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Safety First
Documentation
Environmentally Speaking
JC 101
Medication Musts!
100
This is the online system used to report patient and visitor injuries or adverse events, including potential events (near miss).
What is a PSR?
100
These three elements are mandatory for all documentation entered into the patient chart.
What are signature, date, and time?
100
This term defines our physical surroundings, i.e. the clinic, office, or hospital site in which we work.
What is Environment of Care (EOC)?
100
This is the standard frequency of Joint Commission inspections of a facility.
What is every 3 years?
100
The following items must be kept locked or under constant observation at all time.
What are medications and sharps (including needles, syringes, and scalpels)?
200
This standard, a National Patient Safety Goal, helps prevent giving a patient another person's drug at the pharmacy when they pick up medication.
What is the use of two patient identifiers?
200
This term refers to both a living will and durable power of attorney.
What is Advanced Directives?
200
These are the chemicals which are approved to be used in a given department or clinic. Make sure all of the chemicals used in your department are on it!
What is the Authorized Use List?
200
This is the term used to define specimen testing done outside the confines of the lab. May include blood glucose testing, urine pregnancy testing, or rapid strep testing.
What is Point of Care Testing or Waived Testing?
200
This is the correct protocol for handling all parenteral multi-dose medication vials, with the exception of vaccines, skin test, and patient supplied meds.
What is discard after 28 days? Document expiration date on vial with first use.
300
These should never be recapped and are to be stored in a locked cabinet.
What are needles?
300
The is the process which must be documented in which the correct patient, correct procedure, correct site, correct patient position and availability of implants or special equipment is confirmed through pre-procedure verification. It includes site marking and conducting a final time out immediately prior to an invasive procedure.
What is Universal Protocol?
300
These are substances that pose a health risk or physical danger if stored/handled inappropriately.
What are Hazardous Materials?
300
This is a list of Joint Commission identified safety requirements which highlight problematic areas in health care and describe evidence and expert-based solutions. A new list is published annually.
What is National Patient Safety Goals (NPSG)?
300
This special category of medications require additional checking procedures prior to and during administration due to their high risk of causing injury when misused.
What are High Alert Medications?
400
This term refers to test values (laboratory, cardiology, radiology) which are defined by individual health care organizations and will typically include stat tests, important abnormal test results, etc. that require urgent response. For laboratory results, it applies to both point of care and central lab processing.
What is Critical Values?
400
The terms OD, OS, Q.O.D. and Q.D. are examples of this, which may cause confusion.
What are "Do Not Use" Abbreviations?
400
This information is located on the FAHC intranet. Each sheet describes in detail the chemical makeup and how to treat an exposure to the hazardous material we have on site. They can be found on the NHB Sharepoint page and in the EOC binder.
What are Safety Data Sheets?
400
This is the standard answer to questions from JC inspectors that you may not immediately know.
What is "I'm not sure but I can find out for you."
400
The correct process for labeling secondary medication containers includes these four points:
What are: Name of medication Concentration of medication or solution Amount – if not apparent from container Expiration date - when not used within 24 hrs Expiration time – when it occurs in less than 24 hrs?
500
This is an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof.
What is a Setinel Event?
500
When providing patient education, these are three of the 5 points that must be documented.
What are: -Who was educated (patient or caregiver) -Topic -What was taught -Methods used -Any identified barriers to learning -Outcomes/Level of understanding
500
The presence of this, located on a piece of medical equipment, ensures that it is safe for patient use and must be updated annually.
What is a current boomed inspection sticker?
500
This is the collaborative and interdisciplinary approach to the continuous study and improvement of the processes of providing health care services to meet the needs of consumers and others. Example: Front Desk Re-Design - to improve and maintain patient confidentiality when registering for appointments.
What is Process Improvement?
500
For this process a complete list of current medications is collected from the patient; the list is compared to orders in AHLTA and patient report, and differences are reconciled by correcting duplications/conflicting meds and clarifying discrepancies with the patient. The patient will receive an updated list of medications at the end of every patient encounter (visit).
What is Medication Reconciliation?