Joint Commission Basics
What does the acronym "TJC" stand for?
The Joint Commission
Name one way you reduce the risk of health-care associated infections in your department.
Where can you find the unit Standard Operating Procedures (SOP)?
1. SharePoint: DAD-SS→PACU/SDS/APU-Post-Anesthesia Car...→SOP's
2.At each nurses station in the SOP binder (Hard copy).
At least twice per year (p.21)
Who can implement an evacuation?
The Hospital Commander (Incident Commander)or the authority having jurisdiction (p.24)
What is HIPPA? Name one way protected health information is kept private in your department?
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. Remove CAC card when not in use, 3. close computer screens when away from PC, 4.Shred identifying documents.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) patient identifiers (FULL name and FULL date of birth).
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. (P.11)
Where is the Medical Emergency Management Plan (MEMP) located?
How is ongoing training documented?
Training not required in Relias is documented on the continuing education/ In-service form or CAF. (P.26)
Should bathroom pull cord be wrapped around hand rail?
No, it is a hazard. It could prevent patient from the ability to call for help.
Where is the isolation cart for this unit?
In the hall across from Soiled Utility.
How do you report an adverse drug reaction?
1. Patient Safety Report (located on Sharepoint)
2. Call the pharmacy for help 288-8820/8830
How many codes are there?
There are 11 codes (p.21)
Where is Oxygen stored?
O2 is stored in the back anesthesia Cylinder storage rooms. O2 is "Staged in bay 26.
How often is The Joint Commission survey conducted?
Every 3 Years (P.10)
Where is the AED located for the unit?
Outside of Hallway E
There needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
18" (P.35)
Where can you find the codes?
On your badge, in the red folder, and on MEMP (on share point).
What do you do if a patient locks themselves in the bathroom?
Use the odd shaped key hanging at each nurses station (and with MSA).
How do you report an Employee Accident/ Incident/Near miss?
DHA form 172 by the supervisor and submitted to the Safety office within one working day following the mishap. The form is located on SharePoint, under DCA, Hospital Safety. (P.10)
How many fire extinguishers are there for the unit?
5. 2 on the PACU hall, 2 on the hall outside the unit (near preop and SDS), and 2 on hall E
How do you submit a medical equipment item for repair?
Submit a verbal request by calling Medical maintenance section (254-288-8810) or taking the item directly. (p.13)
How do you communicate during and emergency situation if the telephone system is inoperable?
initiate the Medical Emergency Management Plan (MEMP) which includes issuing hand-held radios, runners, making announcements over local TV and radio, and overhead page. (p.22)
Where is the eyewash station? Who is responsible for checking it, and how often should it be checked?