Policies
PI
The Joint Commission
Codes
Press Ganey
100
Name the 2 locations where our Main OR/PACU department policies located?
1. Binder in the posting office 2. On-line/Intranet
100
Name 2 patient identifiers used whenever you give patient care.
Patient Name and Birthdate
100
When does an opened multidose vial expire and what is written on the vial?
Multidose vials expire 28 days after being opened. The expiration date and initials are written on the vial.
100
Who do you call for a Code Orange?
Environmental Services
100
What group of patients take the Press Ganey Survey for Surgical Services?
Outpatients
200
What 3 things are you required to wear in a radiation case?
1. Dosimeter badge 2. Lead apron 3. Thyroid shield
200
Name something that we monitor for PI on the sterile back table.
Medications and Solutions are labeled
200
Name 2 things that are NOT ALLOWED in pateint care areas?
1. food 2. cardboard 3.personal lotions
200
What do the letters in Act F.A.S.T. represent?
Face Arm Speech Time
200
What is our Outpatient Press Ganey goal?
94.6%
300
What is the policy on fingernails?
short, clean, natural and healthy and not extending past fingertips, no artificial nails, wraps or gel coverings of any type
300
Name something that we monitor on the sterile drapes.
1. Neutral Zone 2. Bovie is in the holster when not in use
300
If the medication refrigerator temperature falls outside the acceptable range, what should be done?
1. Report it 2. Record follow-up actions on the checklist 3. Recheck and record temperature after follow-up actions have been completed
300
What do the letters represent in P.A.S.S.?
Pull Aim Squeeze Sweep
300
Name 1 area of opportunity to improve with our last Outpatient Press Ganey Survey results.
Communicate updates to family/patients 2. Information about delays 3. Information given prior to surgery
400
When are shoe covers needed and when should they be removed?
They are used for PPE. They are removed after a case before leaving the OR room
400
What is the goal for Immediate Use Runs and when is it ok to flash sterilize?
The goal is to never flash sterilize instruments. It is ok to flash an instrument if it is dropped or contaminated.
400
What PPE is needed to clean an OR room between cases?
Gloves are needed. Eyeprotection is needed if there is a risk of fluids splashing.
400
What is a Code Grey?
Elopement
400
What other customers complete the Press Ganey Survey?
Surgeons
500
True or False: Surgeon can schedule any type of procedure.
False - Surgeons have to have privileges for the procedures they schedule. Surgeon procedure credentials need to be verified every time a case is scheduled.
500
Every entry in a medical record needs 2 things. Name them.
Date and Time
500
Name 3 National Patient Safety Goals.
1. Suicide 2. Time Out 3. Critical test results 4. Use 2 Patient Identifiers 5. Labeling medications on sterile field
500
Do you stop compressions to give breaths to the patient in 2 man CPR?
No
500
Name 1 area of opportunity to improve with our last Surgeon Press Ganey Survey results.
1. Start cases on time 2. Faster turnovers 3. block time 4. available posting time 5. scheduling add-on cases