Joint Commission 1
Who is responsible for following and maintaining a safe work space?
What is all Team Members.
How do you wear your hospital badge?
What is Easily visible, above the waist, face out, not flipped over.
When do you perform hand hygiene?
What is Before or after contact with patient or items in the patient's environment, before or after removing gloves, and if hands are visibly soiled.
How can you bring forward a quality or safety concern?
What is complete an UMMSafe report, notify unit leadership escalating through the chain as necessary, participate in unit and organizational committees, make anonymous report the compliance hotline.
What is a Code Pink?
What is a missing infant or infant abduction (6months or younger)?
What is a Site Specific Fire Plan, and where can you find them to reference?
A fire plan specific to each unit. Found on the Intranet.
If you are speaking with a surveyor and don't know the answer (which is ok) what do you say?
What is I would ask my supervisor or look at Intranet. If needed ask the surveyor to repeat the question and really listen to what they are asking for.
When should vital sign equipment be cleaned and other equipment such as ENO, spiro, etc. used on patients?
What is Before and after patient use, if you are not sure if it has been cleaned, please clean before use.
What actions can you take if a patient care error occurs?
What is take immediate steps to ensure the safety of the patient, notify the physician, notify supervisior and complete an UMMSafe report, as appropriate participate in notification of the patient/family, participate in detailed review; anaylze critical factors, participate in developing correction action plan and monitor the effectiveness of the plan.
What are two patient identifiers and when should they be used?
What is name, date of birth or MRN? Verify at least two identifiers whenever administering medications, collecting blood specimens or other specimens for testing, Rooming patients or providing treatment or procedures.
How do we communicate with non-English patients?
What is medical interpreters via ipads.
What is the dwell time on a Oxyvir?
What is 1 minute or look at the label?
What is informed consent?
What is requires that the patient, and when appropriate, the legally authorized representative, is given a clear, concise explanation of the patient’s condition and any proposed treatment or procedures, the potential benefit and drawback of the proposed treatment or procedure, problems related to recuperation, and the likelihood of success. Information is also provided regarding any significant alternative treatment or procedure.
Who is responsible for assuring that the patient's rights are respected and maintained at all times?
What is every team member?
How can we protect patient's privacy and confidentiality?
What is Log out of computers when not in use or when unattended, medical records only accessed when required by job duties, do not leave papers with patient information unattended, provide information only to those permitted by the patient and do not discuss patient information in common areas.
True/False: Are you able to leave any type of containers and/or supplies in the hallway?
False: Only items with wheels and items that are currently in use can be in the hallway. Nothing else should be stored in the hallway.
What do you do in case of a bomb threat?
What is Code Black , alert supervisor to go to the location, identify the threat, inform appropriate authorities, and evacuate the building?
When should sharp containers be replaced and once replaced where do you do with them?
What is when 2/3 full and they should be sealed and placed in the large red container in the hazardous materials room on the 1st floor.
How do you use a fire extinguisher?
What is:
P- pull pin
A- aim nozzle
S- Squeeze
S- sweep
How do employees maintain competence? How often is this done?
What is orientation - all employees attend orientation when hired. Semi-annual and annual competencies are done in person depending on the department and quarterly cornerstones.
Separation of clean and dirty items is critical to preventing the spread of infection. How do you accomplish this?
What is clean and dirty areas clearly separated with signage to indicate CLEAN, DIRTY and/or TESTING. Ex: Signage including green and red X
What is an IFU?
What is Manufacturer Instructions for Use (or IFU = instructions for use)
OneSource is the platform available to team members at all locations. It is a database of IFUs for all kinds of products and devices
True or False: If go into a isolation room gowned up and then realize I forgot a item, I should go back out with my gown and gloves on to the supply room to get the forgotten item?
What is False, Even if clean, it should not be worn outside a room.
If you participate in research you must have documentation of the following training?
What is:
Responsible Conduct of Research (CITI training) Human Subjects’ Protections (CITI training), if applicable
HIPAA (HIPS)
Research CHEX training (annual)
Role-specific EPIC training, if applicable
IATA training (to ship samples), if applicable
What is Regulatory Compliance and Accreditation?
What is Regulatory compliance is an organization's adherence to both state and federal laws, regulations, guidelines and specifications relevant to its business.
Accreditation is the process in which certification is awarded after meeting all regulatory standards.