Formerly known as JCAHO, name was changed to this in 2007.
What is The Joint Commission (TJC). Hard to believe the name changed happened that long ago!
100
Locate your MSDS/SDS information.
What is on the intranet, MSDS (under department) or Patient Safety the online e-binder is found
100
4545 for the hospital or 911 for adjacent/offsite buildings.
What number to call in case of an emergency? These numbers are also located on the back of your badge buddy along with the emergency codes. If staff have panic buttons they need to know how to use this and who the button alerts.
100
These are placed in the patient record upon admission, when cardiac monitoring is initiated, when change in rhythm, initial rhythm during a RRT or Code, Rhythm change, and post RRT or Code.
What is EKG Rhythm strip
100
Identify patients correctly, improve staff communication, use medicine safely, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery.
What is the 2016 National Patient Safety Goals
200
Doctors, Nurses and Office staff
Who are the key people the Surveyors ask questions to? Administrators will be accompanying the Surveyors, but they will want to speak to Staff that do the work!
200
Locate the hospital Performance Improvement Initiatives and your units QAPI Plan.
What is the
Intranet- Patient Safety
and Unit's QAPI Book/Board
200
Run, Hide, Fight
What is What are the strategies for Active Shooter? (Code Silver)
200
Required for all invasive, consented procedures
What is Time Out
200
If used for more than one patient these are not to enter the immediate patient care/treatment area
What is multidose vials
300
Give short concise answers, only answer questions asked-nothing more.
What is How to speak to Surveyors? If the answer is unknown say I don't know, or I know where to find the answer. Don't argue, ask for ideas, ask for clarification on the question if needed.
300
Locate the fire pulls & estinguishers in your area.
What is Know what to do in case of fire and how to evacuate. RACE- Rescue, Announce, Confine, Extinguish PASS- Pull, Aim, Squeeze, Sweep
300
PMCS and/or Managing your Safety
What is "Management of Aggressive Behavior" training? This training is provided to nursing staff and support staff.
300
Surveyors analyze a hospitals systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patients.
What is Tracer Methodology
300
A identified 8" x 11" area that is used for only one purpose and is clear of extraneous materials/supplies.
What is the designated medication preparation area.
400
All shifts are responsible to ensure that refrigerators are checked and expired items discarded, no excess clutter, no food or beverages on the inpatient units, only current days fingerstick results, and only one week of emergency equipment check sheets.
What is unit is always survey ready
400
This is Posted on every unit to inform patients of their rights and responsibilities and this is located on the elevator and the ECMC website.
What is where do you find the Patients Bill of Rights and the ECMC Mission Statement
400
Snowvember
What is External Disaster, Code Triage.
We had a State of Emergency snow storm. Lessons learned: Established protocols needed for housing and operations.
We are required to have drills
400
60 minutes of education to include the diet, activity, weight monitoring, systems worsening, smoking cessation and follow up.
What is the required patient education for patients with CHF
400
Drawn up and immediately labeled with patient name,medication, and dose in the medication preparation area and also verified by a second nurse.
What is Insulin
500
Now through July
What is Joint Commission window for a Survey. We only will get a 30 minute warning the day Surveyors come. We need to always be ready! They will be visiting us anytime between now and July.
What is the EMR- under Patient Summary Risk Legal or Care Activity - intervention. MOLST and Paper Consents will be in the paper chart. Down time forms are on the intranet (Services- EMR Downtime Information) .
500
The laboratory communicates these labs to nursing/clinical staff (physician/provider) and documents the notification in patients medical record/EMR.
What is how Critical Test Results are communicated?
500
Locate items in patient chart: H&P, Pain Medications/Reassessment, Fall Risk, Suicide Risk, Immediate Post Op Note, ED Nursing Care Record.
What is the EMR
500
The proper donning and doffing of PPE and handwashing is communicated to family and visitors.
What is the documentation requirements for patient and family education when a patient is placed in isolation