Performance Improvement
This culture promotes reporting of errors and near-misses without fear of punishment to improve patient
What is a Just Culture?
These two patient identifiers must be used prior to starting a transfusion.
What are name and date of birth (or medical record number
This life-threatening condition occurs when the body’s response to infection causes organ dysfunction.
What is sepsis?
What are alternatives to restraints
This must be attempted and documented before applying a restraint, unless there is an immediate threat to patient or staff safety.
This must be completed promptly after patient care is provided to ensure accuracy and compliance.
What is real-time documentation?
This quality indicator measures the occurrence of pressure injuries that develop during hospitalization
What are Hospital-Acquired Pressure Injuries (HAPI)?
The nurse must remain with the patient during these critical first minutes of the transfusion to monitor for reactions.
What are the first 15 minutes?
Within 3 hours of sepsis recognition, this laboratory test must be obtained to measure tissue hypoperfusion.
What is a serum lactate level?
What is 24 hours
For non-violent restraints, this is the maximum duration of an initial order for adults before it must be renewed.
Copying forward previous documentation without verifying accuracy violates this documentation principle.
What is documentation integrity?
This nursing-sensitive indicator tracks catheter-associated urinary tract infections.
What is CAUTI?
This IV solution is the only compatible fluid used with most blood products.
What is 0.9% normal saline?
These medications must be administered within 3 hours for patients with severe sepsis or septic shock.
What are broad-spectrum antibiotics?
What is a violent restraint?
This type of restraint requires a time-limited provider order and face-to-face evaluation within one hour when used for destructive behavior
This must clearly reflect communication with the provider regarding changes in patient condition.
What is provider notification documentation?
This documentation must reflect timely reassessment after pain medication is administered
What is pain reassessment documentation?
This must be obtained from the patient/ legal representative, and signed, dated, and timed by the licensed clinical practitioner, patient and witness, prior to obtaining the blood product from the Transfusion Service.
What is consent for Blood Product transfusion
This documentation must clearly show the exact time sepsis was recognized to ensure Sepsis compliance
What is the Time of Sepsis Presentation (Time Zero)
What is when the patient no longer meets criteria for restraint?
Restraints must be discontinued at the earliest possible time when this occurs
This must be documented to demonstrate that patient education was provided and understood.
What is education provided with patient understanding/teach-back documented
This core measure focuses on timely interventions to prevent bloodstream infections related to central lines.
What is CLABSI prevention compliance
The time the blood Product is dispatched from the Blood Bank
What is 4 hours
Failure to complete required Sepsis bundle elements within designated time frames primarily impacts this hospital metric.
What is core measure compliance and publicly reported quality performance?
This type of order is not acceptable for restraints under Joint Commission standards.
What is a PRN (as-needed) restraint order?
If it wasn’t documented, Joint Commission surveyors consider that it did not occur.
What is the legal standard of documentation?