Joint Commission Basics
A triennial evaluation of our hospital's compliance with CMS standards.
What is the TJC survey?
Stop
Think
Act Review
What is the error prevention tool STAR?
The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____
30 Minutes
A detrimental response to a medication which is undesired, unintended, or unexpected when administered in generally accepted doses.
What is a medication adverse reaction?
An intentional pause prior to a surgical or invasive procedure.
What is a time out?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
What are Tracers?
MEWS Score of 5 or greater
Patient deterioration
"feel something is note right"
What is calling a Rapid Response?
If you wanted to know what your role is in a bomb threat, which binder would you find the information in?
The Red binder
Resume previous medications
What is a an inappropriate resume order?
Take home instructions and follow up care order by physician.
What are discharge instructions?
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a Veterans PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC
What is HIPPA?
Patient's Name and Date of Birth
What are our two patient identifiers?
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
0.7 versus .7
What is a leading zero?
What do the letters VAP stand for?
What is ventilator associated pneumonia?
The right to effective communication
The right to participate in care decisions
The right to informed consent
The right to participate in end of life decisions
What are patient's rights?
A questioning attitude to check for errors when information does not make sense or is not what we expect.
What is the error prevention tool (EPT) Question and Resolve?
The term used to describe being aware of unusual situations or circumstances and reporting them to security for investigation.
What is situational awareness?
Authenticated within 48 hours
What is a verbal order?
These must be re ordered every calendar day after an evaluation by the physician.
What are non-behavioral restraints?
The name of the regulatory body over our Laboratory accreditation.
What is CAP?
(1) .U or u (unit) (2) IU (international unit) (3) Q.D., QD, q.d. (daily) or Q.O.D., QOD, q.o.d. (every other day) (4) 1.0 (no terminal zeros) .5 (always use a leading zero - "always lead never follow" (5) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)
What are un approved abbreviations?
Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
18"
Medication order includes:
medication starting dose
incremental units to increase/decrease
frequency for incremental doses
maximum rate/dose of infusion
objective end point (RASS score)
What is an appropriate medication titration order?
Hand Hygiene, Patient Identification, and Universal Protocol are examples of these.
What are National Patient Safety Goals?