach to limit bacterial contamination and the investigations of positive cases.

FMS.9
FMS.9.1
FMS.9.2
FMS.9.3	The hospital has the relevant valid license(s) from King Abdulaziz City for Science and Technology.
FMS.9.4	Staff handling nuclear materials are qualified and certified by King Abdul-Aziz City for Science and Technology.
FMS.9.5
FMS.9.6
FMS.9.7
FMS.21
FMS.21.1 There is a fire alarm system that is functioning and regularly inspected as per civil defense guidelines.

FMS.21.2 The fire alarm system testing results are documented. FMS.21.3 The fire alarm system has preventive maintenance. FMS.21.4 The elevators are connected to the fire alarm system.

FMS.23
FMS.23.1 Fire exits are available and are properly located in the hospital.

FMS.23.2 Fire exits are not locked.

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FMS.24.3 Emergency lighting is adequate for safe evacuation of the hospital.

FMS.24.4 Storage areas are properly and safely organized:
FMS.24.4.1 Shelves and racks are sturdy and in good condition.

FMS.24.5 Fire rated doors are available according to the hospital zones with no separation between walls and ceiling to prevent smoke spread between rooms and areas.

FMS.32	The hospital ensures proper maintenance of the medical gas system.

FMS.32.2.2 Commissioning and testing new branching or modifications. FMS.32.2.3 The procedure for ordering and filling liquid oxygen.

FMS.32.2.4 Documenting all repairs/alterations/tests/filling logs/consumption.

FMS.32.7 In case of gas pipe repairs or new extensions, outlets are tested for the type of gas to ensure the correct type is delivered through the new pipe. Results of testing are recorded and maintained with engineering and the unit manager.

FMS.32.8 The hospital keeps standby oxygen and medical air cylinders enough for forty eight hours of average consumption.

FMS.32.10 Emergency shut off valves are available in all units and are clearly marked with areas/rooms affected.

FMS.32.11 The hospital dedicates the responsibility of the closure of shut off valves to well-trained individual(s) available in the unit concerned.