TJC Basics
Patient Safety
Work Place Savenger
Documentation
Potpourri
100
Formerly known as JCAHO
(TJC) The Joint Commission Formerly known as JCAHO, name change happened in 2007!
100
(1) Improve accuracy of patient identification (2) Improve effectiveness of communication among caregivers (3) Improve safety of using medications (6) Ensure medical equipment alarms oare heard and responded to on time. (7) Reduce risk of health-care associated infections (15) Identifies Safety risks (suicide/BH) AND Universal Protocol.
What are the National Safety Patient Goals.
100
Locate Emergency Book in your department.
Make sure they are Up-To-Date! Codes were recently updated in 2015.
100
How do you document in your procedure note that you confirmed the correct identity of the patient and the correct site of the procedure?
What is documentation of Universal Precaution/Time out on forms per policy.
100
What quality performance data is collected in your area? How are you involved?
What is Chart Audits - The data is collected and reviewed on a monthly basis. If there are any deficiencies than a plan is developed on how to improve that outcome. Medication Variance
200
Doctors, Nurses and Staff
Who are the key people that TJC will speak with?
200
Monica Beaulieu
Who is MaineGeneral's Safety Officer?
200
Locate SDS Book in your department, what does SDS stand for? Where is PPE located?
Formerly known as MSDS, now SDS- Safety Data Sheet. Make sure all SDS sheets are up to date. All old MSDS/SDS sheets should be sent to Richard Comstock. He will need to keep these for 30 years!
200
What's wrong with this order? Motrin 600 mg po q 6-8 hours prn pain (standard adult dose)
What is no range orders allowed - no range in time intervals
200
Dr. X is starting his shift in the breast center. He walks down the hall. Starbucks in hand, and waves "hi" to the nurses and clerk. He rounds the corner, going through the propped open fire door to stand in front of the board. He notes that there are 2 patients with the same initials on the board. He dumps his empty coffee cup in the trash, and picks up a chart. Where's the TJC violation?
What is doors may not be propped open.
300
Dispose of PHI per policy, Don't discuss patient information in the hallway or elevators, Keep door to exam room closed, Lock computer screens, Turn over patient information on desks.
What are ways to protect patient information? HIPPA Compliance
300
Call Code Yellow for this
What is an Out of Control Person?
300
Locate your LEM Goals, Waste Wheel, or PI Plan.
PI= Performance Improvement. Improve performance with the ultimate goal of promoting and providing high quality care and pateint safety.
300
What's the fifth vital sign that we document on ALL patients and where do we document it?
What is Pain score! Inpatient-Documented on SCM flowsheet>KBC Adult Assessment Intervention>Pain/Comfort. Outpatient-Touchworks
300
How do you know a piece of equipment (e.g. defibrillator, ultrasound) is okay to use?
What is Check equipment for Preventive Maintenance Sticker.
400
Give Short consice answers, Be Truthful and Gracious. Answer only the questions asked- no more.
How should staff speak to Surveyors?
400
"Stop the Line" and "Speak Up"
What is the two challenge rule? Stop the line: when a patient safety issue is sensed & Speak up: Staff are encouraged to speak up if a patient safety issue is noticed
400
Locate the NPSG Poster.
This should say 2016! Do you have the most current? Be prepared to speak to these items.
400
True or false Can a minor sibling translate for a parent if the minor is 13 years old, clearly fluent in both languages and both the minor and the parent consent to using the minor as the interpreter.
What is False! Need qualified Interperter
400
What card should you have in your badge?
What is Emergency Codes
500
Partnering for Excellence book, Badge- Emergency Codes & Numbers, Manager
What are 3 quick reference resources for TJC?
500
Name, DOB, Medical Record Number, Social Security Number
What are patient identifiers?
500
Locate documents: Downtime Procedures, Advanced Directives, Paper Consent forms, Interpreter Waiver Forms
Know where all of these documents are located in your department. The interpreter waiver is needed if patients refuse our interpreter services and choose to have a family member interpret.
500
What three questions do you need to review in order to decide if a patient is to be placed on Fall Precautions?
What is Fall in last 12 months, Polypharmacy, Central Nervous system or Psychotropic meds, cardiovascular meds, Age greater than 65, Alteration in elemination, Cognitive or sensory deficient, dizziness, vertigo, depression, mobility deficient, weakness
500
What are two Performance Improvement Projects currently under way in your department?
Answer specific to department.
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