Joint Commission Basics
What do we not address the surveryors as?
Name one of the 2026 National Patient Safety Goals
The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____
30 min
Where should single use medications be drawn up?
patient bedside
When should sharps containers be replaced
when they are ¾ full
What is "tracer methodology"?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
Name one way you reduce the risk of health-care associated infections in your department.
andwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
What does the acronym R.A.C.E stand for?
R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
Are anesthesia carts required to be locked between cases?
Are anesthesia carts required to be locked between cases?
Face shields and goggles are examples of this type of equipment
PPE
What is HIPPA?
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations.
Name and DOB
Name one way you reduce the risk of health-care associated infections in your department.
What does the PASS acronym stand for?
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
If a medication has a manufacturer and Pharmacy assigned expiration date, which should you follow?
Pharmacy’s expiration Pharmacy may add a beyond-use date for certain medications Whenever there is a pharmacy assigned beyond-use date, use this date instead of the manufacturer’s expiration date
According to CDC guidelines what is the preferred method for cleaning your hands when they are not visibly soiled
Alcohol based hand sanitizer
-Denial of accreditation
Submission of a falsified document or lack of required license can result in what?
-Patients FULL name -Date of Birth (Month/Day/Year)
How do you Identify a patient without an ID band in your area?
What is a Code Red?
Smoke or Fire condition
This is required if prepared medication is not used immediately
-Labeling to include medication name, strength, amount, date prepared, diluent, and patient name
What is the way we interact with the surveyor?
Be welcoming and polite – SMILE! If caring for a patient, politely indicate you will be right with the surveyor; and arrange for someone to cover your patients. Be enthusiastic and confident – Remember, you know your job better than anyone else.
What is read-back or repeat-back
What is the term for repeating back an order or instruction to confirm accuracy
What are the wet times for the two types of Sani-cloth wipes that we use to disinfect equipment.
4min=Orange Top 2min=Purple Top
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 in
What are examples of Look-Alike Sound-Alike Medications?
1 ado-trastuzumab emtansine (Kadcyla®), trastuzumab (Herceptin®) 2 amoxicillin (Amoxil®), amoxicillin-clavulanate (Augmentin®) 3 ampicillin, ampicillin-sulbactam (Unasyn®) 4 buPROPion, buPROPion XL, busPIRone 5 ceFAZolin, ceFEPime, ceFOTAXime, cefOXitin, cefTAZidime, cefTRIAXone, xxxcefTAZidime-avibactam (Avycaz®), ceftolozane-tazobactam (Zerbaxa®) 6 cloBAZAM, cloNIDine, clonazePAM, cloZAPine 7 clomiPRAMINE (Anafranil®), chlorproMAZINE (Thorazine
What do you do if you get flustered?
Slow down, smile, relax, phone a friend