Life Safety
18" from the ceiling, 6" from the ground
What is the storage clearance for items in all storage rooms
Governing Body
Who is has oversight of the center's operations including case type, physician credentialing decisions, and policy approval?
OneSource
What digital platform is available to look up MIFUs for cleaning instruments & equipment
Posted publicly in lobby
Where in your center can you find accreditation information?
V drive, Infection Control Binder
Where can you find the center's infection control plan?
Inside Sterile Corridor doors and adjacent to each OR
Where are med gas shut off valves located?
VigiLanz
How are variances entered and tracked?
A new box of UPT cartridges are opened.
When is QC required for UPT cartridges?
75% full
When should sharps containers be changed out?
before touching a patient, before procedure, after body fluid exposure/risk, after touching a patient, after touching patient surroundings
What are the CDC's 5 moments for hand hygiene?
Red binders or PolicyStat
Where would you go to find your center's emergency disaster plan?
MDT audit findings are reviewed quarterly at each Quality Committee meeting
How are MDT findings incorporated into our facility's quality program?
If packaging is damaged or compromised
Per policy, how often should peel-packed instruments be resterilized if not used?
Pt name & DOB
What are 2 pt identifiers staff & MDs use prior to care and treatment?
30 days; 90 days
Post-op infections are tracked for ____ days unless the patient had an implant, then it is ____ days.
PASS
What is the acronym for how to use a fire extinguisher?
Fall with injury, mortality, wrong site surgery, blood transfusion reaction, emergent hospital transfer, code
What is an example of a serious safety event?
TIW, D/C, cc, AS, AD, AU, MSO4, U, IU, QOD, QD, trailing zero (2.0mg), or lack of leading zero (.2mg)
What are examples of unapproved/do not use abbreviations per policy?
28 days after removing from fridge
Medications removed from the fridge should be labeled with a BUD that is ___ days after removal.
Post op follow up call, Press Ganey survey, physician survey, implant log/letter
How does the center track, trend, and investigate infections?
Biomed tag
How do you know if a piece of equipment has been safety inspected?
Patient name, procedure, exposure time, mGy
What should be recorded following any procedure using the C-arm or mini C-arm?
Anywhere medications are prepared
Where can you find your high alert and LASA medication lists?
36-46 deg F; 59-86 deg F
What are acceptable ranges for medications stored in the fridge? Room Temp?
Infection Control plan in the IC Binder
What is the written plan that the center has to address how they will manage communicable disease transmission?