Safety 1st
Documentation Counts
Environmentally Speaking
JC 101
Medication Musts!

100

This is the online system usd to record patient and visitor injuries or adverse events, including a potential event (also called a near miss).
What is the S.A.F.E. system?

100

These three elements are mandatory for all documentation entered into the patient record.
What are Date, Time, and Signature?

100

This term defines our physical surroundings, i.e. the clinic, office, or hospital site in which we work and provide care to our patients.
What is Environment of Care

100

This is the online system that houses all of FAHC's policies and procedures.
What is Intradoc?

100

The following items must be kept locked or under constant observation.
What are medications and sharps, including needles, syringes, and scalpels?

200

This standard is followed before administering meds or blood products, taking samples and specimens for testing, or providing any other treatments or procedures.
What is the use of 2 patient identifiers?

200

This term refers to both a living will and a durable power of attorney.
What is Advanced Directives?

200

This term describes the services provided at each site, the patient population served, location, and operating hours.
What is Scope of Service?

200

This is the term used to define specimen testing done outside the confines of the lab. May include blood glucose testing, urine pregnancy testing, or rapid strep testing.
What is Point of CAre Testing/Waived Testing?

200

This is the correct protocol for handling all parenteral multi-dose medication vials, with the exception of vaccines, skin test, and patient supplied meds.
What is Discard after 28 days, or with any suspected or visible contamination; Document expiration date on vial with first use?

300

This is the correct process for labeling blood or other specimens collected in the clinic.
What is in the presence of the patient, at the time of collection?

300

The is the process in which the correct patient, correct procedure, correct site, correct patient position and availability of implants or special equipment is confirmed through pre-operative verification. It includes site marking and conducting a final time out immediately prior to an invasive procedure.
What is Universal Protocol?

300

These are substances that may pose a health risk or physical hazard.
What are Hazardous Materials?

300

This is a list of Joint Commission identified safety requirements which highlight problematic areas in health care and describe evidence and expert-based solutions. A new list is published annually.
What is National Patient Safety Goals (NPSG)?

300

This special category of medications require additional checking procedures prior to and during administration due to their high risk of causing injury when misused.
What is High Alert Medications?

400

This term refers to test values (laboratory, cardiology, radiology) which are defined by individual health care organizations and will typically include stat tests, panic value reports and other results which require urgent response. For laboratory results, it applies to both point of care and central lab processing.
What is Critical Values?

400

The terms OD, OS, Q.O.D. and Q.D. are examples of this.
What are Prohibited Abbreviations?

400

This information is located on the FAHC intranet. Each sheet describes in detail the chemical makeup and how to treat an exposure to the hazardous material we have on site. Cleaning solutions are a common item.
What is Material Safety Data Sheets (MSDS)?

400

Fletcher Allen Health Care has adopted this campaign as a safety strategy to encourage patient’s active involvement in their own health care.
What is the Speak Up campaign?

400

The correct process for labeling secondary medication containers includes the following four points:
What are: Name and strength of medication or solution Amount – if not apparent from container Expiration date - when not used within 24 hrs Expiration time – when it occurs in less than 24 hrs

500

This is an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof.
What is a Sentinel Event?

500

When providing patient education, the following 5 points must be documented.
What are -Who was educated -Topic -What was taught -Methods used -Any identified barriers to learning -Outcomes/Level of understanding?

500

The presence of this, located on a piece of medical equipment, ensures that it is safe for patient use.
What is a current TSP sticker?

500

This is the collaborative and interdisciplinary approach used by FAHC for the continuous study and improvement of the processes of providing health care services to meet the needs of consumers and others.
What is Process improvement?

500

For this process a complete list of current medications is collected from the patient; the list is compared (office list, HISS discharge, medication list from Maple, medication passport, patient’s own recall/list) and differences are reconciled. The list of patient medications will be updated at each encounter (visit) and the comparison/ reconciliation process repeated whenever changes are made. The medication list will be communicated to the next provider of care and to any concurrent providers. The patient will receive a reconciled list of Medications at the end of every patient encounter (visit).
What is Medication Reconciliation?