Tracer Staff Interview
updated: 5-1-14
Data Definition Tool
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Instructions:
Inpatient Units: Interview 5 staff members using the Staff Interview questions.
Outpatient Practices and Procedural Areas: Interview 3 staff members using the Staff Interview questions.
PATIENT SAFETY: STAFF INTERVIEW
Standard
Yes
Patient Identification
Staff name:
How do you identify the right patient?
NPSG.01.01.01 Ask patient for 2 identifiers
EP 1
What two identifiers do you use?
NPSG.01.01.01 2 identifiers used from list: Patient name, MR#, Date of Birth, last 4 digits of SSN,
government issued photo ID, photo taken in PHV
EP 1
When do you use the identification process?
NPSG.01.01.01 Use prior to medication or blood administration, taking blood samples or other specimens,
and / or treatments / procedures.
EP 1
When do you label containers used for blood and
NPSG.01.01.01 Label the container in the presence of the patient.
other specimens?
EP2
Communication
Write verbal/phone order down and read it back to the prescriber for verification of
Explain your process for taking a verbal/phone
PC.02.01.03
accuracy.
order.
EP 20
(1) Write it down and read it
Explain your process for receiving a critical test
NPSG.02.03.01 Process includes:
back
to
the
lab
personel
for
verification
of
accuracy.
result.
EP 2
(2) Document in HED (critical result tab) or Starpanel or the paper record the result.
(3) Document the time the qualified responsible individual received result and name, time
notified and orders given.
8
Explain the "hand-off" communication process.
9
Wrong Site/Patient/Procedure
How is the site marked?
PC.02.02.01
EP 2
Use SBAR format when reporting between caregivers and to MD's etc. Refer to policy CL
30-08.04.
UP.01.02.01
EP 3
Site/side marking is performed by a licensed independent practitioner who is ultimately
accountable for the procedure and is present when the procedure is performed.
NOTE: Site/side marking may be delegated in limited circumstances to an individual who
participates in the procedure, is familiar with the patient, and is present when the
procedure is performed. This includes the following providers:
a. An attending physician, fellow physician, or resident physician;
b. Non-physician proceduralists (nurse practitioner, physician’s assistant).
10 Explain the term "time out" and when it is used in
your area.
Medications
11 Explain the process for medication reconciliation.
UP.01.03.01
EP 1 and 4
Prior to procedures (includes central lines, surgeries, procedures performed at beside and
in your area including but not limited to the OR)
NPSG.03.06.01 (IP) (1)The first set of admission medication orders is considered the initial reconciled list
(reconciled from review of the nursing admission history & medical student/house staff
EP 1, 3, 4, & 5
histories, the Summary Problem List from Star Chart, if one exists) (2) Current MAR is the
reconciled list throughout hospital stay, (3) Discharge medication orders on discharge
summary become the final reconciled list. (4) Patient is given a copy of this list and a copy
is sent to the provider if making a formal referral or transfering of care.
(OP) (1)Patient's home medication list is reconciled with the Star Panel practice list. The
updated list is approved by the provider and changes are entered into Star Panel. (2) At
the end of the visit, a copy of the updated list is given to the patient and a copy is sent to
a provider when making a formal referral or transfering care.
Glucometers
12 Explain the process for external cleansing of the
glucometer including when and how often this must
take place.
CMS H630 1200- External cleaning with Sani-Cloth wipes between patients. For patients
8-1-.06(3)(A)
on isolation, use a dedicated meter when possible. If meters must be
shared, use a bleach wipe followed by wiping the meter with a waterdampened cloth to remove bleach residue.