Frequently Asked Questions

National Accreditation Board for Hospital and Healthcare Organizations

1.What is NABH?
National Accreditation Board for Hospitals & Healthcare Providers.
2.What is the full form of ISO?
International Organization of Standardization
3.NABL stands for?
National Accreditation Board of Testing & Calibration Laboratories
4.What is our mission and vision statement?
Mission To be added
Vision To be added
Core Values to be added
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5. Name the patient identifiers?
MRN (As per NABH Norms Medical Record Number)
6. What Is Code Blue?
CPR (Cardio Pulmonary Resuscitation)
7. What Is Code Red?
Fire
8. What Is Code For Internal Disaster?
Code Grey
9. What Is Code Pink?
Baby Missing
10. What is Code Purple?
For Grievance / Disciplinary Action Likelihood of physical altercation (Fight Likely)
11. What is the time frame within which a medical record of discharge patient should reach
Medical Record Department?
48 hrs
12. What is the retention period for a MLC file and in case of Death?
Up to Case Pending for MLC and up to 20 yrs for Death.
13. What is the retention period for a normal file in medical records?
3 yrs for OPD and 5 yrs for IPD (as per MCI Guidelines)
14. What is the validity period of a signed consent?
30 Days
15. Who are vulnerable patients?
Patients < 12, >65, physically challenged, Patients who cannot perform
ADLs (Activities of Daily Livings), ICU Patients
16. State three measures to ensure patients right to confidentiality?
Covering the patient during transport,
Knocking before entering patient room,
Refraining from discussing patient related information publically
17. Who identifies the patient needs and how?
Nurses identify patients physical, psychological, social, cultural, and
Spiritual status in Nursing Admission Assessment form.
18. How to store a high-risk medicine? Name few?
Under single lock. conc. Kcl, conc NaCl, Midazolam, Diazepam, Pentazocine,
Tramadol, Codeine, Serenace (haloperidol) etc.

19. What is ADR? How is it identified and reported?

Adverse drug reaction. unwanted, unintended at therapeutic doses occurs within a
specified time of drug administration , reported on a ADR form send form to
pharmacologist
20. What is hospital drug formulary?
Booklet with list of drugs in generic, brand names, strengths and dosage
forms available in hospital stock. reviewed in every month PTC
(Pharmacy & Therapeutic Committee) meeting for addition of any new
drug
21. What is PPE? Name few components?
Personal Protective Equipments. Gum boots, goggles, mask.
22. When is discharge planning initiated?
At admission
23. What goes in yellow, red, blue and black bags?
Colour
Waste description
Disposal method
Yellow
Human Tissue
Incineration
Red
Plastics
Autoclaving
Blue
Sharps
Disinfection
Black
Kitchen Waste
Direct disposal
24. What should be the temp of refrigerator in which medication is stored?
20 to 80 C
25. What do you do if you get needle stick?
Wash the area under running water.
Inform the nurse in charge
Report to Triage,
Ensure the incident form is filled.
26. What is a Sentinel Event? List down 4 sentinel events?
Any unexpected occurrence involving death or serious physical or psychological injury,
or the risk thereof. Serious injuries specifically include loss of limb or function(s).
Patient/resident suicide
Restraint death
Patient death due to fall
Blood transfusion death
Amputation of wrong limb
Medication error-related death
27. Elucidate six international patient safety goals?
Improve accuracy of patient identification
Improve effectiveness of communication among caregivers
Improve safety of high alert medication
Eliminate wrong site, wrong patient wrong procedure surgery
Reduce the risk of health care acquired infection
Reduce risk of harm resulting from patient fall
28. What are the seven elements of facility safety?
Risk Management
Security Management
Hazardous materials and waste Management
Emergency Management
Fire Safety
Medical Equipment Management
Utilities Management
29. Why is patient and family education important?

To facilitate patient /family in participation of care being provided

30. What would you do in case of fire?
RACE Rescue, Alarm, Confine the fire, Extinguish/ Evacuate if trained to do so.
31. How many fire zones we have?
To be added
32. Name two radiation safety devices?
TLD badges
Lead aprons
33. What are the seven Rs of drug administration?
Right patient
Right drug
Right dose
Right time
Right method
Right purpose
Right documentation
34. What are the Patient Rights?
Right to Privacy and COnfidentiality
Right to Security
Right to Refusal of Treatment
Right to Information
Right to Consents
Right to Transfer and Continuity of Care
35. Who is the discharge coordinator of the hospital?
To be added
36. The patient and their family members are educated about what?
Education about proposed care
Education about expected results
Education about possible complications
Education about expected cost
37. Who can perform the initial assessment to patient at the time of admission?
Concerned Consultant, Resident Doctor, Nurses
38. Lab and Diagnostics Quality Assurance Program Includes what?
Addresses validation/verification of method
Surveillance of Test Methods
Periodic calibration/Maintenance
Corrective and Preventive Action
39. What is the full form of BMWM and which statutory requirement is applicable to
hospital?
Bio-Medical Waste Management, Bio-Medical Management handling Rules, 1998
under Environment Protection Act.
40. What are the various types of summaries provided by the hospital to admitted patient?
Discharge Summary, Death Summary, Transfer Summary, LAMA Summary
41. What do you mean by MLC and LAMA?
MLC Medico Legal Cases, LAMA Left against medical advice
42. What are timeframe of countersigning the patient care plan by phyician I/c?
Within 24 hours
43. What are NABH accreditation standards for hospitals?
The standards for hospitals have been drafted by the Technical Committee of NABH
and contain complete set of standards for evaluation of hospitals for grant of

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accreditation. The organization is evaluated against 100 standards and 503 objective
elements contained in 10 chapters.
Is NABH accreditation a one-time phenomenon?
NABH accreditation is not a one-time phenomenon. Once the hospital gets accredited,
accreditation shall be valid for a period of 3 years. NABH conducts an annual
surveillance of the accredited hospitals. The surveillance visit will be planned during the
2nd year. Hospital shall apply for renewal of accreditation to NABH at least 6 months
before expiry of validity of accreditation for which reassessment shall be conducted.
What is class A fire?
On paper, wood and linen
What is class B fire?
Spreads with Oil, Grease
On what temperature smoke detector should activate?
68 deg centi
The term HAZMAT Stands for what?
Hazardous Material
How many fire exits are there at 1st Floor?
5
What is HICC and who is the chairperson of the HICC?
Hospital Infection Control Committee, Dr. RA Bhujwala
Name Natural Disasters and Manmade Disasters?

52. How many types of fire extinguishers are there in the institute?
ABC, BC, C/ CO2, Water Type.
53. What are the three hazards for BMW?
Air Pollution, Water Pollution, Land Pollution
54. Which international institutes guidelines, we are following when we are providing
diabetes care to our patients?
American Diabetes Association, International Diabetes Federation (Europe).
55. What is Class D Fire?
Metal
56. For class B fire which extinguisher you will use?
ABC and BC
57. Name the acronym for operating fire extinguisher?
PASS
58. PASS stands for what?
P Pull the pin,
A Aim the fire,
S Squeeze the handle,
S Sweep for fire
59. Name any two priorities while fighting fire?
Protection of life, Prevent spread of hazard, save assets and eliminate the hazard.
60. Name fire fighting equipments?

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Portable extinguisher, Hose reel, fire hose, fire pump, fire hydrants, fire drums, fire
buckets and fire suits.
Name elements for fire detection?
Alarm Panel, Smoke detector, Heat detector and Sprinkler System
Name fire classification?
A, B, C, D
FIRE Triangle consist of
Oxygen, Heat and Material/Fuel
What you should do when you catch fire?
Stop Drop and Roll.
What is ACLS and BCLS stands for?
Advance Cardiac Life Support and Basic Cardiac Life Support
Name the committees?
Waste Management Committee
Fire Safety Committee
Radiation Safety Committee
Lab Safety Committee
Patient Safety Committee
Mortality Review Committee
Medical Audit and Multidisciplinary Committee
Hospital Infection Control Committee
Quality Assurance Committee
Grievance Handling /Disciplinary Committee
Credential Committee
Pharmacy and Therapeutics Committee
Medical Record Committee

67. Name four phases of disaster process

Response, Recovery, Mitigation and Preparedness
68. What is procedure for destroying the needle?
Mutilation, Disinfection and Disposal
69. Name any safety measures used while handling BMW?
Gloves, Mask, Apron, Gum Boot, Goggles, Vaccination and reporting of Incident.