Page 76 - MALAYSIAN PATIENT SAFETY GOALS

ROLES AND RESPONSIBILITIES OF NURSES

1. Education and Training
a) Continuous Nursing Education in the unit/ department/

hospital
b) Orientation and Mentor-Mentee program to new
nurses who report duty and those transfer in to the
Intensive Care Unit.

2. Practicing Standard Of Precaution ( SOP)
a) strict adherence practice to 5 moments of hand hygiene

b) Procedure is conducted following the four key components:
i) Maximal Barrier Precautions - strict sterility during
procedure

ii) Chlorhexidine 4% skin antiseptic
iii) Optimal catheter site selection
iv) Daily review of Central Venous Catheter (CVC) at

8pm everyday until catheter is removed.
- Remind the doctor on the line necessity with prompt
removal of unnecessary line.

c) Ensure the catheter are properly anchored after
insertion and cover with transparent dressing. Date of
insertion is written on the transparent dressing.

d) Change transparent dressing and perform site care with
a Chlorhexidine - based antiseptic every 7 days or
whenever necessary if the dressing is soiled, loose or damp.

e) Change all infusion tubing within 72 hours and for lipid
infusion to change within 24 hours.
f) Ensure all the hub of the catheter is clean properly

using alcohol swab before infuse any drugs.
g) Immediately notify doctor when there are sign and symptom
of infection.

h) Change all stoppers to needleless stopper.
i) Cover all central catheters with sterile towel or follow
the unit policy.

j) Cohort or isolate infected patients.
k) Accurate and prompt documentation
3. Monthly surveillance audit sent to State Health Department and

Ministry.

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