Joint Commission Basics
During the JC survey, the surveyors will talk primarily to:
What is EVERYONE
Found on the LRMC homepage and is used to help staff feel safe within the environment
What is Work Place Violence Prevention and Management Program?
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
What is 30 minutes?
This type of cleaning is performed DURING the case with sterile water and then immediately after a case with Enzymatic Solution to keep instruments moist and reduce bioburden. Instruments are sprayed BEFORE leaving the room.
What is point of use cleaning?
Every syringe, medication cup, and basin must be
What is labeled
Surveyor asks you a question you do not know the answer to, what do you say?
What is saying you will look into an answer
How long must you wait after a chloraprep draping before draping?
What is 3 minutes
RACE stands for
What is R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
AORN requires that cleaning chemicals be used according to what specfic guidline?
What is the manufacturers IFU (contact time)?
These medications require extra steps for safety due to high risk- and where is the sign located
What is high-alert medications? What is by the Pyxis and Block Bay
Where do you find information regarding equipment used in the OR?
What is Manufacture IFU
The correct way of cleaning equipment between cases besides housekeeping items (entire process/ who)
What is using CAVI wipes and following package directions and everyone is responsible in room
PASS acronym stand for?
What is Pull, Aim, Squeeze, Sweep
You are SUPPOSE to do this between every case
What is change your mask
What is Tech orientation/Progam
This error is specifically targeted by the Universal Protocol (3 parts)
What is wrong site, wrong procedure, or wrong patient surgery?
Correct temperature/ humidity ranges in the OR/ where do we record this or find the readings
What is 68 degrees-75 degrees, 20-60% humidity, and at the front desk in a binder
This goes on your back table for fire safety
What is sterile water and normal saline
Peel pack items upstairs in the OR- what is the process with ensuring intergrity
What is checked monthly and then upon every use the packaging is checked & Sterile items should be positioned so that packaging is not crushed, bent, compressed, or punctured and so that their sterility is not otherwise compromised.
The time-out has the following characteristics:
What is it is standardized, as defined by the hospital. - It is initiated by a designated member of the team. - It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.
The most important goal during a survey
Walk me through point of use cleaning
What is starting on the BACK table & instruments must be sprayed with enzymatic spray besides eye instruments
Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
How are we storing our fluids/ process of placing fluids in warmers?
Per manufacture IFU & date applied to fluids in warmers
Top TJC findings listed:
What is: inadequate pre-operative verification, improper labeling of medications, lack of fire safety risk assessment, non compliance with aseptic techniques.