Environment of Care
The hospital must conduct fire drills this often.
What is every 12 months?
The most effective method of reducing Hospital Acquired Infections.
What is Hand Hygiene?
They can assess and reassess the patient.
Whom are qualified staff?
The hospital designs and manages the physical environment to comply with this code.
What is the Life Safety Code?
The number of patient identifiers that must be used when providing care, treatment, and services.
What are two?
The Safe Medical Devices Act of 1990 requires that all hospitals do this.
What is monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual?
These precautions take into account the method by which pathogens are transmitted from organism to organism.
What are Transmission Based?
The hospital plans the patient's care, treatment, and services based on this.
The hospital maintains the means of this at all times in all areas of the hospital.
What is egress?
For Hand Hygiene, the hospital will comply with guidelines from either of these organizations.
Who are the CDC or the WHO?
When planning for demolition, construction, renovation, or general maintenance, the hospital conducts this.
What is a PICRA or Pre-construction Infection Control Risk Assessment?
These isolation precautions require hand washing, wearing a gown, gloves, and N95 with eye protection or a PAPR (Powered Air-Purifying Respirator).
What is Novel Respiratory Isolation or COVID?
Before taking action on a verbal order or verbal report of a critical test result, staff uses this to verify the information.
What is a record and "read back" process?
Doors to patient sleeping rooms are not locked unless the clinical needs of patient require this, and this condition is met.
What are patients pose a security threat, and staff can unlock doors at all times?
This is how TJC develops NPSGs.
What is by gathering information about emerging patient safety issues from widely recognized experts and stakeholders?
For CT, PET, or NM services: after the installation of imaging equipment, a medical or health physicist must conduct this.
What is a Radiation Protection Survey?
This individual is responsible for documentation of the infection prevention and control program and its surveillance, prevention, and control policies and procedures that adhere to law and regulation and nationally recognized guidelines.
Who is the Infection Preventionist?
The hospital conducts this before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered.
What is a presedation or preanesthesia patient assessment?
Building and fire protection features are designed and maintained to minimize the effects of these three things.
What are fire, smoke, and heat?
In procedural settings medication labels must include these five things.
What are medication name, strength, amount of medication, diluent name and volume, expiration date and time?
As a part of the Water Management Program, a hospital must conduct this which includes an evaluation of the physical and chemical conditions of each step of the water flow diagram to identify areas where potentially hazardous conditions may occur.
What is a WICRA or Water Infection Control Risk Assessment?
The Spaulding classification system classifies medical and surgical devices as this based on risk to the patient from contamination on a device.
What is critical, semicritical, or noncritical?
Food and nutrition products, including those brought in by patients or their families, are stored with careful consideration of these.
What are proper sanitation, temperature, light, moisture, ventilation, and security?
This is the maximum individual dispenser capacity for an alcohol-based hand rub.
What is 0.32 gallons or 18 ounces? (0.53 gallons in suites or rooms separated from corridors)
This National Patient Safety goal was retired on January 1st, 2020.
What is CAUTI?