CBAHI Questions Total points 48/49

These CBAHI Questions were created as part of KAMCJ Nursing Department preparations
for the upcoming CBAHI Accreditation. The primary goal of which is to raise staff
awareness regarding standards and safe health care practices to deliver quality nursing
care to our patients and their families.

ERP # *

51

Please specify unit: *

Emergency Department and Respiratory Zone

Out Patient Department

Urology

Cath Lab

Operating Room

CCU

ICU

Wound Management

Endoscopy

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 1 of 49
 Day Surgery Unit

Isolation Unit

2B

3A

3B

4A

4B

Nursing Education

Nursing Quality

Nursing Administration

Hemodialysis Unit

Other:

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 2 of 49
 1. What is the meaning of CBAHI? * 1/1

A. Central Board for Accreditation of Health Care Institutions

(National Accreditation)

B. Center Board for Acceptance of Health Care Institutions

(National Accreditation)

C. Central Board of Accreditation of Health Centers (National

Accreditation)

D. Central Board for Accreditation of Health Course Institution

(National Accreditation)

Feedback

The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) is

the o9cial agency authorized to grant accreditation certi=cates to all
governmental and private healthcare facilities operating today in Saudi Arabia.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 3 of 49
 2. What is the purpose of CBAHI Survey and Accreditation? * 1/1

A. Improve patient safety

B. Enhance community conYdence in the quality and safety of care

provided

C. Improves eZciency and enhance the standard health care

practices

D. All of the above

Feedback

All of the above are the purpose of CBAHI Accreditation. The principal function
of CBAHI is to set the healthcare quality and patient safety standards against
which all healthcare facilities are evaluated for evidence of compliance.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 4 of 49
 3. What is the KAMCJ Hospital Mission? * 1/1

A. To bring healthcare of international standards within reach of

every individual.

B. Provide highly specialized medical care to our patients and

their families through evidence based medicine and with an
emphasis on health research, continous training and
community participation.

C. To maintain and achieve excellence in education, research, and

healthcare for the beneYt of humanity.

D. Provide comprehensive hospital services in a caring

environment.

Feedback

KAMCJ Hospital mission is To provide highly specialized medical care to our

patients and their families through evidence based medicine and with an
emphasis on health research, continuous training and community
participation.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 5 of 49
 4. What is the KAMCJ Hospital Vision? * 1/1

A. Promotes healthy communities supported by a trusted patients

centered hospital.

B. Enhance the health care status and quality of life in a pro active
manner.

C. Provides health and medical tertiary care that rely on the

highest levels of global health care quality standards, and
strives to be specialization center of excellence and a pioneer
of institutional education.

D. To become the most reliable health care provider institute.

Feedback

King Abdullah Medical Complex Hospital Vision is: "Provides Health and
medical Tertiary Care that rely on the highest levels of global health care,
quality standards and strives to be specialization center of excellence and a
pioneer of institutional education".

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 6 of 49
 5. What is the Nursing Department Mission? * 1/1

A. KAMCJ Nursing Team is committed to deliver highest level

of specialized secondary health care services in an integrated
educational and evidenced based practice setting.

B. KAMCJ Nursing Team is committed to cure patient and prevent

diseases through professionally qualiYed team.

C. KAMCJ Nursing Team is committed to create a new genre of

highly qualiYes and trained nurses ready to serve the patient and
their family.

D. KAMCJ Nursing Team is committed to promote quality, family

centered care and eZcient services.

Feedback

Nursing Services Department Mission : KAMCJ Nursing Team is committed to

deliver highest level of specialized secondary health care services in an
integrated educational and evidenced based practice setting

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 7 of 49
 6. What is the Nursing Department Vision? * 1/1

A. To inspire Healthcare professionals to render quality and safety

as core values to guide their work.

B. To be recognized as one of the best nursing services

provided in the kingdom by ensuring safe practise,
collaborating with other disciplines to reach high level of
patient and staff satisfaction.

C. To be a leading Nursing Department recognized by a patient

and staff for excellent and compassionate nursing care.

D. D. Deliver the highest standard of nursing care to the people in

the kingdom within available resources.

Feedback

KAMCJ Nursing Department Vision: To be recognized as one of the best

nursing services provided in the kingdom by ensuring safe practice,
collaborating with other disciplines to reach high level of patient and staff
satisfaction.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 8 of 49
 7. What are the Nursing Department values? * 1/1

A. Compassion, Courage, Leadership and Well-being.

B. Professionalism, integrity, teamwork, conYdentiality,

innovation.

C. Team collaboration, quality care, respect, integrity, safety.

D. Growth, trust, accountability, respect and commitment.

Feedback

KAMCJ Nursing Values are : Professionalism, integrity, teamwork,

con=dentiality, innovation.

8. Can you give the administrative direct chain of command 1/1

from the staff nurse to the CEO Assistant of Nursing Services?

A. Staff Nurse - Nursing Manager - Head Nurse - CEO Assistant of
Nursing Services.

B. Staff Nurse - Nurse Practitioner - Nursing Manager -CEO

C. Staff Nurse - Head Nurse - Nursing Manager - CEO Assistant

of Nursing Services

D. Staff Nurse - Nurse Practitioner - Head Nurse - CEO Assistant of

Nursing Services.

Feedback

Chain of command is the order in which authority in an organization exercise

power and delegation from top management to every employee at every level
of organization.. This shall assists with proper reporting and communication
Qow. KAMCJ has an existing policy for Chain of Command APP-GEN-038.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 9 of 49
 9. What is the name of the CEO Assistant for Nursing Services? 1/1
*

A. Mrs. Wejdan ALhothaly

B. Mrs. Ameerah Radwan

C. Miss Riza Gonzales

D. Mrs. Rowida Mohammed Naholi

E. Mrs. Bodur Alsobhi

Feedback

As per CBAHI, The Nursing Director is considered a member of the hospital

leadership. His/her role is essential in achieving high quality patient care. The
Nursing Director is responsible and accountable for the standard of nursing
care in the hospital along with the Medical Director and Quality Director.
KAMCJ CEO Assistant for Nursing Services is Mrs. Rowida Mohammed Naholi.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 10 of 49
 10. How many General Nursing Standards are there? * 1/1

A. 10 Nursing Standards

B. 11 Nursing Standards

C. 12 Nursing Standards

D. 13 Nursing Standards

Feedback

There are 12 General Nursing Standards

NR.1 Quali=ed nursing director is responsible for managing nursing services
in the hospital.
NR.2 The nursing director assumes a leadership position in the hospital.
NR.3 The nursing director assumes the authority, responsibility, and
accountability for assuring proper and effective nursing services.
NR.4 Nursing reference manuals and policies are readily available and
accessible to all nursing units.
NR.5 The nursing director ensures the competency of the nursing staff.
NR.6 Su9cient nurses are available to meet the needs of patients.
NR.7 The nursing department provides regularly updated work schedule.
NR.8 There is a process for assignment of nurses out of their normal
working areas.
NR.9 Nursing services are provided by quali=ed nurses.
NR.10 There is a comprehensive nursing assessment for each patient
upon admission.
NR.11 There is a nursing plan of care for each patient.
NR.12 The nursing department ensures adequate supplies and equipment
for the safe and effective provision of care.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 11 of 49
 11. Who is responsible to ensure that quality nursing standards 1/1

are adhered to in order to minimize risk and provide safe care

to all patients? *

A. Staff nurses

B. Head nurses

C. Nursing Supervisor

D. All members of the nursing department is responsible to

ensure all standards are implemented in all levels.

Feedback

The Nursing Director and other nurse Managers together with the nursing staff
and nursing aides are the cornerstone for the provision of a high quality and
safe care . A major role is expected from the nursing staff in almost all aspects
of the quality program and competent nursing structure is expected to
participate fully in the implementation of the quality standards.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 12 of 49
 12. What are the key performance indicators presently measured 1/1
by the Nursing Department? *
A. Bed Utilization, Fall, Patient identiYcation, General medication
administration

B. Pressure ulcer, Nursing documentation, Patient identiYcation,

OR Utilization

C. Pressure ulcer, Nursing documentation, Fall, Patient

identiYcation, General medication administration and Pain
Assessment

D. Pressure ulcer, Nursing documentation, Fall, Vital signs

Feedback

Presently, the nursing department are having 6 KPI being measures namely:
Pressure Ulcer, Documentation, Patient Fall, Patient identi=cation, General
medication Administration and Pain Assessment. Data gathering are done
monthly through audits, OVR reports and direct actual observation. These KPIs
are posted and updated monthly in all unit KPI Boards.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 13 of 49
 13. What is the meaning of KPI? * 1/1

A. Key Performance Indicator is a type of performance

measurement to evaluate the success of a hospital.

B. Key Production Indicator is a type of performance measurement

to evaluate the success of a hospital.

C. Keynote Performance Indicator is a type of performance

measurement to evaluate the success of a hospital.

D. Key Performance Index is a type of performance measurement

to evaluate the success of a hospital.

Feedback

Key Performance Indicator or KPI are measures or metrics organizations can

use to concretely gauge their performance. KPIs are designed to measure the
progress of the department strategic goals decided and agreed as a part of the
planning strategy. It helps at improving the e9ciency of hospitals and
healthcare centers.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 14 of 49
 14. What are the International Patient Safety Goals? * 1/1

A. Identify the patient correctly. Improve effective communication.

Improve safety of high alert medications.

B. Identify the patient correctly. Improve effective

communications. Improve safety of high alert medication.
Ensure correct site, correct procedure and correct patient
surgery. Reduce the risk of health care associated infections.
Reduce the risk of patient harm resulting from falls.

C. Identify the patient correctly. Improve effective communication.

Improve safety of high alert medications. Ensure correct site,
correct procedure and correct patient surgery. Reduce the risk of
health care associated infections.

D. Identify the patient correctly. Improve effective communication.

Improve safety of high alert medication. Ensure correct site,
correct procedure and correct patient surgery.

Feedback

International Patient Safety Goals (IPSG) help accredited organizations

address speci=c areas of concern in some of the most problematic areas of
patient safety.
International-Patient-Safety-Goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 15 of 49
 15. What are the correct ways of identifying the patient? * 1/1

A. Ask the patient to state his/her complete name(for conscious

patients), ask relatives(if patient is unconscious)

B. Ask the relative to state the name of his/her patient(for

conscious patients). Check patient's ID band for complete name
and MRN.

C. Ask the patient to state his/her complete name(for

conscious patients), ask relatives(if patient is
unconscious),Check patient's ID band for complete name and
MRN.

D. Checking only the patient's ID Band.

Feedback

KAMCJ policy of Patient Identi=cation APP-GEN-044(2)E details the process by

which patients are identi=ed from another using 2 patient identi=ers: patient's
name and MRN number. All staff involved in the provision of care must ensure
positive patient identi=cation during any encounters in KAMCJ. Nursing staff
will ensure that correct details have been veri=ed with the patient or
appropriate guardian, or next of kin

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 16 of 49
 16. What are the working languages in clinical areas? * 1/1

A. English and Arabic.

B. English and French.

C. Filipino and Arabic.

D. Arabic and French.

Feedback

As part of attaining IPSG#2 To improve effective communication, the

acceptable working languages in KAMCJ are English and Arabic.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 17 of 49
 17. According to the High Alert Medication Policy, how do we 1/1

improve the safety of high alert medications? *

A. Telephone and verbal orders for high alert medications must be
minimized and used only in case of emergency situations.

B. A red Auxiliary label should be aZxed to high alert drugs.

C. Independent double checks by tho nurses prior to the

administration of high alert medications is mandatory.

D. Follow the 9 rights of general medication administration.

E. All patients receiving high alert medications must be closely

observed and monitored.

F. All of the above.

Feedback

As part of achieving the IPSG #3, Improve the safety of high alert medications,
KAMCJ has a policy for High Alert Medications , IPP-PH-006(1)E. This policy
has the purpose to establish a mechanism for handling and use of high alert
medications and to outline the necessary steps to increase the awareness of
these medications. The above mentioned options are steps in improving safety
of these medications in patient care areas.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 18 of 49
 18. As part of risk assessment, how do you assess risk for 1/1

developing pressure ulcer and risk for fall in the Trak Care
System. *
A. Morse Fall Scale- for assessing fall and Braden Scale- for
assessing risk for pressure ulcer.

B. Banner Motility Assessment Tool and pain Assessment Tool

C. Pressure Ulcer Tool

D. Pain Measurement Scale

Feedback

The Braden scale assesses a patients risk of developing a pressure ulcer by

examining six criteria. With a higher score means a lower risk of developing a
pressure ulcer and vice-versa.
6-12 High Risk
13 - 14: Moderate risk
15 - 23: Low risk

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a
patient’s likelihood of falling. It consists of six variables that are quick and easy
to score, and it has been shown to have predictive validity and inter-rater
reliability. The MFS is used widely in acute care settings, both in the hospital
and long term care inpatient settings
51 or higher- high risk
25 -50 - low risk
0-24 No risk

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 19 of 49
 19. How do we ensure correct site, correct procedure, and 1/1

correct patient surgery?

A. Pre-operative veriYcation, use of pre-operative checklist.

B. Site Marking.

C. Time out process with the use of a surgical safety checklist.

D. All of the above

Feedback

As Per JCI,The Universal Protocol was created to prevent wrong person, wrong
procedure, wrong site surgery in hospitals and
outpatient settings. The Universal Protocol consists of three steps:
1. A pre-operative/ pre-procedure veri=cation process- This veri=cation
includes Patient Identi=cation and ensures that all documents are available
prior to the start of the procedure. Missing information and/or discrepancies
must be addressed before the start of the procedure.
2. Marking the operative/procedure site- The site must be marked and veri=ed
for procedures involving right/left distinction, multiple structures (e.g., =ngers,
toes), or multiple levels (as in spinal procedures). The patient should be
involved in site marking if possible.
3. A Time Out (=nal veri=cation) -The Time Out is a deliberate pause in activity
involving clear communication (that includes active listening and verbal
con=rmation of the patient, procedure, site and side) among all members of
the surgical/procedural team. The procedure is not started until any questions
or concerns
are resolved.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 20 of 49
 20. What is the validity of the Surgical, Anesthesia and Blood 1/1

Transfusion consent forms? *

A. Surgical Consent Form: 30 days. Anesthesia Consent Form:
Valid for 30 days. Blood transfusion Consent Form: 30 days.

B. General consent form: Valid for 15 days. Surgical Consent Form:

Valid for 15 days. Anesthesia Consent: valid for 30 days. Blood
Transfusion form: valid for 15 days.

C. General consent form: Valid for 14 days. Surgical Consent Form:

Valid for 30 days. Anesthesia Consent: must be obtained 12 hours
prior to surgery and valid for 30 days. Blood Transfusion form:
Valid for 30 days.

D. General consent form: Valid for 12 days. Surgical Consent Form:

Valid for 60 days. Anesthesia Consent: must be obtained 24 hours
prior to surgery and valid for 30 days. Blood Transfusion form:
Valid for 30 days

Feedback

APP-GEN-150(1)E Informed Consent - policy of KAMCJ made to describe and

de=ne the process of informed consent, how it is obtained, and how it is
related to all aspects of patient care.
Types of consents and validity
1. Consent for surgical, medical and interventional procedure is valid for 30
days. Form to be use is KAMCJ-OR-33
2. Anesthesia Consent- anesthesia consent is valid for 30 days and patient
must be re-assessed 24 hours prior to procedure. Form to be use is KAMCJ-
Anes-46
3. Blood Transfusion Consent- is valid for 30 days.
4. General Consent- valid for a single admission

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 21 of 49
 21. As per policy of Pressure Ulcer Prevention, what are the 1/1

pressure ulcer preventive measures? *

A. Use of Braden Scale within 4 hours of admission to screen
patients at risk of pressure ulcer.

B. Application of position check clock and all bedridden patients

will be repositioned every 2 hours.

C. Proper skin care.

D. Keep bed free of wrinkles and other unnecessary items that

may cause friction or pressure to skin.

E. Use of pressure relieving devices.

F. All of the above.

Feedback

As per policy in Prevention and Management of Pressure Ulcer, all patients

admitted in KAMCJ will be protected from developing pressure ulcer
regardless of the area of admission or help in healing process through a multi
disciplinary approach so as to maintain normal skin integrity, peripheral
circulation and optimum nutritional status by standardized nursing procedures
for assessment, re assessment and documentation of care. All the above
mentioned options are measures to prevent the development of pressure ulcer
especially to populations at high risk.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 22 of 49
 22. Give standard fall preventive measures. * 1/1

A. Orient the patient in his surroundings.

B. Keep the patient area free from clutter.

C. Keep the room well lighted.

D. Lock wheels of bed, side rails up and bed must be in lowest

position.

E. Timely assessment of patient’s risk for fall.

F. All of the Above.

Feedback

Fall is a sudden uncontrolled, unintentional downward displacement of the

body to the ground or other object excluding falls from violent blows or other
purposeful action. Preventive measures were formulated to prevent cases of
fall in health care settings. This is to achieve IPSG#6 Reduce the risk of patient
harm resulting from falls. Standard fall preventive measures are applicable to
all patients regardless of their identi=ed fall risk. This includes: keeping the
room clean and free from clutter, well-lighted, placing call bells within reach,
putting the bed in lowest position while keeping the wheels locked, use of side
rails, assisting able patients to ambulate and others. Morse Fall Scale is a tool
used to identify patient's risk for fall.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 23 of 49
 23. What is the simplest and best way of preventing spread of 1/1

infections?

A.Hand washing/hand hygiene

B.Proper use of PPE

C.Decontamination of the area

D.Using gloves in handling infectious linens or equipmmets

Feedback

The hand hygiene policy APP-GEN-046 was implemented to improve practices

and reduce transmission of pathogenic microorganisms to patients and health
care workers. It includes indications for hand hygiene using soap and water
and alcohol based hand rub. Use of gloves do not replace hand washing or
hand anti sepsis.
In the Standard Precautions Policy APP-GEN-076 Hand washing is also
included in the group of infection prevention practices that apply to the care of
all patients in all health care settings regardless of the suspected or con=rmed
presence of an infectious organism.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 24 of 49
 24.What are the 5 moments of hand hygiene? 1/1

A. Before touching the patient

B. Before any aseptic procedure

C. After exposure to body huids

D. After touching the patient

E. After touching patient’s surroundings

F. All of the Above.

Feedback

According to the World Health organization (WHO) The 5 Moments for Hand
Hygiene approach de=nes the key moments when health-care workers should
perform hand hygiene.

This evidence-based, =eld-tested, user-centered approach is designed to be

easy to learn, logical and applicable in a wide range of settings.

This approach recommends health-care workers to clean their hands

1.before touching a patient,
2.before clean/aseptic procedures,
3.after body Quid exposure/risk,
4.after touching a patient, and
5.after touching patient surroundings.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 25 of 49
 25.What is the sequence in donning of PPE? 1/1

A.Gown, Goggles, Mask, Gloves

B.Mask, Gown, Goggles, Gloves

C.Gloves, Goggles, Mask, Gown

D.Hand Washing ,Gown, Mask, Goggles, Gloves

Feedback

Based on infection control policy for "Guidelines on selection and use of

personal protective equipment(PPE) APP-GEN-048" Sequence for
donning/wearing PPE is : Gown , Mask, Goggles, Gloves
PNEUMONICS: GMGG

26.What is the sequence in removing of PPE? * 1/1

A.Mask, Gown, Goggles, Gloves

B.Gloves, Hand washing, Goggles, Gown, Mask

C.Gown , Mask, Goggles, Gloves

D.Gloves, Gown, Googles, Mask

Feedback

Based on infection control policy for "Guidelines on selection and use of

personal protective equipment(PPE) APP-GEN-048" Sequence for
do9ng/removing PPE is : Gloves, Goggles, Gown, Mask
PNEUMONICS: GGGM

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 26 of 49
 27. How do you manage needle stick injury? * 1/1

A. Wash with soap and water

B. Report to staff clinic or emergency department

C. OVR must be completed

D. Referral to infection control from the physician

E. Referral to other hospital (East Jeddah)

F. Serology order for the patient involved

G. Post exposure prophylaxis must be intitated as soon as

possible.

H. All of the Above

Feedback

Policy for Management of Needlestick injuries and body Quid exposures &
Management of occupational exposure to HBV, HCV, and post exposure
prophylaxis to HIV APP-GEN-090 provides clear guidelines for the management
of health care workers who have had a needle stick injury and other
occupational exposure to blood or body Quids. The options mentioned are all
measures to manage needlestick injuries occurring in the clinical area.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 27 of 49
 29.What are the nursing interventions when blood transfusion 1/1

reaction occurs? *

A. Wait for another 30 minutes and stop transfusion

B. Stop immediately the blood transfusion and immediately give

saline.

C. Stop immediately the blood transfusion and inform the

Physician.Keep an Open line for saline. Immediately inform the
supervisor and blood bank. Monitor vital signs, Yll up the blood
transfusion reaction form, obtain blood & urine sample and
send to laboratory together with the remaining blood
transfusion bag.

D.Finish the transfusion and inform the physician regarding the

reaction.

Feedback

Based on the Blood Transfusion Guidelines APP-GEN-267 , when a blood

transfusion reaction occurs:
1. stop transfusion immediately
2. keep an IV Line for normal saline open
3. Inform treating doctor as well as blood bank doctor
4. close monitoring of patient vital signs
5. Carry out doctor's order based on priority
6. Return blood bag and transfusion set to Blood bank
7. Change transfusion set into a new line
8. Report blood transfusion reaction to blood bank in the system
9. send 4-5 ml of blood sample in plain tube for chemistry, EDTA tube for
regrouping and matching and urine sample for bilirubin and hemoglobinuria to
the blood bank.(doctor's order needed)
10. Assess and reassess as indicated
11. Document in the Trak Care System

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 28 of 49
 30.What are the things to consider prior to Blood transfusion? * 1/1

A.Physicians order only

B.Blood typing and cross matching only

C.Physicians order and blood typing only

D.Physicians order, blood typing and cross matching and active

secured consent

Feedback

Policy in Blood Transfusion Guidelines APP-GEN-267 provides nurses with

procedural guidelines for blood transfusion to ensure safe handling and
administration of blood and blood products so as patient safety will always be
a ensured. The above mentioned options must all be checked and con=rmed
prior to start of blood transfusion.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 29 of 49
 31. How often the vital signs must be monitored during blood 1/1

transfusion? *
A. Measure the vital signs at 0 minute , 15 minutes, 30 minutes
and regularly 30 minutes until transfusion Ynished and
document in blood transfusion monitoring

B Measure the vital signs at 0 minute , 30minutes, 45minutes and

regularly every 1 hour until transfusion Ynished and document in
blood transfusion monitoring

C. Measure the vital signs at 15minutes, 30 minutes and regularly

every 1 hour until transfusion Ynished and document in blood
transfusion monitoring

D. Measure the vital signs at 30minutes, and regularly every 1 hour

until transfusion Ynished and document in blood transfusion
monitoring

Feedback

As per Policy in Blood Transfusion Guidelines APP-GEN-267, Initially regulate

the rate at 16-18 gtts per minute for at least 15 minutes very slowly and
observe for signs of blood transfusion reaction. When there is no reactions,
regulate the rate as prescribed.
Vital signs monitoring must be done starting initial baseline v/s,(0), 15 minutes
then 30 minutes then regularly after 30minutes until end of transfusion.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 30 of 49
 32. What is the maximum time that blood and blood products 1/1

must be returned to the blood bank if was not transfused? *

A. 30 minutes

B. 60 minutes

C. 15 minutes

D. 10 minutes

Other:

Feedback

As per policy of "Blood Transfusion Guidelines APP-GEN-267, blood and blood

products that are not transfused must be returned to the blood bank,
immediately within half an hour at maximum to reissue again if needed
according to TAT or turn around time of the product

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 31 of 49
 33.Which among the choices best describes the procedure for 0/1

labeling blood specimens? *

A.Match the barcode to the patient’s identiYcation band using two
identiYers.

B. Label the specimens in the presence of the patient. Attach the

Label to the appropriate tube and according to laboratory protocol.

C.Match the barcode to the patient’s identiYcation using two

identiYers and label the specimen in the presence of the
patient.Attach the label to the appropriate tube and according to
the laboratory protocol.

D. Match the barcode to the patient’s identiYcation using two

identiYers. Attach the label to the appropriate tube and
according to the laboratory protocol

Correct answer

C.Match the barcode to the patient’s identiYcation using two

identiYers and label the specimen in the presence of the
patient.Attach the label to the appropriate tube and according
to the laboratory protocol.

Feedback

As per policy of labeling specimen APP-GEN-230, The patient must be

consistently identi=ed before any phlebotomy or specimen collection. Once
collected, all specimens must be labeled with 2 patient identi=ers in the
presence of the patient. Labeling of specimen at patient's bedside reduces the
risk of errors and mismatching.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 32 of 49
 34. Which among the choices should a nurse do when 1/1

discovering a medication error?

A. Medication Error must be Ylled up in the system (ERP)
Medication Error within 24 to 48 hours.

B. SigniYcant error should be reported immediately.

C. Reporting of medication error shall be done by the person who

discovered the error.

D. Patient should be monitored for untoward side effects.

E. All of the above

Feedback

Medication Errors Reporting Policy IPP-PH-011(1)E provides a method for

documenting all medication errors in a manner that allows reviewing types and
causes with the aim of preventing and minimizing errors. The above mentioned
guidelines are to be followed during reporting of medication error. The
following details must be documented in the report: Patient's information, date
and time of occurrence, location, individuals involved in the error and
description of the error. Medication safety o9cer shall collect and analyze data
to improve the medication use process, prevent medication errors and improve
patient safety.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 33 of 49
 35.It Is a medication error that was prevented and corrected 1/1

before it reached the patient? *

A. Near Miss

B. Omission error

C. SigniYcant medication error

D. Adverse Event

Feedback

As per policy of Medication Error Reporting IPP-PH-011(1)E, a medication error

is any preventable event that may cause or lead to inappropriate medication
use or patient harm. Signi=cant medication error is an error or event that
results to permanent patient harm (Category G), requires intervention
necessary to sustain patient's life(Category H) and may result in patient's
death(Category I). Omission error is failure to dispense and or administer
medication upon physician order within a correct period of time. Near miss is a
medication error that was detected and corrected before it reached the patient.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 34 of 49
 36.What are High Alert Medications? * 1/1

A. are medications that bear a heightened risk of causing

signiYcant patient harm when used in error

B. are medications that can be bought over the counter

C. are medications that can be taken by patient at home.

D. None of the above

Feedback

High Alert Medications Policy IPP-PH-007(1)E describes High Alert

medications as medications that bear a heightened risk of causing signi=cant
patient harm when used in error. All high alert medications stocked in patient
care areas will have a red auxillary labeled "high alert". Independent double
check by 2 nurses must be done before giving these medications. Medications
considered as high alert are Narcotics, Neuromuscular agents,
Chemotherapeutic Agents, Parenteral Concentrated Solutions, Anti thrombotic
Agents, All types of Insulin, Anesthetic agents, and some special group of
medications such as parenteral nutrition preparations and epidural injectable
medications.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 35 of 49
 37. Which IPSG is related to safety of high alert medications? * 1/1

IPSG #1

IPSG #2

IPSG #3

IPSG #4

IPSG #5

IPSG #6

Other:

Feedback

IPSG #3 is Improve the safety of high alert medications. In the policy of High
Alert Medications IPP-PH-006, limited quantity of high alert medications shall
be kept in patient care areas where it will be kept safe and secured inside
controlled access medication room. Floor stock should be stored on separate
drawer or cabinet clearly labeled with high alert label on the drawer or cabinet.
Concentrated electrolytes are not allowed as Qoor stock for general patient
care areas except as part of crash cart medications. Critical Care Areas(ICU,
CCU, OR and ER) may stock limited quantity of concentrated electrolytes as per
clinical use.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 36 of 49
 38.What is a single dose vial? * 1/1

A. Are large volume parenterals which is for single use only.

B. Are small volume parenterals without antimicrobial

preservative and for single use only.

C. Are small volume parenterals with antimicrobial preservative

and for single use only.

D. Are small volume parenterals with long stability and for single
use only.

Other:

Feedback

The policy of multi-dose vials/containers IPP-PH-034 describes single dose

vials as small volume parenterals without antimicrobial preservative and for
single use only. All medications packed as ampules are intended for single use
only, and any unused portion shall be discarded once opened.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 37 of 49
 39.What is a multidose vial? * 1/1

A. Are small volume parenterals with anti microbial preservatives

B. Are large volume parenterals without antimirobial preservatives

that permit multiple entries into the vilas with long stability

C. Are small volume parenterals with antimicrobial preservative

that permit multiple entries into the vials with long stability.

D. Are small volume parenterals without antimicrobial

preservatives

Feedback

The policy of multi-dose vials/containers IPP-PH-034 describes multi dose

vials as small volume parenterals with antimicrobial preservative that permit
multiple entries into the vials with long stability. There must be No expired
open or unlabeled multi dose vials available in the pharmacy or any patient
care areas.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 38 of 49
 40.How to label multidose vial? * 1/1

Shall be labelled with the expiry date and time with initials of the
staff who open the vial.

Shall be labelled with the open date and expiry date and initials of
the staff who open the vial

Shall be labelled with the open date,time and with the initials of the
staff who open the vial

Shall be labeled with the open date,expiry date,time with initials

of staff who open the vial.

Feedback

The policy of multi-dose vials/containers IPP-PH-034 sets guidelines for

stability of multi dose vial and containers.All opened multi dose
vials/containers shall carry opening date, expiry date, initial for opening staff
and time of opening. No unlabeled or expired opened multi dose vial shall be
seen in any patient care areas.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 39 of 49
 41.What is the stability for opened multidose vials/ containers 1/1

for the following : EYE, EAR,NOSE DROPS, ointments, nasal

spray, NEBULIZERS, INSULIN vials or pen, Heparin vial? *

30 days

28 days

60 days

15 days

Feedback

According to the Stability Guidelines for opened multi-dose

vials/containers(attachment in the policy of IPP-PH-034, Handling multi-dose
vials/container), Eye, Ear, Nose Drops and ointments as well as nasal sprays
are stable for 28 days. Storage opening must be refrigerated between 2-8
degrees or at controlled room temperature below 25 degrees.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 40 of 49
 42.What is the number to call in the event of fire or internal 1/1

disaster? *

5454

5656

5566

5544

Feedback

Based on the approved Fire Safety Plan PLAN-GEN-003, and the Nursing
Internal Disaster Plan Policy IPP-NUR-16(1)E,The emergency
procedure/protocol RACE will be implemented upon discovery of =re. The
emergency number to call is 5566. State: There is Code Red, in Operating
Room(Unit), Recovery Room Area, First Floor Main Building, My name is
Ameerah Vito, Nursing Quality Coordinator(position), Please repeat it back to
me.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 41 of 49
 43.Give an example of internal disaster? * 1/1

stampede

plane crush

overturned bus

hazardous material spills

Feedback

As per policy of Nursing Departmental Internal Disaster Plan IPP-NUR-16(1)E,

an internal disaster is any event that may disrupt operations, jeopardize the
safety and well being of occupants of the facilities or signi=cantly cause
damage to facilities like earthquake, hazardous material spill, electrical power
shutdown, discontinuation of water supply and the likes. The rest of the
options mentioned are considered external disasters.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 42 of 49
 44.As a staff nurse, what are your responsibilities related to 1/1

internal disaster plan? *

A.Be oriented with the procedural guidelines on the speciYc nature
of disaster, which are available in nursing units.

B.Be informed and comply with the unit’s nursing disaster on-call
schedule.

C.Report to assembly area(Auditorium 1) upon announcement and

wait for instruction.

all of the above

Feedback

The Nursing Departmental Internal Disaster Plan IPP-NUR-16(1)E is

implemented to serve as a guide and protect nursing staff, patients and
visitors from any related events that may cause disruption in the medical tower
facilities affecting the environment of care. This also provides direction for
response related to any internal disaster. All member of the nursing
department has their own roles and responsibilities during a disaster. As a
staff, primary responsibility is to be aware of their disaster on call schedule
and must report on time to assembly area upon announcement and wait for
instruction.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 43 of 49
 45. What Protocol is immediately activated upon discovery of 1/1

Fire? *

CARE Protocol

ACER Protocol

RACE Protocol

CERA Protocol

Feedback

Based on the Nursing Internal Disaster Plan Policy, IPP-NUR-016(1)E upon

discovery, the person discovering a =re activates the RACE Protocol.
R- Rescue, remove any patient and other individuals to the designated safe
area.
A- Alarm- alert others by pulling the nearest alarm and calling the emergency
number 5566 to announce Code Red.
C-Con=ne- After making sure, room is empty, close all windows and doors and
place signage "Room Checked". Place a towel or sheet, under the door to
minimize passage of smoke. Ensure Oxygen supply is cut off.
E- Extinguish-/ Evacuate- Utilize the PASS Method in using the extinguisher.
Follow unit speci=c Internal Emergency Disaster Plan, escort all patients to the
nearest exit or designated assembly point.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 44 of 49
 46. What is the color code for FIRE? * 1/1

code blue

code yellow

code red

code white

Feedback

A code Page is an emergency page that overrides all other pages and is used
for emergencies only. The page announcement is always preceeded with the
word "Code". Codes are words used to represent other words in order to keep
announcements brief and alert personnel with an emergency without alarming
patients and other visitors. The KAMCJ Fire Code is CODE RED.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 45 of 49
 47. How do you report a fire incident when talking to the 1/1

operator(5566) *
A.State clearly: There is Code Red, in Operating Room(Unit),
Recovery Room Area, First Floor Main Building, My name is
Ameerah Vito, Nursing Quality Coordinator(position), Please
repeat it back to me.

B.State Clearly: There is Code Orange, in Operating Room(Unit),

Recovery Room Area, First Floor Main Building, My name is
Ameerah Vito, Nursing Quality Coordinator(position), Please repeat
it back to me.

C. State clearly: There is Code Red, I'm Ameerah. Bye

D. There is Code Red, in Operating Room(Unit), Recovery Room

Area, First Floor Main Building, Please repeat it back to me.

Other:

Feedback

When reporting Fire, dial 5566 and clearly state the Code, Location, Reporter
Name and Position. Please repeat it back to me.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 46 of 49
 48.What is the emergency code for hazardous chemical spills? * 1/1

Code Pink

Code Yellow

Code white

Code Orange

Feedback

Code Orange(Spill Management) APP-GEN-029(2)E is implemented to identify

exposure conditions, safely evacuate an area and protect others from exposure
within the health care facility or on its grounds, due to a hazardous material
spill/release. In an event of a major spill, Notify code orange team by dialing
5566 and follow departmental procedures. Follow the guideline in spill
handling according to policy provided. Alert personnel/people to evacuate the
area if necessary.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 47 of 49
 49.What are the safety measures to remember in case of a 1/1

hazardous material spill? *

A. Protect yourself with appropriate PPE, approach the scene with
caution. Alert the people in the area.

B. Attempt to identify the hazardous material.Activate Code

Orange if the spill is more than 100ml

C.Notify the facility safety operation oZcers to describe the nature

of the problem, and to provide technical advice and how to handle
the emergency.Notify immediate head , supervisor and make an
OVR..

All of the Above

Feedback

Code Orange(Spill Management) APP-GEN-029(2)E includes procedures and

guidelines to do when a code orange was announced. The above mentioned
are safety measure to consider and do during incident of major hazardous
chemical spill.

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 48 of 49
 50.When is the external emergency plan be activated in case of 1/1

internal disaster?

A.If the number of critical cases exceeds 30

B.If the number of critical cases exceeds 20-25

C.If the number of critical cases exceeds 5-10

D. If the number of critical cases exceeds 10-15

Feedback

In the policy of Nursing Internal Disaster Plan IPP-NUR-016, If the number of

critical cases exceeds 10-15, nursing supervisor will inform the triage team to
advise the Emergency Response Group(ERG) Leader to activate the external
emergency plan.

This content is neither created nor endorsed by Google. - Terms of Service - Additional Terms

Forms

https://docs.google.com/forms/d/e/1FAIpQLSeBqr58pEdkcDF…SLJndjXUgrFFrYw9x1nudscSEcbOEG-N0VL14hkglzzhP6dMxrg 05/07/2018, 16Z16

Page 49 of 49