Low Hanging Fruit
Facility Follies
EOC Round-Up
Medication Safety
Infection Prevention
Mixed Bag
10
Always locked or logged off when not in use to keep PHI from being visible?
What are computers in public areas?
10
Two items that must be inspected, correctly placed, and kept unobstructed in the event of a fire.
What are Exit Signs and Fire Alarm Pull Stations?
10
Pull, Aim, Squeeze, Sweep.
What is PASS?
10
Stocked, secured, inspected daily, and has no expired products keeps these readily available to use in the event of a medical emergency.
What are code carts/crash carts?
10
Required upon entering and exiting of a patient room, this observation is needed to meet Leapfrog Requirements.
What are Hand Hygiene Observations?
10
Lab values significantly out of normal range that must be reported to the attending physician within a strict timeframe.
What are Panic Values/Critical Lab Values?
20
Used as a means of identification, these should always be in plain sight.
What are ID Badges?
20
Used every day to keep liquids cold, these must be kept clean and in good working order.
What are Ice Machines?
20
Rescue, Alarm, Contain, Evacuate.
What is RACE?
20
A safety practice designed to minimize the potential for adverse events related to medication discrepancies.
What is Medication Reconciliation?
20
Coworkers who provide patient care or work in areas responsible for the preparation of materials for direct patient use or patient consumption should not wear these.
What are artificial nails or nail ornaments?
20
It is not acceptable to only use video/security camera footage to perform this routine task on Behavioral Health patients.
What are 15 minute checks?
30
In the event of a spill or splash, this station must never be blocked.
What is an eyewash station?
30
This Baggot Street tool is the best way to notify facilities that something is broken, unsafe and in need of repair.
(i.e. stained ceiling tiles, penetrations to walls, doors, and floors)
What is a Work Order/Maintenance Request Form?
30
Coworkers must be able to describe and respond to these atmosphere conditions.
What is Severe Weather Warnings?
30
When using a scanning system for medication administration, this step is still required before giving the patient the medication.
What are two patient identifiers?
30
Coworkers must follow all of the listed precautions on these.
What are Isolation Precaution signs?
30
A way patients formally communicate what type of healthcare they want if they are no longer able to make decisions due to illness or incapacity, and to appoint a person to make such decisions on their behalf.
What is an Advance Directive?
40
These doors throughout the hospital act as an added barrier and provide protection when latched and activated properly?
Clue: The higher the number, the longer the protection
What are fire rated doors?
40
Clearly marked in red, these are used for critical equipment only.
What are Emergency Power Outlets?
40
Considered to be an unauthorized heat source.
What are space heaters or candles?
40
Right patient, right med, right dose, right time, right route.
What are the 5 rights of medication administration?
40
This body fluid, if found on a glucometer, is considered a potentially infectious material.
What is blood?
40
This process occurs before starting a patient procedure.
What is a time out?
50
A common practice at the nurses station that is not in compliance with policy requirements.
What is food and drinks at the nurses station?
50
These items must never be flushed down the toilet.
What are wipes?
50
Kept separate by fullness, storage is limited to room size but typically there should be no more than 12.
What are Oxygen Cylinders?
50
Replaced when less than 3/4 full, stored appropriately and should be readily accessible.
What are sharps containers?
50
Always cleaned, disinfected and stored at least 5 inches from the floor.
What is Patient Care Supplies/Equipment?
50
The organization at MHJ authorized to approach the patient's next of kin and offer them the opportunity for organ donation.
Who are MTN staff?
60
Located in the patient bathroom, this item must always be hanging freely and never tied or wrapped.
What is the emergency pull cord?
60
This must be labeled and stored in appropriate red bag waste containers and disposed of properly.
What is regulated medical waste?
60
Three common coworker personal items that must be kept in either a locker or better yet, left at home.
What are hand lotions, soaps, backpacks, purses, baby wipes?
60
Action taken when titration orders for drips do not specifically account for what the patient needs.
What is call the doctor?
60
Supplied to keep our coworkers safe from exposure to splash and splatter of body fluids.
What is Personal Protective Equipment (PPE)
60
Individualized for each patient and updated as needed during their inpatient stay, this provides a method for tracking a patient's progress.
What are patient care plans?
70
What, besides me, are past their prime.
What are expired supplies?
70
Paying attention to these being in good condition will keep you from having a "bzzzettt" kind of day.
What are electrical plugs and cords?
70
Horizontal, then vertical, co-workers must be able to describe and demonstrate this unit specific plan.
What is the Fire Evacuation Plan?
70
This product is kept in a secure location, dated for less than a year, and used to waste narcotics.
What is Rx Destroyer?
70
Kept off the floor when stored and removed from the outside shipping package, these are an IP "No, No."
What are corrugated cardboard boxes?
70
Surveyor's always directly observe and check this common bedside treatment to assure our process and documentation are in compliance.
What is blood transfusion documentation?
80
In the event an emergency response is required, coworkers must be able to show where this document is located in their department.
What is the Emergency Response Chart?
80
Obstructed hallways with inappropriate exit signage impacts.
What is EGRESS?
80
Coworkers are knowledgeable of the time requirements for these specific disinfectant products they use.
What are wet times?
80
Locked, monitored, and logged, Surveyors will check to see if the gaskets around these doors are clean.
What are medication refrigerators?
80
This type of precaution requires the use of a private room, negative pressure airflow, and a fitted N95 respirator or PAPR.
What is Airborne Precautions?
80
Found online, these sheets provide information and instructions for managing a chemical spill, etc.
What are MSD sheets?
90
Always kept 18 inches below the sprinkler heads.
What are stored items?
90
These materials are properly labeled, stored in appropriate containers and designated to specific locations to prevent an explosion.
What are combustible materials?
90
Always store these items in a covered cart (flap down) or in closed cabinets.
What are clean linens?
90
This must be labeled, store in an appropriate black box container, closed, and dated less than a year.
What is pharmaceutical waste?
90
Stored at least 2 inches from the wall, these items must be kept away from environmental touch contamination.
What are sterile items?
90
This item should be given to all new patients to inform them about their right to be treated with respect, to be involved in decisions related to their care, and that they must also treat our staff with courtesy and respect.
What are patient rights and responsibilities or patient handbook?
100
These must be followed to ensure appropriate equipment use cleaning and storage. If these are not followed this will invalidate the warranty.
What are Manufacturer IFU's?
100
Kept labeled and locked to limit access these devices follow the 36 inch rule.
What are electrical panels?
100
The only staff/individuals authorized to shut off a medical gas valve.
Who are Respiratory Therapist, Anesthesia, and the Fire Department.
100
Surveyors love to ask about assessment and reassessment for this treatment to determine it's overall effectiveness of treatment.
What is pain management?
100
This infection control practice considers all patients to be possible carriers of bloodborne pathogens and requires PPE to be used when coming into contact with ALL patient's blood, urine, or other body fluids.
What are Universal Precautions?
100
Unlike violent restraints, non-violent restraint orders are good for this period of time.
What is 24 hours?