BUSTAMANTE CHILDREN’S HOSPITAL OPERATING ROOM ROOF A LEAK

The Bustamante Hospital for Children provides medical, surgical, specialist and
diagnostic services for children up to 12 years of age. The Hospital has a bed capacity of 283
including a 5 bed Intensive Care Unit that provides critical care service to critically ill
patients.
The areas audited were the Neonatal Nursery, Accident and Emergency Department,
Intensive Care Unit and Operating Theatre Suite.
NON-CONFORMANCES
Accident and Emergency Department
Patient’s lavatories are immaculate
a) Cleaning procedures and methods are not in accordance with standards.
b) Chemicals are not labelled and need to be stored away from the children.
c) Medical records are not being completed according to standards.
Intensive Care Unit
a) The central AC unit is defunct. 3 split units are being used.
b) There is no ICU Policy and Procedures Manual available within the unit.
c) There are no dedicated ICU beds. The beds from the wards are being used. These
however are not able to be tilted and have the necessary changeable positions for
efficient patient care and resuscitation.
d) The storage area is congested with the same room serving for counselling, lunch
room, overnight room, meetings and storage.
e) There is no changing room or shower for staff.
f) Lockers are needed for staff to keep their personal items.
g) Containers for the collection of trapped sputum are not available.
h) Monitors are old and at times unreliable.
i) Additional back-up ventilators are needed.
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Operating Theatre Suite
a) Access areas are not clearly delineated.
b) Cabinets for the storage of sterile supplies etc are door-less, in different stages of
disrepair and scattered in various parts of the O.T suite.
c) The main storage room is disorganised. This does not facilitate any form of
inventory control or the rotation of items to prevent wastage due to items becoming
outdated.
d) A cleaning schedule is to be developed and documented with clear SOPs for the
janitorial staff and Patient Care Assistants. There is too much individualisation in
the preparation of cleaning solutions.
e) A monitoring schedule for the assessment of Infection control practices is to be
prepared.
f) Janitorial staff are not provided with utility gloves and mops of the appropriate
quality or quantity.
g) The OT doors are in a poor state. Hinges are rusted and functioning poorly, windows
are broken and some have termites. The majority of theatre doors are unable to be
properly closed.
h) Sterile items are being passed through the sluice room. This is unacceptable.
i) The janitorial staff assigned to the operating theatre requires training in the proper use
of the cleaning materials.
j) There is need for the overall standardisation of the cleaning and disinfecting solutions
to be used in the high risk areas.
k) There is no monitoring of the health or immunisation status of staff working in the
OT suite.
l) The recovery room has a leaking roof