بِسْمِ اللهِ الرَّحْمٰنِ الرَّحِيْمِ

Abuhurairah Trust

Hospital SOP

Madem Madiha (Admin Hospital)

Hospital infection control committee  


NameControl Program
Dr Shumaila HussainMS of Hospital
Dr Adeel Medical Officer
Mr Rohail Akram Admin Officer
Kanwal Head Nurse
Muhammad Irfan OT INCHARGE
Murtaza Akhtar OT Technician
Irfan LAB Technician
Muneeba Pharmacist

The HICC supervise the implementation of the hospital infection control program

  • To ensure the proper conduct of steriliziation and disinfection
  • Ensure that by medical waste management is being carried out

Review and update hospital infection control procedures from time to time.

The Hospital infection control committee review meeting should be held every month.

Equipment List

Bionet(Cardio Care)
Hair AC
HSU 18LZA/011L(W)
Oxygen Cylender1

Operation Theator

 Operation Theator 
Anesthesia MachineWato Ex-20
Anesthesia Machine
Cardic Monitor
Suction machine
Suction machine
Daither Machine
Auto Clave
(Gas operate)
OT Light
12 Bulbs
OT Table
Wall Heater
Air ConditionerKEA2401S1


Weight Machine
Suction Machine
Suction machine
Ambo BagPeads1

Packing Area

 Packing Area 
Air Conditioner
RefrigeratorOR 114F1


BP Appratus
Pulse oximeter

OR 114F
Oxygen Cylender
Blood Glucos meterOn.callplus
Air Conditioner

Suction Machine7E-A1

Labour Room

 Labour Room 
CTG Machine
BP Appratus
BP Appratus
Delivery Table
Examination Laght
OT Light
4 Bulbs (Moveable)
Suction Machine
Weight Machine
Air Conditioner
Wall Heater
Oxygen Cylender1

Gynae OPD

 GEN/Gynae OPD 
BP Appeatus
Weight Machine
Altra Sound MachineAloka(SSD-1000)
Air Conditiner
Examination Laght
OT Light
4 Bulbs (Moveable)
Suction Machine
Weight Machine
Air Conditioner
Wall Heater
Oxygen Cylender
Air Conditioner
BP AppratusManual1

Medical Store

 Medical Store 
Air Conditioner

Gynae Ward

 Gynae Ward 
Air Conditioner
Wall Heater
Insect KillerSeco1

 Admin Office

 Admin Office 
Fax MachineKX-FP7011


N20 Regulator
02 Point
N20 Point
Fire Extinguisher

SOP’s For Obstterical&Gynaecological Ward

  1. Patients come here either from OPD admitted Gynecologist/ obstetrical surgeries on list
  2. Nursing staff have their own duty Roster
  3. Already worked up & investigated patients are prepared here for list
  4. Post Operative is also provided here once the patient is satisfied from operation theater
  5. If every thing goes well, patient, is usually discharged on 3rd&  sometimes forth post of operation day
  6. Diabetic Hypertensive Anaemic Patient are kept in the ward for a longer periods of time for pre operative preparation & post- of cure
  7. Those who are severely Anomic waiting surgery are treated by blood transfusions
  8. Blood transfusion register is maintained separately in addition to transfusion notes
  9. In addition to a regularly responsible WMO a senior consultant visit the ward daily in the morning hours and evening

 (Dr Shumaila Hussain M.B.B.S   Consultant Gynecologist)


Infection Prevention And Universal Precautions

Hand washing is the single most important measure for prevention for prevention of infection

Key points

  1. A safe injection does not harm the recipient, does not expose the provider to any avoidable risk and does not result in y waste that is dangerous for other people
  2. Use a sterile syringe and needle for each injection and to reconstitute each unit of medication
  3. Ideally, use new, quality controlled disposable syringes and needles
  4. If single –use syringes and needles are unavailable, use equipment designed for steam sterilization
  5. Prepare each injection in a clean, designated area where blood or body fluid contamination is unlikely
  6. Use single-dose vials rather than multi dose vials
  7. If multi-dose vials must be used, always pierce the septum with a sterile



It is essential for hospitals to have the protocols to deal with biological waste and contaminated materials. All staff must be familiar with them and follow them.

  • All biological waste must be care fully stored and disposed of safely.
  • Contaminated materials such as blood bags, dirty dressings and disposable needles are potentially hazardous and must be treated accordingly.
  • If biological waste and contaminated materials are not disposed of properly, staff and members of the community could be exposed to infectious material and become infected.
  • Disposal of bio hazardousmaterialsis time consuming and expensive, so it is important to separate non – contaminated material such as waste paper, packaging and non- sterile but not biologically contaminated materials. (Only 15% to 20% of medical wastes are considered infectious.)
  • Make separate disposal containers avail able where waste is created so that staff can sort the waste as it is being discarded. A three color coding systemwith blue for noninfectious  waste, white for infectious and yellow for sharps is recommended.(continued next page)


  • Organize thingsin a way to discourage the need for people to be in contact with contaminated waste.
  • All infected waste should then be treated of by steam sterilization or high temperature incineration equipped with emission control devices. Whenever feasible plastic material such as syringes or blood bags should not be incinerated.
  • Burying waste is the only option in some areas where not controlled landfill exists. If this is the case, you should do as much as possible to protect the burying site to prevent access and to avoid environmental pollution, especially for underground water sources.
  • Prior to burying, for safety infected waste can be disinfectedby soaking in a 0.5% hypochlorite solution for at least 30 minutes.
  • Do not waste mix waste chemicals, unless you are certain that a chemical reaction will not take place. This is essential to prevent any unwanted or dangerous reactions between the chemicals, which could endanger laboratory staff.
  • Always follow local guidelines on the disposal of waste chemicals to avoid any chemical contamination of the surrounding land or water supply
    • Provide a safe system for getting rid of disposable items such as scalpel blades or needles. The risk of injury with sharp objects increases with the distance they are carried and the amount they are manipulated.
    • A container for the safe disposal of sharp objects should be:
  • .Well labeled.Puncture proof, Water tight.Break resistant (a glass containerr could break and provide a serious hazard to the person cleaning up).Opening large enough to pass needles and scalpels blades, but never large for someone to reach in. Secured to a surface, such as a wall or counter, to ensure stability during use. Removable for disposal
    • These containers must then be disposed of safely.

    (They can be steam sterilized, then shredded and disposed of to a controlled land fill with municipal waste, encapsulated in a pit or any other options according to national protocols approved by the public health department and ministry of environment.)

    • Health- care workers and waste handlers should wear protective equipment such as gloves, apron, mask and be immunized against HBV.
  • A budget line for a safe waste management should be systematically included when planning a medical activity.


1.WHO surgical care at the District Hospital Manual 2003

  1. WHO Surgical Management of Solid Health – Care Waste at primary Health-Care Centers : a decision making guide 2005

        (Dr Shumaila Hussain M.B.B.S Consultant Gynachologist)

No Objection Letter

Re: Application for Turkey Visa Request.

It is stated that Mr Hamza Butt  S/O Obaid ur Rehman ID No: 35201-4822571-1is currently working with us as an administer officer from February 2012.

His monthly salary is 90 thousand Pak Rupees along with all allowances and bonuses.

Mr Hamza intends to visit to turkey Istanbul as he already visited before Istanbul and Antalya.  

We have no any hesitation for his tour of turkey due to our lack of the season and he can enjoy his holidays freely.

As Hamza is our one of the best of our team member and he will be happy to providing him return air flight ticket from our company.

We wish him to enjoy able holidays in Turkey.

Your Faithfully

SOP’s For Labour Room

Equipments Required

  1. Slipper Stand
  2. Clean Slippers
  3. Curtains for Privacy
  4. Drug Trolley
  5. CTG Machine
  6. Emerging try with drugs
  7. Mau tosh for delivery tables
  8. BMW BIN
  9. New Born Care Corner
  10. Open care systemradiant
  11. Pump Station
  12. Shadow less lamp
  13. Feto Scope
  14. Oxygen  cylinder with mask
  15. Episiotomy Lite

SOP’s For Labour Room

  1. Slipers stand should be present at the enterence of labour room
  2. The Labour Room should have tap of water and with facility of warm water when required
  3. There should be curtains in between eac table for maintainary privacy
  4. New born care corner(NBCC) should be present iside the labour room
  5. Instruments should be sterlized and arranged properly inside the racker use
  6. A list of instruments should be posted
  7. There should be two delivery tables in the labor room.
  8. Infection control measures n the labour room
  9. Cleaning of floors and other areas should be done as specified in the housekeeping SOP
  10. Cleaning of delivery tables
  11. The delivery tables should be covered with Mau tosh
  12. Maut Tosh should be first wiped with hypochlorite solution and then with disfectant.

Similarly any blood spilled area in the delivery table as well as floors should be first cleared with hypochlorite solution.

Management of labour Room

It should be one as per the SBA training protocols

Immediate Post Portum Care

  • Weight of new born is measured
  • Sanitory napkins are used
  • Assement of blood Loss is Done

By counting the blood soak pads

  • Vitals are monitoredat periodic intervals
  • Information of new born baby and mother are recorded in Labour Room

Essential Care of New Born Baby

Essential new born care is given including maintaining body tempreture maintaining airrway and breathing, breast feeding of new born,care of cord and eyes

New born care corner

Grading of Hypotherma

  • Temprature of room should be 37.50– 36.50c
  • Cold stress: 36.40 -36.00 c
  • Moderate Hypotherma: 35.90 -320c
  • Severe Hypotherma : 320 c

Management of Hypotherma

  • Record Actual body tempreture
  • Re warm a hypothermic body as posible

Severe Hypothermia……..Radiant Warmer

Management of SevereHypotherma

  • Keep under radiant warmer
  • Infuse I V 10% Dextrose @ 60ml/kg/day
  • Inject vitamin K 1.0 mg intra musular
  • Provide oxygen
  • Consider and ases for sepsis

House Keeping Protocol ForLabour Room

    • Radiant Warmers
    • Daily canopy and matteress should be cleaned with detergent solution and dried
    • Weekly throughout cleaning after dismantting weekly and every Time after shifting af body
    • Cots and mattresses
    • Clean daily with 3% phenoil or 5% lysol
    • Replace mattresses ahenever surface covering is broken
    • Suction Appratus
    • Suction bottle should contain 3% phenoil or 5% lysol
    • Suction bottle should be cleaned with detergent and changed daily
    • Change tube connected to bottle daily Flush with water and dry .
    • Use disposiblesuctoncatchter
    • Oxygen Nood
    • Clean with detergent daily and after each use

    5)Floors and walls

    • Walls and sinks must be cleaned with 3% phenoil 5% Lysol atleast once a day.
    • Wet mopping of the room should be done three times a day
    • Avoid sweeping and dry dusting

    6)Disposal of water and soiled linen

    • Water disposal bins with covers should be available
    • The bins must be kept covered and emptied at regular intervals
    • Plastic bags shoud be used in the bins and these bags should be sealed before they are removed
    • The waste bin Should be sealed before they are removed
    • The waste bin should be cleaned and washed properly under running water every day

    7)Needle and Sharps

          Discard in polar bleach a needle proof container     

  (DrShumaila Hussain M.B.B.S Consultant Gynachologist)

Normal  Delivery Set

  1. Sponge Holding Forceps
  2. Auvord Vaginal Specula
  3. Needle Holder
  4. Disseeting Scissor
  5. Sims Vaginal Specula
  6. Stainless Steel bowl
  7. Epi Scissor
  8. Kidney tray
  9. Artery Forces
  10. Kocher
  11. Outlet forceps
  12. Instruments storing tray with covers

SOP’s For Operation Theater

Preparing for hand Washing

Remove jewelry (rings, bracelets) and watches before washing hands.

Personel Protective Equipment (PPE)

PPE Includes:

  1. Gloves
  2. Protective eye wear (gorggles)
  3. Masks
  4. Aprons
  5. Gowns
  6. Boot/ Shoe Covers
  7. Caps hair Covers

Hospital Infection Control (HIC)

Prevention of health care Associated with infections (HIC)

Represents one of the major safety initiatives a hospital can undertake. A large number of patients admitted to hospitals acquire infections that were not related to the condition for which results in a considerable number of deaths and add to treatment costs.

Notification of Infection Control Committee

Wide representation from the relevant department

  1. Management Medical Superintendent/Administrator or AMS/DMS
  2. Medical specialist
  3. Surgical specialist
  4. Microbiologist
  5. Operation Theater in charge
  6. Infection Control Nurse
  7. Pharmacist
  8. In Charge CSSD
  9. In charge Maintenance
  10. In chare Catering
  11. In charge Housekeeping
  12. In charge Sanitary Services
  13. Bio Medical/ Civil Engineer
  14. In charge Training

A central Sterlization Services Department (CSSD) is Vital for an effective infection control and prevention program.

Accomplish the functions of sterilization, Collection/Washing Portaging, Sterile Processing, Sterile Storage, and sterile distribution.

The air moves from the clean area to the dirty area to avoid cross contamination.

Routh Areas have separate storage facilities.

There are adequate hand disinfection facilities.

Quality Assura

  1. SteRile / Storage
  2. Steilization
  3. Pack Aging
  4. Inspection Tray
  5. Cleaning Disinfection
  6. Transportation
  7. Use
  8. Transport

 (Dr Shumaila Hussain M.B.B.S Consultant Gynecologist)                   

 SOP’sFor new Born handling Over of baby to Mother and parentIn Labour Room + Gynee OT

  1.  For pregnancy, apply a newborn child (Tag) on the basis of the child .As a parent must name the name, gender, birth date, date
  2. The package will be given to parents only
  3. When the child is given to the parent, then the thumb and the signature on the registration must be written in NIC number time and date.
  4. All parents are instructed to keep their child safe
  5. Babysitter will be delivered to parents in presence of nurse

SOP’s For Obstterical&Gynaecological

   (8:00AM TO 2:00PM)(4:00PM TO 9:00PM)


 Patients Coming to the Hospital for Routine Check up


  • will come to the counter for slip
  • With slip, they will be guided to room where consultant with nursing staff is available
  • Antenatal  cards  are filled with proper history & B.P & weight checkup by a staff nurse, helper or by a LHV
  • Patients are seen in daily by the doctors in room in Room # 4 investigations advised, diagnosis made & treatment given as per requirement
  • Seprate slips are given for Lab Tests
  • After complete work up & treatment plan patient is either given to next plan with treatment or she is referred to Labor Room or Gynae ward for further management.

      (DrShumaila Hussain M.B.B.S Consultant Gynachologist)

SOP’s For Obstterical&Gynaecological& Emergency

  •    All patients will be seen by WMO on duty room # 4
  •    WMO on duty granted according to requirement
  •    A short history will require dinvestigation& prescription will be written on the slip
  •   Date and time along with the name and stamp of the WMO will be given on the slip attended by WMO in the Labor Room
  •   Detail History, Examination & investigations will be done to confirm the diagnosis
  •   Consultant duty will be to plan further management
  •   Labor Room & emergency operation Theater facilities will concerned staff consultant gynecologists and Anesthetists      are available throughout at the day and night and patients will be managed without delay

(DrShumaila Hussain M.B.B.S Consultant Gynachologist)

Protocols for safe Blood Transfuction

  • At least two samples (1cc citrated/ Non clotted blood groupings and 3cc non citrated/ clotted for cross matching and screening etc.) be sent in specific viral.
  • The sample virals be properly labled. (For names, ward ,bed, Red No, date and time etc.)

             Note: An improperly or non labeled samples will not be accepted.

  • Separate Trans fusion registers having following entries should be maintained. Name of patient (along with consent forms initials) and names of transfusion officials; blood grouping cross matching, and screening results etc. Including vital signs and transfusion responses after transfusion. Moreover, transfusion of blood and its components should include.

Consent form for blood OR blood component Transfusion duly signed by patient/Parent/Guardian. Suppose

  • Reception of blood component
  • Checking Labels on blood bag
  • Inspection of blood bags
  • Temporary Storage
  • Selection of blood infusion sets
  • Preparation of transfusion Site
  • Transfusion of Components
  • Transfusion reaction
  • Management of adverse reaction
  • Reporting of transfusion reaction to HIC through usage of blood transfusion reaction Investigation/ form.


Summary of Sop for Sample Collection Identification, Handling, safe Transportation, processing and disposal

  • Sample collection
  1. Wash hands before and after the collection
  2. Sterilized and disposable syringes are used for sample collection
  3. The area of blood collection is properly cleaned with alcohol swabs
  4. Collect or place the specimen aseptically in a sterile and appropriate divides the blood sample in respective vails as per refustione.g for chemistry, a plane vacutainer/vaccuta or gel vaccuta-iner/ vial is used for CBC as EDTA vial is used and for microbiologicaltests,sterile containers are used.
  5. Ensure that the outside of specimen container is clean and uncombined.
  6. Close the container tightly so that its contents do not leak during transportation
  • Identification
  1. The request form of the patient is allocated a number which is identification number. The same number is put on his sample and all the relevant recorded in computer/ register under the same identification number. The number also placed on test report
    • After receiving Specimen/ Sample from the phlebotomy section, the technologist at the receiving bench identifies the sample accordingly
  • Complete blood examination
  1. Blood collected in vacuum tube containing anticoagulant is process on a rotator for 20 minutes before performing testBio-ChemistrySamples are collected in vacuum tubes without anticoagulant, Serum is seprated by using centrifuge machine. The separated Serum is used to Perform the bio-Chemistry Test
  • Safe Transportation
  1. The Samples safely transported to the place of testing in the lab
  •  Processing
  1. After identification of the samples/Specimen, the processing of each sample is performed as follows Tests


  •  The CBC performed on automatic hematology analyzer and after processing the peripherals maar and ESR are also performed on requested sample
  • Routine Chemistry
  • The samples are performed on fully automatic chemistry analyzer

Special chemistry:

  • The samples are performed on elisa Machine after centrifugation
  • Molecular Biology
  • The samples are performed on state of the art machine Roter Gene


  • Test results are reported on printer forms which also shows the normal value ranges.

Disposal of Specimen:

  • Syringes needles are cut with a cutter,sharp are collected in prescribed box the rest in yellow polythene used for infectious.


  • Non infectious waste is collected in white poly thene bags. These bags are sealed and sent to temporary storage for on ward disposal in incise.

Suggestions for proper Sample collection and delivery of Lab reports

  • Sampling will be done in indicated sampling rooms only allocated for sampling purpose.
  • No lab Reports will be given to patient without skip having allocated number.

 (Dr Akif Qasim Pathologist)

Fire Plan:

Fire Emergency Evacuation Plan & Fire Procedure

  • Fire Ecacuation Strategy
  • Action on discovering a fire
  • Action on hearing the fire
  • Calling the fire brigade
  • Fire Fighting Equipment Provided

Personal Emergency Evacuation Plan
Simultaneous Evacuation:

  • As in most premise evacuation in case of fire will simply be by means of everyone reactting to the warning signal given when fire is discovered then making their way, by the means of escape, to a place of safety away from the premises.
    This is known as a simultaneous evacuation and will normally be initiated by the sounding of the general alarm over the fire warning system.

Action on hearing the fire alarm

  • The fire workers (Sultan Khan, Muhammad Rafaqat) on hearing the alarm, should proceed to pre determined positions to assist members of the public and staff to leave the building by the nearest safe route.
    Personnel should not re enter the building with the possible exception of the fire team.

Calling the fire brigade.

Responsibility of fire wardens

  • The fire service should also be informed immediatly by the person discovring fire, dependant on conditions.
    Remainder of staff (cleaners, caretakers etc) also to be conversant with procedure.

The fire wardens

The responcible person where necessary to safeguard.
The safety of employment nominate employes to implement certain fire safety mesures which will include the fire evacuation.
The general term used for these people are fire wardens
(1)Sultan Khan
(2)Muhammad Rafaqat

The Fire Wardens should be responsible For

  • Fire reutire and evacuation drill procedure.
  • Ensuring Personel known location of fire alarm point
  • Ensuring regular use of primary and secondary escape routes

Procedure for nominated staff to assist employes and members of the public to nearest exits

  • A senior fire warden should be made responsible for ensuring that notices are correctly sited the fire emergency evacuation plan is properly distributed under stood by all.

Fire Fighting Equipment Provided

  • A nominated fire team if available or any trained competent persomn should wear possible attack fire with appropriate equipment. However fire fighting is always secondary to life safety.

 Do Not put any persons at risk fire alarms and drills

  • Held at regular intervals records kept
  • There should be drills completed atleast once a year
  • Fire alarms and fire fighting equipment should be tested weekly intervals and records kept
  • Fire equipments regularly serviced liasion with emergency serviced.

 Place of assembly and Roll Call

  • Pre determined assembly point in front of hospital(Parkin Area) should be arranged and roll call of staff/patients.
    The person who is incharge of the assembly point should report to the person who has been nominated the fire service liasion person. Indicating all persons accounted for or whose missing and where they were last seen.

Types of fire

  1. Class fire (solid) : A fire that would be due to wooden, paper and clothes.
  2. Class fire (Liquids) : A fire that contains fuel oil or paint.
  3. Class fire (Gases) : A fire that falls due to natural gas or LPG.
  4. Class fire ( Metals) : Such a metal that is due to metal, such as aluminum and mechanism.
  5. Class fire (Electric Appliances) :  A fire that causes active electrical devices.

Fire Control Commetti , Rules and Responsibilities , Chief Fire Marshal Responsibilities

Dr Adeel Abbas/ C/N Naseem Fire Marshals
He/She is responsible for arranging periodic Emergeency drill
Muhammaad Irfan ,Murtaza ,Madiha Younis
Subsequent reviews to identify
Rectify any problems in Countered
Each appointed fire marshal shall seek to Maintain reasonable awareness amongest staff of the fire precautions with in the buildings.
In the event of an emergency check on the effective evacuation of his/her part of the building.
Assist staff together at the external assembly point.

Every staff member is responsible for maintaining fire safety by avoiding creating fire hazards with flameable metirials (carefull, storage,disposal) or sources of ignition (smoking,electrical equipments). Staff hosting visitors are required to draw theit attentions to the fire safety arrngements and to guide them out in the event of an evacuation.
  • Type of Material Burning and methods needed to deal with them wood paper textile fabric etc
  • Water extinguishers, Fire blanket (Glass Fibre) 
  • Burning Liquids Such as Solvents and petrolium Fuels
  • Foam extinguishers
  • Burning Liquids Electrical Fires
  • Powder extinguishers
  • Burning Liquids, Electrical Fires
  • Carbon Dioxide extinguishers

Evacuation Procedure

  • Evacuate the building and orderly maners.
  • Use closest exit route as outlined on map
  • Avoid using lift for evacuation
  • Take along your personal belonging,if possible
  • Switch off electric equipment before leaving
  • Assis others in need for help
  • Proceed to the assembly area
  • Do not enter the building unit announced.
  • Stay calm and do not panic

Safety Precautions against fire

Your Hospital and its safety against Fire

  1. Place your hospital furniture,equipment,etc in an orderly manners so that it does not create hurdel during emergency.
  2.  Remove unnecessery files,papers,furniture,items etc from your work station before you leave office.
  3. Combusstible metirial must be placed inside cover boxes at secure places.
  4. Smoking is strictly prohibited in the hospital
  5. Must ensure availibility of fire extingushires in your hospital as a mandatory item.

In Case of Fire

  1.  Try and extiguishe fire yourself using fire extinguisher
  2. Call for help
  3.  Inform Markaz Abu Huraira on following numbers
    Cell No: 0300-4880673
    Tell No: 04236531945
  4.  Immedidiatly switch off main electric board and gas supply valve
  5. Comtinue efforts to extinguishe fire till arival of fire fighters

List of Fire Control committee

NameControl committee
Dr Adeel Ahmad (Medical Officer) Incharge
Iffat Jabeen(Staff Nurse)Member
Naseem(Staff Nurse) Member
Khalid(OTA) Member
Murtaza(OTA) Member
Madem Madiha (Admin Gyne) Member
Muhammad Abbas (Security Officer) Member

This all staff can control any kind of emergency situation in hospital. This staff has already applied for better fire fighting training to government. We have already applied to rescue for our better training. Which will be held soon under rescue officers. We are trying to complete all the safety measurements to control the fire situation. We have basic equipments but  we are improving it. we have made a committee in hospital and this committee will be trained in better way by rescue officers soon. (Admin Officer : Ali Raza)