INSPECTION REPORT

I. General Information:

Region/ Zone/ City Name of facility Type of Facility

s Addis Ababa Federal Police GH

II. Description of the Inspection

 Follow-up
III. Findings
1. Emergency service

Practice:

 The emergency side laboratory were not available

Premise:

 Instrument processing room were not available

Product

The following products were not available:

 Defibrillator
 Lumbar brace
 Pelvic binder
 Hard board
 Pericadiocentesis set
 Portable ultrasound
 Oxygen concentrator
 Fluid warmer
 2. Internal Medicine service

Practice:

 The following written protocols and procedures were not available at

internal medicine service
 Consultation and the management of the medical conditions in the unit
 Admission and discharge criteria specific to the service;
 Visitors policy Transfer and referral of patients
 Monitoring and follow-up of patients

Premises:

 The following premises were not available:

 nursing station service at OPD
 Isolation room
 Physician office
 store room
3. Intensive Care unit (ICU) Services

Practice

 There was no policy or protocol available that state availability of 24 hours access for the
services of advanced diagnostic facilities.
Premises:

 ICU setup was not located in access restricted area

 The following ICU premise layout were not available
 changing station
 washing facilities
 devoted area for nursing management for the care of intermediate patients
 full glassed nurses’ station / telemetry monitoring system and utility room
 duty room
Professionals

 There was no assigned anaesthesiologist for the ICU service

4. Gynecology/Obstetrics service
Practice
 The gynecological and obstetrics services had no written protocols and procedures for the
following activities.

 Antenatal care  Manual removal of placenta

 Follow up of labour  Assisted delivery
 New born care  Infertility
 Postnatal care  Admission and discharge
 Immunization  Transfer and referral
 Administration of antibiotic,  Infection prevention
oxytocin and anticonvulsant  Pre- and post-operative care

 There were no emergency obstetric and new born care (BEmONC) and comprehensive
emergency obstetrics new born care (CEmONC) for 24 hours a day.
 The following non-emergency maternal health services were not available.
 Comprehensive Abortion care (CAC)
 Adolescent and youth sexual reproductive health unit (AYSRH)
 Gender based violence /GVB/ sexual violence/SV/ first line support unit
 There was no emergency kit for PPH and pre-eclampsia).

Premises

Maternity ward
 Maternity ward didn’t have patient privacy and confidentiality.
 Additional one delivery couch was required for delivery room.

Operation theatre:

 There was no shower service in OR.

 There was no clear zonal demarcation.
 No operation theatre equipment and sterile supply store.
  Scrub sink was not appropriate for scrubbing.

Changing room

 Only one changing room was available for female and male.

Outpatient OBGYN service

 Procedure room was not easily cleanable and materials were rusted
 The following rooms were not available in outpatient service.
 Adolescent and youth SRH unit and gender-based violence first line support room
 Comprehensive Abortion care (CAC)
 Family planning procedure room

Emergency and inpatient service

 Obstetric emergency /labor triage and gynecology emergency room were not available.
 No OBGYN septic room

Products

 The following products were not available in the immunization service.

 MUAC tap
 EPI monitoring
 Height /length scale
 The following products were not available in the family planning and procedure room.
 Overhead light
 Garbage bin
 Instrument tray
 Shelve and cabinet
 Inpatient Gynecology Procedure had no the following equipment’s
 Delivery couch rusted
 3-section screen
 Stethoscope
 BP apparatus
Equipment for Maternity ward:
 The following products were not available in the maternity ward
 Refrigerator with temperature control
 baby cot,
 over bed table
 bed screen

Maternity ward Nurse Station

 There was no crash cart (with sufficient equipment’s including defibrillator, intubation set and
resuscitation including mother and neonate).
Maternity ward cleaners’ room
 The following products were not available in the maternity ward cleaners’ room.
 Cleaning trolley
 Mop
 Worktable
 Pail with handle
 There were no products for maternity ward kitchen, Milk formula room, and Nursery as per
the standard
Labour bay
 There was no wall clock, bedside cabinet and waste basket use office bin.
Delivery room
 The following equipment was not available for in the delivery service.
 bowl and stand,
 kick bucket stainless steel
 wall clock
 bed screen
 trolley for oxygen
 IV standard
 Baby coat
 Infusion pump
 mayo table
 ceiling mounted light
  new born care table only one
 Mobile examination light

Operation theatre:
 The following equipment were not available in the operation theatre service
 kick bucket
 stool
 coagulation unit, electro mobile 200W
 infusion pump
 IV fluid pressure bag
 swab count record board
 bowl and stand
5. Pediatric service

Practice:
 The following written policies and procedures were not available at paediatric service
 The age below which Patients admitted to a pediatric service
 Admission and discharge criteria specific to the service
 Transfer and referral of patient
 Monitoring and follow up of pediatric patients

 The unit didn’t avail updated reference materials, treatment guidelines and manuals (e.g.
national TB, Malaria, ART etc.)
Premises
 The following premises were not available:
 Separate emergency service
 Room for severe acute malnutrition
 Adequate toilet facilities for patients
 Milk preparation room

 NICU service didn’t have zonal demarcation with changing area and hand washing facilities.
 There was no dedicated isolation room for the inpatient service.
Product:
 The following equipment’s were not available on the respected units;
OPD
 Otoscope,
 Ophthalmoscope
 Reflex hammer
IPD:
 ECG machine
 Radiant heat source
 Sufficient infant size oxygen mask
 Paediatric size endotracheal tubes
 Laryngoscope
NICU
 New born size endotracheal tube
 Laryngoscope,
 Butterflies
Premises

 Staff changing room had no shelves, hand washing basin, toilet and shower for each.
 Scrub area sink was not a wide
 There was multiple cracks and toilet leakage from OR roof
CSR

 There was no reception, sorting of equipment’s and decontamination process room

 There was no room for storing and shelving sterile equipments
 There is also a decontamination and food plate washing area in same room.
 There was only one functional autoclave and no back up autoclave.
 There was no washable and metallic rack shelves
Recovery facilities

 There was no monitor for 3 beds

 There was no a 1.2m gap between beds
6. Surgical and orthopedic service
Practice

 The following written policy ,procedure and protocols were no available at the Surgical and
orthopedic service

 The management of surgical condition.

 Nursing care plan for patients undergoing surgery.
 Safe surgery checklist to all patients undergo for surgery.
 The appropriate safety before, during and immediately after surgery including aseptic
technique, sterilization and disinfection, selection of draping and gowning.
 sending pathological specimen
 surgical activities done at outpatient level, surgical referral clinic, follow up clinic, minor
operation and orthopedic procedures.
Minor OR

 There was a high traffic area

 There was no mark on the floor for restriction of movements of unauthorized person and /or
person without suit.
 There were no utility room, nurse station, toilet and cleaners’ room
Profession

CSR

 There was no Nurse professional in CSR service

Products

 The following products were not available in the surgical ward

 Pillows
 Chairs
 Hand washing basin
 The following OR sterile supply equipment’s were not available
 Locked intramedullary nail set
 Orthopedic bed with fixtures
 Rush nail set
  Thomas splint
 Flexible nail set
 Hamby knife with blade
 The following equipment’s were not available in the OR room
 Time clock
 Stools
 Swab count record boards
 Infusion pump
 The following equipment’s were not available in recovery area
 Oxygen concentrator
 Defibrillator
 Pedal bin
 Mobile examination light
7. Dermatology Service

Practice

 The dermatology service didn’t have the following written protocols and procedures ,
 patient admission, and discharge
 Referral and transfer of patient ,
 Appointment of patient ,
 patient care,
 management of specific service
Products
 The following products were not available

 Thermometer  minor set

 Examination lamp  Phlebotomy set and other
 Wood lamp  Cautery machine
 Dermojet,  Equipment for electro cautery
 Dermatoscope,  Cryotheraphy machine
 Punch biopsy set
 Equipment for cryosurgery and storage for liquid nitrogen
 8. Otorhinolaryngology (ORL) service

Practice

 The following written policies and procedures didn’t available at for ORL service.
 Admission and discharge
 Management of specific service
 Transferring and referral of patient
 Appointment of patient
 Visitor policy
Premise

 The ORL service didn’t have the following facility

 Hand washing basin

 ORL diagnostic and procedure room

 Nurse station

 Shortage of water

 The examination room wasn’t spacious enough to handle the equipment, the staff & the patient

Professional

 There was no ENT trained nurse

Product
 the following products weren’t available:

ORL Service Unit Product

OPD  Compressed air system
 Sterilizer(Not functional)
 X-ray view

Major OR  Cold light source

  Myryngoplasty sets
 Rhinoplasty sets
 Septoplasty sets
 Neck dissection sets
 Laryngoscopy
 Otoplasty sets
 FEES sets
 Parotidectomy sets
 Adeno-tonsillectomy sets

Minor OR  Resuscitation trolley

 ENT OR table with head set

Diagnostic service  Tympanometry

9. Dentistry service

Practices

 The Dental service didn’t have the following written protocols and procedures
 Admission and discharge
 management of dental condition
 consultation,
 Referral and transfer of inpatients/outpatients.
 The following dentistry service were not available
 Implant and pre-prosthetic surgery
 Facial cosmetic surgery
 Dental laboratory for orthodontic and prosthodontic service
Professionals

 The following professional was not available at dental service

  Dental Therapist
 Dental technician
Products

 The dental services didn’t have the following equipment and instrument:

a) instruments for filling treatment

 Matrix retainer
 Proximal trimmer
 Carves
b) Materials & instruments to keep the area free from moistures & to improve visibility
 Rubber dam equipment
 Clamps (different type, posterior & anterior, mandibular & maxillar)
 Universal rubber-Dam clamps forceps
 Rubber- dam punch
 Holder young frame
 Automation
c) Equipment for sterilization
 Super-heated steam under pressure (Autoclave)
 Cotton roll sterilizer
 Different pans use for disinfections & sterilization of instruments
d) Equipment used for amalgam restoration:
 Amalgam mixing machine (Amalgamatory)
e) Other rotating instruments:
 Mandrel (straight and latch type)
 Carborundum, Silica, Crocus, discs and stones
f) Hand cutting instruments:
 Enamel Hatches  Gingival margin Trimmer
 Enamel chisel  Angle former
 Discoid-cleoid  Dental Hoe
g) Other surgical instruments
 Farabeut  Mouth props
 3rd molar retractors  Contouring pliers (Number 112,114,118,800,417

10.Ophthalmology service

Practice

 The following services weren’t available in the ophthalmology services:

 Keratometry
 Ultrasound examination
 Visual field examination
 The ophthalmology service didn’t have following protocols and procedures:

 Admission and discharge

 Referral and transfer of patient
 Follow up and monitoring of patient
 IPC
 Penetrating eye injury
 Glaucoma management
 Red eye
 Corneal laceration
 Surgical interventions

Premises

 OPD of ophthalmology service didn’t have the following premises:

 Clean utility room
 Sterilization area/room
 Store
 The minor OR service didn’t have the following layout
 Changing room
 Hand washing basin

Products
  The following products weren’t available:
 Eye pad
 IOL
 Lang stereo test
11.Mental Healthcare Services

Practice

 The following written policy procedure and protocols were not available at mental healthcare service
 for the management of the psychiatry conditions
 the admission, and discharge of patient
 consultation
 transfer and referral of patient
 follow-up of psychiatric patients
 The following services were not available as part of the program of the psychiatry care unit;
 Group therapy;
 Mental rehabilitative services; Psychological service
 ECT
 substances use disorder’ detoxification and treatment
 There were no safety and security precautions for the prevention of suicide, assault and patient
injury.

Premises

 The following rooms were not dedicated for psychiatry service;

 ECT (Electro convulsive therapy) procedure room
 Outpatient layout;
o Waiting area of psychiatry wing; lobby with public telephone, TV area, gender
specific toilet
 Room for providing injection
 Day room/dining room.
 Space for structured physical exercise

Product
  The psychiatry OPD didn’t have the following equipment’s;
 Weighting scales for adult and children
 Examination couch, medicine trolley and Cup board
 Hand washing basin for OPD
 The psychiatry inpatient didn’t have the following equipment’s;
 ECT
 Self-inflating bags for respiratory support, masks
 Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
 Self-inflating bags for respiratory support, Masks, endotracheal tubes,

12.Laboratory service

Practice

 The laboratory did not have policy and procedure for preliminary lab result analysis and
utilization of results
 The lab request form did not provide space for the appropriate anatomic site where sample is
taken from
Products and diagnostic tests
 The following products/tests were not available in the hospital laboratory service
Serology

 Toxoplasma latex

Liver function test

 GGT
Hematology

 The following tests were not being done due to reagent stock-out
 Reticulocyte count
 Prothrombin time
 PPT
 INR
 13.Blood transfusion

Premises

 There was no protocol for adverse transfusion reaction (ATR) identification, investigation, and
management
 The national guideline for appropriate clinical use of blood and blood products was not available
 Written consent signature was not being taken from patients or care giver
 There was no transfusion follow-up form
Premises

 There was no water supply (under installation)

 There was no Telephone for the service
Professional

 There were no permanently assigned lab professionals for the service (lab staff)
Products

 The following products were not available:

o Timer
o Anti-human globulin anti-sera

14.Pathology service

Practice

 The pathology service did not have written procedures and protocols
 There were no system for paraffin blocks maintained in the service
 The service did not have quality control and assurance (QA) mechanisms
 The pathology service was not providing histopathology service
Premises

 The following premises were not available for the pathology services:
 Specimen reception and recording room(9sq.m)
 Preparation/tissue processing and staining room (20sq.m)
 Grossing and sectioning room (20 sq.m)
 Laboratory staff room
Professional

 The pathology service didn’t have a receptionist

Products

 The pathology service didn’t have the following products:

a. Gross room
 Dissection table with cold and warm water
 Wheeled chair
 Tissue shelf store
 Leak-proof garbage container
b. Cytology examination room:

 Mobile examination light

 Fume extractor
 HE staining table (placed in other room)

c. Chemical reagent store:

 Fume extractor

15.Radiology service

Practice

 The following written policies and procedures were not available

 Safety practices;
 Emergencies;
 Adverse reactions;
 Management of the critically ill patient;
 Infection control, including patients in isolation;
 Timeliness of the availability of diagnostic imaging procedures and the results
 Quality control program covering the inspection, maintenance, and calibration of all

Product:

 Fluoroscopy service was not available in the unit

 Radiation workers were not checked periodically the amount of radiation exposure
  The radiological equipment quality assurance/control test was not available
 CT and MRI examinations were not interpreted within eight hours.

Premise: Patient toilets (male/female) was not available within the imaging unit

Product

 The following products were not available

 portable ultrasound machine
 Mobile x-ray machine
 mammography machine
 resuscitation equipment’
 refrigerator
 procedure set
 lead glove
 dosimeter
16.Pharmaceuticals Service

Practice

 Standard operating procedure for dispensing and medication use counseling was not established and
posted to ensure patients’ safety and correct use of medications.
 All medicines to be dispensed were not labeled and the labels shall be unambiguous, clear, legible
and indelible.
 Individualized information for patients with chronic illnesses was not kept.
 Policies, guidelines and procedures for reporting any errors or any suspicion in
administration or provision of prescribed medications were not available.
 Emergency pharmacy service were not opened for 24 hours
 Written procedures/SOPs for hospital based pharmaceutical preparations were not
established for preventing errors, medicine/medicine interactions and medicine
contamination.
 licensed pharmacists shall be responsible for the preparations of various pharmaceutical
formulations such as eye drop preparations, dosage form changes, extemporaneous
preparations, IV infusions and IV admixture when deemed necessary by the hospital.
 Appropriate stability evaluation were not performed or determined using international
standards for establishing reliable beyond-use date to ensure that the finished preparations
have their expected potency, purity, quality, and characteristics, at least until the labeled
beyond-use date.
 Written procedures and records doesn’t exist for investigating and correcting failures or
problems in compounding, testing, or in the preparation itself.
 Medicine preparations compounded in the hospital were not packaged in containers
meeting standard requirements mentioned under the official national or international
standards for such preparations.
 Clinical pharmacy services was not available
 An ADE (adverse drug event) focal person was not appointed who is responsible for the
collection, compilation, analysis and communication of adverse drug reaction, medication
error and product quality defects related information to the DTC and then to regulatory
body.
 Daily medicine consumption at different outlets of the hospital were not recorded,
compiled and analyzed for the appropriate supply and use of medicines.
 Filled prescriptions were not signed by the dispensing pharmacist.
 There were no policies and procedures to control the administration of narcotic drugs and
psychotropic substances with specific reference to the duration of the order and the dosage
in accordance with relevant laws
 The administration of all controlled substances to patients were not carefully recorded into
the standard record for controlled substances and returned back to the pharmacist upon
refill of controlled substances
 All partially used quantities of controlled substances were not recorded in to the control
substance record and returned back to the responsible pharmacist for control substances for
disposal
 Controlled substances were not returned to the pharmacy if they are left and not
documented by a licensed pharmacist responsible for controlled substance handling in the
hospital
 The hospital did not submit regular report to the appropriate organ regarding the
consumption and stock of controlled drugs
  The hospital did not have policies and procedures for the provision of clinical pharmacy
services
 Written procedures were not available for the return of expired, damaged, leftover and
empty packs from outlets to medical store to prevent potential misuse.

Premises

The area(s) of counselling were not arranged or constructed in such a that it provides adequate space, have
professional look and ensure reasonable privacy to the patient at all times and eliminate background noise as much
as possible.
 Compounding premise were not maintained adequate, clean and ventilated

Products

 There was no thermometer for refrigerated items

 Adequate compounding supplies were not available
17.Physical therapy service
Practices:
 There were no specific treatment and/or procedure protocols for each service available and
rendered in the unit,
 There were no written orders given to patients when patients are discharged with exercise
or treatment to continue at home.
Premises:

 The entrance of the physical therapy service was not disable friendly and was not smooth
pavement rail for wheelchairs
Professional
 There was no trained and certified therapist available and supervise daily sessions of
physiotherapy.
Products

The following equipment’s were not available for rehabilitation services:

 exercise mat
 Bo bath balls/ gym ball
  Trade mall
 Goniometers
 Reflex hammer
 Educational toys
 Crutches
 Pillows, different size
 Dumbbells set with different weight

18. Pre facility service

Practice:

 The ambulance consumables were not be checked, refilled.

 The ambulance shall didn’t have telephone/radio communication means

Professional:

 Two Emergency medical technician/health professional trained on EMT shall not available
 The driver was not be trained on first aid and basic IPC.

Product:

The pre facility service of the hospital didn’t have products in accordance with the the general
hospital standard.

19.Medical recording

Practice:

 The hospital didn’t have following written policies and procedures

 Procedure for recording Completion
 Conditions, Procedure , and fees for releasing medical information
 Procedures for the Protection of medical record information against the loss tampering
alteration, destruction or unauthorized use.
Premises:
 There was not supply/ Storage room

Products:

 The following products weren’t available in the medical record service:

 Standard reporting Format
 Log book
 fire extinguisher
20. . Infection Prevention and control service
Practice:
 The following infection risk-reduction activities were not performed properly:
 Appropriate use of personal protective equipment’s
 Laundry and linen management
 Operation of the mortuary
 Providing IPC training for all Hospital staffs as per the national infection prevention and
control guideline recommendation
21.Sanitation and waste management
 Reusable containers for infectious medical waste and general medical waste were not
decontaminated each time.
 Waste segregation was not takes place at the source properly.
 There was no waste management plan in that hospital that clearly shows from storage to
disposal.
22.Laundry service
 The laundry was not uses leak-proof containers for all textiles..
 The staff didn’t follow special guidelines for textiles used in isolation areas for patients
with highly infectious diseases (e.g., viral hemorrhagic fever).
 Processing areas for soiled textiles was not physically separated from areas used for
folding and storing clean textiles.
 The Hospital was not use color coded /labeled containers for collecting and transporting
used textiles.
 The staff was not transport collected soiled textiles to the processing area in closed bags,
containers with lids, or covered carts.
 Water supply
 There was no water safety plan.
 There was no reliable drinking-water point accessible for staff, patients and attendants at
all times.
Premises:

 The Hospital laundry service didn’t have separate areas for:

 Collection and sorting of soiled linen Washing, drying area.

 Ironing and Clean linen storage and mending area room
 Separate entry and exit door
 There was no soiled linen storage room / area.
 The construction of the placenta disposal pit was not appropriate as per the standard.
 There were not surgical waste and ash pits.
Professionals:

 There was no functional IP committee.

 All staffs of the hospital were not trained on the new basic IPC.

Products

 The following products/equipment were not available

 Shelves

 Dryer machine/drying rack /line was not functional

 Irons

 Covered wheel barrows (to transport linens to/from Wards )

Personal Protective Equipment

 Gown (dietary)

 Masks (shortage in laundry)

  Boots (for dietary service )

23. Food and Dietary service

Practice:

 There were no written policies and procedures for all dietary services.

 There was no diet order prescription.

 The dish washing system was not appropriate.

Premises:

 The following minimum facilities were not available for dietary services

 Janitor’s closet
 hand washing facilities in the toilet
 Approved automatic fire extinguisher system in range hood.
 Cart storage
 Dish washing sink with three compartment
 Pot washing sink
 Cart cleaning sink
Professional

 The hospital dietary service unit was not directed by licensed dietitian or catering chef or
food science personnel.

 The food handler’s routine health examination was not according to the standard (it should
be every 3 months).

24. Morgue service

Practices:

 The hospital did not have the following written policies and procedures for morgue (dead
body care) services.
  Confirmation of death by physician, identification of the body, recording and
labeling;
 Safe and proper handling of the body to prevent damage and this shall be
according to the patient religion and culture;
 Safeguarding personal effects of the deceased and release of personal effects to the
appropriate individual or family;
 Proper handling of toxic chemicals by morgue and housekeeping staff;
 Infection control, including disinfection of equipment as per IP standard;
 Identifying and handle high-risk and/or infectious bodies;
 Release of the body to the family shall be as immediately as possible;
Premises

 The hospitals did not have dead body refrigerator or cold chain room

 The morgue premises didn’t have ,Hot and cold water sink

Service Score

Service Score

Emergency Service 86%

Internal Medicine 73.58%

Pediatric Service 72.58%

Surgery & Orthopaedic Service 58.9%

Gynecology & Obs Service 62.5

Intensive Care Unit Service

Mental Health service 65%

Dentistry Service 68%

69%
ORL Service

Ophthalmology Service 67%

Dermatology Service 68%

67%
Physical therapy Service

Radiology Service 71%

Medical Laboratory service 94.4%

Pathology Service 57%

74%
Pharmaceutical Service

Blood Transfusion Service 74%

Ambulance service 62.5%

Medical Record Service 79%

59%
Infection Prevention Service

52%
Food and Dietary Service

54%
Morgue Service

Inspectors Name
S. Name of Inspectors Signature
no
1. Mr Jemal Mohammed
2. Mr Aseged Bekele
3. Dr Awoke Andualem
4. Ms Rahema Ibirahim
5. Mr Gashanaw Aserat
6 Mr Kemal Bedaso
7 Mr Sami Muhamed
8 Mr Sirak Damitew
9 Mr Neway H/Mikial
1 Sr Nigist w/Selassie
0