DNV Prep 2019 OR
"If it hits the table, it must be labeled" with medication name, strength (if applicable), amount and expiration date for all medications drawn up but not immediately administered.
Are all medications being labeled as per the National Patient Safety Goals?
Remember to ask the patient to state their first and last name and birthdate and verify the MRN on the patient's chart. Don't say, "Are you John Smith and is your birthday January 31, 1945?"
Are the team members asking and locating the two patient identifiers (name and MRN) when they interact with patients or take them to surgery/procedure?
NO, medications may not be stored in fridges used food
Are there any medications stored in refrigerators with patient or staff consumables?
Instadose Badge should be routinely worn above the waist, preferably at collar level.
Are you wearing your dosimetry badge according to policy?
Tracking of OTIS reports per quality management equates into educational initiatives for such things like Falls Prevention hospital-wide.
Describe how data is used in the organization to improve care and service?
Annual evaluation conducted by Manager. Annual competency are paper or computerized in Helathstream.
Do all team members have a current evaluation and competency on file?
TIME OUT
Do this prior to every exam to verify the correct patient, body part, exam and side to be examined
They should be located in the area where the chemical is located at. Check the expiration date and pull the SDS form to know what to do if the chemical got in someones eye. There needs to be yearly competencies reminding staff of this information.
Do we have spill kits for Formalin, Cidex, or any other chemical our department has?
FGH provides annual communications regarding flu shots at the beginning of each flu season. It is mandatory for all team members with any patient contact to obtain a flu vaccination each year or fill out a declination form yearly.
Do you get an annual flu shot? Do you receive information regarding flu shots each flu season?
annually
Document Control Matrix is updated _________.
Medical Records
Using Wite-Out on these prohibited
The Safety Data Sheets (SDS) formerly known as MSDS (Material Safety Data Sheets) that outline the hazardous materials present in particular areas should be readily accessible to all staff on FGH ONLINE under quick links. Each department should designate an area (FGH ONLINE under Quick Links). for the SDS and orient all employees to the location and use of the sheets. Surveyors will ask someone to locate.
WHAT IS A SDS? WHERE IS IT LOCATED?
Among the protective equipment available to employees are face shields, gowns, masks, shoe covers, safety glasses, and gloves, as well as hazardous spill kits. You should know the location of these
WHAT PERSONAL PROTECTIVE EQUIPMENT IS AVAILABLE TO YOU?
All employees should be able to locate the closest fire alarm pulls and fire extinguishers in their work area.
WHERE IS THE FIRE ALARM PULL FOR YOUR AREA? WHERE IS THE CLOSEST FIRE EXTINGUISHER
Usually, Attempt, Try, Sometimes
WORDS TO AVOID USING WHEN ANSWERING A SURVEYOR.
Everything! All equipment and all instruments.
What has IFU's?
LOOK at your badge
What is FGH Mission, Vison and Philosophy?
Instructions for Use (IFUs)
What is IFUs?
The drug name, strength, amount, expiration date if not used within 24 hours
What must be on the medication label?
No, recapping of needles.
When can I recap a needle?
-A Brown Shipping BOX can never enter the OR and must be broke out downstairs in the basements breakout room. Procedural and patient care areas should not allow brown/ shipping boxes in there clean/sterile storage areas.
When can a Shipping Box enter the OR/Procedure/Patient care area?
Anytime they are drawn up and not immediately used, if it is transferred from its original packaging to another container and at nay shift change where different team members take over patient care. Syringes in power injectors must be labeled.
When do medications have to be labeled?
Personnel dosimetry is reviewed by physicists and the radiology department. Actual exposure reports are maintained by your manager and posted by badge board monthly.
When does Alliance Radiology review the results of staff dosimetry reports?
In a designated areas for clean items only. Wipeable equipment items can not be placed in places where clean and sterile items are stored.
Where can CLEAN items be stored at ?
IFU's for instruments are located in the SPM system in Central Sterile. The IFU's for equipment are hardback manuals at the OR desk area. In 2020, they should all be on FGH online under departments--surgery-- Endo's has hardback manuals in the bottom drawer at the desk, and they are located online at FGH---Departments--Endoscopy BIOMED can also assist with the manuals sometimes;
Where can I find IFU's?
The Orthopedic Supply room or in a room dedicated only to reusable/wipeable equipment.
Where can Reusable equipment be stored?
All instruments MUST be taken down stairs to Decontamination to be washed and then returned to Surgery Area if IUSS is required.
Where do we wash an instrument that fell on the floor during the surgery case?
Fgh Online --- Forms--- then click document control matrix. tabs at the bottom show you if it is internal or external document. All IFUs or Manufactures guidelines are kept on document control matrix or SPM in Central.
Where is the Document Control Matrix?
The credentialing department, Millie Swans office on the first floor. Also ECHO located on FGH online and a hard copy is kept at the OR desk.
Who keeps up with maintenance on physician credentialing files?
ALL staff, physicians, students, everyone!
Who participates in fire drills?
Gloves
Worn during all injections
Don't block fire extinguisher equipment, gas gauges, or electrical panels
_____________fire extinguisher equipment, gas gauges, or electrical panels
Temperature
A daily _____ log is required for each blanket warmer and refrigerator.
lines and supplies
All medical equipment in every room must be disinfected after each patient and all ___________ and ______brought into a patients room or left out on a counter are considered contaminated and must be disposed of.
Labeled
All medication syringes
temperature, humidity, positive pressure Temp and Humidity is usually handled by engineering and they will call if there is an issue or abnormality. Positive pressure is monitored with a gauge and checked daily or the use of a tissue test.
All supply rooms with Sterile items in them MUST have there _________, ________ and maintain _______________ pressure.
Be able to produce your Dosmetry records online. Joe Marcello the Director of Radiology can assist you with this. They should be filed in the radiation safety binder, signed by the Radiation Safety Officer, and at least one year of records is available in the radiation safety binder.
All team member Dosimetry records are available for review if requested by surveyor.
Annually
All thermometers (fridge, cidex) must be calibrated ______.
Readback
All verbal orders must be ____ to the practitioner and documented
Communicate
Always do this throughout any patient exam to ensure the patient is informed of their care
Ensure there is an SDS for all chemicals used—do not purchase or clean off-brand Chemicals that are NOT on the SDS (FGH Online--> Quick links--->) They can be added by talking to Melissa Mazer the infection preventionist. There are many choices in the SDS database for whatever chemical you might need to use.
Are all chemicals for which there is no SDS (Safety Data Sheets)?
This is done to keep them from falling and spilling on your face, eyes, or just simply more of your body if the chemical is spilled.
Are all cleaning supplies and chemicals (formaldehyde and Cidex) stored in labeled lower cabinets?
negative
Breakout areas must maintain ______________pressure.
Technically, they need to be in separate areas; however, if they are in the same room/ area they must be in separate drawers, shelves, or areas to promote as much separation as possible. If Clean and Sterile items are stored together, then a higher level of storage should ALWAYS be maintained which is the sterile storage requirements.
Can CLEAN items and STERILE items be stored together?
NO, use of single-dose vials or IV bags
Can I use single-use vials on multiple patients?
Sentinel events are unexpected events that result in a patient's death or a serious physical or psychological injury. Complete an OTIS Report located at FGH ONLINE. 1-Unintended retention of a foreign object events 2-Suicide events 3. Wrong patient, wrong site, wrong procedure events 4. Operation/post-operation complication events 5. Medication error events 6. Fire-related events
Can all team members explain what a Sentinel Event is and what to do if one occurred?
That is an Unsecured meds. All medications are to kept the medication storage area locked.
Can nurse or staff leave an antibiotic on the counter at the desk?
Laryngoscope Handle and code cart
Check batteries for expiration date in ______ and ______ cart.
HIPAA violations such as open patient charts, and visible patient information in common areas
Computers left open are _________________ violations.
Make sure manufacturers' recommendations are followed, particularly for high-level disinfectant test strips. All test strips need to be dated when opened. There is also a requirement to test the strips themselves after opening a new bottle. Do a positive and negative solution test using 3 strips in the positive and 3 in the negative to determine that strips are reading the appropriate color. Document that the testing was performed on the same day the bottle was opened and the date that's on the bottle. The strips should be used to test the minimum effectiveness concentration (MEC) of the high-level disinfectant solution prior to each load. "I still have hospitals saying they do this testing only once a day. The requirement is that you test the MEC for each load and document each test Surveyors look for proper air exchanges in the room where endoscopes are high level disinfected. They also check to make sure there is a separation of clean and dirty reprocessing areas to prevent cross-contamination of scopes. If the reprocessing area is small, the staff should impress upon the surveyor that they are removing endoscopes from the high-level disinfectant when no other contaminated scopes are in the room. It is also wise to have a time-out process in a small reprocessing area. That is, when a scope comes out of the washer sterilizer or scope washer, a time-out is called so no one else in the room moves or handles a dirty scope at that time to avoid the risk of cross-contamination,
Endoscope/ Bronchscope cleaning and disinfection?
Surveyors will go all through the cabinets, refrigerators, etc. and they will ask what is stored and check expiration dates.
Ensure there are no expired medications, supplies, hand sanitizer or anything else with expiration dates.
The OR suite cannot have equipment blocking fire alarm pull boxes, fire extinguishers, electrical breaker panels, or medical gas shut-off valve boxes. These areas are "no parking zones" Surveyors will ask staff about the preparation and training they have received to prevent surgical fires and how they would respond if a fire were to happen. "They are looking to see if you have studied the best practices associated with preventing and responding to fires. Best practices are available from ECRI Institute (www.ecri.org) and the Anesthesia Patient Safety Foundation (www.apsf.org/resources_video.php). Make sure the code cart, pediatric code cart, and malignant hyperthermia carts are all checked daily to ensure that the contents have not expired and that all required contents are there. Check the biomedical stickers on the defibrillator and suction equipment and make sure those are not expired or out of date. Also check supplies such as defibrillator pads that have an expiration date on them. Surveyors will open the carts and check the laryngoscope flashlight handle to see if the batteries are expired. Because these carts are infrequently used, the handles may sit there for years without being checked. Also, check to make sure any spare batteries in the cart aren't expired.
Environment of care or crisis issues?
monthly
Fire extinguishers must be inspected by the team members on a _____ basis and changed Yearly.
Healthcare organizations MUST follow the manufacturer instructions for use (IFU) for equipment, supplies, and products used and are required to resolve any conflicts that may exist. When there are conflicts, the organization must resolve these. For example: If a manufacturer indicates varying cycle parameters must be met to sterilize a variety of instruments, but the organization's sterilizer is set to only one of those parameters, then the organization must contact the instrument manufacturer to determine if it is acceptable to use that parameter. If it is not acceptable, the organization must contact the sterilizer to determine if the parameters of the sterilizer can meet the various requirements. If it does not the policy direct individuals responsible for sterilization to an alternative location where the parameters can be met. Another example related to flexible scopes. Flexible scopes IFU/manufactures guidelines change frequently so written policies at your organization will have to mimic the guidelines exactly an update every time the manufacturer updates them. This continuous change cannot be maintained so IFU/ manufactures guidelines are commonly used as references instead of writing procedures/policies for such.
Follow MANUFACTURE's Guidelines
Segregated
Full and empty O2 tanks must always be _____
Avoid the outmoded term "flash" when referring to steam sterilization of instruments intended for immediate use. The key document is the "Immediate-Use Steam Sterilization" position paper issued over a year ago by the Association for the Advancement of Medical Instrumentation, AORN, and others. Two caveats regarding the position paper: • Instrument inventories should be sufficient to meet the anticipated case volume to avoid the need for immediate use sterilization. • A sterilized item intended for immediate use should not be stored for future use or held from one case to another. Pointers on data collection: • The Joint Commission expects data to be collected routinely and aggregated monthly on the number of immediate-use sterilization episodes and on episodes attributed to a lack of instruments. • The data needs to be evaluated by the OR leadership and submitted to the infection control committee for evaluation. • The leadership group should know the number of immediate-use sterilization episodes owing to a lack of instrumentation so they can present the data to the hospital's finance department to justify the need to buy more instruments.
Immediate-use sterilization?
Staff members should be able to describe the process specific to each area related to sharps disposal boxes and biohazard waste storage. All biohazard boxes cannot be more than 3/4 full. When the boxes are 3/4 full they should be replaced.
HOW DO YOU HANDLE SHARPS AND OTHER HAZARDOUS MATERIALS?
In our organization, the R.A.C.E. Procedure (rescue, alert, confine, extinguish) is used to respond to situations where fire threatens the safety of patients, visitors, or staff. Surveyors may ask staff to describe the last time they were involved in a fire drill.
HOW WOULD YOU RESPOND IN THE CASE OF A FIRE?
30 minutes
Hallway clutter: Time limit for wheeled items in corridor is _____ minutes. (Exception: Crash carts/isolation carts)
Use per instructions on the hand cleaner container. Do NOT dry with a paper towel after using alcohol-based hand cleaner. YOU Must wash with soap and water anytime hands are visibly soiled and after using the restroom.
Hand Hygiene - Are team members following hand hygiene principles
medication and supplies
Have a system for rotating stock of ________________________ and _______________ to prevent expirred items.
The patient's history and physical (H&P) can be performed no more than 30 days before or must be completed within 24 hours after admission. The documentation that the surgeon enters in the record needs to state: "I examined the patient, I reviewed the H&P, and there are no changes to that H&P." When there are changes, the surgeon must document them. The surgeon must sign the entry and enter the date and time the entry was made. Finally, the "rules" pertaining to H&Ps (what constitutes an H&P, when it is to be performed and updated, who may perform it, etc) need to be spelled out in the medical staff bylaws.
History and physical update ?
Telephone orders are read back, verbal orders are read back, avoidance of "Do Not Use" abbreviations, opportunity to ask questions when transferring patients. Instituting Language of Caring a new initiative to promote communication between patients, physicians, and employees
How are you improving the effectiveness of communication between caregivers?
Read documents out loud, use paper to write instructions, use sign language interpreters call the Patient Care supervisor as they have an Ipad system to aid in this process.
How do you communicate with a patient who speaks another language or has a vision, speech or hearing impairment?
Listen and report to patient advocate
How do you handle Patient Complaints?
The correct answer is that the light source is tested in a way that ensures the blade doesn't touch bare hands, he says. For example, First use an alcohol hand rub and/or gloves, and leaving the blade in the bag or peel pouch, attach it to the light source to test the light.
How do you test the light source of a laryngoscope?
Inservices, continuing education opportunities, newsletters
How does FGH provide you with on-going training?
Use of folders for patient documents, turning patient documents face down, Minimize computer screens Refrain from interviewing patients in public areas. Cover pages are required for all faxes When leaving a message on an answering machine, voice mail or with a third party, leave your name, identify yourself as being with AHCS and the Site-specific name if necessary, and your call back number. Do not leave detailed information about the account or PHI. Passwords must NEVER be shared
How is patient PHI protected?
Patients infected with C. Diff. Must use soap and water and a bleach based product. Make sure to observe the manufacturer's dry time.
How would you know if a patient is a candidate for a C. Diff infection? How do you disinfect after a patient with possible C. Diff?
Annually. S&C: 14-44-Hospital/CAH/ASC directs surveyors to look for evidence that all personnel who perform immediate use steam sterilization (IUSS) are trained and competent to correctly follow the manufacturer's IFUs regarding IUSS with respect to each instrument, sterilizer(s), container(s) and cleaning supplies they are using for IUSS.
IUSS/ Steam Sterilizer training should be done _________.
Repeated
If a critical blood glucose level is obtained from a patient, the test must be ____ immediately to verify the results prior to documenting and reporting
Three key concepts essential for high-quality health care are safety culture, high-reliability organizations, and robust process improvement (RPI). A safety culture requires an environment where staff feel comfortable reporting unsafe practices and trends. Trust between staff and leadership is foundational, and organizations need to eliminate intimidating behaviors that stop communication and reporting. A safety culture needs to focus not just on no harm to patients but also no harm to staff so that they are not afraid of repercussions for reporting concerns. High-reliability organizations balance learning and accountability to empower staff so that they feel comfortable speaking up and making recommendation for improvements. RPI requires a focus on making improvements, sustaining gains through change management, and providing staff with the skills and tools needed to look for potential opportunities. To achieve this, RPI encourages organizations to evaluate their culture and explore what happens once improvements have been made—when no one is looking.
Implement Safety Culture, High Reliability, and Quality Improvement?
All entries in the medical record, including signatures on the consent form for surgery, including the patient's signature, must be dated and timed.
Informed consent?
No tape residue on monitors Keyboards Clean and neat No taped holding cords together. Cables clean and dust free and Zip tied together.
Is the computer area neat, clean and organized?
Safe medication storage including temperature logging of medication storage refrigerators. • Labeling of medications/syringes • Maintenance of eye wash stations including the corresponding logs • Medical equipment inspection tags (biomed checks) • Oxygen cylinder storage, labeling and current dates on cylinder • Be sure to keep clean and dirty utility room, and storage room doors closed • Keep both patient refrigerators and staff refrigerators/freezers clean and defrosted • Medical devices, equipment, and supplies are free of materials that cannot be disinfected, like nonlaminated paper instructions on countertops and cabinets • Perform proper hand hygiene frequently as surveyors will be observing this practice • Surgical time out: Correct procedure on the correct Patient • History and Physical update (H&P's) • Assessment and reassessments of pain • Following Universal Protocol
KEY POINTS:
Labeling all medications on and off the sterile field must be full compliance. This means surveyors only have to find something unlabeled once, and you're going to get a finding. You can't argue it! "Propofol is easy to spot because of its white milky nature. If a surveyor sees a syringe still containing some propofol, and it is not labeled, they will cite the organization. There's one exception, notes Rosing. If an anesthesia provider draws up propofol and gives it all immediately, he or she doesn't need to label it. But if the anesthesia provider doesn't use it all and sets the syringe down on the cart, it must be labeled. The label on a partially used syringe should also include an expiration time because propofol has a 6-hour shelf life once drawn into a syringe. "Surveyors look at all basins and syringes for labels as they walk into a room.
Label all medications?
Laryngoscope blade storage continues to be problematic. These blades must be stored in a manner that prevents recontamination. A simple plastic bag can be used for storage. The bag does not need to be zipped and sealed; it simply needs to cover the blade and protect it from being contaminated by airborne substances that fall on a blade as it rests in a cart or on top of a cart
Laryngoscope blades?
FGH Online -- Procedures --- then type in procedure like moderate sedation
Locate Procedural Manual?
FGH Online Protocols
Locate protocols?
FGH Online -- Patient care --- your department
Locate your departments Policy?
Drills
Must participate in these each year to ensure preparedness from emergent situations
Proper hand washing before AND after each patient contact even if you used gloves, including washing vigorously for a minimum of 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. diff is not suspected. Disinfection all items in the room after the patients leave.
Name one way you reduce the risk of health-care associated infections in your department.
-Identify patients correctly using two ways, especially when administering blood transfusions. -Carefully label, record, and communicate about patient medications. -Prevent infection by following proven guidelines and proper hand hygiene. -Prevent mistakes in surgery. -Improve staff communication related to test results. -Use alarms safely. -Identify patients at risk for suicide.
National Patient Safety Goals 7/1/2019
open
Neither Negative or Positive pressure can be maintained if doors are ____________.
Interpreter
Non-English speaking patients require the use of qualified ____, not a family member and must use the device hotline in Patient Care Services for Consents and legal matters.
Drytime
On all the containers of all disinfectants and it varies.
Sedation
Patients are not permitted to drive or make decisions on legal matters within 24 hours of _____
The post-anesthesia assessment must occur and be documented within 48 hours of recovery from anesthesia—not while the patient is still in the operating room. The reason for not conducting the assessment too soon: The patient has to be able to participate in the assessment for the anesthesia provider to determine whether the patient is safely recovered from anesthesia. For outpatients, the assessment can be based on data collected by an RN. When a patient is discharged from same-day surgery, the nurse notes the patient's mental status, respirations, and so forth. The anesthesia provider can write an assessment based on that data even though the patient may have already been discharged. CMS does not consider sedation cases to be anesthesia for purposes of this standard, so no post-sedation assessment by a physician is required
Post-anesthesia assessment?
The postoperative report must be written or dictated by the surgeon before the patient is transferred to the next level of care unless a postoperative note is entered immediately after the procedure. In that case, the report may be written or dictated in a timeframe defined in hospital policy. The report and note (if done) should include at a minimum the name of the physician, procedure name and description, findings, estimated blood loss, any specimens removed, and postoperative diagnosis. The postoperative report policy should be in the rules and regulations for the medical staff but does not need to be in the medical staff bylaws.
Postoperative report?
News Letter
Reading this will keep you up to date on all EPIC matters.
If the surveyor finds a neat and tidy nurse work area or office space that is well organized and clean they will be less likely to look for other things. Disinfect your desk and computer keyboards.
Should I have my office or work area clean?
HIPAA
Taking pictures of patient documents with your cell phone is a ______ violation
Informed
The type of consent for all procedures
Time-out for pre-procedure patient verification is conducted in the room where the procedure will be performed just before starting the procedure. "They think this step is one where there's still a window of opportunity to make an error, and they're highlighting this because errors are still being reported at a rate suggesting 6 wrong-site cases per day in the US. If the patient's armband is visible, the nurse is able to compare 2 identifiers on the armband with the medical record. But if the armband is not visible because of the draping, one of the following options must be used: • Two team members confirm the patient ID upon arrival in the OR using 2 identifiers. One of the team members remains with the patient during the entire procedure. During the final time-out, this team member confirms the patient's ID. • Two team members identify the patient upon arrival in the OR. The 2 identifiers are written on a whiteboard in the room and confirmed by the 2 team members. These 2 team members do not have to stay with the patient during the procedure. They can be replaced by others who confirm the patient ID against the information on the whiteboard during the final time-out. • A patient ID band is placed on an exposed extremity, and then the 2 identifiers on this ID band are referenced during the final time-out.
Time-out?
Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic. These precautions include hand hygiene, use of PPE, needlestick and sharps injury prevention, cleaning and disinfection, respiratory etiquette (cover your cough), proper waste disposal, and safe injection practices. Follow the proper process for donning and doffing PPE per policy.
Use of standard precautions for all patients. Know the location of your PPE including gloves, masks and gowns.
Identifiers
Use two for every single patient: Name and MRN
