Al Shifa Surgical Hospital

OFFIEC ORDER

It is notified to all members of Operation Theatre management Committee

.that meeting will be held on 03-02-2024 at 4:00 PM at surgeon’s office

Duration of meeting will be half hour.

It is requested to all Members of OTMC to ensure availability.

Agenda of Meeting

 Discussion on OT SOP’s
 Surveillance of OT
 Decisions to improve quality

CEO
AL SHIFA SURGICAL HOSPITAL
Al Shifa Surgical Hospital

Minutes of Meeting OTMC

Date. 03/02/2024 Venue. CEO Office

Time: 4 PM
Sr.# Agenda Discussion & Decision Responsibility Timeline Follow-up
Observations
1 CEO directed OTT to monitor OT temp OT- 01-12-2023 Next
OT Temp & Humidity Temp Maintained to 18- regularly, and maintain OT’s Technician to 31-01- Meeting
Monitoring 22 C’ on the day of List. Temperature as per SOP’s OT Attendant 2024
other days Temp remain Admin
20- 30 C’

2. CEO directed OTT to liaise with Bio-Eng OT- 01-12-2023 Next

Equipment maintenance All Equipment of OT is to Maintain and Calibrate Equipment’s Technician to 31-01- Meeting
maintained and calibratedon scheduled date. Remind him before OT Attendant 2024
by Biomedical Engineer date of schedule. Admin
and record is maintained Inform immedietly to admin if any
in LOG Book equipment of OT is malfunctioned
Directed to admin ensure rectify issue as
Last Calibrated and soon as possible
Maintained by

3. Emergency Medicine and CEO directed OTT and OTA to inform OT- 01-12-2023 Next
Inventory Management consumables maintained pharmacy staff about the list of Technician to 31-01- Meeting
by pharmacy Store In- operations and directed to pharmacy staff OT Attendant 2024
charge. to ensure availability of all medicine and Admin
Inventory Register of consumables demanded by OT –
Al Shifa Surgical Hospital

OT is maintained Technician.
In case of unavailability of any medicine
or consumable arrange before surgery
starts.
Directed Optometrists to ensure that lens
required in List of operations available.
Inform admin in case of unavailability.

4 Duty Roaster of OT CEO directed to Admin that OT and 01-12-2023 Next

Proper staffing and managed by CEO And labor staff strictly follows OT Roaster, in to 31-01- Meeting
supplies Admin case of Leave and emergency Absence 2024
Relieving Staff must be informed about
roaster.
And also gave direction to admin to
remind MO to ensure availability on day
of surgery, in case of unavailability he
must be inform to administration.
Admin will inform to reliever MO about
the duty on the day of surgery list

5 Pre Op protocols being Good, Keep Following SOP;s MO 01-12-2023 Next

Pre op protocols followed. Optometrist to 31-01- Meeting
followed OTT 2024

6 Consents forms Being Keep Following SOP’s of Informed MO 01-12-2023 Next

I. Consent form taken Consents Optometrist to 31-01- Meeting
OTT 2024
Al Shifa Surgical Hospital

7 Timeout protocol being Keep following Timeout protocols. MO 01-12-2023 Next

ii. Timeout protocols followed Optometrist to 31-01- Meeting
OTT 2024

8 a) Mopping. Moping , Carbolization CEO Directed to OT staff to carbolize 01-12-2023 Next

done daily, fumigate OT daily either list planned or not. And to 31-01- Meeting
b) Carbolization
1 day before surgery. Fumigate before and after the day of 2024
c) Fumigation Record is maintained surgery.
Ensure fumigate 30 hours before the
procedure.

d) Calibrating Equipment checked as CEO directed to Optometrist and OTT to

per standard. check equipment’s on the day start of
machines surgeries. And document that you had
checked all equipment and maintain
record.

e) Protocols of OT SOP’s are being Keep following SOP’s

followed
entering in OT

Gases cylinders CEO Directed OTT’s to maintain gas

f) Gases Supplies maintained supplies and remain in contact with gases
suppliers for prevention of shortage in
emergencies.
Al Shifa Surgical Hospital

Procedure done by given CEO direct OTT’s of make list of

g) Procedure
list of surgeries. procedures on priority of emergency,
Schedule need of surgery and availability of
surgeons.

CEO directed to supervisor to monitor all

things and report periodically
9 Swab culture reports Swab Culture done CEO directed to OTT’s and supervisor to Admin 01-12-2023 Next
every 06 month of each And reports were do swab culture on scheduled date. OTT to 31-01- Meeting
OT clear. Directed to OTT to contact with 2024
laboratory and ask them to plan schedule
to get culture swab from AC air Filter
also as per PHC Guideline
10 Surgical site infection 01-12-2023 Next
Rate SSI Rate = 0 % Good, Keep Following SOP’s to to 31-01- Meeting
Maintain the 0 % infection rate 2024
Total # of Operation of
Dec & Jan:13

Total # of Follow Up
Patients of Dec & Jan:

Total # of SSI of Dec &

Jan: 0

CEO
AL SHIFA SURGICAL HOSPITAL
Al Shifa Surgical Hospital
Al Shifa Surgical Hospital

ATTENDANCE SHEET OTMC MEETING

Date. 03-02-2024 Time 4 pm

Sr. No Name Designation Signature

CEO
AL SHIFA SURGICAL HOSPITAL