Accreditation Showdown: Are You Survey-Ready?

National Patient Safety Goals

100

What are two ways staff can help prevent patient misidentification errors?

• Always use at least two patient identifiers (e.g., name and date of birth) before administering medication, treatment, or procedures.
• Verify patient identification using the wristband and electronic medical record (EMR) before performing any interventions.

200

What are the three required elements of closed-loop communication in critical results reporting?

Sender states the information, receiver, repeats it back, sender confirms accucracy.

300

What is a procedure in Urgent Care that requires a “time-out”? Name the components of a "time out. 

Lumbar Puncture

Verify the patient, procedure, and site before starting.

400

What are the required steps when labeling medications that are prepared but not immediately administered?

Reference the Careforce page and policy title.  

Medication administration and documentation 18.30 Medication name, Strength, Quantity, Diluent volume, Date, and Time 

500

Where can you find the official hospital policy on patient identification? (Use the Careforce to find the document and cite the title.)

Reference the Careforce page and policy title

Infection Prevention

100

How long should you wash your hands with soap and water?

A minimum of 15 seconds. 

200

What is the “wet contact time” for gray-top Sani wipes?

Three minutes

300

A patient arrives to UC with fever/rash and exposure to varicella. What isolation is this patient placed? Name policy. 

Airborne and Contact 

Policy 3.01 Symptom-Based Isolation 

400

What is the proper sequence for donning PPE in an airborne isolation room?

Gown → N95→ Eye protection → Gloves.

500

What is the difference between contact and enhanced contact-droplet precautions?

Enhanced contact-droplet requires gown, gloves, mask, and eye protection.

Emergency Preparedness

100

What does the acronym RACE stand for in a fire?

Rescue, Alarm, Confine, Extinguish.

200

In the event of a fire, where is your site meeting location?

ANM - confirm answer. 

300

A parent reports that a 4-year-old patient is locked in the bathroom. What would you do?

Retrieve the key and unlock the door. 

400

During a power outage in urgent care, what steps should staff take to ensure patient safety?

• Notify site leadership (after hours/weekends/holidays admin on call)
• Use backup lighting sources if needed to maintain visibility.
• Follow downtime procedures for documentation and medication administration.

500

A severe weather warning is issued while patients and staff are inside urgent care. What three actions should staff take to ensure safety?

• Move patients and staff to designated safe areas away from windows and exterior doors.
• Secure medical equipment and essential supplies.
• Follow the facility’s emergency communication plan to receive further instructions.

High Risk/Workplace Violence

100

What is the first step staff should take when a patient or visitor shows signs of escalating aggression?

• Stay calm and use a non-confrontational approach.
• Maintain a safe distance and assess the situation.
• Attempt verbal de-escalation before involving security if it is safe to do so

200

A patient has eloped from the unit. What are the first three actions staff should take? 

• Immediately notify security and leadership to initiate the response plan.
• Conduct a rapid search of the unit and surrounding areas while maintaining patient confidentiality.
• Alert the care team and document the incident in the EMR, including time, location, and patient condition if found.

300

What is a Marcus Crisis Prevention Program (MCPP) strategy for de-escalation?

Identify patient triggers, maintain a calm tone, and provide clear choices.

400

When should the ASQ (Ask Suicide-Screening Questions) tool be used?

• Chief complaint involves behavioral or mental health concerns.
• A history of abuse, self-harm, or an eating disorder is documented in the chart.
• If the patient verbalizes thoughts of self-harm or harming others

 

500

A caregiver begins yelling at staff and making threats. What are three immediate actions staff should take to ensure safety

• Maintain a calm, non-threatening posture and tone.
• Alert security or follow the facility’s escalation protocol.
• Ensure an exit route and remove other patients/staff if necessary

Documentation/Medication Management

100

What are the 5 Rights of medication administration?

Right:

Patient, Drug, Dose, Route, and Time.

200

Where can you find the policy on verbal orders? 

Reference the Careforce page and policy title.

300

The nurse should review and ______ medications at each visit. 

Reconcile 

400

What are two safety steps when administering a high-alert medication?

Independent double-check by two licensed staff, verifying Five Rights.

500

An order is placed for IV clindamycin; the rate is not listed on the order. What are your available resources for determining the rate?

Lexicomp and/or call the hospital (SR/AMB) pharmacy.