Patient Rights & Safety
This federal regulation requires hospitals to provide patients with a written statement of their rights, including confidentiality and informed consent.
What is the Patient Bill of Rights?
The Joint Commission requires that all medical records be completed within this number of days following patient discharge.
What is 30 days?
PASS - P- Pull the pin A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
What does the PASS acronym stand for?
The survey process used by the Joint Commission to assess healthcare organizations.
What is Tracer Methodology
Behavioral health hospitals must have policies for reporting and managing these events that involve serious harm or death.
What are Sentinel Events?
Under Joint Commission standards, this type of patient restraint or seclusion must be used only when less restrictive interventions have failed.
What is a therapeutic restraint or seclusion?
This type of documentation must be completed every 15 minutes for patients in restraints or seclusion.
What is patient observation documentation?
R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
What does the acronym R.A.C.E stand for?
This is awarded upon successful completion of an on-site survey which is conducted by a specially trained Joint Commission surveyor or team of surveyors who assess the organization's compliance to JC standards.
What is accrediation?
The Joint Commission requires behavioral health facilities to have this type of evacuation plan in case of emergencies.
What is a Fire and Disaster Plan?
According to Joint Commission standards, suicide risk assessments must be conducted at these specific times during a patient’s care.
What are upon admission, during changes in condition, and at discharge?
The Joint Commission requires behavioral health hospitals to document this type of assessment within 72 hours of admission.
What is a comprehensive psychosocial assessment?
Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
What are always to reduce the risk of health-care associated infections in your department
Every three years.
What is how often the Joint Commission conducts accreditations.
To maintain emergency preparedness, hospitals must conduct these exercises twice a year.
What are emergency response drills?
The Joint Commission’s Speak Up program encourages patients to do this regarding their treatment and safety.
What is ask questions and advocate for themselves?
This type of review is required after a serious patient safety event to identify root causes and prevent future occurrences.
What is a Root Cause Analysis (RCA)?
18"
What is Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
The Joint Commission requires all staff to receive training on this federal patient privacy law.
What is HIPAA (Health Insurance Portability and Accountability Act)?
During a community disaster, hospitals must be prepared to sustain operations for this minimum number of hours without external assistance.
What is 96 hours?
In behavioral health settings, ligature risks must be identified and addressed as part of this specific safety plan.
What is the Environmental Risk Assessment?
According to Joint Commission standards, all treatment plans must be individualized and reviewed at this frequency for long-term inpatients.
What is every 7 days?
In behavioral health units, all furniture, fixtures, and equipment must meet this type of design requirement to prevent harm.
What is ligature-resistant/free.
All direct care staff must complete competency assessments in this timeframe after being hired.
What is annually and during new hire orientation?
Joint Commission emergency management standards require behavioral health hospitals to establish this backup system for critical patient information.
What is an Electronic Medical Record (EMR) contingency plan?