Safety
Emergency and Downtime
Patient Care
Projects and Performance Improvement
Policies and Procedures
100

Call 0-Risk to report this

What is a patient/visitor injury?

100

This individual is the department contact for emergency information

What is the Clinical Nutrition Manager or Associate Director?

100

These orders are seen as soon as possible not to exceed one day

What are consults and inpatient clinical requests?

100

This workgroup streamlines charting through updating flowsheets, smartlists, smartphrases, and Smartforms

What is the Epic workgroup?

100

This is the time it takes to appropriately wash hands according to CLN0452

What is 20 seconds?

200

Orange top disinfection wipes are used for this

What is C-Diff?

200

Navy is the color of this folder in the Emergency Operations Plans

What is Downtime Procedures?

200

Two priority patient identifiers (including for phone and video visits)

What is full name and date of birth?

200

This workgroup ensures all cheat sheets are up to date and updates Clinical Practice Guidelines quarterly

What is the Clinical Nutrition Resource Management Workgroup?

200

This is the location of where your badge is worn

What is above the waist, unobstructed and free of decoration?

300

This is where you report safety incidents

What is the Safety Reporting System?

300

RACE stands for this

What is rescue, alarm, confine, and extinguish?

300

Physical findings of NFPE measure this

What are subcutaneous fat and muscle loss?

300

These metrics are presented at annual QAPI meetings each February

What is completion time for consults and PNS (inpatient and ambulatory), inpatient RD reach, and malnutrition diagnosis percentage?

300

This is approved annually by the Executive Committee of the Medical Staff for approval, most recently in March 2024

What is the Diet Manual?

400

This action is used to immediately address and prevent potential harm

What is Stop The Line?

400

This is used to prioritize inpatient and outpatient care during downtime

What are the most recent BCA reports?

400

Documentation of patient care must be done within this time frame (inpatient and ambulatory)

What is one calendar for inpatient and three business days for ambulatory?

400

This framework ensures standardized terminology to describe the characteristics of food and drinks with aims to be culturally sensitive, measurable, and applicable to all age groups in all care settings

What is the International Dysphagia Diet Standardization Initiative?

400

The number of days before all restaurant/home-prepared food items brought in for the patient expires 

What is three days beginning on the date it was placed in the refrigerator?

500

Actions to take when there is an active shooter in patient care areas

Wat is Avoid, Deny, Defend?

500

During recovery, paper clinical downtime forms are sent here

What is Health Information Management?

500

When a patient might be at risk for suicide, apply SAVE, which stands for this

What is Stay with the patient, Activate assistance, Validate feelings, and Evaluate the environment for safety?

500

This workgroup created Clinical Nutrition's NFPE skills competency checklist

What is the malnutrition workgroup?

500

Two policies MDACC follows requiring timely entry of information in the patient's medical record

What are CLN0555 (Medical Documentation Policy) and CN602 (Nutrition Assessment and Documentation of Nutrition Care Policy)

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