Joint Commission Basics
How do you identify a hospital employee?
Their hospital issued identification badge (p.10).
How do you call a code blue?
In the hospital call 553-1111
Vocera prompt "Urgent broadcast: Code blue (give location and indicate if adult or pediatric
Code blue wall alarm (p.70)
Where is the chemical spill kit located?
Under the cabinet in the Biohazard room
Where is the SDS Rally point?
"H2" Hospital parking lot
Where are the wheelchairs stored?
Bay 25 "Equipment storage"
How would one locate the contact time for cleaner/disinfectant?
The label on the cleaner/ disinfectant being used. (p.34)
Does a "near miss" need to be reported?
Yes, it can prevent the error from occuring in the future.
Before using medical equipment, you should check for the Medical equipment verification certification. WHAT COLOR IS THIS?
Yellow (p.12)
How do you report a security incident?
Main hospital:553-1111
Off campus: 911(p.14)
What is a forensic patient?
A prisoner or person in the custody of law enforcement or the prison system.
How often should staff and patient refrigerators be cleaned?
Both must be cleaned weekly.
Where are the crash carts for this unit?
PACU and GI hallway
How do you report an adverse drug reaction?
1. Patient Safety Report (located on Sharepoint)
2. Call the pharmacy for help 288-8820/8830
What is the policy on verbal orders?
Verbal orders are generally discouraged but allowed in emergent situations. (p.81)
What are the fingernail expectations?
-Length must be less than 1/4 inch
-No artificial nails (p.33)
Who is responsible for obtaining informed consent?
Licensed independent provider (p. 87)
What is required to use a restraint on a patient?
1. Documentation that less restrictive measures have been tried.
2.Providers order (specific to episode and time limited)
3. The patient must be monitored every 2 hours and reassessed for continued need. (p75)
Where would one find how to operate and clean equipment?
Instructions for use (IFU) binders.
How many fire extinguishers are on the unit and where?
5 extinguishers.
1 on Hall E, 1 SDS hall, 1 outside preop hall, 2 on PACU hall.
Who is required to have a Competency Assessment Folder (CAF)?
ALL employees (all personnel assigned/ attached, volunteers, housekeepers, students, and contractors). (p. 27)
How are visitors and staff made aware of what precautions to take before entering a patient's room?
Signs are posted on the patient's room door that identifies the type of isolation and the personal protective Equipment (PPE) required. (p.29)
What system of communication does SDS use during handoff to ensure continuation of care?
IPASS
Illness Severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver. (p.8)
Where are the Instructions for use (IFU) stored?
How are the staff involved in performance improvement? (This will be asked in all departments)
-Chart Audits
-BCMA (Medication scan reports)
-Training days
-In services
-Tracers
If a patient has an unresolved issue, who do you refer them to?
Unresolved issues are forwarded to the department director and/ or the Patient Advocate. (P. 86)