Joint Commission Basics
Name one of the 2021 National Patient Safety Goals
and give an example.
1. Improve the accuracy of patient identification.
2. Improve staff communication.
3. Improve the safety of medication administration.
4. Reduce patient harm associated with clinical alarm systems.
5. Reduce the risk of healthcare-associated infections.
6. Better identify patient safety risks in the hospital.
7. Better prevent surgical mistakes.
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
30 Minutes
When approached by a JC surveyor what is the first thing to do?
1.) Run fast in the opposite direction
2.) Welcome them to your area
3.) Act like you do not speak English.
What is "tracer methodology"?
Surveyors analyze a ASC's systems by following individual patients through the process of their surgical procedure, evaluating multiple care units, departments, and services rendered to the patient.
Who is our Safety Officer and who is our Compliance Officer?
Larry Craig
Abby Winowich
What do you tell a surveyor if you do not know the answer to their question?
"I do not know, but I can get the answer for you from the resources we have here"
What is HIPAA? Name one way protected health information is kept private in your department?
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a patient's PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC and lock screen.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) identifiers used at NMSCO when doing your introduction and nursing assessment, and during time-out. Patient's FULL name, and patient's FULL birthdate.
If asked a question and you know the answer, what is the best way to respond?
Just the facts. Only answer the question they are asking and do not elaborate of go off subject.
Name the components of a complete Time-out here at NMSCO?
Entire Surgical Team verbally confirms surgeon, correct patient (using full name and DOB), procedure, side, site, (read off of signed consent), allergies, abx, and that a marked site is visible after draping.
(Additional items can include implants, local medications, length of procedure and special equipment)
1) What should you do in the event of a Minor hazardous material spill? 2) For Major Spills?
1) Check the MDS book and follow instructions 2) Evacuate patients and staff away at a safe distance and alert the safety officer.
If asked "tell me what the process is for a needle stick in the OR" what should your answer be?
Isolate dirty needle, and remove from field, break scrub and thoroughly cleanse the affected area before returning to the procedure, alert a charge nurse to arrange for a blood draw, fill out an incident report.
What does MSDS stand for and where can you find it?
Material Safety Data Sheets, behind the O.R. Desk
what is the answer to "where are your Policies and Procedures kept and who has access to them?"
They are kept on the (V:)drive, also known as the public shared drive and everyone has access to them.