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JC Basics
Patient Safety
Work Place
Documentation
Potpourri
100
During the JC survey, the surveyors will talk primarily to: A. The Hospital Administrators B. The doctors, nurses and staff C. The patients D. The Rome News Tribune
B. YOU! That's why you are playing this game, right?
100
Name one of the 2015 National Safety Patient Goals
(1) Improve accuracy of patient identification (2) Improve effectiveness of communication among caregivers (3) Improve safety of using medications (4) Reduce risk of health-care associated infections (5) Accurately and completely reconcile medications across the continuum of care (6) Identify safety risks inherent to population - suicide
100
Where are the fire extinguishers in the Breast Center? Bonus: Where's the oxygen shutoff values in case of a fire?
(1) In E hallway by the assignment board, by U and T elevators. (2) The oxygen shut off valve is in Bluebonnet main hallway only to be shut off by Respiratory Therapist
100
How do you document in your procedure note that you confirmed the correct identity of the patient and the correct site of the procedure?
Document on the Universal Precautions form found in forms anywhere
100
What quality performance data are collected in your area and how are you involved?
Chart Audits - The data is collected and reviewed on a monthly basis. If there are any deficiencies than a plan is developed on how to improve that outcome. Medication Reconciliation
200
What is "tracer methodology"?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
200
Name one way you reduce the risk of health-care associated infections in your department.
Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
200
What number do you call to report concerning behavior, perceived threats or acts of hostility?
2-STOP (27867), if immediate danger call 911 or 22890
200
What's wrong with this order? Motrin 600 mg po q 6-8 hours prn pain (standard adult dose)
No range orders allowed - no range in time intervals
200
Dr. X is starting his shift in the breast center. He walks down the hall. Starbucks in hand, and waves "hi" to the nurses and clerk. He rounds the corner, going through the propped open fire door to stand in front of the board. He notes that there are 2 patients with the same initials on the board. He dumps his empty coffee cup in the trash, sets down his trusty Harriet Lane Handbook on the counter, and picks up a chart. Where's the JC violation?
Only special fire doors may remain open. Doors may not be propped open.
300
What is HIPAA? Name one way protected health information is kept private in your department.
No! Not Hippo HIPAA: Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. (1) Shedders, (2) don't discuss patient information in the hallway or elevators, (3) keep door to exam room closed, (4) close computer screens.
300
How do you improve the accuracy of patient identification in your department?
Use TWO (2) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's name and Patient's Date of Birth. NOT patient's room number and chief complaint (e.g the mastectomy patient in 3112)
300
What do RACE and PASS mnemonics stand for when there is a fire?
R - Remove patients and others, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
300
What's the fifth vital sign that we document on ALL patients and where do we document it?
Pain Level Documented on the nurse pain assessment sheet
300
How do you know a piece of equipment (e.g. defibrillator, ultrasound) is okay to use?
Check on the equipment for a dated sticker that has been serviced by biomed
400
What does TJC stand for? Hint: It's not "Julia comes and hangs out"
The Joint Commission, also known as Joint Commission on Accreditation of Healthcare Organizations
400
How are you improving the effectiveness of communication between caregivers?
(1) Telephone orders are read back (2) Critical lab values are read back (3) SBAR Format and hand off report (4) We use standardized abbreviations and avoid certain unapproved dangerous abbreviations
400
What should you do in the event of a hazardous material spill?* * Material more hazardous than cafeteria food, but less hazordous than anthrax
Evacuate at a safe distance and Call EH&S at 713-792-2888
400
True or false Can a minor sibling translate for a parent if the minor is 13 years old, clearly fluent in both languages and both the minor and the parent consent to using the minor as the interpreter.
So VERY, VERY False!
400
What four cards should you have in your badge?
(1.) Mission, Vision and Core Value (2.) Aim for Excellence Performance Improvement (3.) Institutional Code of Conduct (4.) Environmental Health and Safety card
500
How often are fire drills conducted?
We conduct them quarterly at the hospital and Floyd Behavioral Health, and annually at the off site physician practice locatons and business occupancy locations. .
500
Name 3 of the unapproved abbreviations.
(1) .U or u (unit) (2) IU (international unit) (3) Ug (microgram) (4) 1.0 (no terminal zeros) (5) .5 (always use a leading zero - "always lead never follow" (6) x3d (for 3 days or for 3 doses) (7) qD or qoD (every day, daily or every other day) (8) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)
500
What level of operational status are we working at during hurricane season?
Normal Operations - All managers and employees assigned responsibilities for hurricane/severe weather and emergency planning and implementation are required to assess, review and prepare plans to ensure a constant state of readiness
500
What three questions do you need to review in order to decide if a patient is to be placed on Fall Precautions?
Any recent falls in the past month? Does the patient use any assistive devices? Was the patient give any sedation at his appointment?
500
What are two Performance Improvement Projects currently under way in the Breast Center?
Room Utilization Project Decrease wait time for new patient to be seen in the breast center.