Patient Rights
How are patients informed of their rights and responsibilities as patients?
A: Patients are offered and/or provided the Patient’s Rights document at time of registration.
Cribs, PPH carts, crash carts, and isolation carts are all approved items to remain in the hallway. T/F
False: Isolation and Code carts are the only approved items that can remain in the hallway. We would need to move our PPH carts during survey. These are no approved as a crash cart. Nothing can be unattended in the hallway for more than 20 minutes
How must medications be secured?
All meds should be secured and inaccessible to the public, preferably behind locked doors or in a locked cart or cupboard. Narcotics must be locked.
Where is the nearest fire extinguisher, pull station, crash cart and/or AED?
It depends. FIND YOURS!
Where can you consume food and beverages?
Food and drinks are allowed in designated areas such as cafeteria, break rooms or conference rooms. Covered drinks are allowed in designated areas per department policy. Food and drinks are never allowed near lab specimens.
How do you identify patient prior to medication administration, blood draws, passing dietary trays and procedures?
A: With two identifiers: name (first & last) and date of birth (use MRN if necessary).
Remove any visible blood, have instruments open, put in a closed lid grey bio hazard bin, spray, wheel over to the elevator to go to SPD.
Transport dirty equipment in properly labeled and covered containers.
Do narcotic medication need to be secured or in a locked area?
Yes, all medications should be secured, they should not be carried in your pockets.
What must gas control/shut off valves be labeled with?
Room numbers/areas controlled. Make sure you know where all the gas shut off are located on our unit.
What is an IFU and what is it used for?
A manufactures Instructions for Use used as the authoritative reference for care, cleaning, maintenance, and storage of equipment.
We have a pink binder in the unit and there is an option to find these manuals online as well.
Explain the Universal Protocol and Time Out process.
Conducted prior to Invasive Procedures in the OR and Non-OR settings:
Conduct a pre-procedure verification process
Mark procedure site, if indicated, by practitioner accountable for the procedure
Perform and document the Time-Out (final verification) Immediately prior to starting the procedure with active communication from all members:
Correct patient
Correct site (marked if necessary)
Correct procedure
See “Universal Protocol: Site Verification, Site Marking and Time Out (Comprehensive Surgical Checklist)” policy GN-016.
Cardboard boxes are acceptable in storage areas. T/F
False. Remove patient supplies from shipping containers before placing them in departmental storerooms or closets. No stored items within 18 inches of the ceiling. Nothing attached to or touching sprinkler heads or pipes.
What are "high alert" medications?
Insulins, anti-coagulants, chemo, narcotic infusions, intrathecal medications, and paralytic infusions.
What action do you take if you noticed smoke or fire in your area?
RACE; Rescue, Alarm, Contain, Extinguish and Evacuate.
How can you identify the hazard levels of chemicals?
The 4 colored diamond label with pictograms on the container describes the hazards. Refer to the SDS (Safety Data Sheet) for further information. Contact the 3E Company (1-800-451-8346) as seen on the yellow and black posters and stickers throughout the facility.
When may an invasive or high-risk procedure be performed without first obtaining informed consent?
A: Only emergency procedures where delay of consent may pose eminent risk to life or loss of limb.
How are medications in emergency carts (such as Crash Carts) secured?
They are kept in staffed departments/areas. If an area is not staffed 24/7 the cart must be secured in a locked location. Be sure to keep daily logs up to date.
What are the Look Alike Sound Alike medications?
The list is updated annually, located on the intranet and should be posted near Pyxis machines.
What does PASS stand for?
Pull, Aim, Squeeze, Sweep
Do you know the correct wet contact (dwell) times for the disinfectant products used in your department?
1) Super Sani Cloth/purple top - 2 minutes,
2) Sani Cloth AF3/gray top - 3 minutes
3) Sani Cloth Bleach/orange top - 4 minutes.
Who obtains informed consent from the patient prior to procedures or administration of blood products?
A: Informed consent is obtained from the patient by the provider prior to the procedure. Physician and patient signatures (date and time) on the consent form attests that this has occurred Or it is dictated in the H & P Interval prior to the procedure.
Describe how the clean supply room should look.
Storage racks must have a solid bottom shelf. Do not mix dirty and clean items together. Store linen in closed cupboards, covered carts with solid bottoms or designated clean storage areas away from traffic.
How often are Pyxis machines to be checked for discrepancies?
Once per shift.
What resource is available for you to use to assist with Emergency Preparedness?
The Emergency Preparedness Quick Reference Guide flipchart located in your department. There are two versions: one for the Hospital and one for off-site locations. It contains information regarding what to do in case of:
Medical Emergencies
External and Internal Alerts
Fire response
Weather Alerts
Evacuation
Security Alerts (show of force, weapons, missing person…)
Were do look to find out the action you need to take for a sever weather alert?
See “Emergency Preparedness Quick Reference Guide” flipchart for more information.