Joint Commission
2013
Questions and Answers
A pocket guide to making quality, safety
and preparedness a permanent part of your job
&A
Index
Important Phone Numbers...................................................................3
About This Guidebook......................................................................... 4
You and the Survey Process.................................................................5
The AAMC Mission Statement.............................................................. 9
National Patient Safety Goals............................................................. 11
Ethics, Rights and Responsibilities.....................................................16
Provision of Care, Treatment and Services.......................................... 24
Assessment (nutrition, pain, abuse/neglect)—POCT—Restraints
—Learning Assessment—Patient Education—Handoff/SBAR—
Continuum of Care—Blood Administration—Falls—
Code Blue/Rapid Response—Code Carts
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Medication Management...................................................................53
Surgical Services...............................................................................59
Surveillance, Prevention, and Control of Infection...............................67
Improving Organizational Performance...............................................78
Management of the Environment of Care............................................85
Radiation Safety................................................................................92
Emergency Management....................................................................93
Leadership........................................................................................95
Information Management...................................................................97
Human Resources............................................................................. 99
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Important Phone Numbers
• The hospital emergency number to contact security officers (i.e. fire) is
x6911
• In the Sajak Pavilion, Wayson Pavilion, or Health Sciences Pavilion,
dial 9-1-1 for police or fire emergency
• Patient Safety/Incident Report Hotline x4787 (“4PTS”).
• Compliance Officer, Shirley Knelly, x1328/ Compliance Hotline x1338
• Privacy Officer, Robin Smith, x4130
• Patient Safety Officer, Shirley Knelly, x1332
• Environment of Care Safety Officer, Tony Kuzawinski, x4798
• Emergency Repair Hotline at x4777 3
About This Guidebook
While this guidebook is meant to prepare you for a Joint Commission
survey, its larger purpose is to make that level of preparation a
permanent presence in the way you go about your job­–every day, every
time. You are responsible for being familiar with the information in the
guidebook, which means you share in the responsibility for making
sure that quality, safety and preparedness are not the exception but the
constant rule.
Check with your director/manager about your specific responsibilities in
preparing for the survey, and about what specific information will assist
you in responding to surveyors’ questions during the survey process.
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You and the Survey Process
1.What is the Joint Commission?
The Joint Commission is an accrediting organization that evaluates a health
care organization’s performance in areas that most affect patient health
and safety. These areas are defined in The Joint Commission Standards. By
achieving accreditation, a health care organization has demonstrated its
commitment to provide safe, quality care to its patients.
2.What is your role during the survey?
All employees should know that a surveyor must first be identified by
administration as a bona fide surveyor before any hospital business is
discussed. If you are the first contact a surveyor has made, smile, introduce
yourself, including your title, and accompany the surveyor to your area
manager to contact the Vice President of Quality and Patient Safety.
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3.What is Tracer Methodology?
Tracer methodology is an evaluation method in which a surveyor selects
a patient and uses that individual’s record as a roadmap to assess and
evaluate an organization’s compliance with selected standards and the
organization’s system for providing care and services.
4.What is the role of the staff in the survey/during a tracer?
As surveyors move around the hospital, they will ask to speak with the staff
members who have been involved in the tracer patient’s care, treatment
and services. Assume they will want to talk with you, so have confidence in
yourself–you provide awesome care, so let them see it! Remember that you
are prepared to answer their questions.
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Consider the following recommendations:
> Answer their questions directly (keep your answers short and sweet) and ask
the surveyor to repeat or rephrase the question if you don’t understand it.
> Be polite and smile–do not let the questions make you feel defensive
or angry.
> Be honest–if you do not know the answer, do not make one up. If you don’t
know, state your resources.
> Be specific, provide examples for an answer and refer to policies or
procedures whenever possible.
> Be enthusiastic about what you do.
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Examples of what will be asked:
>Your role in patient safety (i.e., NPSGs)
>What makes you competent in your role and how you were oriented in that
role (i.e., licensure, yearly competencies)
> How care is coordinated and communicated with other disciplines (i.e. care
planning)
>What you would do in an emergency (i.e. fire)
> How do you support patient rights
>What are your Performance Improvement Projects on your unit
>What is a Sentinel Event/Near Miss
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The Anne Arundel Medical Center Mission Statement
It is important that all employees know, understand and can speak
about the mission of the hospital.
The mission of Anne Arundel Medical Center is to enhance the health of
the people we serve.
AAMC enhances the health of the people we serve by recognizing its
responsibilities for following the highest standards of care, treatment
and services in meeting the needs of individual patients, affiliated
physicians, third party payers, subcontractors, independent contractors,
vendors, consultants, our community, and one another.
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1. How do you support the mission of AAMC? Anne Arundel Medical Center staff provides patient care in a manner
consistent with the mission statement.
2. Do you know what is meant by one level of care? Yes. The care we provide is the same for all patients throughout the hospital
who have similar needs. We assure that all patients receive the same level
of care when we use common policies/procedures and collaborate with
other departments in the provision of care. Outcomes then can be assessed
and measured through performance improvement activities.
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National Patient Safety Goals
Each year the Joint Commission identifies National Patient Safety Goals and
surveys organizations’ efforts to achieve these goals, as appropriate to their
settings and services. Each employee is expected to know how these safety goals
are being applied in their particular area of service. Please refer to the National
Patient Safety Goals flipcharts and/or posters in your departments for details.
The current National Patient Safety Goals are on the following pages:
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GOAL 1:Improve the accuracy of patient identification > Double identification of patient: >> Name and contact serial number (CSN)
> Two person verification process for the administration of blood and
blood products
GOAL 2: Improve the effectiveness of communication among caregivers Critical value results reporting process
GOAL 3: Improve medication safety
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> Labeling of meds
> Management of anticoagulation therapy
> Accurately and completely reconcile medications across the
continuum of care
GOAL 7: Reduce the risk of healthcare associated infections
> Comply with CDC or WHO hand hygiene guidelines and
compliance monitoring
> Implementation of evidence based practices to prevent:
>>Health care associated infections due to multi-drug resistant
organisms (MDRO) and Cdiff flagging and isolation, patient and
health care worker education.
>>Central Line Associated Bloodstream Infections (CLABSI): central
line insertion checklist, patient education prior to insertion.
>>Surgical Site Infections (SSI): proper antibiotic prophylaxis, patient education prior to surgery.
>>Catheter Associated Urinary Tract Infections (CAUTI): limit Foley
use, leg securement.
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GOAL 15:Identify safety risks inherent in its patient population
> Identify patients at risk for suicide
>Provide suicide information (i.e., crisis hotline) to the patient and
family members
Universal Protocol to prevent wrong site, wrong procedure
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> Pre-procedure verification process
> Mark procedure site
> Perform a time-out just prior to the procedure
What are the responsibilities of the Patient Safety committee?
>>Integration and coordination of all components of the Patient
Safety Program.
>>Oversight and implementation and monitoring of the National Patient
Safety Goals.
>>Reviewing and recommending actions related to patterns/trends identified
in occurrences reports.
>>Promoting a non-punitive culture of safety.
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Ethics, Rights and Responsibilities
The hospital has an ethical responsibility to the patients and community
it serves. To fulfill this responsibility, ethical care, treatment, services and
business practices must go hand-in-hand. The hospital’s system of ethics
supports honest and appropriate interactions with patients. The system of
ethics also includes patients whenever possible in decisions about their care,
treatment, and services, including ethical issues. Refer to policy ERR3.1.03
1. What is an ethics consult and how do you initiate it?
A patient, family member, physician, caregiver, other party or an employee
may request an Ethics Consult. An ethic consult can be initiated through
a clinical consultation in Epic or can be initiated through the hospital
operator. This consult accesses an ethics representative who is on call 24
hours a day, seven days a week. The on-call person will ensure all supports
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are in place to facilitate the decision making at hand, this may include
ensuring family conferences have taken place to convening a patient care
advisory committee to provide clarification or assistance in facilitating care
decisions as needed. A Patient Care Advisory Committee must include an
administrator, a physician, a social worker and a nurse that are uninvolved
in the care of the patient or issue in order to give an objective view and
facilitation. Refer to policies ERR3.1.10/ERR3.1.09
2. How are patients informed of their rights?
Patients are given an Advance Directive pamphlet, Patient Guide and
brochures during the admitting process. Information is also located in
patient rooms. Volunteers visit with new patients and provide additional
information if needed. Interpreters are available to assist when needed.
Refer to policy ERR3.1.03
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3. What is an Advanced Directive?
An Advance Directive is either a living will or a durable power of attorney for
health care. It allows patients to indicate their wish for health care in case
they become involved in an end of life situation or are unable to speak for
themselves. Refer to policy ERR3.1.02
4. What is the hospital policy on ‘Do Not Resuscitate’ orders?
It is the policy of AAMC to honor the wishes of patients and their families
who express a desire to withhold or withdraw life-sustaining treatment
when specific criteria can be met. Refer to policy ERR3.1.08
5. How does a patient, family member or visitor initiate a complaint?
Any patient, family member, visitor, or nurse/caregiver can initiate a
complaint to any hospital employee. Hospital employees should do as much
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as they can for the patient at the time. Access Patient Advocacy at x4820.
During off shifts, the administrative coordinator or clatanoff pavilion
administrative coordinator would handle such issues. Refer to policy
ERR3.1.04
6. How do you ensure patient privacy?
>Only access a patient’s medical record when you have a “need to know,”
for example, you are involved in the direct treatment, payment, or other
healthcare operations related to that specific patient.
>Never discuss patients in public areas (i.e. elevators, cafeteria).
>Maintain confidentiality of patient information when talking on the
telephone or at the computer.
>Sign off the computer when finished.
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patient privacy cont.
>Maintain security of the patient’s physical medical record
>Knock before entering the patient’s room
>Be sure a patient’s body is adequately covered
Refer to policy ERR3.1.05
7. How would you address the care and learning needs of patients with
religious, cultural or language barriers?
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>Consult with Patient Advocacy, Social Services and Spiritual Care
>Involve hospital in-person Spanish interpreters for all language barriers,
including hearing and sight impairments, and they will facilitate support
and interpretation for you through the Martti units or Pacific Interpretation
audio interpretation services.
>For hearing and/or sight impaired patients, refer to policy ERR3.1.01
>A patient’s learning needs are assessed with each hospitalization
by all professionals who interact with the patient, the information is
documented in patient education tab assessment.
8. Why must we document a patient’s primary language and where do
we document this information?
Language barriers can have a significant impact on safe patient care and
patient care outcomes. As the diversity of our region continues to grow,
Anne Arundel Medical Center is encountering more patients with language
barriers. To communicate effectively with our patients, we must provide
patient care that is linguistically appropriate to all patients. The first step in
providing this care is to identify and to document the patient’s
primary language.
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>The following are the steps to document on the Adult Profile Flow Sheet:
>>Language Assistance–Answer ‘Yes’ or ‘No’
>>Language Needed–Open pull down menu and select language
>>Order an interpreter consult (x3801)
9. What are the components of an Informed Consent?
The goal of the informed consent process is to establish a mutual
understanding and agreement between the patient or surrogate and the
individual who provides the care or procedure that the patient received. The
process allows each patient or surrogate to fully participate in decisions
about his/her care, treatment and services. Obtaining consent to treatment
ensures that any patient receiving surgery or medical procedures will be
fully informed by the “individual performing the procedure” as to all the
material risk, benefits and alternatives prior to giving consent. 22
The consent form, Record of Consent for Procedure is required for all surgical
procedures and certain categories of invasive and a several types of noninvasive procedures, such as radiological procedures, administration of blood/
blood products, refusal of blood transfusions, radiation therapy.
A properly executed informed consent contains documentation by the individual
performing the procedure of the patient’s understanding of the information
pertaining to the nature of the proposed care, treatment, services, medications,
interventions or procedures, material risks, benefits and side effects of the
proposed care, therapy or procedures. It also contains documentation of the
likelihood of achieving care goals, the reasonable alternatives to the proposed
care or procedure, the material risk, benefits and side effects related to
alternatives, including the possible results of not receiving care, treatment and
services, and whether other healthcare professionals will be performing tasks
related to the proposed care or procedures.
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Provision of Care, Treatment and Services
The provision of care, treatment, and services to patients is composed of four
core processes or elements:
• Assessing patient needs. • Planning care, treatment, and services. • Providing the care, treatment, and services the patient needs.
• Coordinating care, treatment, and services.
1. Who can make a referral to Nutrition Services?
Any direct caregiver for the patient may request a nutrition consult.
Nutritional needs are initially assessed within the first 24 hours as part of
the admission screening.
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2. When and how often is pain assessment done?
Pain assessments are done by a professional nurse on admission, after each
intervention and as-needed, at least once per shift. Interventions are made
based on the reassessment and in evaluation of the pain management.
Patients are assessed for their risk of pain upon entering AAMC by a
professional nurse.
Factors that increase a patient’s “risk for pain” include being
developmentally or medically non-verbal, English is not the patient’s
primary language, extremes of age, cultural and religious beliefs. If pain
is present upon entering AAMC, a comprehensive pain assessment is
completed. See NAP12.1.18 for components of a comprehensive pain
assessment. Pain is subsequently assessed every shift, each report of pain,
within one hour of administering a PRN opioid, any new or changed pain;
prior to and following a procedure, per PCA policy and at discharge.
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3. How is pain assessed and managed for our patients?
Pain management goals are set with the patient and family. All professionals
who interact with the patient assess pain. Interventions are initiated as
appropriate through an interdisciplinary process. Pain is assessed using
developmental/age and cognitively appropriate pain assessment tools.
** Know which pain assessment tools available in Alec are appropriate for your
patient **
Pain management is included in the patient’s individualized plan of care
and supported by Clinical Practice Guidelines (CPG’s) that address both
acute and chronic pain. AAMC provides multi-modal and interdisciplinary
pain management.
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4. Who would you notify if you suspect abuse and/or neglect of a
patient?
Notify the supervisor/designee and the social worker. There is also a
domestic violence coordinator at x1209 who can assist. A consult can also
be entered into Alec based on the admission screenings.
5. What are some specific reportable criteria for suspected abuse
of a patient?
• Physical signs: cigarette burns, scalding burns, certain types of fractures
or internal injuries
• Personality: overly shy or aggressive, cries easily • Coping skills: inappropriate low tolerance, expresses desire to die
• Personal appearance: unkempt, poor hygiene, malnourished
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6. What is Point of Care Testing (POCT)?
Point of Care tests are laboratory tests done outside of the lab by non-lab
personnel. Because an accredited laboratory has many quality controls
built into its processes, as well as highly trained lab personnel, any lab
tests done outside the walls of the lab must be done with the same level of
quality control.
7. What POCT is performed in your patient care area?
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Each patient care area at AAMC has defined POCT. In order to know what POCT is authorized (permitted) in your area, refer to the POCT grid
under Lab Administration on the intranet. All POCT performed at AAMC is
for screening purposes and should not be used as a sole source of patient
diagnosis.
8. What is the organization’s policy on restraints?
AAMC’s philosophy is to strive toward a restraint free-environment by
continuously improving our practice to protect patients and respect their
right and dignity.
9. How do you monitor use of restraints?
AAMC is committed to preserving a patient’s rights and dignity. AAMC
utilizes retrospective chart review to monitor use of restraints to identify
opportunities to introduce preventive strategies, alternative use, and
process improvements that reduce the risk associated with use of restraints
on an ongoing basis.
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10. What are the two types of restraints that are used at AAMC?
Medical-Surgical: Used to promote medical-surgical healing. These restraints
are used for patients climbing out of bed or pulling at tubes or lines.
Behavioral Restraints: Used in an emergency to protect the patient against
injury to self or others because of violent or abhorrent behavior.
11. What procedures are required for each type of restraint?
The revised Restraint Policy and the Physician Order Sets list all the
requirements for each type of restraint.
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Key Medical/Surgical Restraint Requirements: >A physician order within 12 hours of application.
>When a verbal order is given to restrain, the physician must evaluate the
patient within 24 hours. >Physician must renew the order, based on reevaluation, at least every
calendar day >Care and assessment every two hours Key Behavioral Restraint Requirements:
>A physician order and face-to-face assessment within one hour
of application
>The care and assessment is done every 15 minutes
>A time-limited order based upon age (four hours for adults, two hours for
ages 9 to 17, one hour for under age nine).
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12. Do you utilize seclusion (the involuntary confinement of a person in
a locked room) at AAMC?
No, we do not use seclusion at AAMC.
13. How do we determine the educational needs of patients, families
and significant others?
Patient, family and significant others’ learning needs are assessed on
admission and then reassessed on an ongoing basis. This information
is documented in the patient education tab. The answers to the learning
assessment questions can be viewed in the SBAR handoff report.
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14. What are considerations in a learning assessment?
>Literacy, educational level and language >Emotional barriers and motivations >Physical and cognitive limitations >Learning needs preferences and readiness to learn >The specific questions to be answered in Alec regarding learning
assessment are the following:
1. Does the patient/guardian have any barriers to learning?
2. What is the primary language of the patient/guardian?
3. How does the patient/guardian prefer to learn new content?
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15. Based on the needs identified in the learning assessment,
patients/families should receive education on:
>Disease processes and treatment plan >Safe and effective use of medication and medical equipment
>Potential drug-food interaction >Nutrition and dietary needs >Rehabilitative techniques >Community resources >When and how to obtain further treatment
These items are teaching points on the General Teaching Title in Patient Education.
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16. Where do you find the hospital’s guidelines on patient education?
The policy for patient education is EDU 17.1.01 and handouts are available in
Alec via Clinical References, we use software from ExitCare.
17. What are you required to document regarding patient education?
>Preferred language, barriers to learning, preferred learning style(s)
>The reassessment of learning needs and challenges >Ongoing teaching, including informal sessions and structured classes >Patient/caregiver responses
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18.How do you involve patients in education and how do you know they
have learned what you have taught?
Encouraging questions and involving patients and families in decisions
about their care promotes an interactive approach to patient education.
Asking patients questions such as “What would you do if your catheter falls
out after you go home?” is a good way to evaluate teaching effectiveness.
Having patients perform demonstrations of a self-care measure is another
method of evaluation. Your evaluation of the patient’s learning must be
documented in the medical record.
19. How do you make patient education collaborative andinterdisciplinary
when more than one discipline is involved in teaching?
When more than one discipline is involved in the care of the patient, those
same disciplines participate in the various aspects of patient and family
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teaching. Each discipline has access to all documentation in the patient
medical record.
20.What is meant by continuum of care?
One of our goals in providing patient care is to maximize the coordination
of services among health care providers across a variety of settings.
Continuum of care refers to our process for coordinating care and
services to: >Meet the ongoing needs of individuals before, during and after
hospitalization
>Assess that appropriate information is provided, not only to the patient
and family, but to subsequent caregivers as well.
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Examples of services provided within the acute care setting include
pharmacy, dietary, physical medicine and rehabilitation, care management,
social services and pastoral care. Examples of services which extend beyond
the hospital include sub-acute care, extended nursing facility care, home
care, hospice and other community based healthcare services (i.e., a clinic,
community education).
21. How do we ensure that patients who come to AAMC have access to care?
Our goal is to ensure access to appropriate care. Admission to each patient
care unit is guided by criteria. Prior to, during, and after admission, we assess
the patient’s status to determine if we can provide the needed care. If not, we
facilitate transfer to a more appropriate unit or to another health care facility.
When patients are admitted, referred, transferred or discharged, we make
sure the appropriate patient care information is communicated to subsequent
health care providers.
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22. What do we do to ensure that the patient and/or family receive
information concerning the care to be given during the patient’s
hospitalization?
Dissemination of information regarding procedures and/or treatment
options are initiated by the physician and reinforced by all disciplines
involved in the patient’s care.
23. Describe some of the ways you communicate information to other
healthcare professionals?
We communicate with each other by written forms, telephone, fax,
computerized documentation and/or in person to be certain information
is relayed from one health care provider to the next. We document
assessments, plans and interventions on the medical record for review by
all team members.
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24. What standardized tool does AAMC use in communicating hand off
patient care?
SBAR
25. What does SBAR stand for?
S–Situation: What is happening at the present time?
B–Background: What are the circumstances leading up to this situation?
A–Assessment: What do I think the problem is?
R–Recommendation: What should we do to correct the problem?
26. Why do we use SBAR?
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To help our healthcare team communicate in ways that improve patient
safety, increase clarity, and provide a concise reporting method. This in
turn, will lead to a reduction in harm, increased satisfaction for all providers
and overall better outcomes for patients and their families.
27. How do we make referrals to the Care Management department?
Care Managers and Social Workers are easily accessible on the unit,
collaborating with other members of the healthcare team to facilitate
meeting patient needs. In addition, anyone can make a referral to the
Care Management department by telephone at x4180, fax at x4184, or by
entering a clinical consult into Alec.
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28. When does discharge planning begin?
Upon admission. It is a multidisciplinary process.
29. How are the needs of patients met after discharge if home care or
hospice is necessary?
Family/patient in coordination with the care coordinator or social worker
would assist in making decisions for discharge.
30. How is the Interdisciplinary Plan of Care developed?
The patient’s Plan of Care is determined and developed through
collaboration with all disciplines involved in the patient’s care. Each
patient’s plan of care in individualized based on the patient’s needs. Goals
are identified and mutually agreed upon between the patient and the
interdisciplinary team. This information is communicated and documented
using the computerized interactive Plan of Care.
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31. How is the Plan of Care individualized for your patient?
>Individualization of a patient’s Plan of Care can be done at several levels:
>It starts on assessment when you assess your patient with the fall and
skin risk tools, if the patient scores an appropriate level, the care plan
topic will be recommended for you via Best Practice Alert (BPA).
>Next when you are creating your care plan by applying a template, select
specific topics based on what your patient needs. For example, if your
patient has had hip surgery then you select that template.
>Within the template, select the interventions that apply to your patient.
>Finally, write a patient specific goal that you anticipate the patient will
reach during the hospital stay.
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32. What are the Blood Product Administration Key Points?
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>Obtain pre-transfusion vital signs
>Verification of blood product and patient must be made by two nurses
before initiation
>Blood must be initiated within 30 minutes of Blood Bank release to nurse
>Monitor patient during the first 10 to 15 minutes of the transfusion and
observe for reaction
>Vital signs must be taken 15 minutes after the transfusion was initiated
>Continue to monitor vital signs every hour until transfusion is complete
>PRBC must be completed within four hours
>Vital signs must be taken one hour after the transfusion completed
>Once blood product transfusion has completed, stop the blood in the EMR
and complete the section
33. What are some fall prevention measures that you can take?
>Communicate. Notify the transporter if a patient is at risk for falling. Notify
the receiving department if there is a high risk for falls.
>Include the fall risk in the handoff report and charge nurse reports.
>Assess for risk of falling on admission (within 24 hours), every shift, when
transferred to another unit, or after a significant condition change.
>
Maintain a safe unit environment by conducting an environmental
assessment of patient’s environment at the time of admission and at
least every shift.
>> Remove clutter and tripping hazards from patient’s room.
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>> Place the call light and frequently used objects within reach.
>On admission, discuss patient/staff partnership in preventing falls
while hospitalized and provide patient and family with copy of patient
education on preventing falls while hospitalized.
>Basic fall prevention interventions for all patients include:
>> Orient patient to surroundings including bathroom location, use of
bed, location of call light.
>> Use properly fitting nonskid footwear
>> Keep bed in lowest position during use
>> Unless specifically indicated, avoid the use of four side rails.
Patients can crawl over side rails and fall to floor.
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> In addition to basic fall prevention interventions, interventions for
moderate fall risk patients include:
>> Place yellow wrist band on patients.
>> Post yellow falling star outside patient’s room.
>> Assist patient to the bathroom/commode every two hours, as required
by service line. Stay with patient while toileting.
>> Supervise and/or assist with bedside sitting, as appropriate.
>> Use bedside commode, as appropriate.
>> Monitor and assist patient in daily activities.
>> Reorient confused patients as necessary.
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> Evaluate need for:
>> PT and/or OT consult
>> Activation of bed/chair alarms
>> Hip Protectors
In addition to basic and moderate fall prevention interventions, the
following interventions for high fall risk patients include:
> Post red falling star outside of patient’s room
> Remain with patient while toileting and performing personal
hygiene at sink
> Activate bed and chair alarm
> When necessary, transport throughout the hospital with assistance
of staff. Notify receiving area of high fall risk patients.
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> For patients who are high fall risk due to neurological deficits:
>> Use two person lift until physical therapy has evaluate for specific
transfer recommendations
>> Following orientation to call light, have patient demonstrate use of
call light
>> Assist patient with edge of bed sitting > Conduct post-fall assessment on all patients that have fallen and
provide either low risk or high risk monitoring.
>> Low Risk monitoring – no apparent injury from witnessed fall
>> High Risk Monitoring – all unwitnessed falls, falls with actual or
potential head/neck injuries, bleeding disorders, and use of
anticoagulant and/or antiplatelet agent.
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34.How do you activate Emergency Response Teams – Code Blue and
Rapid Response?
Code Blue: Push Code Blue button in patient’s room and/or call x1111
Rapid Response: Call x1111
Who can call Rapid Response?
Anyone–Staff (nurse, PCT, dietary, etc.), family members, patients, volunteers, etc.
Why would you call Rapid Response?
> You are worried about your patient–Call even if you are unsure!!
> Acute change in heart rate <40 or >130 beats/minute
> Acute change in systolic BP <90 mmHg
> Acute change in RR <8 or >28 breaths/minute
> Acute change in saturation <90% despite O2
> Acute change in LOC
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35. What areas call 9-1-1 for medical emergencies?
Wayson, Donner, Health Sciences, and Sajak Pavilions including all
outpatient regulated space and campus parking areas
Exception: Donner Pavilion–inpatient and outpatients in radiation oncology
and outpatient infusion center (Code Blue for outpatients; Code Blue and
Rapid Response Team for inpatients)
36. How often do you check your emergency code carts?
The carts are checked once daily using the code cart checklist to verify that
the lock identification number matches the number on the checklist, locks
are intact, expiration date is valid, and appropriate items are on top of cart
with valid expiration dates.
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37. How long must an area keep the code cart logs?
The current month’s log is kept with the crash cart. A department must keep
prior month’s logs in a separate location on the unit for one year.
38.Who controls code carts?
Distribution stocks the supplies. The cart is sent to the Pharmacy for drug
replacement, a final check and locked. The carts are kept in Distribution for
redeployment to patient care areas.
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Medication Management
1. What does AAMC’s high alert acronym PPINNCH stand for? Pitocin
Potassium concentrated IV
Insulin
Narcotics
Neuromuscular blockers
Chemotherapy
Heparin and other anticoagulants
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2. What are several ways medications are secured in your work area?
Most medications are secured in Pyxis. Individual patient medications are
stored in locked drawers outside patient’s rooms, and in med rooms. The
code carts contain medications but are secured with a tamper evident lock
and checked.
3. What must you do when opening a multi-dose vial?
Check the expiration date to ensure it is not out of date. Multi-dose vials
must be dated with a 28 day expiration date after opening or shorter as per
manufacturer’s recommendations. Vials may be used until the expiration
date as long as there is no evidence of contamination. Undated vials must
be discarded.
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4. What is important to remember about labeling medications in
OR/Procedural areas?
All medications that are removed from the original manufacturer’s container
for use in a procedure are to be labeled with the medication name,
concentration/strength, quantity/amount, diluents and volume of diluents
(if not apparent from the container), and expiration date (24 hours or less).
See SNP15.4.12 - Medication labeling and administration in the operating
room/procedural areas for more detail.
5. When are Pyxis overrides permitted?
Pyxis overrides are permitted during urgent patient care situations when
patient harm could result from delay in administration of a medication.
When a medication is removed via override, it becomes the responsibility of
the person removing and administering the medication to perform the same
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safety review that a pharmacist would perform before administration to the
patient. The override order in the eMAR is then “linked” to a physician’s
order by the administering nurse once the original order has been verified
by the pharmacist.
6. What is the hospital definition of adverse drug reactions (ADR)?
A response to a drug that is unintended and/or unexpected and occurs at
doses used for prophylaxis, diagnosis, and treatment.
7. Why is the Medications Reconciliation process important?
Patients are at high risk for harm from adverse drug events when
communication about medications is not clear. The chance for
communication errors increases whenever individuals involved in a
patient’s care change.
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8. When should medication be reconciled?
At admission, transfer, and discharge.
9. Who is responsible for ensuring reconciliation occurs?
Physicians, nurses, and pharmacists.
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Medication Reconciliation Tips for Success:
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• Ensure the medication list is accurate on admission: Enter nurse up-dates
to PTA medications via a “note” attached directly to the medication on the
admission navigator “Review PTA Meds.”
• Ensure all medications have been reconciled at transfer from one unit or
service to another.
• Ensure all medications have been reconciled at discharge: View “Med Rec
Status” on the discharge navigator.
• View the “Order Reconciliation History” on the “Patient Summary” as a
quick look to see if all medications have been reconciled on admission, at
transfer, and discharge.
Surgical Services
How do you label medications on and off the sterile field?
1. Medication containers include syringes, medicine cups and basins.
2. Label medications and solutions that are not immediately administered.
This applies even if there is only one medication being used. Note: An
immediately administered medication is one that an authorized staff
member prepares or obtains, takes directly to a patient, and administers
to that patient without any break in the process.
3. Labeling occurs when any medication or solution is transferred from the original packaging to another container.
4. Labels include the following: Medication name, strength, quantity,
diluent and volume (if not apparent from the container), expiration time
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when expiration occurs in less than 24 hours (for example, Propofol).
Note: The date and time are not necessary for surgical and interventional
procedures when medications are discarded at the end of the procedure
or the end of the day.
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5. Label each medication or solution as soon as it is prepared, unless it is
immediately administered.
6. Label the container after the medication is prepared.
7. Verify all medication or solution labels both verbally and visually
whenever the person preparing the medication or solution is not
the person who will be administering it. Verification is done by two
individuals qualified to participate in the procedure.
8. All medications and solutions both on and off the sterile field and their
labels are reviewed by entering and exiting staff responsible for the
management of medications.
9. Immediately discard any medication or solution found unlabeled.
10.Remove all labeled containers on the sterile field and discard their
contents at the conclusion of the procedure.
11. An expiration date is required when all multi-dose vials are opened and
not used within 24 hours.
When and how do you conduct a Pre-procedure verification
(Universal Protocol)?
1.
Pre-procedure verification begins when the patient is scheduled for a
procedure.
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2. Key elements to verify include the patient’s name, procedure to be
performed and laterality (correct side/site).
3. A pre-anesthesia time out must be done before sedation is given to the
patient so that the patient can participate in the time out and confirm
the key elements. This timeout is led by the physician providing
the sedation.
4. In cases of laterality, the incision site must be marked with the
surgeon’s or proceduralist’s initials.
5. Only the indelible ink marker provided by the hospital is to be used the
mark the site.
6. If site marking is not possible, the alternative site marking process must
be used. In the alternative site marking process the nurse places a white
alternative site marking band on the patient during the pre-procedure
verification and writes the correct side and site with an approved
surgical marking pen. The physician or practitioner performing the
procedure must initial the band itself prior to moving the patient to the
operating or procedure room to confirm the side or site. Documentation
of placement will follow the same documentation for all site markings.
The band will not be removed until after the procedure is completed.
Note: In NICU, the babies are marked with a betadine swab.
7. The site marking must be visible after the site has been cleansed and
draped for the procedure
8. A surgeon/proceduralist-led time-out must occur immediately before the
start of the procedure (initial incision or insertion of instrumentation).
9. During the time out, all other activities and conversations are
suspended, to the extent possible without compromising patient
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safety, so that all relevant team members are focused on the active
confirmation of the correct patient, procedural site and other critical
elements of the procedure. If laterality is indicated, all team members
must confirm that the site marking is visible.
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10.Time-outs must also be conducted before anesthetic blocks (scalene,
local, etc.) are done. This time out is led by the physician providing
the anesthetic.
11. If a central line must be inserted before the procedure starts, the
physician inserting the central line must perform a time-out with
members of the procedural team. The central line checklist is to be
completed by that physician.
12.All time-outs are to be documented in the patient’s medical record.
What is proper surgical attire?
1.
Scrubs: Only scrub tops and pants provided by this hospital are worn.
Scrubs used in restricted areas are not brought or worn in from home.
Personnel are to change into street clothes prior to leaving the hospital.
2.
Scrub jackets: Either disposable or non-disposable, only scrub jackets
provided by the hospital are to be worn.
3.
Clean, fresh, personal scrub hats may be worn in restricted areas only if
covered with a fresh, disposable scrub hat/bonnet prior to entry into the
operating rooms/sterile procedure areas.
4.
Dedicated shoes for restricted areas are recommended. Shoes not
dedicated to the restricted areas should be worn with shoe covers while
in the restricted areas.
5.
Remove shoe covers and masks when leaving the operating room suite.
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6.
Undergarments (e.g., undershirts, turtlenecks) are not permitted to
extend beyond the necklines or sleeves of the scrubs.
7.
Any jewelry (earrings, necklaces, watches, and bracelets, etc.) that
cannot be confined within the surgical attire is not permitted.
8.
Fingernail jewelry is not permitted (see policy IC5.1.04 Hand Hygiene).
Fingernail polish is not permitted for scrubbed personnel.
9.
Remove all personal protective equipment (gloves, masks, booties, etc.)
prior to exiting the OR/CSP. Personal protective equipment (PPE) is not
permitted beyond the area in which it was used. Disposable surgical
bonnets are allowed outside of the restricted areas only if not visibly
soiled or wet, and must be replaced upon re-entry into restricted areas.
10.
Fanny packs, backpacks, and briefcases should not be taken into the
restricted area.
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Surveillance, Prevention, and Control of Infection
1. What are some measures used to prevent transmission of infectious
diseases to staff and to patients?
Isolation precautions may be instituted by the nursing staff without a
physician’s order. AAMC’s mandatory immunization program protects
both staff and patients. Environmental cleaning has become increasingly
important in the fight against transmission, particularly with
antibiotic-resistant organisms. Hand hygiene remains the single most
important factor in preventing the spread of infectious diseases.
2. When should hand hygiene be performed?
Hand hygiene (washing hands or use of alcohol-based handrub) should
be performed before and after touching a patient or any equipment that
touches a patient. Wash your hands with soap and water when hands are
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visibly soiled/contaminated, before eating, after using the restroom, and
whenever caring for a patient with Clostridium difficile (Cdiff). AAMC follows
Centers for Disease Control and Prevention (CDC) guidelines.
3. How is hand hygiene monitored and promoted at AAMC?
Hand hygiene is monitored through audits conducted by “secret shoppers”
on every patient unit and the Emergency Department. Compliance is
compared housewide, per patient unit, and per type of healthcare worker
role. AAMC is a member of the Maryland Hand Hygiene Collaborative in
order to foster improved hand hygiene by healthcare workers, patients, and
visitors. Alcohol-based handrub, hand wipes on food trays, hand hygiene
education in the patient handbook, and housewide signage are only some
of the examples of how hand hygiene is promoted at AAMC. Be prepared to
discuss the most current data on hand hygiene compliance for the hospital
and your area, as well as how your area is promoting hand hygiene.
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Fingernails are to be short (less than ¼ inch in length); if nail polish is used,
it should be clear and intact. Persons involved in patient care or handling
linen, patient supplies, food, etc. are not allowed to wear artificial nails.
4. What are the steps to placing a patient in isolation?
>Identify the appropriate isolation and hang an isolation sign on entry to
the patient room.
>Order isolation in the computer (physician’s order is not required).
>Gather the correct personal protective equipment (PPE) and place at entry
to patient room.
>Educate patient/family members on need for isolation and expectations
of them to maintain isolation. Use handouts located on intranet to assist
with education.
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>Perform hand hygiene and put on PPE prior to entry. Dispose of PPE in
room upon exit and perform hand hygiene.
>With patient transfer or discharge, leave the isolation sign posted for
environmental services (EVS) to remove following cleaning of room.
5. What infection control and prevention education is important to
provide to your patient/patient’s family?
Any time a patient is diagnosed with an infectious disease or is about
to undergo a procedure there is an opportunity for infection prevention
education. Upon admission and throughout a patient stay, hand hygiene is
emphasized. The Joint Commission emphasizes the need for education of
patients and family members, and looks for documentation of education for
the following conditions/situations:
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>Identification of multidrug-resistant organisms (MDROs), such as MRSA,
VRE, etc., and Clostridium difficile (Cdiff)
>Placement in isolation
>
Prior to insertion of a central line (central line-associated bloodstream
infection (BSI) prevention)
>
Prior to surgery (surgical site infection (SSI) prevention)
6. What infection prevention strategies are used during the insertion
of a central line (central venous catheter)?
Remember the central line insertion checklist (make sure to document):
> Have proper hand hygiene
> Use a sterile drape to cover patient (maximum barrier precautions)
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>
PPE: sterile gloves, cap, gown, mask, eye protection for
inserter/assistant; mask with eye shield for everyone else in the room
>Chlorhexidine skin prep or alternative if allergic
>Avoid femoral vein unless there are no other options.
7. How long does a disinfectant wipe or solution need to make contact
in order to kill bacteria and other microorganisms?
Germicidal wipes or bleach-impregnated wipes are used to wipe down
equipment, including IV pumps, stethoscopes and keyboards between
patient use. Sometimes staff will also use germicidal solution (for example,
Virex), used mostly by environmental service (EVS) staff for cleaning rooms,
for bigger items, such as stretchers. Whatever used, you are expected
to know how long the equipment needs to stay wet (contact/kill time) in
minutes to be effective.
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Remember: Germicidal PDI AF3 (grey top) Wipes = 3 minutes
Bleach Wipes (for example, Dispatch) = 5 minutes
Virex Spray Solution = 10 minutes
8. How are employees exposed to bloodborne pathogens reported?
Exposures are reported by the exposed employee to their supervisor.
Employees exposed to bloodborne pathogens must be evaluated in
Employee Health Monday to Friday 7:30am to 4pm and in the Emergency
Department at all other times. This evaluation must occur immediately as
the window for giving antiviral medications, if needed, is two hours.
9. How are communicable diseases reported at AAMC?
The Infection Control Department has the responsibility for reporting
communicable diseases to the local and state health departments.
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Physicians may also report as needed. The laboratory also reports any test
results regarding communicable diseases.
10. How are infection control concerns reported?
Infection control concerns may be reported to Infection Control at x6446 or
the 4PTS hotline at x4787. Immediate concerns can also be addressed by
paging the hospital epidemiologist and/or director of Infection Control.
11. Where does staff receive education on infection control?
All staff receive infection control education in orientation and annually
on Healthstream. Also, infection control practices are integrated into
competencies. Infection control programs are also offered in specific
departments as issues and concerns are identified. Infection Control
personnel may be contacted for questions or consultation. Resources are
also found on the hospital Infection Control intranet site.
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12. What are some of the monitors in AAMC’s Infection
Control program?
The Infection Control program does surveillance of surgical site infections
in high risk, high volume surgeries, central line-associated bloodstream
infections, ventilator-associated pneumonias, urinary catheter-associated
urinary tract infections, blood culture contamination rates and other high
risk indicators. Surveillance also includes incidence of hospital-acquired
multidrug-resistant organisms (MDROs) and Clostridium difficile (Cdiff)
and other organisms. Environmental testing, such as water testing for
Legionella, is coordinated through engineering and monitored by Infection
Control. Infection Control Risk Assessments (ICRAs) are conducted prior to
construction projects.
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13. How is selection of surveillance/monitoring determined by
Infection Control?
Selection of what surveillance/monitors are conducted is dependent on
the level of risk associated with patients, staff, and visitors. Periodic and
as needed risk assessments are performed in order to prioritize needs
for surveillance/monitoring. Annually, the risk assessments are used to
determine priorities; goals for the coming year are determined based on the
risk assessment and listed in the Infection Control Plan, available for review
on the Infection Control section of the hospital intranet.
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14. How are data from the Infection Control activities reported?
All reports are presented at the monthly Infection Control Committee; data
for specific patient populations are reported at service line and nursing
quality councils, critical care committee, and shared at staff meetings.
Nursing Quality indicators (NDNQI) include unit-based infections data. Be
aware of the infections data which relates to your area of service.
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Improving Organizational Performance
1. What are Core Measures?
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They are measures identified by the Joint Commission that allow for a robust
assessment of care provided in focused areas. The following are Core Measure areas which are collected and monitored:
• Acute Myocardial Infarction (AMI)
• Heart Failure (HF)
• Pneumonia (PN) • Surgical Care Improvement Project (SCIP)
• Children Asthma Care (CAC)
• Venous Thromboembolism (VTE )
For more information on metrics, contact Carole Clarke at x1327.
2. How do I know what is important in terms of performance?
The Board of Trustees determines strategic aims that are important to
AAMC. The following are the strategic aims for FY14:
> Preventable death
> Harm reduction
> Patient satisfaction
> Hospital acquired infections
> Re-admissions
> Medication reconciliation
> Core measures
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These are based on organizational priorities, considered important,
high volume, high-risk, and sometimes, new services. This information is
communicated through our Quality unit and services line councils.
3. How can I improve performance on my unit? Work with your unit leadership and/or participate in unit quality councils
and performance improvement projects.
4. How do I know what performance improvement projects are
occurring on my unit?
Information is posted in staff areas regarding projects. Frequently, the
data is displayed graphically so you can visually see how successful we
are. Please ensure you know your department’s performance Improvement
projects, how you are doing and what actions are being taken to improve
the measure.
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5. What if the data shows we are not doing as well as we hoped?
We closely analyze the data to determine what the issues and obstacles
(opportunities for improvement) are. Once issues are identified we can
make corrections.
6. What is the specific methodology used at AAMC for performance
improvement activities?
PDCA (Plan-Do-Check-Act) is our problem solving framework:
Plan: Plan the improvement
Do: Do the improvement and data collection
Check: Check the results of the implementation
Act: Act to maintain the gain and continue improving.
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7. What is the definition of a Sentinel Event?
A Sentinel Event is an unexpected occurrence involving death or serious
physical or psychological injury, or the inherent risk thereof, including any
process variation for which a recurrence would carry a significant chance of
serious adverse outcome. (See Sentinel Event policy QI6.1.09 for criteria).
8. What is a Near Miss?
A Near Miss is an event that does not meet the definition of a Sentinel
Event, but involves a process variation for which a recurrence would carry a
significant chance of a serious outcome.
9. How are incidents reported at AAMC?
Incidents can be reported directly to Department Managers and in turn
are reported to Administration. You may also use the 4PTS Patient Safety
Hotline (443-481-4787).
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10. What is the process of Failure Modes Effects Analysis (FMEA)?
This is a process that is used for systematic, proactive approach for
identifying the ways that a process or design may fail, and how it can be
safer. The focus is on preventing errors before they occur, enhancing patient
safety and increasing customer satisfaction.
11. What is a Root Cause Analysis (RCA)?
A Root Cause Analysis is systematic process that uses information gathered
during an investigation to determine the fundamental system deficiencies
that led to the incident. The goal is to analyze incidents to identify root
causes and fix underlying system problems to prevent recurrence of a
similar event. AAMC conducts root cause analyses for identifying the base
or contributing casual factors that underlie variations in performance
associated with adverse events or near-misses (See Sentinel Event QI6.1.09
policy for details).
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12. What are the terms Lean and RIE?
Lean: The core idea is to maximize customer value while minimizing waste.
RIE: A rapid improvement event is a part of the Lean toolkit and provides a
mechanism for making radical changes to current processes and activities
within a very short time scale.
What are some examples of Lean RIEs implemented:
> Linen management > Perioperative scheduling
> Care management > Pharmacy
> Revenue cycle > Supply chain
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Management of the Environment of Care
1. What is the smoking policy of the hospital?
AAMC has a smoke-free hospital campus.
2. What are the codes to signal an emergency?
The codes are:
> Code Red Mr. Firestone: Fire
> Code Pink: Infant/Child Abduction
> Code Blue: Cardiac Arrest
> Code Gold: Bomb Threat
> Code Orange: Hazardous Material Spill
> Code Yellow: Emergency or Disaster
> Code Silver: Active Weapon Threat
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3. What should you remember in the event of a fire?
The employee should be aware of the location of the pull stations (near the
exit) and the fire extinguishers in their work area. Areas to respond to the
fire should be the floor of origin, one floor below and two floors above the
fire’s origin. One strip of tape should be placed on empty patient rooms to
indicate the room is empty.
The acronym used is R.A.C.E., which stands for:
Remove the patient from danger
Announce (pull the alarm)
Contain the fire (shut doors)
Extinguish the fire or evacuate
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4. How frequently are fire drills conducted?
Fire drills are conducted once per shift per quarter in each area, except
during periods of construction when frequencies are two per shift per
quarter.
5. In what ways does the hospital support a secure work environment?
The hospital provides four security officers on duty per shift. These officers
do hazard surveillance rounds internally and externally.
6. What should an employee do if they see a suspicious person or
activity on campus or need help restraining a violent person?
They should ask the person if they need assistance, and should keep the
person in view and call Security immediately at x6911.
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7. What body within the hospital is charged with evaluating the
institution in terms of general safety, utilities management,
equipment management, emergency management, security interim
life safety and hazardous materials/waste?
The Environment of Care Committee leads these efforts.
8. How do you identify emergency powered electrical outlets?
These outlets are red or labeled.
9. How are you notified of expected utility interruptions?
Advanced notice is given to all staff via email, or the PA system is used for
immediate notification.
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10. Are extension cords prohibited for hospital use?
The use of extension cords is limited to certain situations and must
be approved by Maintenance or Biomedical Engineering for medical
equipment.
11. What should you do if the hospital lost access to water?
The loss should be report to the Engineering department. They will provide
alternatives (i.e., bottled water for drinking).
12. Who is authorized to shut off an area’s medical gas?
In an emergency situation the charge nurse shuts off oxygen as authorized
by the fire marshall. When the emergency situation is identified, notify the
hospital operator and the administrative coordinator. Take the necessary
actions to handle the situation according to hospital policy and communicate
the shut down of the gases to the appropriate people i.e., Respiratory Therapy.
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13.What should you do if there is a chemical spill?
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> Remove everyone from the immediate area
> Consult the Material Safety Data Sheets (MSDS). To obtain the necessary
information, call the 3E Company at 1-800-451-8346. They will respond
immediately by fax or email.
> Please follow the Spill Response-Action by Category Chart (Code Orange in
the Emergency Procedure Quick Reference Guide).
> If it is mercury, the spill kits are available from the Environmental Services
Department.
> Notify your manager/supervisor.
> Complete a Patient Safety Report (formerly known as an Incident Report).
14. How can you protect yourself, patients and the environment from
exposure to hazardous chemicals?
• Read and follow directions from the Material Safety Data Sheets (MSDS)
• Proper storage, handling and disposal of waste.
Report any unsafe conditions to your supervisor or Security at x6911.
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Radiation Safety
If you are identified as a worker in a radiation area, how do you protect
yourself from radiation exposure at work?
After using your lead apron, hang it up.
Protective aprons have a sheet of soft lead impregnated rubber on the inside. If
it is folded or creased it can fracture. When this happens, the protective nature
of the apron is lost. Don’t forget to hang up your lead apron properly every time
you take it off.
Wear your radiation badge, store it appropriately, and turn it in every month, on
time. That is the best way to know if you have been exposed to radiation. 92
Emergency Management
1. How does the hospital prepare staff for a disaster which might
involve a large number of patients admitted to the hospital?
The Incident Commander conducts two disaster drills per year.
2. What are the six critical functions of hospitals in relation to
Emergency Management?
1) Communications
2) Resources and assets
3) Safety and security
4) Staff roles and responsibilities 5) Utilities management
6) Patient clinical and support activities
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3. What are staff responsibilities during any type of a disaster?
Know and follow the guidance in the EOC 4.4.01 Emergency Operations
Plan. The main aspects for staff to follow are:
1. To protect the lives of your patients and families to the best of
your ability
2. To conserve property, such as knowing what to do in a fire (RACE)
3. To continue to provide and manage patient care to the best of abilities
during a disaster.
4. How do you maintain patient safety when utilities fail?
Some of the ways these situations are managed is by using portable oxygen,
flashlights, cell phones, bottled water, and manual respiratory equipment.
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Leadership
The Leadership at AAMC is responsible for:
>The safety and quality of care, treatment, and services
>A culture that fosters safety as a priority for everyone who works in the
hospital
>The planning and provision of services that meet the needs of patients
>The availability of resources—human, financial and physical—for
providing care, treatment and services
>The existence of competent staff and other care providers
>Ongoing evaluation of and improvement in performance
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How do we ensure that our clinical contracted services are performing
high quality and safe care to our patients?
Each service line quality council is responsible to select the measures for the
clinical contracted services in their area and monitor those measures on a
quarterly basis to ensure that high quality and safety care are provided through
the contractual agreement.
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Information Management
1. Do you have the necessary computer access to do your job?
Yes. My computer access is based on my role as caregiver. If my role
changes, my new role will require different access. Access changes are
requested by my supervisor.
2. How often is the computer system unavailable?
Every third Wednesday of the month at 2am the system is potentially
unavailable for two hours maximum for routine maintenance and upgrades.
Longer downtimes are coordinated and communicated differently.
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3. What guidelines do you follow if the computer system is down?
I follow the Integrated Computer Downtime Management policy. IS9.1.03.
Depending on the scope of the downtime I may have access to
> SRO (Shadow Read Only): The network is still available which will allow
read only access to the patient record or
> BCA (Business Continuity Access) printers: These allow you to print a
patient summary, which is used when there is no network connectivity.
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Human Resources
1. Do you function according to your job description?
Yes. All employees sign off on their job descriptions through Performance
Manager at time of hire, or transfer into new job/department. All job
descriptions are available to any employee through the Job Descriptions tab
in Performance Manager.
2. What skills are you required to maintain for competency in
your department?
There are department- and job-specific competencies that are required in
addition to the hospital-wide competencies. These are documented and
kept on file with your job description, annual performance evaluation and
other educational records.
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3. What education programs are you required to attend?
All employees are required to attend AAMC’s new hire orientation. All
employees are expected to complete annual hospital-wide educational
programs (for example, fire safety, electrical safety, infection control,
hazardous materials, right to know, personal safety, TB, bloodborne
pathogens [for those at risk for exposure] and cultural awareness). Nurses
attend the Nursing Service Orientation during the first week on the job.
Employees that use Alec are required to take Alec computer training courses
appropriate for their duties. Any job-specific educational offering to address
particular patient populations and unit specialty topics, or any applicable
new rules or regulations may also be required. From time to time, there is a
house-wide competency, such as Disruptive Behavior training.
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4. Why are specific competencies chosen?
Specific competencies are determined by your position responsibilities
and are based on risk; volume; whether it’s a new procedure, equipment or
technology; and changes in policy or procedures.
5. Are you provided with education to maintain population-specific
competency?
Yes. Training is related to the population (age, bariatric,
developmental challenges, etc.) served and competencies are
updated and defined annually.
6. What educational programs have you attended recently?
Think about what educational program you have completed recently and
write them down in the following space (for example, pain management,
ethics seminars, hospital grand rounds, weekly cancer conferences, etc.).
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Notes:
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2001 Medical Parkway
Annapolis, MD 21401
443-481-1000
TDD: 443-481-1235
www.aahs.org