Workshop

Ministry Of Health, General Directorate Of Nursing
nd NURSING ADMINISTRATION
2 Edition
anual of
ursing
olicies and
rocedures
Prepared by:
Nursing Policies and Procedures Committee 2011
Supervised by:
Dr. Munira Al Oseimy

General Director of Nursing-MOH
Ministry of Health, General Nursing Administration
Functions and Duties Policies and Procedures
______________________________________________
NURSING ADMINISTRATION
TABLE OF CONTENTS
INDEX
S.N POLICY TITLE
NUMBER
.1 PATIENT RIGHTS AND RESPONSIBILITIES GNR - 01-01
PEDIATRIC RIGHTS AND RESPONSIBILITIES OF PARENTS /
.2 GUARDIANS
GNR - 01-02
.3 NURSING PERFORMNCE APPERISIAL GNR - 01-03
PERFORMANCE APPRAISAL AND PEER PERFORMANCE
.4 REVIEW
NEW GNR - 01-04
.5 RETENTION PLAN NEW GNR-01-05
.6 CHAINE OF COMAND & REPORTING NEW GNR - 01-06
.7 VACATION SCHEDULE NEW GNR - 01-07
.8 SCHEDULING NEW GNR-01-08
.9 CHANGE OF DUTY NEW GNR - 01-09
.10 ON CALL NEW GNR - 01-10
.11 GUIDELINES FOR INTERNAL SWAPPING / TRANSFER NEW GNR - 01-11
.12 FLOATING & CROSS TRAINING NEW GNR - 01-12
.13 DRESS CODE FOR NURSING STAFF GNR - 01-13
.14 NURSING CODE OF ETHICS GNR - 01-14
.15 OPD STAFFING PLAN NEW GNR - 01-15
.16 STAFF PLAN IN ORTHOPEDIC DEPARTMENT. NEW GNR - 01-16
.17 STAFFING PLAN IN OPERATING ROOM NEW GNR - 01-17
.18 STAFFING PLAN MEDICAL WARD NEW GNR - 01-18
.19 STAFFING PLAN IN SURGICAL DEPARTMENT NEW GNR - 01-19
.20 NURSING RESPONSIBILITIES IN QUALITY IMPROVEMENT GNR - 01-20
.21 SENTINEL EVENT ROOT CAUSE ANALYSIS GNR - 01-21
.22 NURSES ROLE IN INFORMED CONSENT GNR - 01-22
NURSES ROLE ON PROTECTING PATIENT'S PRIVACY AND
.23 CONFIDENTIALITY
NEW GNR - 01-23
PREVENTION OF INFANT \CHILD ABDUCTION ( CODE PINK )
.24 DISASTER
NEW GNR - 01-24
.25 CODE BLUE POLICY NEW GNR - 01-25
.26 CODE RED NEW GNR - 01-26
.27 CODE CRISIS NEW GNR - 01-27
.28 VIOLENT PATIENT (code violet) NEW GNR - 01-28
.29 VIOLENT SITUATION IN OPD NEW GNR - 01-29
.30 EMERGENCY CALL NEW GNR - 01-30
.31 PATIENT FALLS NEW GNR - 01-31
.32 POLICE HOLD POLICY NEW GNR - 01-32
.33 MAINTENANCE OF MEDICAL EQUIPMENT NEW GNR - 01-33
.34 BCLS/ACLS CERTIFICATE GNR - 01-34
.35 NURSING ESCORT DUTY GNR - 01-35
______________________________________________
TABLE OF CONTENTS
INDEX
S.N POLICY TITLE
NUMBER
.36 OCCURRENCE VARIANCE REPORTING SYSTEM GNR - 01-36
.37 NURSING CARE OF PATIENT AT END OF LIFE GNR - 01-37
.38 NURSING MEETINGS GNR - 01-38
.39 General Environment Observations NEW GNR - 01-39
.40 Overtime (Backtime) NEW GNR - 01-40
.41 Physical Assault On Staff NEW GNR - 01-41
.42 Dirty Utility Room NEW GNR - 01-42
.43 Clean Util
ilit
it
ityyR
Rooom NEW GNR - 01
01--43
44 SUPPLIES NEW GNR - 01-44
45 SUPPLIES AND EQUIPMENTS NEW GNR-01-45
46 MOI CASES NEW GNR-01-46
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ADMINISTRATIVE POLICY AND PROCEDURE

POLICY NUMBER: GNR: 01-01 APPLIES TO: NURSING
TITLE: PATIENT RIGHTS AND RESPONSIBILITIES
APP APPROVAL DATE: EFFECTIVE DATE:
DUE FOR REVIEW: NUMBER OF PAGES 1 of 6
1.0 DEFINITION
Patient rights and responsibilities- the doctrine of informed consent is that competent
adult patients have a right of self-determination which include the right to refuse
treatment.
2.0 PURPOSE
To assist patients to know their basic rights and responsibilities as patients, to

themselves, the health care team and the institution.
3.0 POLICY
1. It is the responsibility of every members of the health care team to identify and
adhere to patients rights and responsibilities that would promote trust and
respect as part of the dimensions of patient care.
2. It is the policy of the organization, that in order to protect the personal welfare
and safeguard the dignity of every patients as human being, the hospital and
medical staff have adopted the following rights and responsibilities of patients.
4.0 RESPONSIBILITIES
Nurses must respect clients rights and abide by the Patients Bill of Rights.
5.0 MATERIALS & EQUIPMENT
1. Informed Consent IPP

2. Discharged Against Medical Advise IPP
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6.0 PROCEDURES
GUIDELINES
1. Patient Rights:
1.1 The right to considerate care, with full respect of patients dignity, regardless of
nationality, color, age, sex, religion, and disability (if any).
1.2 The right to know them by name the physician, nurses, and staff
members involved in the treatment.
1.3 The right to be seen by the consultant within twenty four hours from admission
and on a regular basis after that during the episode of admission.
1.4 The right to know the physician in a language that patient understands all the
information about the case, diagnosis, and the treatment plan any other
instructions about the follow-up care.
1.5 Convenient atmosphere should be provided where patient can discuss openly
and in full confidentiality about his illness.
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1.6 To know the reason for any test or diagnostic procedures that will be done, and
who is going to do them and the right to know the treatment and who is going to deliver
it.
1.7 The right to know the nature and inherent risks of any procedure to which the
patient has given consent.
1.8 The right to refuse signing the consent form for any test that he feels does not have
information about.
1.9 The right to change his mind and to refuse the test that has been agreed upon.
1.10The right to limit those persons who would visit or call during admission, in
accordance with the hospital policy and procedure.
1.11The right to refuse treatment after knowing and being aware of the consequence.
1.12The right to expect his personal privacy to be respected to the fullest extent
consistent with the care prescribed for.
1.13 The right to expect that all communications and other records pertaining to, be
kept confidential.
1.14 The right to obtain any information or documents, such as medical reports, sick
leave, etc. as documented in the medical chart
1.15 The right to request consultation or second opinion from another physician(s)
through the treating consultant guided by the Hospitals administrative policy.
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1.16The right to request for a change of physician as per hospital policy.
1.17The right to change or transfer to other hospital as per hospital policy.
1.18The right to refuse to participate in Medical Training Program and Research

Projects. And he / she also has the right to withdraw at any stage, from an on-going
research in which the patient has been participating, without the consequences that
affect the care given to him.
1.19The right to be discharged from the hospital, against the physicians advice.
1.20The right to choose the person who would represent him in signing the hospital
documents including release of information.
1.21When discharged from the hospital, have the right to have medicine prescriptions,
follow-up appointments and all the information and the training needed to be able
to take care of themselves at home (if case requires).
2. Patient Responsibilities:
2.1 To know and follow the law of the Kingdom of Saudi Arabia and the hospital
rules and regulations as explained by the hospital staff.
2.2 To provide accurate and Complete information concerning the present

complaints, past illnesses and hospitalizations, and other matters relating to
his / her illness.
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6.0 PROCEDURES
2.3 To make it known whether he / she clearly comprehend the course
of the medical treatment.
2.4 To follow the treatment plan established by the physician,including the

instructions of nurses and other health professionals as they carry out the
doctors orders.
2.5 Is responsible for the actions should he refused treatment or no to follow the
physicians order.
2.6 To notify the physician, the Head Nurse or the Social Worker representative of
any dissatisfaction to the care at the hospital.
2.7 Be considerate of the rights of other patients and hospital personnel, and assist in
the control of noise, smoking, and other possible sources of unnecessary
disturbance and / or discomfort.
2.8 Show respect and consideration of other patients, visitors and hospital priorities.
2.9 Sign the informed consent for surgery, medical or interventional procedures that
may be needed during admission or in case he insisted to be discharged against
medical advice, and other forms requested by the hospital.
1.10 Be aware that the hospital is committed to high standards of care and hospitality
for patients and their families.
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7.0 ATTACHMENTS
Patients Bill of rights
8.0 REFERENCES
Kingdom Saudi Arabia- Ministry Of Health Policy
NAME: DATE
PREPARED BY: Kingdom Saudi Arabia- Ministry Of Health 2010
Saleh Ziad Al-Juaid - RN, BSN, MSN. KFH-TAIF

REVIEWED BY: Michelle R.Anapi - RN, BSN, MSN. KFH-TAIF 2010
Central Committee Of NPP 2010

APPROVED BY: 2010
General Directorate Of Nurs-ing- MOH.KSA
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POLICY NUMBER: GNR-01-02 APPLIES TO: NURSING
PEDIATRIC RIGHTS AND RESPONSIBILITIES
TITLE:
APP APPROVAL DATE:
OF PARENTS / GUARDIANS
EFFECTIVE DATE:
1.0 DEFINITION
Patients Rights are ethical legal principles and privileges in which patients are
entitled to be upheld and observed by the health care procedure.
Beneficence affirms the inherent professional aspiration and duty to help promote
the well-being of others.
Non maleficence - complements beneficence and obligates the professional nurse

not to harm the patient directly or with intent.
2.0 PURPOSE
To assist parents / guardians on their rights and responsibilities in belief of patient
whose rights / responsibilities are dependent from others.
3.0 POLICY
1. In addition to the rights of adult patients, the needs of children / adolescent and /
or handicapped patient and they, with their parents / guardian, shall have the
following rights;
Respect for:
Each child, adolescent and / or handicapped patients as a unique individual.
The care-taking role and individual response of the parent.
2. Provides for normal physical and physiological needs include nutrition, rest,
sleep, warmth, activity and freedom to move and explore.
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TITLE:
APP APPROVAL DATE:
EFFECTIVE DATE:

3. Consistent, supportive and nurturing care which meets the emotional and
psychosocial needs of patients, and fosters open communication.
4. Provision for self esteem which will be met by attempts to give;
The reassuring presence of a caring person, especially a parent / family

member.
Freedom to express feeling of fears with appropriate reaction, if possible,
To maintain control as possible over self and situation;
Opportunities to work through experience before and after they occur,

verbally, in play or in other appropriate ways;
Recognize and reward the coping well doing difficult situations.
5. Provision for varied and normal stimuli of life which contributes to cognitive,
social, emotional and physical development needs;
Play, educational and social activities essential to all children and

adolescents.
6. Information about what to expect prior to, during and following procedure /
treatment and support in coping with it.
7. Participation of children / families in decision affecting their own medical

treatment.
8. Minimization of the hospital stay duration by planning patients discharge needs.
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TITLE:
APP APPROVAL DATE:
EFFECTIVE DATE:
All Medical And Non Medical Staff
8.0 REFERENCES
NAME: DATE

Saleh Ziad Al-Juaid - RN, BSN, MSN. KFH-TAIF
REVIEWED BY: Michelle R.Anapi - RN, BSN, MSN. KFH-TAIF 2010

APPROVED BY: 2010
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POLICY NUMBER: GNR - 01-03 APPLIES TO: NURSING
TITLE: NURSING PERFORMNCE APPERISIAL
1.0 PURPOSE :
1.1. To assess the professional skill & implementation ability.
1.2. To determine the success of Nursing Care.
1.3. To identify the areas of improvement that needs to be made in the nursing practice.
2.0 DEFINITION :
2.1. Performance Evaluation refers to appraisal/monitoring of staff performance according to goals

or available resources within a period of time to determine efficiency in delivery of care as required
by the standards of Nursing education and practice.
2.2. Probationary Evaluation: (FIRST 3-6 months of orientation period for new staff).
Head Nurse/ Supervisors/ Nursing Director.
4.0 POLICY
4.1. The Head Nurse is responsible for performance appraisal of his/ her personnel.
4.2. Probationary evaluations must be completed and sent to Nursing Department within the required
time .
4.3. During the probationary period, a verbal report is given to the employee from time to
time.
4.4. Progress notes are to be signed by Head Nurse and employee. Head Nurse to place
reports in employees file.
4.5. The Assistant Director of Nursing must be kept informed on an-going basis of any
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unresolved problems.
4.6. Annual Evaluation:
4.6.1. Annual evaluations must be completed and sent to Personnel through the
Nursing Department, at least 2 months (as per hospital / MOH policy)
4.6.2. prior to the end of the employees service year. It must be signed by the Head
Nurse and employee before submission.
4.7. Written anecdotal notes, conferences/ counseling session are to be kept by the Head
Nurse on all employees throughout the contract year.
4.8. The Assistant Director of Nursing must be informed on an on-going basis of any
unresolved problems.
4.9. Staff Nurse is expected to complete self-evaluation as required.
4.10. All employees must be notified at least 90 days prior to end of service date, if a further
contract will or will not be offered.
4.11. Probationary Period (3-6 months)
4.12. Head Nurse is responsible for making initial contact with employee when he / she arrived on the
unit.
4.13. Head Nurse to review skills check list, expectations and job description with new
employee.
4.14. Introduce the assigned preceptor and outline his / her responsibilities in the presence of
new employee.
4.15. Head Nurse is responsible to have the employee checked off any unfamiliar procedure
prior to end of three (3) to six (6) months probationary period.
4.16. Head Nurse to make a notation in employees file, regarding discussion and any planned
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follow-up.
4.17. On at least two (2) weekly basis, the Head Nurse assess employees
performance in the following manner :
4.17.1. Review documentation on the medical record.
4.17.2. Evaluates care given to assigned patients i.e. observe employee at bedside,
ascertain knowledge of patient diagnosis, medical and nursing management.
4.17.3. Evaluate written care of plan
4.17.4. Listen to shift report.
4.17.5. Obtain feedback from other staff/ preceptor (if applicable)
4.18. For any problem identified and still not resolved during the first three (3) months of
employment, employee should be told specifically that he/she is not meeting
expectations and may not be retained beyond the 90 day probationary period; have the
employee sign and give him / her a copy.
4.20Goals with target date for the next six (6) nine (9) months should be discussed with the
employee. Itshould be emphasized that these goals must be met, otherwise may result in
employee not being re-contracted at the end of the year, or a less satisfactory performance
rating.
4.21. Head Nurse must document each session and employee should also sign.
4.22. Head Nurse is expected to keep accurate and current files on employees.
CRITERIA FOR EVALUATION

1.0 Experience
1.1. Experience & work performance
1.2. Interest and ability to learn
1.3. Efficiency to handle emergencies
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1.4. Interest in work

2.0 Personal
2.1. Appearance
2.2. Accepts correction or not
2.3. General behavior
3.0 Relation with

a. 3.1. Head of Department
b. 3.2. Colleagues
c. 3.3. Patients
5.0 PROCEDURES RATIONALE

6.1. Pen, blue or black
7.0 ATTACHMENTS
7.1. Performance Appraisal Form
7.2. Performance Standard Indicators
7.3. Employee Unit File / Documentation
7.4. Completion of Employee Performance Appraisal
8.0 REFERENCES
8.1 Ministry Of Health policy & procedure CD
8.2 CBAHI standards
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NAME: DATE

Mrs. Mrs.Ashwag O. Shibah RN,BSN King Fahd hospital -
REVIEWED By:
jedsdah 2010
APPROVED BY: General Directorate Of Nurs-ing- MOH.KSA 2010
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PERFORMANCE APPRAISAL AND PEER
TITLE:
APP APPROVAL DATE:
PERFORMANCE REVIEW
EFFECTIVE DATE:
1.0DEFINITION
1.1 Performance evaluation is a constructive process to acknowledge the employee
performance of a non probationary career employee.
1.2 Peer is an employees co-workers or individuals other than the employees

supervisors who are familiar with the employees performance work products and /
services
2.0 PURPOSE
2.1To ensure that that the quality and quantity of work performed by staff member.
2.2. To allow for continuous communication between manager /leaders and employee about
job performance.
2.3 To offer the manager / leader and employee the opportunity to develop a set of expectation
for future performance.
2.4 To used the opportunity for the manager /leader and employee to assess the employees
best performance.
2.5 To use for future development plan of the employee.
2.6 To provide supporting documentation for pay increment, decisions, promotions,
grievances, complaints, disciplinary actions and termination.
3.0 POLICY
3.1 Performance Appraisal
3.1.1 Performance appraisal shall be done for all staff yearly.
3.1.2 New staff nurses shall be evaluated after the 3 months probationary period, if the result
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TITLE:
APP APPROVAL DATE:
PERFORMANCE REVIEW
EFFECTIVE DATE:
fair or poor educational plan must be done by head nurse and nursing supervisor and to
be re evaluated by the end of the year. Annually this should focus on employees ability
to perform the duties listed in the job description.
3.1.3 All performance appraisals should be done according to the staff job description.
3.1.4 The evaluator should be capable of evaluating performance in an effective manner
3.1.5 Performance appraisal should reflect the performance of the staff
3.1.6 Result of the evaluation process will be the identification of individual development
needs and the creation of a plan by which that development will be achieved.
3.1.7 Development plan should include the area most in need of improvement, action and
strategies to improve performance.
3.1.8 The criteria on which performance is evaluated must be clearly communicated to the
individual prior to the commencement of the evaluation process. The evaluator should
set up private meeting with the staff to discuss the evaluation.
3.1.9 Leader / manager and the staff must sign the evaluation form.
3.1.10 In case unsatisfied staff with his / her evaluation after discussion with evaluator
appointment should be
arranged with Assistant Nursing Director or Director of Nursing to discuss the issue.
3.2 Peer Performance Review
3.2.1 Peer performance review shall be done for all staff yearly.
3.2.2 Peer input should be captured independent of the evaluation being conducted by the
supervisor.
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TITLE:
APP APPROVAL DATE:
PERFORMANCE REVIEW
EFFECTIVE DATE:
3.3 Peer Performance scale.

3.3.1 Strongly agree
3.3.2 Agree
3.3.3 Neutral
3.3.4 Disagree
3.3.5 Strongly Disagree
3.4 Name and Signature of the Appraiser
4.1 Head Nurse for regular nursing staff
4.2 Supervisor for head nurses
4.3 Asst. Nursing Director for Supervisor
4.4 Nursing Director for Asst. Nursing Director and the staff who are directly under her
supervision.

N\A
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
Performance scale form
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TITLE:
APP APPROVAL DATE:
PERFORMANCE REVIEW
EFFECTIVE DATE:
8 REFERENCES
8.1 Ministry of Health Nursing Policy And Procedures 2006
8.2 INTERNAL NURSING POLICY AND PROCEDURES KFH-J NRS-IPP-ADM-001E (2

8.3 Columbia university HR, nursing practice
8.4 Canadian clay and Glass Gallery performance appraisal policy
8.5 Staff performance appraisal policy UPPSN. 04 & 20 issue no. 7
effective date 03/3/2007
8.6 Agency for workforce performance evaluation system.
NAME: DATE
Mrs. Mrs.Ashwag O. Shibah RN,BSN King Fahd

REVIEWED By: 2010
hospital -jedsdah

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TITLE: RETENTION PLAN
1.0 PURPOSE
To retain staff in order for them to work in the hospital setting with satisfaction.
2.0 DEFINITION
Retention Plan is the process of keeping staff currently employed for longer period
of time with satisfaction on their job.
Director of Nursing
4.0 POLICY
It is the policy Rehabilitation Hospital to retain staff who are currently employed, with
comfort and satisfaction, to function in their full capacity, providing good nursing
services and quality nursing care to the patients.
5.0 PROCEDURES
5.1 Assess the current situation.

5.2 Develop a satisfaction survey or hold various meetings to determine how to make the
work environment better for nurses.
5.3 Assess the leaderships interest and support for a program.
5.4 Assess your current turnover rate because the program is aimed at reducing nurse
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turnover which should reduce costs and also assist in creating a safer patient care
environment.
5.5 Hold meetings with the nurses.
5.6 Provide good working environment.
5.7 Assign staff in their area of specialty.
5.8 Provide support and the feeling of cooperation with every staff.
5.9 Provide training and education programs.
5.10 Avoid pressure to the staff
particularly at time of work.
5.11 Follow contract agreements:
2.1.1. 5.11.1 Benefits
2.1.2. 5.11.2 Leave
2.1.3. 5.11.3 Medical Care
2.1.4. 5.11.4 Transportation
2.1.5. 5.11.5 Days Off
2.1.6. 5.11.6 Uniform
6.0 ATTACHMENTS
8.0 REFERENCES
KSA- MOH- GENERAL DIRECTORATE OF NURSING POLICY2010
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NAME DATE
Prepared By: Khalid A. Alharthi Nursing Total Quality Coordinator GND-

2010
MOH - KSA
Approved By: Central Committee Of NPP 2010 - General Directorate Of Nursing-
2010
MOH.KSA
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TITLE: REPORTING RELATIONSHIP
1.0 PURPOSE
1.1 To outline a reporting format on each level of the Nursing Services Department.
1.2 To ensure effective communication to all relevant personnel at all times.
1.3 To facilitate quality nursing service.
2.0 DEFINITION
This policy outlines the reporting relationship of each level of the nursing department.
Nursing Staff in all levels
4.0 POLICY
4.1 Staff nurse / in-charge shall inform the Head Nurse of any change in any patients
status (i.e. medication treatment, physical or behavior status).
4.2 Medical nurses must immediately inform the Head Nurse / In-charge and the
appropriate medical officer(s) of all significant changes in a patients vital signs.
4.3 Nurses monitoring any patient on special observation status must immediately inform
the Head Nurse / In-charge of any significant issues during their period of
observation.
4.4 Head Nurse / In-charge must immediately inform the Nursing Supervisor on duty on
all significant patient and non- patient related incidents, ICU admissions, seclusion or
physical aggression by or against staff members.
4.4.1 A written report will be written at the end of each nursing shift. This will
include a current census figure, number of admissions, discharges, home
passes, and transfers in and out and other returns to the unit. The report shall
also contain brief details of critical / unusual occurrences, admissions, ICU
cases and any other patient related issue that is significant. A copy is to be
maintained on the unit and a copy sent to Nursing Administration at the end
of the shift.
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4.4.2 The Head Nurse / In-charge shall sit with all members of the nursing staff for
the oncoming shift and give a verbal report of the status of each patient on the
ward. This is to include medication change, physical status, restraints and
seclusion, behavioral patterns, etc.
4.4.3 The staff nurses on duty shall continue to monitor the ward until the
completion of the report and the oncoming duty nurses are physically present
on the ward.
4.5 Supervisor Level:

4.5.1 Shift Supervisors shall use the written unit reports and critical / unusual
occurrences reports as a basis for providing a detailed report to the oncoming
supervisor. Any other relevant information gained on their shift through
rounds of the units and hospital environment should be included in this hand
over.
4.5.2 All shift supervisors shall report directly to the Deputy Director of Nursing
concerning significant management / clinical issues that occur during their
period of duty.
4.5.3 Deputy Director of Nursing will also read all unit reports and critical /
unusual occurrence reports.
4.5.4 The Nursing Administrator on-call and the Director of Nursing must be
informed of all critical / unusual occurrences and other events of significance
that occur during a supervisors shift.
4.5.5 All unit reports and critical / unusual occurrence reports from the previous
day are to be forwarded to the Director of Nursing on the following morning.
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6.0 ATTACHMENTS
8.0 REFERENCES
1. General Directorate Of Nursing NPP Manual Of 2007
2. Al Amal Hospital, Jeddah MOH-NPP 2010
NAME DATE
Prepared By: Khalid A. Alharthi Nursing Total Quality Coordinator
2010
GND- MOH - KSA
Approved By: Central Committee Of NPP 2010 - General Directorate Of
2010
Nursing- MOH.KSA
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TITLE: VACATION SCHEDULE
1.0 PURPOSE
1.1 To have an organized leave for staff.

1.2 To manage each unit with sufficient number of staff.
1.3 To control the leave of staff
2.0 DEFINITION
Vacation schedule is the arrangement / scheduling of leave for the members of the Nursing
Department without affecting the number of staff thereby rendering continuity of care to the
patient with sufficient staff
Head Nurses, Staff Nurses
4.0 POLICY
4.1 The Head Nurses receives and organize the schedules of vacation for the staff.
4.2 Maximum of 45 days is allowed for each staff, minimum of five (5) days for
annual leave.
4.3 Maximum of 4 staff can be scheduled for leave each month if the requests indicates.
4.4 There should be an overlapping of 1 week between the leaves, last week of the staff
on vacation overlapping with the first week of leave of the staff leaving for
vacation.
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5.0 PROCEDURES
5.1 Nursing staff submits request (leave form with supporting papers) to the Head
Nurse of the unit, the HN then list the name of the staff in the Schedule of
Vacation Board.
5.2 If the staff wants to swap their leave from time to time, they must arrange with
colleagues and the Head Nurse of the unit.
5.3 Staff should commit in day-out / day-in for good management of leave of other
staff schedule.
5.4 Vacation leave form must be submitted one (1) month prior to the schedule for
leave for processing.
5.5 In case of emergency while staff is on leave, and he cannot come back from
vacation on time, he must send message through fax in the hospital with enough
time for arrangement of schedule.
5.6 Local vacation (compensation- annual leave, emergency leave)
5.6.1 Compensation must be

filled and send to personnel
before 24 hour at least for
processing.
5.6.2 Local annual leave must be filled and send to personnel before one
(1) week at least for processing
Emergency leave could be the same day of leave but staff must arrange evidence or a valid
reason for the leave.
6.0 ATTACHMENTS
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8.0 REFERENCES
Kingdom Of Saudi Arabia MOH - Policy
NAME DATE
2010
MOH - KSA
2010
MOH.KSA
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TITLE: Scheduling
1.0DEFINITION
1.1 Cyclic Scheduling is the staffing requirement based on equitable distribution of
hours of work and time off for staff and the basic time pattern for a certain number of
weeks is established and repeated in cycle.
2.0 PURPOSE
2.1 The purpose of the nursing schedule is to enhance the availability of nursing staffs, and
thereby ensure patients safety.
3.0 POLICY
3.1 Nursing schedule is made for a period of one month ( monthly schedule) by the head nurse
which includes productive and non productive time such as day off, owing day off, education,
training, committee meeting and etc. The area supervisor in charge to counterchecks and approves
the schedule before submission to the nursing office.
Schedule must be submitted two weeks before the ongoing schedule ends. Three copies
must bemade, one of which will be forwarded to the Nursing Service office and one will be kept in
the unit where
it is accessible to the staffs and the 3rd copy must be send to Dormitory matron with the
mobile numbers written under each name.
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TITLE: Scheduling
Official duty time for 3 shifts are as follows:

Morning Shift
0700H 1600H
Evening Shift 1500H 2400H
Night Shift 2300H 0800H
For 12 HOURS SHIFT

0700H 1900H
Morning Shift
OPD
From 7:30 AM to 12:30 PM 1:30 PM to 5:00 PM
Operating Room
Morning Shift
0730H 1630H
Rotation Nursing Supervisor
SATURDAY - WEDNESDAY
WEEKENDS
First Shift
0700H 1900H
Second Shift 1900H 0700H
Break Time
Lunch
hour Anytime between 11 am 2 pm
Dinner hour Anytime between 4 -7 pm
Supper hour Anytime after 1 am.
ADMIN-29
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TITLE: Scheduling
3.2 Schedule Request
Before the Head Nurse/ CN makes the schedule staff nurses are being asked to submit their
request for off duty or any other request which is schedule related. The HN/ CN will decide if
the request will be granted or not depending on the need of the unit, or the requests will not
affect the manpower, thereby affecting the delivery of patient care.
3.3 Changes in schedules
Once the schedule has been finalized, approved and submitted changes must be made under
the discretion of the head nurse/charge nurse, depending on the needs of the unit. In the event
that the staff needs a change of duty a request must be made and submitted to the HN for
approval.
In the event that a nurse who is scheduled for duty is absent, or on sick leave or emergency
leave, a reliever must be arranged by the HN or area supervisor during morning shift and
charge nurse or rotation nursing supervisor for evening and night shift. Nurses who are going for
sick leave must inform the head nurse or supervisor 2 hours before her or his duty hours.
In cases wherein, the staff is absent without notifying the HN/ Supervisor, the head nurse or
supervisor should make an attempt to contact the staff to clarify the reason. Absent for duty is
subject to disciplinary action. Three incidents will result to investigation and dismissal.
On call nurses are scheduled and the schedule available in nursing office. In case of any need
arise they can be contacted easily through the nursing supervisor on duty.
A. GENERALUNIT:
1. Upon notification to the head nurse that the staff nurse is on sick leave, emergency
leave or absent, nursing supervisor on duty should be informed to arrange a staff
nurse to cover the area.
ADMIN-30
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TITLE: Scheduling
2. During evening duty, night duty and weekend the charge nurse will coordinate with the
rotating nursing supervisor to arrange scheduling depending on the ward situation,
or to be call off duty staff from the dormitory through the matron on duty.
3. Head nurse/ charge Nurse must arrange the next duty schedule for the nurse
who is on call.
4. Nursing Supervisor endorse to the Rotating Supervisor on duty in cases of

sick leave, emergency leave or absent or vice versa.
B. ON CALL NURSES
A. Endoscopy
1. On call duty nurse start from 1630 H until 0730 Hthe next morning.
2. Thursday and Friday 24 hours covered by on call duty nurse.
3. First or second on call duty nurse to be called by the rotating supervisor on duty
through dormitory matron.
4. Overtime hours will be paid back to the on call nurse according to the work situation in
the unit.
B. DIALYSIS UNIT: (JEDDAH KIDNEY CENTER)

1. Friday duty starts from 0700 hours to 1530 hours for morning shift, 1500 hours 2330
hours evening shift and 2300 hours to 0730 hours night shift.
2. On Friday there is one nurse in morning and afternoon shift and 2 nurses for night
duty.
3. Friday duty nurse will have Saturday off or Thursday off or other days depending on
the ward situation.
C. OPERATING ROOM:
ADMIN-31
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TITLE: Scheduling
1. Regular on call schedule is provided according to monthly schedule.

2. On call duty starts at 1800 H to 0730 H from Saturday to Thursday.
3. On call duty on Friday will be called anytime according to the work needs.
4. 2 nurses are assigned from morning and afternoon at 0800H to 2000H ours in order to
cover and help the work and emergency operation, sick leave, emergency leave or
absent.
5. In case on call nurses are still extending his/ her duty and they need additional staff
nurse, the charge nurse will inform the rotating nursing supervisor on duty to call the
previous day first on call through the dormitory matron on duty.
6. Nurses who attended the call still have to report on regular duty according to their
schedule.
7. Overtime hours will be replaced to on call nurse according to the work situation in the
unit
Overtime Guidelines
1. Overtime is any time worked in a week which exceeds the schedules 48 hours.
2. Overtime will be closely monitored and controlled. It must be approved by the Director
of Nursing or the Deputy Director of Nursing, the Nursing Supervisor and Head of the
unit. In case of severe shortage of manpower, overtime must be approved by the
appropriate hospital leaders according to hospital protocol (According to MOH and the
hospital internal policy).
3. Overtime may be paid back in terms of extra days off in case financial remunerations is
not applicable / approved. (According to MOH and / or hospital internal policy).
4. Staff may not work more than five overtime shifts (4 hours per day x 5 days a week or
20 hours of the Hijjra month (payroll period) or work more than five (5) consecutive days
without authorization of the Director of Nursing / Assistant Chief of Nursing.
5. Advancement Planning / Approval.
ADMIN-32
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TITLE: Scheduling
5.1 Assistant Chief of Nursing are responsible for the monitoring and control of overtime
within their
clinical service by.
Requesting administrative approval for the required number of overtime hours.
Ensuring that the department does not exceed the amount of overtime
authorized.
Nursing Personnel Vacation Policy & Other Leave Benefits
PURPOSE:
To provide guidelines on annual vacation for MOH- Saudi Staff- MOH, non Saudi staff and
PIO staff and other leave benefits.
Application policy and procedure (vacation/emergency leave) for Saudi staff MOH
a) Application for annual vacation should be applied 5 days prior to the date of vacation
and follow vacation
plan in the unit.
b) The annual vacation is 36 days per annum. The vacation can be taken with minimum of
5 days, and
maximum of 3 months in one year.
c) Vacation application form issued by the personnel department should be approved /

signed by the:
Unit Head Nurse

Nursing Supervisor
Nursing Administration after verification by the vacation allocation in charge.
ADMIN-33
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TITLE: Scheduling
Chief Nurse
d) Approved vacation request form should be returned back to the personnel department.
2) Maternity Leave Policy
As per Ministry of Health Maternity leave is 60 days .
3) Emergency Leave
a) Emergency leave is granted to the staff with valid reason and is subject to
approval by the Nurse Supervisor who is authorized by the Director of Nursing
and Nursing Administration.
b) The nurse is entitled for a maximum of 5 days emergency leave per

application. Emergency leave is not allowed to save for next year contract.
4) Sick Leave Policy
a) First 6 months with full salary
b) Next 6 months with 1/2 salary
c) Next 6 months with 1/4 salary
d) If extended no salary shall be paid till he /she comes back for duty.
e) Otherwise he /she will be referred to Medical Assembly.
5) Education / training activities if any staff attends education or training activities out of duty
owing hours will be refunded.
6) Attending meetings, committees and quality management activities.
The assigned members must be attend committees, meetings and quality management activities
as per schedule
ADMIN-34
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TITLE: Scheduling
Vacation Application Policy & Procedure
MOH Nursing Personnel Non Saudi
Entitled for 45 days
a) Application for annual vacation should be applied 2 months prior to the due date of
vacation, to give enough time for clearance ticket and visa processing by the
administrative personnel.
b) Personnel Department will not entertain any vacation application earlier than the allowed
2 months period before the DDV
c) Maximum period of extending vacation is- 5 months from the date of contract.
d) Vacation application form issued by the personnel department should be approved /

signed by the :
Unit Head Nurse
Nursing Supervisor
Nursing Administration after verification by the vacation allocation in-charge
e) Approved vacation request form should be returned back to Personnel Department for
processing of clearance paper.
Vacation Clearance Processing Procedure:
MOH Nursing Personnel Non Saudi
a. Personnel Department will issue the Vacation Clearance Form.
b. Clearance Form has to be approved and signed by the following department / personnel
in the following order.
ADMIN-35
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TITLE: Scheduling
1. Head Nurse with Narcotic Clearance Form
2. Supervisor
3. Vacation allocation In-charge
4. Nursing Service Office
5. Pharmacy
6. Computer / 1D Department
7. General Store
8. Stock control committee(for Head Nurse & Charge Nurse)
9. Dietary
10. PRO
11. Cashier
12. Dormitory Matron ( not for live-out)
13. Personnel Department
14. Hospital Director / Administrative Director
For the Head Nurse and the charge Nurse, three additional forms need to be accomplished as
follows:
1. Clearance Certificate
2. Change of Authority Form
3. Pharmacy Form from chief Nurse to Head of Pharmacy
ADMIN-36
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TITLE: Scheduling
After clearance has been made with the above mentioned department, return the clearance
form to the Administration Department for completion and approval.
One (1) copy for visa processing and one copy for ticketing / voucher processing.
Maternity Leave Policy:
As per Ministry of Health Policy on Maternity Leave.
a) During the first 3 years of contract not entitled on maternity leave.
b) On the 4th year contract period entitled 25 days maternity leave.
c) Upon completion of 4 years of contract entitled for 45 days maternity leave and can
attach 45 days annual vacation at the same time.
d) Gap of 4 years between pregnancies also entitled for 45 days maternity leave.
e) Gap of 3 years between pregnancies also entitled for 25days maternity leave.
Legend:
Due date of vacation - D.D.V.
Requested vacation date - R.V.D.
Maternity Leave vacation _ M.L.V
Emergency Leave - E.L.
Partial Leave - P.L.
Application Policy & Procedure PIO Nursing Personnel)
ADMIN-37
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TITLE: Scheduling
Vacation & Emergency Leave
1) Vacation Application Policy Procedure:
Entitled for 30 days
a. Application for annual vacation should be applied 2 months prior to the due date of
vacation, to give enough time for clearance, ticket and visa processing by the
administrative personnel.
b. Personnel Department will not entertain any vacation application earlier than the
allowed 2 months period before the D.D.V.
c. Maximum period for extending vacation is six months from the date of contract.
d. Vacation application form issued by the personnel department should be approved

/ signed by the:
- Unit Head Nurse
- Nursing Supervisor
- Nursing Administration after verification by the Vacation Allocation In-
Charge.
e. Approved Vacation Request should be returned back to the Personnel Department

of PIO.
2) Application for Ticket:
a. Send request to personnel department of PIO for signature and follow-up ticket.
Emergency Leave
1) 10 days per year, it can be taken anytime within the contract year with the coordination
of the unit.
ADMIN-38
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TITLE: Scheduling
2) Take request from PIO personnel department to be signed by Head Nurse, Supervisor
and Nursing Administration.
3) Send back request to personnel department .
4) Then give it back to Nursing Office Secretary.
5) When the staff comes back from emergency leave head nurse or supervisor must inform
the secretary.
6) Nursing Administration must sign the back to work on the same form then send it back to
PIO office.
Maternity Leave Policy
Entitled for 30 days Maternity Leave per annum.
Legend:
Due Date of Vacation - D.D.V.
Requested Vacation Date _ R.V.D.
Maternity Leave Vacation - M.L.V.
Emergency Leave - E.L.
Partial Leave - P.L.
Forms:
Nurse monthly schedule form KFH -40
Vacation form KFH 103
ADMIN-39
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TITLE: Scheduling
Emergency Leave Form -
4.1 Unit schedule are being made by the respective head nurses ( HN) or charge nurses
(CN) in the absence of the head nurse of the unit.
6 PROCEDURES
6.1 Have the master plan for 3 to 4 months (night duty only) and posted on the
bulletin board for the nurses to know their night duty schedule so that they can
plan their activities earlier.
6.2 Place all nurses on night duty and their day off according to cyclic scheduling.
Meaning all the nurses should take turn to do night duty. Only 2 nights per person
at one time.
6.3 Count on each day how may staff left and record on the bottom of the format.
Circle those days where you have less number of staff to remind you that the
request cannot be granted on those days.
6.4 Enter the staff requests if request can be approved ( to approve as much as you
can ) by using the guideline for the number of staff you have. Any owing day/time
off can also be given back accordingly.
6.5 Then the reminder of the staff sill be distributed sufficiently between AM & PM
duty and according to the requirement of the unit setting.
6.6 New staff going for first time night duty should be placed as tagging (T).
6.7 Staff coming back from vacation, maternity leave and long sick leave should not
ADMIN-40
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TITLE: Scheduling
be immediately placed on night duty.
6.8 Staffs who are pregnant should not be placed on night duty after 7 months
pregnancy.
6.9 Write the number of staff accordingly on the side of the format.
6.10Complete the format by writing the number of staff on AM, PM and night duty and
the total number
of staff including the head nurse and other relevant information at the bottom of
the format.
6.11Before sending to nursing office the area supervisor is responsible to double
check the schedule.
6.12The completed staff scheduling sent to nursing office should show the relevant
information that
are required when doing the scheduling.
6.13To update all the changing of staff duty in nursing office.
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
8 REFERENCES
8.2 King Fahd General Hospital NRS-IPP-ADM-003E (2)
ADMIN-41
______________________________________________

TITLE: Scheduling
NAME: DATE
Kingdom Saudi Arabia- Ministry Of Health 2010

PREPARED BY:
Mrs. Mrs.Ashwag O. Shibah RN,BSN King Fahd 2010
REVIEWED BY: hospital -jedsdah
Central Committee Of NPP 2010 2010

APPROVED BY: General Directorate Of Nurs-ing- MOH.KSA
ADMIN-42
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TITLE: CHANGE OF DUTY
1.0 PURPOSE
1.1. To give opportunity for staff to change duty with another staff, with valid reason.
1.2. To provide opportunity for Head Nurses to rearrange the schedule based on the need of
the unit
1.3. To limit staff request for permission or incurring absence.
2.0 DEFINITION
Changing of schedule of staff according to the need of the concerned staff, or according
to the need of the unit, either with another staff or change of individual schedule.
Head Nurses, Staff Nurses
4.0 POLICY
4.1 Give chance for staff to finish any activity with ease without affecting his work.
4.2 Allow change of duty between staff with similar work classification.
4.3 Change of duty must not affect the balance in the number of staff.
ADMIN-43
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TITLE: CHANGE OF DUTY
5.0 PROCEDURES
5.1 Utilized the official form in changing of schedule between staff.

5.2 Concerned staff affixed their signatures as
sign of acknowledgement of the change.

5.3 Form shall be approved by the Head Nurse and submitted to Nursing Office for
approval.
5.4 Concerned staff will be notified of the approval.
Change of individual schedule will be determined by the Head Nurse
6.0 ATTACHMENTS
8.0 REFERENCES
NAME DATE

2010
MOH - KSA
Approved By: Central Committee Of NPP 2010 - General Directorate Of Nursing- 2010
MOH.KSA
ADMIN-44
______________________________________________

TITLE: ON CALL
1.0PURPOSE
1.1 To identify the need for staff.

1.2 To provide coverage in time of need for staff.
1.3 To provide nursing care.
2.0 DEFINITION
On call is the duty of any staff out of regular duty hours. Where staff is required to appear
in the hospital as per the need
4.0 POLICY
On call only on cases of emergency.
ADMIN-45
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TITLE: ON CALL
5.1 Staff to be scheduled must provide the

following information:
5.1.1 Telephone number (mobile
and/or landline number)
5.1.2. Location of place of residency
5.2 Prepare the schedule.
5.3 If on call emergency has emerged, on-
call must be covered by colleagues .
5.4 Notify the staff concerned.
5.5 Schedule must be posted, each of the
staff on schedule will be provided with a
copy of the schedule
6.0 ATTACHMENTS
None

None
8.0 REFERENCES
General Directorate Of Nursing- MOH.KSA-2010
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-46
______________________________________________

TITLE:
GUIDELINES FOR INTERNAL
APP APPROVAL DATE:
SWAPPING / TRANSFER
EFFECTIVE DATE:
1.0 DEFINITION
1.1 Swapping - transferring or changing from the unit.
2.0 PURPOSE
2.1 To provide guidelines for policy of swapping staff.
3.0 POLICY
3.1 The Nursing Director will consider the internal transfer(swapping of staff)depending
on the request
of the staff.
3.2 Transfer form to be filled which is available in the nursing office and to be sent to the
nursing
department.
3.3 Staff shall be transferred if no replacement required otherwise it can only be
considered with the
arrival of new nurses.
All nursing staff

N\A
ADMIN-47
______________________________________________

TITLE:
APP APPROVAL DATE:
SWAPPING / TRANSFER
EFFECTIVE DATE:
6.0 PROCEDURES
6.1 The Staff initiated the swapping must put into writing his/ her request for swapping,
which include not limited to the following;
6.1.1 Name and position

6.1.2 Area/ward of assignment
6.1.3 The reason/ purpose of sapping
6.1.4 Urgency of the requests
6.1.5 Area/ward to be preferred to be assigned.
6.2 The signed request must be submitted to the Head Nurse, Nurse Supervisor of the unit.
6.3 The Head Nurse and the Nurse Supervisor must discuss with the staff about his/her
request for swapping to determine the underlying reason for the request, not necessarily
to discourage but to allow the staff to reconsider his request or enough time to recognize
the possible impact of his intent for swapping.
6.4 Head Nurse and Nurse Supervisor should decide together the decision for
approval/disapproval of the request ,decision making must be made on which the welfare
of the ward in the top priority to consider.
6.5 The Nursing Assistant Director responsible to the area must be informed once the decision
has been finalized between the head nurse and the nurse supervisor.
6.6 Incase of conflict with the decision between head nurse and nurse supervisor ,the issue
must be discuss with the Assistant Nursing Director responsible to the area.
6.7 Request must be submitted to the Director of Nursing or Assistant Nursing Director
responsible to the area for final decision.
6.8 Decision for approval or disapproval must be clearly stated and understood by the
ADMIN-48
______________________________________________

TITLE:
APP APPROVAL DATE:
SWAPPING / TRANSFER
EFFECTIVE DATE:
requesting staff.
6.9 Requesting staff received the final decision as soon as possible ,at least 24-48 hours of the
final decision.
6.10 Staff for swapping must be fully free of accountability at the ward of origin before
release to the other ward.
6.11 A copy of the request with the decision must be keep in the unit for reference purposes.
7.0 ATTACHMENTS
N\A
8.0 REFERENCES
8.2 Internal Nursing Policy and Procedures KFH-J NRS-IPP-ADM-009E (2)2009
NAME: DATE
Mrs.Ashwag Shibah 2010

PREPARED BY:
Head of Nursing Education Unit At KFH_J
Central Committee Of NPP 2010 - General
REVIEWED BY: 2010
Directorate Of Nursing- MOH.KSA
ADMIN-49
______________________________________________

TITLE: Floating & Cross Training
1.0DEFINITION
1.1 Float Assignment is a short term reassignment of a nursing staff member to a unit or the unit he /
she permanently assigned for few hours to one shift .
1.1.1 Float Staff .
1.1.1.1 General Float Nurse (GFH) is assigned to work with a staff nurse assigned to the unit he
/ she is floated to ,and is not expected to assume a patent assignment alone .
1.1.1.2 Cross- Trained is prepared to assume full responsibilities in another unit with a
different patient population than the nurse's regular unit .
1.1.1.3 Cross-Training is a competency based , in depth , organized preparation for a
different role full patient care or management responsibilities on a unit with a patient population
different from that on the nurse's regular unit of assignment .
2.0 PURPOSE
2.1 To provide a mechanism for provision of safe patient care by nurses when
working outside their usual area of assignment or responsibility
3.0 POLICY
3.1 Nursing Staff members are not eligible to float until they have satisfactorily complete
competency-based orientation and the 90-day probationary period on their own unit .
3.2 The float nurse must be cross-trained in advance of a float assignment , complete the
competencies referred to administering nursing care on an assignment unit when she is going to
assume the full responsibility in the new assigned unit (to be assigned patient care, even in
charge ) .
3.3 Cross training criteria must be applied, refer to nursing education policy and procedure
ADMIN-50
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3.4 Floating between sister units requires an environmental orientation and any complete the
competencies that are required to ensure safe patient care for any difference in set up with unit
specific orientation .
3.5 Each unit will have its own cross-training criteria, and will state the minimum period
required to cross- train to that area ..
3.6 Cross trained nurses list should be available in nursing office to facilitate the floating
assignment.
4.1 Nursing Supervisor :
4.1.1 Maintain a competency based orientation and cross- training program within each
/area to meet anticipated needs for short term staffing flexibility .
4.1.2 Maintains a current list of cross- trained staff before making float assignments .
4.1.3 Checks the list of approved cross-trained staff before making float assignments .
4.1.4 Notes the name and badge number of the floated staff member on the assignment
worksheet and documents on the schedule which unit the nurse is assigned to .
4.2 Float training :
4.3.1.1 Appoints a preceptor or trainer for staff assigned for cross-training .
4.3.1.2 Determines eligibility of unit staff cross training .
4.3.1.3 Develops and maintains a competency based cross-training checklist ,to include
ADMIN-51
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Environment Orientation , Internal and External Emergency action , Environment

of Care Program location of crash cart, special safety concerns ( e.g. hazardous materials
and equipment ) .
4.3.1.4 Assists in float preparation and orientation as necessary .
4.3.1.5.Upon completion of cross- training , documents and maintains completed cross-
training record
in the employees unit file .
4.3 Float Supervisor and Assignments :
4.3.1 Receiving unit makes the float nurse feel welcome and appreciated .
4.3.2 Assigns permanent staff nurse to support and work with the GFN, and specifies the
role on
the patient assignment record .
4.3.3 Makes a patient / work assignment that is based on competency and needs.
4.3.4 Notes the name and badge number of each staff member floated in or out on the unit
schedule .
4.3.5 Should the float nurse be given an assignment or task for which he/she/ does not feel
competent, he/she must inform the charge nurse/ supervisor and the work in question discussed .
4.4 Cross-trained Nurse :
4.4.1 Receives patient assignment report
4.4.2 Requests assistance from a staff nurse assigned to the unit when unfamiliar
procedures / equipment are encountered .
4.5 Float Nurse:
ADMIN-52
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4.5.1 Is Assigned with a staff nurse assigned to the unit where he/she is floated .
4.6.2 Performs basic, routine nursing care , and only procedures for which the float nurse
is qualified .

N\A
6.0 PROCEDURES
N\A
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
7.2 Floating table
7.3 Cross training evaluation form
8.0 REFERENCES
8.1 New York State Nursing Association.(2005) NYSNA position treatment. RN staffing
effectiveness and
nursing shortage, Latham, NY Author .
8.2 New York State Nursing Association (2006) Nursing right and responsibilities. What to do in
outside patient
care situations, Latham, NY Author.
8.3 Mustard, LW.(2002) Perspectives. The paradigm shift in RN staffing in hospitals, corporate
responsibility and
institutional, Journal of Nursing low, 8(2), 31-4
8.4 Floating & Cross Training NRS-IPP-ADM-0010E(2)
ADMIN-53
______________________________________________

NAME: DATE

Mrs. Mrs.Ashwag O. Shibah RN,BSN King Fahd
REVIEWED BY:
hospital -jedsdah 2010
ADMIN-54
______________________________________________

TITLE: DRESS CODE FOR NURSING STAFF
1.0 DEFINITION
Dress code is an established guideline for all nursing / hospital staff which requires
uniformity, appropriateness and professionalism on nursing attire which reflect the
customs of Islamic Religion in the Kingdom of Saudi Arabia.
2.0 PURPOSE
1. Uniforms presents an image of high standard and professionalism within a
hospital, staff dressed appropriately in clean uniform forms part of that image.
2. Maintain professional levels of appearance and cleanliness.
3. A uniform gives confidence to the patients and their visitors.
4. Traditionally, the public expects to identify staff by the uniform they wear.
3.0 POLICY
1. In addition to the approved Hospital Dress Code, all nursing department staff will
adhere to the following guidelines.
1.1 All nursing personnel who come into patient contact are to wear the approved
uniform which has been issued by the hospital and according to the rules of
the MOH. Personalized alterations are not acceptable.
1.2 Uniforms are to be worn on the hospital premises only.
1.3 At the end of each duty uniforms must be changed.
1.4 It is the responsibility of the Nursing Supervisor and the Head Nurse to
ensure that the staff are wearing a clean and correct uniform prior to
ADMIN-55
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commencing of duty.
1.5 The uniform will be loose fitting and not body hugging or in other ways
revealing.
1.6 Sleeve should be of a suitable, but practical length.
1.7. Hair should be covered for female. Long hair must be pinned up.
1.8 The hair of both male and female should be kept off the collar.
1.9 Fingernails should be short and uncolored. Ladies may use only clean nail
polish.
1.10 Jewelry with exception of smooth wedding ring and watch, must not be
worn.
1.11 Heavy make-up, and bright colored nail polish are NOT PERMITTED.
1.12 Strong perfumes must not be used by either male or female nurses. Anti-
perspirants is a must.
1.13 Nurses who are pregnant are permitted to wear a suitable white maternity
top and trouser.
1.14 Uniform will be clean and ironed.
1.15 Undergarments must be plain white or fresh colored so as not to be

noticeable through uniform fabric.
2. Foot Wear:
2.1 All nurses must wear suitable footwear all times for duty.
ADMIN-56
______________________________________________

Should be plain white, flat or low heeled, and low quiet rubber or leather
heel / sole.
High and noisy heels will not be worn. No heel or closed shoe must be
worn.
White or fresh colored socks or lose must be worn
Frilly or colored socks will not be worn.
Clogs are not acceptable except in certain specialty areas i.e.

OR/Delivery Room
3. Ornamentation
3.1 Nurses watch
Nursing leaders , supervisors, staff
5.0 REFERENCES
KSA- MOH- GENERAL DIRECTORATE OF NURSING POLICY2010
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-57
______________________________________________

TITLE: NURSING CODE OF ETHICS
1.0 DEFINITION
Code of Ethics is a branch of philosophy dealing with standard of conduct and moral
judgments.
2.0 PURPOSE
To provide basis for interpreting and analyzing clinical situations in decision making.
3.0 POLICY
1. Nurses are obligated to provide ethical and legal patient care that demonstrate
respect for other.
2. Nurses have four fundamental responsibilities: to promote health, to prevent

illness, to restore health and to alleviate suffering. The need for nursing is
universal.
3. Inherent in nursing is respect for human rights, including the right to life, dignity
and to be treated with respect. Nursing care is unrestricted by considerations of
age, color, creed, culture, disability or illness, gender, nationality, politics, race or
social status.
4. Nurses render health services to the individual, the family and the community
and co-ordinate their services with those of related groups.
International Code of Ethics for Nurses:
1. The nurse, in all professional relationships, practices with compassion and

respect for the inherent dignity, worth and uniqueness of every individual,
unrestricted by considerations of social or economic status, personal attributes,
or the name of health problems.
ADMIN-58
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2. The Nurses primary commitment is to the patient, whether an individual, family,

group or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and
rights of the patients.
4. The nurse is responsible and accountable for individual nursing practice and
determine the appropriate delegation of tasks consistent with the nurses
obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility
to preserve integrity and safety, to maintain competence, and to continue
personal and professional growth.
6. The nurse participates in establishing, maintaining and improving healthcare

environment and conditions of employment conducive to the provision of quality
health care and consistent with the values of the profession through individual
and collective action.
7. The nurse participates in the advancement of the profession through

contributions to practice, education, administration, and knowledge development.
8. A nurse treats clients with respect for their individual needs and values.
9. Based on respect for clients and regard for their right to control their own care,
nursing care reflects respect for the right of choice held by clients.
10.The nurse holds confidential all information about a client learned in the
healthcare setting.
ADMIN-59
______________________________________________

11. The nurse is guided by consideration for the dignity of clients.

12. The nurse provides competent care to clients.
13. The nurse maintains trust in nurses and nursing.
14.The nurse recognition the contribution and expertise of colleagues from nursing
and other discipline as essential to excellent healthcare.
15. The nurse takes steps to ensure that the client receives competent and ethical
care.
16. The nurse advocates the interests of clients.

17. The nurse represents the values and ethics of nursing before colleagues and
others.
18. Professional nurses organizations are responsible for clarifying, securing, and
sustaining ethical nursing conduct. The fulfillment of these tasks requires that
professional nurses organizations remains responsive to the rights, needs, and
legitimate interests of clients and nurses.
All staff nurses
8.0 REFERENCES
MOH.KSA standard Policy
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-60
______________________________________________

TITLE: OPD STAFFING PLAN
1.0 DEFINITION
It is the distribution of competent registered nurses in accordance with their experience,
skill and knowledge to deliver twenty four hours patient care.
2.0 PURPOSE
To ensure that an adequate supply of manpower is available to run the unit and that the services
delivered will meet optimum level of care.
3.0 POLICY
3.1 The head nurse ensures that the staff has completed the hospital general orientation
program, the nursing department orientation program being conducted by the education
department and the unit orientation before the staff will be exposed to the clinic.
3.2 The head nurse assigns one nurse to each clinic and ensures that other areas under his
jurisdiction have adequate man power. Nurse's assignment is being based on their
credentials and skills.
3.3 All nurses must be registered from their country of origin as well as with the Saudi Health
Council.
3.4 All nurses must be BCLS certified.
3.5 An educational program for nurses must be developed and carried out and nurses are sent
to attend continuous educational activities conducted by the nursing education department.
3.6 Competency test must be conducted periodically to ensure appropriate competency level
for the delivery of care.
3.7 Nurses vacation schedule is being guided by the vacation plan .10% of the total number of
staff in the unit can be scheduled for vacation at the same time.
3.8 A monthly schedule is being made and submitted a week before the previous schedule
ends.
3.9 A head nurse with three years or more experience is assigned to handle administrative and
clinical issues.
ADMIN-61
______________________________________________

3.10 There is a qualified registered nurse assigned as charge nurse who handle the unit at all
times
3.11 Staff rotation in other clinics is considered to promote professional growth.
3.12 There is a disaster plan and the nurses will be assigned accordingly and must be aware of
their role during disaster basing on the different action card formulated by the Disaster
Planning Committee.
3.13 Nurses must adhere to the infection control policy as well as the policy and procedure of
different departments needed for the delivery of patient care.
3.14 Nurses must be aware on what to do during injury and a statistics must be made and kept
in the unit so as to monitor the occurrence as well as an action plan can be made to prevent
future occurrences.
3.15 Staff performance evaluation is being made every year or if the need arises.
3.16 A monthly unit meeting is being conducted to update the staff of the recent nursing issues
and to identify the problems so as to address them promptly. Attendance is compulsory, in
the event that the staff apologized or is absent she or he will be made to read the minutes
of the meeting. Three consecutive absences will be subject foe a disciplinary action.
3.17 Nurses going for emergency leave must adhere to the hospital policy.
3.18 A mandatory course is being conducted by the education department and nurses are
scheduled to attend.
3.19 An organizational chart is available in the unit so as the staff will be guided on the proper
chain of command.
Head nurse / Charge nurse
ADMIN-62
______________________________________________

6.0 PROCEDURES
7.0 ATTACHMENTS
8.0 REFERENCES
NAME: DATE
Mrs.Ashwag Shibah 2010

PREPARED BY:
REVIEWED BY: 2010
ADMIN-63
______________________________________________

TITLE: Staff Plan in Orthopedic Department.
1.0 DEFINITION
2.0 PURPOSE
To organize Orthopedic Nursing Service that provides 24-hour nursing services
3.0 POLICY
3.1. All staff nurses will have training experience and documented current competence in the
care and management of patient in orthopedic department.
3.2 .As required by MOH all nurses are to be registered with the Saudi Health Council and is
licensed from the country of origins.
3.3. Cyclic Schedule shall be done monthly and disaster schedule copy should be given to
female dormitory.
3.4. Nursing staff will be scheduled on a rotation for 9 hours duty either morning, evening or
night, and 4month master plan should be available in the area.
3.5. All new nurses shall attend hospital orientation program, nursing department orientation
conduct by Nursing Education and Training Department, and unit orientation.
3.6 All Staff nurses will be expected to attend mandatory course and continuous educational
program.
3.7. Staff nurses will be expected to accept temporary reassignment to other units as
instructed when ever necessary.
ADMIN-64
______________________________________________

3.8 All student and orientee staff will be supervised by nursing staff.
3..9 Head nurse with 3 years experience is assigned at unit level to handle administrative and
clinical issues.
3.10 A qualified registered nurse is assigned to be in charge of the unit at all times.
3.11 There is a charge nurse with 2 years clinical experience assigned to be in charge of the
nursing unit at all times.
3.12 There is a Disaster Plan and the nurses shall be assigned accordingly.
3.13 There is an on going cross training for the nurses to ensure that when they are assigned
out of the
normal working area they have appropriate competency level to care for patient safety.
3.14 Ensure that assignments of nurses based according to his/her skill level with
appropriate qualifications and their scope of current practice and the number, types
and acuity of patients in the unit.
3.15 All nurses working in orthopedic department shall be BCLS certified.
3.16 There is a performance appraisal for all nursing staff conducted on a regular basis to
assess staff performance and to promote professional growth. New comers, skill
assessment during the first 3 months follows by evaluation. Current staff evaluation
is being done once a year.
3.17 Internal and external educational opportunity for nursing personnel to up date their
knowledge and skills.
3.18 There is a vacation plan that allows 10%from nurses in each area to go vacation at the same
ADMIN-65
______________________________________________

time
5.19 Staff meeting shall be done monthly or as needed and all nurses have to attend, for those
who did not attend they have to read and sign the minutes of meeting.
3.20 Any nursing staff will go for emergency leave should follow the hospital policy.
6.0 PROCEDURES
7.0 ATTACHMENTS
8.0 REFERENCES
NAME: DATE
PREPARED BY: Mrs.Ashwag Shibah 2010
REVIEWED BY: Central Committee Of NPP 2010 - General
2010
ADMIN-66
______________________________________________

TITLE: STAFFING PLAN IN OPERATING ROOM
1.0 DEFINITION
1.1 Distribution of competent nurses for all aspect of operating room procedures.
2.0 PURPOSE
2.1 To provide a significant number of permanently assigned competent staff
nurses to cover the operating room on 24 hours basis.
3.0 POLICY
3.1. All staff nurses working in OR are qualified and competent with good knowledge &
experience.
3.2. All staff nurses working in OR shall be BCLS certified, ACLS preferred.
3.3. All staff nurses working in OR must be registered with Saudi Health Council.
3.4. All staff nurses working in OR shall be on 9 hours duty & rotated as required.
3.5. All new nurses shall attend general hospital orientation, nursing department orientation, unit
orientation and pass the required unit competency test.
3.6. A monthly schedule / daily assignment should be drawn up to ensure equal distribution of
the staff according to availability, knowledge, experience & the need of the procedure.
3.7. A minimum of one circulating nurse & one scrub nurse to a procedure is to be maintained.
3.8. A registered nurse with post operative care unit experience must be assigned in recovery
room.
3.9. Monthly on call schedule to all nurses staying in the dormitory on a daily / weekly basis to
maintain the work need.
3.10. Attending on call & overtime shall be when ever necessary.
3.11. All nurses to attend & participate in unit regular meeting.
3.12. All nurses are encouraged to attend educational program & on going cross training to
ensure that when they are assigned out of the usual working area they have appropriate
ADMIN-67
______________________________________________

competency level for patient care.

3.13. All staff working in OR will be encouraged to attend internal & external activities
including nursing mandatory course to update their knowledge.
3.14. Preceptor & Head nurse in OR will supervise all nursing students / intern and orient staff.
5.15. All staff goes for annual vacation as scheduled in the unit vacation plan not more
than 10% of the total number of staff at a time.
6.0 PROCEDURES
6.0 PROCEDURES
7.0 ATTACHMENTS
8.0 REFERENCES
8.2 Internal Nursing Policy and Procedures KFH-J NRS-IPP-ADM-0021E(1))2009
NAME DATE
Mrs.Ashwag Shibah RN,BSN
PREPARED BY: 2010
Central Committee Of NPP 2010 - General Directorate Of
REVIEWED BY: Nursing- MOH.KSA
2010
ADMIN-68
______________________________________________

ADMIN-69
______________________________________________

TITLE: STAFFING PLAN MEDICAL WARD
1.0 DEFINITION
1.1 To meet the patient's needs based on those needs and the specialized qualifications and
competencies of the hospital nursing staff available.
2.0 PURPOSE
2.1 To provide significant competent skilled nurses to meet patients needs
3.0 POLICY
3.1 All nursing staff must be BCLS and registered with Saudi Health Council and is license
from the country of origin.
3.2 All new nurses should attend Hospital Orientation, Nursing Department Orientation and
Unit Orientation.
3.3 All nurses must attend Mandatory Course conducted by Nursing Education & Training
Department.
3.4 All new staff nurses must continue 3 months morning shift duty and can be rotated
according to her evaluation.
3.5 All staff nurses must read and sign their respective job description.
3.6 All staff nurses should have their own staff file in the unit with all completed
requirements.
3.7 There is an adequate registered nurse to provide safe nursing care to patient and staff
assignment will be based on acuity, needs of patients and staff credentials & skills.
3.8 There is a monthly unit schedule to ensure adequate manpower in the unit with 3 shifts of
9 hours duty using the cyclic format schedule.
ADMIN-70
______________________________________________

3.9 There should have a master plan schedule for the unit at least 3 to 4 months and display to
the staff so that they can plan their activities in advance.
3.10 All staff nurses are required to have Unit Specific Skills Competency & Orientation Base
Competency.
3.11 There is a head nurse with 3 years experience is assigned at unit level to handle
administrative & clinical issues.
3.12 There is a Charge nurse with 2 year clinical experience to be assigned to handle
administrative and clinical issues in the absence of the head nurse.
3.13 There is a monthly unit meeting to with attendance & all staff gets the opportunity for open
discussion.
Attendance is a must & excuses only accepted with valid reason. Three consecutive
absences will consider for strict action. Those who did not attend must read the minutes
of meeting with their
signature.
3.14 There is Continuous Education Program scheduled twice a month in the unit where in
each staff is given a topic to be discussed.
3.15 There is an External & Internal Education Program & staffs are encouraged to attend.
3.16 There is an going cross training for nurses to ensure that when they are assigned out of
their unit they have appropriate competency level to care for patient safety.
3.17 There is available Policy procedure Manual which is accessible for all the staff to read.
3.18 There is Disaster Plan Schedule & the nurses shall be assigned accordingly. One copy
submitted to matron office.
ADMIN-71
______________________________________________

3.19 The staff will be recalled to report for duty whenever necessary.
3.20 There is a performance appraisal for all staff conducted on a regular basis to assess staff
performance end to promote professional growth. New staff, skill assessment done after
3 months follows by evaluation.Current staff evaluation is being done twice a year.
3.21 There is an annual vacation plan where in 10 % of the total number of staff in medical
unit will be allowed to go for vacation at the same time. Emergency Leave and
Maternity leave will be allowed for all staff according to hospital rules and regulation.
3.22 The staff should follow the proper channel of communication.

N\A
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
8.0 REFERENCES
8.2 Internal Nursing Policy and Procedures KFH-J NRS- IPP- ADM- 012E(12009
ADMIN-72
______________________________________________

NAME DATE
PREPARED BY: Mrs.Ashwag Shibah RN,BSN 2010
REVIEWED BY: Central Committee Of NPP 2010 - General Directorate Of 2010
Nursing- MOH.KSA
ADMIN-73
______________________________________________

TITLE:
STAFFING PLAN IN SURGICAL
APP APPROVAL DATE:
DEPARTMENT
EFFECTIVE DATE:
1.0 DEFINITION
N/A
2.0 PURPOSE
To organize Surgical Nursing Service that provides 24- hour nursing services.
3.0 POLICY
3.1 All staff nurses have training experience and documented current competence in the care
and management of patient in surgical department.
3.2 As required by MOH all nurses are to be registered with the Saudi Health Council and is
licensed form the country of origin.
3.3 Cyclic schedule shall be done monthly and disaster schedule copy should be given to female
dormitory.
3.5 Nursing staff will be schedule on a rotation for 9 hours duty either morning, evening or
night and 4 month master plan should be available in the area.
3.6 All new nurses shall attend hospital orientation program, nursing department orientation
conducted by
Nursing Education and Training Department and unit orientation.
3.7 All staff nurses will be expected to attend mandatory course and continuous educational
program.
3.8 Staff nurses will be expected to accept temporary reassignment to other units as instructed
whenever necessary.
ADMIN-74
______________________________________________

TITLE:
APP APPROVAL DATE:
DEPARTMENT
EFFECTIVE DATE:
3.9 All student and orienteer staff will be supervised by nursing staff.
3.10 Head nurse with 3 years experience is assigned at unit level to handle administrative and
clinical issues.
3.11 A qualified registered nurse is assignee to be in charge of the units at all times.
3.12 There is a charge nurse with 2 years clinical experience assigned to be in charge of the
nursing unit at all times.
3.13 There is a Disaster Plan and the nurses shall be assigned accordingly.
3.14 There is an on going cross training for the nurses to ensure that when they are assigned out
of the normal working area they have appropriate competency level to care for patient
safety.
3.15 Ensure that assignments of nurses based according to his/her skill level with appropriate
qualifications and their scope of current practice and the number, types and acuity of
patients in the unit.
3.16 All nurses working in surgical department shall be BCLS certified.
3.17 There is performance appraisal for all nursing staff conducted on a regular basis to assess
staff performance and to promote professional growth. New comers, skill assessment
during the first 3 months follows by evaluation. Current staff- evaluation is being done
once a year.
3.18 Internal and external educational opportunity for nursing personnel to update their
knowledge and skills.
ADMIN-75
______________________________________________

TITLE:
APP APPROVAL DATE:
DEPARTMENT
EFFECTIVE DATE:
3.19 There is a vacation plan that allows 10 % from nurses in each area to go vacation at the
same time.
3.20 Staff meeting shall be done monthly or as needed and all nurses have to attend, for those
who did attend they have to read and sign the minutes of meeting.
3.21 Any nursing staff will go for emergency leave should follow the hospital policy.

N\A
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
NA
8.0 REFERENCES
8.2 Internal Nursing Policy and Procedures KFH-J NRS-IPP-ADM-0162009
NAME DATE
Mrs.Ashwag Shibah RN,BSN
PREPARED BY: 2010
REVIEWED BY: Nursing- MOH.KSA
2010
ADMIN-76
______________________________________________

NURSING RESPONSIBILITIES IN QUALITY
TITLE:
APP APPROVAL DATE:
IMPROVEMENT
EFFECTIVE DATE:
1.0 DEFINITION
Quality Improvement Program allows for a systematic, deliberate, and on-going
mechanisms for the evaluation and monitoring of professional nursing practice in
terms of the quality patient care and organizational management.
2.0 PURPOSE
To provide guidelines on the responsibilities of the nursing staff / leadership
towards quality management department.
3.0 POLICY
Nursing Responsibilities towards Quality Improvement Activities / Program.
1. QUALITY NURSING CARE

1.1 Quality management / performance improvement activities in hospital
based Nursing Services are guided by the MOH functional and nursing
standards.
1.2 Quality management / performance improvement activities in accordance
with all performance improvement standards.
1.3 Infection control activities to promote and improve patient safety.
1.4 Focus on patient care needs assessment (physical, psychological, and
social).
1.5 Involvement of patient and significant others.
1.6 Interdisciplinary patient care and collaboration with physicians and other
clinical disciplines.
1.7 Patients rights and education.
ADMIN-77
______________________________________________

TITLE:
APP APPROVAL DATE:
IMPROVEMENT
EFFECTIVE DATE:

1.8 Need for continuing care and coordination.
1.9 Nursing Documentation:
1.9.1 Initial assessment

1.9.2 Nursing diagnoses / patient care need
1.9.3 Interventions
1.9.4 Patients response to and outcomes of care provided.
1.10 Nursing care data integrated into the clinical information system.
1.11 Assessment of nurse competency including performance expectations and
learning needs.
1.12 Development of policy and procedures, nursing standards of patient care
(patient expectations), and standards of nursing practice (nurse
expectations).
1.13 Provision for orientation, in-service training, and continuing education.
1.14 Defined mechanism for addressing ethical issues.
1.15 Determination of number, qualifications, and competence of nursing staff .
2. NURSING LEADERSHIP RESPONSIBILITIES:
The participation of nursing leaders with leaders from governing body, management,
medical staff, and other clinical areas in:
Policy decisions affecting patient care services

Developing and communicating the organizations mission,
strategic plans, budgets, resource allocation, operational
plans, and policies.
ADMIN-78
______________________________________________

TITLE:
APP APPROVAL DATE:
IMPROVEMENT
EFFECTIVE DATE:

Planning, promoting and conducting organization wide
performance activities.
Evaluating current nursing practice and patient care
processes to improve the quality and efficiency of patient
care.
Promoting collaboration between nursing, medical staff, other
clinical practitioners, and other departments.
Recruitment, retention, development, and continuing
education of nursing staff.
Evaluating, selecting, and integrating technology and
information management system.
Collaborating with nursing educators to influence curricula, if
applicable.
All Nursing Staff

MOH / Nursing Standards
7.0 ATTACHMENTS
View NTQM attachments
ADMIN-79
______________________________________________

TITLE:
APP APPROVAL DATE:
IMPROVEMENT
EFFECTIVE DATE:
8.0 REFERENCES
1. Aspden P, Corrigan J, Wolcott J, et al., eds. Patient safety: achieving a new standard for care.
Washington, DC: National Academies Press; 2004.
2. Adler M, Goman W. Quality. In: Adler M, Goman W, eds. The great ideas: a syntopicon of
great books of the Western world. Chicago: Encyclopedia Britannica; 1952:p. 513-6.
3. Harteloh PPM. The meaning of quality in health care: a conceptual analysis. Health Care
Analysis 2003; 11(3):259-67.
4. Lohr K, Committee to Design a Strategy for Quality Review and Assurance in Medicare, eds.
Medicare: a strategy for quality assurance, Vol. 1. Washington, DC: National Academy Press;
1990.
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-80
______________________________________________

TITLE: SENTINEL EVENT ROOT CAUSE ANALYSIS
1.0 DEFINITION
Sentinel Events is defined as unexpected occurrences that involve deaths or serious
physical injury or psychological injury or the risk event.
2.0 PURPOSE
develop guidelines for root cause analysis of Sentinel Events.
3.0 POLICY
1. All sentinel events shall have a root cause analysis performed within 10 working
days of discovery and an appropriate action plan.
2. A Root Cause Analysis Team shall be formed from a multi-disciplinary members,

the term and membership of which depends on the nature of the incident
involved.
3. The Quality Management Department will serve as the coordinator / facilitator of

the team.
Quality Management,coordenators,staff

See attachments chapter
ADMIN-81
______________________________________________

6.0 PROCEDURES RATIONAL

1. A Root Cause Analysis will be 1. As per hospital internal policy.
performed by a multi-disciplinary
root cause analysis team, after an
incident has been identified as a
Sentinel Event, within 24 48
hours of occurrences.
2. To provide tools / for better understanding
2. Brainstorming, Flow Charting and of the incident.
other related QM tools shall be
utilized to determine potential
cause(s) of the incident.
2. Collection of data concerning the 3. Data gathering phase
process would verify the potential
cause(s) of variations.
3. The actual causes(s) of the 4. Identifying the c\actual cause of

variation or at least the most variation.
probable cause will be made,
after collection of date, and
analysis of the results.
4. The Quality Management will 5. QM will serve as the facilitator for all QM
initiate the activity by coordinating related activity.
with the concern department
about the intent and purpose of
the planned monitoring activity.
5. Criteria for monitoring shall be

established accordingly.
ADMIN-82
______________________________________________

6. Responsible person for data

collection and data entry, shall be
identified for each activities.
7. Findings and analysis of the

monitoring activities shall be a
coordinated effort of the concern
department and the QMD.
8. Final reports of the monitoring 9 . For reporting and documentation.

activities shall be received by
Department concern, Quality
Management Committee,
Hospital General Director,
Hospital Assistant Directors,
Chief of Medical Staff, Chief of
Medical Support Services for
approval, comments,
recommendation & action to be
done and for general information.
9. Action to be taken and its 10. Implementation stage of the planned

implementation shall be based on action.
the findings, and
recommendation of the Quality
Management Committee, or the
Hospital Director or any of the
Deputies, Chief of Staff, Chief of
the Medical Service; or Head of
the Quality Management
Department in the absence of the
QM Committee.
ADMIN-83
______________________________________________

10. Evaluation of the effectivity of 11. Evaluation stage to evaluate the

action taken shall be done at action taken.
least within 3-6 months of its
implementation but not more than
(1) year.
11. Regular feedback shall be 12. To update concern departments of the

received by all concern issues involved.
departments and as identified at
Step # 5.
12. Frequency of subsequent 13. Monitoring depends upon the activity

monitoring depends on the and the subsequent action taken
outcome of the follow-up findings of the previous.
evaluation activities, unless
previously determined according
to established criteria for
monitoring and evaluation.
7.0 ATTACHMENTS
See NTQM tools attached
8.0 REFERENCES
1. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National
Academy Press; 2004.
2. Reason JT. Human error. Cambridge, UK: Cambridge University Press; 1990.
3. Mick JM, Wood GL, Massey RL. The good catchprogram: increasing potential error reporting. J Nurs Adm 2007;37(11):499-
503.
4. Reason J. Human error: models and management. BMJ 2000;320:768-70.
5. Reason J. Managing the risks of organizational accidents. Aldershot, UK: Ashgate; 1997.
ADMIN-84
______________________________________________

NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-85
______________________________________________
\
TITLE: INFORMED CONSENT.
1.0 PURPOSE
1.1 To define obligations in obtaining and documenting informed consent by physicians and
nursing staff.
1.2 To ensure that informed consent is obtained from patients in accordance with patient right
policy.
1.3 To obtain patients informed consent for medical and surgical procedure.
1.4 To out line procedures for refusal of treatment.
2.0 DEFINITION
2.1 Attending Physician the Physician with primary responsibility for a patients treatment and
case management.
2.2 Adult Patient - a person 18 years of age or older or a person under 18 years of age who has had
the disabilities of minor removed.
2.3 Minor - is a person under eighteen (18) years of age and has not been legally emancipated by a
court and is:
- Not legally or previously married
- Not at least 16 years old and living away from home managing his own financial affairs.
2.4 Informed Consent - Consent for treatment/procedure from a competent patient or authorize
person not acting under duress, fraud or undue pressure, who is adequately informed by the
healthcare worker of the following information concerning the contemplated procedure/treatment:
2.4.1 Patients diagnosis.
2.4.2 General nature of the contemplated procedure, its purpose, whether it is experimental, and
the name (s) of the person(s)who will perform the procedure or administer the direct
treatment.
2.4.3 The benefits, risks, discomforts and complications associated with the procedure,
treatment and potential problems related to recuperation that may reasonably be expected,
including all risks of the procedure or treatment.
2.4.4 The likelihood of success.
2.4.5 The patients prognosis if procedure is not performed.
2.4.6 Reasonable alternatives to medical treatment, if any.
2.5 Expressed Consent - Either oral/written consent given by a competent person or authorized
representative for incapacitated patient.
1. Oral Consent conveyed through speech.
2. Written Consent conveyed though written document for diagnosis and treatment or specific
ADMIN-86
______________________________________________
\
treatment or procedure.
2.6 Emergency Consent - Medical Emergency is defined as a situation, where in competent medical
judgment, the proposed surgical or medical treatment or procedures are immediately or
imminently necessary and any delay caused by an attempt to obtain consent would jeopardize
the life, health or safety of the person affected or would result in disfigurement or impaired
faculties. This is a medical decision.
Registered Nurse.
Physician
4.0 POLICY
4.1 The underlying principle of informed consent is that patients have the right to be told what to
expect and to determine what will be done with and to their bodies.
4.2 Except in emergencies, medical or surgical treatment or procedures shall not be administered
to any patient until informed consent has been obtained from the patient or one legally
authorized to act on behalf of the patient.
4.3 All adult patients have the right to make decisions regarding their treatment and to be
provided sufficient information in order to make informed decisions regarding their
healthcare.
4.4 The physician performing the medical and/or surgical procedure on patients is generally
responsible for obtaining the patients informed consent prior to the treatment or procedure.
4.5 Inform Consent shall be obtained and placed in the patients medical record for all surgical
procedures, emergency service treatment, administration of blood and/or blood products,
ambulatory care treatment and other services including treatment of minors, mentally
challenged, radiographic procedures, all surgical and endoscopic procedures including but not
limited to:
4.5.1 General anesthesia
4.5.2 Local anesthesia.
4.5.3 Spinal anesthesia.
4.5.4 Minor surgical interventions.
4.5.5 Major surgical interventions.
4.5.6 Any other procedure that requires a specific explanation to the patient.
ADMIN-87
______________________________________________
\

5.1 It is the legal responsibility of the attending To insure that patient understand the
physician responsible for performing the nature of the treatment, including
medical or surgical treatment or procedure to: potential complications.
5.1.1 Disclose all medical information that To protect the patient against
he/she believes is relevant to making an unauthorized procedures and to insure that
informed in a language the patient can the procedure is performed on the correct
understand. body.
5.1.2 Obtain an informed consent from the
patient or one authorized, and capable of To protect the surgeon and hospital
consenting on behalf of the patient. against legal action by patient who claims
that an unauthorized procedure was
performed.
5.1.3 The patient's signature on the Informed
Consent Form is witnessed by a .
medical/nursing staff not involved in the
procedure. The witness' signature on the
consent form signifies only that the
patient's signature is indeed his own.
Witnessing the signature implies nothing
about the Witnesss knowledge of the
patient's ability to give consent or
completeness of the information shared
by the physician with the patient.
ADMIN-88
______________________________________________
\
5.1.4 Because of the distance involved or

because of an extreme emergency
situation, verbal or phone permission
from any of the persons authorized to
give consent on behalf of the patient may
be obtained in the presence of two (2)
witnesses by the use of extension phones
(the physician and a hospital employee),
and signed by both. The person giving
the consent should be asked to sign as
soon as possible. It is not necessary for
the hospital employee to witness the
information provided by the physician,
merely the person's consent.
6.0 ATTACHMENTS
Informed Consent Form

None
8.0 REFERENCES
NAME: DATE
PREPARED BY: Kingdom Saudi Arabia- Ministry Of Health Policy
2010
REVIEWED BY: Mss.Lina AL-Harbi - Clinical Instructor GS Unit 2010
King Fahad Hospital-Jeddah
ADMIN-89
______________________________________________

NURSES ROLE ON PROTECTING PATIENT'S
TITLE:
APP APPROVAL DATE:
PRIVACY AND CONFIDENTIALITY
EFFECTIVE DATE:
1.0DEFINITION
1.1 Privacy : Patient privacy is essential part of ethical and professional medical care.
All reasonable measures based on the situation must be taken to ensure that each
patient is assessed and treated with privacy of environment as possible.
1.2 Confidentiality : Patient confidentiality is strictly regulated by law . All reasonable
measures, based on the situation must be taken to protect any identifying or medically revealing
patient information .
2.0 PURPOSE
2.4 1.1 To set guidelines on how patient's privacy and confidentiality can be protected .
3.0 POLICY
5.1 Be sure to knock before entering patient's rooms.
5.1.1 Patient should be informed prior to doctor's rounds
5.1.2 If in a female ward a male entry must be limited and the nurse on duty must be
informed so that
The patients will be informed as well. Thus, visiting hours must be strictly
observed.
5.2 Greet the patient upon entering the room.
5.3 In a room where more than one patient is admitted curtains must be drawn while the
patient is being
Examined or a special procedure is being performed where private parts have to be
exposed.
5.4 The doctors must be assisted by a nurse while examining the patient.
5.4.1 In the clinic the nurse should not leave the male doctor alone with a female patient.
A relative
or companion must be with the patient if the nurse has to leave the clinic for a short
period of time .
5.5 Patient must be properly covered while being transported be it on wheelchair or in a
ADMIN-90
______________________________________________

TITLE:
APP APPROVAL DATE:
EFFECTIVE DATE:
stretcher.
5.6 Female patients must be provided with a head cover all the time.
5.7 Confidentiality must be maintained as below :
5.7.1 The nurse must know when is it appropriate to breach confidentiality and should
be aware of it's
Legal implications.
5.7.2 Patient's file must remain confidential.
5.7.3 Confidential issues regarding the patient must not be discussed in public and to
those who are not
a member of the health team .
4.1 All nursing staff.

NA
6 PROCEDURES
NA
ADMIN-91
______________________________________________

TITLE:
APP APPROVAL DATE:
EFFECTIVE DATE:
6.0 PROCEDURES
NA
7.0 ATTACHMENTS
8 REFERENCES
8.2 INTERNAL NURSING POLICY AND PROCEDURES KFH-J NRS-IPP-ADM-006E (2)

8.3 http://www,indiana.edu/~iuems/Pages/Members/privacy%20and%20 confidentiality
8.4 Policy Protecting Patient Privacy and Confidentiality KFHJ NR-1816 year 1428.
DATE
NAME:

PREPARED BY:
Mrs. Mrs.Ashwag O. Shibah RN,BSN King Fahd 2010
REVIEWED BY:
hospital -jedsdah
APPROVED BY: General Directorate Of Nurs-ing- MOH.KSA
ADMIN-92
______________________________________________

TITLE:
APP APPROVAL DATE:
EFFECTIVE DATE:
ADMIN-93
______________________________________________
GENERAL NURSING: ADMINISTRATION

Pediatrics, NICU, Nursery
POLICY NUMBER: GNR - 01-24 APPLIES TO: ,L&DL , MAT, Security
staff
APP TITLE :
APPROVAL DATE:
PREVENTION OF INFANT ABDUCTION ( CODE PINK ) DISASTER
EFFECTIVE DATE:
1.0 PURPOSE
1.1 To establish Infant Security Program in __________________.
1.2 To provide a rapid, organized and thorough response to a suspected or actual infant/child
abduction.
2.0 DEFINITION
Code Pink - when an infant between birth and six months of age is taken from the hospital by an
unauthorized individual.
Responsible to Staff Nurse/ Security guard.
Other in-house Security Department personnel when available shall :
1.1 Respond to exits to secure the entire hospital.

1.2 Director of Security will direct available personnel to the appropriate exits to the shut
and lock all doors.
2. Director of Security shall:
2.1 Notify the floor involved (Charge Nurse, Nurse Supervisor)
2.2 Call law enforcement and transit office. Have an operator notify all cab companies, airline
terminals, bus depots, etc, if needed.
2.3 Assist is managing the respective search teams in the hospital .
2.4 Assist in formal documentation with the Hospital Risk Manager.
ADMIN-94
______________________________________________

staff
APP TITLE :
APPROVAL DATE:
EFFECTIVE DATE:
4.0 POLICY STATEMENT
It is the policy of _________________ to provide a process for the response to suspected or actual
infant/child abductions. _____________ are open to the public for the specific purpose of providing
health care and other associated services to patients. Visitor access to the medical facilities for incidental
purposes associated with health care services is acceptable provided that patient care is not disrupted. To
ensure a secure patient care environment for infants, the Security Management Program establishes
Pregnancy and Newborn Services as 'security sensitive' areas. The Pregnancy and Newborn Services areas
include Labor & Delivery, Maternity , Well Baby Nursery, Neonatal Intensive Care Unit (NICU) and
Intermediate Intensive Care Nursery (IICN). In addition, security procedures are implemented throughout
the facility to safeguard children as well. There are no guarantees that an abduction will not occur, but by
preventative measures such as parental and staff awareness, 'security sensitive' area training and use of
security systems minimizes such an occurrence.
5.0 PROCEDURES
Measures that will Assist in Infant Abduction Prevention and Enhance Recovery
1. All staff will be required to wear proper hospital identification at all times.
2. Hospital scrubs and lab coats will be kept in an access - controlled area and are not to
be loaned to unauthorized personnel.
3. Staff will ensure that infants are always in the direct line-of sight or parents or hospital staff.
4. Parents will be informed of security measures at earliest opportunity after the birth of the infant.
5. Parents will be instructed to tell family members to use the Visitors Elevators, not the Staff
Elevators or stairs(According to hospital settings).
6. Only hospital authorized staff members are allowed to transport an infant while in the
healthcare facility.
8. Parents or staff members are NOT allowed to carry the infant outside of the mothers room
or within the facility at any time.
ADMIN-95
______________________________________________

staff
APP TITLE :
APPROVAL DATE:
EFFECTIVE DATE:
9. NICU staff will transport the infant within the healthcare facility via wheeled bassinet, incubator
or cart.
10. NICU staff will escort the family at the time of discharge to the admission/discharge office.
11. Staff will immediately report any unidentified individuals, suspicious activity or behavior
or unfamiliar persons to the charge nurse. The Charge Nurse will in turn contact hospital
Security Department.
12. Staff will require every one entering the department to identify themselves and reason
for their visit.
Suspected or Actual Infant Abduction
1. The staff member suspecting an infant abduction will conduct a brief search of the immediate
vicinity (e.g. patients room and nearby hallway).
3. If the staff member continues to suspect an infant abduction, the charge nurse is notified
immediately.
4. The charge nurse or his/her designee announces Code Pink in progress.
5. The charge nurse shall immediately CALL to notify Communications of the
emergency.
6. Upon notification that CODE PINK has been called, the Communications Operator will
announce CODE PINK on the public address system
5. The staff members will immediately check to see that each baby in their care is present and
accounted for. Staff must immediately search the entire unit and adjacent areas:
Nursery and Maternity staff as Primary Responders will within their areas:
a. Post staff at all entrances and exits of unit.
b. Close all patient doors.
c. Begin search of all vacant rooms.
d. Search all equipment, linen and break rooms.
e. Be prepared to be questioned by Security Services and Police.
f. Report any suspicious activity to Security Services.
ADMIN-96
______________________________________________

staff
APP TITLE :
APPROVAL DATE:
EFFECTIVE DATE:
7. If there is reason to suspect that a baby may be in another vicinity on the Floor (e.g.
Treatment room, or mothers room, those rooms are quickly checked before calling the
hospital Security Department.
8. It is important to remember to search in unlikely places such as closets, beneath beds, behind
curtains, in offices, in call rooms, in locker rooms, in dumpsters, etc.
9. If there is little or no reason suspect that a baby may be in another vicinity on the Floor, the
Hospital Security Department are called immediately.
10. The SOP Director/Muraqib or Medical Director on Duty shall and/or his designee will
conduct with the Security Department and responding law enforcement agencies and will be
responsible for the direction.
11. Once the abduction has been confirmed, the attending physician should notify
the parents.
11. The Security Department will block all of the exits.
12. All persons are detained from leaving the unit until cleared by the Charge Nurse and / or
the search of the unit has been finished and authorities completed proper questioning.
13. When the search is concluded, the Director of Security will notify the Communications
Operator to announce CODE GREEN using the public address system.
Care of the Family Experiencing an Infant Abduction
1. Move the parents of the abducted infant to a private room.

2. Have the nurse assigned to the infant remain with the parents at all times.
Other Specific Administrative Duties of the Charge Nurse

1. Locate and secure the infants medical record.
2. Page the Unit Head/Director and the Nursing Office Supervisor.
3. Nurse manager or Charge Nurse briefs all staff on the unit.
4. Nurses should then explain the situation to each mother on the unit while the mother and their
infant(s) are together.
ADMIN-97
______________________________________________

staff
APP TITLE :
APPROVAL DATE:
EFFECTIVE DATE:
5. Conduct mandatory group debriefing sessions for personnel.

6. Document the incident from the discovery of the abduction until infant is located.
Incident report/Occurrence Variance Report should be accomplished.
6.0 ATTACHEMENTS
6.1 Occurrence Variance Report Form

None
8.0 REFERENCES
8.1 Security Management Program, King Faisal Specialist Hospital And Research Center - Jeddah
8.2 JCI & CBAHI Standard Code Pink Policy Nr-39
8.3 Hera General Hospital - Holy Makkah - Policy No- Sec-007
8.4 Photo Guide of Nursing Skills 2004, by Smith, Duell, Martin
8.5 Lippincott Manual of Nursing Practice, 7th editon by Nettina
8.6 Ministry of Health Policy and Procedure SNR-NICU-035
NAME DATE
Prepared By: Khalid A. Alharthi Nursing Total Quality Coordinator GND- MOH
2010
- KSA
2010
MOH.KSA
ADMIN-98
______________________________________________

TITLE: CODE BLUE
1.0PURPOSE
1.1 To outline the role of each responding code blue member.
1.2 To identify the steps to take for an organized, efficient and effective response to a
medical emergency.
1.3 To prevent overcrowding the affected area with unnecessary staff.
2.0 DEFINITION
Code Blue code for medical emergencies.
Defines the roles and responsibilities of each nursing code blue team in case of medical
emergencies
Head Nurse, Staff Nurses
4.0POLICY
4.1 Head nurse in each unit shall designate a treatment room nurse and assistant
in each duty shift.
4.2 The treatment room nurse and assistant / Internist nurse in each unit shall be the
nursing members of the code blue team.
4.3 Only the code blue members of each unit shall respond to the code blue situation.
4.4 Staff nurse discovering a patient in a cardiopulmonary arrest or other medical
emergency must not leave the patient while summoning help.
4.5 Nurse on office duties or nurse in-charge shall notify the operator by dialing 333
and must mention the location clearly.
4.6 Details of the event must be documented in the patient's file and in the code blue
flow sheet in a chronological order.
ADMIN-99
______________________________________________

TITLE: CODE BLUE
5.0 PROCEDURES
5.1 Staff nurse discovering the patient (if not the Treatment Room nurse):
5.1.1 Stay with the patient.
5.1.2 Summon help by whatever means available.
5.1.3 Indicate that a code blue needs to be called.
5.1.4 Immediately commence CPR or required emergency first aid.
5.2 Nurse on office duties:
5.2.1 Notify the operator of the code blue by dialing (_ _ _) and clearly stating
name, position and the exact location of the code blue.
5.2.2 Secure confirmation from the operator by asking the operator to repeat the
information given
5.2.3 Label appropriate documents with the patients name and medical record
number
5.3 Treatment Room Nurse and assistant (internist nurse):
5.3.1 Rush to the area.
5.3.2 Establish EKG monitoring and run strip as soon as possible.
5.3.3 Connect patient to vital signs monitor, if available.
5.3.4 Prepare defibrillator for use.
5.3.5 Establish an IV line and administer IV solutions as directed by the physician.
5.3.5.1 If physician has not yet arrived, commence 500ml of dextrose 5% in
normal saline.
5.3.6 Connect Ambu bag to oxygen supply.
5.3.7 Prepare all medications as directed by the physician.
5.3.8 When time permits, Label all prepared medications including name and
dosage or tape empty ampoules to syringe ensuring that drug name, dosage
and expiration date are visible. And / or put each separate medication order
in a separate plastic container. This should include the syringe and needle,
empty medication vial and swabs.
5.3.9 Verbal medication orders given by the physician must be repeated by the
nurse.
5.3.10 Check prepared medications and hand to physician for his administration.
ADMIN-100
______________________________________________

TITLE: CODE BLUE
5.3.11 Nurse will hand prepared medication to the physician / internist for his
administration.
5.3.12 Repeat aloud medication that is being handed to the physician.
5.3.13 Use additive labels for all medications added to IV solutions.
5.3.14 Carry out other physician orders
5.3.15 Check and record vital signs and pupillary response every 15 minutes.
5.4 Head Nurse or Charge Nurse
5.4.1 Take in-charge of the Code Blue until supervisor / physician arrives on the
code blue scene.
5.4.2 Make the decision whether to:
5.4.2.1 Rush patient to Treatment Room, or
5.4.2.2 Deliver code cart and contents to scene of the code.
5.4.3 If patient is not in an ICU bed, place CPR board under the patient.
5.4.4 Establish code blue baseline observations for pulse, B/P, respiration and
papillary response. Notify Nursing Supervisor of same or record directly.
5.4.5 Check and record pulse, B/P, respiration, and papillary response every 15
minutes until cardiac monitor and B/P monitor machine is hooked up.
5.5 Nursing Supervisor;
5.5.1 Note the time Code Blue was called.
5.5.2 Clear the room of unnecessary equipment and people.
5.5.3 Ensures that initial baseline observations are taken and recorded.
5.5.4 Coordinates all nursing activities and ensures that all designated code blue
nursing activities are being performed as specified.
5.5.5 Records code events in chronological order on the special form provided.
5.5.6 Assists with CPR, if necessary, until the arrival of physician.
5.5.7 Complete the critique of the code blue and submit to Medical Director for
review by Code Blue Committee.
5.5.8 Assist Head Nurse / Charge Nurse with documenting the incident in nursing
progress notes.
ADMIN-101
______________________________________________

TITLE: CODE BLUE
6.0 ATTACHMENTS
None

Patients file, Code Blue Sheet
8.0 REFERENCES
1- Sarasota Memorial Hospital Policy. (2007) Code Blue Management
and Responsibilities (01.PAT.03). Sarasota Memorial Hospital: Author
2- Schilling-McCann, Judith A., RN Critical Care Nursing Made Incredibly Easy.
Lippincott Williams and Wilkins 2008 Code Master XL and Defibrillator/Monitor
Users Guide.
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-102
______________________________________________
ADMINISTRATIVED POLICY AND PROCEDURE

TITLE: CODE RED
1.0PURPOSE
1.1 To outline the role of each responding code red team.
1.2 To facilitate an efficient and effective response to a code red situation.
1.3 To ensure safety of patients, staff and important documents.
2.0DEFINITION
2.1 Code Red code for fire emergencies.
2.2 Defines the roles of nursing during Code Red
Staff Nurses
3.0 POLICY
3.1 There shall be a prompt and professional response to potentially dangerous situation.
3.2 All nurses to be alert to the RISK OF FIRE breaking out.
3.3 It is the responsibility of all nurses to be aware of the location of fire hoses and fire
extinguishers on their units.
3.4 If a known fire is discovered and is small enough to be dealt with e.g. litterbin fire, the
fire should be extinguished and a critical / unusual occurrence report shall be completed.
3.5 If the fire cannot be extinguished, the nearest fire alarm should be sounded and Code
Red be instigated.
3.6 If a CODE RED is heard, 2 nurse from each unit to report to the affected area
immediately.
ADMIN-103
______________________________________________

TITLE: CODE RED
5.1 ACTION IN THE EVENT OF FIRE IN

WARDS
5.1.1 Nurse discovering fire to put it
out if small. Report incident to
the Head Nurse.
5.1.2 Nurses discovering fire, out of
control or suspected of being
large:
5.1.2.1 If smoke is detected
from under door, do not
open the door.
5.1.2.2 If door to affected room is
open, closed the door
immediately (to cut off
spread).
5.1.3 In both situations, raise alarms.
5.1.4 Evacuation of patients / Staff of
the affected Ward.
5.1.5 Follow fire and safety policy.
5.2 DESIGNATED NURSING ROLES:

5.2.1 Head Nurse / In-charge role
5.2.2 Role of checking the number of
patients on the affected unit.
Carried out by the nurse on
office duties.
5.2.3 Role of safeguarding patients
files
Carried out by the nurse assigned
on Store /Laundry Duties.
ADMIN-104
______________________________________________

TITLE: CODE RED
5.2.4 Role of searching/ evacuation of

the unit
Carried out by the remaining
nurses available in the unit.
These nurses to report to the nurses office and
awaits instructions from the head nurse.
5.3 HEAD NURSE / IN-CHARGE PERSON

ROLE
5.3.1 Check alarm raised to get help.
5.3.2 Take possession of :
5.3.2.1 fire exit keys
5.3.2.2 key to safe area in the unit.
5.3.3 Designate the area to evacuate (re-
assess with Hospital Fire Officer
when he arrives).
5.3.4 Divide nurse without specific roles
into two Search / Evacuation
groups. Ensure each group has a
master key. Assign a nurse to
safeguard patients files if fire
occurs during night duty.
5.3.5 Coordinate all nursing roles during
code red.
5.3.6 Prepare to hand over, with brief
verbal report of situation, to
HOSPITAL FIRE OFFICER when
he arrives.
5.3.7 Coordinate with Hospital Fire
Officer throughout the code red.
ADMIN-105
______________________________________________

TITLE: CODE RED
5.4 CONTROLLING THE FLOW OF

PERSONNEL ENTERING THE
AFFECTED UNIT IN CODE RED
SITUATION
5.4.1 The security personnel on door
duty performs this role when a
code red is called.
5.4.2 In Unit A, Head Nurse will
assign a specific nurse to liaise
with MOI guard. In Unit B/C,
the security personnel should
coordinate with the charge/head
nurse of the unit.
5.4.3 Part of door duties should
include, maintaining at all times
a current record of patients off
unit.
5.4.4 During a code red, only the
following personnel should be
allowed into the affected unit.
5.4.4.1 Unit nursing / medical
staff, housekeeping
supervisor.
5.4.4.2 Two (2) nurses from
each of the other
units (i.e. 8 nurses)
5.4.4.3 Engineering Personnel
5.4.4.4 Nursing / medical /
hospital administration
personnel
5.4.4.5 MOI personnel
5.4.4.6 HospitalFire Officer
ADMIN-106
______________________________________________

TITLE: CODE RED
5.4.4.7 Other personnel as

specifiedby Hospital
Fire Officer.
5.4.4.8 Nopatients currently
on off unit should
not be allowed to re
enter the unit
during a code red.
5.4.4.9 Nursing staff with
patients off unit
should remain off
unit with those
patients.
5.5 CHECKING THE NUMBER OF

PATIENTS ON THE AFFECTED
UNIT
This role is always performed by the
nurse assigned to office duties.
5.5.1 The most current patients
list, (supplied by the
medical records
department) should be
utilized as a basis for
checking patients by:
5.5.1.1 Adding transfers-in
to the unit.
5.5.1.2 Admissions to the
unit.
5.5.1.3 Deleting transfers-
out from the unit
5.5.1.4 Deleting discharges
ADMIN-107
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TITLE: CODE RED
from the unit

5.5.1.5 Acknowledging
those gone for home
pass
5.5.1.6 Re-registering home
pass returns
5.5.2Established from Head Nurse,
where designated safe areas
are and go to entry of same
if on unit.
5.5.3 Go to exit being used to
evacuate patients if safe area
is off unit.
5.5.4 As each patient enters the safe
area / leaves the unit, check his
name off the current list of
patients.
5.5.5 Do not allow patients that are
evacuated / in safe area to re-
enter the unit.
5.5.6 Remain at this point until
receiving further instructions
from the Head Nurse, Hospital
Fire Officer.
5.6 SAFEGUARDING PATIENTS
FILES
This role is always performed by the
nurse assigned to Store / Laundry
duties.
5.6.1 All files should be gathered
and carried, in most
ADMIN-108
______________________________________________

TITLE: CODE RED
convenient container
available, to the designated
safe area if possible.
5.6.2 Remain with and safeguard
files until further
instructions are received
from Head Nurse / Hospital
Fire Officer.
5.7 SEARCHING / EVACUATION OF

THE UNIT
This role is always carried out by:
a. Nurses from code red
unit without any other
assignment in code red.
b. Nurses from other units
who responded to code
red.
5.7.1 Nurses should assemble at
Nurses Office and await
instructions from the Head
Nurse.
5.7.2 Each group should remove
patients from the immediate
vicinity of fire area.
5.7.3 Each group should then
proceed in opposite
directions away from the
fire area and search in
consecutive sequence all
rooms / spaces until they
reach the safe area /
ADMIN-109
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TITLE: CODE RED
emergency exit being used.

5.7.4 Search procedure should
consist of the following:
5.7.4.1 At least 2 nurses to
remain outside the
area being
searched,
5.7.4.2 To ensure
patients/others do
not return to areas
already searched
5.7.4.3 To direct patients
who come out of
area being
searched, towards
safe area.
5.7.4.4 Remaining nurses
will search the area
and calmly ask
occupants to
proceed towards
the safe area.
Assistance will be
given to any
patient requiring
help.
5.7.5 Once the room is safely
evacuated, the room will
be locked and put a mark
on it.
5.7.6 Once safe area is reached,
the group will remain in
ADMIN-110
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TITLE: CODE RED
the hallway to prevent

personnel re entering the
searched area.
5.7.7 Await further instructions
from the Head Nurse or
Hospital Fire officer.
5.8 STAFF WITH OFFICES IN THE

UNIT
All staffs are expected to take
responsibility for their own
areas by:
5.8.1 Directing patients/others who
may be in their offices
towards the safe area.
5.8.2 Taking medical files in their
office to the safe area; or
making designate nurse
aware of same if too many
files.
5.8.3 Once the office is safely
evacuated of personalities, it
should be locked.
5.9 DURING NIGHT DUTY

5.9.1 Head nurse Night to report
to affected area
immediately and follow
steps as per daytime
5.9.2 You are unlikely to receive
help externally for some
ADMIN-111
______________________________________________

TITLE: CODE RED
time, but:
Ring Switchboard to alert re:

emergency
Duty Nursing
Administration
Hospital Administration
AS SOON AS PRACTICABLE,
All other nursing roles remain as during the day.
6.0 ATTACHMENTS
None

None
8.0 REFERENCES
- Noji EK.the public health consequences of disaster .pre-hospital and disaster
med.2000,15:147-157.
- Abbott D. disaster public health considerations. pre-hospital and disaster med.
2000,15:158-166
- Alamal Hospital Jeddah Ksa-Code Red Policy 2010.
NAME DATE
2010
MOH - KSA
2010
MOH.KSA
ADMIN-112
______________________________________________

TITLE: CODE CRISIS
1.0PURPOSE
1.1 To outline the role of each responding code crises team.
1.2 To facilitate an efficient and effective response to a code crises situation.
1.3 To put potentially dangerous situations under control. .
1.4 To ensure safety of patients and staff.
2.0 DEFINITION
1.2 Code crises code for any potentially dangerous and violent situation.
1.3 Defines the role of each nursing member of the team responding in a potentially
dangerous situation (Code Crisis ).
1.4 Silent code crises = A moderate or partially dangerous situation (lesser code Crisis
situation) Operator will not be inform anymore, instead the Head Nurse / Charge Nurse
will only inform the Nursing Management that in turn will arranged to send needed staff
from other units to control the situation.
Head Nurse, Charge Nurse, Staff Nurses
4.0POLICY
4.1 There shall be a prompt and professional response to potentially dangerous situation.
4.2 In the event of potentially dangerous situation within the ward environment, the Head
Nurse or his designate may initiate Code crises .
4.3 To summon the code crises team, dial ______ and notify the switchboard operator or the
code crises location three times at 10 seconds interval.
4.4 Code crises team should attend ward immediately.
4.5 Code crises Team will consist of 2 designated nurses from each unit and the Head Nurse
/ In-charge of the units.
ADMIN-113
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TITLE: CODE CRISIS
4.6 The head nurse or nurse- in charge in each unit shall designate two (2) staff nurses in each
shift as members of the code crises team. This will be documented in the daily job
allocation sheet.
4.7 Head Nurse or designate will be in-charge of code crises team.
4.8 Personnel on entry door duties will admit:
4.8.1 code crises team
4.8.2 unit clinical team members
4.8.3 members of nursing and medical administration
4.8.4 other personnel as indicated by nursing administration
4.8.5 members of security department, except in unit A (MOI unit).
ADMIN-114
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TITLE: CODE CRISIS

5.1 Code crises team will take full control
of crisis situation, and in case the team
is unable to handle the crisis, personnel
from MOI should be called
immediately to help control the
situation.
5.2 Unit pharmacy nurse will coordinate
with unit specialist / resident / doctor-
on-duty for any emergency medication
orders and to administer any such
orders.
5.3 All other clinical staff present will
channel the remaining unit population
away from the immediate crisis area.
5.4 Unit Head nurse or designate will
complete a critical / unusual occurrence
report and submit to Nursing
Administration.
5.5 Unit Head Nurse or designate will
ensure that the incident is reviewed by
the Unit Clinical Team as soon as
possible.
5.6 In case of crisis situation is not
potentially dangerous enough, Head
Nurse / In-charge could initiate by
calling Nursing Administration as a
Silent Code crises
6.0 ATTACHMENTS
None
ADMIN-115
______________________________________________

TITLE: CODE CRISIS

Critical or unusual occurrence report
8.0 REFERENCES
Fundamentals of disaster management a handbook for medchal professionals,second
edition 2008
Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the
Nonviolent Crisis Intervention training program. Brookfield,WI: Author
Internal Nursing Policy And Procedures Alamal Hospital Jeddah
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-116
______________________________________________

TITLE: VIOLENT PATIENT( code violet)
1.0PURPOSE
1.1 To bring the violent behavior under control.

1.2 To ensure safety of patients and staff.
2.0 DEFINITION
A patient expressing feelings of anger, dissatisfaction, fear or hopelessness through

aggressive behavior.
Unit Head Nurses, Charge Nurses, Staff Nurses
4.0 POLICY
4.1 Whenever a violent situation involving patient(s) arises, the Head Nurse or designate
should contain the situation with the assistance of other nurses in the unit.
4.1.1 Nurse must not attempt to control a violent patient alone.
4.1.2 If the nurses on the unit are unable to contain the situation, the Head Nurse or
designee should call upon the assistance of the nurses from other units or when
necessary, a code violet should be instigated, and physician must be informed.
4.2 All efforts must be done to protect patient and staff from harm during the crisis.
4.3 Any occurrence of violent situation should be documented (incident report,
documentation on patient's file), for reference purposes.
4.4 The head Nurse / in-charge must ensure that a full review of the incident by the clinical
treatment team takes place as soon as possible.
ADMIN-117
______________________________________________

5.1 Assess the situation.

5.1.1 Determine how many patients
are involved and identify.
5.1.2 Determine the reason
causing the violent behavior.
5.1.3 Check for the presence of
weapon.
5.1.4 Inform the physician. Give
details of the situation
5.2 Help patient bring violence under
control.
5.2.1 Initiate conversation in the
presence of the attending
physician.
5.2.2 Give the patient space. Do
not make any sudden
movement.
5.2.3 Avoid touching an agitated
patient or stand too close to
him.
5.2.4 Adopt a calm, non-
confrontational approach.
5.3 Talk and listen to the patient.
Acknowledge his state of agitation
and give him opportunity to
ventilate anger verbally.
5.3.1 Keep other patients away from
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the crisis area.

5.4 If the situation cannot be controlled
by the nurses in the unit charge nurse
may initiate a Code Violet.
5.5 Call for help of police or Ministry of
Interior (MOI) staff if violent patient
has weapon and refuses to
surrender it to the nurses.
5.6 With doctor's order, bring patient to
the seclusion room (follow the policy
& procedure in secluding patient).
5.7 Administer prescribed tranquilizer.
5.8 Let doctor examine the patient for
any possible injury. Administer first
aid if deemed necessary.
5.9 Write incident report and document
in the nursing progress notes.
6.0 ATTACHMENTS
None

7.1 Gloves
7.2 Critical/unusual occurrence form
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8.0 REFERENCES
- Crisis Prevention Institute. (2006). Measuring Success: Evidence, research and the
Nonviolent Crisis Intervention training program. Brookfield,WI: Author.
- Jambunathan, J., & Bellaire, K. (1996). Evaluating staff use of crisis prevention
intervention techniques: A pilot study. Issues in Mental Health Nursing, 17, 541558.
- Jonikas, J., Cook, J., Rosen, C., Laris, A., & Kia, J.(2004). A program to reduce use of
physicalrestraint in psychiatric inpatient facilities.Psychiatric Services, 55, 818820.
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-120
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TITLE: VIOLENT SITUATION IN OPD
1.0PURPOSE
1.1 To ensure safety of patient and hospital staff.

1.2 To prevent damage to any hospital properties.
1.3 To contain any violent situation.
2.0 DEFINITION
A situation involving an aggressive patient that is posing danger to himself, other patient,
hospital staff or other personnel while in OPD.
Head Nurse/ Charge Nurse, Staff nurses, Security personnel
4.0 POLICY
4.1 Whenever a violent situation involving patient arises, it must be contained

immediately.
4.2 There is a warning sign bell / light with switches placed at physicians' offices,
nursing counter, and security office that can be operated, seen or heard at both ends.
4.3 Once the warning sign bell rings or warning light lit up, the concerned (nurses &
security) personnel must rush to the site immediately to evaluate and control the
situation.
4.4 Nursing staff should not put themselves at high risk by attempting to control a
violent or aggressive patient on their own. The security personnel will be available
to help in controlling the situation.
4.4.1 MOI personnel's help shall be sought whenever deemed necessary to
control the situation.
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4.5 Head / nurse in charge shall coordinate the procedure.

4.6 All precaution must be taken to avoid injury to the patient who is being restrained
and to the staff performing the restrain.
Note: Details should be documented in the patient medical file including the reason that
leads to the incident and intervention rendered.
5.1 Determine the location and the extent

of the situation.
5.2 With other nurses and security staff,
rush to the area immediately and try
to restrain the violent patient.
5.3 Seek the help of the MOI if deemed
necessary.
5.4 Inform physician on duty and should
see the patient ( if wasn't seen so far).
5.5 Move the involved patient in a safe
area most likely to the observation
room.
5.6 Apply physical restraints as ordered.
5.7 Immediately administer medication
ordered.( if there is any order ) .
5.8 Notify nursing administration ASAP,
complete an unusual occurrence
report and send to nursing
administration.
5.9 Keep the involved patient closely
observed through out the time he
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stays in OPD.
5.10 Document the details in the
patient's medical file including the
reason that leads to the incident and
interventions rendered.
6.0 ATTACHMENTS
None

7.1 Gloves.
7.2 Critical/unusual occurrence form
8.0 REFERENCES
- Jambunathan, J., & Bellaire, K. (1996). Evaluating staff use of crisis prevention
intervention techniques: A pilot study. Issues in Mental Health Nursing, 17, 541558.
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-123
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TITLE: EMERGENCY CALL
1.0 PURPOSE
To Ensure The Safety And The Welfare Of Patient Employee And Visitors
2.0 DEFINITION
Call for help during emergency when there is risk for patients or staff
Staff Nurses
4.0 POLICY
4.1 To call for more staff to aid or to assist in the control of emergency situation.
4.2 Establish a systematic role of nursing in emergency.
4.3 Provide guideline for evacuation of the patients and identify the location of the
emergency.
4.4 To provide or established a process or procedure for call during emergency .
4.5 To provide guidance for staff on how to evaluate the situation and whom to call.
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5.1 The Head Nurse or the Charge Nurse will
evaluate the situation and to decide whether
to call for help or just to control the situation.
5.2 Calling for emergency situation:
5.2.1 Dial Hot Line( _ _ _) in
emergency
5.2.2 Identify yourself
5.2.3 Identify the type of
emergency clearly
5.2.4 Identify your location
clearly.
5.2.5 Operator should repeat the
message back to the caller
for confirmation,
5.2.6 Operator air the request
clearly, at least twice
5.3 Head Nurse should allocate two (2) staff
daily for emergency call.
5.4 Staff should be controlled and supervise
well.
5.5 Patient should be controlled well.
5.6 Staff should serve as a guide for patients in
time of evacuation.
5.7 Review the policy and procedure for the
different codes.
5.8 In case of disaster, all areas should be
notified immediately
5.9 Request transport to have an emergency car
ready at all times.
5.10 Incident report to be filled and send to
Nursing administration
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6.0 ATTACHMENTS
None

None
8.0 REFERENCES
- The University Of Connecticut Health Center - John Dempsey Hospital - Dministrative Manual
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-126
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TITLE: PATIENT FALLS
1.0PURPOSE
1.1 To prevent trauma.

1.2 To improve balance
1.3 To prevent disuse atrophy and retard progressive bone
1.4 For patient safety
1.5 To avoid and alerting patient from falls.
2.0 DEFINITION
Prevention of patient from falling down and guideline to patient safety and protection from
harm and how to act in case of occurrence of patient falling down.
Staff nurses
4.0 POLICY
4.1 SUSPECTED CASES OF PATIENT'S FALL:
4.1.1 Patient with psychiatric disorder 4.1.6 Ophthalmologic patient

4.1.2 Geriatric patient 4.1.7 Hypertensive patient
4.1.3 Hemiplegics patient 4.1.8 Over dose patient
4.1.3 Epileptic patient
4.1.4 Diabetic patient
4.1.5 Post operative patient
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5.1 Upon admission, orient the patient

with the environment room, bed,
toilet, doctor's room, meeting room,
etc
5.2 Demonstrate to patient ways to obtain
help when needed.
5.3 Placed bed in low position with brakes
locked if possible, or placed the
mattress on the floor (particularly for
patients who are prone to falls, history
of frequent fall, or patient at high risks
of falling.
5.4 If patient is alone, instruct the patient
to utilize the help of the nearest person
around.
5.5 Make sure that footwear is fitted and
not slippery and is used properly.
5.6 Utilized night light.
5.7 Keep floor surface clean and dry.
5.8 Make sure that patient knows where
personal belongings are, and that he
can safely and easily access them.
5.9 Ensure adequate hand rails in the
bathroom.
5.10 Evaluate effects of medication that
increases the risk of patient fall.
5.11 Monitor patients regularly and
encourage safe activities.
5.12 In case of occurrence of patient
falling down:
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5.12.1 Call for assistance and

inform the charge or the
head nurse.
5.12.2 At least two members of
the nursing staff in the unit
must care for the patient.
5.12.3 Assess patient for any
injuries, especially cervical
and spinal injury, and
patients level of
consciousness (LOC).
5.12.4 Move patient as a whole
(log roll), supporting the
neck and spine.
5.12.5 Place wooden board under
the patient.
5.12.6 Turn patient back over the
wooden board in supine
position.
5.12.7 Carry patient to treatment
room using the wooden
board moving in
synchronized manner.
5.12.8 Transfer the patient to the
treatment room bed lifting
the patient from the
wooden board to the bed
(moving as one).
5.12.9 Check for vital signs
5.12.10 Call for the internist
5.12.11 Carry out Doctors order.
5.12.12 Document in the file.
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6.0 ATTACHMENTS
View attached forms(attachment capter)

Wooden board, Patient's file, BP apparatus
8.0 REFERENCES
- Clinical Protocol Nursing Practice Manual John Dempsey - ospital The University of Connecticut
Health Center- Falls: Risk Identification, Prevention Management, and Treatment- REVISION
DATES:8/06, 10/06, 8/07, 9/07, 8/09, 9/10
- Morse JM, Morse RM, Tylko, SJ. Development of a scale to identify the fallprone patient.
Canadian Journal on Aging. 8 (4): 366-367, 1989.
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-130
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TITLE: POLICE HOLD
1.0 DEFINITION
2.0 PURPOSE
1. To cooperate with local law enforcement agencies in managing patients whom the
police have their custody.
3.0 POLICY
1. The Hospital will notify the police of our intent to discharge a patient on whom a
police department has placed a "Police Hold".
2. The Emergency Department or Nursing Unit will make the Police Department aware of
patients who have been admitted on Police Hold.
3. The Hospital has no responsibility in retaining patients who want to leave Against
Medical Advice.
4. Hospital personnel should not engage in any business or personal negotiations with the
patient or police department.
5. Local police will provide personnel coverage for those patients who are under arrest and
deemed dangerous. This will be in conjunction with Health Center Police Department
and coordinated through Public Safety Administration.
6. All questions are to be directed to the Police Department.
As clarified in policy
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TITLE: POLICE HOLD
6.0 PROCEDURES
1. Patients are classified as being on "Police Hold" are:
A. Those who are under arrest.
B. Those who are not under arrest but who are to be retained for
questioning after discharge.
2. The police officer who accompanies a patient under arrest will state to the admitting
interviewer that the individual is to be held for the police upon discharge.
3. The interviewer and Emergency Department nurse, or the primary nurse should indicate
"Police Hold" on the hospital record, on permission to treat form and on the records that
accompany the patient to the unit.
4. The nurse or clerk who transcribes orders and places charts in order on the unit
should indicate this clearly on the Kardex. "Police Hold Upon Discharge."
5. In addition to completion of routine discharge planning, the following additional steps

should be implemented:
A. Notify the Police Department of discharge ahead of time so they can in

turn notify the local police on time.
B. Plan for the patient on "Police Hold" to be ready when the police come for
him/her.
7.0 ATTACHMENTS
NA
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______________________________________________

TITLE: POLICE HOLD
8.0 REFERENCES
NPP 2010 - General Directorate Of Nursing- MOH.KSA
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-133
______________________________________________

TITLE: Maintenance of Medical Equipment
1.0 DEFINITION
Maintenance of medical equipment is a process provides for the safe and proper use of
medical equipments used in patient care.
2.0 PURPOSE
2.1 To assess and control the physical and clinical risks of all equipment used in the
diagnosis, treatment, monitoring, and care of patients.
2.2 To ensure safe and eecv e us e of me di cal devi ce.
equipment from Biomedical department.
3.0 POLICY
3.1 All medical devices shall be rigidly inspected and tested by biomedical sta prior to
use.
for use of the specific medical device.

3.3 Any medical department should not accept and use any medical devices unless
inspected and registered (BME Number) by biomedical department.
3.4 Emergency work order request for any medical equipment failure.
3.5 Medical equipment /devices are defective and out of order should be labeled by red
stickers and not to be used.
3.6 Prevenv e m a i nt enance of the equi pme nt is car ri ed out accor di ng to ri gi d schedul e
prepared by Biomedical department: White Sticker on the equipment indicates the
next due date for the preventive maintenance.
3.7 Record all problems ,repairs and PPM done in the cardex of each device
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4.1 Head nurse/Charge nurse:
4.1.1 Orientation of new staff for basic operating, special procedures and safety
procedures of medical equipments.
4.1.2 Identification of any equipment problems and reporting procedures
4.1.3 Initiation of the emergency work order request for any medical devices
failures
4.1.4 Checking of tags (White Stickers / red stickers) on all medical devices in the
ward
4.2 Staff Nurse:
4.2.1 Safe use procedures of medical equipments
4.2.2 Initiation of the emergency work order request for any medical devices
failures
4.2.3 Report to the Head nurses/charge nurses any equipment problems
4.2.4 Cleanliness, appropriate arrangement and storage of medical equipments

5.1 Job order book
5.2 Disinfectants according user manual of each medical device
5.3 Log book
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6.1 Receive of the new medical device 6.1 All medical equipments and non
from property control department medical equipments should be
received through property control
department
6.2 Call the biomedical dept for the 6.2 All medical devices should have BME
installation of the medical device and number and PPM tag for the follow up
tagging of the medical device; BME of the device: date of next PPM and
Number and PPM Sticker work orders.
6.3 Record the medical device and the

BME Number of the in the log book
6.4 Organize a training sessions for the 6.4 For the safe use of the device
ward staffs with collaboration of
biomedical dept
6.5 Reporting of any problem or 6.5 To evaluate the performance of the
inconvenient of the medical device to device
biomedical dept
Medical device out of order
6.6 Call the biomedical dept to initiate a 6.6 For urgent repair
work order
6.7 Record in the job order book : the 6.7 For the follow up of the work order
name and the BME Number of the
medical device, date &time of the
request and the work order number
6.8 Record the date and the time of the
completion of the work order in the
job order book
6.9 Assist the biomedical engineer to 6.9 To follow up the history of the device
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______________________________________________

record the problem of the device and

the kind of the repair done with date
and time in the Kardex of the device
7.0 ATTACHMENTS
Non
8.0 REFERENCES
MOH policy
King fahad hospital Jeddah -ksa
NAME: DATE
PREPARED BY Ahmed Sallami- RN- KAASH 2010
Mrs.Ashwag o. Shibah,RN BSN-Head Of nursing
REVIEWED BY 2010
Education
APPROVED BY 2010
ADMIN-137
______________________________________________

TITLE: BCLS/ACLS CERTIFICATE
APP APPROVAL DATE: EFFECTIVE DATE
DUE FOR REVIEW NUMBER OF PAGES 1 OF 6
1.0 DEFINITION
BCLS/ACLS Certificate is acquiring of certificate after underwent training for
BCLS/ACLS.
2.0 PURPOSE
To establish the sufficiency of the nursing staff to respond during emergency situation and
related nursing situations requiring the practice of CP Resuscitation that is current and
according standard of patient care.
All registered nurses and nursing Aid
4.0 POLICY
1. All Nursing Personnel, who have direct patient contact, will maintain CPR skills as
evidence by an annual update review or recertification class.
All new nursing personnel, who have direct patient contact are required to present
verification of a current BCLS certification card upon hiring.
1.1.1 Nurses hwo work in critical care unit must be cirtified by BLS AND BLS
1.1.2 A copy of the certification will be kept in the employees file and will be
updated according to policy and procedure.
ADMIN-138
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4.0 POLICY
1.1.3 It is the responsibility of the employee to maintain a current BCLS/ACLS
certification and provide evidence of recertification, according to policy and
procedure.
1.2 Existing Employee
1.2.1 It is the responsibility of the employee to maintain a current BCLS/ACLS

certification and to provide evidence of certification, according to policy and
procedure.
1.2.2 A copy of the card will be kept in each nursing employees file, current
and updated according to policy and procedure.

1. As per MOH Standards requirement.
1. BCLS Initial Certification
1.1 All nursing staff having direct

patient contract is required to be
BCLS certified.
1.2 If the employee has never been
certified, then the employee attends
an 8 hour initial certification class
2. BCLS Re-certification
2.1 Each direct patient contact staff will 2.1 As per hospital internal policy
recertify his/her BCLS card every 2
years at least 30 days before expiration.
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1.2 Recertification can be satisfied by
any one of the following methods.
1.2.1 Attend a four (4) hour BCLS

recertification class.
1.2.2 Complete the CPR recertification
class.
1.2.3 Participate in mock CPR drill and
verify certification on the sign in
sheet.
2. ACLS Certification
3.1 All nursing staff assigned at high

risk areas (ICU, Burn, Coronary Care,
OR/ER) will be required for ACLS
certificate.
3. ACLS Re-certification
4.1 All nursing staff recertifies their

ACLS card every two (2) years, at least
30 days before expiration.
6.0 ATTACHMENTS
None
ADMIN-140
______________________________________________


1. BCLS \ ACLS course training set
8.0 REFERENCES
MOH.KSA PP
NAME: DATE
Central Committee Of NPP 2007 General

PREPARED BY: 2007
Saleh Ziad Al-Juaid - Rn, Bsn, Msn. KFH-Taif

REVIEWED BY: 2010
Michelle R.Anapi - Rn, Bsn, Msn. KFH-Taif

APPROVED BY: 2010
General Directorate Of Nursing- MOH.KSA
ADMIN-141
______________________________________________

ADMIN-142
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TITLE: NURSING ESCORT DUTY
1.0 DEFINITION
A Nursing escort is assigned Nursing staff that accompanies patient to another facility or
institution.
2.0 PURPOSE
To ensure continuity of any nursing care of escorted patients from the ward/unit concerned
to transferred destination e.g. hospital, airport or medical lift or vice versa.
3.0 POLICY
The Nursing Supervisor will select the Nursing staff that will escort the patient and will be
the one to arrange all documentation e.g. permit and ambulance papers. Female nurse will
be accompanied by female health care provider for both male and female patient while
male nurse will escort male patient alone unless circumstances dictate otherwise. When
patient transferred from outside city to the city, a completed transfer attendance form
should be secured from receiving hospital or institution for submission to the administration
for claim of travel allowance.
Nursing Supervisor
Escort Nursing staff

5.1 Portable suction available from Neonatal or Pediatric Department
ICU, General Nursing Supervisor
5.2 Oxygen cylinder with adequate oxygen supply and oxygen tubings
5.3 Airway
5.4 Intravenous fluids
5.5 Medications
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5.6 Ivac machine battery operated
5.7 Portable cardiac monitor
5.8 SPO2 machine
5.9 Emergency kit

Before patients transfer:
6.1 Report to the department concerned To prepare the patient and know all the
at least thirty minutes before the necessary information about the patient.
planned departure and be
informed of the diagnosis,
medication and reason for the
referral.
To keep and bring during transfer for
6.2 Secure any medical or nursing handover to receiving institution.
reports, transferrable letter or
acceptance letter, X-rays or any
radiological reports and keep record
of medications. To have available equipment on hand
when needed especially in case of
6.3 Prepare items or equipments as emergency.
required for transfer according to
Patients condition. To ensure the patient for safe keeping
of belongings.
6.4 Assume responsibility of patient
belongings or positions endorsed by
the nurse in absence of
Accompanying relatives. To maximize patient dignity.
6.5 Keep patient well covered or dressed
ADMIN-144
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To ensure patients safety and make

him or her relax.
6.6 Assist the patient on the trolley and
place safety belts. Put him or her in a
comfortable position inside the
transport.
During patient transfer: To know immediately in any change of

patients health condition.
6.7 Observe end monitor the patient
continuously and maintain an open To continue nursing care required by
communication. the patient.
6.8 Perform nursing intervention as To maintain IV fluid infusion and correct

necessary such as: IV fluid rate.
6.8.1 Ensure the patency of IV lines

maintain the rate of intravenous To prevent aspiration.
fluids as ordered by the doctor.
To ensure accurate monitoring of
6.8.2 Suction patient as necessary. patient.
6.8.3 Check connection or machine or

equipment functions tubings if To treat the patient.
properly attached.
6.8.4 Prepare and administer

medications as required.
To ensure immediate transfer of patient

Arrival to the receiving institution: to the required area.
6.9 Ask for assistance if needed for the

pick up point and assist the patient
to the trolley, wheel chair or and To ensure patients safety.
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incubator for a baby if required.
In the airport, transfer of the patient

in the departure lounge and dont
leave the patient at any time until
taken over by the airport authorities To give appropriate information about
and formalities proceed. the patient for the continuity of care and
to transfer responsibility and
6.10 Ensure that the patient, photo copy accountability of patient belongings.
of all papers works if needed and
medications are handed over to
receiving staff including and up to
date summary of care needs.
Patient belongings should be
endorsed and appropriate signature To make the receiving staff aware that
will be obtained. relatives is around whenever in need of
any assistance and information about
the patient.
6.11 If there is an accompanying relative
with the patient, dont fail to To ensure patients safety.
introduce him or her to the
receiving staff.
6.12 Ensure that the patient is safe in

the new area before leaving e.g. To endorse patients file to medical
transferred to new bed with side records and to complete the inventory of
rails up. equipments brought. To endorse the
transfer attendance form to the
6.13 Collect patients file if brought administration for claim of travel
during transfer and medical allowance.
equipment for return. Also collect
the completed transfer attendance To go back immediately to the point of
form. origin.
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6.14 Return directly to the transport after To keep the nursing supervisor well
endorsement is finished. informed.
Upon return to the point of origin:
6.15 Report immediately to the duty To prepare the equipment for the next
nursing supervisor and inform any use.
problem encountered during the
transfer.
6.16 Return and clean the medical

equipment used. Return the
medications to the ward stock or
Pharmacy.
7.0 ATTACHMENTS
7.1 Transferrable or Acceptable Form
7.2 Transfer Attendance Form
7.3 Laboratory results
7.4 Permit or ambulance forms
8.0 REFERENCES
8.1 http://www.guysandstthomas.nhs.uk/resources/patient
info/cardiothoracic/transfer_patients_policy.pdf
8.2 http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_031.pdf
8.3 http:/www.tamesidehospital.nhs.uk/Documents/Transfer
PolicyAdultTamesideAcute.pdf.
ADMIN-147
______________________________________________

DATE
NAME:
PREPARED BY: Central Committee Of NPP 2007 -General 2007

REVIEWED BY: Mrs. Ashwag Omar Shibah , Head of Nursing 2010
Education
APPROVED BY Central Committee Of NPP 2010 - General 2010
ADMIN-148
______________________________________________

TITLE: Occurrence Variance Reporting System
1.0 PURPOSE
1.1. To provide a systematic hospital wide problem identification mechanism as quality improvement
tool for early detection and prevention of problems which have (or may have) an adverse patient
outcome and represent a potential hazard to patients, visitors, volunteer, trainee or employees.
1.2. To define the responsibilities and authorities of all individuals involved in the occurrence
reporting activity.
1.3.To plan and implement corrective measures through identification by root cause analysis.
2.0 DEFINITION
2.1. Occurrence :
It is an event which is not consistent with routine patient care or with the routine operation of the
facility
and which adversely affects or threatens the health or life of patient, visitor, employee, student or
volunteer which involves loss or damage to personal or hospital property. An occurrence also includes
any event that might other wise result in any other adverse situation or a claim against the
organization.
2.2. Occurrence Variance Report (OVR):
It is an internal form which is issued to document the details of the occurrence/ event and the
investigation of an occurrence and the corrective actions taken.
2.3. Sentinel Event :
An unexpected occurrence involving death, serious physical or psychological injury or the risk
thereof, and any event that might cause embarrassment or risk to the hospital with potential legal
implications and/or media inquiries or coverage. The phrase or the risk thereof includes any
process variation for which a recurrence would carry a significant chance of a serious adverse
outcome. Such events are called sentinel because they signal the need for immediate investigation
and response.
2.4. Near Miss :
An event or situation that could have resulted in an adverse event but did not either by chance or
through timely intervention .
2.5. Malpractice:
It is improper or unethical conduct or unreasonable lack of skill by a holder of a professional or
official position; often applied to physicians, dentists, nursing to denote negligent or unskillful
performance of duties when professional skills are obligatory. Malpractice is an action for which
ADMIN-149
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damage is allowed.
2.6. Adverse Event ;

Are unexpected incidents, misadventure , iatrogenic injuries or other adverse occurrences directly
associated with care or services provided .adverse events can be categorized as either sentinel event
or near miss that result from commission or omission .
2.7. Variation : the differences in results obtained in measuring the same event more than once .too much
variation often leads to waste and loss ,such as the occurrence of undesirable patient health outcomes
and increased coast of health services .
3.1 The employee who witnesses or discovers an occurrence has the professional obligation and the
responsibility for:
3.1.1. Immediate notification to:
3.1.1.1. The Physician on call if the occurrence involves patient or employee injury or harm
3.1.1.2. The Immediate Supervisor.
3.1.2.Initiating the OVR form before the end of the current shift .
3.1.3.Submitting the OVR Form to the Immediate Supervisor/head of department for completion.
3.2. .The area Supervisor /Head of department is responsible for:
3.2.1.Ensuring that all employees are aware of Occurrence Variance Reporting System and how
to report and process OVR Form.
3.2.2. Conducting immediate follow-up of the occurrence by initiating and documenting on
the OVR form the actions taken
3.2.3. Indicate the category & contributing factors of the occurrence..
3.2.4. The head of department responsible to complete the occurrence with their recommendations
3.2.5. Conducting any further investigation and documenting findings of the reported occurrence
upon request of the Hospital Administration, the Quality Management or the Safety
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Committee.
3.2.6. Submit the original copy of his department OVR log sheet to TQM .
3.2.7. Forwarding the completed OVR Form to the Total Quality Management office within 72
hours of the occurrence.
3.3.The Physician: the physician who attends to patient / employee involved in occurrence is
responsible for :
3.3.1. Examination & management of affected person .
3.3.2. Documenting a brief statement of his /her actions on the OVR form
3.4.The Total Quality Management Department is responsible for:
3.4.1.Monitoring all OVR for follow up with concerned departments/hospital
administration so that necessary steps may be taken by those in charge to resolve the
situation if necessary.
3.4.2.Trending and preparing a monthly summary of all reported OVR .
3.4.3.Submitting a quarterly report to the Quality Management patient safety council for
discussion and further action if deemed necessary by the QMPS council .
3.4.4.Maintaining a file of all OVR submitted to the TQM office for three (3) years.
3.5.The Safety Officer is responsible for:
3.5.1.Investigating all safety related occurrences referred for investigation by initiating
department and/or Head, TQM .
3.5.2.Activating a review team of selected Safety Committee Members to investigate critical
safety related occurrences.
3.5.3.Documenting the results of investigation and corrective action taken on the OVR form.
3.5.4.Returning the completed form to the TQM office.
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4.0 POLICY
5.1. It is the responsibility of all staff to immediately report the details of any
occurrence, which negatively impacts the care of a patient.
5.2.The Occurrence Variance Report Form will be initiated immediately following the occurrence and
submitted to the immediate supervisor/head of department within the current work shift.
5.3. This report is to be used to identify the facts surrounding the occurrence and will not be used to
criticize or speculate on actions of the staff involved.
5.4. Corrective actions shall be taken to minimize and eliminate the risk of injury and adverse
outcomes.
5.5. Corrective action(s) shall be documented.
5.6. The Occurrence report shall not be placed in the medical record. The terms incident and error
shall not be used in the medical record when making an entry regarding an occurrence or the
results of an occurrence.
5.7. Confidentiality:
5.7.1. All Occurrence Variance Reports shall be handled and maintained in a confidential
manner, with access to such documentation restricted only to authorized individuals.
5.7.2. Occurrence Variance Reports shall not be duplicated with exception of the TQM
department, when deemed necessary.
5.7.3. The information contained in the OVR form cannot and shall not be used against any
individual as the sole basis for disciplinary action except in extreme situations e.g patient
harm.
5.7.4. Hospital staffs are not at liberty to discuss the contents of an Occurrence Variance Report
or the events and circumstances related to the occurrence either with patient, visitor or
other members of the staff, unless clarifying facts under investigation with the proper
authorities.
5.7.5. Discussion of general issues on OVR for instructional or educational purposes with view to
improving patient care is, however strongly encourage
5.7.6. Names of involved/concerned person should not be used, instead use the ID number.
ADMIN-152
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6.1. Write in clear legible handwriting using

blue or black ink, avoid using pencils.
6.2. The Occurrence Variance Report Form
consists of the following sections:
6.2.1. Occurrence details filled by the
employee who witness or discover
an occurrence
6.2.1.1.Event Details.
6.2.1.2.Person(s) Affected.
6.2.1.3.Brief Description of
Occurrence.
6.2.2. filled by immediate
supervisor /head of involved
department.
6.2.2.1. Immediate action
taken .
6.2.2.2. Evaluate the
occurrence if it is
sentinel event or not
according to sentinel
event criteria .
6.2.2.3. If the occurrence is
sentinel event follow
the sentinel event
procedure .
6.2.2.4. Document if the
occurrence needs
physician evaluation .
6.2.2.5. The immediate
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supervisor /head of
department indicate
the occurrence
category and
contributing factors
in the OVR form
6.2.2.6. If a physician was
notified and actually
attended the patient,
the physician is
responsible for
recording a brief
statement
6.2.3. Action Taken (by
involved/concerned
department for follow up;
this includes corrective
action taken and
recommendations to
prevent recurrence of the
incident.
6.2.3.1. To be filled by TQM.
6.2.3.2. TQM will return
back the OVR form
to concerned
department if it is not
completed .
6.2.3.3. The supervisor /head
of department will
verify & return the
OVR form within the
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same day .
6.2.3.4. TQM will record the
occurrence in hospital
OVR log sheet .
6.3. If the occurrence happened in various
departments after working hours :
6.3.1. Area supervisor /hospital
director on duty
6.3.2. Area supervisor submit OVR
form to the head of the
department next day .
6.3.3. The hospital director on duty

submit the OVR form every
day Moring to TQM for
redistribution to the head of
concerned department.
6.4. Departmental OVR log sheet should be
used during the transfer of the form
from one employee to anther to indicate
the date ,time name and signature .
6.5. The original copy of all monthly
departmental OVR log sheet should be
delivered by the departmental head to
TQM department at the end of each
month to be kept their .
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6.0. MATERIALS & EQUIPMENT

N/A
7.0 ATTACHMENTS
OVR FORME
8.0 REFERENCES
8.2. King Fahad General Hospital
8.2. Hera General Hospital .
8.3 JEDDAH EYE HOSPITAL TQM-APP-003 E/A(2)
DATE
NAME:
PREPARED BY: Central Committee Of NPP 2007 -General Directorate 2007

Of Nursing- MOH.KSA
REVIEWED BY: Mrs. Ashwag Omar Shibah , RN,BSN-Head of Nursing 2010
Education
APPROVED BY: Central Committee Of NPP 2010 - General Directorate 2010
Of Nursing- MOH.KSA
ADMIN-156
______________________________________________

TITLE: Nursing Care Of Patient At End OF Life
1.0 DEFINITION
Palliative Care - The active total care of patient whose disease is not responsive to
curative treatment. It also focuses on opportunities for growth at the end of life.
Control of pain and other symptoms and providing psychological, social and spiritual
support of utmost importance.
2.0 PURPOSE
2.1To provide the best quality of compassion to care for patient at the end of life
.and to provide relief of suffering when disease cannot be cured
2.2 To improve professional preparation for end of life care among registered nurses.
3.0 POLICY
1. The components of end of life care include communication, physical comfort,

social needs, spiritual needs, patient centered decision making, age-related
considerations, and legal ethical indications.
All registered nurses involve in caring for patients requiring end of life care.
1. Informed Consent IPP

2. Discharged Against Medical Advise IPP
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6.1 The responsible registered nurse providing
care for patient requiring end of life care is
competent to provide following care.
6.1.1 Promote the provision of comfort care to

the dying as an active, desirable, and
important skill and an integral component of
nursing care.
6.1.2 Communicate effectively and

compassionately with the patient family and
health care team about the end of life care.
6.1.3 Facilitate participation in religious or
spiritual activities.
6.1.4 Encourage families to minimize social

isolation.
6.1.5Provide private time for relationships ,
6.1.6 Discuss end of life issues early in

patient's treatment plan.
6.1.6.1 Advance directions such as a
living will.
6.1.6.2Durable power of attorney.
6.1.6.3Allow for the refusal of further treatment
or authorize a family member or friend to make
decision for the patient.
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6.1.6.4 After discussion with the patient

and family. The physician will write a Do not
Resuscitate (DNR) order on his progress
notes, physician order sheet, and DNR form
(KFH-737).
6.1.7 Asses and treat multiple dimensions
including physical, psychological, social and
spiritual needs to improve quality at the end of
life.
6.1.8Assist the patient, family, colleagues and

one self to cope with suffering, grief, loss and
in a cute state of sadness in end of life.
6.19 Demonstrate skill at implanting a plan

for improved end of life care within a dynamic
and complex health care delivery system.
.
6.2 Providing Physical Comfort
6.2.1 Provides comfortable environments,
nourishments hydration and symptoms relief.
6.2.2 Provide pain relief and symptoms

control care ( hunger, nausea constipation ,
anxiety, agitation and prevention of
constipation(
6 . Psychological Comfort.
6. Provide emotional support not only to

the patient but also to family and friends.
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6. Establish trust with the patient

and family.
6. Allow the patient and family to

express fears and concern.
6. Promote open non-judgmental

environment.
6. Making referrals as indicated

(e.g. counseling, social services and support
from the religious group.
6.3.1.5 Accepting ones own feeling

6.3.1.5 to therapeutically provide for
about death and being able
the needs of the others.
.6 Social Needs
6. Facilitating social needs by:
6. Providing privacy anytime the

patient wishes
6. Maintaining dignity and value
through respect caring comfort and
communication.
6. Maintaining the patients personal

independence and self determination.
6.5 Spiritual Needs
6. To provide more positive attitudes
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towards end of life.

6. Facilitate participation in religious or
spiritual activities.
6. For Muslim dying patient the health care
giver should have access to a Muslim (sheikh)
who can read the Quran and make special
prayers in consultation with the patient or
family, Islamic Relation Office
6. As the patients death approaches, give
them emotional support.
6. Turn those who are near to death to the

kiblah side.
6. Turn off channel where dying people

lie down on the floor.
6. Turn on the Holy Quran channel.
6.5.8 Show the importance of keeping the

privacy of dying people the private parts.
.6. Documentation
6. Record changes in the patient vital

signs, intake and output, and local of
consciousness.
6.6.2 Note the time of cardiac arrest at the

end of respiration and notify the physician
when these occur.
ADMIN-161
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7.0 ATTACHMENTS
Patients Bill of right
8.0 REFERENCES
8.1 Daaliman, T, & Van de Creck, L (200) Placing Religion and Li Spirituality in End
of life care Jame. 284(19):
8.2 World Helath Organization (2004) who Definition of palliative care. Retrieved
June 1,2004 from http:/www.who int/dsa/justpub/cpl.htm
8.3King Fahd Policy and Procedures NRS-IPP-PRC-033E (2)
NAME: DATE
Central Committee Of NPP 2007 -General Directorate Of

PREPARED BY: 2007
Nursing- MOH.KSA
Mrs. Ashwag Omar Shibah , RN,BSN-Head of Nursing
REVIEWED BY: 2010
Education
APPROVED BY: 2010
Nursing- MOH.KSA
ADMIN-162
______________________________________________

TITLE: NURSING MEETINGS
1.0 PURPOSE
1. To Clearly defined procedures for such events.
2. To Accommodating and giving a voice to all staff members .
3. To Fostering collaborative decision making
4. To plan, effectively for routines of organization.
5. To allow for a sense of staff through appropriate delegation.
6. To involve all staff in the decision making process
2.0 DEFINITION
NA
All staff had a role in the implementation of this policy
4.0 POLICY
4.1 Staff meetings should be regular and provide an opportunity for all staff to have input into planning
and decision making on centre issues, offer feedback on policies and procedures, formulate goals and
strategies, network and share ideas with each other (this is especially beneficial if staff
are working in different centres) and develop a co-operative approach to the management of day to day
ADMIN-163
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issues.
4.2 staff meetings should be well prepared, organized and kept on pathway
4.3 Staff should have a clear understanding of the expectation of staff meeting attendance.
4.4 ensure that staff have written documentation (i.e. in their job descriptions) explaining that out-of-
hours staff meetings are an expectation.
4.5 Staff meetings should be compulsory for staff this means they must attend and therefore must get
reimbursed
4.6 staff will Give adequate advance notice of meeting dates and times and rotate the day to ensure that all
staff have the opportunity to attend. Some staff teams like the meeting schedule ( agenda)to be set
for the year so they can plan around the dates.
4.7 staff will Involve in deciding upon the agenda items then prepare and distribute the agenda prior to
the meeting .
4.8 Every staff meeting should have a purpose with agenda items that are relevant and useful.
4.9 The minute taker records any discussion and summarizes as the meeting progresses .
4.9.1 The minute taker ensures that the minutes clearly document any decisions made and includes a
clear list of actions, with timelines and who is responsible for each action .
4.9.2 The minute taker ensures that the minutes are distributed soon after the meeting while the topics
are still fresh in everyones mind.
4.10 The Environment ( venue)
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4.10.1 The meeting facilities should be comfortable and adequate (i.e .no baby chairs if possible .(
4.10.2 Ensure that everyone has an opportunity to present their views in an environment where they are
listened too and no one tends to dominate the discussion .
4.10.3 Vary locations for staff meetings as appropriate, Include a meal or nibbles for staff
4.11 Staff will Accept responsibility for agreed action points and respect colleagues contributions to the
meeting

5.1This helps to avoid over-domination of
5.1 Invite staff to consider items for the agenda any one issue or individual
5.2 Draw up and distribute the agenda in advance
of the meeting
5.3Chair the meeting as appropriate
5.4Ensure minutes and action points are recorded
5.5 Monitor and follow-up on action points

5.6 for time management .
5.6 The meetings should begin and end on

time (negotiate with staff appropriate
times.
5.7 Put aside time at each meeting for both
business and socializing .
5.8 Include opportunities for small group work

which is useful, relevant and deals with
ADMIN-165
______________________________________________

important issues/problems.
5.9Small groups can break off to
brainstorm ideas then come back to the whole
groups to share their thoughts .
6.0. MATERIALS & EQUIPMENT

N/A
7.0 ATTACHMENTS
8.0 REFERENCES
8.2 EAST DUNBARTONSHIRE COUNCIL
2008 Griffith Barracks MultiDenominational School - site by lib-lab
NAME DATE
PREPARED BY: Mrs. Ashwag Omar Shibah , Head of Nursing Education 2010
Central Committee Of NPP 2010 - General Directorate Of 2010
APPROVED BY:
Nursing- MOH.KSA
ADMIN-166
______________________________________________

TITLE: GENERAL ENVIRONMENT OBSERVATIONS
1.0PURPOSE
1.1 To monitor the unit environment and patient activities.
1.2 To maintain a safe, secure and therapeutic environment.
2.0 DEFINITION
Observation and inspection of all areas of the unit with open access to patients by the
assigned nurse.
Nursing staff
4.0 POLICY
4.1 Head Nurse / In-Charge of shift is to assign a nurse for routine unit rounds for a period
of 2 hours, divided into fraction of 20 minutes each documentation It is permissible to
assign a nurse for more than one 2-hour period during a shift. However, no one is to be
assigned for 2 consecutive periods. Unit rounds to be carried out correctly.
4.2 Appropriate action should be taken whenever anything unusual is reported by the
assigned nurse. Cases which are directly related to patients must be documented in their
progress notes.
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5.1 IN-CHARGE OF THE SHIFT

/HEAD NURSE
5.1.1 Head Nurse / nurse in-charged of the
shift has to assign a nurse to routine
unit rounds for a period of two hours.
It is permissible to assign a nurse for
more than one two-hour period during
a shift. However, no one is to be
assigned for routine rounds on two
consecutive periods.
5.1.2 Appropriate action should be taken
whenever anything unusual is reported
by the assigned nurse.
5.1.3 Ensure that anything unusual which is
directly related to the patients should
be documented in the progress notes.
5.1.4 Ensure that the job allocation is signed
by the nurse assigned.
5.1.5 Ensure that the routine round is
carried out correctly.
5.2 ASSIGNED NURSE

5.2.1 Check the time of assignment in the
job allocation form, affix signature.
5.2.2 In the two hour period of assignment,
round has to be carried out every ten
(10) minutes as indicated, and
signature to be in the corresponding
box.
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5.2.3 A round is to be made at all areas

accessible to patients:
5.2.3.1 Patients rooms including their
comfort rooms
5.2.3.2 Games room
5.2.3.3 TV room
5.2.3.4 Prayer room
5.2.3.5 Garden
5.2.3.6 Other areas accessible to
patients
5.2.4 Check for:
5.2.4.1 Contrabands
5.2.4.1 Items or situations that are
hazardous to patients and staff.
5.2.5 Observe condition and status of
patients
5.2.6 Observe patients behaviours and
activities.
5.2.7 Report to the charge nurse an
unusual observations.
5.2.8 Use flash light when entering
patients rooms (for night duties).
5.2.9 At the end of the two hour period,
hand over directly to the next assigned
nurse.
6.0 ATTACHMENTS
None
ADMIN-169
______________________________________________


None
8.0 REFERENCES
Psychiatric Services, 55, 818820. McCue, R., Urcuyo, L., Lilu, Y., Tobias, T.,
&Chambers, M. (2004). Reducing restraint use in a public psychiatric inpatient service.
Journal of Behavioral Health Services &Research, 31(2), 217224.
Al Amal Hospital, Jeddah MOH-NPP 2010
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-170
______________________________________________

TITLE: OVERTIME (BACK TIME)
1.0PURPOSE
1.1 To provide sufficient staff at a specified time

1.2 To provide continuity of nursing care.
1.3 To provide quality nursing care.
1.4 To established guideline for staff duty during off hours.
2.0 DEFINITION
Overtime is the working hours of the staff outside the regular duty hours, providing staff to
give necessary nursing care to patients at a specified time.
Director of Nursing, Nursing Supervisors, Head Nurses
4.0 POLICY
There must be sufficient number of staff to cover a certain period of time, outside the
regular duty time so as to provide the necessary care to the patients.
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5.1 The Nursing department determines

the need for additional staff.
5.2 The Nursing Department coordinates
with the Hospital administration
regarding the need for additional staff.
5.3 The Nursing Department will
organized the schedule for staff for
extra duty hours.
5.4 Nursing Department should inform the
concerned staff regarding the
schedule.
5.5 The staff will report on the specified
time and should continue on if needed.
5.6 Nursing Department will record the
number of hours the staff went on
duty.
5.7 The extra hours the staff went on duty
will be compensated by giving the
staff the chance to take back the time
on another day as back time.
5.8 The Head Nurse of the unit will
determine the appropriate time for the
staff to take back the time, without
affecting the number of staff on duty.
6.0 ATTACHMENTS
None
ADMIN-172
______________________________________________


None
8.0 REFERENCES
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-173
______________________________________________

TITLE: PHYSICAL ASSAULT ON STAFF
1.0 PURPOSE
1.1 To ensure that all nursing staff receive appropriate attention and support following a
physical assault during the course of their duty.
1.2 To investigate the incident and render appropriate disciplinary action.
2.0 DEFINITION
An unlawful threat of bodily violence or harm to staff by patient or other personnel in the
hospital.
Nursing staff
4.0 POLICY
4.1 All physical assault on nursing staff by patients or fellow staff must be reported to
Nursing Administration immediately.
4.2 The physically assaulted staff must be seen at the staff health clinic during office
hours, and by the internist on duty if incident occurred at night time.
4.3 When a patient is involved, the primary physician must be notified immediately of the
patients behavior.
4.4 Any occurrence of physical assault to staff should be documented (incident report,
documentation on the staff's file), as reference for future review by the Nursing
Administration and QA Department.
ADMIN-174
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5.1 Determine the presence of assault

and identify the individuals involved.
5.2 Let the physically assaulted nursing
staff proceed to the Staff Health
Clinic and be evaluated by the staff
physician for any injuries and
treatments required.
5.3 A full description of the incident
must be documented in the staff's file
and in the patient's file (if patient is
involved). This must include details
of:
5.3.1 Time of assault
5.3.2 Events leading up to the
assault
5.3.3 Interventions taken
5.3.4 Medical officer notification
( if patient is Involved)
5.3.5 Medical officer interventions
5.3.6 Details of staff injuries
sustained
5.4 Complete a critical / unusual
occurrence report
6.0 ATTACHMENTS
Use the incident report form in your hospital for employees

Employees Incident Report Form
ADMIN-175
______________________________________________

8.0 REFERENCES
Smalls Y. (2004). Utility of the implementation of programmatic systems to reduce and
eliminate restraint use for the treatment of problem behaviors with individuals with
mental retardation. Unpublished dissertation.
Retrieved February 20, 2006 from http://etd.lsu.edu/docs/submitted/etd-01282004-
145119/unrestricted/Smalls_dis.pdf.
Al Amal Hospital, Jeddah MOH-NPP 2010
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-176
______________________________________________

TITLE: DIRTY UTILITY ROOM
1.0 PURPOSE
To provide area for dirty / used items from the patients.
2.0 DEFINITION
An area in the unit where dirty / soiled items used by patients are stored/kept for
safekeeping before taken by the personnel from the laundry department for cleaning process.
Staff Nurses, Laundry Staff
4.0 POLICY
4.1 Only dirty / used items from the patients should be in the hamper for the laundry.
4.2 Never mix soiled items with the clean ones.
4.3 Maintain tidiness in the hamper, not to let the soiled items to be scattered in the floor.
4.4 Laundry personnel's taking the soiled items be provided with necessary protection while
handling the items gloves
4.5 The room should only be accessible to the store nurse.
4.6 Key to the room should always be with the store nurse
4.7 The hamper for the dirty items should never be used for clean items
ADMIN-177
______________________________________________


5.1 Provide protection for the laundry worker
by giving gloves and mask, possibly apron
if available.
5.2 The laundry worker should check all soiled
or dirty items for any patient's belongings.
5.3 Put all soiled items in a hamper provided
for transporting the items to the laundry,
and close the hamper with cover
5.4 Keep the dirty utility room always closed.
5.5 Any item aside from the thobe, blanket,
linens, underwear's, towels and other
clothing's should be removed from the
room and put in a garbage bin.
5.6 Give instructions to the patients to put all
soiled items inside the hamper and not to
scatter in the floor.
5.7 Put the hamper in an area easily accessible
to the patients.
6.0 ATTACHMENTS
None

Dirty patient care items, hampers for dirty linens
8.0 REFERENCES
Standard policy
ADMIN-178
______________________________________________

NAME DATE

2010
MOH - KSA
2010
MOH.KSA
ADMIN-179
______________________________________________

TITLE: CLEAN UTILITY ROOM
1.0PURPOSE
To provide area for clean unused items for patients.
2.0 DEFINITION
An area in the unit where clean items for patients are stored / kept for safekeeping
before distribution to patients for use.
Staff Nurses
4.0 POLICY
4.1 Only new, clean, unused items to be kept in the clean utility room.
4.2 Never mix soiled items with the clean ones.
4.3 Maintain an updated record of items in the room.
4.4 Items to be separated from each other, marked with identification of the item.
4.5 The room should only be accessible to the store nurse
5.1 Separate items according to category

( towels, underwear, footwear, etc. ).
5.2 Arrange them in a manner providing the
store nurse adequate space when taking
any of the items.
5.3 Shelves containing the clean items
should always be covered with clean
linen, to avoid exposure of the clean
items to dust in the air.
ADMIN-180
______________________________________________

TITLE: CLEAN UTILITY ROOM

6.0 ATTACHMENTS
None

Clean and unused items for patients
8.0 REFERENCES
Standard policy
NAME DATE

2010
MOH - KSA
MOH.KSA
2010
ADMIN-181
______________________________________________
GENERAL NURSING: NURSING ADMINISTRATION

TITLE: SUPPLIES
1.0 DEFINITION
1.0PURPOSE
1.1 To provide request for items needed in the work.

1.2 To provide what patient needs as well as the needs of the staff.
1.3 The care provider functions well if the needed supplies are available.
2.0 DEFINITION
Items used by the patients, and the care providers in the performance of their
duties/functions in providing quality nursing care to patients.
Head Nurse, Charge Nurse
4.0 POLICY
4.1 The Head Nurse or the Charge Nurse determines the supplies needed.
4.2 Supplies should be requested according to need.
4.3 There should be enough supply in the unit to provide continuous care to the patients.
4.4 Don't make request only when items are all consumed. Anticipate the need to request for
supplies.
4.5 The request is approved and signed by the Head Nurse before forwarding to the
Department head for approval.
4.6 Request to be approved and signed by the Department head.
______________________________________________

TITLE: SUPPLIES
5.1 Head Nurse or Charge Nurse will do the

round in the unit to determine the items
needed. Items should be listed accordingly.
5.2 Head Nurse coordinates with store nurse
with regards to the stock of items and
furnished the Head Nurse with the items or
supplies needed.
5.3 The Head Nurse brings the signed request to
the Nursing Office for approval and signing,
then to the Central Store for submission and
approval by the Head of the central store.
5.4 Supply Department to notify the requestor
regarding unavailable items, that needed
special request.
5.5 Special request to buy item from outside to
be filled and approved by the Department
Head and the Hospital Manager.
5.6 Items received from central store to be kept
in special area.
5.7 Disposable item to be used under control for
one use only.
5.8 Items received from CSR, should be checked
for expiration date before receiving the items.
5.9 Items receive should be endorsed to the store
Nurse .
7.0 ATTACHMENTS
NA
______________________________________________

TITLE: SUPPLIES
8.0 REFERENCES
th
- Manual Of Nursing Practice - 8 Edition 2001
th
- Fundamentals Of Nursing Practice - 5 Edition 2001
th
- Niraj Ahuja, Textbook Of Psychiatry (6 Edition)
- Al Amal Hospital Jeddah-Drug Rehabilitation Hospital- Nursing Department
NAME DATE

2010
MOH - KSA
2010
MOH.KSA
______________________________________________

TITLE: SUPPLIES AND EQUIPMENTS
1.0 PURPOSE
To check for proper functioning of supplies and equipments to be used in the unit/area.
2.0 DEFINITION
List of equipment and supplies that must be available and functioning in all the units.
Staff Nurses
4.0 POLICY
4.1 There must be a checklist of equipments and supplies in the units.

4.2 Nurses have to check the equipments for functioning in every shift during endorsement.
4.3 Any malfunction should be labeled properly and reported to biomedical technicians.
4.4 Head nurses or charge nurses should be notified.
5.1 Checked equipment and supplies every shift during endorsement.

5.2 Follow the checking procedure for machinery and equipments.
______________________________________________

TITLE: SUPPLIES AND EQUIPMENTS
6.0 ATTACHMENTS
None
7.1 Scales appropriate to the age group and mobility of the patients
7.2 Stretchers with safety straps
7.3 Equipment for taking vital signs (thermometer, stethoscope, sphygmomanometer)
7.4 Wheelchairs
7.5 Sharp Box
7.6 Foot stools
7.7 Soft restraints
7.8 Bed rails
7.9 Oxygen and suction
8.0 REFERENCES
- Manual Of Nursing Practice - 8th Edition 2001
- Fundamentals Of Nursing Practice - 5th Edition 2001
- Al Amal Hospital Jeddah-Drug Rehabilitation Hospital- Nursing Department
NAME DATE
Khalid A. Alharthi Nursing Total Quality Coordinator GND-

Prepared By: 2010
MOH - KSA
Central Committee Of NPP 2010 - General Directorate Of Nursing-
Approved By: MOH.KSA 2010
______________________________________________

TITLE: MOI CASES
1.0 PURPOSE
1.1 To render effective and efficient services to the patient.
1.2 To provide guideline in dealing with MOI patients.
2.0 DEFINITION
Any patient referred to the hospital and accompanied by Ministry of interior (MOI)
officer for management and treatment of substancerelated problem.
Nursing staff, MOI officer, Doctors
4.0 POLICY
4.1 All MOI patients shall be given priority to have him seen by physician as soon as
possible.
4.2 MOI patients with leg chains must stay in separate room (MOI office at OPD) away
from general waiting area and should be moved via wheel chair within the hospital
confines, under any circumstances should never let the patient walk around with
shackled leg.
4.3 An employee from patient's affair department shall take the required personal
information in opening a file inside the MOI office.
4.4 Any information obtained from the patient that sounds not reliable, the patient's affair
employee may ask the MOI officer to have clear patient data.
4.5 Accompanying MOI officer must stay with the patient all the time.
4.5.1 If patient is for admission, the accompanying officer shall stay with the
patient until being brought to the unit.
______________________________________________

TITLE: MOI CASES
5.1 Check for the MOI referral letter.

5.2 Provide patient with wheel chair
and white linen to cover the
patient's lower extremities, if the
patient is with leg chain.
5.3 Perform nursing assessment
including vital signs.
5.4 Prepare patient file and attach all
documents brought either by MOI
or the patient.
5.5 Once patient file is ready it should
be hand over to the nurse in charge
of OPD.
5.6 Refer the patient to the physician
on duty and remain with him until
finish.
5.7 Get the patient to specimen
collection room to obtain the
required specimen as order by the
physician.
5.8 Check the physician order care
fully and make sure that all
required specimen is taken before
allowing the patient to leave the
hospital (if for OPD treatment
only).
5.9 Carry out other physician orders.
5.10 Head nurse or the nurse in
charge should then follow up the
case for sending a medical
______________________________________________

TITLE: MOI CASES
report if needed.
5.11 Put a copy of the MOI referral
letter in the patient's file and in the
OPD file.
6.0 ATTACHMENTS
None

MOI Referral letter, Patients file
8.0 REFERENCES
- Manual Of Nursing Practice - 8th Edition 2001
- Fundamentals Of Nursing Practice - 5th Edition 2001
- Niraj Ahuja, Textbook Of Psychiatry (6th Edition)
- ANN Isaac's Mental Health And Psychiatric Nursing (2nd Edition 1992)
- Textbook Of Substance Abuse Treatment (2 nd Edition 1994)
- Gallantar And Klebber , American Psychiatric Press
NAME DATE
Prepared By: Al Amal Hospital Jeddah-Drug Rehabilitation Hospital- Nursing 2010
Department
Reviewed & Central Committee Of NPP 2010 - General Directorate Of Nursing- 2010
Approved By MOH.KSA

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Ministry Of Health, General Directorate Of Nursing

Nursing Policies and Procedures Committee 2011

Dr. Munira Al Oseimy

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 1 of 6

To assist patients to know their basic rights and responsibilities as patients, to

5.0 MATERIALS & EQUIPMENT

1. Informed Consent IPP

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 2 of 6

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 3 of 6

ADMINISTRATIVE POLICY AND PROCEDURE

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1.16The right to request for a change of physician as per hospital policy.

1.17The right to change or transfer to other hospital as per hospital policy.

1.18The right to refuse to participate in Medical Training Program and Research

2.2 To provide accurate and Complete information concerning the present

ADMINISTRATIVE POLICY AND PROCEDURE

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2.4 To follow the treatment plan established by the physician,including the

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 6 of 6

PREPARED BY: Kingdom Saudi Arabia- Ministry Of Health 2010

Saleh Ziad Al-Juaid - RN, BSN, MSN. KFH-TAIF

Central Committee Of NPP 2010

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 1 of 3

Non maleficence - complements beneficence and obligates the professional nurse

Each child, adolescent and / or handicapped patients as a unique individual.

The care-taking role and individual response of the parent.

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 2 of 3

The reassuring presence of a caring person, especially a parent / family

Freedom to express feeling of fears with appropriate reaction, if possible,

To maintain control as possible over self and situation;

Opportunities to work through experience before and after they occur,

Recognize and reward the coping well doing difficult situations.

Play, educational and social activities essential to all children and

7. Participation of children / families in decision affecting their own medical

8. Minimization of the hospital stay duration by planning patients discharge needs.

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 3 of 3

PREPARED BY: Kingdom Saudi Arabia- Ministry Of Health 2010

Central Committee Of NPP 2010

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 1 of 5

1.1. To assess the professional skill & implementation ability.

1.2. To determine the success of Nursing Care.

2.1. Performance Evaluation refers to appraisal/monitoring of staff performance according to goals

ADMINISTRATIVE POLICY AND PROCEDURE

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4.6. Annual Evaluation:

4.9. Staff Nurse is expected to complete self-evaluation as required.

4.11. Probationary Period (3-6 months)

ADMINISTRATIVE POLICY AND PROCEDURE

DUE FOR REVIEW: NUMBER OF PAGES 3 of 5

performance in the following manner :

4.17.1. Review documentation on the medical record.

4.17.3. Evaluate written care of plan

4.17.4. Listen to shift report.

4.17.5. Obtain feedback from other staff/ preceptor (if applicable)

CRITERIA FOR EVALUATION

ADMINISTRATIVE POLICY AND PROCEDURE