Joint Commission Basics
Name 3 patient rights.
Right to be treated in a dignified and respectful manner
Right for effective communication and to receive information in a manner in which they understand
Right to privacy and confidentiality
Right to religious and other spiritual services
Right to participate in decisions about their care, treatment and services
Name 2 National Patient Safety Goals
1. Improve the accuracy of patient identification: Do the 2! Two patient identifiers
2. Reduce the risk of healthcare associated infections: Practice good handwashing; proper LLD, HLD, and sterilization of instruments and surfaces
Doors to the lab, dirty utility room, clean storage room, and break room should be kept closed?
Yes. Doors to all of these areas should be kept closed.
When using the intercom, what code words should be used to indicate there is a fire in the clinic?
Dr. Red
What is the difference between a SDS sheet and a MSDS sheet? How do you find it?
Nothing. They mean the same thing. However, the SDS (Safety Data Sheet) is the new term for it rather than MSDS (Material Safety Data Sheet).
Type in SDS and it will take you to the EOC webpage. Go to the SDS hub and type in product name.
Who do you call for a fire?
911
Give some examples of various patient safety initiatives that you conduct at your clinic.
- Two patient identifiers
- Labeling specimens in the presence of the patient
- Assuring that meds, supplies, and equipment are not expired/optimally functioning
- Fall prevention questions; assuring facility and grounds have no trip hazards; wiping up spills; clearing the halls
- Covid precautions: masking, cleaning of EOC, social distancing, staying home when sick
- Universal Protocol (time outs)
- Standard precautions
-Doing periodic safety drills: i.e. fire, child abduction, active shooter, tornado, etc.
How do you know equipment is safe to use?
Current green tag from CES
What do RACE and PASS mnemonics stand for when there is a fire?
RACE - 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 PASS - 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
What does 1:1 observation include.
Staff does nothing other than be present in the exam room with the patient and the person is within their direct observation at all times. Direct observation is required even when the patient goes to the restroom.
How do you know what a faculty member is credentialed to do? Have staff tell you how to pull it up on the computer.
UTMB home page: Resources: Clinical: Privileges: Type in the person’s last name and it will display a list of items that are approved.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) of the 3 identifiers used at Nothport when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, and patient's FULL birthdate.
Where are the following items located:
ER box, AED, Wheelchair, and Eye wash station
ER box - med room
AED- at nurses station by Ashley's desk
Wheelchairs- check in
Eye was station- Labs and dirty room
How do we assure that all employees, patients and family members have been evacuated?
Close the doors on the way out. Closed door signifies that room has been checked and no one in the room. Do immediate head count at the rendezvous point. If possible take the daily patient schedule with you and list of employees to confirm all accounted for.
How does Ambulatory screen patients for suicide precautions? And what is the first thing you do if you determine the patient is actively suicidal?
Select whether the patient is presenting for a behavioral conditions and their primary reason for care and, if yes, answering the question about harming themselves.
Notify the provider for immediate assessment and implement suicide precautions.
What does the acronyms "TJC"?
TJC = The Joint Commission
How do you unlock the patient restroom?
You can use a penny located on the outside of the bathroom door.
How do you handle the storage of exterior corrugated boxes with clinical supplies?
Exterior corrugated boxes can harbor bugs. Corrugated boxes may not be found in the clean storage rooms or in any patient exam/procedure rooms. You place the corrugated box in the hallway and dispense the items from there into the clean area.
Supplies need to be put up ASAP. They shouldn't be left out for more than 30 minutes.
What is your role in a Dr. Pink?
Staff should be assigned to monitor the exits look in the parking lot; other staff should be looking for the baby/child in clinic.
Give a description of the child over the Intercom; e.g. “Dr. Pink – Hispanic 3 year old boy; blue t-shirt; khaki shorts, white sneakers.” Call 911 if cannot find child after short period of time.
What does modifying the environment mean when dealing with an active suicidal patient?
Removing any equipment/supplies or chemicals that can easily moved out of the room i.e. hand sanitizer, formalin that could cause harm; locking all cabinets if possible; moving the patient to an exam room closer to the nurse’s station where more staff are present and can easily assist.
The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
c) Every 3 Years
How many inches do all items need to be from the ceiling?
18 inches and make sure that you have no banners or items hanging from the ceiling.
How many inches should something be off the floor?
5”. If on metal shelves, the bottom shelf must be covered to prevent water splatters/dust from cleaning the floor.
If you wanted to know what your role is in a bomb threat, which binder would you find the information in? And where is it located?
The Red binder at check in
How often is documentation required on a patient on suicide precautions?
Every 15 minutes. And initially by a nurse and every 2 hours thereafter.