Prep, Scan and Index
This group has the ultimate responsibility for the safety and quality of care, treatment and services that are provided by the hospital.
The Governing Board
LD.01.03.01 EP 1,2,3,4,5,6,8,9,10,27
EM.10.01.01 EP 1, MM.09.01.01 EP10, NR.01.01.01 Ep 3
This employee implements policies and procedures to minimize the risk of communicable disease exposure.
Infection Prevention Nurse - Fawn H.
Three Crosses provides access to knowledge-based information resources 24/7 through this tool on the intranet.
Lippincott
IM.03.01.01 EP 2
This must be assessed and documented prior to and after the administration of a narcotic.
Pain score
Name two preferred ways to report workplace violence
Compliance line
Incident Report
The __________ ___________ directs the delivery of nursing car, treatment and services.
Nurse Executive - CNO
NR.01.01.01 EP3
LD .01.02.01 EP 1
The number one way to prevent infection
Hand washing/Hygiene
The process of comparing medications the patient has been taking prior to entry or admission to the hospital
Medication Reconciliation
A patient must receive a medical __________ and _________ examination no more than 30 days prior to, or within 24 hours after registration, but prior to a surgery or procedure that requires anesthesia services.
History and Physical
PC.01.02.03 EP 4
MS.01.01.01 EP 38
MS.03.01.01 EP's 6,19
RC.02.01.03 EP 3
The requirements for this training is upon hire and annually for all employees assists in prevention of workplace violence.
Verbal Handle With Care
The systematic approach used by Three Crosses Regional Hospital to make changes in performance improvement measures.
PDSA cycle - Plan-Do-Study-Act
LD.03.05.01 EP 1, 2, 3
These guidelines must be followed when using cleaning, disinfection and sterilization devices.
Manufacturer's Instructions for Use
The hospital's process for __________ provides the opportunity for discussion between the giver and receiver of patient information.
Hand-off Communication - Examples (SBAR, BSSR)
PC.02.02.01 EP 1,2,3, 10
PC.04.02.01 EP1
A register nurse completes a nursing assessment within this timeframe after the patient's inpatient admission
24 hours
PC.01.02.03 EP 6
RC.02.01.01 EP 2
Harassing phone calls, emails, text messages, social media posts, and vandalism are considered this kind of threat.
Indirect threat of violence
The purpose of the hospital's ______, _______ and __________ define how the hospital will achieve safety and quality
Mission, vision and values
LD.02.01.01
These infections are those that may have been prevented if proper infection control practices were consistently used while a person was a patient in the hospital.
Hospital Acquired Infections
This law ensures the compliance with privacy and security regulations
HIPPA
IM.02.01.01 EP 1,3,4
RI.01.01.01 EP 7
MM.01.01.01 EP 1
This document must be completed prior to a procedure or surgery.
Informed Consent
This two-person system is recommended for use when personal safety could be jeopardized.
Buddy system
These groups are accountable to the Governing Board for the quality of care provided to patients.
The organized Medical Staff and the Medical Executive Committee
LD.01.05.01 EP 2,3,4,6
Gowns and gloves are the PPE required to be worn for all interactions with this type of patient.
Patient in contact isolation
These types of suspicions must be reported in good faith to external agencies in accordance with the law and regulation by the any person within the facility that first has the suspicion.
Abuse, neglect, and exploitation
RI.01.06.03 EP 3
PC.01.02.09 EP's 6, 7
This allows for a variety of disciplines to share care, treatment, and services provided to the patients in an interdisciplinary, collaborative manner.
Interdisciplinary Plan of Care (IPOC)
PC.02.01.05 EP 1
This only used when clinically justified or warranted by patient behavior that threatens the physical safety of the patient, the staff or others.
Restraint or Seclusion
PC.03.05.01 EP 1, 4