The Joint Commission Survey Preparation

Front 1

What is National Patient Safety Goal 1?

Back 1

Improve the accuracy of patient identification. At least two patient identifiers are used.

Front 2

Give examples of how you meet National Patietn Safety Goal 1.

Back 2

1) Prior to specimen collection, medication administration, transfusion, or treatment, the patient, & as needed, the family is involved in the identification process.

2) The patient's room number or physical location is not used as an identifier. Ask the patient and/or family for the patient's name & birthdate.

3) Containers used for specimen collection are labeled with the patient's identification information in his or her presence.

4) Prior to starting a blood transfusion, 2 nurses (either 2 RNs or an RN & an LPN) objectively match the patient to the blood component at the bedside.

Front 3

What is National Patient Safety Goal 2?

Back 3

Improve the effectiveness of communication among caregivers

Front 4

NPSG 2

What are some examples from the "do not use" list?

Back 4

U, u, IU, Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d., qod, trailing zero (X.0 mg), lack of a leading zero (.X mg), MS, MSO4, MgSO4

Front 5

NPSG 2

Describe how to document physician orders or critical lab/test results received by telephone.

Back 5

1) Write down the complete order or result.
2) Read back the order or result as you've written it.
3) The person who gave the order or result confirms that it is correct.
4) Once confirmed, sign your entry as: "T.O./R.B. Dr. Smith/Nurse Julie, RN.

Front 6

What is the most frequently cited root cause for sentinel events?

Back 6

Ineffective communication.

Front 7

Why is it important to use two patient identifiers when providing care?

Back 7

1) To reliably identify the individual as the person for whom the service or treatment is intended
2) To match the service or treatment to the individual

Front 8

"Hand-off" communication during end-of-shift report should be clear & concise. What are the critical communication points that must be shared between caregivers?

Back 8

1) Description of the patient's current status (review pertinent flow sheets & reports)
2) Perinent background
3) Plan for continued care & review of the IPOC, including discharge plan
4) Review of medications via the electronic medication record (MAK)
5) Review of other medical orders such as pending labs & scheduled procedures.

Front 9

The hospital's process for effective hand-off communication includes.......

Back 9

interactive communication that allows for questioning between the giver & receiver of patient information.

Front 10

True or False -- Caregivers should be allotted time to "hand-off" patient communication & to ask questions with minimal interruption.

Back 10

True!! Caregivers may often share important information or think of questions that the patient may not remember.

Front 11

We use SBAR as a guide to organize patient information that needs to be shared with other health care providers. What is SBAR?

Back 11

S = Situation (What is going on with the patient?)
B = Background (Any pertinent history that applies to the current situation.)
A = Assessment (What is the patient's immediate condition?)
R = Response or Recommendation (How did the patient respond to intervention? Are there new orders?)

Front 12

What is National Patient Ssafety Goal 3?

Back 12

Improve the safety of using medication

Front 13

Talk about one of your lean projects.

Back 13

Some of the changes we've implemented are:
1) moved supplies to a storage closet closer to patients' rooms so that nurses don't have to walk so far the get what they need.

2) started frequent rounding to try & address patients' needs before they have to ask.

Front 14

How does frequent rounding improve patient care?

Back 14

1) When patients' needs are addressed, they are less likely to get out of bed on their own and potentially fall.

2) We are able to make sure that the rooms are uncluttered so that patients are able to get around without tripping.

3) Occassions of incontinence are decreased when we help patients with toileting often. Skin is kept clean & dry, helping to prevent skin breakdown.

4) Call lights are used less often, allowing nurses time to complete tasks such as documentation & making phone calls. This in turn allows staff more time to spend at the patients' bedside.

5) Patient & staff satisfaction is improved.

Front 15

Where is the MSDS information for cleaning chemicals that are kept on the unit?

Back 15

The MSDS information is on-line on our hospital's website. A hard copy is kept in the emergency department for use when the computer system is down.

Front 16

How do you know if a physician is privileged to work at your hospital?

Back 16

A list of physicians who have practicing privileges is on-line at our website. If I am unable to find a particular physician on the list, I contact Medical Affairs.

Front 17

Where is insulin stored?

Back 17

Patient specific insulin in labeled with a patient identification sticker & kept in the pull-down box by the patient's door. Insulin vials that are used for multiple patients are stored in our Accudose cabinet.

Front 18

When was your hospital's last disaster drill?

Back 18

As of May 14th, 2009, our last drill was during the last week of April. The situation was a flood that effected several surrounding counties.

Front 19

Describe your anticoagulation protocol.

Back 19

We have a very thourough anticoagulation protocol. A link is provided on our website under "Clinical/Physician". It is listed under "Directories and Reference" as "Anticoagulation management". Here you will find order sets, patient education forms & resources, forms & flowsheets, and several professional resource & education web links.

Patients receiving Warfarin (Coumadin) have daily lab tests (PT/INR) to assess for therapeutic levels of medication. Dosages are changed accordingly. Heparin doses are based on the patients' weight.

Front 20

Do you do double checks by nursing for any medications?

Back 20

Yes. PCA pump setting, or pain medication infusion controlled by the patient, are checked by two RNs. Chemotherapy drugs are also checked by 2 RNs. We use MAK which requires both nurses' identification tags be scanned prior to drug administration.

Front 21

How do you document your patient's plan of care?

Back 21

IPOC (Interdisciplinary Plan Of Care) is the document we use. It provides space on which all disciplines caring for the patient may record assessments & other information. The IPOC is updated continuously & used as a guide for end-of-shift report.

Front 22

How do you rate skin breakdown?

Back 22

We use a system called Braden Scale. It provides criteria for staging potential and/or actual skin breakdown. It is updated daily and whenever changes in the patient's condition occur.

Front 23

How do you do pain assessment? If I had a "5" pain score, what would you do?

Back 23

We ask patients to rate their pain on a 0 to 10 scale. If someone is unable to understand this scale, we have a tool that has smiley faces on it. A very happy face indicates no pain. A face that is crying indicates a pain score close to or at a 10. Patients may point to the picture that most closely matches their pain level. A pain level of 5 would require pain medication. A reassessment of pain is done no longer than 2 hours after medication is given & documented the new score is documented in MAK.

Front 24

If a patient is identified during collection of the admission nursing data base that they are interested in completing advanced directives forms, what do you do?

Back 24

I page our Social Worker for assistance. We also have educational resources available for patients and families on our "on-demand" video system, and in paper format on our website.

Once advanced directives have been completed, a sticker is placed on the front of the patient's chart indicating they have directives in place.

Front 25

What are some of your department's quality improvement projects?

Back 25

Escort the surveyor to our conference room. Current projects are displayed there. Some of them include fall prevention, pain management, pressure ulcer prevention, & so on.

Front 26

How often do you change dressings on Infusa-Ports?

Back 26

Port dressings are changed every 7 days. The needle is changed every 7 days as well.