Joint Commission Basics
Your ID badge should be where?
Name and picture displayed above the waist
What Universal Protocol prevents wrong site, wrong procedure?
Time Out
How many feet can objects be near the fire extinguisher?
3 feet radius
How many days must a H&P be documented or updated for TJC compliance?
30 days
Pain medication reassessment time frames:
IV and PO/IM
IV 15-30 minutes
PO/IM 30-60 minutes
How does your facility measure competency?
By observed performed skills in everyday work, if there is no opportunity to do so, then demonstrate through simulation. And yearly skills fair.
For some competencies, you must complete education and test, i.e. rhythm recognition.
How do you comply with CDC Hand Hygiene Guidleines
Hand washing with soap and water before and after each patient contact: Even if you used gloves wash, vigorously for 15 seconds.
Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected.
C.Diff patients: hand washing only; no alcohol rubs
Glucometer controls must have open date and expiration of __ days from open dated on vial.
90
When is the medication reconciliation performed?
On admission, on transfer to next level of care, and on discharge.
SKIN Bundle patients must be turned and documentation, every ___ hours
2
How can you ensure patient privacy and HIPPA rights?
Patient's name is not facing out in alcove, tapping out of WOWs, Lock off or shut down Dynamaps, etc., pertinent papers flipped over, etc.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) patient identifiers when providing treatment, administering medications, collecting specimens, discharging the patient.
Identifiers: Patient's name, DOB, MR#
What do RACE and PASS mnemonics stand for when there is a fire?
RACE - R - Remove person(s), A- Alarm/Activate, C- Confine the disaster, E- Extinguish or Evacuate
PASS - P- Pull the pin, A-Aim the nozzle , S-Squeeze the handle, S-Spray in sweeping motion
Name Pain medication severity ranges
PRN Mild 1-3
PRN Moderate 4-6
PRN Severe 7-10
Restraint orders are active for ___ hours. Reassessment for restraints ___ hours.
Order active for 24 hours (Bonus: what does STR require to keep the order active, per shift?)
Reassess every 2 hours
Can you name at least 2 banned abbreviations?
U (unit), IU (International Unit), Q.D./ Q.O.D. (Once daily/ Every other day), Trailing zero (#.0 mg), The Greek symbol "m" (for microgram), T.I.W. (three times weekly), MS, MSO4, Mag, Mg, MgSO4 (magnesium), AND All chemotherapeutic drug names
When can you screen your patient for suicide?
During admission and every shift.
(Bonus: Which question on the admission, pertains to suicide screening risk?)
A patient has brought in their own supply of Glucerna supplemental drinks and has asked to store them. What do you do?
Label with name and date of when item is being stored, place in patient refrigerator
*No employee items in patient designated refrigerator
A new patient comes in for SOB r/t CHF Exacerbation; comorbidities are hypertension, COPD, Falls, BPH, and MRSA from last admission 3 months ago. What care plans would you initiate in regards to this new admission?
Non-Surgical, Cardiovascular, Core Measure Congestive Heart Failure, Respiratory, Infectious Process
How long do you have to chart your new patient's admission assessment?
Per STR policy
Medical Surgical: 12 hours
Critical Care: 4 hours
The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
c) Every 3 Years
Vasopressors, anticoagulants, chemo, insulin, opiates, neuromuscular blockers, parenteral nutrition, PCA and epidurals
Who has the authority to close the oxygen shut off valves?
Clinical Leader of the unit has authority in the event of a fire.
You just received a new lab result of Potassium at 6.2. What are you required to do?
Communicate lab results to provider within 60 minutes of receiving results. Chart results in Ad Hoc: Event Charting :Critical Lab. Follow whatever preceding orders from provider after results have been given.
Multi Dose vial of insulin must be dated with ___ day expiration
28