Regulations
HIPAA
What is the federal regulation governing privacy?
Maximum number of suicidal patients a sitter/constant observer can effectively watch at a time.
What is one (1)?
Tool used to measure staff perceptions of teamwork, safety, job satisfaction, stress recognition, burnout, work/life balance, unit management, hospital management and working conditions.
What is the safety culture assessment?
Pull
Aim
Squeeze
Sweep
(PASS)
What is the proper method for using a fire extinguisher?
The number one means for stopping the chain of infection.
What is hand hygiene?
The Association for periOperative Registered Nurses (AORN); Association for the Advancement of Medical Instrumentation (AAMI); Centers for Disease Control and Prevention (CDC).
What are examples of evidenced-based and/or professional guidelines?
A process in the OR used to prevent wrong side / wrong site procedures or surgery.
What is a time out?
Identify patients at risk for suicide.
What is one of the requirements of the National Patient Safety Goals (NPSG.15.01.01)? Also, what is a requirement for all behavioral health patients during the registration and admission process? Or, what is the suicide risk assessment?
The safety information on specific hazardous chemicals.
What are safety data sheets (SDS) (previously material safety data sheets (MSDS))? Or, what is ChemWatch?
The amount of time needed for the disinfectant to adequately clean and disinfect surfaces, according to the manufacturer's instructions for use.
What is contact time; wet time; dwell time?
A type of CMS survey conducted when CMS has received a complaint and determined that it raises a "credible allegation" of a condition-level deficiency.
What is a complaint, allegation, or for-cause survey?
An investigation, focused on current systems and processes, to find the reason for an unexpected poor outcome or event.
What is a root cause analysis (RCA)?
A proactive approach to problem resolution, evaluating issues before an event happens.
What is a proactive risk assessment? Or, what is an FMEA (Failure Modes Effect & Analysis)?
Without points where a cord, rope, bed sheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.
What is the definition of ligature-resistant?
1) Puncture resistant; 2) Biohazard labeled or red colored; and 3) Leak-proof.
What are transport containers for reusable sharps or pointed-tipped instruments?
Name for a CMS deficiency when there is noncompliance with requirements in a single standard or several standards within a condition of participation that has or could cause severe injury, harm, impairment, or death.
What is a CMS Condition-level deficiency?
Failure to maintain sterile technique during invasive procedures. Blocking exit doors in an egress corridor. Failure to follow manufacturer’s instructions for use in the high-level disinfection process of an endoscope. Failure to mitigate ligature risks in the built environment in a behavioral health locked unit.
What are examples of Immediate Jeopardy or Immediate Threat to Life?
A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment; and every voice is heard no matter what level they are in the organization.
What is a Culture of Safety or Just Culture?
18 inches or 18-inch rule
What is the length of clearance from a sprinkler head for storage of equipment or supplies?
The infection control process surveyed by The Joint Commission for cleaning scopes and contaminated operating room instruments?
What is High-Level Disinfection / Sterilization?
Joint Commission standards, CMS Conditions of Participation (CoPs), and COMAR state licensing regulations.
What are the 3 main sets of regulations the hospital must comply with?
Focus on being ready for the next patient, not the next survey.
What is Continuous Readiness (versus survey readiness or preparation)?
These organizations maintain a commitment to safety at all levels, from front-line providers to managers and executives.
What are high-reliability organizations?
Must not be wrapped around handrail, nor hang more than 6” from the floor (to ensure it is within reach of any patient who may have fallen to the floor), nor meet with any obstruction when pulled (to ensure proper activation).
What are emergency pull cords?
A written document containing the activities and frequencies for maintaining, storing, inspecting, testing, cleaning and disinfecting medical equipment.
What is the Manufacturer's Instructions for Use (IFU)?