Joint Commission Basics
What kind of education is required for a new staff to receive an account access for patient information?
A new staff must receive HIPAA and Privacy Act Training, Cyber Awareness training, and sign an Acceptable Use Policy (AUP) upon arrival, before granting account access and is an annual requirement thereafter to maintain network access on the hospital’s network.
What is the system of record for reporting an event involving a patient?
Patient Safety Reporting (PSR) system
What is the single, most important practice within the hospital in infection control?
Hand Hygiene
How is patient food (from outside source) marked and how long can it be stored in a ward/unit refrigerator.
Food put in the ward refrigerator must have the patient’s name and room number along with the date and time of storage.
Food will be discarded 24 hours after storage.
The prescriber must countersign a telephone order within _____ hours.
24 hours. Telephone orders are only used in EMERGENCIES!
What are your initial actions in the event of a suspected infant/pediatric abduction (CODE PINK)?
Perform a search of the area; Secure entrances/exits to the area; Activate the duress alarm; Call Security at 6-0999/0799; No staff, presently on duty, will leave the area.
How frequently are clinical alarms reviewed?
Review alarms settings every 12 hour shift: and PRN upon the patient’s condition.
Memo 40-243 para 1.5.3 Clinical Alarm Management
To proper disinfect a piece of equipment with CAVIWipes, how long should the piece of equipment remain totally wet?
3 minutes
How are staff members educated about safety?
New Employee Orientation (NEO)
Annually through SWANK Health
Environment of Care rounds
Fire and Safety inspections through the BAMC Safety Specialists.
How are crash carts exchanged?
Sterile Processing Division (SPD) (basement) is the central location for exchanging crash carts.
How is the confidentiality of patient information protected?
Patient’s privacy is maintained, whether the information is written, verbal, or electronic.
Computerized systems are password/CAC protected, and access is position specific.
Staff members complete both HIPAA and Cyber Security Awareness training annually.
Who has the responsibility to stop a procedure/treatment and request clarification if there is a question, difference, or discrepancy?
ALL members of the healthcare team have this responsibility.
Is Prepzyme Forever Wet at risk of aerosolizing when spraying vigorously?
No. Prepzyme is a humectant spray with gel like consistency that will not aerosolize.
How often are Eye Wash Stations Checked and how often is the water temperature measured?
Eye wash stations are checked weekly and the temperature is measured within the first five days of every month.
Can you explain to a surveyors what the BAMC Chaperone Policy states for Patients and Staff?
All patients are informed of their right to a chaperone in the Patient Rights and Responsibilities handout.
Chaperones must be medical / dental personnel or properly trained volunteers at least 18 years of age.
Providers must offer chaperones when examining them in their beds or in ward & clinic examination rooms.
A chaperone is mandatory during sensitive exams (upper and lower sensitive areas being examined for both males and females).
Offering the use of a chaperone is MANDATORY. Patients can refuse.
Evidence of Standards Compliance (ESC) is due What does FSA stand for and how frequently does BAMC conduct it?
Focused Standards Assessment (FSA)
Occurs 12 and 24 months after a Full Triennial Survey.
What are the three components of Universal Protocol?
(1) Pre-operative/pre-procedural verification to prevent errors and promote safe patient care.
(2) Marking of the operative/procedural site.
(3) Time-Out for all surgeries or procedures to ensure that the correct patient, site, and procedure are consistent with the plan of care. The Time-Out is required for all surgeries or procedures.
MEDCOM Reg 40-54
Why do we use sterile water instead of tap or NS during Point of Use decontamination/cleaning?
Sterile water does not contain minerals that can damage instruments.
How are Oxygen tanks stored and segregated in clinical areas?
Full cylinders are stored separately from in use and empty cylinders.
What is one of the first steps you take before using a piece of medical equipment on a patient?
Ensure its operational and maintenance is not expired.
What two additional Required Follow-Up Activity interrogatives have to be addressed for findings at or above a moderate/pattern on the SAFER Matrix?
Leadership Involvement
Preventive Analysis
Name 4 of the 7 NPSGs
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 policy number that governs Infection Prevention and Control at BAMC and where is it found?
BAMC Memo 40-2. Found on BAMC Intranet policy page or IP&C Home Page
What happens if a piece of medical equipment malfunctions while in use on a patient.
Remove defective equipment immediately and replace with serviceable item.
Assess the patient. Based on patient assessment, contact Supervisor, or Nursing Supervisor, and Patient’s Physician, as appropriate.
Collect and secure all evidence, and complete an incident report BAMC Form 889 and PSR if necessary.
What are my responsibilities related to pain assessment and management?
Each health care provider is expected to aid in the management of pain based on his or her area of specialty; Staff members should refer to BAMC Memo 40-185, Pain Assessment and Management, which includes detailed information on pain assessment and management for both inpatient and outpatients.