Low Hanging Fruit
Facility Follis
EOC Round-Up
Medication Safety
Infection Prevention
Mixed Bag
100
Always locked or logged off when not in use to keep PHI from being visible?
What are computers in public areas?
100
Two items that must be inspected, correctly placed, and kept unobstructed in the event of a fire.
What are Exit Signs and Fire Alarm Pull Stations?
100
In the event of a spill or splash, this station must never be locked.
What is an eyewash station?
100
Stocked, secured, inspected daily, and has no expired products keeps these readily available to use in the event of a medical emergency.
What are code carts/crash carts?
100
This is the easiest and simplest way to prevent the spread of infection.
What is Hand Hygiene?
100
Lab values significantly out of normal range that must be reported to the attending physician within a strict timeframe.
What are Critical Lab Values?
200
Used as a means of identification, these should always be in plain sight.
What are ID Badges?
200
Used every day to keep liquids cold, these must remain clean, properly maintained, and free from scale or mineral buildup.
What are ice machines?
200
Located in patient bathrooms, this safety device must remain hanging freely in front of the grab rail and may never be tied, looped, or wrapped.
What is the emergency pull cord?
200
A safety practice designed to minimize the potential for adverse events related to medication discrepancies.
What is Medication Reconciliation?
200
Caregivers are knowledgeable of the time requirements for these specific disinfectant products they use.
What are wet times?
200
It is not acceptable to only use video/security camera footage to perform this routine task on Behavioral Health patients.
What are 15-minute checks?
300
A common practice at the nurses station that is not in compliance with policy requirements.
What is food and drinks at the nurses station?
300
These doors throughout the hospital act as an added barrier and provide protection when latched and activated properly?
Clue: The higher the nuber, the longer the protection.
What are fire rated doors?
300
Obstructed hallways with inappropriate exit signage impacts.
What is EGRESS?
300
This must occur when a medication error reaches the patient and results in harm to the patient.
What is disclosure.
300
Caregivers must follow all of the listed precautions on these signs.
What are Isolation Precautions?
300
A way patients formally communicate what type of healthcare they want if they are no longer able to make decisions due to illness or incapacity, and to appoint a person to make such decisions on their behalf.
What is an Advance Directive?
400
These items no longer belong in active inventory.
What are expired supplies?
400
This Baggot Street tool is the best way to notify facilities that something is broken, unsafe and in need of repair.
(i.e. stained ceiling tiles, penetrations to walls, doors, and floors)
What is a Work Order/Maintenance Request Form?
400
Pull, Aim, Squeeze, Sweep.
What is PASS?
400
Right patient, right med, right dose, right time, right route.
What are the 5 rights of medication administration?
400
This body fluid, if found on a glucometer, is considered a potentially infectious material.
What is blood?
400
This process occurs before starting a patient procedure.
What is a time out?
500
Always kept 18 inches below the sprinkler heads.
What are stored items?
500
Clearly marked in red, these are used for critical equipment only.
What are Emergency Power Outlets?
500
Rescue, Alarm, Contain, Evacuate.
What is RACE?
500
Replaced when less than 3/4 full, stored appropriately and should be readily accessible.
What are sharps containers?
500
Supplied to keep our coworkers safe from exposure to splash and splatter of body fluids.
What is Personal Protective Equipment (PPE)
500
In the event an emergency response is required, coworkers must be able to show where this document is located in their department.
What is the Emergency Response Guide?
600
These must be followed to ensure proper equipment cleaning, handling, and storage, or the warranty may be voided.
What are Manufacturer IFU's?
600
This requires appropriate labeling, placement in approved red bag containers, and proper disposal.
What is regulated medical waste?
600
Caregivers must be able to describe and respond to these atmosphere conditions.
What is Severe Weather Warnings?
600
This item is secured, dated annually, and utilized for wasting controlled substances.
What is Rx Destroyer?
600
What type of container is not allowed in patient care or clean storage areas.
What are corrugated cardboard boxes?
600
Individualized for each patient and updated as needed during their inpatient stay, this provides a method for tracking a patient's progress.
What are patient care plans?
700
This system ensures staff are referencing the most current, approved version of hospital policies.
What is PolicyTech?
700
Paying attention to these being in good condition will keep you from having a "bzzzettt" kind of day.
What are electrical plugs and cords?
700
These are stored by fullness classification, and storage quantities are restricted, usually to no more than 12 in a room.
What are Oxygen Cylinders?
700
These must remain secured, temperature monitored and documented, and free of debris around the door seals.
What are medication refrigerators?
700
This type of precaution requires the use of a private room, negative pressure airflow, and a fitted N95 respirator or PAPR.
What is Airborne Precautions?
700
Surveyors always directly observe and check this common bedside treatment to assure our process and documentation are in compliance.
What is blood transfusion documentation?
800
Unlike a simple complaint resolved at the time of service, this requires formal review and a written response to the patient.
What is a greivance?
800
These materials are properly labeled, stored in appropriate containers and designated to specific locations to prevent an explosion.
What are combustible materials?
800
Always store these items in a covered cart (flap down) or in closed cabinets.
What are clean linens?
800
This must be labeled, store in an appropriate black box container, closed, and dated less than a year.
What is pharmaceutical waste?
800
Stored at least 2 inches from the wall, these items must be kept away from environmental touch contamination.
What are sterile items?
800
This item should be given to all new patients to inform them about their right to be treated with respect, to be involved in decisions related to their care, and that they must also treat our staff with courtesy and respect.
What are patient rights and responsibilities or patient handbook?
900
Per policy, caregivers will use ____ and ___ as the two patient identifiers
What is name and dob?
900
Kept labeled and locked to limit access these devices follow the 36-inch rule.
What are electrical panels?
900
The only staff/individuals authorized to shut off a medical gas valve.
Who are Respiratory Therapist, Anesthesia, and the Fire Department.
900
Surveyors often ask about assessment and reassessment of this treatment to determine its overall effectiveness
What is pain management?
900
This infection control practice considers all patients to be possible carriers of bloodborne pathogens and requires PPE to be used when coming into contact with ALL patient's blood, urine, or other body fluids.
What are Universal Precautions?
900
These are used only when less restrictive measures have failed and require a provider order.
What are restraints?
1000
This tool supports a culture of safety by encouraging reporting of errors and near misses.
What is SAFE reporting?
1000
Considered to be an unauthorized heat source.
What are space heaters or candles?
1000
Found online, these sheets provide information and instructions for managing a chemical spill, etc.
What are Safety Data Sheets (SDS)?
1000
These medications must be stored separately and clearly labeled to reduce the risk of selection errors.
What are look-alike, sound-alike medications?
1000
Always cleaned, disinfected and stored at least 8-10 inches from the floor.
What is Patient Care Supplies/Equipment?
1000
Under this law, patients must receive a medical screening exam and stabilizing treatment regardless of their ability to pay.
What is EMTALA?