Environment of Care
Who is the DFC Medical Director
Shelby Neal, MD
How do we report a workplace injury?
The Green bandaid on the clinical work stations or by calling EOWH.
Who is our Infection Prevention Liaison at Duke Fertility Center?
Ashley Joseph
Who is the patient safety liasion at Duke Fertility Center?
Cammie!
What do we do if a patient is upset and would like to escalate their concern?
1. Offer clinic leadership
2. If further escalation is needed, give patients information to Patient Relations
3. Contact The Joint Commission at # listed on poster in lobby
What is your role in the event of a fire?
Remove all patients
Activate the alarm
Close all doors
Extinguish the fire by using PASS if able (Pull, Aim, Squeeze, Sweep)
What tools do we have in place in the event of a security event?
-Panic Buttons, overhead paging, rooms that lock
-Badge Access only Doors
-yearly drill review
Please articulate how to properly use the disinfectant wipes?
It's based on the situation and the IFU/Label of container.
How do we ensure that we have communicated effectively with our patients?
-Translation services if needed via interpreter
-Learning screening 1x year - ask our patients the best way they receive information!
-AVS given/explained
When completing the weekly check offs on the autoclave, what is required to ensure our autoclave is working properly and how long are instruments sequestered for?
Verification of sterilization from BI (biological indicator) and instruments must be sequestered until BI is resulted and recorded.
Where is the best place to find the instructions for use for our equipment?
The intranet (demonstration required) OR our IFU binders located in Kim's office
What is the process for patients who do not have a government issued ID?
Verify all demographics including name, DOB, address, telephone number, last 4 of SS# if applicable.
DFC answer: if creating life, they must present an accepted form of ID
Please articulate when soap and water must be used instead of alcohol based hand rub
enteric precautions (vomiting or diarrhea - needs soap and water) or visibly soiled.
When should specimens be labeled?
In the presence of the patient with confirmed name/DOB on label
Please name the 6 rights of medication administration
Right patient, right drug, right dose, right route, right time, right indication
How do you know a piece of equipment is ready to be used? How do you know if it cannot be used? Ex. an US machine
It has a gray Clinical Engineering tag on it that is checked yearly.
If equipment is broken/not functioning per MIFU, it should be removed from service, a repair request ticket entered and copy of it with DO NOT USE taped to the front of it.
What do you do in the event of an active shooter?
Run, Hide, Fight.
What is the process when the Trophon2 cleaning fails?
Run it again. If it fails again, contact Clinical Engineering
What do you do if you suspect abuse and/or neglect?
Front Desk: report to provider/charge nurse immediately if patient reports abuse, has bruising, timid behavior during check-in
MA/RN: Call the patient back alone so provider can talk with them, PHQ-2 screening. In the state of NC, universal mandating reporting for children under the age of 18
How does the clinic complete performance improvement projects?
utilizing the DQS (Duke Quality System) ie - daily huddles, "see something - say something," PDSA (plan/do/study/act), Just Do Its, A3
What is the DFC scope of service and where is it located?
The scope of service is located in the redbook and outlines "the story of our clinic." Ie, the age range of patients (all ages) that we see as well as what conditions/procedures/types of visits we complete such as Obstretric care, gynecologic care, cervical cancer screenings etc.
What are the ways that we protect informational security?
Lock workstations when not in use, turn over paper to shield patient information, empty temporary shred bins at the end of each day, patient information is locked/secured at the end of each day, report PHISH activity
How do we prevent mistakes in surgery/procedure?
DHIP Time Out Policy that includes documentation of the following:
1. Correct Patient
2. Meds/Allergies Reviewed
3. Site marked (if applicable)
4. Correct procedure documented
5. Clinical personnel in room documented
6. Consent verified
7. Preprocedure pregnancy test
if provider leaves the room and comes back, time out must be done again; anyone can initiate the Time Out procedure
What is a sentinel event?
A type of patient safety event, not primarily related to the natural course of the patient’s illness or underlying condition, that reaches a patient and results in any of the following:
Death
Permanent Harm
Temporary Harm
What should our peel packs have on their labels after sterilization? Where should this be written?
labeled with date, load #, and initials of person packing on the plastic coating of the peel pack (must not be on the paper)