Joint Commission-Patient Safety & Compliance
Who is responsible for following and maintaining a safe work space in MaineHealth?
What is all Team Members
R.A.C.E - meaning
What is Rescue, Activate, Contain, Extinguish/Evacuate
When should sharp containers be replaced?
What is when sharps container is no more that 3/4 full,
Ceiling tiles, when do you replace?
What is stained, cracked or has a hole
Who is responsible for assuring that the patient's rights are respected and maintained at all times?
What is every team member?
How do you wear your badge?
What is Easily visible, above the waist, face out, not flipped over.
How do you use a fire extinguisher?
What is:
P- pull pin
A- aim nozzle
S- Squeeze
S- sweep
How can we protect patient's privacy and confidentiality?
What is Log out of computers when not in use or when unattended, medical records only accessed when required by job duties, do not leave papers with patient information unattended, provide information only to those permitted by the patient and do not discuss patient information in common areas.
Purple top wet time
What is 2 minutes
These audits, often performed monthly or quarterly, help maintain continuous readiness
What are compliance or quality audits (e.g., chart audits, hygiene audits)
What are two patient identifiers and when should they be used?
What is name, date of birth or MRN?
What is Check in, Check out and rooming
Location and /or locations of the Emergency Preparedness Binder
What is -
Check-in/front desk
Surg/Onc clinical area,
ACS/GS check-out area
These must be completed on time to demonstrate Joint Commission compliance with staff competency
What are annual mandatory education modules (LMS & CBO tools)
Hand Hygiene-This is the minimum points at which staff must wash hands with Alcohol based sanitizer or soap & Water
What is Before or after contact with patient or items in the patient's environment, before or after removing gloves
If you are speaking with a surveyor and don't know the answer (which is ok) what do you say
What is I would ask my supervisor or look at the Policy and Procedure site on intranet. (Simple say I don't know but where to get the information)
Do not guess answers
How can you bring forward a quality or safety concern?
What is complete a safety net, notify direct supervisor, make anonymous report the compliance hotline
Fire Pull Stations, how many and location
What is 3
outside both stairwells and next to elevators (NorDx pick up)
These documents, found on the MaineHealth intranet, describe proper handling, storage, and dangers of hazardous chemicals
What are Safety Data Sheets (SDS)
These two items must never be stored under sinks due to splash contamination risk
What are clean supplies and sterile supplies
No pillows :)
What actions can you take if a patient care error occurs
What is take immediate steps to ensure the safety of the patient, notify the physician, notify supervisor and complete a safetynet, contact HIM to remove from record if necessary
Policy and Procedures - how do you access
What is go to MaineHealth Intranet
This Joint Commission requirement ensures staff know how to handle emergencies like active shooters, fires, or cardiac arrests
What is annual emergency preparedness training
How long is a surgical consent good for?
Instruments labeled as “sterile” must undergo this process before reuse
What is high-level disinfection
Who Enforces the HIPAA Privacy Rules?
What is the Federal Government