General requirements of NABH Safe-ITSM

  • Minimum 80% of nurses should be trained on Safe-I at any point of time.
  • 100% ward in-charges should be trained on Safe-I
  • There should be1 trainer for every 30 nurses
  • Hand washing culture should be implemented
  • All HCW should be Hep B vaccinated
  • Nursing Superintendent will be responsible for maintaining nurses standard requirements.
  • Safe injection protocol should be in place
  • Safe infusion protocol should be in place
  • Functioning Infection control committee in place
  • NSI, BBF reporting system and PEP policy should be in place
  • Biomedical waste management policy in place
  • Records of Infection Control should be maintained and shared with the NABH Safe-ITSM secretariat
  • Re-use of the syriges should not be done
  • Re-use prevention syringes should be used
  • NSI should be prevented by using bedside disposal procedures (sharps collectors)
  • NSI during IV cannulation should be prevented by using Safety IV cannula
  • Surveillance mechanism for VAP, CRBSI, UTI, NSI/BBF, Phlebitis, SSI should be in place
  • Improper reports should be actioned upon by management
  • Posters & protocols on Injection & infusion safety, infection control, biomedical waste management should be exhibited in every nursing station.
  • All doctors should be trained on Safe-I
  • Safe-I committee will be formed with Institution head, Medical Superintendent, Nursing Superintendent, Pediatrician as compulsory members (In places where such faculty are not available, senior management would be a part of this)
  • Safe-I certification is for a period of 2 years, with reassessment happening in second year