Joint Commission Basics
What are our current non-dress uniforms called and what does it stand for?
Army – OCP – operational camouflage pattern
AF – ABU – airmen battle uniform
What is the proper way to dispose of Protected Health Information (PHI)?
Place in appropriate shredder receptacle in your department. PHI must never be discarded in a regular trashcan. Receptacles for this type of information are labeled “HIPAA.”
A history and physical (H&P) must be written within ____ hours of admission.
The history and physical (H&P) must be written within 24 hours of admission.
In an emergency, it is permissible to transport a patient on a bed with unsecured O2 tanks? Yes or no.
No...It is a violation of EC.02.05.09 EP 6 to transport a patient throughout the facility with an unsecured O2 cylinder on their bed or wheelchair.
What is Brooke Army Medical Center's vision?
To be our patients' first choice in healthcare.
If a patient or family member has a complaint, concern, or grievance, what resources are available to you and them?
Patients and families may express concerns to the clinic advocate, ward advocate, or clinic staff member to help resolve your concerns in the clinic or the service area providing services to you and Family.
If the clinic advocate, ward advocate, or staff members were not able to resolve the concerns, please do not hesitate to contact the Patient Experience Office at 916-2330 or email at usarmy.jbsa.medcom-bamc.list.bamc-patient-advocacy-center@mail.mil
Or the Joint Commission at 1-800-994-6610, or by email at complaint@jointcommission.org.
How often does an RN document on the Plan of Care?
Planning of care will be documented in the Nurse Clinical Shift Note each shift and will contain the patient’s stated goal (s), the nurse identified problems for the shift with appropriate interventions, patient education and outcomes.
Who is authorized to contact the Rapid Response Team (RRT)?
Any member of the health care team or family member concerned about a patient’s change in condition.
What does RACE stand for?
R- Rescue persons directly threatened by the fire.
A- Activate Alarms
C- Contain the fire by closing doors and windows
E- Evacuate the zone or area
What is a Safety Data Sheet (SDS)?
A Safety Data Sheet (SDS) an information or data sheet for identification of chemical compounds in the workplace covering the health, physical, fire, reactivity, precautionary use, and how to handle and store the chemical safely.
In the event a staff member is asked a question where they are not confident they know the answer, what are some appropriate actions they can take?
If you do not know an answer, say so, and tell the surveyor where or to whom you would go for the answer. Remember you may use any resources available to you, such as intranet policies, department resources, or your manager.
What color are Neonatal crash carts?
Neonatal crash carts are PURPLE
According to BAMC policy, when can verbal orders be given?
Verbal Orders are oral communication between the physician and RN, given only in “emergency/STAT” situations. The order must be countersigned by the prescriber as soon as possible after the emergency but no later than 24 hours.
What are a few of the steps you take when a hazardous materials spill occurs?
Protect yourself by using appropriate PPE.
Identify the material and approximate quantity to select the appropriate absorbent or other spill kit material.
Stop the spill (e.g., right the overturned container).
Contain the spill, prevent it from spreading with absorbent or other appropriate spill kit material.
Clean-up spill residue, place it in a container compatible with the hazardous substance, and label the container as Spent Spill Materials and with its contents.
Decontaminate personnel, equipment and area.
Inform your supervisor and the BAMC Safety/Fire Prevention Division (phone: 916-1427/5678).
Initiate evacuation of area, if necessary.
Notify the Fort Sam Houston Fire Department by dialing 911.
List some behaviors that undermine a culture of quality & safety.
Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive behaviors such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, and impatience with questions. These types of behaviors undermine team effectiveness and compromise the safety of our patients.
What to do:
Contact your immediate supervisor, department/section leadership, or another manager with whom you are comfortable.
Report any incident of inappropriate or disruptive behavior using Patient Safety Reporting System (PSR) if the event involving patients or visitors.
Generally speaking, what is the purpose of BAMC's Antimicrobial Stewardship Program (ASP)?
The purpose of the Antimicrobial Stewardship Program (ASP) is to continually improve the ability of Brooke Army Medical Center (SAMMC and outlying clinics) to provide the best patient care in the safest possible environment by limiting inappropriate usage of antimicrobials, thereby decreasing the development of antimicrobial resistance.
According to BAMC policy, learning needs of the inpatient are assessed within 24 hours of admission to the hospital. What are some examples of when learning needs are required to be re-evaluated?
Learning needs of the inpatient are assessed within 24 hours of admission to the hospital and reassessed on inter-ward transfer, identification of a new problem, or as needed. Educational needs assessment for outpatients will be documented in the outpatient medical record.
When is discharge planning initiated?
Discharge planning begins on admission and continues through the patient’s actual discharge.
List one of your security-related responsibilities?
Report any suspicious or threatening persons promptly to the Security at 916-0799.
Staff member have the responsibility to immediately bring any threat of violence made to themselves, others, or the facility to the attention of their supervisor and/or Security.
Staff member are required to wear their BAMC identification badges at all times while at work. Badges must be displayed with duty position and photo clearly visible and on the upper portion of the body.
Minimize incidences of “tailgating” where personnel gain unauthorized access to a secured area while another staff badges in to that area.
What are a few components of Standard Precautions? (e.g., hand hygiene)
Standard Precautions include hand hygiene, safety-engineered devices, safe work practices, and the use of appropriate Personal Protective Equipment (PPE) such as gloves, gowns, eye protection and masks, whenever touching or exposure to patient 1) blood, 2) body fluids, secretions, and excretions, except sweat, regardless of whether it contains visible blood, 3) non-intact skin, or 4) mucous membranes is anticipated.
Referencing the SAFER matrix, when requirements for improvement are in the higher categories, what are the two (2) additional items required in additional to the Who, What, When and How of our response?
Leadership Involvement
Preventive Analysis
The prescriber must countersign the a telephone order within _____ hours.
24
Did 2018 bring about any changes in pain assessment and management?
Of course, they are listed below:
Pain assessment and pain management, including safe opioid prescribing, is identified as an organizational priority for the hospital.
The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.
The hospital collects data on pain assessment and pain management including types of interventions and effectiveness.
What are a few of the initial steps a staff member take during a CODE SILVER?
Notify Security (916-0999) and staff personnel in the immediate area, with the goal being to locate and reunite the person with his/her caretaker as soon as possible.
Give a clear description of the person to Security. Include approximate age, gender, height, weight, hair color and style, and type of clothing.
Tell Security where the person was last seen and secure the department entrances/exits to that area. Begin a local search of the ward/clinic and immediate vicinity (within 20 meters of all exits to the area).
When might a medication be administered prior to the pharmacist reviewing the order?
When the resulting delay would harm the patient
When a physician is present and controls the ordering, preparation and administration of the medication