EOC
When does EOC checks have to be completed
Within 1 hour of the beginning of each shift
What are ILSMs?
For Life safety deficiencies that cannot be immediately corrected, Interim Life Safety Measures (ILSM) are put into place. What are our active ILSM?
What is the criteria for storing medical equipment?
Disinfection prior to storage is important to prevent spread of harmful bacteria.
Once cleaned, tag should be placed on item if applicable to indicate state of device.
All equipment in storage room are clean to prevent contamination of other clean equipment in same room.
What is our silent knight?
The ward pill crusher, it should be free of residue and weekly rinsing is documented.
Critical tests/results have to be communicated to providers within what time frame?
60 minutes of receving results! and it must be documented with the provider you contacted (FIRST AND LAST NAME) and the subsequent actions taken!
How many O2 Tanks can be in the oxygen room?
What is, no more than 12; this is to ensure we do not exceed 300 cubic feet of gas in a smoke compartment
Did you know unsecured tanks increase the potential to create a "missile" hazard should the cylinder fall? This why it is important to put away unsecured O2 cylinders
What are the specific details about the eye wash station? Temp of water? Where its positioned?
caps should be in the closed position
water should be tepid (60-100F)
pressure should not overspray onto the ground
How do you activate a code?
if you are outside the hospital tower (911)
if you are in the hospital tower (code Blue)
How often are access rosters updated outside the Medication rooms?
Monthly
the pharmacy RX destroyer is full! What do you do?
Call pharmacy to have the disposal RX destroyer replaced
How do we identify if patient nutritional items are not expired?
They are either stored in plastic bags brought up by nutrition with the expiration date on them, or have expiration dates clearly labeled on the item.
Why can we not prop doors open or tape strike plates to prevent proper latching?
Propped doors jeopardize the smoke compartment by allowing smoke to pass. Taping strike plates are security access and fire safety violation.
Where do we access translation services and hearing impared services?
Language Line Desktop icon!
When are insulin vials discarded?
28 days after opening
Who can turn off a clinical alarm?
Clinical alarms systems should not be turned off without a written order by a LIP with clearly defined reasons for turning off the alarm. Patient care staff shall NOT disable/silence an alarm without first assessing the patient.
Can we have corrugated boxes with outside shipping labels on the floor?
No! Outside shipping boxes are reservoirs for dust, vermin, and bacteria. Storing these next to clean and sterile supplies puts patients and staff at risk.
You opened an EKG electrode pack, but did not use up all the stickers-- what do you do?
Water Infection Control Risk Assessment? (WIRCA)
This is the water management plan to identify any water stagnation points within all buildings and mandates water testing for bacteria. (done annually; and identified high risk stagnation points require weekly flushing)
The water advisory flushing is a separate policy set by command to mitigate the issues of sediment in the water system. (done weekly/reported monthly)
Can we have pill cutters on the floor?
Yes! Only if assigned to a specific patient.
What is IPASS?
I- ILLNESS SEVERITY
P-PATIENT SUMMARY
A-ACTION LIST
S-SITUATION AWARENESS AND CONTINGENCY PLANNING
S-SYSTENSIS BY RECIEVER
How far off the ground and the ceiling do supplies have to be?
20 inches from the ceiling ( nothing may be stored closer than 20 inches from the ceiling to allow unobstructed water spray from sprinklers when triggered to extinguish fires)
8-10 inches from the floor, and the bottom shelf must have a plastic barrier ( supplies can become contaminated from dirty mops; the plastic barrier protects against splashes)
What logs are required for glucometers? how do you label QC vials?
They require temperature and humidity logs, QC vials need to be labeled (initials, open date, exp date (90 days after opening) and there should be no loose lancets outside the original box. Additionally-- Alcohol swabs cannot be left outside boxes, expiration dates are not printed on individual alcohol swabs.
What are the procedures when you have an SI patient visitor?
SI binder at charge nurse station; visitors have to be screened by security prior to visiting the patient.
Which labels do we use for medications?
The hospital approved yellow syringe labels; this is because it has the template with all the TJC requirements
What is the difference between Code Green and Code Violet?
Green is violence from the patient
Violet is Staff/Employee workplace violence situation