Procedural safety
A hospital was in violation of this specific chapter when: 2 surgical residents in the sterile field were observed with exposed beards.
What is Infection Control
Multiple hospitals were in violation of this chapter when: the surveyor found extensive discrepancies between pre- and post- op diagnoses, but the hospital did not have a process to identify and review these discrepancies.
What is performance improvement?
This is when a patient experiences a sudden, unexpected descent from a higher plane to a lower one.
Limited exclusions exist for when patients are getting out of bed or getting up out of a chair.
What is a fall?
This phrase is used to guide staff response to a fire emergency, and is abbreviated R.A.C.E.
What is rescue, alarm, contain, evacuate?
A hospital was found with condition level finding when: 3 large bugs were found on the wall in an ED storage room, rust was found on an IV pole, dirt and rust on furniture and equipment, dust on air diffusers.
What is Environment of care
A hospital was in violation of this specific chapter when: a sedation nurse in an EGD was observed changing gloves twice without using hand sanitizer in between
What is infection prevention?
A hospital was found in violation of this specific chapter when: the use of abbreviation HDS (hemodynamically stable) was noted in a patient's clinical documentation.
What is Information Management?
Before:clean procedure, touching a patient.
After: touching patient, environment, or biowaste.
What is hand hygiene or W.H.O. 5 moments of hand hygiene?
This phrase used for fire extinguishers is abbreviated P.A.S.S.
What is pull (pin), aim, squeeze, sweep?
A hospital was found with condition level finding from this chapter: when Decon air pressure was positive to an adjacent corridor.
What is environment of care?
A hospital was in violation of this specific chapter when: a pharmacy technician in sterile compounding was observed NOT handwashing up to the elbows per USP 797 requirements.
What is Infection Control?
A hospital was in violation of this specific chapter when: a computer at the nurse station displaying patient information was left unattended for 10 minutes. Non- employees in the immediate area could read the screen.
What is information management?
Morse fall scale of 0-45, bed alarms are used at RN discretion, yellow wrist bands should be removed and yellow door light turned off.
What are low or moderate fall risk patients?
The preparation for this includes identifying exit routes that won't leave you cornered, identifying safe rooms by their ability to be barricaded (yet ideally is not a dead end), and identifying the types of objects that can be used to distract or incapacitate.
What is run / hide / fight or Active Shooter training.
A hospital was found with condition level finding in this chapter when: a sterilizer drain was not being wiped down weekly with the product specified by the manufacturer.
What is EOC?
A hospital was in violation of this specific chapter when: a circulator nurse in cath lab passed meds to the scrub tech while verbally confirming medication, dose and expiration. But the scrub tech did not visually confirm the details.
What is National Patient Safety Goals. Our own policy states "All labels are verified both verbally and visually by two qualified individuals. No more than one medication or solution is labeled at one time."
A hospital was found in violation of this chapter when the immediate PACU note was present, but only mentioned "note dictated" without any content available.
What is record of care?
Morse fall scale of 50+, these patient shall automatically receive yellow band, bed/chair alarm, and yellow door light.
What are high fall risk patients?
A hospital was found with condition level finding from this chapter: when Decon air pressure was positive to an adjacent corridor.
What is environment of care?
A hospital was found with condition level finding in this chapter when: triage screening indicated high risk for suicide, but patient not placed on 1:1 observation. Some of the screening items were also left blank.
What are national patient safety goals?
A hospital was in violation of this specific chapter when: There was no evidence that CT imaging protocols had been reviewed and kept current with input from all required individuals (interpreting physician, medical physicist, and lead imaging technologist). Most recent review was signed off by the Imaging Chair, Director, and CNO, but not lead technologist or medical physicist.
What is provision of care?
A hospital was found in violation of this chapter when: consents were found that lacked the time of physician signature.
What is rights of the individual?
mid-level finding
This type of report should include AIDET, enable staff to review the condition of the patient, and give the patient an opportunity to participate.
What is bedside report?
This is the maximum distance into the hallway an object may extend before it becomes an obstruction. Suites are excluded. Applicable areas are 3W, 2W, 2N (213-224), 2E, and 2S.
What is 4 inches?
A hospital was found with condition level finding in this chapter when: the decon room did not contain any visible markings of a buffer area. Individuals entering room were observed without required PPE. Some individuals also observed returning to the semi-sterile OR coordior without changing attire. Process is inconsistent with AAMI ST79.
What is infection control?