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Infecton Control
Patient Care
Life Safety/EOC
National Patient Safety Goals
Documentation
100
It is known that their is one main effective process to avoid infection in the hospital setting
What is Handwashing?
100
When the patient is admitted certain assessments are required if a patient comes in with a complaint of the abdomen, or from a trauma, or any symptoms that may require medication to provide comfort, TJC standards indicate the need for a baseline and ongoing documentation of the patients condition this is called?
What is assessment and reassessment of pain per MCH policy?
100
fire drills done in clinics such as the Family Health Clinic periodically, Joint Commission has a set time period and it must be documented.
What is every 12 months?
100
What are the two patient identifiers organizational wide?
What is full name and date of birth?
100
Documenting a date or time on the physician's signature line by a person other than the physician is considered a illegal document paractice and Joint Commission will give this finding
What is falsification of the medical record?
200
Nationally handwashing compliance is 60% or slightly above. Recent monitoring at MCH has found our compliance to be less from observation of staff and physicians.
What is 50%?
200
When a nurse or pharmacist is given two like medication orders and decides which one to give without having the reason for use or clarifying the order, TJC will identify what finding.
What is not practicing within their scope of licensed practice?
200
When wires are run or areas in the ceiling/roof have open holes with no filler around them TJC calls has a name for this finding and require the areas to be filled appropriately?
What is penatrations?
200
What is required to identify the patients full name and date of birth?
What is ID band and supporting documents such as orders, medication record, bar code scanner, and the patient if they are able to participate?
200
If a physician or staff member writes a order that is incomplete or contains like meds the TJC requires the nurse or pharmacist are required to call the doctor or person writing the order before it is put in the system TJC has a name for this verification process.
What is clarification of the order?
300
Equipment going in and out of patients room often is a source of introduction of infection in the hospital setting. MCH has a process where equipment such as x-ray machines, blood pressure machines, IV pumps ect., must be cleaned daily. MCH utilizes a certain color card with certain required information.
What is a green tag with the date cleaned?
300

TJC standards indicate that a evaluation be done immediately prior to the start of a procedure.

What is Pre-Anesthesia Assessment?

300
Items are only allow to be stacked so far from and sprinkler head and from the ceiling in any area. TJC has a set distance from the ceiling and does the state and local fire marshal.
What is 18 inches?
300
All patients that are receiving warfarin must not only receive education on the drug but there is a requirement for certain lab work to be obtain prior to administration.
What is a INR with in the prior 24 hours?
300
Physicians at MCH have a time frame for authenticating telephone orders if they are not a resident.
What is 48 hours?
400

MCH leadership following OSHA guidelines require that certain items may not be allowed in patient care areas.

What is food or drink?

400
?Patients sometimes have adverse drug reactions to certain medications that may cause them to develop symptoms of shortness, rash, nausea or vomiting. When these symptoms occur MCH policy requires these events be reported on a event form.
What is Medication Occurance Report Trending form? (MORT form)
400
TJC has standards developed related to medication storaged a medication found unsupervised or unmonitored including saline would be sited by TJC for what reason.
What is unsecured medication?
400
Current TJC standards require that a pre-procedural checklist is completed prior to the patient going to the procedural room or prior to the procedure if the patient remains in the same room. At MCH has a form for this process and it requires both the inpt staff and/or the holding room staff to complete their sections.
What is Universa Pre-Procedural Protocol?
400

TJC has set standards for the time a History and Physical is placed on the chart.

What is less than 30 days and prior to a surgical procedure but after admission with a update?

500

When storing items in the storage areas or patient care areas items are required to meet 3 standard requirements.

What is not placed on the floor, if placed on the bottom self it must be a solid surface and linens must be covered even in closets if ceiling vents are present?

500
When patients are admitted they are required to have a nutrition assessment this assessment needs to include data that could trigger a dietary consult.
What is Dietary Nutritional Assessment Score?
500
MCH sometimes utilizes outside contracted workers such as security guards for individual patients. Under the Human Resource standards they are required to receive what information and education.
What is a forensic orientation packet that includes; how to interact with pts, Procedures for responding to unusual clinical events and incidents, MCH channels of clinical, security, and administrative communication, Distinctions between administrative and lcinical seclusion and restraint?
500
Handoff communication is a requirement for patients being transferred across the care setting and ancillary departments. This is often done during shift report, from on level of care to another, or in between physicians. At MHC we provide guidelines to utilize on process which looks at the patient's situation, background, assessment, and requirements.
What is SBAR handoff communication?
500
Resident documentation must be authenticated per the MCH bylaws within what time frame?
What is 24 hours