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[]
[null,null,null,null,"--------------------------------------- "]
[1,null,"Done",null,"Afghanistan",null,null,1]
[0.5,null,"On Process",null,"Bahrain",null,null,0.75]
[0,null,"Late",null,"Djibouti",null,null,0.5]
["NA",null,"Not Started",null,"Egypt",null,null,0.25]
[null,null,null,null,"Iraq",null,null,0]
[null,null,null,null,"Islamic Republic of Iran",null,null,"NA"]
[null,null,null,null,"Jordan"]
[null,null,null,null,"Kuwait"]
[null,null,null,null,"Morocco"]
[null,null,null,null,"Occupied Palestinian territory"]
[null,null,null,null,"Oman"]
[null,null,null,null,"Pakistan"]
[null,null,null,null,"Qatar"]
[null,null,null,null,"Saudi Arabia"]
[null,null,null,null,"Somalia"]
[null,null,null,null,"South Sudan"]
[null,null,null,null,"Sudan"]
[null,null,null,null,"Tunisia"]
[null,null,null,null,"United Arab Emirates"]
[null,null,null,null,"Yemen"]

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[]
[null,"World Health Organization EMRO"]
[null,"PATIENT SAFETY FRIENDLY HOSPITAL INITIATIVE"]
[]
[]
[null," PATIENT SAFETY FRIENDLY HOSPITAL ASSESSMENT TOOL (HAT), Version 3"]
[]
[null,"Country:",null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,"Date:",null," "]
[]
[null,"Hospital",null," "]
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[]
[null," ",null,"    All ights eseved 2016"]

{"sheet":"Document Review","index":2,"n_rows":382,"n_cols":12,"rows_kept":382,"cut":false,"hidden":false,"merged":[[1,6,1,9],[4,6,4,9]]}
[]
[null," ",null,null,null," ","PATIENT SAFETY FRIENDLY HOSPITAL INITIATIVE - WORLD HEALTH ORGANIZATION (EMRO)"]
[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null," ",null,null,null," ","Document Review ",null,null,null," ","Date:"]
[null,null,null,null,null,null,"Hospital:",{"$f":"MAIN!$D$10","v":" "}]
[]
[]
[null,null,"Category","Domain","Category","Type","Standard no.","Requested document","Score","Comment","Recommendation"]
[null,null,"Critical","Domain A",null,"Administrator","A.1.1.1","Document demonstrating patient safety strategy and/or hospital  strategy"]
[null,null,"Critical","Domain A",null,"Administrator","A.1.1.3","Stratified random samples of patient safety executive walk  reports"]
[null,null,"Core","Domain A",null,"Administrator","A.1.2.2","Code of ethics, for example, in relation to research, resuscitation, consent and confidentiality"]
[null,null,"Core","Domain A",null,"Administrator","A.1.2.2","Reports including monitoring of compliance with code of ethics"]
[null,null,"Core","Domain A",null,"Administrator","A.1.2.2","Policies and procedures for implementing the code of  ethics"]
[null,null,"Core","Domain A",null,"Administrator","A.2.2.1","Organizational structure of the hospital"]
[null,null,"Core","Domain A",null,"Administrator","A.5.2.5","Occupational health records for all staff"]
[null,null,"Core","Domain A",null,"Administrator","A.5.2.5","Occupational health policies and procedures"]
[null,null,"Developmental","Domain A",null,"Administrator","A.5.3.1","Workplace violence prevention programme policies and procedures"]
[null,null,"Core","Domain A",null,"Administrator","A.6.2.1","Policies and procedures for all departments and services"]
[null,null,"Core","Domain B",null,"Administrator","B.1.2.1","Written and approved patient and family rights  statement"]
[null,null,"Core","Domain B",null,"Administrator","B.1.2.2","Written and approved patient and family rights statement in which patient safety is incorporated"]
[null,null,"Core","Domain B",null,"Administrator","B.1.2.2","Patient safety rights policies and procedures"]
[null,null,"Developmental","Domain B",null,"Administrator","B.3.3.1","Documents explaining bar coding with check digits to ensure proper patient identification"]
[null,null,"Core","Domain B",null,"Administrator","B.6.2.1","Satisfaction surveys, leadership walk rounds, focus groups, complaint letters, safety hotline, staff feedback, suggestion box and community focus  groups"]
[null,null,"Core","Domain B",null,"Administrator","B.7.2.2","Reports on entertainment for patients"]
[null,null,"Core","Domain B",null,"Administrator","B.7.2.3","Reports on patients’ spiritual and religious needs"]
[null,null,"Core","Domain B",null,"Administrator","B.7.2.3","Patient satisfaction reports"]
[null,null,"Core","Domain C",null,"Administrator","C.1.2.7","Policies and procedures for effective communication"]
[null,null,"Core","Domain C",null,"Administrator","C.1.2.8","Policies and procedures for handover of patients"]
[null,null,"Core","Domain C",null,"Administrator","C.2.2.7","Staff health records"]
[null,null,"Core","Domain C",null,"Administrator","C.4.2.1","Safe injection policies and procedures"]
[null,null,"Critical","Domain C",null,"Blood bank","C.3.1.1","Guidelines, including WHO guidelines, on safe blood and blood  products"]
[null,null,"Critical","Domain C",null,"Blood bank","C.3.1.2","Policies and procedures for safe pre-transfusion procedures, including for recruitment, selection and retention of voluntary blood donors, and blood screening (e.g. HIV and hepatitis B and C viruses)"]
[null,null,"Core","Domain C",null,"Blood bank","C.3.2.1","Policies and procedures for cross-matching of blood  samples"]
[null,null,"Core","Domain C",null,"Blood bank","C.3.2.2","Policies and procedures for management of post-blood transfusion  incidents"]
[null,null,"Developmental","Domain C",null,"Blood bank","C.3.3.1","Clinical practices that reduce blood loss and the need for blood  transfusion"]
[null,null,"Developmental","Domain C",null,"Blood bank","C.3.3.2","Guidelines on safe and appropriate prescribing of blood and blood products, including the use of alternative fluids"]
[null,null,"Critical","Domain A",null,"Clinical","A.2.1.1","Morbidity and mortality committee or equivalent terms of  reference"]
[null,null,"Critical","Domain A",null,"Clinical","A.2.1.1","Morbidity and mortality committee or equivalent minutes of  meetings"]
[null,null,"Core","Domain A",null,"Clinical","A.5.2.1","Duty rosters for clinical staff"]
[null,null,"Core","Domain A",null,"Clinical","A.5.2.1","Policies and procedures for clinical staffing levels"]
[null,null,"Critical","Domain B",null,"Clinical","B.2.1.1","Policies and procedures for informed consent"]
[null,null,"Critical","Domain B",null,"Clinical","B.2.1.1","List of procedures for which informed consent is required, including but not limited to: invasive procedures, surgical procedures, anaesthesia, blood transfusion, high- risk procedures, high-risk treatments, and organ donation and  transplantation"]
[null,null,"Critical","Domain B",null,"Clinical","B.2.1.1","Educational material used, including flyers, literature and lecture notes"]
[null,null,"Core","Domain B",null,"Clinical","B.2.2.1","Policies and procedures for health education on specific health issues and patient safety"]
[null,null,"Core","Domain B",null,"Clinical","B.2.2.1","Minutes of last three disease-specific support group meetings and their signatures of attendance"]
[null,null,"Core","Domain B",null,"Clinical","B.2.2.2.","Policies and procedures for complete updated information on patients’ diagnosis and treatment"]
[null,null,"Core","Domain B",null,"Clinical","B.2.2.3","Policies and procedures for patient carers’ training on post-discharge  care"]
[null,null,"Developmental","Domain B",null,"Clinical","B.2.3.1","Policies and procedures for patients’ participation in planning and making decisions regarding their health care"]
[null,null,"Developmental","Domain B",null,"Clinical","B.2.3.2","Health education material"]
[null,null,"Developmental","Domain B",null,"Clinical","B.2.3.2","Patient safety education material"]
[null,null,"Critical","Domain B",null,"Clinical","B.3.1.1","Policies and procedures for patient identification and  verification"]
[null,null,"Critical","Domain B",null,"Clinical","B.3.1.1.","Policies and procedures for patient identification and verification, with special emphasis on high-risk groups such as newborn babies, patients in coma, and senile patients"]
[null,null,"Critical","Domain B",null,"Clinical","B.3.1.1.","List of high-risk procedures"]
[null,null,"Core","Domain B",null,"Clinical","B.3.2.1","A system in place to identify allergies, e.g. a colour-coding system"]
[null,null,"Core","Domain B",null,"Clinical","B.3.2.1","Policies and procedures for identification of allergies"]
[null,null,"Core","Domain B",null,"Clinical","B.7.2.4","End-of-life policies and procedures"]
[null,null,"Critical","Domain C",null,"Clinical","C.1.1.1","List of urgent critical diagnostic results developed by multispecialty   committee"]
[null,null,"Critical","Domain C",null,"Clinical","C.1.1.1","Policies and procedures for channels of communication for urgent critical  results"]
[null,null,"Critical","Domain C",null,"Clinical","C.1.1.2","Surgical safety checklist used in operating rooms for every surgical procedure"]
[null,null,"Critical","Domain C",null,"Clinical","C.1.1.3","Policies and procedures for systems for recognition and response to clinical deterioration"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.1","Clinical practice guidelines based on at least the top five diagnoses and top five high-risk diseases, including WHO guidelines where available"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.10","Policies and procedures to reduce risk of falls"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.2","Policies and procedures in place to ensure safe communication of pending test results to patients and care providers after discharge"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.3","Guidelines for top five invasive diagnostic procedures"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.4","Guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary embolism)"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.5","Policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.6","List of approved abbreviations of medical terms"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.6","List of dangerous abbreviations, symbols and dose designations that are prohibited for use in hospitals"]
[null,null,"Core","Domain C",null,"Clinical","C.1.2.9","Safe childbirth guidelines"]
[null,null,"Developmental","Domain C",null,"Clinical","C.1.3.1","Clinical guidelines committee notification  letter"]
[null,null,"Developmental","Domain C",null,"Clinical","C.1.3.1","Clinical guidelines committee terms of reference"]
[null,null,"Developmental","Domain C",null,"Clinical","C.1.3.1","Clinical guidelines committee minutes of meetings"]
[null,null,"Developmental","Domain C",null,"Clinical","C.1.3.1","Clinical guidelines"]
[null,null,"Core","Domain C",null,"Clinical","C.5.2.4","Policies and procedures for patient (or carer) education about medication at discharge policy and procedure"]
[null,null,"Core","Domain D",null,"Clinical","D.1.2.10","Radiation safety policies and procedures"]
[null,null,"Developmental","Domain E",null,"Clinical","E.2.3.1","Terms of reference for medical staff or other committee"]
[null,null,"Developmental","Domain E",null,"Clinical","E.2.3.1","Minutes of meetings of medical staff or other  committee"]
[null,null,"Critical","Domain A",null,"FMS","A.4.1.1","Lists of essential functioning equipment"]
[null,null,"Core","Domain A",null,"FMS","A.4.2.1","Reports/records of preventive equipment maintenance"]
[null,null,"Core","Domain A",null,"FMS","A.4.2.1","Policies and procedures for preventive equipment maintenance"]
[null,null,"Core","Domain A",null,"FMS","A.4.2.2","Policies and procedures for corrective equipment maintenance"]
[null,null,"Core","Domain A",null,"FMS","A.4.2.2","Records of corrective equipment maintenance"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.1","Notification letter for the multidisciplinary environmental safety  committee"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.1","Terms of reference of the multidisciplinary environmental safety committee"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.1","Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.11","Policies and procedures for warning signs"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.12","Policies and procedures for appropriate and safe food and drinks for patients, staff and visitors"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.12","Policies and procedures for safe kitchen programmes"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.12","Special diets according to disease and patient  needs"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.12","Employee screening and health certificates"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.13","Housekeeping policies and procedures"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.14","Smoke-free policy"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.2","Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.2","Building blueprints"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.3","Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.3","Records of preventive maintenance programme for physical environment"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.3","Policies and procedures for building safety"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.4","Security policies and procedures"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.5","Policies and procedures for staff wearing identification, including a visible name badge and appropriate uniform"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.6","External emergency plan"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.7","Internal emergency plan"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.8","Fire and smoke safety policies and procedures"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.9","Utility systems plan"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.9","Policies and procedures for preventive maintenance of utility systems"]
[null,null,"Core","Domain D",null,"FMS","D.1.2.9","Backup plan for utility systems in case of failure or  interruption"]
[null,null,"Critical","Domain D",null,"FMS","D.2.1.1","Policies and procedures for waste segregation according to hazard level (see guidelines) and colour coding it"]
[null,null,"Critical","Domain D",null,"FMS","D.2.1.2","Guidelines (including WHO guidelines) on management of sharps waste"]
[null,null,"Core","Domain D",null,"FMS","D.2.2.1","Guidelines (including WHO guidelines) on safe management of waste from healthcare activities"]
[null,null,"Core","Domain D",null,"FMS","D.2.2.2","Guidelines (including WHO guidelines) on management of biological waste"]
[null,null,"Core","Domain D",null,"FMS","D.2.2.3","Guidelines (including WHO guidelines) on management of chemical waste"]
[null,null,"Core","Domain D",null,"FMS","D.2.2.4","Guidelines (including WHO guidelines) on management of radiological waste"]
[null,null,"Core","Domain A",null,"Human resources","A.1.2.2","Training records of staff trained in policies and procedures for implementing the code of ethics"]
[null,null,"Core","Domain A",null,"Human resources","A.4.2.1","Training records of staff trained in policies and procedures for preventive equipment maintenance"]
[null,null,"Core","Domain A",null,"Human resources","A.4.2.2","Training records of staff trained in policies and procedures for corrective equipment maintenance"]
[null,null,"Developmental","Domain A",null,"Human resources","A.4.3.1","Training records of staff trained in use of all infusion  pumps"]
[null,null,"Critical","Domain A",null,"Human resources","A.5.1.1","Policies and procedures for staff qualifications and licences"]
[null,null,"Critical","Domain A",null,"Human resources","A.5.1.1","Training records of staff trained in policies and procedures for staff qualifications and licences"]
[null,null,"Critical","Domain A",null,"Human resources","A.5.1.1","Personnel files with evidence of staff qualifications and licences (registration to practice within appropriate  body)"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.1","Training records of staff trained in policies and procedures for clinical staffing  levels"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.2","Duty rosters for nonclinical support  staff"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.2","Policies and procedures for nonclinical support  staff"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.2","Training records of staff trained in policies and procedures for nonclinical support staff"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.3","Policies and procedures for sufficient rest breaks to practise safely"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.3","Training records of staff trained in policies and procedures for sufficient rest breaks to practice safely"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.4","Policies and procedures for students and trainees working within their competencies and under appropriate supervision"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.4","Training records of staff trained in policies and procedures for students and trainees working within their competencies and under appropriate  supervision"]
[null,null,"Core","Domain A",null,"Human resources","A.5.2.5","Training records of staff trained in occupational health policies and  procedures"]
[null,null,"Developmental","Domain A",null,"Human resources","A.5.3.1","Training records of staff trained in workplace violence prevention programme policies and procedures"]
[null,null,"Core","Domain A",null,"Human resources","A.6.2.1","Training records of staff trained in departmental and/or services policies and procedures"]
[null,null,"Core","Domain B",null,"Human resources","B.1.2.3","Training records of staff trained in patient and family rights policies and  procedures"]
[null,null,"Critical","Domain B",null,"Human resources","B.2.1.1","Training records of staff trained in informed consent policies and  procedures"]
[null,null,"Core","Domain B",null,"Human resources","B.2.2.1","Training records of staff trained in policies and procedures for health  education"]
[null,null,"Core","Domain B",null,"Human resources","B.2.2.2","Training records of staff trained in policies and procedures for complete updated information on patients’ diagnosis and  treatment"]
[null,null,"Core","Domain B",null,"Human resources","B.2.2.3","Training records of staff trained in policies and procedures for training patients’ carers in post-discharge care"]
[null,null,"Developmental","Domain B",null,"Human resources","B.2.3.1","Training records of staff trained in policies and procedures to encourage patients to participate in planning and making decisions regarding their health  care"]
[null,null,"Critical","Domain B",null,"Human resources","B.3.1.1","Training records of staff trained in policies and procedures for patient identification and verification"]
[null,null,"Core","Domain B",null,"Human resources","B.3.2.1","Training records of staff trained in policies and procedures for identification of allergies"]
[null,null,"Developmental","Domain B",null,"Human resources","B.4.3.1","Training records of staff trained in community involvement policies and  procedures"]
[null,null,"Developmental","Domain B",null,"Human resources","B.5.3.1","Training records of staff trained in disclosure policies and  procedures"]
[null,null,"Developmental","Domain B",null,"Human resources","B.5.3.2","Health care mediator training records"]
[null,null,"Developmental","Domain B",null,"Human resources","B.6.3.1","Training records of staff trained in policies and procedures for patient engagement for patient safety"]
[null,null,"Core","Domain B",null,"Human resources","B.7.2.1","Training material for staff to be supportive and deal with patients’  anxieties"]
[null,null,"Core","Domain B",null,"Human resources","B.7.2.4","Training records of staff trained in relevant policies and procedures for end-of-life care"]
[null,null,"Critical","Domain C",null,"Human resources","C.1.1.1","Training records of staff trained in policies and procedures for channels of communication for urgent critical  results"]
[null,null,"Critical","Domain C",null,"Human resources","C.1.1.2","Training records of staff trained in surgical safety guidelines"]
[null,null,"Critical","Domain C",null,"Human resources","C.1.1.3","Training records of staff trained in policies and procedures for systems for recognition and response to clinical  deterioration"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.1","Training records of staff trained in selected clinical practice  guidelines"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.10","Training records of staff trained in policies and procedures to reduce risk of  falls"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.2","Training records of staff trained in policies and procedures for safe communication of pending test results to patients and care providers after  discharge"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.3","Training records of staff trained in invasive diagnostic procedures guidelines"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.4","Training records of staff trained in guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary embolism)"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.5","Training records of staff trained in policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.6","Training records of staff trained in application of lists of approved abbreviations of medical terms and lists of dangerous abbreviations, symbols and dose designations that are prohibited for use in hospital"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.7","Training records of staff trained in policies and procedures for effective communication"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.8","Training records of staff trained in policies and procedures for handover of  patients"]
[null,null,"Core","Domain C",null,"Human resources","C.1.2.9","Training records of staff trained in safe childbirth  guidelines"]
[null,null,"Critical","Domain C",null,"Human resources","C.2.1.1","Training records of staff trained in infection prevention and control policies and procedures"]
[null,null,"Critical","Domain C",null,"Human resources","C.2.1.2","Training records of staff trained in policies and procedures for cleaning, disinfection and sterilization of equipment"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.1","Training records of staff trained in infection prevention and control  guidelines"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.2","Training records of staff trained in policies and procedures for infection prevention and control equipment and supplies"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.3","Training records of staff trained in policies and procedures for surveillance system for health care-associated infections"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.4","Training records of staff trained in isolation protocols policies and  procedures"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.5","Training records of staff trained in policies and procedures for rational use of antibiotics and antimicrobial  stewardship"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.6","Training records of staff trained in hand hygiene guidelines"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.7","Training records of staff trained in staff screening policies and  procedures"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.8","Training records of staff trained in policies and procedures for protection of staff and volunteers from healthcare-associated infections"]
[null,null,"Core","Domain C",null,"Human resources","C.2.2.9","Training records of staff trained in bundle management"]
[null,null,"Critical","Domain C",null,"Human resources","C.3.1.1","Training records of staff trained in guidelines for safe blood and blood  products"]
[null,null,"Critical","Domain C",null,"Human resources","C.3.1.2","Training records of staff trained in policies and procedures for safe pre-transfusion procedures"]
[null,null,"Core","Domain C",null,"Human resources","C.3.2.1","Training records of staff trained in policies and procedures for cross-matching of blood groups"]
[null,null,"Core","Domain C",null,"Human resources","C.3.2.2","Training records of staff trained in policies and procedures for post-blood transfusion incident management"]
[null,null,"Developmental","Domain C",null,"Human resources","C.3.3.1","Training records of staff trained in guidelines for clinical practices that reduce blood loss and the need for blood transfusion"]
[null,null,"Developmental","Domain C",null,"Human resources","C.3.3.2","Training records of staff trained in guidelines for safe and appropriate prescribing of blood and blood products, including the use of alternative   fluids"]
[null,null,"Core","Domain C",null,"Human resources","C.4.2.1","Training records of staff trained in safe injection policies and  procedures"]
[null,null,"Critical","Domain C",null,"Human resources","C.5.1.1","Training records of staff trained in policies and procedures for life-saving  medications"]
[null,null,"Critical","Domain C",null,"Human resources","C.5.1.2","Training records of staff trained in policies and procedures for removal of high concentrations of electrolytes and storage in a safe place"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.1","Training records of staff trained in safe medication policies and  procedures"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.2","Training records of staff trained in policies and procedures to ensure legible handwriting when prescribing or writing physicians’  orders"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.3","Training records of staff trained in policies and procedures for medication reconciliation"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.4","Training records of staff trained in policies and procedures for patient (or carer) education about medication at  discharge"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.5","Training records of staff trained in policies and procedures to standardize and limit the number of medication  concentrations"]
[null,null,"Core","Domain C",null,"Human resources","C.5.2.6","Training records of staff trained in pain management policies and  procedure"]
[null,null,"Developmental","Domain C",null,"Human resources","C.5.3.1","Training records of staff trained in clinical pharmacy policies and  procedures"]
[null,null,"Developmental","Domain C",null,"Human resources","C.5.3.2","Training records of staff trained in policy and procedures to manage medication errors"]
[null,null,"Core","Domain C",null,"Human resources","C.6.2.1","Training records of staff trained in medical records archiving system policies and procedures"]
[null,null,"Core","Domain C",null,"Human resources","C.6.2.2","Training records of staff trained in policies and procedures for single completed medical records"]
[null,null,"Core","Domain C",null,"Human resources","C.6.2.3","Training records of staff trained in policies and procedures for standardized codes for diseases"]
[null,null,"Core","Domain C",null,"Human resources","C.6.2.4","Training records of staff trained in medical records access policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.10","Training records of staff trained in radiation safety policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.11","Training records of staff trained in policies and procedures for warning  signs"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.12","Training records of staff trained in relevant policies and procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.13","Training records of staff trained in housekeeping policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.14","Training records of staff trained in smoke-free policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.3","Training records of staff trained in physical environment policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.4","Training records of staff trained in security policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.5","Training records of staff trained in staff identification policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.8","Training records of staff trained in fire and smoke safety policies and  procedures"]
[null,null,"Core","Domain D",null,"Human resources","D.1.2.9","Training of staff in policies and procedures for utility system  plans"]
[null,null,"Critical","Domain D",null,"Human resources","D.2.1.1","Training records of staff trained in policies and procedures for waste  segregation"]
[null,null,"Critical","Domain D",null,"Human resources","D.2.1.2","Training records of staff trained in guidelines for management of sharps  waste"]
[null,null,"Core","Domain D",null,"Human resources","D.2.2.1","Training records of staff trained in guidelines for safe waste management"]
[null,null,"Core","Domain D",null,"Human resources","D.2.2.2","Training records of staff trained in guidelines for biological waste  management"]
[null,null,"Core","Domain D",null,"Human resources","D.2.2.3","Training records of staff trained in guidelines for chemical waste management"]
[null,null,"Core","Domain D",null,"Human resources","D.2.2.4","Training records of staff trained in guidelines for radiological waste  management"]
[null,null,"Core","Domain E",null,"Human resources","E.1.2.1","Training records of staff trained in patient safety during orientation  programme"]
[null,null,"Core","Domain E",null,"Human resources","E.1.2.1","Personnel files that contain evidence of orientation to patient  safety"]
[null,null,"Core","Domain E",null,"Human resources","E.1.2.2","Training records of staff trained in scientific research tools and retrospective and prospective methods to address patient safety  problems"]
[null,null,"Core","Domain E",null,"Human resources","E.1.2.2","Training records of staff trained in safe patient care practices based on their individual training needs"]
[null,null,"Developmental","Domain E",null,"Human resources","E.1.3.1","Training records of staff trained in reporting procedures for near misses, adverse events and sentinel events and steps to be taken during or after an adverse event"]
[null,null,"Developmental","Domain E",null,"Human resources","E.2.3.2","Records to verify the credentials of all health care professionals including staff received from other national, regional and international institutions"]
[null,null,"Core","Domain E",null,"Human resources","E.3.2.2","Training records of staff trained in policies and procedures for patient safety  research"]
[null,null,"Developmental","Domain E",null,"Human resources","E.3.3.2","Training records of staff trained in policies and procedures for reporting adverse events, sentinel events and near misses"]
[null,null,"Critical","Domain C",null,"IPC","C.2.1.1","Infection control organizational structure"]
[null,null,"Critical","Domain C",null,"IPC","C.2.1.1","Terms of reference and notification letter for infection prevention and control committee"]
[null,null,"Critical","Domain C",null,"IPC","C.2.1.1","Stratified random samples of minutes of infection prevention and control   committee"]
[null,null,"Critical","Domain C",null,"IPC","C.2.1.1","Infection prevention and control policies and  procedures"]
[null,null,"Critical","Domain C",null,"IPC","C.2.1.2","Policies and procedures for cleaning, disinfection and sterilization of  equipment"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.1","Recognized guidelines for infection prevention and control, including WHO guidelines"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.2","Policies and procedures for equipment and supplies for infection prevention and control"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.3","Policies and procedures for surveillance system for health care-associated infections"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.4","Isolation protocols policies and  procedures"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.5","Policies and procedures for rational use of antibiotics to reduce resistance, and antimicrobial stewardship"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.6","Recognized current guidelines for hand hygiene, including WHO guidelines"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.7","Policies and procedures for screening of staff for colonization and transmissible infections"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.8","Policies and procedures for protection of staff and volunteers from healthcare- associated infections"]
[null,null,"Core","Domain C",null,"IPC","C.2.2.9","Care bundles"]
[null,null,"Core","Domain C",null,"Medical Records","C.6.2.1","Medical records archiving system policies and  procedures"]
[null,null,"Core","Domain C",null,"Medical Records","C.6.2.2","Policies and procedures for single completed medical  records"]
[null,null,"Core","Domain C",null,"Medical Records","C.6.2.3","Policies and procedures for standardized codes for diseases"]
[null,null,"Core","Domain C",null,"Medical Records","C.6.2.4","Medical records access policies and procedures"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.1.2.2","Reports that include monitoring of compliance with code of ethics"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.3.2.1","Reports that include reviewing targets related to patient safety  goals"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.3.2.2","Performance measurement reports"]
[null,null,"Developmental","Domain A",null,"Monitoring and evaluation","A.3.3.1","Benchmark reports"]
[null,null,"Critical","Domain A",null,"Monitoring and evaluation","A.4.1.1","Reports that include measurement of compliance with availability of essential functioning equipment standards"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.4.2.1","Reports that include measuring compliance with policies and procedures for preventive equipment maintenance"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.4.2.2","Reports that include measuring compliance with policies and procedures for corrective equipment maintenance"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.4.2.3","Reports that include measuring compliance with and whether staff receive appropriate training for existing and new equipment  standards"]
[null,null,"Critical","Domain A",null,"Monitoring and evaluation","A.5.1.1","Reports that include measuring compliance with policies and procedures for staff qualifications and licences"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.5.2.1","Reports that include measuring compliance with policies and procedures for clinical staffing levels"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.5.2.2","Reports that include measuring compliance with policies and procedures for nonclinical  support staff"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.5.2.3","Reports that include measuring compliance with policies and procedures for safe practice during rest breaks"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.5.2.4","Reports that include measuring compliance with policies and procedures for students and trainees working within their competencies and under appropriate supervision"]
[null,null,"Developmental","Domain A",null,"Monitoring and evaluation","A.5.3.1","Reports that include measuring compliance with workplace violence prevention programmes policies and procedures"]
[null,null,"Core","Domain A",null,"Monitoring and evaluation","A.6.2.1","Reports that include measuring compliance with departments and/or services policies and procedures"]
[null,null,"Core","Domain B",null,"Monitoring and evaluation","B.1.2.3","Reports that include measuring compliance with policies and procedures for patient and family rights"]
[null,null,"Critical","Domain B",null,"Monitoring and evaluation","B.2.1.1","Reports that include measuring compliance with informed consent policies and procedures"]
[null,null,"Core","Domain B",null,"Monitoring and evaluation","B.2.2.1","Reports that include measuring compliance with health education policies and procedures"]
[null,null,"Core","Domain B",null,"Monitoring and evaluation","B.2.2.2","Reports that include measuring compliance with policies and procedures for complete updated information on patients’ diagnosis and  treatment"]
[null,null,"Core","Domain B",null,"Monitoring and evaluation","B.2.2.3","Reports that include measuring compliance with relevant policies and procedures for post-discharge care"]
[null,null,"Developmental","Domain B",null,"Monitoring and evaluation","B.2.3.1","Reports that include measuring compliance with policies and procedures for patients’ participation in planning and making decisions regarding their health  care"]
[null,null,"Critical","Domain B",null,"Monitoring and evaluation","B.3.1.1","Reports that measure compliance with policies and procedures for patient identification and verification"]
[null,null,"Core","Domain B",null,"Monitoring and evaluation","B.3.2.1","Documents or reports that measure compliance with policies and procedures for identification of allergies"]
[null,null,"Developmental","Domain B",null,"Monitoring and evaluation","B.4.3.1","Reports that include measuring compliance with policies and procedures for community involvement"]
[null,null,"Developmental","Domain B",null,"Monitoring and evaluation","B.5.3.1","Reports that measure compliance with disclosure policies and  procedures"]
[null,null,"Developmental","Domain B",null,"Monitoring and evaluation","B.6.3.1","Reports that include measuring compliance with policies and procedures for patient engagement for patient safety"]
[null,null,"Developmental","Domain B",null,"Monitoring and evaluation","B.6.3.1","Reports or minutes of meetings that include engagement of patients and their carers in setting polices and suggesting quality improvement and patient safety  projects"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.1.1.1","Stratified random sample of reports that include measuring compliance with policies and procedures for channels of communication for urgent critical  results"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.1.1.2","Reports that include measuring compliance with surgical safety  guidelines"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.1.1.3","Reports that include measuring compliance with policies and procedures for systems for recognition of and response to clinical  deterioration"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.1","Reports that include measuring compliance with selected clinical practice   guidelines"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.10","Reports that include measuring compliance with policies and procedures to reduce risk of falls"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.2","Reports that include measuring compliance with policies and procedures for safe communication of pending test results to patients and care providers after  discharge"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.3","Reports that include measuring compliance with guidelines for invasive diagnostic procedures"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.4","Reports that include measuring compliance with guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary  embolism)"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.5","Reports that include measuring compliance with policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.6","Reports that include measuring compliance with lists of approved abbreviations of medical terms, and lists of dangerous abbreviations, symbols and dose designations that are prohibited in hospitals"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.7","Reports that include measuring compliance with policies and procedures for effective communication"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.8","Reports that include measuring compliance with policies and procedures for handover of patients"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.1.2.9","Reports that include measuring compliance with safe childbirth  guidelines"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.2.1.1","Reports that include measuring compliance with infection prevention and control policies and procedures"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.2.1.2","Reports that include measuring compliance with policies and procedures for cleaning, disinfection and sterilization of equipment"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.1","Reports that include measuring compliance with infection prevention and control guidelines"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.2","Reports that include measuring compliance with policies and procedures for equipment and supplies for infection prevention and  control"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.3","Reports that include measuring compliance with policies and procedures for surveillance systems for health care-associated infections"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.4","Reports that include measuring compliance with isolation protocols policies and procedures"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.5","Reports that include measuring compliance with policies and procedures for rational use of antibiotics and antimicrobial  stewardship"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.6","Reports that include measuring compliance with hand hygiene  guidelines"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.7","Reports that include measuring compliance with staff screening policies and procedures"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.8","Reports that include measuring compliance with policies and procedures for protection of staff and volunteers from health care-associated  infections"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.2.2.9","Reports that include measuring compliance with relevant care  bundles"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.3.1.1","Reports that include measuring compliance with guidelines for safe blood and blood products"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.3.1.2","Reports that include measuring compliance with policies and procedures for safe pre-transfusion practice"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.3.2.1","Reports that include measuring compliance with policies and procedures for cross- matching of blood groups"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.3.2.2","Reports that include measuring compliance with policies and procedures for post- blood transfusion incident management"]
[null,null,"Developmental","Domain C",null,"Monitoring and evaluation","C.3.3.1","Reports that include measuring compliance with guidelines for clinical practices that reduce blood loss and the need for blood  transfusion"]
[null,null,"Developmental","Domain C",null,"Monitoring and evaluation","C.3.3.2","Reports that include measuring compliance with guidelines on safe and appropriate prescribing of blood and blood  products"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.4.2.1","Reports that measure compliance with safe injection policies and  procedures"]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.5.1.1","Reports that include measuring compliance with policies and procedures for life- saving medications."]
[null,null,"Critical","Domain C",null,"Monitoring and evaluation","C.5.1.2","Reports that include measuring compliance with policies and procedures for removal of high concentrations of electrolytes and storage in a safe  place"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.1","Reports that include measuring compliance with safe medication policies and procedures"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.2","Reports that include measuring compliance with policies and procedures for legible handwriting when prescribing or writing physicians’  orders."]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.3","Reports that include measuring compliance with policies and procedures for medication reconciliation"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.4","Reports that include measuring compliance with policies and procedures for patient (or carer) education about medication at discharge"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.5","Reports that include measuring compliance with policies and procedures for standardizing and limiting the number of medication  concentrations"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.5.2.6","Reports that include measuring compliance with pain management policies and procedures"]
[null,null,"Developmental","Domain C",null,"Monitoring and evaluation","C.5.3.1","Reports that include measuring compliance with clinical pharmacy policies and procedures"]
[null,null,"Developmental","Domain C",null,"Monitoring and evaluation","C.5.3.2","Reports that include measuring compliance with policies and procedures for medication errors"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.6.2.1","Reports that include measuring compliance with medical records archiving system policy and procedures"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.6.2.2","Reports that include measuring compliance with policies and procedures for single completed medical records"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.6.2.3","Reports that include measuring compliance with policies and procedures for standardized codes for diseases"]
[null,null,"Core","Domain C",null,"Monitoring and evaluation","C.6.2.4","Reports that include measuring compliance with medical records access policies and procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.10","Reports that include measuring compliance with radiation safety policies and procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.11","Reports that include measuring compliance with policies and procedures for warning signs"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.12","Reports that include measuring compliance with national laws and regulations for food and drink safety"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.12","Reports that include measuring compliance with relevant policies and  procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.14","Reports that include measuring compliance with smoke-free policies and  procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.3","Reports that include measuring compliance with physical environment policies and procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.4","Reports that include measuring compliance with security policies and   procedures"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.5","Reports that include measuring compliance with policies and procedures for staff identification"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.6","Reports to measure implementation of external emergency plans"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.7","Reports to measure rehearsal of internal emergency plan implementation"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.8","Reports that include measuring compliance with policies and procedures for fire and smoke safety"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.1.2.9","Reports that include measuring compliance with utility system policies and procedures and plans"]
[null,null,"Critical","Domain D",null,"Monitoring and evaluation","D.2.1.1","Reports that include measuring compliance with policies and procedures for waste segregation"]
[null,null,"Critical","Domain D",null,"Monitoring and evaluation","D.2.1.2","Reports that include measuring compliance with guidelines for management of sharps waste"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.2.2.1","Reports that include measuring compliance with guidelines for safe waste management"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.2.2.2","Reports that include measuring compliance with guidelines for biological waste management"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.2.2.3","Reports that include measuring compliance with guidelines for chemical waste management"]
[null,null,"Core","Domain D",null,"Monitoring and evaluation","D.2.2.4","Reports that include measuring compliance with guidelines for radiological waste management"]
[null,null,"Core","Domain E",null,"Monitoring and evaluation","E.1.2.1","Reports that include measuring compliance with patient safety orientation programme"]
[null,null,"Core","Domain E",null,"Monitoring and evaluation","E.1.2.2","Reports that include measuring compliance with ongoing training for all staff to ensure safe patient care standards"]
[null,null,"Developmental","Domain E",null,"Monitoring and evaluation","E.1.3.1","Reports that include measuring compliance with standards to ensure all staff are familiar with the reporting procedures for near misses, adverse events and sentinel events and the steps to be taken during or after an adverse event"]
[null,null,"Core","Domain E",null,"Monitoring and evaluation","E.3.2.2","Reports that include measuring compliance with policies and procedures for patient safety research"]
[null,null,"Developmental","Domain E",null,"Monitoring and evaluation","E.3.3.2","Reports that include measuring compliance with policies and procedures for reporting adverse events, sentinel events and near misses"]
[null,null,"Critical","Domain A",null,"Patient safety","A.1.1.1","Patient safety self-assessment and/or external assessment reports"]
[null,null,"Critical","Domain A",null,"Patient safety","A.1.1.1","Patient safety action plan at both hospital and departmental  levels"]
[null,null,"Critical","Domain A",null,"Patient safety","A.1.1.2","Notification letter for appointment of senior patient safety staff  member"]
[null,null,"Critical","Domain A",null,"Patient safety","A.1.1.2","Terms of reference for senior patient safety staff member"]
[null,null,"Critical","Domain A",null,"Patient safety","A.1.1.3","Stratified random samples of reports showing improvements are made based on findings of patient safety executive walk rounds"]
[null,null,"Core","Domain A",null,"Patient safety","A.1.2.1","Annual budget for patient safety activities based on a detailed action  plan"]
[null,null,"Core","Domain A",null,"Patient safety","A.1.2.3","Questionnaire on staff attitude towards patient safety"]
[null,null,"Core","Domain A",null,"Patient safety","A.1.2.3","Results of staff attitudes towards patient safety culture and actions taken towards gathered data"]
[null,null,"Critical","Domain A",null,"Patient safety","A.2.1.2","Terms of reference for patient safety coordinator or equivalent"]
[null,null,"Critical","Domain A",null,"Patient safety","A.2.1.2","Notification letter for patient safety coordinator or  equivalent"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.2","At least four reports that include retrospective analyses of adverse events carried out on a yearly basis"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.2","Improvements are implemented based on recommendations of the root cause analysis"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.3","Patient safety audit reports"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.4","Terms of reference for multidisciplinary patient safety internal body or  equivalent"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.4","Minutes of meetings of multidisciplinary patient safety internal body or  equivalent"]
[null,null,"Core","Domain A",null,"Patient safety","A.2.2.5","Reports on different patient safety activities"]
[null,null,"Developmental","Domain A",null,"Patient safety","A.2.3.1","Reports on different patient safety activities, disseminated externally to Ministry of Health, WHO and/or patient safety organizations"]
[null,null,"Developmental","Domain A",null,"Patient safety","A.2.3.2","Reports of proactive patient safety improvement  projects"]
[null,null,"Core","Domain A",null,"Patient safety","A.3.2.1","Proactive risk reports may include examples from patient safety goals"]
[null,null,"Developmental","Domain A",null,"Patient safety","A.3.3.2","Benchmarking results"]
[null,null,"Developmental","Domain A",null,"Patient safety","A.3.3.2","Action plan and patient safety improvement projects  reports"]
[null,null,"Developmental","Domain A",null,"Patient safety","A.3.3.2","Lessons learnt from reports/emails about patient safety performance  measurement"]
[null,null,"Core","Domain B",null,"Patient safety","B.4.2.2","Minutes of the last three meetings and events showing community involvement"]
[null,null,"Core","Domain B",null,"Patient safety","B.4.2.2","Written information provided to community leaders about their role in patient safety improvement"]
[null,null,"Core","Domain B",null,"Patient safety","B.4.2.3","Media material to promote patient safety (e.g. press releases announcing patient safety activities)"]
[null,null,"Core","Domain B",null,"Patient safety","B.4.2.3","Marketing material to promote patient safety (e.g. press releases announcing patient safety activities)"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.4.3.1","Strategy for community involvement"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.4.3.1","Policies and procedures for community involvement"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.4.3.1","Patient safety improvement task force minutes or reports of meetings"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.5.3.2","Healthcare mediator terms of reference"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.5.3.2","Healthcare mediator notification letter"]
[null,null,"Core","Domain B",null,"Patient safety","B.6.2.2","Feedback reports of how patients’ complaints were managed and changes that have taken place to prevent recurrence of the complaints"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.6.3.1","Strategies for patient and community empowerment and engagement for patient safety"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.6.3.1","Policies and procedures for patient and community empowerment and engagement for patient safety"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.6.3.2","Chat/message board for patients and their carers to express their concerns and share successful solutions"]
[null,null,"Developmental","Domain B",null,"Patient safety","B.6.3.3","Information on patient safety, health literacy and patient  well-being"]
[null,null,"Core","Domain E",null,"Patient safety","E.1.2.1","Patient safety orientation programme"]
[null,null,"Developmental","Domain E",null,"Patient safety","E.3.2.1","WHO cross-sectional studies to assess the magnitude and nature of adverse events to ensure safer care"]
[null,null,"Core","Domain E",null,"Patient safety","E.3.2.2","Policies and procedures for patient safety research"]
[null,null,"Core","Domain E",null,"Patient safety","E.3.2.2","Minutes of meetings of patient safety internal body or relevant  committee"]
[null,null,"Developmental","Domain E",null,"Patient safety","E.3.3.1","Prospective studies and reports to assess the magnitude and nature of adverse events to ensure safer care, conducted on a regular basis"]
[null,null,"Developmental","Domain E",null,"Patient safety","E.3.3.2","Policies and procedures to report adverse events, sentinel events and near misses"]
[null,null,"Developmental","Domain E",null,"Patient safety","E.3.3.2","Investigation of events to learn from the event, prevent its recurrence and improve patient safety"]
[null,null,"Critical","Domain C",null,"Pharmacy","C.5.1.1","Life-saving medications based on needs of each  department"]
[null,null,"Critical","Domain C",null,"Pharmacy","C.5.1.1","Policies and procedures for life-saving medications"]
[null,null,"Critical","Domain C",null,"Pharmacy","C.5.1.2","Policies and procedures for removal of high concentrations of electrolytes from inpatient departments and storage in a safe place"]
[null,null,"Core","Domain C",null,"Pharmacy","C.5.2.1","Safe medication policies and procedures"]
[null,null,"Core","Domain C",null,"Pharmacy","C.5.2.2","Policies and procedures for legible handwriting when prescribing or writing physicians’ orders"]
[null,null,"Core","Domain C",null,"Pharmacy","C.5.2.3","Standard operating practice for medication  reconciliation"]
[null,null,"Core","Domain C",null,"Pharmacy","C.5.2.5","Policies and procedures for standardizing and limiting the number of medication concentrations"]
[null,null,"Core","Domain C",null,"Pharmacy","C.5.2.6","Pain management policies and procedures"]
[null,null,"Developmental","Domain C",null,"Pharmacy","C.5.3.1","Clinical pharmacy policies and procedures"]
[null,null,"Developmental","Domain C",null,"Pharmacy","C.5.3.2","Policies and procedures to manage medication errors"]
[null,null,"Developmental","Domain C",null,"Pharmacy","C.5.3.2","Reports of lessons learnt from medication errors analysed"]
[]
[null,null,null,"www.abulmajd.us",null,null,"khalidabulmajd@gmail.com"]

{"sheet":"STANDARDS DOCUMENT","index":3,"n_rows":512,"n_cols":4,"rows_kept":512,"cut":false,"hidden":false,"merged":[]}
[]
[]
[]
[]
[null,null,null,"DOC. SCORE"]
[null,null,"A.1.1.1"]
[null,null,"Document demonstrating patient safety strategy and/or hospital  strategy"]
[null,null,"Patient safety action plan at both hospital and departmental  levels"]
[null,null,"Patient safety self-assessment and/or external assessment reports"]
[null,null,"A.1.1.2"]
[null,null,"Notification letter for appointment of senior patient safety staff  member"]
[null,null,"Terms of reference for senior patient safety staff member"]
[null,null,"A.1.1.3"]
[null,null,"Stratified random samples of patient safety executive walk  reports"]
[null,null,"Stratified random samples of reports showing improvements are made based on findings of patient safety executive walk rounds"]
[null,null,"A.1.2.1"]
[null,null,"Annual budget for patient safety activities based on a detailed action  plan"]
[null,null,"A.1.2.2"]
[null,null,"Code of ethics, for example, in relation to research, resuscitation, consent and confidentiality"]
[null,null,"Policies and procedures for implementing the code of  ethics"]
[null,null,"Reports including monitoring of compliance with code of ethics"]
[null,null,"Reports that include monitoring of compliance with code of ethics"]
[null,null,"Training records of staff trained in policies and procedures for implementing the code of ethics"]
[null,null,"A.1.2.3"]
[null,null,"Questionnaire on staff attitude towards patient safety"]
[null,null,"Results of staff attitudes towards patient safety culture and actions taken towards gathered data"]
[null,null,"A.2.1.1"]
[null,null,"Morbidity and mortality committee or equivalent minutes of  meetings"]
[null,null,"Morbidity and mortality committee or equivalent terms of  reference"]
[null,null,"A.2.1.2"]
[null,null,"Notification letter for patient safety coordinator or  equivalent"]
[null,null,"Terms of reference for patient safety coordinator or equivalent"]
[null,null,"A.2.2.1"]
[null,null,"Organizational structure of the hospital"]
[null,null,"A.2.2.2"]
[null,null,"At least four reports that include retrospective analyses of adverse events carried out on a yearly basis"]
[null,null,"Improvements are implemented based on recommendations of the root cause analysis"]
[null,null,"A.2.2.3"]
[null,null,"Patient safety audit reports"]
[null,null,"A.2.2.4"]
[null,null,"Minutes of meetings of multidisciplinary patient safety internal body or  equivalent"]
[null,null,"Terms of reference for multidisciplinary patient safety internal body or  equivalent"]
[null,null,"A.2.2.5"]
[null,null,"Reports on different patient safety activities"]
[null,null,"A.2.3.1"]
[null,null,"Reports on different patient safety activities, disseminated externally to Ministry of Health, WHO and/or patient safety organizations"]
[null,null,"A.2.3.2"]
[null,null,"Reports of proactive patient safety improvement  projects"]
[null,null,"A.3.2.1"]
[null,null,"Proactive risk reports may include examples from patient safety goals"]
[null,null,"Reports that include reviewing targets related to patient safety  goals"]
[null,null,"A.3.2.2"]
[null,null,"Performance measurement reports"]
[null,null,"A.3.3.1"]
[null,null,"Benchmark reports"]
[null,null,"A.3.3.2"]
[null,null,"Action plan and patient safety improvement projects  reports"]
[null,null,"Benchmarking results"]
[null,null,"Lessons learnt from reports/emails about patient safety performance  measurement"]
[null,null,"A.4.1.1"]
[null,null,"Lists of essential functioning equipment"]
[null,null,"Reports that include measurement of compliance with availability of essential functioning equipment standards"]
[null,null,"A.4.2.1"]
[null,null,"Policies and procedures for preventive equipment maintenance"]
[null,null,"Reports that include measuring compliance with policies and procedures for preventive equipment maintenance"]
[null,null,"Reports/records of preventive equipment maintenance"]
[null,null,"Training records of staff trained in policies and procedures for preventive equipment maintenance"]
[null,null,"A.4.2.2"]
[null,null,"Policies and procedures for corrective equipment maintenance"]
[null,null,"Records of corrective equipment maintenance"]
[null,null,"Reports that include measuring compliance with policies and procedures for corrective equipment maintenance"]
[null,null,"Training records of staff trained in policies and procedures for corrective equipment maintenance"]
[null,null,"A.4.2.3"]
[null,null,"Reports that include measuring compliance with and whether staff receive appropriate training for existing and new equipment  standards"]
[null,null,"A.4.3.1"]
[null,null,"Training records of staff trained in use of all infusion  pumps"]
[null,null,"A.5.1.1"]
[null,null,"Personnel files with evidence of staff qualifications and licences (registration to practice within appropriate  body)"]
[null,null,"Policies and procedures for staff qualifications and licences"]
[null,null,"Reports that include measuring compliance with policies and procedures for staff qualifications and licences"]
[null,null,"Training records of staff trained in policies and procedures for staff qualifications and licences"]
[null,null,"A.5.2.1"]
[null,null,"Duty rosters for clinical staff"]
[null,null,"Policies and procedures for clinical staffing levels"]
[null,null,"Reports that include measuring compliance with policies and procedures for clinical staffing levels"]
[null,null,"Training records of staff trained in policies and procedures for clinical staffing  levels"]
[null,null,"A.5.2.2"]
[null,null,"Duty rosters for nonclinical support  staff"]
[null,null,"Policies and procedures for nonclinical support  staff"]
[null,null,"Reports that include measuring compliance with policies and procedures for nonclinical  support staff"]
[null,null,"Training records of staff trained in policies and procedures for nonclinical support staff"]
[null,null,"A.5.2.3"]
[null,null,"Policies and procedures for sufficient rest breaks to practise safely"]
[null,null,"Reports that include measuring compliance with policies and procedures for safe practice during rest breaks"]
[null,null,"Training records of staff trained in policies and procedures for sufficient rest breaks to practice safely"]
[null,null,"A.5.2.4"]
[null,null,"Policies and procedures for students and trainees working within their competencies and under appropriate supervision"]
[null,null,"Reports that include measuring compliance with policies and procedures for students and trainees working within their competencies and under appropriate supervision"]
[null,null,"Training records of staff trained in policies and procedures for students and trainees working within their competencies and under appropriate  supervision"]
[null,null,"A.5.2.5"]
[null,null,"Occupational health policies and procedures"]
[null,null,"Occupational health records for all staff"]
[null,null,"Training records of staff trained in occupational health policies and  procedures"]
[null,null,"A.5.3.1"]
[null,null,"Reports that include measuring compliance with workplace violence prevention programmes policies and procedures"]
[null,null,"Training records of staff trained in workplace violence prevention programme policies and procedures"]
[null,null,"Workplace violence prevention programme policies and procedures"]
[null,null,"A.6.2.1"]
[null,null,"Policies and procedures for all departments and services"]
[null,null,"Reports that include measuring compliance with departments and/or services policies and procedures"]
[null,null,"Training records of staff trained in departmental and/or services policies and procedures"]
[null,null,"B.1.2.1"]
[null,null,"Written and approved patient and family rights  statement"]
[null,null,"B.1.2.2"]
[null,null,"Patient safety rights policies and procedures"]
[null,null,"Written and approved patient and family rights statement in which patient safety is incorporated"]
[null,null,"B.1.2.3"]
[null,null,"Reports that include measuring compliance with policies and procedures for patient and family rights"]
[null,null,"Training records of staff trained in patient and family rights policies and  procedures"]
[null,null,"B.2.1.1"]
[null,null,"Educational material used, including flyers, literature and lecture notes"]
[null,null,"List of procedures for which informed consent is required, including but not limited to: invasive procedures, surgical procedures, anaesthesia, blood transfusion, high- risk procedures, high-risk treatments, and organ donation and  transplantation"]
[null,null,"Policies and procedures for informed consent"]
[null,null,"Reports that include measuring compliance with informed consent policies and procedures"]
[null,null,"Training records of staff trained in informed consent policies and  procedures"]
[null,null,"B.2.2.1"]
[null,null,"Minutes of last three disease-specific support group meetings and their signatures of attendance"]
[null,null,"Policies and procedures for health education on specific health issues and patient safety"]
[null,null,"Reports that include measuring compliance with health education policies and procedures"]
[null,null,"Training records of staff trained in policies and procedures for health  education"]
[null,null,"B.2.2.2"]
[null,null,"Reports that include measuring compliance with policies and procedures for complete updated information on patients’ diagnosis and  treatment"]
[null,null,"Training records of staff trained in policies and procedures for complete updated information on patients’ diagnosis and  treatment"]
[null,null,"B.2.2.2."]
[null,null,"Policies and procedures for complete updated information on patients’ diagnosis and treatment"]
[null,null,"B.2.2.3"]
[null,null,"Policies and procedures for patient carers’ training on post-discharge  care"]
[null,null,"Reports that include measuring compliance with relevant policies and procedures for post-discharge care"]
[null,null,"Training records of staff trained in policies and procedures for training patients’ carers in post-discharge care"]
[null,null,"B.2.3.1"]
[null,null,"Policies and procedures for patients’ participation in planning and making decisions regarding their health care"]
[null,null,"Reports that include measuring compliance with policies and procedures for patients’ participation in planning and making decisions regarding their health  care"]
[null,null,"Training records of staff trained in policies and procedures to encourage patients to participate in planning and making decisions regarding their health  care"]
[null,null,"B.2.3.2"]
[null,null,"Health education material"]
[null,null,"Patient safety education material"]
[null,null,"B.3.1.1"]
[null,null,"Policies and procedures for patient identification and  verification"]
[null,null,"Reports that measure compliance with policies and procedures for patient identification and verification"]
[null,null,"Training records of staff trained in policies and procedures for patient identification and verification"]
[null,null,"B.3.1.1."]
[null,null,"List of high-risk procedures"]
[null,null,"Policies and procedures for patient identification and verification, with special emphasis on high-risk groups such as newborn babies, patients in coma, and senile patients"]
[null,null,"B.3.2.1"]
[null,null,"A system in place to identify allergies, e.g. a colour-coding system"]
[null,null,"Documents or reports that measure compliance with policies and procedures for identification of allergies"]
[null,null,"Policies and procedures for identification of allergies"]
[null,null,"Training records of staff trained in policies and procedures for identification of allergies"]
[null,null,"B.3.3.1"]
[null,null,"Documents explaining bar coding with check digits to ensure proper patient identification"]
[null,null,"B.4.2.2"]
[null,null,"Minutes of the last three meetings and events showing community involvement"]
[null,null,"Written information provided to community leaders about their role in patient safety improvement"]
[null,null,"B.4.2.3"]
[null,null,"Marketing material to promote patient safety (e.g. press releases announcing patient safety activities)"]
[null,null,"Media material to promote patient safety (e.g. press releases announcing patient safety activities)"]
[null,null,"B.4.3.1"]
[null,null,"Patient safety improvement task force minutes or reports of meetings"]
[null,null,"Policies and procedures for community involvement"]
[null,null,"Reports that include measuring compliance with policies and procedures for community involvement"]
[null,null,"Strategy for community involvement"]
[null,null,"Training records of staff trained in community involvement policies and  procedures"]
[null,null,"B.5.3.1"]
[null,null,"Reports that measure compliance with disclosure policies and  procedures"]
[null,null,"Training records of staff trained in disclosure policies and  procedures"]
[null,null,"B.5.3.2"]
[null,null,"Health care mediator training records"]
[null,null,"Healthcare mediator notification letter"]
[null,null,"Healthcare mediator terms of reference"]
[null,null,"B.6.2.1"]
[null,null,"Satisfaction surveys, leadership walk rounds, focus groups, complaint letters, safety hotline, staff feedback, suggestion box and community focus  groups"]
[null,null,"B.6.2.2"]
[null,null,"Feedback reports of how patients’ complaints were managed and changes that have taken place to prevent recurrence of the complaints"]
[null,null,"B.6.3.1"]
[null,null,"Policies and procedures for patient and community empowerment and engagement for patient safety"]
[null,null,"Reports or minutes of meetings that include engagement of patients and their carers in setting polices and suggesting quality improvement and patient safety  projects"]
[null,null,"Reports that include measuring compliance with policies and procedures for patient engagement for patient safety"]
[null,null,"Strategies for patient and community empowerment and engagement for patient safety"]
[null,null,"Training records of staff trained in policies and procedures for patient engagement for patient safety"]
[null,null,"B.6.3.2"]
[null,null,"Chat/message board for patients and their carers to express their concerns and share successful solutions"]
[null,null,"B.6.3.3"]
[null,null,"Information on patient safety, health literacy and patient  well-being"]
[null,null,"B.7.2.1"]
[null,null,"Training material for staff to be supportive and deal with patients’  anxieties"]
[null,null,"B.7.2.2"]
[null,null,"Reports on entertainment for patients"]
[null,null,"B.7.2.3"]
[null,null,"Patient satisfaction reports"]
[null,null,"Reports on patients’ spiritual and religious needs"]
[null,null,"B.7.2.4"]
[null,null,"End-of-life policies and procedures"]
[null,null,"Training records of staff trained in relevant policies and procedures for end-of-life care"]
[null,null,"C.1.1.1"]
[null,null,"List of urgent critical diagnostic results developed by multispecialty   committee"]
[null,null,"Policies and procedures for channels of communication for urgent critical  results"]
[null,null,"Stratified random sample of reports that include measuring compliance with policies and procedures for channels of communication for urgent critical  results"]
[null,null,"Training records of staff trained in policies and procedures for channels of communication for urgent critical  results"]
[null,null,"C.1.1.2"]
[null,null,"Reports that include measuring compliance with surgical safety  guidelines"]
[null,null,"Surgical safety checklist used in operating rooms for every surgical procedure"]
[null,null,"Training records of staff trained in surgical safety guidelines"]
[null,null,"C.1.1.3"]
[null,null,"Policies and procedures for systems for recognition and response to clinical deterioration"]
[null,null,"Reports that include measuring compliance with policies and procedures for systems for recognition of and response to clinical  deterioration"]
[null,null,"Training records of staff trained in policies and procedures for systems for recognition and response to clinical  deterioration"]
[null,null,"C.1.2.1"]
[null,null,"Clinical practice guidelines based on at least the top five diagnoses and top five high-risk diseases, including WHO guidelines where available"]
[null,null,"Reports that include measuring compliance with selected clinical practice   guidelines"]
[null,null,"Training records of staff trained in selected clinical practice  guidelines"]
[null,null,"C.1.2.10"]
[null,null,"Policies and procedures to reduce risk of falls"]
[null,null,"Reports that include measuring compliance with policies and procedures to reduce risk of falls"]
[null,null,"Training records of staff trained in policies and procedures to reduce risk of  falls"]
[null,null,"C.1.2.2"]
[null,null,"Policies and procedures in place to ensure safe communication of pending test results to patients and care providers after discharge"]
[null,null,"Reports that include measuring compliance with policies and procedures for safe communication of pending test results to patients and care providers after  discharge"]
[null,null,"Training records of staff trained in policies and procedures for safe communication of pending test results to patients and care providers after  discharge"]
[null,null,"C.1.2.3"]
[null,null,"Guidelines for top five invasive diagnostic procedures"]
[null,null,"Reports that include measuring compliance with guidelines for invasive diagnostic procedures"]
[null,null,"Training records of staff trained in invasive diagnostic procedures guidelines"]
[null,null,"C.1.2.4"]
[null,null,"Guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary embolism)"]
[null,null,"Reports that include measuring compliance with guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary  embolism)"]
[null,null,"Training records of staff trained in guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary embolism)"]
[null,null,"C.1.2.5"]
[null,null,"Policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"Reports that include measuring compliance with policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"Training records of staff trained in policies and procedures for pressure ulcers, suicide, infection, and nutrition needs"]
[null,null,"C.1.2.6"]
[null,null,"List of approved abbreviations of medical terms"]
[null,null,"List of dangerous abbreviations, symbols and dose designations that are prohibited for use in hospitals"]
[null,null,"Reports that include measuring compliance with lists of approved abbreviations of medical terms, and lists of dangerous abbreviations, symbols and dose designations that are prohibited in hospitals"]
[null,null,"Training records of staff trained in application of lists of approved abbreviations of medical terms and lists of dangerous abbreviations, symbols and dose designations that are prohibited for use in hospital"]
[null,null,"C.1.2.7"]
[null,null,"Policies and procedures for effective communication"]
[null,null,"Reports that include measuring compliance with policies and procedures for effective communication"]
[null,null,"Training records of staff trained in policies and procedures for effective communication"]
[null,null,"C.1.2.8"]
[null,null,"Policies and procedures for handover of patients"]
[null,null,"Reports that include measuring compliance with policies and procedures for handover of patients"]
[null,null,"Training records of staff trained in policies and procedures for handover of  patients"]
[null,null,"C.1.2.9"]
[null,null,"Reports that include measuring compliance with safe childbirth  guidelines"]
[null,null,"Safe childbirth guidelines"]
[null,null,"Training records of staff trained in safe childbirth  guidelines"]
[null,null,"C.1.3.1"]
[null,null,"Clinical guidelines"]
[null,null,"Clinical guidelines committee minutes of meetings"]
[null,null,"Clinical guidelines committee notification  letter"]
[null,null,"Clinical guidelines committee terms of reference"]
[null,null,"C.2.1.1"]
[null,null,"Infection control organizational structure"]
[null,null,"Infection prevention and control policies and  procedures"]
[null,null,"Reports that include measuring compliance with infection prevention and control policies and procedures"]
[null,null,"Stratified random samples of minutes of infection prevention and control   committee"]
[null,null,"Terms of reference and notification letter for infection prevention and control committee"]
[null,null,"Training records of staff trained in infection prevention and control policies and procedures"]
[null,null,"C.2.1.2"]
[null,null,"Policies and procedures for cleaning, disinfection and sterilization of  equipment"]
[null,null,"Reports that include measuring compliance with policies and procedures for cleaning, disinfection and sterilization of equipment"]
[null,null,"Training records of staff trained in policies and procedures for cleaning, disinfection and sterilization of equipment"]
[null,null,"C.2.2.1"]
[null,null,"Recognized guidelines for infection prevention and control, including WHO guidelines"]
[null,null,"Reports that include measuring compliance with infection prevention and control guidelines"]
[null,null,"Training records of staff trained in infection prevention and control  guidelines"]
[null,null,"C.2.2.2"]
[null,null,"Policies and procedures for equipment and supplies for infection prevention and control"]
[null,null,"Reports that include measuring compliance with policies and procedures for equipment and supplies for infection prevention and  control"]
[null,null,"Training records of staff trained in policies and procedures for infection prevention and control equipment and supplies"]
[null,null,"C.2.2.3"]
[null,null,"Policies and procedures for surveillance system for health care-associated infections"]
[null,null,"Reports that include measuring compliance with policies and procedures for surveillance systems for health care-associated infections"]
[null,null,"Training records of staff trained in policies and procedures for surveillance system for health care-associated infections"]
[null,null,"C.2.2.4"]
[null,null,"Isolation protocols policies and  procedures"]
[null,null,"Reports that include measuring compliance with isolation protocols policies and procedures"]
[null,null,"Training records of staff trained in isolation protocols policies and  procedures"]
[null,null,"C.2.2.5"]
[null,null,"Policies and procedures for rational use of antibiotics to reduce resistance, and antimicrobial stewardship"]
[null,null,"Reports that include measuring compliance with policies and procedures for rational use of antibiotics and antimicrobial  stewardship"]
[null,null,"Training records of staff trained in policies and procedures for rational use of antibiotics and antimicrobial  stewardship"]
[null,null,"C.2.2.6"]
[null,null,"Recognized current guidelines for hand hygiene, including WHO guidelines"]
[null,null,"Reports that include measuring compliance with hand hygiene  guidelines"]
[null,null,"Training records of staff trained in hand hygiene guidelines"]
[null,null,"C.2.2.7"]
[null,null,"Policies and procedures for screening of staff for colonization and transmissible infections"]
[null,null,"Reports that include measuring compliance with staff screening policies and procedures"]
[null,null,"Staff health records"]
[null,null,"Training records of staff trained in staff screening policies and  procedures"]
[null,null,"C.2.2.8"]
[null,null,"Policies and procedures for protection of staff and volunteers from healthcare- associated infections"]
[null,null,"Reports that include measuring compliance with policies and procedures for protection of staff and volunteers from health care-associated  infections"]
[null,null,"Training records of staff trained in policies and procedures for protection of staff and volunteers from healthcare-associated infections"]
[null,null,"C.2.2.9"]
[null,null,"Care bundles"]
[null,null,"Reports that include measuring compliance with relevant care  bundles"]
[null,null,"Training records of staff trained in bundle management"]
[null,null,"C.3.1.1"]
[null,null,"Guidelines, including WHO guidelines, on safe blood and blood  products"]
[null,null,"Reports that include measuring compliance with guidelines for safe blood and blood products"]
[null,null,"Training records of staff trained in guidelines for safe blood and blood  products"]
[null,null,"C.3.1.2"]
[null,null,"Policies and procedures for safe pre-transfusion procedures, including for recruitment, selection and retention of voluntary blood donors, and blood screening (e.g. HIV and hepatitis B and C viruses)"]
[null,null,"Reports that include measuring compliance with policies and procedures for safe pre-transfusion practice"]
[null,null,"Training records of staff trained in policies and procedures for safe pre-transfusion procedures"]
[null,null,"C.3.2.1"]
[null,null,"Policies and procedures for cross-matching of blood  samples"]
[null,null,"Reports that include measuring compliance with policies and procedures for cross- matching of blood groups"]
[null,null,"Training records of staff trained in policies and procedures for cross-matching of blood groups"]
[null,null,"C.3.2.2"]
[null,null,"Policies and procedures for management of post-blood transfusion  incidents"]
[null,null,"Reports that include measuring compliance with policies and procedures for post- blood transfusion incident management"]
[null,null,"Training records of staff trained in policies and procedures for post-blood transfusion incident management"]
[null,null,"C.3.3.1"]
[null,null,"Clinical practices that reduce blood loss and the need for blood  transfusion"]
[null,null,"Reports that include measuring compliance with guidelines for clinical practices that reduce blood loss and the need for blood  transfusion"]
[null,null,"Training records of staff trained in guidelines for clinical practices that reduce blood loss and the need for blood transfusion"]
[null,null,"C.3.3.2"]
[null,null,"Guidelines on safe and appropriate prescribing of blood and blood products, including the use of alternative fluids"]
[null,null,"Reports that include measuring compliance with guidelines on safe and appropriate prescribing of blood and blood  products"]
[null,null,"Training records of staff trained in guidelines for safe and appropriate prescribing of blood and blood products, including the use of alternative   fluids"]
[null,null,"C.4.2.1"]
[null,null,"Reports that measure compliance with safe injection policies and  procedures"]
[null,null,"Safe injection policies and procedures"]
[null,null,"Training records of staff trained in safe injection policies and  procedures"]
[null,null,"C.5.1.1"]
[null,null,"Life-saving medications based on needs of each  department"]
[null,null,"Policies and procedures for life-saving medications"]
[null,null,"Reports that include measuring compliance with policies and procedures for life- saving medications."]
[null,null,"Training records of staff trained in policies and procedures for life-saving  medications"]
[null,null,"C.5.1.2"]
[null,null,"Policies and procedures for removal of high concentrations of electrolytes from inpatient departments and storage in a safe place"]
[null,null,"Reports that include measuring compliance with policies and procedures for removal of high concentrations of electrolytes and storage in a safe  place"]
[null,null,"Training records of staff trained in policies and procedures for removal of high concentrations of electrolytes and storage in a safe place"]
[null,null,"C.5.2.1"]
[null,null,"Reports that include measuring compliance with safe medication policies and procedures"]
[null,null,"Safe medication policies and procedures"]
[null,null,"Training records of staff trained in safe medication policies and  procedures"]
[null,null,"C.5.2.2"]
[null,null,"Policies and procedures for legible handwriting when prescribing or writing physicians’ orders"]
[null,null,"Reports that include measuring compliance with policies and procedures for legible handwriting when prescribing or writing physicians’  orders."]
[null,null,"Training records of staff trained in policies and procedures to ensure legible handwriting when prescribing or writing physicians’  orders"]
[null,null,"C.5.2.3"]
[null,null,"Reports that include measuring compliance with policies and procedures for medication reconciliation"]
[null,null,"Standard operating practice for medication  reconciliation"]
[null,null,"Training records of staff trained in policies and procedures for medication reconciliation"]
[null,null,"C.5.2.4"]
[null,null,"Policies and procedures for patient (or carer) education about medication at discharge policy and procedure"]
[null,null,"Reports that include measuring compliance with policies and procedures for patient (or carer) education about medication at discharge"]
[null,null,"Training records of staff trained in policies and procedures for patient (or carer) education about medication at  discharge"]
[null,null,"C.5.2.5"]
[null,null,"Policies and procedures for standardizing and limiting the number of medication concentrations"]
[null,null,"Reports that include measuring compliance with policies and procedures for standardizing and limiting the number of medication  concentrations"]
[null,null,"Training records of staff trained in policies and procedures to standardize and limit the number of medication  concentrations"]
[null,null,"C.5.2.6"]
[null,null,"Pain management policies and procedures"]
[null,null,"Reports that include measuring compliance with pain management policies and procedures"]
[null,null,"Training records of staff trained in pain management policies and  procedure"]
[null,null,"C.5.3.1"]
[null,null,"Clinical pharmacy policies and procedures"]
[null,null,"Reports that include measuring compliance with clinical pharmacy policies and procedures"]
[null,null,"Training records of staff trained in clinical pharmacy policies and  procedures"]
[null,null,"C.5.3.2"]
[null,null,"Policies and procedures to manage medication errors"]
[null,null,"Reports of lessons learnt from medication errors analysed"]
[null,null,"Reports that include measuring compliance with policies and procedures for medication errors"]
[null,null,"Training records of staff trained in policy and procedures to manage medication errors"]
[null,null,"C.6.2.1"]
[null,null,"Reports that include measuring compliance with medical records archiving system policy and procedures"]
[null,null,"Training records of staff trained in medical records archiving system policies and procedures"]
[null,null,"Medical records archiving system policies and  procedures"]
[null,null,"C.6.2.2"]
[null,null,"Reports that include measuring compliance with policies and procedures for single completed medical records"]
[null,null,"Training records of staff trained in policies and procedures for single completed medical records"]
[null,null,"Policies and procedures for single completed medical  records"]
[null,null,"C.6.2.3"]
[null,null,"Reports that include measuring compliance with policies and procedures for standardized codes for diseases"]
[null,null,"Training records of staff trained in policies and procedures for standardized codes for diseases"]
[null,null,"Policies and procedures for standardized codes for diseases"]
[null,null,"C.6.2.4"]
[null,null,"Reports that include measuring compliance with medical records access policies and procedures"]
[null,null,"Training records of staff trained in medical records access policies and  procedures"]
[null,null,"Medical records access policies and procedures"]
[null,null,"D.1.2.1"]
[null,null,"Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"Notification letter for the multidisciplinary environmental safety  committee"]
[null,null,"Terms of reference of the multidisciplinary environmental safety committee"]
[null,null,"D.1.2.10"]
[null,null,"Radiation safety policies and procedures"]
[null,null,"Reports that include measuring compliance with radiation safety policies and procedures"]
[null,null,"Training records of staff trained in radiation safety policies and  procedures"]
[null,null,"D.1.2.11"]
[null,null,"Policies and procedures for warning signs"]
[null,null,"Reports that include measuring compliance with policies and procedures for warning signs"]
[null,null,"Training records of staff trained in policies and procedures for warning  signs"]
[null,null,"D.1.2.12"]
[null,null,"Employee screening and health certificates"]
[null,null,"Policies and procedures for appropriate and safe food and drinks for patients, staff and visitors"]
[null,null,"Policies and procedures for safe kitchen programmes"]
[null,null,"Reports that include measuring compliance with national laws and regulations for food and drink safety"]
[null,null,"Reports that include measuring compliance with relevant policies and  procedures"]
[null,null,"Special diets according to disease and patient  needs"]
[null,null,"Training records of staff trained in relevant policies and procedures"]
[null,null,"D.1.2.13"]
[null,null,"Housekeeping policies and procedures"]
[null,null,"Training records of staff trained in housekeeping policies and  procedures"]
[null,null,"D.1.2.14"]
[null,null,"Reports that include measuring compliance with smoke-free policies and  procedures"]
[null,null,"Smoke-free policy"]
[null,null,"Training records of staff trained in smoke-free policies and  procedures"]
[null,null,"D.1.2.2"]
[null,null,"Building blueprints"]
[null,null,"Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"D.1.2.3"]
[null,null,"Minutes of meetings of multidisciplinary environmental safety  committee"]
[null,null,"Policies and procedures for building safety"]
[null,null,"Records of preventive maintenance programme for physical environment"]
[null,null,"Reports that include measuring compliance with physical environment policies and procedures"]
[null,null,"Training records of staff trained in physical environment policies and  procedures"]
[null,null,"D.1.2.4"]
[null,null,"Reports that include measuring compliance with security policies and   procedures"]
[null,null,"Security policies and procedures"]
[null,null,"Training records of staff trained in security policies and  procedures"]
[null,null,"D.1.2.5"]
[null,null,"Policies and procedures for staff wearing identification, including a visible name badge and appropriate uniform"]
[null,null,"Reports that include measuring compliance with policies and procedures for staff identification"]
[null,null,"Training records of staff trained in staff identification policies and  procedures"]
[null,null,"D.1.2.6"]
[null,null,"External emergency plan"]
[null,null,"Reports to measure implementation of external emergency plans"]
[null,null,"D.1.2.7"]
[null,null,"Internal emergency plan"]
[null,null,"Reports to measure rehearsal of internal emergency plan implementation"]
[null,null,"D.1.2.8"]
[null,null,"Fire and smoke safety policies and procedures"]
[null,null,"Reports that include measuring compliance with policies and procedures for fire and smoke safety"]
[null,null,"Training records of staff trained in fire and smoke safety policies and  procedures"]
[null,null,"D.1.2.9"]
[null,null,"Backup plan for utility systems in case of failure or  interruption"]
[null,null,"Policies and procedures for preventive maintenance of utility systems"]
[null,null,"Reports that include measuring compliance with utility system policies and procedures and plans"]
[null,null,"Training of staff in policies and procedures for utility system  plans"]
[null,null,"Utility systems plan"]
[null,null,"D.2.1.1"]
[null,null,"Policies and procedures for waste segregation according to hazard level (see guidelines) and colour coding it"]
[null,null,"Reports that include measuring compliance with policies and procedures for waste segregation"]
[null,null,"Training records of staff trained in policies and procedures for waste  segregation"]
[null,null,"D.2.1.2"]
[null,null,"Guidelines (including WHO guidelines) on management of sharps waste"]
[null,null,"Reports that include measuring compliance with guidelines for management of sharps waste"]
[null,null,"Training records of staff trained in guidelines for management of sharps  waste"]
[null,null,"D.2.2.1"]
[null,null,"Guidelines (including WHO guidelines) on safe management of waste from healthcare activities"]
[null,null,"Reports that include measuring compliance with guidelines for safe waste management"]
[null,null,"Training records of staff trained in guidelines for safe waste management"]
[null,null,"D.2.2.2"]
[null,null,"Guidelines (including WHO guidelines) on management of biological waste"]
[null,null,"Reports that include measuring compliance with guidelines for biological waste management"]
[null,null,"Training records of staff trained in guidelines for biological waste  management"]
[null,null,"D.2.2.3"]
[null,null,"Guidelines (including WHO guidelines) on management of chemical waste"]
[null,null,"Reports that include measuring compliance with guidelines for chemical waste management"]
[null,null,"Training records of staff trained in guidelines for chemical waste management"]
[null,null,"D.2.2.4"]
[null,null,"Guidelines (including WHO guidelines) on management of radiological waste"]
[null,null,"Reports that include measuring compliance with guidelines for radiological waste management"]
[null,null,"Training records of staff trained in guidelines for radiological waste  management"]
[null,null,"E.1.2.1"]
[null,null,"Patient safety orientation programme"]
[null,null,"Personnel files that contain evidence of orientation to patient  safety"]
[null,null,"Reports that include measuring compliance with patient safety orientation programme"]
[null,null,"Training records of staff trained in patient safety during orientation  programme"]
[null,null,"E.1.2.2"]
[null,null,"Reports that include measuring compliance with ongoing training for all staff to ensure safe patient care standards"]
[null,null,"Training records of staff trained in safe patient care practices based on their individual training needs"]
[null,null,"Training records of staff trained in scientific research tools and retrospective and prospective methods to address patient safety  problems"]
[null,null,"E.1.3.1"]
[null,null,"Reports that include measuring compliance with standards to ensure all staff are familiar with the reporting procedures for near misses, adverse events and sentinel events and the steps to be taken during or after an adverse event"]
[null,null,"Training records of staff trained in reporting procedures for near misses, adverse events and sentinel events and steps to be taken during or after an adverse event"]
[null,null,"E.2.3.1"]
[null,null,"Minutes of meetings of medical staff or other  committee"]
[null,null,"Terms of reference for medical staff or other committee"]
[null,null,"E.2.3.2"]
[null,null,"Records to verify the credentials of all health care professionals including staff received from other national, regional and international institutions"]
[null,null,"E.3.2.1"]
[null,null,"WHO cross-sectional studies to assess the magnitude and nature of adverse events to ensure safer care"]
[null,null,"E.3.2.2"]
[null,null,"Minutes of meetings of patient safety internal body or relevant  committee"]
[null,null,"Policies and procedures for patient safety research"]
[null,null,"Reports that include measuring compliance with policies and procedures for patient safety research"]
[null,null,"Training records of staff trained in policies and procedures for patient safety  research"]
[null,null,"E.3.3.1"]
[null,null,"Prospective studies and reports to assess the magnitude and nature of adverse events to ensure safer care, conducted on a regular basis"]
[null,null,"E.3.3.2"]
[null,null,"Investigation of events to learn from the event, prevent its recurrence and improve patient safety"]
[null,null,"Policies and procedures to report adverse events, sentinel events and near misses"]
[null,null,"Reports that include measuring compliance with policies and procedures for reporting adverse events, sentinel events and near misses"]
[null,null,"Training records of staff trained in policies and procedures for reporting adverse events, sentinel events and near misses"]
[null,null,"Grand Total"]

{"sheet":"Domain A","index":4,"n_rows":42,"n_cols":16,"rows_kept":42,"cut":false,"hidden":false,"merged":[[4,12,4,13],[1,12,1,13],[5,1,5,5],[1,6,1,11],[4,1,4,4],[4,7,4,8],[4,9,4,10],[4,5,4,6],[8,3,13,3],[14,3,22,3],[23,3,26,3],[27,3,31,3],[32,3,38,3]]}
[]
[null," ",null,null,null," ","PATIENT SAFETY FRIENDLY HOSPITAL INITIATIVE - WORLD HEALTH ORGANIZATION (EMRO)"]
[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null,"Country:",null,null,null,{"$f":"MAIN!D8","v":" "},null,"Hospital:",null,{"$f":"MAIN!D10","v":" "},null,"Date:",{"$f":"MAIN!T8","v":" "}]
[]
[]
[null,"Sub","Domain ","Standard","Category","#","Statement","Score","%","Gap","Recommendation","Responsible ","Target Date","Follow up",null,"Domain"]
[null,"A.1","Domain A","Leadership and governance","Critical ","A.1.1.1","The hospital has patient safety as a strategic priority. This strategy is being implemented through a detailed action plan.",null,{"$f":"H9","v":0},null," "," ",null,"Not Started",null,"Domain A"]
[null,"A.1","Domain A",null,"Critical ","A.1.1.2","The hospital has a designated qualified senior staff member with responsibility, accountability and authority for patient safety.",null,{"$f":"H10","v":0},null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.1","Domain A",null,"Critical ","A.1.1.3","The leadership conducts regular patient safety executive walk-rounds to promote patient safety culture, learn about risks in the system, and act on patient safety improvement opportunities.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.1","Domain A",null,"Core ","A.1.2.1","The hospital has an annual budget for patient safety activities based on detailed action plan.",null,0,null,null,null," ","Not Started",null,"Domain A"]
[null,"A.1","Domain A",null,"Core ","A.1.2.2","The hospital follows a code of ethics.",null,0,null,null,null," ","Not Started",null,"Domain A"]
[null,"A.1","Domain A",null,"Core ","A.1.2.3","The leadership assesses patient safety culture regularly on a quarterly basis.",null,0,null,null,null," ","Not Started",null,"Domain A"]
[null,"A.2","Domain A","Patient safety programme","Critical ","A.2.1.1","The hospital conducts regular monthly morbidity and mortality meetings.",null,0,null," "," "," ","Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Critical ","A.2.1.2","A designated qualified person co-ordinates patient safety and risk management activities (middle management).",null,0,null," "," "," ","Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Core ","A.2.2.1","Patient safety is reflected in the organizational structure of the hospital.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Core ","A.2.2.2","Risk is managed reactively.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Core ","A.2.2.3","The hospital audits its safety practices on a regular basis.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Core ","A.2.2.4","The hospital has a multidisciplinary patient safety internal body or any other committee, whose members meet regularly to ensure an overarching patient safety programme.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Core ","A.2.2.5","The hospital regularly develops reports on different patient safety activities and disseminates them internally every quarter.",null,0,null," ",null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Developmental ","A.2.3.1","The hospital regularly develops reports on different patient safety activities and disseminates them externally.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.2","Domain A",null,"Developmental ","A.2.3.2","Patient safety-related risk is managed proactively.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.3","Domain A","Data to improve safety performance","Core ","A.3.2.1","The hospital sets and reviews targets related to patient safety goals.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.3","Domain A",null,"Core ","A.3.2.2","The hospital has a set of process and output measures that assess performance with a special focus on patient safety.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.3","Domain A",null,"Developmental ","A.3.3.1","The hospital compares its process and outcome patient safety indicator data over time, and/ or with other patient safety friendly hospitals, and/or desirable known practices or standards.",null,0,null,null,null," ","Not Started",null,"Domain A"]
[null,"A.3","Domain A",null,"Developmental ","A.3.3.2","The hospital acts on benchmarking results through an action plan and patient safety improvement projects.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.4","Domain A","Equipment and supplies","Critical ","A.4.1.1","The hospital ensures availability of essential functioning equipment.",null,0,null," "," "," ","Not Started",null,"Domain A"]
[null,"A.4","Domain A",null,"Core ","A.4.2.1","The hospital undertakes regular preventive maintenance of equipment, including calibration.",null,0,null,null,null," ","Not Started",null,"Domain A"]
[null,"A.4","Domain A",null,"Core ","A.4.2.2","The hospital undertakes regular repair or replacement of broken (malfunctioning) equipment.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.4","Domain A",null,"Core ","A.4.2.3","The hospital ensures that staff receive appropriate training for available equipment.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.4","Domain A",null,"Developmental ","A.4.3.1","The hospital trains relevant staff on appropriate and safe use of all infusion pumps.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A","Technically competent staff for safer patients","Critical ","A.5.1.1","Qualified clinical staff, both permanent and temporary, are registered to practise with an appropriate body.",null,0,null," "," "," ","Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Core ","A.5.2.1","Clinical staffing levels reflect patient needs at all times.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Core ","A.5.2.2","Sufficient, trained and appropriate non-clinical support staff are available to meet patient needs at all times.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Core ","A.5.2.3","Staff are allowed sufficient rest breaks to practise safely and adhere to national labour laws.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Core ","A.5.2.4","Students and trainees work within their competencies and under appropriate supervision.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Core ","A.5.2.5","An occupational health programme is implemented for all staff.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.5","Domain A",null,"Developmental ","A.5.3.1","The hospital has a workplace violence prevention programme.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[null,"A.6","Domain A","P & P","Core ","A.6.2.1","The hospital has policies and procedures for all departments and services and has systems in place for monitoring their implementation.",null,0,null,null,null,null,"Not Started",null,"Domain A"]
[]
[null,null,null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

{"sheet":"Domain B","index":5,"n_rows":38,"n_cols":16,"rows_kept":38,"cut":false,"hidden":false,"merged":[[4,12,4,13],[5,1,5,5],[1,12,1,13],[27,3,31,3],[32,3,35,3],[1,6,1,11],[4,1,4,4],[4,5,4,6],[4,7,4,8],[4,9,4,10],[8,3,11,3],[12,3,17,3],[18,3,20,3],[21,3,24,3],[25,3,26,3]]}
[]
[null," ",null,null,null," ","PATIENT SAFETY FRIENDLY HOSPITAL INITIATIVE - WORLD HEALTH ORGANIZATION (EMRO)"]
[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null,"Country:",null,null,null,{"$f":"MAIN!D8","v":" "},null,"Hospital:",null,{"$f":"MAIN!D10","v":" "},null,"Date:",{"$f":"MAIN!T8","v":" "}]
[]
[]
[null,"Sub","Domain ","Standard","Category","#","Statement","Score","%","Gap","Recommendation","Responsible ","Target Date","Follow up",null,"Domain"]
[null,"B.1","Domain B","Patient and family rights","Core ","B.1.2.1","The hospital has a patient rights statement and it is visible to patients.",null,{"$f":"H9","v":0},null,null,null," ","Not Started",null,"Domain B"]
[null,"B.1","Domain B",null,"Core ","B.1.2.2","Patient safety is included in the patient rights statement.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.1","Domain B",null,"Core ","B.1.2.3","Patients and their families are briefed about, and aware of, their rights.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.1","Domain B",null,"Developmental ","B.1.3.1","Patient and community are involved in development of patient and family rights.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.2","Domain B","Health awareness","Critical ","B.2.1.1","Informed consent is signed by the patient or authorized person. He/she is informed of all risks, benefits and potential side-effects of a procedure in advance. A physician explains, and a nurse oversees the signing.",null,0,null," "," "," ","Not Started",null,"Domain B"]
[null,"B.2","Domain B",null,"Core ","B.2.2.1","The hospital builds health awareness for all of its patients and their families for their specific health problems and for general patient safety issues",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.2","Domain B",null,"Core ","B.2.2.2","All patients obtain from their treating physicians complete updated information on their diagnosis and treatment.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.2","Domain B",null,"Core ","B.2.2.3","The hospital trains patients’ carers in postdischarge care.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.2","Domain B",null,"Developmental ","B.2.3.1","The hospital encourages patients to participate in planning and making decisions regarding their health care.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.2","Domain B",null,"Developmental ","B.2.3.2","The hospital has a health care website and patients have access to it. ",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.3","Domain B","Patient identification","Critical ","B.3.1.1","The identification process used throughout the hospital requires at least two ways in which to identify a patient and these two different identifiers are used in all locations within the hospital and in any circumstance involving patient interventions. ",null,0,null," "," "," ","Not Started",null,"Domain B"]
[null,"B.3","Domain B",null,"Core ","B.3.2.1","A system is in place to identify allergies.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.3","Domain B",null,"Developmental ","B.3.3.1","The hospital uses bar coding with check digits for patient identification.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.4","Domain B","Community involvement","Core ","B.4.2.1","The hospital conducts patient safety campaigns that share solutions and raise awareness of patient safety in the community.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.4","Domain B",null,"Core ","B.4.2.2","The hospital plans events to promote patient safety through meetings on a regular basis with civic groups, nongovernmental organizations and community leaders.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.4","Domain B",null,"Core ","B.4.2.3","The hospital uses media and/or marketing to promote patient safety.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.4","Domain B",null,"Developmental ","B.4.3.1","The hospital involves the community  in designing and implementing patient safety programmes and improvement projects.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.5","Domain B","Communication of patient safety incidents to patient and carers","Developmental ","B.5.3.1","B.5.3.1 The hospital has a structured system for disclosure to patients and their carers and staff.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.5","Domain B",null,"Developmental ","B.5.3.2","B.5.3.2 The hospital has a health care mediator to explain incidents to patients and their carers.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.6","Domain B","Patient involvement","Core ","B.6.2.1","The hospital obtains patients’ and their carers’ feedback through different tools.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.6","Domain B",null,"Core ","B.6.2.2","The hospital responds to patients’ complaints by sending them feedback on how each complaint was managed and changes that have taken place to prevent recurrence of the complaint.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.6","Domain B",null,"Developmental ","B.6.3.1","The hospital engages and empowers patients and/or patient safety advocacy associations in setting policies and suggesting quality improvement and patient safety projects.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.6","Domain B",null,"Developmental ","B.6.3.2","The hospital provides a chat/message board for patients and their carers to write their concerns and share successful solutions.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.6","Domain B",null,"Developmental ","B.6.3.3","The hospital provides access to computerbased information on patient safety, health literacy and patient well-being.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.7","Domain B","Patient friendliness","Core ","B.7.2.1","The hospital staff are trained to be supportive and to deal with patients’ anxieties.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.7","Domain B",null,"Core ","B.7.2.2","The hospital has entertainment for patients. ",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.7","Domain B",null,"Core ","B.7.2.3","The hospital has a place for prayers and meets patients’ spiritual and religious needs. ",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[null,"B.7","Domain B",null,"Core ","B.7.2.4","The hospital staff support the patient’s family in end-of-life cases.",null,0,null,null,null,null,"Not Started",null,"Domain B"]
[]
[null,null,null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

{"sheet":"Domain C","index":6,"n_rows":60,"n_cols":16,"rows_kept":60,"cut":false,"hidden":false,"merged":[[5,1,5,5],[1,12,1,13],[4,12,4,13],[1,6,1,11],[4,1,4,4],[4,5,4,6],[4,7,4,8],[4,9,4,10],[8,3,21,3],[22,3,32,3],[33,3,38,3],[40,3,49,3],[50,3,57,3]]}
[]
[null," ",null,null,null," ","PATIENT SAFETY FRIENDLY HOSPITAL INITIATIVE - WORLD HEALTH ORGANIZATION (EMRO)"]
[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null,"Country:",null,null,null,{"$f":"MAIN!D8","v":" "},null,"Hospital:",null,{"$f":"MAIN!D10","v":" "},null,"Date:",{"$f":"MAIN!T8","v":" "}]
[]
[]
[null,"Sub","Domain ","Standard","Category","#","Statement","Score","%","Gap","Recommendation","Responsible ","Target Date","Follow up",null,"Domain"]
[null,"C.1","Domain C","General clinical safety","Critical ","C.1.1.1","The hospital maintains clear channels of communication for urgent critical results.",null,{"$f":"H9","v":0},null," "," "," ","Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Critical ","C.1.1.2","The hospital implements the use of a surgical safety checklist and conforms to guidelines, including WHO guidelines on safe surgery.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Critical ","C.1.1.3","The hospital has systems in place to ensure hospital-wide recognition of and response to clinical deterioration.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.1","The hospital conforms to clinical practice guidelines wherever appropriate, including WHO guidelines where available.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.2","The hospital has systems in place to ensure safe communication of pending test results to patients and care providers after discharge.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.3","The hospital ensures invasive diagnostic procedures are carried out safely, and according to standard guidelines.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.4","The hospital implements guidelines to reduce venous thromboembolism (deep venous thrombosis and pulmonary embolism).",null,0,null,null," ",null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.5","The hospital screens patients to identify those vulnerable to harm and acts to reduce risk.",null,0,null,null," ",null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.6","The hospital maintains a list of approved abbreviations of medical terms and a list of dangerous abbreviations, symbols and dose designations that are prohibited for use in hospital.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.7","The hospital minimizes use of verbal and telephone orders and transmission of results, and “read back” is practised where verbal communication is essential.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.8","The hospital has systems in place for safe and thorough handover of patients between clinical teams (including shift staff).",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.9","C.1.2.9 The hospital implements safe childbirth guidelines, including WHO safe childbirth checklist.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Core ","C.1.2.10","The hospital screens patients to identify those vulnerable to falls and acts to reduce risk.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.1","Domain C",null,"Developmental ","C.1.3.1","The hospital has a local clinical guideline committee that meets regularly to select, develop and ensure implementation of guidelines, protocols and checklists relevant to safety.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C","System to reduce health care-associated infections","Critical ","C.2.1.1","The hospital has an implemented infection prevention and control programme, including an organization scheme, guidelines, plan and manual.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Critical ","C.2.1.2","The hospital ensures proper cleaning, disinfection and sterilization of all equipment with a special emphasis on high-risk areas.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.1","The hospital conforms to recognized guidelines for infection prevention and control, including WHO guidelines.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.2","The hospital ensures continuous availability of essential, functioning infection prevention and control equipment and supplies.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.3","The hospital has a surveillance system for health care-associated infections.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.4","The hospital has functioning isolation protocols, definitions and precautions.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.5","The hospital implements policies and procedures for rational use of antibiotics to reduce resistance and has an active antimicrobial stewardship programme.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.6","The hospital implements recognized guidelines for hand hygiene, including WHO guidelines.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.7","Staff are screened before employment and regularly afterwards for colonization and transmissible infections.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.8","The hospital acts to protect staff and volunteers from health care-associated infections, including by provision of hepatitis B vaccination.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.2","Domain C",null,"Core ","C.2.2.9","The hospital conforms to bundle management wherever appropriate.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.3","Domain C","Safe blood and blood products","Critical ","C.3.1.1","The hospital implements guidelines, including WHO guidelines, on safe blood and blood products.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.3","Domain C",null,"Critical ","C.3.1.2","The hospital has safe pre-transfusion procedures.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.3","Domain C",null,"Core ","C.3.2.1","The hospital ensures that patient blood samples for cross-matching are securely identified with two unique identifiers.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.3","Domain C",null,"Core ","C.3.2.2","The hospital has policies and procedures for post-blood transfusion incident management.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.3","Domain C",null,"Developmental ","C.3.3.1","The hospital uses clinical practices that reduce blood loss and the need for blood transfusion.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.3","Domain C",null,"Developmental ","C.3.3.2","The hospital complies with guidelines on safe and appropriate prescribing of blood and blood products, including the use of alternative fluids.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.4","Domain C","Safe injections","Core ","C.4.2.1","The hospital has systems in place to ensure safe injection practice.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C","Medication management system","Critical ","C.5.1.1","The hospital ensures availability of life-saving medications at all times.",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Critical ","C.5.1.2","The hospital keeps high concentrations of electrolytes in a safe place. ",null,0,null," "," "," ","Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.1","The safe medication system of the hospital covers: selection and procurement; storage of medication; ordering and transcribing; preparing and dispensing; administration and follow-up.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.2","The hospital ensures legible handwriting when prescribing or writing physicians’ orders. ",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.3","The hospital ensures medication reconciliation at admission, transfer and discharge. ",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.4","The hospital ensures patient (or carer) education about medication at discharge.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.5","The hospital standardizes and limits the number of medication concentrations.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Core ","C.5.2.6","The hospital has a pain management system and controls access to narcotic products in inpatient departments.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Developmental ","C.5.3.1","The hospital has clinical pharmacists who participate in medication orders and a system to identify drug–drug and drug–food interactions.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.5","Domain C",null,"Developmental ","C.5.3.2","The hospital has an implemented policy and procedures to manage medication errors.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C","Medical records system","Core ","C.6.2.1","The hospital has and maintains a medical records archiving system. ",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Core ","C.6.2.2","The hospital ensures that each patient has a single completed medical record with a unique identifier.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Core ","C.6.2.3","The hospital uses standardized codes for diseases (International Classification of Diseases, 10th Revision), diagnosis and procedures.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Core ","C.6.2.4","The hospital ensures that medical records are easily accessed by care providers whenever needed. ",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Developmental ","C.6.3.1","Patients have access to their medical records with the opportunity to review and amend.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Developmental ","C.6.3.2","The hospital has an automated information management and electronic medical records system with an appropriate backup system.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Developmental ","C.6.3.3","The hospital has a computerized physician order entry.",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[null,"C.6","Domain C",null,"Developmental ","C.6.3.4","The hospital has an effective automated clinical alarm system",null,0,null,null,null,null,"Not Started",null,"Domain C"]
[]
[null,null,null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

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[]
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[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null,"Country:",null,null,null,{"$f":"MAIN!D8","v":" "},null,"Hospital:",null,{"$f":"MAIN!D10","v":" "},null,"Date:",{"$f":"MAIN!T8","v":" "}]
[]
[]
[null,"Sub","Domain ","Standard","Category","#","Statement","Score","%","Gap","Recommendation","Responsible ","Target Date","Follow up"]
[null,"D.1","Domain D","Safe physical environment","Core ","D.1.2.1","The hospital has a multidisciplinary environmental safety committee.",null,{"$f":"H9","v":0},null,null,null," ","Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.2","The hospital design is maximized to provide a safe environment, including for infection control.",null,{"$f":"H10","v":0},null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.3","The hospital has a preventive maintenance programme for its physical environment.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.4","The hospital implements a security programme and uses secure areas whenever appropriate.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.5","The hospital ensures that staff display personal identification.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.6","The hospital implements an external emergency plan.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.7","The hospital implements an internal emergency plan.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.8","The hospital implements a fire and smoke safety programme with an evacuation plan.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.9","The hospital has an effective utility system plan including water, medical gases, fuel, communication systems, preventive maintenance, and a backup plan in case of failure or interruption.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.10","The hospital has an implemented  radiation safety programme.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.11","The hospital displays warning signs marking unsafe areas.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.12","The hospital supplies appropriate and safe food and drinks for patients, staff and visitors.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.13","The hospital maintains a clean environment.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.1","Domain D",null,"Core ","D.1.2.14","The hospital has an implemented smoke-free policy.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.2","Domain D","Waste management","Critical ","D.2.1.1","The hospital segregates waste according to hazard level (see guidelines) and colour codes it.",null,0,null," "," "," ","Not Started",null,"Domain D"]
[null,"D.2","Domain D",null,"Critical ","D.2.1.2","The hospital conforms to guidelines (including WHO guidelines) on management of sharps waste.",null,0,null," "," "," ","Not Started",null,"Domain D"]
[null,"D.2","Domain D",null,"Core ","D.2.2.1","The hospital conforms to guidelines (including WHO guidelines) on safe management of wastes from health care activities. ",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.2","Domain D",null,"Core ","D.2.2.2","The hospital conforms to guidelines (including WHO guidelines) on management of biological waste.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.2","Domain D",null,"Core ","D.2.2.3","The hospital conforms to guidelines (including WHO guidelines) on management of chemical waste.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[null,"D.2","Domain D",null,"Core ","D.2.2.4","The hospital conforms to guidelines (including WHO guidelines) on management of radiological waste.",null,0,null,null,null,null,"Not Started",null,"Domain D"]
[]
[null,null,null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

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[null,null,null," ",null,null,null,null,null," "," "," "]
[]
[null,"Country:",null,null,null,{"$f":"MAIN!D8","v":" "},null,"Hospital:",null,{"$f":"MAIN!D10","v":" "},null,"Date:",{"$f":"MAIN!T8","v":" "}]
[]
[]
[null,"Sub","Domain ","Standard","Category","#","Statement","Score","%","Gap","Recommendation","Responsible","Target Date","Follow up"]
[null,"E.1","Domain E","Staff professional development programme","Core ","E.1.2.1","All hospital staff are provided with a patient safety orientation programme.",null,{"$f":"H9","v":0},null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.1","Domain E",null,"Core ","E.1.2.2","The hospital promotes ongoing training for all staff to ensure safe patient care. ",null,{"$f":"H10","v":0},null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.1","Domain E",null,"Developmental ","E.1.3.1","All staff are familiar with the reporting procedures for near misses, adverse events and sentinel events, and steps to be taken during or after an adverse event.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.2","Domain E","Clinical competency","Developmental ","E.2.3.1","The medical staff committee or other committee monitors competency for all health care professionals.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.2","Domain E",null,"Developmental ","E.2.3.2","The hospital verifies the credentials of all health care professionals, including staff received from other national, regional and international institutions.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.3","Domain E","Research in patient safety","Core ","E.3.2.1","The hospital conducts WHO cross-sectional studies to assess the magnitude and nature of adverse events to ensure safer care on a regular basis at least once every year.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.3","Domain E",null,"Core ","E.3.2.2","All patient safety research is approved and monitored by the patient safety internal body or other committee according to the needs of the hospital.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.3","Domain E",null,"Developmental ","E.3.2.3","The hospital conducts prospective studies to assess the magnitude and nature of adverse events to ensure safer care on a regular basis.",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[null,"E.3","Domain E",null,"Developmental ","E.3.3.2","The hospital has an implemented reporting system for adverse events, sentinel events and near misses. ",null,0,null,null,null,null,"Not Started",null,"Domain E"]
[]
[null,null,null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

{"sheet":"PIVOTS","index":9,"n_rows":143,"n_cols":11,"rows_kept":143,"cut":false,"hidden":true,"merged":[]}
[]
[]
["Row Labels","Average of %",null,"Row Labels","Average of %",null,"Row Labels","Average of %",null,"Row Labels","Count of Domain "]
["Domain A",0,null,"A.1.1.1",0,null,"A.1",0,null,"Not Started",139]
["Domain B",0,null,"A.1.1.2",0,null,"A.2",0,null,"Grand Total",139]
["Domain C",0,null,"A.1.1.3",0,null,"A.3",0]
["Domain D",0,null,"A.1.2.1",0,null,"A.4",0]
["Domain E",0,null,"A.1.2.2",0,null,"A.5",0]
["Grand Total",0,null,"A.1.2.3",0,null,"A.6",0]
[null,null,null,"A.2.1.1",0,null,"B.1",0]
[null,null,null,"A.2.1.2",0,null,"B.2",0]
[null,null,null,"A.2.2.1",0,null,"B.3",0]
[null,null,null,"A.2.2.2",0,null,"B.4",0]
[null,null,null,"A.2.2.3",0,null,"B.5",0]
[null,null,null,"A.2.2.4",0,null,"B.6",0]
[null,null,null,"A.2.2.5",0,null,"B.7",0]
[null,null,null,"A.2.3.1",0,null,"C.1",0]
[null,null,null,"A.2.3.2",0,null,"C.2",0]
[null,null,null,"A.3.2.1",0,null,"C.3",0]
[null,null,null,"A.3.2.2",0,null,"C.4",0]
[null,null,null,"A.3.3.1",0,null,"C.5",0]
[null,null,null,"A.3.3.2",0,null,"C.6",0]
[null,null,null,"A.4.1.1",0,null,"D.1",0]
[null,null,null,"A.4.2.1",0,null,"D.2",0]
[null,null,null,"A.4.2.2",0,null,"E.1",0]
[null,null,null,"A.4.2.3",0,null,"E.2",0]
[null,null,null,"A.4.3.1",0,null,"E.3",0]
[null,null,null,"A.5.1.1",0,null,"Grand Total",0]
[null,null,null,"A.5.2.1",0]
[null,null,null,"A.5.2.2",0]
[null,null,null,"A.5.2.3",0]
[null,null,null,"A.5.2.4",0]
[null,null,null,"A.5.2.5",0]
[null,null,null,"A.6.2.1",0]
[null,null,null,"B.1.2.1",0]
[null,null,null,"B.1.2.2",0]
[null,null,null,"B.1.2.3",0]
[null,null,null,"B.1.3.1",0]
[null,null,null,"B.2.1.1",0]
[null,null,null,"B.2.2.1",0]
[null,null,null,"B.2.2.2",0]
[null,null,null,"B.2.2.3",0]
[null,null,null,"B.2.3.1",0]
[null,null,null,"B.2.3.2",0]
[null,null,null,"B.3.1.1",0]
[null,null,null,"B.3.2.1",0]
[null,null,null,"B.3.3.1",0]
[null,null,null,"B.4.2.1",0]
[null,null,null,"B.4.2.2",0]
[null,null,null,"B.4.2.3",0]
[null,null,null,"B.4.3.1",0]
[null,null,null,"B.5.3.1",0]
[null,null,null,"B.5.3.2",0]
[null,null,null,"B.6.2.1",0]
[null,null,null,"B.6.2.2",0]
[null,null,null,"B.6.3.1",0]
[null,null,null,"B.6.3.2",0]
[null,null,null,"B.6.3.3",0]
[null,null,null,"B.7.2.1",0]
[null,null,null,"B.7.2.2",0]
[null,null,null,"B.7.2.3",0]
[null,null,null,"B.7.2.4",0]
[null,null,null,"C.1.1.1",0]
[null,null,null,"C.1.1.2",0]
[null,null,null,"C.1.2.1",0]
[null,null,null,"C.1.2.2",0]
[null,null,null,"C.1.2.3",0]
[null,null,null,"C.1.2.4",0]
[null,null,null,"C.1.2.5",0]
[null,null,null,"C.1.2.6",0]
[null,null,null,"C.1.2.7",0]
[null,null,null,"C.1.2.8",0]
[null,null,null,"C.1.3.1",0]
[null,null,null,"C.2.1.1",0]
[null,null,null,"C.2.1.2",0]
[null,null,null,"C.2.2.1",0]
[null,null,null,"C.2.2.2",0]
[null,null,null,"C.2.2.3",0]
[null,null,null,"C.2.2.4",0]
[null,null,null,"C.2.2.5",0]
[null,null,null,"C.2.2.6",0]
[null,null,null,"C.2.2.7",0]
[null,null,null,"C.2.2.8",0]
[null,null,null,"C.2.2.9",0]
[null,null,null,"C.3.1.1",0]
[null,null,null,"C.3.1.2",0]
[null,null,null,"C.3.2.1",0]
[null,null,null,"C.3.2.2",0]
[null,null,null,"C.3.3.1",0]
[null,null,null,"C.3.3.2",0]
[null,null,null,"C.4.2.1",0]
[null,null,null,"C.5.1.1",0]
[null,null,null,"C.5.2.1",0]
[null,null,null,"C.5.2.2",0]
[null,null,null,"C.5.2.3",0]
[null,null,null,"C.5.2.4",0]
[null,null,null,"C.5.3.1",0]
[null,null,null,"C.5.3.2",0]
[null,null,null,"C.6.2.1",0]
[null,null,null,"C.6.2.2",0]
[null,null,null,"C.6.2.3",0]
[null,null,null,"C.6.2.4",0]
[null,null,null,"C.6.3.1",0]
[null,null,null,"C.6.3.2",0]
[null,null,null,"C.6.3.3",0]
[null,null,null,"C.6.3.4",0]
[null,null,null,"D.1.2.1",0]
[null,null,null,"D.1.2.10",0]
[null,null,null,"D.1.2.11",0]
[null,null,null,"D.1.2.12",0]
[null,null,null,"D.1.2.13",0]
[null,null,null,"D.1.2.14",0]
[null,null,null,"D.1.2.2",0]
[null,null,null,"D.1.2.3",0]
[null,null,null,"D.1.2.4",0]
[null,null,null,"D.1.2.5",0]
[null,null,null,"D.1.2.6",0]
[null,null,null,"D.1.2.7",0]
[null,null,null,"D.1.2.8",0]
[null,null,null,"D.1.2.9",0]
[null,null,null,"D.2.1.1",0]
[null,null,null,"D.2.1.2",0]
[null,null,null,"D.2.2.1",0]
[null,null,null,"D.2.2.2",0]
[null,null,null,"D.2.2.3",0]
[null,null,null,"D.2.2.4",0]
[null,null,null,"E.1.2.1",0]
[null,null,null,"E.1.2.2",0]
[null,null,null,"E.2.3.1",0]
[null,null,null,"E.2.3.2",0]
[null,null,null,"E.3.2.1",0]
[null,null,null,"E.3.2.2",0]
[null,null,null,"E.3.2.3",0]
[null,null,null,"E.3.3.2",0]
[null,null,null,"C.1.1.3",0]
[null,null,null,"C.1.2.9",0]
[null,null,null,"C.1.2.10",0]
[null,null,null,"C.5.1.2",0]
[null,null,null,"C.5.2.5",0]
[null,null,null,"C.5.2.6",0]
[null,null,null,"E.1.3.1",0]
[null,null,null,"A.5.3.1",0]
[null,null,null,"Grand Total",0]

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[]
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[]
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[null,null,"www.abulmajd.us",null,"khalidabulmajd@gmail.com"]

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