GAIMS Safety Manual 12.05.22

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 201 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The Link Nurse shall at all times supervise the steps taken by the Housekeeping staff for the management of the spills.  The Housekeeping staff shall always wear requisite personal protective equipment such as gloves.  The Housekeeping staff shall use the appropriate colored bag for disposal (Yellow bag).  Wear mask and gloves (unsterile) throughout the procedure. If needed plastic apron may also be worn.  The cleaning of the spill should be done by the Housekeeping staff, under the supervision of the Sister- In- Charge of the area.  Clean up the initial spill with absorbent material and with gloved hands, discard in the yellow bag.  Pour 1% Sodium hypochlorite over and around the spill.  The spillage should be covered with absorbent material like newspaper, tissue paper.  Leave it undisturbed for 30minutes.  Remove the absorbent material with gloved hands, after half an hour.  Discard in YELLOW BAG.  Wipe the surface with a mop soaked in 1% sodium hypochlorite solution.  This mop should then be disinfected in 1% sodium hypochlorite solution and then washed and dried.  Broken glass should be swept into a sharps container with the help of brush.  All spills and/or accidents should be reported by way of Incident Report to the Infection control nurse / supervisor.  A written record of all such incidents is maintained, and also the action taken to contain them. RESPONSIBILITY  All staff and management Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 202 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RECORDS  List of Hazardous Material  MSDS MANAGEMENT OF MERCURY SPILLS PURPOSE  To establish uniform procedures for management of mercury spills. SCOPE  Hospital wide PROCEDURES:  Mercury is the content of Thermometer and BP apparatus. At the time of breaking of thermometer or BP apparatus, there are chances of mercury spillage  The user is responsible for the cleanup of minor Mercury spills.  Always wear gloves when cleaning up a spill. Clean up any broken glass using tongs or heavy towel/forceps. Do not pick up broken glass by hand.  Put Caution Board/ Entry Restricted  Open Window and allow Ventilation in Spillage Area  Remove Jewelry and use appropriate Personal Protective Equipment (Gloves, Mask)  Clean Mercury with the help of X Ray Film or 10ml Syringe without needle.  Use syringe to aspirate the Mercury beads  Use Torch to determine all Mercury has been collected  Collect the Mercury into a leak proof, tight, wide mouth container half filled with water. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 203 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Label the container properly. On label add name of spillage, ward name date and time and spilled material.  Discard all the items that comes in contact with Mercury in a yellow bag  Store separately and send it to Biomedical Department for Recycle  Mop the area with soap and water  Dry the mop under sunlight  Wash your hands thoroughly CLINICAL STORAGE GUIDELINES POLICY  Hospital shall use the following procedures for the safe storage of equipment, supplies and medications. PURPOSE  To establish guidelines for clinical storage. PROCEDURE Specific Information  Supplies/Equipment - Store all supplies at least 18 inches below the ceiling in buildings that have sprinkler systems.  Store all equipment and supplies at least 6 inches off the floor.  Store items containing liquid below other supplies.  Store only cleaning supplies under sink. (If pediatric area, secure cabinet with lock.)  Place linens in a covered cart with a solid bottom or cabinet.  Store appropriate personal protective equipment (PPE) such as, gloves, gowns, eyewear, masks, goggles, and face shields at the worksite.  Keep all corridors free and unobstructed by equipment, furniture, and storage. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 204 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  For temporary placement, items with wheels are permissible in corridors (e.g., medical carts, wheelchairs). Items are all on one side of the corridor and cannot block fire prevention equipment, electrical panels, and/or exit doors. Refrigerator/Freezer Contents:  Place medications, specimens, and food in separate refrigerators.  Post signage on outside of refrigerators to specify contents  Store specimens in refrigerator labeled with a biohazard sticker. Sharps Container:  Place Sharps containers in an easily accessible area out of children’s reach.  Close and lock Sharps containers when contents reach the fill line and place in a dirty area.  Secure Sharps containers in a manner to avoid spillage. Medications  Store medications in a clean dry area.  Store all medications (including sample meds), sharps, and prescription pads in a locked area away from patient view.  Separate internal medications from external medications.  Double lock controlled medications. Radiology Equipment/Supplies  Store x-ray films in a clean, dry area.  Hang lead aprons and gloves crease free on rack.  Store sandbags off floor. Chemicals Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 205 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Label secondary containers with name of chemical and appropriate hazard (list specific organ effected).  Label secondary container for high level disinfectant (Cidex) with mixture/expiration dates and staff initials. Medical Records:  Store medical records in a location not easily accessible to patients/visitors Miscellaneous  Food and/or drink may not be located or consumed in areas where blood or body fluid/tissue are present, collected, handled, or processed.  Have manuals readily available to all staff 18. BLOOD AND BODY FLUID SPILL MANAGEMENT  In case of spills of blood or body fluids, the staff shall report immediately to the Link nurse of the ward or area.  The record of the incident shall be maintained in a Register in each Ward by the Link nurses.  The Housekeeping staff shall immediately manage the spill, according to the protocol.  The Link Nurse shall at all times supervise the steps taken by the Housekeeping staff for the management of the spills.  The Housekeeping staff shall always wear requisite personal protective equipment such as gloves.  The Housekeeping staff shall use the appropriate colored bag for disposal (Yellow bag).  Wear mask and gloves (unsterile) throughout the procedure. If needed plastic apron may also be worn. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 206 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The cleaning of the spill should be done by the Housekeeping staff, under the supervision of the Sister- In- Charge of the area.  Clean up the initial spill with absorbent material and with gloved hands, discard in the yellow bag.  Pour 1% Sodium hypochlorite over and around the spill.  The spillage should be covered with absorbent material like newspaper, tissue paper.  Leave it undisturbed for 30 minutes.  Remove the absorbent material with gloved hands, after half an hour.  Discard in YELLOW BAG.  Wipe the surface with a mop soaked in 1% sodium hypochlorite solution.  This mop should then be disinfected in 1% sodium hypochlorite solution and then washed and dried.  Broken glass should be swept into a blue bag with the help of a brush after disinfecting with 1% Sodium Hypochlorite solution.  All spills and/or accidents should be reported by way of Incident Report to the supervisor, Medical Administrator and to the Infection Control Nurse.  A written record of all such incidents is maintained, and also the action taken to contain them. Record  Spillage Monthly report 19. MEDICAL GAS SAFETY POLICY  In GAIMS, the procurement, handling, storage, distribution, usage and replenishment of medical gases vacuum and compress air are done in a safe manner. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 207 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The procedure addresses the safety issue at all level.  Alternate arrangement is made available for medical gases vacuum and compressed air in case of failure. Organization regularly tests this alternate source.  Preventive maintenance done according to manufacture recommendation on regular basis for the medical gases manifold, vacuums and compressed air.  Standardize Pipeline Color coding is applied all over the hospital. Proper signages are used. Purity Certificates is checked periodically once a year. PURPOSE  Supply of right medical gases (Oxygen, nitrous oxide) to user departments of the hospital at the appropriate pressure.  Supply of compressed air to the user departments at the right pressure.  Supply of clinical vacuum to the user departments at the right pressure.  Ensure proper planned maintenance of all equipment, including distribution network, so as to maintain optimum operational efficiency at all time with outbreak.  Ensuring an optimum level of cleanliness and pollution free environment.  Taking all actions to ensure prevention of all possible hazards such as fire, explosion or contamination of gases supplied at manifold area.  Installation and preventive maintenance of medical gases alarm. SCOPE  All over Hospital PROCEDURE  Procurement: Medical gases are procured in a hospital from Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 208 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Handling: Qualified and trained staff is handing and distributed the cylinder in a safe manner. Separate manifold is made available for all type of cylinder supply.  Storage: Separate storages is identified for empty and full cylinders.  Distribution: Centralize gas pipeline all over the hospital to distribute the medical gases.  Replenishment: Maintenance department take care for all type of replenishment of medical gases. Air purity is checked for compressed air once in a year.  Purity certificates is checked for liquid oxygen. Medical Gasses Safety:  Only technically trained persons shall handle all medical gases cylinders, filled or empty. The medical gases come in authorized cylinders with safety valves and pin index system.  Various types of cylinders received from the vendor at a schedule time nominated by the hospitals.  The process by which the cylinders are received and empty cylinder returned is documented and signed by the authorized representative of the hospitals.  There is separate enclosure for empty and filled cylinders. The pressure of the oxygen cylinders regarding volume of gas in any particular cylinder is checked and recorded.  The cylinders are attached to the automatic change over panel. The details regarding its installation, maintenance and operations is with the work instructions shall be available in the department.  The empty cylinders are returned to the vendor and recorded. This procedure is continued throughout the month and at the end, a detailed summary is submitted in commercial & F&A department.  The wards and department indent the demands, which are met, and the same is recorded in appropriate registers. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 209 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The cylinders in the manifold system have the day and date recorded on the cylinders and this helps to identify cylinders, which are getting empty.  These should be kept away from inflammable materials and direct rays of the sun.  Care must be taken when handling or transporting cylinders to prevent their being dropped since they are liable to break and explode with violent effects.  If large stocks of cylinders are being handled suitable trolleys should be provided for transporting and handling them.  Slings should not be used and the practice of rolling cylinders of compressed gases along the ground is forbidden.  Oil or grease of any kind must not be used for lubricating cylinder valves, gauge regulators or other fittings and white lead or other paint must not be used for fixing them.  It is essential that all threads of cylinder valves and seating be kept free from dirt and foreign matter to enable joints to be made gastight.  When putting a cylinder into use the valve should never be opened suddenly.  The valve of every cylinder should be tightly closed immediately after use and should be kept in a closed condition when the cylinder is exhausted and returned to the depot /supplier.  They should be identified as empty or filled and should be stored separately in earmarked locations.  No person is allowed to smoke/use Explosive material/fire/inflamed material within 100 meters from where the gas cylinders are placed. Fire extinguishers will be made available within the complex for any fire hazards.  Never test with a flame for leakage; always use water when testing valve sockets for leakage.  The cylinder should be painted correctly according to the color code for their identification e.g. oxygen – black body and white top, carbon dioxide – grey and nitrous oxide – blue. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 210 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Cylinders should not be stacked too high, underweight or near inflammable material.  Cylinders should never be stored in places where greases or oils are stored. These are spontaneously explosive in the presence of oxygen. Grease or oil should not be used on cylinder valves or pipe connections.  Cylinder must not be kept in warm places where temperature is high such as in the neighborhood of furnaces, boilers etc. This may cause an undesirable rise of pressure owing to expansion of the gas. The floor of the oxygen cylinder goes down and the unloading and loading platform should not be brick lined or cemented. Ordinary earth or sand or ashes are best to avoid damage to cylinders.  Medical gases are procured, handled, stored, distributed, used and replenished in the store as per the standard procedure.  Records as required by Indian Explosives Act, Gas cylinder rules and Static & Mobile pressure vessels shall be maintained. Safety Measures for Liquid Oxygen Handling: Potential Hazards:  Potential hazards associated with Liquid Oxygen include:  Extreme cold which can freeze human tissue and brittle the materials such as carbon steel, and rubber.  Extreme pressure which can result in a violent explosion due to vaporization of liquid Oxygen resulting from heat leaking into the containment system.  Personnel Protection:  Personnel handling cryogenic liquids should be fully aware of the properties of the materials and equipment being used. Appropriate Material Safety Data Sheets (MSDS) should be Available.  Rapidly warm the affected area by immersion in water not exceeding a temperature of 40°C (105°F), or with body heat, or exposure to warm air. In the Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 211 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL event of massive exposure, affected clothing should be removed and victim given a warm shower. Affected areas of the victim should be maintained at normal body temperature until professional help is administered.  Keep victim calm and avoid aggravation of the injury such as walking on frostbitten feet.  Prevent infection by cleaning the affected area with a mild soap and applying dressings if the skin has been abraded.  If eyes have been affected, flush with warm water for at least 15minutes.  Personnel protective equipment should include the following:  Eye protection–goggles  Hand protection -loose, easy to remove, heavy, non-asbestos gloves such as leather-welding gloves without gauntlets should be used.  Body protection -boots and trousers which extend over the boots should be worn. Safety for Storage of cylinders  Cylinders shall be stored in a cool, dry, well ventilated place and such place of storage shall be easily accessible.  Cylinders shall always be kept in an upright position and shall be so placed that they cannot be knocked over.  Empty cylinders shall be segregated from the filled ones and care shall be taken that all the valves are tightly shut.  No flammable material should be stored in the immediate vicinity of this cylinder or in the same room in which it is kept.  Safety signages are displayed near LMO, Compressed Gases Cylinder.  For fire safety at cylinder storage area a no smoking zone is created and signage is displayed. Fire extinguishers as recommended are put like sand / water buckets and ABC fire extinguishers. The vessel and storage area are well maintained for cleanliness and prevention of oils pillage. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 212 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Safety procedures for handling cylinders:  Most cylinder are heavy, bulky & can cause personal injury or damage to property (including Cylinder) if mishandled. Following precautions should be taken:  Cylinder must always be secured by chain or belt during transportation & use.  Trolleys of adequate strength shall be used when moving the cylinders.  Sliding, dropping or playing with cylinders is prohibited.  No oil or similar lubricant should be used on the valves or other fittings of this cylinder.  While receiving the cylinder ensure that the cylinder is full & gauge indicates 150Kg/cm.  While receiving the cylinder the valve must be partially opened momentarily to blow away any grit or foreign matter which may have accumulated in the valve gas outlet.  Ensure no leaks are present at the junction between the cylinder valve spindle & gland nut of FA Valve. If in doubt, use a soapy water solution to detect leaks & wiped it off after checking.  When the cylinder is not being used, the cylinder valve should be closed. In Emergencies following step has to be followed  For User: Inform to Biomedical Engineering & Medical Gases Dept if any leakage found.  In case of excessive leakages or Fire close the Isolation valves provided on each floor and immediately call on above numbers & inform Fire & Safety Manager. Medical gases color coding RESPONSIBILITY  Bio Medical Engineering staff is responsible for carrying out the procedure Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 213 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RECORD Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 214 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 20. OTHER CLINICAL SAFFETY 1. Blood transfusion safety in patient care area  Doctor’s order is checked on progress notes.  Informed Consent is taken prior to transfusion of blood and blood products.  Blood grouping and cross matching is done.  Blood bag checked and blood transfusion is monitored. Details are filled in blood transfusion monitoring form.  Blood reactions are observed during transfusion and recorded on blood transfusion form.  Patient is monitored during transfusion for vital signs and signs of reaction. 2. Safety of medical equipment’s those are used for the patients  Emergency Medical equipment’s checked by the biomedical engineer and verified by the user for working condition.  Defibrillator check strips are taken regularly to see the working condition.  Calibration is done for all measuring and monitoring equipment’s.  Preventive maintenance is carried out timely as per schedule  Training for the staffs to operate it properly. 3. Safety in Operation Theatre  WHO Surgical safety checklist is followed to prevent wrong surgery on wrong site, wrong patient. (WHO surgical safety checklist) by following sign, sign in and time out protocol followed by anesthetist, surgeon and nursing staff.  Site marking for avoiding wrong site surgery.  Zoning of OT area for maintaining unidirectional flow and sterility. (restricted entry)  Surgical hand wash protocol for all cases Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 215 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Environmental Surveillance activity of engineering control like Humidity, temperature, air changes and pressure differential is monitored  OT validation is done for engineering control.  Cleaning and fogging as per the HIC protocols.  Safe sterilization practices are followed to ensure safety  Prophylactic antibiotics policy is followed.  Surgical site infection for all Implant cases is tracked down for one year. For traceability implant stickers and registers are maintained.  Patient education to all post-operative patients 4. Human Resource Department  Training and safety requirement  All staffs are adequately trained on various safety related issues & occupational safety. (HRM- 4.a)  Risk & Safety related training will be imparted to all staff including Patient and Relative safety. (HRM-4.a)  Organization identify the areas with occupational hazards for which staff are trained on occupational safety aspects like:  Biological Hazards (blood, body fluids),  Chemical hazards (formalin, Cidex, mercury),  Physical Hazards (fall, backache)  Safety Hazards (electric hazard, broken equipment)  Psychological Hazards (work related stress).(HRM-4.d) 5. CSSD Central Sterile Supply Department  Recall policy is followed to avoid surgical use of unsafe and unsterile material.  Biological and chemical indicator is used in Sterilization unit to ensure sterility.  Regular validation of sterilization processes. 6. General Precautions Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 216 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL All patients shall be oriented to the clinical area(s). Orientation may include the following:  Room number and unit layout  Bed operation.  Visiting hours, as applicable.  All staff shall wear photo I.D. cards when on duty.  The patient care area is clean, well-lighted, and free from clutter.  The floor shall be clean and dry. Appropriate signages is in place when floor is wet.  Furniture is in good condition.  Patient room night lights, where applicable, are functional.  Patient beds and treatment tables shall be kept at the lowest possible height except when elevated for delivery of care and when the staff member is continuously at the bedside (e.g., intensive care units).  Supplies, machines, and equipment are stored in designated areas. Equipment under maintenance will be removed from site and send to maintenance dept.  Patient care equipment is inspected and labeled by the Biomedical engineering. Department prior to initial use and according to Preventive Maintenance Schedules.  Do not use equipment if calibration sticker is out-of-date.  Broken or malfunctioning equipment to be removed from clinical area.  Report immediately to the concern Biomedical and maintenance Department.  All spills are cleaned immediately according to applicable guidelines for the type of spill.  Each staff member continuously assess for unsafe conditions and takes appropriate corrective action.  \"Near misses\", accidents, and occurrences (patients, visitors, and staff) are immediately reported to Head Operations and Head Medical Services and documented. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 217 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Appropriate Identification Bands to be applied. TRANSPORT OFPATIENT Getting in and out of vehicles:  Consider these general guidelines for transfers in and out of vehicles:  Transfers involving two-door vehicles are usually easier because the doors tend to open further than similar four-door models. 1. Wheel Chairs (having braking system)  Wheel chairs must be provided with brakes. Whenever wheel chairs have to be left unattended, the brakes must be put on so that the wheel chair does not move and cause accidents or patient falls due to such accidents. At the time of preventive maintenance, the brakes must be checked for their performance and repaired immediately if required. Wheel chairs also should have belts installed on the chair so that patients can be secured while being shifted on the same. 2. Patient Trolleys  Trolleys used for patient transfers should have braking system and side rails to reduce events of patient falls. Preventive maintenance should be carried out regularly. 3. Patient Beds  Patient beds should be provided with side rails to avoid patient falls. During preventive maintenance, it should be checked for its desired operation and ease of operation.  Patients shall be placed in a bed that has functional side rails.  The following patients have side rails raised when unattended by staff:  Those given pre-op or pre-procedural medication;  Patients on stretchers (unless equipped with safety belts) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 218 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  All pediatric patients in cribs 4. Grab Bars:  Grab bars are provided for patients to take support of during their movements. Areas should be identified where such grab bars need to be installed. . Transportation  Wheels of stretchers, wheel chairs, scales, and beds are locked when a patient is lifted from or assisted on to them.  Side rails are raised on stretchers, when present.  The nurse responsible for the patient determines the safest and most reasonable means of transporting for tests/procedures or transfer to another room or unit. Patient's Role in Promoting Safe HealthCare:  Patients are encouraged to become an active, involved, and informed member of their health care team. Listed below are ways that the patients may be encouraged to promote their own safety.  Patients are instructed to ask if they have questions about their health or safety.  If the patient is having an operation, the patient is asked to verify prior to the procedure, the site/side of the body that will be operated on.  If the patient's ID band is not checked before medications are given, blood/blood products are administered; blood samples are obtained or prior to an invasive procedure, the patient are asked to remind the staff.  The patient is taught to know what medications they take and why they take them.  Patients are instructed to adhere to the hospitals No Smoking Policy  Patients are instructed to follow the ‘patient’s responsibilities’ Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 219 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 21. ISOLATION & NURSING BARRIER FACILITY POLICY (HIC 2. e)  The GAIMS hospital defines the conditions where isolation is required and the conditions wherein barrier nursing or both are required. PROCEDURE  The patient should be isolated in a single cubicle, or room, depending on the clinical indication. If not available, isolate the patient by placing him in one corner of the room, close to the wash basin.  In case of an outbreak, the patients should be isolated in a room with a dedicated staff nurse (Cohort isolation).  All staff including the Housekeeping and other domestic staff (e.g. F&B staff) must be aware that isolation is in progress, and be aware of the specific precautions that need to be taken.  Mops and buckets used should be disinfected with 1% sodium hypochlorite for half an hour, then rinsed in water, dried and reused.  Dedicated equipment should be provided; this remains in the isolation room for the duration of the isolation.  Reusable equipment should be decontaminated at the end of isolation before use on any other patient.  Protective Personal Equipment such as gloves, aprons, masks, should be used for single care episode and disposed as clinical waste.  Contaminated waste should be tied up and bagged in the room prior to being removed for disposal.  Infected linen must be placed in a separate bag in the room, tied, and then sent to the washing area for decontamination within 30 minutes and then sent to the laundry.  Linen must be send to the laundry on every day Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 220 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Hand hygiene should be strictly implemented. Hands should be washed on entry and exit from the room, and between each care episode, and also on contact with body fluid or contaminated material/ equipment.  All environments should be kept clean.  Nursing staff must ensure that all staff is informed about the need for isolation precautions.  The receiving unit should be informed of the infectious state of the patient.  Food & Beverages- Patients who are in isolation should not enter the dining rooms for meals and also avoid share& take-away meals with other patients or relatives.  Environment conditions for special infections- negative pressure, exhaust- for protective isolation.  Immunization of staff and patient, relatives should be ensured. 22. STANDARD PRECAUTIONS POLICY (HIC3. a)  GAIMS Hospital adheres to Standard Precautions at all times. PURPOSE  To avoid Hospital Acquired Infection. SCOPE  Entire hospital and patient care area. PROCEDURE  Hand hygiene should be performed after touching blood, body fluids, secretions, excretions and contaminated items, immediately before wearing and after removing gloves and between patient contacts, before and after patient contact and after touching patients surroundings. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 221 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Personal Protective Equipment should be used. Gloves for touching blood, body fluids, secretions, excretions and contaminated items, mucous membranes and non-intact skin; gowns to be worn during patient procedures and activities involving contact of clothing or exposed skin with blood, body fluids, secretions and excretions.  Mask, eye protection and face shield should be worn during procedures that are associated with splashes or sprays of blood, body fluids and secretions.  For patients with suspected or proven infections transmitted by respiratory aerosols, a fit- tested N95 or higher respirator should also be worn.  Cuts, sores and wounds in staff and patients should be covered with impermeable dressings  Used needles should not be recapped, bent, broken or manipulated by hand.  One-handed scoop technique only should be used when recapping is required.  In case of sharps injury or splashes from body fluids, wash under running cold water, report the injury to ICN, and in-charge and seek advice.  All environments should be kept clean.  Waste should be disposed of safely according to the correct waste management color coding, and at the point of generation.  Linen is placed directly into the correct colored linen bag and stored appropriately.  Patient care equipment, soiled linen and laundry should be handled appropriately (if visibly contaminated, gloves should be worn, and hand hygiene should be performed).  All reusable equipment should be properly sterilized.  All single use items are discarded properly. RESPONSIBILITY  HIC and All staff REFERENCE  NABH 5TH edition HIC3 a 23. HAND HYGEINE (HIC 3 b) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 222 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL POLICY  GAIMS Hospital adheres to National / International guidelines on Hand Hygiene. PURPOSE  To remove transient microbial contamination which has been acquired by recent contact with infected, or colonized patients, or environmental sources  Reduce the resident microbial count to a minimum  To prevent the transmission of potentially pathogenic organisms. SCOPE  All hospital area DEFINITION  Hand hygiene is vigorous rubbing together of lathered hands for at least 20 to 30 seconds, followed by thorough rinsing with clean water or cleaning of hands using hand rub solution. It can be achieved with either plain soap or antimicrobial products. INDICATIONS FOR ROUTINE HAND HYGIENE  On arrival for duty at the hospital and on completion of duty.  Before having direct contact with patients.  Before donning gloves.  Before any minor invasive procedures that do not require a surgical procedure.  After contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).  After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings.  If moving from a contaminated-body site to a clean-body site during patient care.  After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 223 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  After removing gloves. WHAT TO USE FOR HAND WASH  When hands are visibly dirty or contaminated or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.  If hands are not visibly soiled, you may either use an alcohol-based chlorhexidine hand rub.  Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. METHOD OF HAND HYGIENE HAND RUB  Apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use.  The hand rub bottles should be dated and can be used till it gets over or till its expiry, whichever comes first. HAND WASH  When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 40-60seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet SURGICAL HAND WASH  Remove rings, watches, and bracelets before beginning the surgical hand scrub.  Remove debris from underneath fingernails using a nail cleaner under running water. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 224 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures.  When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 3-5 minutes  When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. Before applying the alcohol solution, pre wash hands and forearms with non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves. PROMOTION OF HAND HYGIENE  Keep the hand rub solution at the patient bedside, and replace as soon as empty.  Educate health care workers about need and method of hand hygiene.  Display posters in all areas.  Monitor adherence to hand hygiene on a periodic basis and give feedback to health care system. RECORD  Hand hygiene survey Checklist file 24. OTHER NON CLINICAL SAFETY - IT SAFETY Electronic Data safety in ensured by  USB Access Denied for Data Security Purpose.  To provide strong Data Security using Firewall.  Assign username & password for all users.  Using UPS Backup system avoiding Data loss and Equipment Damage.  Total System Backup available on NAS server.  Antivirus Installed on all nodes with database server.  Contingency plan during downtime. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 225 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Virus Protection:- o Firewall Policy and Rules installed for Virus protection. o Net Protector Antivirus Installed on All Systems. Server Room Safety IT Department ensures Server Room Safety by following all possible safety Norms. 1. Temperature Control  The server room must have sufficient temperature control to maintain temperatures within the operational limits defined for the hardware located in the room.  In our Server Room, we are maintaining sufficient temperature as per server room requirement. 2. Fire / Flood  The server room have fire detection and suppression, adequately maintained and routinely tested.  In our Server Room, we are using Auto Modular ABC Cylinder for fire detection. 3. Cabling  Cabling are maintained in an orderly fashion to reduce the possibility of an accidental outage. 4. Power  The server room have sufficient dedicated circuits for all equipment, plus one or more additional circuits, as needed for flexibility in the event a circuit fails.  All system is properly grounded. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 226 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 25. ENGINEERING CONTROL (HIC4 a) POLICY  GAIMS Hospital has appropriate engineering controls to prevent infections PURPOSE  Appropriate engineering controls to prevent infection & to minimize the risk of Infection during construction & renovation. SCOPE  Maintenance department, HIC department RESPONSIBILITY  Maintenance department, HIC department PROCEDURE  All the infectious waste collecting, dust accumulating, areas and probable epicenter of the infection within the territory of the engineering to be identified by the engineer Executive and infection control nurse.  After changing the HEPA filters it is to validated with the Laser particle count test  A very high degree of precaution is to be taken by the engineering staff while handling any equipment’s relating to patients  Any injury to Engineering personnel while working with the equipment of patient care is to be informed immediately to infection control nurse and a relevant incident report to be made  Any accidental spillage of any infectious material and the area of spillage are informed to the engineering team. The engineering team is to asses any soaking Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 227 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL and seepage into any clean area is to be found and corresponding defection procedure is to be coordinated with the infection control nurse/committee.  All the process/procedural change relating to engineering service in the hospital is to be notified to the engineering service.  Any leakage or seepage and any abnormal moisture accumulation is to be notified and bought to notice immediately to the engineering service  Any gaps, cracks, holes, etc., which can potential accumulation area for dust or dirt is notified immediately to engineering team  In case if the biological indicator or the bowie dick test fails in the Autoclave is to be immediately intimated to engineering service  Engineering service should always play a role in infection control committee.  All the engineering staff is to be vaccinated as per the hospital policy  The concerned Sister I/C and the Maintenance department shall inform the Infection Control Team regarding proposed construction activities. ENGINEERING CONTROL 1. CONSTRUCTION  The concerned incharge and the Maintenance department shall inform the Infection Control Team and Medical Administrator regarding proposed construction activities  Depending on the type and nature of construction being carried out, it is divided into the following levels: Level I: Electrical fittings, Painting jobs, Minor plumbing activities:  Only Standard Precautions to be followed by staff. Level II: False ceiling repairs, Flooring, Floor replacement and repairs:  Standard Precautions to be followed by staff.  The area should be isolated or cordoned off. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 228 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Patients are moved away from the area.  Daily cleaning to be done  Pre-filter and micro filters are cleaned at the end of each such activity.  Fogging is carried out at the end, at least once, and if needed twice, and followed by settle- plate counts at the end. Level III: Demolition, Construction of walls, Fixing tiles, complete ceiling replacement:  All activities as for Level II. Three fogging cycles followed by settle plate counts at the end of the third fogging.  Any incidents are reported to the Infection Control Team in a written form. 2 ENGINEERING CONTROLS  Normal maintenance work like o Choking/ Leaking plumbing o Cleaning of ducts o Replacement of filters o A/C plants & AHUs  Need to be carried out taking standard precautions  ICN shall be informed before taking up of such work.  ICN shall decide conducting any surveillance from HIC point of view after site survey.  Any seepage detected shall be reported to Maintenance I/C, who in turn shall inform ICN.  ICN shall make site visit to assess possibility of fungal colonization, and where necessary shall collect samples.  Before starting any new construction/corrective work, facility department take the permission from HIC Department by filling the ‘ICRA’ Form ( Infection Control Risk Assessment (ICRA) Form ) and submit to HIC Department (HIC 4 b) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 229 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Any renovation work in hospital patient-care areas should be planned with infection control team with regard to architectural segregation, traffic flow, use of materials, etc. Infection Control Risk Assessment (ICRA) Permit 26. VISITOR ACCESS CONTROL POLICY  Access control measure to different areas in the hospital by staff, patient, visitors and vendors are defined in a systematic way. Restricted area is defined and display accordingly. PURPOSE  GAIMS operates in a planned manner to ensure safety of patients, their families, staff and visitors and promotes environment friendly measure. SCOPE  Entire hospital PROCEDURE All visitor/vendors staff check in accordingly with proper identification. Check in only through main gate. 1. Access to staff: Hospital area. ID card is issued to all the staff including contractual staff and should wear ID card at all times while on duty. 2. Access to patient and Relative: Only OPD and IPD area Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 230 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 3. Access to service repair personal: Company Maintenance and BME engineers are given access according to the requirement accompany with the hospital biomedical and maintenance staff. 4. Access to vendors /Supplier: only to store and purchase dept. 5. Medical representative: Only in OPD area 6. Visitors: To offices, prior appointment. 7. Restricted and prohibited area: - Pump room, Liquid oxygen, DG area, Electrical panel and transformer area., MRD , Laboratory , conference and meeting room , OT area, Server room etc., terrace. Visiting hours are defined and display in various area.  Attendant pass - Yellow pass (24 hrs. one attendant.)  Only one visitor with a visiting pass is allowed at time Vendor access  Visitors Pass will be issue to all the vendor /supplier by security dept.  Material Access in: Entry in Security register with detail and vehicle number and inform to store in timely manner.  Material OUT: material will be dispatched from the institute through returnable and non-returnable gate pass. 27. INCIDENT ANALYSIS POLICY  GAIMS provides safe &secure environment & place. PURPOSE Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 231 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To protect hospital- Patients, staff, visitors and the hospital assets” SCOPE  Entire Hospital FUNCTION  Patrolling (watching/guarding)  Surprise check  Identification system  Tele monitoring  Drills  Key management  Parking and traffic control  Visitor’s Management  Patient Safety  Patient Identification  Code management PROCEDURE 1. PATROLLING  Means watching, supervising on duty patrol the hospital campus and complex round the clock. Boundaries of campus, parking area and other structures within the campus come under his preview. Maintain discipline through visiting hours Follow the gate pass. Non visiting hours check gate pass in the all area. every hours patrolling in all hospital area. All passage OPD area OPD waiting without hurdles’ Security need to ensure all office closed in time. 2. SURPRISE CHECK  Random checks of the staff are done at the office at Main Gate as well at the time office at main entrance. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 232 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 3. IDENTIFICATION SYSTEM  The HR department issues the identification cards to all regular staff, contract staff, trainees, visiting doctors, drivers (including personal drives of the staff). The security checks all the ID - cards and those individuals without a valid I-card are not allowed entry into the premises. For the contract staff, trainees and construction workers, the expiry date of the ID is also checked. 4. TELE MONTORING  Employees are permitted only from the time office entrance.  Punching of the employee identity cards is done under the supervision of security guard. 5. QUEUE MANAGEMENT SYSTEM  For calling vehicle drivers at the main entrance is under security control.  All security of hospital area ensures the vehicle is parked at a designated places &parking zone only.  Patient relative seating in designated place. Virtual queue management system in hospitals for safe patient journeys  The COVID-19 pandemic has shown the need for a queue management system that can handle patient flow in a safe and efficient manner. With the regulations to maintain a safe distance and a limit of maximum number of people in indoor space, healthcare facilities need to adapt and be agile to maintain the services while keeping everyone (including patients, staff, and visitors) safe.  Here are a few examples of use cases where a virtual queue management system can help with safer patient journeys, especially in the current situation regarding COVID-19 pandemic: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 233 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Manage appointments, arrivals, and queues for residents and people who are getting their COVID-19 vaccination with patient scheduling solutions o Manage the flow of people who want to get a COVID-19 test o Reduce the number of people waiting in the lobby or waiting room o Pandemic has shown the need for a queue management system that can handle patient flow in a safe and efficient manner. o With the regulations to maintain a safe distance and a limit of maximum number of people in indoor space, healthcare facilities need to adapt and be agile to maintain the services while keeping everyone (including patients, staff, and visitors) safe. o Here are a few examples of use cases where a virtual queue management system can help with safer patient journeys, especially in the current situation regarding COVID-19 pandemic: o Manage appointments, arrivals, and queues for residents and people who are getting their COVID-19 vaccination with patient scheduling solutions o Manage the flow of people who want to get a COVID-19 test o Reduce the number of people waiting in the lobby or waiting room. 6. Emergency ward crowd management  Cordon off the area, restrict movement of patient’s relatives in emergency room.  Stop movement of the people/ Patient relative into the emergency room by closing the door.  Security will guide the people towards waiting area.  Security will help people find their way around by making sure everyone knows where they are going.  Ask the only one attendee to stay outside the emergency ward. Ensure clear flow of people in &around the patient care area.  Direct people /crowd to stay outside the hospital to avoid the disturbance to hospital staff.  Security will ensure the hospital environment is noise free. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 234 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 7. GATE PASS  Returnable Gate Pass: Items going out of hospital and which will be brought back are issued a returnable gate pass. E.g. Repairs etc.  All the material going from the hospital should be check by security &collect photo copy of gate pass &store passes in designated area  Non – Returnable Gate Pass o All the discards, defective and scrap items are given a non-returnable gate pass. o These passes are signed by the security at receiving Store and countersigned by the Security  Visitor gate pass  Checking for supplier & agencies gate pass all over the hospital area 8. DRILLS  The Fire Drills are done on a 6 monthly basis. Security plays an important role in the fire evacuation plan. 9. Key Management Placed to be Locked Operational Keys Duplicate Keys Main Door, inner Doors With Security Control Room. Security Control Room and Departmental Security Supervisors to issue Security Control Room Cupboards / Cabinet only to authorized person Individual User Room / Desk / Cabinet  The individual who withdraw the keys from Security Control room shall ensure it’s safe during the office hours and till the time it is deposited back in the Security Control Room. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 235 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  In case the individual has to leave the office earlier than the closing time, he will physically hand over these keys to another authorized individual in the department who shall deposit the keys with the Security Control Room.  To keep the keys in safe custody during non-office hours, a keyboard / safe cabinet with lock and key shall be provided in the security control room. The keys of the cabinets / drawers shall be kept by the HOD / authorized individual who will be responsible for their safe custody.  Excepting keys to individual desks, no keys shall be taken out of hospital under any circumstance.  In the events of a key being lost, the concerned HOD shall immediately inform the Security. Engineering Department shall change the entire lock, cost of which will be recovered from the person(s) responsible for their safe custody. For this, Engineering will send a suitable intimation to Human Resources with copy to Accounts  Duplicate of any key by an individual is strictly forbidden and shall be viewed as misconduct. 10. Parking and Traffic Control  In GAIMS Hospital parking facilities for both car & two wheelers are in the premises.  Surveillance cameras shows the entry and exit of vehicle from the parking lot.  Traffic control is also handled smoothly at Main gate, which is meant for the vendor and hospital employees using the above gate. 11. Patient Safety  Patient Identification  The identification band is applied for initial identification of the patient.  Patient is identified with hospital patient’s dress.  Kindly see that inpatient should not leave the hospital premises without intimation or referring note. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 236 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 12. VISITOR SECURITY  Strictly follow the visiting hours. Admission counter will issue two visitor pass to each patient relative.  Monitor the movement of visitor number.  Check visitor pass for every visitor.  Please ensure that visitors will not carry away visitors pass at home and return back to security. 13. Attendance Pass  Attendance pass is given to every patient to avail 24 hrs. Services to attend the patient bedside.  Ask the patient attendance pass during non-visiting hours. 14.General Guild line for security  Proper dress code  To know all emergency contact No.  Maintain a calm, mature approach to all situations.  Be alert to the possibility of confrontation with individuals or groups. Be aware of times when crowds can be expected like mass casualty shoot out , RTA etc. 15.Emergency operation  The system must work in emergency situations.  Vulnerable nodes should be carefully analyzed to determine which ones could  be interrupted in instability or disaster 16.Responsibility on Code Red Situation  Cordon the area, restrict movement, & assist the first responder Other staff and visitors will be moved out to assembly area by fire exit route by Security Staff Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 237 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Stop movement of the people into the danger area due to confused situation.  Ensure that no pilferage in stores and any equipment take place  Do not allow any crowd to collect around the scene  Security personnel at main gate will vacate the parking area with the help of parking contractor to create space for Fire Engine on authorization by safety manager.  Assist the firefighting party if required. 17. Responsibility on Emergency  Monitor continuously the affecting area from beginning to end.  Provides traffic control, access control, perimeter and internal security patrols, and fire prevention services as needed.  Maintains telecommunications support as necessary. INCIDENT ANALYSIS POLICY  GAIMS has a well-defined incident management system which includes: o Identification o Reporting o Review, and o Action on incidents.  The Incident management system promotes Just culture, and is focused on process improvement.  Hospital has defined sentinel events and has a mechanism to identify sentinel events PURPOSE  To appropriately identify, report and review incidents; and to implement appropriate actions on incidents. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 238 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To identify risk, if any.  To Supports factual reporting and learning  To promote capturing of all incidents without going into severity or whether harm was caused.  To report occurrence of incidents on standardized incident report forms. SCOPE  Entire Hospital Definitions  Sentinel Event - A relative infrequent, unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services.  Major and enduring loss of function refers to sensory, motor, physiological or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.  Near- Miss- A near-miss is an unplanned event that did not result in injury, illness, or damage- but had the potential to do so.  Errors that did not result in patient harm, but could have, can be categorized as near-miss.  Near miss can also be defined as when an error is realized just in the nick of time & abortive action is taken to avoid further complications.  No Harm Event- This is used synonymously with near miss. In No Harm case, the error is not recognized & the deed is done but fortunately for the healthcare professional, the expected adverse event does not occur. PROCEDURE Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 239 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 1. All incidents shall be captured without going into the severity or whether harm was caused. 2. All the incidents are reported in the incident reporting form and submitted to the Quality Department. 3. The Quality Head shall analyze the report and document accurately if it is a near miss, no harm, injury or a sentinel event. 4. Based on the incident report, the form is immediately forwarded to either Operations Head, Medical Administrator, Nursing Superintendent, Billing Head, Clinical safety officer or Safety Officer or any other concerned departmental for RCA and CAPA if required. They are required to take necessary action, document the same in the form and send it back to Quality Department for documentation within 48 Hours. Incidence Sentinel Surgical events events Near Miss Device or product No Harm events Patient protection events Environment al events Care management events Criminal events 5. Reporting of medication errors, Blood transfusion reaction and adverse drug reactions: The process for reporting of these events remain the same however such events are reported in Medication Error Reporting form/ BT reaction/ Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 240 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Adverse Drug Reaction Reporting form and all these forms are forwarded to Medical Administrator for necessary action. 6. Incident Report process proceedings shall be initiated when an event occurs resulting in:  Process error in service activities;  Patient health care deficiencies;  Noncompliance in preventive processes as per safety norms;  Employee under performance in any of the above. 7. Who should Report and How?  For incidents involving patients, the person should be the individual who witnessed, first discovered, or is most familiar with the incident.  The report must be immediately presented to the reporter's immediate supervisor or HOD  The description of the incident should be a brief narrative, which should consist of an objective description of the facts. It should not include the writer's judgment as to the cause of the event.  The Report of Incident should be completed no later than the end of the shift during which the incident occurred or was discovered to have occurred and must be forwarded to the Quality department along with signature of HOD within 24 hours. 8. Root Cause Analysis (RCA)  RCA is a process analysis method, which can be used to identify the factors that cause incident. The RCA process is a critical feature of any safety management system because it enables answers to be found to the questions posed by high risk, high impact events—notably, what happened, why it occurred, and what can be done to prevent it from happening again. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 241 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  HOD and In charges use RCA analytical methods to investigate (‘drill down’ into) serious incidents (including near misses) to identify the underlying causes and to guide solutions to address system failures  RCA investigation principles o Focus on systems and processes, not individual performance o Be fair, thorough and efficient o Focus on problem solving o Use recognized analytical methods o Use a scale of effectiveness to develop recommendations.  Major steps in an RCA investigation o Verify the incident and define the problem o Commission the RCA investigation o Map a timeline (event and causal factor chart) o Identify critical events o Analyze the critical events (cause and effect chart) o Identify root causes o Support each root cause with evidence o Identify and select the best solutions o Develop recommendations o Write and present the report. 9. Root cause analysis is compulsorily done when  The occurrence involves an unanticipated death or major permanent loss of function.  The occurrence is associated with significant deviation from the usual processes for providing health care services or managing the organization;  The event has undermined or has significant potential for undermining the public’s confidence in the organization. 10.Guidelines for root cause analysis: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 242 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  RCA shall focus on organizational system and processes.  Direct or “immediate” cause of the Incident/ Sentinel Event and the processes and systems related to its occurrence shall be determined.  Related systems and processes shall be analyzed.  Special causes in clinical processes and common causes in organization processes shall be considered in the analysis.  Possible risk prevention activities shall be considered. 11. Corrective and preventive actions are performed based on the findings of the analysis. These findings and recommendations are communicated to all the concerned departments’ heads. Based on the nature of the near miss or adverse event or sentinel event, HOD inform the relevant stakeholders including patient and family where applicable. 12. Reporting: All the incidents/ sentinel events are discussed in the related committee meetings on a monthly basis. RESPONSIBILITY  All Hospital staff RECORDS:  Incident reporting form 28. SENTINEL EVENT POLICY  Hospital has defined sentinel events and has a mechanism to identify sentinel events PURPOSE Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 243 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To have a positive impact in improving patient care, treatment, and services and in preventing unintended harm  To focus the attention of on understanding contributing factors (such as underlying causes, latent conditions, and active failures in defense systems or organization culture), and on changing the organization’s culture, systems, and processes to reduce the probability recurrence  To increase the knowledge about patient safety events, their contributing factors, and strategies for prevention  To maintain the confidence of the public, clinicians, and health care organizations and keep patient safety as a priority in the organizations SCOPE  Entire Hospital Definitions  Sentinel Event - A relative infrequent, unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services.  Major and enduring loss of function refers to sensory, motor, physiological or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition. Types of Sentinel Events: 1. Surgical events 2. Device or product events 3. Patient protection events 4. Environmental events 5. Care management events Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 244 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 6. Criminal events 1. Surgical Events  Surgery performed on a wrong body part.  Surgery performed on wrong patient.  Wrong surgical procedure performed on the wrong patient.  Retained instruments in patient discovered after surgery/procedure.  Patient death during or immediately post-surgical procedure.  Any Anesthesia-related event occurring during the surgery as well in the post. 2. Device or product events  The use of contaminated drugs devices, products supplied by the organization  The use or function of a device in a manner other than the device’s intended use  The failure or breakdown of a device or medical equipment  Intravascular air embolism 3. Patient protection events  Discharge of an infant to the wrong person  Patient death or serious disability associated with elopement from the healthcare facility  Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability  Intentional injury to a patient by a staff member, another patient, visitor, or other  Any incident in which a line designated for oxygen or other came to be delivered to a patient and contains the wrong gas or is contaminated by toxic substances  Nosocomial infection or diseases causing patient death or serious disability 4. Environmental Events Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 245 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Patient death or serious disability while being cared for in a healthcare facility associated with: o A burn incurred from any source o A slip, trip, or fall while being cared for in a facility o An Electric shock o The use of or lack of restraint or bedrails while being cared for in a facility 5. Care Management Events  Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood & blood products  Maternal death or serious disability associated with labor or delivery in a low- risk pregnancy  Medication error leading to the death or serious disability of patient due to incorrect  Administration of drugs for example o Omission error o Dosage error o Dose-preparation error o Wrong-time error o Wrong rate of administration error o Wrong administrative technique error o Wrong-patient error  Patient death or serious disability associated with an avoidance delay in treatment or response to abnormal test results 6. Criminal Events  Any instance of care ordered by or provided by an individual impersonating a clinical member or other healthcare staff  Abduction of patient of any age Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 246 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Sexual Assault on a patient within or on the grounds of the healthcare facility  Death or significant injury of a patient or staff member resulting from a physical assault or other crime that occurs within or on the grounds of the healthcare facility. Examples of Sentinel events-  Wrong site / wrong patient surgery  Operative/ procedural complication  Medication error –/ wrong BT  Patient fall  Injury or death due to restrain  Injury in fire catastrophe  Burn due to phototherapy, hot water application. PROCEDURE  When incident is a potential Sentinel Event, as defined under definition, the individual noting the incident shall notify the Quality Executive / Head - Quality / CMS / Medical director immediately; who shall pursue event processing further by the defined procedure sequence.  In case of Sentinel event, when root cause analysis is initiated, Quality head shall pursue further till the corrective action/ preventive action as determined by HOD is implemented with the approval of medical director.  The Quality Department shall maintain all records of all such Incident/Sentinel Event Reports and their evidences. o Direct or “immediate” cause of the Incident/ Sentinel Event and the processes and systems related to its occurrence shall be determined. o Related systems and processes shall be analyzed. o Special causes in clinical processes and common causes in organization processes shall be considered in the analysis. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 247 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Possible risk prevention activities shall be considered.  Corrective and preventive actions are performed based on the findings of the analysis.  Staff is made aware regarding sentinel event by training. RESPONSIBILITY  All Hospital staff 29. POLICY ON PRIORITIZING ACCESS TO THE HEALTHCARE SERVICES FOR PATIENTS ACCORDING TO THE NEED POLICY  GAIMS has a policy and procedure for prioritizing access to the healthcare services for the patients according to their clinical needs in all care settings. PURPOSE  To identify impending risk  To avoid adverse event SCOPE  In all patient care areas (Outpatient, Inpatient, Emergency and diagnostic services. PROCEDURE Emergency  All the patients coming in the hospital premises are prioritize while they come as walk in patients or emergency patients in the emergency department. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 248 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  All patients coming in Emergency department are prioritize according to Triage system. Emergent patients (most urgent) are take on the Red Zone bed, Urgent (delayed) are taken on Yellow zone bed and patients , non-urgent patients are asked to wait in the Green zone area and are examined on the bed when all higher priority patients have been evacuated,  In case of disaster management field Triage is done at the scene of disaster. Patients are categorized as per algorithm, suitably identified using color bands and for trauma patients Tags are placed besides the band. Secondary Triage is done at Emergency Room. (If field triage is not carried out, and mass casualty victims are brought to Emergency room, Primary triage is carried out at the entrance door. Re-categorization is done at Secondary Triage. OPD, IPD and diagnostic  Staff is well aware about policy of vulnerable patient. All vulnerable patients are identified. Priority is given to all vulnerable patients for service.  All outpatients are screened for primary clinical assessment in OPD assessment room. Those having some warning sign are prioritized according to their clinical needs either to OPD or emergency room for further assessment.  All IPD vulnerable patients are identified with yellow band and are monitored closely. For early warning sign and prioritize according to EWS.  In all areas of the hospital staff is trained for BLS and as a first responder in Code blue situation where priority is given to collapsed condition of patient. RESPONSIBILITY  All hospital staff. RECORDS  Triage register 30. CRITICAL RESULT REPORTING Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 249 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL POLICY  Diagnostic department (LAB and +Radiology) ensures that all the critical results for IPD & OPD are immediately communicated to the personnel concerned and it is documented.  The Diagnostic department (LAB and Radiology) of GAIMS Hospital shall establish its biological reference intervals for different tests. The Diagnostic department (LAB and Radiology) shall establish and document critical limits for tests which require immediate attention for patient management, and the same shall be documented. PURPOSE  It is not practical to establish the biological reference interval for a particular analysis, the Diagnostic department (LAB and Radiology) should carefully evaluate the published data for its reference intervals. Critical results of outsourced investigations are also included. SCOPE  OPD and IPD PROCEDURE  The critical test values are identified and is played in the Diagnostic department (LAB and Radiology).  The register is made in the Diagnostic department (LAB and Radiology) in a given format  Whenever the critical values are identified, it is immediately informed to the concerned consultant of that ward.  The details of test are documented in the register with date and time and name of the person who gives and receives the information. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 250 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  MO will again inform to the concerned consultant for the same. RESPONSIBILITY  Pathologist  Consultant  Technicians  Nurses on duty RECORDS  Critical result report register 31. PROCEDURE OF REQUISITION, COLLECTION, IDENTIFICATION & DISPOSAL OF LAB SPECIMEN POLICY  Lab has well defined & implemented procedures for ordering of tests, collection, identification, handling, safe transportation, processing, reporting & disposal of specimen PURPOSE  The GAIMS laboratory shall ensure that the unique identification number is used for identification of the patient also it could use another number to identify the samples. The disposal of waste shall be as the statutory requirement. SCOPE  Laboratory, wards and collection center Laboratory services as per laboratory scope Signatory Prepared by Reviewed by Approved by Name Designation Signature