Category Archives for "Quality"

Continuous IV Checklist

Administering Intravenous Push Medication Through an Existing Infusion (Continuous IV)


Start hand hygiene and wear a suitable glove.


Check doctor order and review patient file for allergies.


Check medication compatibilities with current active medications.


Verify rate of administration.


Start preparing the required dose.


Verify correct patient.


Assess IV for signs and symptoms of infiltration or phlebitis (and if present, stop until new IV site is obtained).


Turn off IV by turning off pump and/or clamping the tubing directly above the access port.


Swab access port with alcohol or other antiseptic agent according to institutional policy.


If medication is not compatible with IV solution, flush IV line with 2 to 5 mL of normal saline before administration of medication. If medication is compatible with IV solution, normal saline flush is not necessary; continue to next step.


Connect medication syringe to access port via needleless adaptor.


Pull back on plunger of syringe to observe blood return (which verifies placement of IV in vein).


Gently instill medication over required time frame (typically 2 to 5 minutes).


Assess patient carefully during administration for any adverse reactions.


Disconnect syringe when medication is completed.


Flush IV line with 3 to 5 mL of normal saline, instilling at same rate of medication administration in order to administer the medication left in tubing at proper infusion rate.


Turn IV back on or unclamp tubing, then readjust rate appropriately.


Dispose of syringe in sharps container.


Remove gloves, perform hand hygiene, and document medication administration.

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The communication structure Identify, Situation, Background, Assessment and Recommendation (ISBAR) was created to standardise the effective transfer of information in the US armed forces. ISBAR was adopted by the public health service in the 2000s




Introduction (Hello Dr. my name is) 

  • Who are you?
  • Where are you?
  • Patient's name, age, gender and department


Situation (What’s this about?) 

  • I'm calling because... (describe)
  • I have observed major changes... (ABCDE)
  • I have measured the following values...
  • (RR*, Sp020, pulse/heart rhythm, BPA, capillary refill time, etc...)
  • I have received test results...


Background (Brief & pertinent info) 

If it's urgent and/or you are concerned — speak up.

Brief and relevant case history

Admission diagnosis and date

Previous illnesses of significance

Relevant problems and treatment/interventions to date



Assessment (Your analysis and consideration of options) 

  • I think the problem/reason for the patient's condition is related to (respiration, circulation, neurology).
  • I don't know what the problem is but the patient's condition has deteriorated.
  • The patient is unstable, we need to do something.
  • I am concerned.


Recommendation (What do you want the physician to do?)

I suggest.../What interventions do you recommend?

  • Immediate intervention
  • Investigation/treatment
  • How often should I...

When should I next make contact? When will you be here?

Confirm messages and interventions with a closed loop.

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Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Are you familiar with range orders for medications like MORPHINE 2-9MG IV Q6hr PRN at your facility? Does your hospital policy contains any restrictions on these orders?! And in case of a ranged order; how does the nurse determine the exact dose to be given and at which frequency?!

Where I work, we do allow them, and the nurse is giving all the needed training for pain assessment. We’re also using an electronic system, where prescriber must enter the required indication for each scenario. And not leaving the medication order prune to error and assumptions of the other healthcare staff.

Other hospitals might only allow one range... perhaps dose or maybe frequency! Yet, in both cases, the physicians must clearly enter the required dose range [i.e. for pain score 1-3 give 2MG, for pain scale 4-9 give 4MG …. etc.]

In some cases if the physician does not specify – the lowest dose and shortest frequency are used. A nurse must start at the lowest dose unless the patient has recently received a higher dose of the medication (or equivalent)

During the doctor's entry for the ranged order, they were using a free text field, and that doesn’t really help our clinical support system. That's why in most cases we had to verify the ranged doses manually and double checking them while dispensing and administration.

For orders with insulin doses from our insulin pumps and doses from our PCAs; ranged orders are required.

For non-pain medications, we instruct the nurse to start low and assess for effect, then proceed as necessary to address the condition.   Also have a Pain Management policy that guides the nurse to choose the pain order and dose that matches the pain score obtained from the assessment of the patient pain medication asks the prescriber to choose a Pain severity (mild, moderate or severe), all of which have scores assigned to them in the policy. For example, if the dose range is 1-2MG when mild pain, and the patient expressed the higher end of that range, then the nurse would choose 2MG.  If there are multiple products ordered, the nurse first picks the one attached to the pain score and then determines the dose which gives the nurse a guideline, but allows some flexibility in adjusting to the patient response.

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A common medical abbreviation for urgent or rush. From the Latin word statum, meaning 'immediately.'

Often used in medical contexts.

The patient's heart just stopped working.
We need a defibrillator in here stat!

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Analysis of Medical Records


How to Analysis of Medical Records

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Medical Record

A record of health information uniquely assigned to a single person generated by one or more encounters and maintained in written paper base or electronic format, or a combination of both,. The health record connects the physicians and other caregiver's entries. Included-but not limited to - in this information are patient demographics, progress notes, problems, medications, medical history, and post-operative summary (if applicable), laboratory data, radiology reports and discharge summary.

Quantitative Analysis

check and analyze the components parts of the Medical Record to ensure
that it is complete, adequate and accurate and its available at all times for legitimate needs of the patients, the hospital, and the Physician.

Qualitative Analysis

A review of medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete.

Completion of Medical Records

Completing the medical records, which are deficient in number of forms or contents as per the established standard. The medical record staff reviews each case and notes down the deficiencies and (doctors visit the MRD weekly and complete them) verify with concerned staff.

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Tips And Guidance After Tonsillectomy

  • The patient is given fruit juices except (orange-lemon)3-4 hours after operation as small doses and after that ice cream (without nuts) – jelly.
  • Chewing gum helps a lot to return the throat muscles to normal.
  • Starting from the second day of the operation; it is advised to eat soft foods such as (eggs – bread – butter – rice – jam – pasta – vegetables) and not rely of beverages and liquids
  • Stay away from solid food (hard) or added spices (spicy food).
  • Do not avoid talking because of throat pain, because talking helps throat muscle movement return to their activity that accelerates healing.
  • After going back home it is advised to stay on bed and return to the activity and movement gradually.
  • Back to school is a week after the operation.

Common things could happen and do not have to worry about:

  • 1
    High body temperature on the day of the operation may occur but it will return to normal rates as soon as the return of bowel movement.
  • 2
    Vomiting may occur after the operation as a result of interaction with anesthesia drugs
  • 3
    Throat and ear pain is expected and it is advisable to use pain killer, such as ACETAMINOPHINE like products.
  • 4
    A change in the voice (twang), but is usually a temporary change.
  • 5
    The presence of a white layer on the place of the tonsils and stays for 1-2 weeks until full recovery.
  • 6
    When there is bleeding, you should go immediately to the hospital (emergency room)
  • 7
    Do no hesitate to contact our doctor if there is any question.

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Colorectal Cancer

The colon is the last part of the intestines which called the large intestine and it connects the small intestine with the anus with the length of about one meter and 60 CM. It absorbs water and salts which leads to solid stored stool until taken out and the rectum is the path that connects the colon with the anus.

What is colorectal cancer?

It is a cancerous tumor that may affect any part of the colon and rectum; affects men and women alike. Colorectal cancer ranked first in the kingdom of Saudi Arabia in terms of the spread of the disease according to recent statistics and is the second largest type of cancer leading to death, affecting about a third of patients who are infected due to lack of early detection of this type of tumor. Therefore, early detection is very important because most of these tumors grow over long periods and then converts it to be difficult to eradicate and treat; so we recommend the importance of the periodic medical examination after the age of fifty for early detection of these tumors. 

  1.  Early detection of colon and rectum tumors and their discovery at an early stage means treatment and full recovery of them.
  2. Periodic preventive screening for the detection of polyps and eradication may reduce the incidence of colorectal cancer by about 90%
  3. The early detection of cancerous tumors in the colon increases the chance of successful treatment and reduces the mortality rate resulting from this disease.

What are the factors leading to the high incidence of this type of cancer?

There are certain factors that increase the incidence of the disease by two or three times of the normal rate; including:

  • A family history of occurrence of the disease; if a family member has the disease or found that more than one individual in the family is infected with the disease, the percentage of the tumor incidence increases, especially if this member close to first class(father or mother or sister or brother or son)
  • Ulcerative colitis, chronic inflammatory increase the incidence of such tumors.
  • Previous infection with a tumor or polyps may increase the incidence of this tumor again. Especially when the infection at an early age less than 50 years.

There are some factors that may lead to increased incidence of such tumors such as:

  1. Eat meals rich in fat and meat and low in fiber and weight gain.
  2. Lack of physical activity such as sports and others.
  3. Smoking

How can we prevent colorectal cancer?

  1. Eating enough calcium may contribute to reducing the incidence of colorectal cancer.
  2. Continuous physical activity may reduce the incidence of such disease.
  3. Eating foods rich in fiber and reduce fat intake may reduce the incidence of such tumors.
  4. Most people who are at risk of colorectal cancer may require early frequency tests than others.

Symptoms of colorectal cancer:

Most patients do not have any symptoms

Symptoms of colorectal cancer:

Most patients do not have any symptoms of the disease, but there are some indicators; such as:

  1. Severe constipation, especially in the elderly; therefore advised doing a colonoscopy in such cases.
  2. Blood with stool, especially after the age of thirty could mean the presence of tumors or polyps in the colon or rectum.
  3. Severe chronic abdominal pain, especially after the age of forty.
  4. Underweight.

What is the plan for early screening of colorectal cancer?

  • An early screening process for colorectal cancer begins for people aged over 5O years.
  • When there are other factors to increase the incidence of such tumors, such as genetic reasons or inflammatory ulcerative colitis and other, only rely on the colonoscopy and at an early age from 20-year.
  • Early screening options for colorectal tumors.

There are many options for early screening for colon tumors including:

  1. Occult blood test in the stool.
  2. Colonoscopy
  3. Colored colon X-rays.


First: Occult blood test in stool: It is known that colon cancer can cause bleeding in the intestines which may be very small quantities and cannot be seen with the naked eye, so the detection of occult blood in the stool helps in the diagnosis process.

How effective is this test?

  • If this test is done every year, it leads to avoid or reduce the number of death resulting from colorectal cancer by about a third.
  • It is not the optimal test to detect polyps.
  • It must be done annually.

Second: colonoscopy (see colonoscopy brochure):

  • Colonoscopy is considered the most accurate examination of reliable early screening for the colon and rectum tumors and it is safe examination if it is conducted by endoscopy specialist.
  • This endoscope is repeated every i0 years.
  • Removes any polyps detected during endoscope, which takes from 2-3 minutes.

Third: Colored colon X-rays:

  • The preparation process for this screening is similar to the colons- copy process to be drinking the same solution as well as put a tube in the rectum to inflate the colon to examine the colon walls accurately.
  • In the case of suspected tumor or the presence of polyps, a colonoscopy must be done, or take a sample or remove these polyps.
  • Most studies indicate the inaccuracy of this type of screening for early detection of colorectal tumors; therefore, it has been replaced in many centers with (CT-Colonography).

Forth: (CT- Colonography):

  • This type of scan is considered as one of the new scans for early detection of colon tumors.
  • Initial studies indicate the effectiveness of this type of scanning for the early detection of colon and rectum tumors, as well as in the detection of polyps larger than 1 cm.
  • In the case of suspected tumor or the presence of polyps, a colonoscopy must be done, or take a sample or remove these polyps.
  • The preparation process for this screening is similar to the colons- copy process to be drinking the same solution as well as put a tube in the rectum to inflate the colon to examine the colon walls accurately.
  • This scanning is repeated every 5 years if there are no tumors or polyps.

Finally, remember, dear reader, the colon and rectum tumors rarely can be avoided and the early detection ensures full recovery of them.

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Arteriovenous (AV) graft and/or fistula precautions



  1. Arteriovenous (AV) Fistula – is the surgical creation of an internal vascular connection, created by joining a vein directly to an artery.
  2. Arteriovenous (AV) Graft – is the surgical creation of an internal vascular connection, created by interposing a fabric or Teflon tubular graft between a vein and an artery.
  3. Thrill – is the vibrating sensation created by pressurized arterial blood striking the walls and valves of veins as it circulates through the graft or fistula.
  4. Bruit – is the swishing turbulence sound heard by using a stethoscope or Doppler, created as blood flows from an artery to a vein inside a graft or fistula.

It’s important to define the standards for the care of patients with AV grafts and fistulas in order to minimize clotting, trauma, and infection.

Make sure that:

No veni-punctures on the extremity designated for access creation.
Put an AV Graft/Fistula Precautions sign at the bedside when the patient is identified for access creation. Ensure that patients ID band is not on the extremity to be used for access creation. Teach the patient and family how to care for the graft or fistula.

Make sure that:

Palpate the AV graft and/or fistula vascular access for a thrill and auscultate for a bruit every eight hours and document ongoing assessment.

Make sure that:

If patient is for surgery, ensure that the patient is positioned for his/her operative procedure in such a manner to avoid putting undue pressure or obstruction to the access extremity.



Observe the access site closely for bleeding and bruising, inspect for approximation of suture line. Auscultate for bruit, and palpate for thrill over access site every hour post access creation for 4 hours, then every 4 hours for 12 hours and then every 8 hours thereafter.


Notify physician if no bruit or thrill are present, bleeding occurs, or if suture line edges are not closed.


Ensure that dressing and clothing are loose over the access site.


Stop any bleeding with only direct, localized pressure. Do not use wrap-around elastic bandages over access extremity.


Absolutely no veni-punctures or blood pressure measurements should be performed on access extremity.

Post Hemodialysis Treatment (for Ward and ICU Nurses):


Observe access site closely for signs of unusual swelling, bruising, heat, redness or pain.


Palpate for thrill and auscultate for bruit over access site upon receiving patient to the ward and then every 8 hours. Notify physician immediately if no thrill or bruit is present.


Observe access site closely for bleeding.


Notify physician immediately if bleeding is observed. Use only direct localized pressure over bleeding access site. Does not use wrap-around elastic pressure dressing.


Remove band-aids, plasters, from needle sites six hours after hemodialysis treatment, or the next morning.

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Basic Concepts of Healthcare Quality

“Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge.”  – Institute of Medicine (IOM)

There are three aspects of Healthcare Quality

  1. Measurable Quality
  2. Appreciative Quality
  3. Perceptive Quality

Measurable Quality

  • Compliance with, or adherence to standards.
  • Standards may take the form of practice guidelines or protocols, or they may establish acceptable expectations for organization performance.
  • At their best, however, standards serve as guidelines for excellence.

Appreciative Quality

  • Comprehension and appraisal of excellence beyond minimal standards and criteria, requiring judgments of skilled, experienced practitioners and sensitive caring persons.
  • Peer review bodies rely on the judgments of like professionals in determining the quality and nonquality of specific patientpractitioner interaction.

Perceptive Quality

  • Degree of excellence that is perceived and judged by the recipient or the observer of care rather than by the provider of care.
  • Quality as perceived by the patient is generally based more on the degree of caring expressed by physicians, nurses, and other staff than on the physical environment and technical competence.

According to Avedis Donabedian, structure, process, and outcome are merely kinds of information we use to draw inferences about the quality of care. 


The arrangement of parts of care system or elements that facilitate care. 

  • Resources 
  • Equipment 
  • Number of staff
  • Qualification of staff
  • Work space


Refer to the procedures, methods, means or sequence of steps for providing or delivering care, producing outcomes.

  • Clinical process
  • Care delivery process


Refers to the results of care, adverse or beneficial


  • Short term
  • Complication


  • Long-term health status
  • Activities of daily living


  • Patient / family satisfaction

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Fixing applications failing to start with error “api-ms-win-crt-runtime-l1-1-0.dll not available”

Yesterday I faced this issue while trying to launch few applications on my windows 7 PC.

Error while launching an app
The program can’t start because api-ms-win-crt-runtime-l1-1-0.dll is missing from your computer. Try reinstalling the program to fix this problem.


The missing dll api-ms-win-crt-runtime-l1-1-0.dll is installed with a Windows update. To resolve this issue, download and install the Update for Universal C Runtime in Windows from Microsoft.

This update applies to the following operating systems:

  • Windows Server 2012 R2
  • Windows 8.1
  • Windows RT 8.1
  • Windows Server 2012
  • Windows 8
  • Windows RT
  • Windows Server 2008 R2 Service Pack 1 (SP1)
  • Windows 7 SP1
  • Windows Server 2008 Service Pack 2 (SP2)
  • Windows Vista SP2


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