Show:
TJC Basics
Patient Safety
Environment of Care
Infection Control
Potpourri
100
Who do the TJC surveyors want to speak to?
YOU (the staff)
100
Name a National Patient Safety Goal (NPSG). What is the purpose of NPSGs?
- Improve accuracy of Patient Identification - Improve the effectiveness of communication - Improve the safety of using medications - Improve the safety of clinical alarm systems - Reduce the risk of health care associated infections - Identifying safety risks within the patient population - Keep surgical procedures safe Purpose: To promote specific improvements in patient safety
100
What is your procedure in the event of a fire?
RACE (Rescue, Alarm, Contain, and Evacuate/Extinguish)
100
How do you know if patient equipment is clean?
Patient equipment is cleaned and disinfected: - between each patient use - when it is visibly soiled or - when contamination is suspected Equipment is disinfected each time it is removed from a patient room/care area and before placing in a clean storage area.
100
How do you inform your patients of their rights?
Every inpatient is given a copy of the patient guide upon admission. Patient's Rights are also posted in multiple areas throughout LMH.
200
What is the 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
What are the two patient identifiers used when providing care, treatment or services?
Patient name and date of birth Verification should be an active process involving the patient with the patient stating their name and date of birth if they are able to do so.
200
How do you extinguish a fire? Where are our extinguishers located on 3 West?
PASS (Pull, Aim, Squeeze, sweep) Fire extinguishers are located to the right of the computers outside of 372 and across from 379
200
What is the wet time/contact time of the low level disinfectants commonly used in our department?
Oxivir: - 1 minute: bacteria, virus - 5 minutes: TB - 10 minutes: Fungi Clorox: - 3 minutes: C-diff, norovirus Stickers are on all of our low level disinfectants with these times!!
200
When should you use the FLACC scale to assess pain?
- When a patient is developmentally or cognitively unable to use a self report. - Unresponsive patients *THIS SHOULD NOT BE USED FOR SLEEPING PATIENTS*
300
What is HIPPA? What are ways that we keep protected health information private on 3 West?
HIPPA: Heath Insurance Portability and Accountability Act. This states that PHI may only be used for purposes of treatment, payment, and healthcare operations. 1. Paper shredders 2. Lock computer screens when walking away 3. We don't discuss patient information in hallways or elevators 4. Close patient doors when appropriate
300
Explain Clinical Alarm Safety. Give an example of a clinical alarm on 3 West.
Clinical Alarm Safety provides guidance on safe operation of alarms on medical equipment and monitoring systems in patient care areas. Clinical Alarms are intended to protect the patients receiving care or alert the staff that patients are at an increased risk and needs immediate assistance. Alaris pumps, bed alarms, ETCO2 monitors
300
Describe LMH's smoking policy
LMH is a tobacco free workplace and environment. Everyone is prohibited from smoking or using tobacco on LMH premises
300
How do you know if your patient has a history of a MDRO (multi-drug resistant organism) such as MRSA, VRE, CRE, ESBL and C-diff?
Go to the EMR banner bar. Locate "MDRO" listed on the right side. Upon positive test results, the EMR places the MDRO organism in that location.
300
Who may summon a Medical Evaluation Team (MET) for assistance in assessment, evaluation and stabilization of the patient?
Staff, patients or families may activate the Medical Evaluation Team for additional assistance to respond to a change in condition and/or if they feel the patient's medical needs are not being addressed.
400
What are LMH's PRIDE values?
Professionalism Responsibility Integrity Dedication Excellence
400
What is the policy on reporting critical values/test results to the physician? And where is this documented?
The time frame from test result/interpretation to communication of critical results to the LIP will be within 60 minutes so that the patient can be promptly treated. Documentation MUST occur in IView (Med-Surg Quick View --> Critical Results). Documenting in a clinical note or care plan is also acceptable.
400
Who is authorized to turn off medical gas? Where is the medical gas shut off located on 3 West.
Any associate can turn off gasses after discussion with direct care providers about the patients current oxygen needs. Shut off is located across from the nurse's station
400
How do you know a patient is in isolation precautions?
Isolation sign is posted at the patient's door and there is an order in the EMR for isolation
400
How do we communicate a patient is a strict fall risk?
- Discuss fall risk with patient/family and why it is important to call for assistance without getting up. - Identify the patient (so others recognize their strict fall risk) by applying a yellow fall risk band and yellow fall prevention sign on the patient's door. - Communicate fall risk during shift report and transitions of care
500
What is a Sentinel Event?
An unexpected occurrence involving death or physical or psychological injury, or the risk thereof.
500
Do you have a list of look alike/sound alike drugs? If so, where is it located? What safety strategies are employed to prevent errors with these medications?
LA/SA list is available in policy tech. Policy is High Risk Medications. Tallman lettering is what we use to distinguish between these drugs Ex. prednisone and prednisolone = predniSONE and prednisoLONE
500
What do you do if you find yourself in an active shooter event?
RUN - evacuate the area/building HIDE - if not safe to run, shelter in a safe place, turn off the light and lock the door if possible FIGHT - if not safe to run or hide, take actions to incapacitate the shooter if possible.
500
How do you clean a blood and body fluid spill?
We wear appropriate personal protective equipment (gowns, gloves, mask, tongs are used to pick up sharps and place in sharps container). The area is cleaned and disinfected with a germicidal solution. Disposable cleaning materials are placed in a biohazardous waste container. Housekeeping can be contacted to assist with large spills.
500
What is LMH's performance improvement methodology?
DMAIC (Define, Measure, Analyze, Improve, Control)