Environment of Care/Emergency Management
Safety
Universal Protocol
Process & Documentation
Mix of ?
100
What is a Code Pink and what is your role during a Code Pink?
Internal code for child abduction. Report to nearest stairwell or hallway and remain alert for suspicious activity.
100
How do you report safety concerns?
Call 8080
100
What is the “Universal Protocol”?
A pre-operative/pre-procedure verification process created to prevent wrong person, wrong procedure, wrong site surgery in hospitals and outpatient settings.
100
What are the requirements for verbal and telephone orders?
a. Verbal orders will only be accepted in emergency situations or if the situation occurs during a surgery or procedure. b. All orders must be date and timed. c. Verbal orders require a “repeat back” verification of the complete order by the person receiving the order.
100
What is the best way to prevent the transmission of disease?
Hand hygiene remains the most effective method for preventing the transmission of disease. Wash with soap and water for at least 15 seconds or clean with an alcohol based solution.
200
What is a MSDS and where is it located?
Material Safety Data Sheets. VV Intranet or by calling 800.451.8346
200
What is a sentinel event?
A patient safety event that reaches a patient and results in any of the following: Death, permanent harm, or sever temporary harm
200
What are VV’s two Patient Identifiers?
Patient name & Date of Birth
200
How do you address formulating and honoring advance directives?
The attending physician has the responsibility to provide all necessary medical information to the patient and answer any medical questions. VV will make every attempt to honor a patient’s Advance Directive while receiving services/care. VVH will inform the patient if it is unable to honor his/her wishes for any reason (i.e., anesthesia).
200
How do you address patient communication needs(language barrier)?
A VV certified Interpreter may be utilized or the Cyracom translation services may be used.
300
How would you respond in the case of a fire?
R.A.C.E – Rescue, Alarm, Confine/Contain, Extinguish/Evacuate
300
What is medication reconciliation?
A process for obtaining and documenting a complete list of the patient's current medications upon admission to the organization with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. The process continues with each transfer throughout the patient care process and at the time of discharge.
300
What procedures at VV require “Time Out?”
All surgical and nonsurgical invasive procedures will conduct a pre-procedure verification process, identify those sites that require marking of the incision or insertion area and conduct a time-out immediately before starting the procedure or making an incision.
300
What is the process for adding a medication to the formulary?
a. The requesting physician will notify the pharmacy or the chairperson of the P & T Committee of the request. b. The pharmacy will forward a formulary addition request form to the physician. c. The physician will fill out the form in its entirety and return it to the pharmacy. d. The pharmacy will present the request to the committee in the framework of the above criteria. e. The P & T Committee will review the information and approve or disapprove the request.
300
How do you address privacy and security?
1) Privacy curtains, which are available and should be used when a patient is receiving direct care. Avoid hallway and cafeteria conversations about patients. 2) Patient doors should be closed when delivering care. 3) No confidential information such as vital signs, intakes and outputs, etc. should be posted in view of the public. 4) VV has established various HIPAA privacy policies and procedures to follow that help ensure patient confidentiality.
400
How do you know that your equipment is up to date and safe for use on patients and its inspections?
Medical equipment is tagged with a sticker that displays the day the device was inspected and the date that it’s due for re-inspection.
400
What would you do in the event of a chemical spill?
Small spills are neutralized/contained by workers in the immediate release area by utilizing spill kit. Larger spills, greater than 2 liters, dial *4 and report code orange.
400
How does VV document “Time Out” to verify correct patient, correct site, and correct procedure?
A designated member of the team initiates the time-out and it includes active communication among all relevant members of the procedure team. Completion time of the timeout is documented in the EMR or the appropriate EMR Downtime form.
400
What are the requirements for documentation and timing of the physician History and Physical?
H&P exam will be completed on all Valley View patients no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. For a medical H&P exam that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient’s condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. All or part of the H&P may be delegated to other practitioners (example, Nurse Practitioners or Physician Assistants) but must be co-signed by an MD/DO.
400
When is a physician’s order necessary for restraint?
a. For non-violent/ non-self-destructive restraints, a written order for restraints must be entered into the medical record within 24 hours. Restraint orders for Non-violent/non-self-destructive behavior must be reordered by the provider every 24 hours. b. Violent/self-destructive restraint orders are required prior to or immediately (within minutes) following the application of restraints and the face to face evaluation. Orders for restraints for violent/self-destructive behaviors are limited to: 4 hours for patients 18 and older, 2 hours for children/adolescents ages 9-17, 1 hour for children under 9. If restraints for violent/self-destructive behaviors continue to be necessary they will be re-ordered at the same frequency.
500
What is your role in the event of an actual disaster?
Staff responsibilities are outlined in the VV Emergency Operations Plan. Physicians will report to the medical branch director.
500
“U”, “IU” and “QD” all appear on this list and is found where?
“Do Not Use” list of Abbreviations and on Compliance 360 and in the Med Staff Rules & Regs
500
What are the exceptions to marking the surgical site?
a. In the case of an emergent procedure or emergent surgery, site marking and documentation is not required as long as the physician deems the surgery/procedure to be an emergency (life-threatening). b. Single organ cases, such as uterus, bladder, or gallbladder. c. Interventional cases for which the catheter/instrument insertion site in not predetermined, such as cardiac catheterization. d. C-Sections do not need to be marked. e. When the insertion site is not predetermined as with a Portacath, Groshong, pacemaker, triple lumen catheters, or any central line when both sides are prepped. f. In the case of patient refusal documentation should be completed about the refusal and alternative site marking process should be followed if applicable.
500
How do you address obtaining “informed consent?”
The physician performing the procedure is responsible for the process of obtaining informed consent prior to the start of the surgery or procedure and the physician performing the procedure is responsible for verifying the existence of the valid, informed consent. This will be based on a clear, concise explanation of the patient’s condition and of all proposed technical procedures, risks and benefits of treatment, potential problems related to recuperation, possible result of no treatment, likelihood of success, alternatives for treatment, risks and benefits of alternative treatment, and notification of the physician who is responsible for performing the procedure(s). If applicable, if a patient has not appointed a healthcare agent and they are unable to make or express decisions for themselves, a “proxy” is needed.
500
What process do you have in place for handling medical errors and what do you tell the family?
a. Explanation by the attending physician of record, of how the injury occurred and its short and long term effects. When an error contributed to the injury, the patient and the family or representative should receive a truthful and compassionate explanation for the error and the remedies available for the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.
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