The Joint Commission Readiness Game

Radiation Safety

100

Repeat Rejection logs

Monthly reports are done from portables and Fuji rooms to check for number of repeats

Radiation Safety meets quarterly

200

" I peldge to put my patient's safety, health and welfare first. To routienly review imaing protocols... to monitor examination radiation dose... "

Image Wisely Pledge

Documented once a year, expires 12/31

300

To correctly identify patients/procedures

3 patient identifiers

400

Monitors Radiation exposures

RSO reivews monthly readings, book is located in Rad locker room

Individulas are notified of high dose reports- ALARA dosimetery report

500

Pregnancy Policy for patients and caregivers

Patients are to sign a pregnancy waiver prior to exams/ shielding

Caregivers declare pregnancy in writing to RSO/ wears dosimeter at waist level 

Policy and Procedures

100

Keeps policy and procedures for PSJH Mission Hospital

QuickLinks/ Lucidoc- Mission

200

Completes Lead apron checks

Completed yearly by Jowell, log kept in the G drive

If a lead is soiled or torn, it will be disposed but not in the regular trash

300

Storage of Medication

Meds are to be locked in cabinets and checked for expiration dates prior to using on patients

Pharmacy has oversite of medications used

Saline is a medication

400

Keeps info on Physician Licensures

Physician Privileges can be seen in shortcuts

Fluoro License can also be verified in RHB website

500

Hospital education

Healthstreams/ Q streams allows for caregivers to have Hospital and Imaging dept education

EPIC

100

when starting exam

Move right to left when you are ready to complete exam

Move back to the left side if the patient is not ready

200

after sign orders, this icon must be clicked

click the syringe 

then click "Due"

300

these contrasts are to be documented in EPIC

Omnipaque

Gastro when used for tube checks

Gadavist

Optiray

400

must be ordered with CARM charges

All body parts

Do not add CARM charges to FL exams i.e. FL Cysto, FL ERCP, FL Cholangiogram

500

"Begin to End" 

Correct end and begin times are to be used to properly track turnaround times

Infection Prevention

100

2,3,4

2 minute- Purple Top wipes

3 min- Red Top wipes

4 min- Orange Top wipes

200

Easiest thing you could do

Wash your hands

Hand sanitizer

300

Cannot be more than 2/3 full

Blue sharps containers

Lid must be closed

400

This should be done for covid inpatients

This should be done for covid outpatients

After each exam, portable is to be wiped down

Keep lead shield in cassette cover

Outpatients are to be brought to open room- registered in room- complete exam- then walk out

500

this is put on first

this is put on last

Gowns are put on first, then mask, face shield, gloves

N95s are to be used once a shift if it is visibly soiled, use new mask

Miscellaneous

100

Code requires caregivers to be at entrances/exits

Code pink

200

Schedules PM

Preventative Maintance for machines are scheduled with Bio Med

check Bio Med stickers for next due date

300

HRO

High Reliability Organization

Caring Reliably done through healthstreams

400

Broken handle

Place bio med work order, escalte if there is no update on next shift

Place work orders on the machine and in the QC room to allow team communication

500

can be asked questions regarding TJC survey

All of us :)