The Laboratory has a well-documented safety and risk assessment Programme AAC 8a

Radiation Risk evaluation before procedure AAC 11c

pre-procedure checklist available to mitigate the risk of wrong site/side, wrong patient and wrong procedure COP7d

Vulnerable patient care documented and monitored to reduce risk COP 16a,b

Obstetric services are organised and provided safely. Should define whether care for high risk obstetric cases is provided or not COP 10a

Facilities to take care of high-risk obstetric cases. COP 10b,g

Persons caring for high-risk obstetric cases are competent COP 10c

The organisation has an ethics committee to oversee all research activities. ROM 2b

Organization identifies the list of high-risk medication and every order is verified by an appropriate person so as to ensure accuracy of the dose, frequency and route of administration MOM5,3

Informed consent includes information regarding the procedure; it's risks, benefits, alternatives. PRE 4c

The organization has well established procedure for reducing/eliminating infection risks to patients, visitors and providers of care. HIC 1

Organisation identifies various different disinfectants being used in patient care units and are monitored, dilution protocols are established, and its usage in the appropriate situation is complied with. Risks and hazards due to usage of disinfectants are identified and staff is aware of these risks and hazards. HIC 4c

The organisation adheres to kitchen sanitation and food-handling standard protocols HIC 4f

The organisation has appropriate engineering controls to prevent infections HIC 4a

The organisation adheres to housekeeping procedures HIC 4f

The organisation performs surveillance activities to capture and monitor infection prevention and control data. HIC 6

There is a structured quality improvement and continuous monitoring PSQ 2

programme in the organisation. PSQ 2

Organization has a structured patient safety and risk management programme to identify the adverse events ranging from ―no harm‖ to ―sentinel events PSQ 1c

Performance of the KPIs are closely monitored and the necessary RCA, CAPA are being taken and the areas concerned are communicated PSQ 3

Leaders ensure that patient-safety and risk-management issues are an integral part of patient care and hospital management ROM 5

Those responsible for governance support safety initiatives and quality improvement plans. ROM 1

The functioning of committees is reviewed for their effectiveness. ROM 4d

Management provides resources for proactive risk assessment and risk reduction activities ROM 5

Organisation conducts an exercise of Hazard Identification and Risk Analysis (HIRA) in both clinical & non clinical area and accordingly takes all necessary steps to eliminate or reduce such hazards and associated risks PSQ 1

Sufficient back up are provided in critical areas like, equipments, water, gases and electricity FMS 2

Staff are trained on the risks within the organisation‘s environment. HRM 6