Joint Commission Basics
During the JC survey, the surveyors will talk primarily to: A. The Hospital Administrators, doctors, nurses and staff B. Administrators only C. The patients D. The Houston Chronicle
A. They will interact with Hospital Administrators, doctors, nurses and staff
Name one of the 2021 National Patient Safety Goals
Identify patients correctly, Improve staff communication, Use medicines safely, Use alarms safely, Prevent infection, Identify patient safety risks, Prevent mistakes in surgery
What is the hospital fire safety plan?
RACE
What does MSDS stand for?
Materials Safety Data Sheet
Name one way you reduce the risk of health-care associated infections in your department.
Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Handwashing with soap and water before and after each patient contact: LATHER UP!
Where can you locate your facilities emergency codes?
On each unit on info sheet provided by facilities.
Who is our radiation safety officer?
Dr. Richard Shuler
What does LASA stand for?
look alike sound alike
What is HIPPA? Name one way protected health information is kept private in your department? Who is THR's Privacy Officer:
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a Veterans PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC and lock screen if leave area. Bob Brace.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) patient identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, patient's FULL birthdate.
What do RACE and PASS mnemonics stand for when there is a fire?
RACE - R - Remove patients and others, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate PASS - P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
What is Press Graney?
A survey that measures patient satisfaction as a means to improve performance
What does RPT stand for?
Relocatable Power Tap
What is the main goal of the Joint Commission?
Zero Harm
Can employees caring for patients have artificial fingernails?
Use of artificial or long fingernails is prohibited.
1) Where can you find information on chemicals found in the hospital?
1) Call from any phone in the hospital using the information provided on the yellow sticker on the handset, or use the hard copy supplied in the kitchen.
How many MRI Safety zones do we have?
Four
What does JCAHO stand for?
Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
c) Every 3 Years
Name 3 of the unapproved abbreviations.
(1) .U or u (unit) (2) IU (international unit) (3) Q.D., QD, q.d. (daily) or Q.O.D., QOD, q.o.d. (every other day) (4) 1.0 (no terminal zeros) .5 (always use a leading zero - "always lead never follow" (5) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)
Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
18"
What is the plan for active shooter?
Run, Hide, Fight
What is HCAHPS?
Hospital Consumer Assessment of Healthcare Providers and Systems