Infecton Control
Patient Care
Life Safety/EOC
PI and Patient Safety
Documentation
100
The one main effective process to avoid infection
What is Handwashing for 15 seconds?
100
Patient complains of abdominal discomfort or symptoms that require medication to provide comfort, what is the baseline and ongoing documentation of the patients management called?
What is assessment and reassessment of pain?
100
What is the set time period to check fire extinguishers in the hospital?
What is every month?
100
What are the two patient identifiers organization wide?
What is full name and date of birth?
100
Documenting a date or time and physician's signature by a person other than the physician is considered a illegal document practice and Joint Commission will give this finding
What is falsification of the medical record?
200
Nationally handwashing compliance is 60%. Recent monitoring at PSMEMC has found our compliance to be better from patient surveys and observation of staff and physicians.
What is 85-90%?
200
When a nurse or pharmacist is given two like medication orders and decides which one to give without having the reason for use or clarifying the order, TJC will identify what finding.
What is not practicing within their scope of licensed practice?
200
When wires are run or areas in the ceiling/roof have open holes with no filler around them TJC calls has a name for this finding and require the areas to be filled appropriately?
What is penetrations?
200
What is required to identify the patients full name and date of birth?
What is ID band, supporting documents, bar code scanner, and the patient if they are able to participate?
200
If a medication order is incomplete or contains like-meds the TJC requires the nurse or pharmacist to call the prescriber before it is put in the system, the TJC has a name for this verification process.
What is clarification of the order?
300
Equipment going in and out of patients room often is a source of introduction of infection in the hospital. PSMEMC has a process where equipment such as blood pressure machines, IV pumps etc., must be cleaned daily. PSMEMC utilizes a certain color card with certain required information.
What is a green tag with the date cleaned?
300
TJC standards indicate that a time out be done immediately prior to the start of a surgical or invasive procedure.
What is Universal Protocol?
300
Items are only allow to be stacked so far from a sprinkler head and from the ceiling in any area.
What is 18 inches?
300
All patients that are receiving warfarin must not only receive education on the drug but there is a requirement for a certain test to obtain prior to administration.
What is a PT or INR?
300
Physicians at PSMEMC have a time frame for authenticating telephone orders.
What is 48 hours?
400
Leadership following OSHA guidelines require that certain items may not be allowed in patient care areas.
What is food or drink?
400
Patients sometimes have adverse reactions or unexpected outcomes from medications or treatments. When these reactions or symptoms occur, policy requires these events be reported on a form.
What is an Incident or Variance Report?
400
TJC has standards related to medication storage. A medication found unsupervised or unmonitored including saline would be sited by TJC for what reason.
What is unsecured medication?
400
Current TJC standards require that a pre-procedural act is completed by the surgeon with the patient prior to the patient going into the procedural room.
What is marking the site with surgeon initials?
400
TJC has set standards for the time a History and Physical is placed on the chart.
What is less than 30 days and prior to a surgical procedure but after admission with a update?
500
When storing items in the storage areas or patient care areas items are required to meet 5 standard requirements.
What is not placed on the floor, if placed on the bottom self it must be a solid surface, out of original packing box, 18 inches from the ceiling and linens must be covered even in closets if ceiling vents are present?
500
When patients are admitted they are required to have initial assessments within a defined time frame. Reassessments needed and frequency are based on 2 primary sources/types of information.
What are the patient's condition and the plan of care?
500
PSMEMC confirms specific elements of performance with acceptable agencies or organizations to make decisions about clinical staff job responsibilities and two additional requirements for a total of five key elements.
What are required licensure, certification or registration; credentials; education and experience each verified by the primary source; criminal background check and applicable health screening?
500
Handoff communication is a requirement for patients being transferred across the care setting and ancillary departments. This is often done during shift report, from one level of care to another, or in between units/dept/caregivers/physicians. At PSMEMC we utilize a communication process which looks at the essential elements of a patient's status.
What is SBAR handoff communication-situation, background, assessment and recommendation.
500
Medical staff bylaws must specify three medical staff responsibilities pertaining to medical histories and physical examinations for inpatients.
What are minimal content, quality and validation timeframes?
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