- Egyptian Accreditation Standards for Hospitals
General Patient Safety
PS.1 The organization and staff are aware of the Egyptian and WHO Patient Safety recommendations and solutions.
PS.2 The patient safety standards and solutions are posted in all applicable areas.
PS.3 At least two (2) ways are used to identify a patient when giving medicines, blood, or blood products, taking blood samples and other specimens for clinical testing; or providing any other treatments or procedures.
PS.4 Current published and generally accepted hand hygiene guidelines, laws and regulations are implemented to prevent healthcare-associated infections.
PS.5 Single use injection devices are discarded after one time use to prevent healthcare-associated infections.
PS.6 There is a list of tests that have critical values/test results and the critical values/test results are defined for each test.
PS.7 A process for taking verbal or telephone orders and for the reporting of critical test results, that requires a verification "read-back " of the complete order or test result by the person receiving the information is implemented.
PS.8 Systems are implemented to prevent catheter and tubing misconnections.
PS.9 Each patient's risk for falling, including the potential risk associated with the patient's medication regimen is assessed and periodically reassessed.
PS.10 Action is taken to decrease or eliminate any identified risks for falling.
PS.11 Each patient's risk for developing pressure ulcers is assessed and documented.
PS.12 Action is taken to decrease or eliminate any identified risks for developing pressure ulcers.
PS.13 Preventive maintenance and testing of critical alarm systems is implemented and documented.
PS.14 Alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
PS.15 A standardized approach to hand over communications, including an opportunity to ask and respond to questions is implemented.
Medication Management Safety
PS.16 Abbreviations not to be used throughout the organization are:
U / IU
Q.D.,QD,q.o.d.,qod
MS, MSO4
Trailing zero
No leading zero
PS.17 Look-alike and sound-alike medications are stored and dispensed in a way that minimizes risk.
PS.18 Concentrated electrolytes (including, but not limited to potassium chloride, potassium phosphate, sodium chloride > 0.9%) are removed from patient care areas.
PS.19 Concentrated medications not removed are segregated from other medications with additional warnings to remind staff to dilute before use.
PS.20 All medications, medication containers (eg., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperaive and other procedural settings are labeled.
PS.21 A process is implemented to obtain and document a complete list of the patint's current medications upon admission to the organization and with the involvement of the patient.
PS.22 A complete list of the patient's medication to be taken after discharge is provided to the patient.
PS.23 The discharge medication list is communicated to the next provider of service when the patient is referred or transferred outside the organization.
Operative and Invasive Procedures Safety
PS.24 A process or checklist is developed and used to verify that all documents and equipment needed for surgery or invasive procedures are on hand, correct and functioning properly before beginning.
PS.25 There is a documented process just before starting a surgical or invasive procedure, to ensure the correct patient, procedure, and body part (a double check).
PS.26 The precise site where the surgery or invasive procedure will be performed is clearly marked with the involvement of the patient.
PS.27 There is a documented process to verify an accurate accounting of sponges, needles and instruments pre and post procedure.
