Dr. Steinhardt JOINT COMMISSION & NATIONAL PATIENT SAFETY GOALS Test File

10. If an organization receives a requirement for improvement (RFI) for non compliance with a standard that is classified as a direct impact RFI: a. It poses a greater risk to patient safety, so the organization has 45 days from the end of the survey to submit an ESC and identify MOS. b. It poses less of a risk to patient safety, so the organization has 60 days from the end of the survey to submit an ESC and identify MOS c. It poses a greater risk to patient safety, so the organization has between 45 and 60 days from the end of the survey to submit an ESC and identify MOS d. It poses less of a risk to patient safety, so the organization has 45 days from the end of the survey to submit an ESC and identify MOS

A

12. Select the choice below that represents a correct sequence of accreditation decisions that are made when an organization consistently fails to successfully address accreditation requirements: a. Accreditation with Follow Up Survey-->Contingent Accreditation-->Preliminary Denial of Accreditation-->Denial of Accreditation b. Accreditation with Follow Up Survey-->Contingent Accreditation-->Accreditation c. Accreditation with Follow Up Survey-->Denial of Accreditation d. Accreditation with Follow Up Survey-->Contingent Accreditation-->Denial of Accreditation

A

13. After being awarded accreditation, the organization should expect to do all of the following except: a. Undergo a full, announced survey between 18 to 36 months of the last survey b. Undergo a full, unannounced survey between 18 and 36 months of the last survey c. Submit an annual subscription payment d. Submit an annual Intracycle Monitoring profile with a Focused Standards Assessment

A

18. The category titles for the typical structure of a Joint Commission standard consist of: a. Standard, Rationale, Elements of Performance b. Statement, Purpose, Scoring Criteria c. Standard, Purpose, Scoring Criteria d. Statement, Rationale, Elements of Performance

A

3. All are reasons an organization would seek Joint Commission accreditation EXCEPT: a. To fulfill a requirement to be named a "Listed PSO" b. Gain competitive edge in the marketplace and strengthen public confidence in quality of care c. To obtain deemed status to participate in Medicare and Medicaid programs d. Educate staff and engage in a customized review of services

A

41. Technician Jesse discovered a bunch of unlabeled drug-containing syringes on a table in the operating room next to a pile of assorted used drug vials. What should he do with the medication according to NPSG.03.04.01 on Medication Labeling? a. Discard the medication b. Compare the drugs to similar labeled medications found in the operating room to discover the identity, then label them properly and use them for the procedure c. Track down Pharmacist Walt and ask him for the identity of the medications, then label them properly and use them for the procedure d. Inject the patient and monitor the patient for a response

A

51. All of the following are elements of performance for NPSG.15.01.01 (Identifying patients at risk for suicide) except for: a. Monitoring of all patients receiving treatment in both general and psychiatric hospitals round the clock for suicidal behavior is required. b. A risk assessment must be conducted that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. c. The patient's immediate safety needs must be addressed as well as the most appropriate setting for treatment. d. Suicide prevention information, such as a crisis hotline, must be provided to the patient and his or her family when a patient at risk for suicide leaves the care of the hospital

A

20. Although the requirements affect multiple departments throughout the hospital, the pharmacy department is regarded by Joint Commission as providing leadership for compliance with this category of standards: a. Performance Improvement b. Medication Management c. Rights and Responsibilities of the Individual d. Emergency Management

B

29. Areas of focus to ensure clear and accurate medication orders as required by MM.04.01.01include all except: a. Precautions for look-alike/sound-alike medications b. Emphasis on utilizing phone and verbal orders c. Procedures for managing illegible/unclear orders d. Requirements for diagnosis, condition, or indication on medication orders (especially PRN medications)

B

37. Walter White MD was approached by a Joint Commission surveyor who asked him to list the two patient identifiers Blue Sky Hospital had chosen for patient identification in his area of the hospital. In a nearby room, Pharmacist Saul Goodman overheard the surveyor's question and knew that all of the following would be appropriate identifiers Blue Sky Hospital could have selected for their patient identifiers in compliance with NPSG.01.01.01 except for: a. Patient Name b. Patient's Room Number c. Patient's Medical Record Number d. Patient's Telephone Number e. Other patient specific identifier like date of birth

B

4. An organization with deemed status: a. Must have maintained Joint Commission accreditation for at least 5 years before being awarded the deemed status designation b. May participate in and receive payment from Medicare and Medicaid programs as they have met the requirements of Joint Commission's Deemed Status Survey which meet or exceed the Conditions of Participation requirements in federal regulation c. Must be granted deemed status by CMS and Joint Commission separately d. Are not subject to any oversight by CMS, as Joint Commission has been granted deeming authority and has sole responsibility for oversight of an organization with deemed status e. B and D

B

42. According to NPSG.03.04.01 on Medication Labeling, all medication labels must be verified: a. Verbally and visually by only the attending physician b. Verbally and visually by two individuals participating in the procedure if the person preparing the drug will not be administering it c. Verbally by two individuals participating in the procedure if the person preparing the drug will not be administering it; no visual verification required d. Visually by two individuals participating in the procedure if the person preparing the drug will not be administering it; no verbal verification required

B

49. Which one statement is not an element of performance for NPSG.07.05.01? a. Educate staff and licensed independent practitioners involved in surgical procedures about surgical site infections and the importance of prevention. b. Implement policies and practices aimed at reducing the risk of surgical site infections that meet regulatory requirements and are not aligned with evidence based guidelines c. Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations. d. Educate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.

B

50. What is an activity in compliance with NPSG.07.04.01 to prevent infection of the blood from central lines that should be performed to prevent a patient's blood infection? a. Educate staff on the importance of prevention of central line-associated bloodstream infections through the proper management of central lines only upon hire with no additional retraining b. Ensure sinks are operational and perform proper hand hygiene prior to the procedure c. Ignore standardized protocol for sterile barrier precautions during central venous catheter insertion d. Use a homeopathic antiseptic for skin preparation during central venous catheter insertion that is not cited in scientific literature or endorsed by professional organizations

B

56. The Joint Commission individual tracer methodology is: a. An evaluation method where the surveyor selects an individual facility within a multi hospital health system and traces its compliance with Joint Commission standards then applies the accreditation decision to all hospitals in the system b. An evaluation method where the surveyor selects an individual patient and uses that patient's record to move through an organization to assess and evaluate the organization's compliance with selected standards and their system to provide care and services c. An evaluation method where the surveyor selects an individual department of the hospital and traces its interdisciplinary extensions within the organization d. An evaluation method where the surveyor follows individual members of the C-suite (CEO, COO) to trace the future strategic plan for the organization and whether it incorporates quality improvement

B

8. Although duration for a Joint Commission survey may be shorter for smaller organizations and longer for larger organizations, as indicated by Joint Commission and included on the powerpoint: a. Most surveys last 7 days using a team of 10 to 15 surveyors b. Most surveys last from 3 to 5 days using a team of 3 to 10 surveyors c. Most surveys last 2 days using a team of 20 surveyors d. Most surveys last 14 days using a team of 1 to 2 surveyors

B

9. Following an onsite Joint Commission survey, if an organization is found to be non compliant with any standards: a. Joint Commission issues an immediate denial of accreditation and the organization must wait a year to reattempt accreditation b. The organization is issued a requirement for improvement (RFI) and must submit an Evidence of Compliance with Standards (ECS) report and submit data on Measures of Success (MOS) c. The organization must undergo a second survey within 3 months demonstrating compliance with the standards d. The surveyor notifies the organization of the failures during the visit and the organization corrects them during the course of the survey

B

16. Black-out dates, which are specific days upon which organizations can request an unannounced Joint Commission survey not be held: a. Are not allowed by Joint Commission b. May include federal holidays c. Are limited to only 10 days d. Once the days are selected and approved, Joint Commission will not conduct a survey on those days

C

19. If an Element of Performance for a standard was given a score of 2: a. The hospital has demonstrated insufficient compliance with the standard b. The hospital has demonstrated partial compliance with the standard c. The hospital has demonstrated satisfactory compliance with the standard d. The hospital has demonstrated substandard compliance with the standard

C

2. As of 2015, The Joint Commission accredits: a. More than 100,000 health care organizations and approximately 90% of the nation's hospitals b. More than 50,000 health care organizations and approximately 82% of the nation's hospitals c. More than 20,000 health care organizations and approximately 89% of the nation's hospitals d. More than 5,000 health care organizations and approximately 74% of the nation's hospitals

C

23. For management of high alert and hazardous medications, the hospital will have to do all of the following to comply with MM.01.01.03 except: a. The hospital must develop its own list of high alert and hazardous medications based on its own medication use patterns and internal data on medication errors and sentinel events b. The hospital must have a process to handle high alert/hazardous medications c. The hospital is required to use ISMP's list of high alert medications and integrate national data on medication errors and sentinel events as opposed to creating a list based on medication use at their individual facility d. Examine their facility's use of and sentinel events associated with controlled substances, investigational medications, look-alike/sound-alike medications, psychotherapeutic medications, and medications with a narrow therapeutic range when constructing their list

C

26. All of the following are requirement for compliance with MM.02.01.01 for the Selection and Procurement of Medications except: a. Development and maintenance of a formulary b. Development of a process to manage non formulary medications c. Development of a procedure to handle patient's home medications d. Development of written medication substitution protocols

C

34. Why are the National Patient Safety Goals a separate category within the Joint Commission standards? a. NPSGs address critical issues that do not overlap with standards in any of the categories b. NPSGs are compiled by a group separate from Joint Commission with no Joint Commission involvement and thus are reported separately c. NPSGs are the topics that are of highest priority to patient safety and quality care and are given a "spotlighted" status within the standards d. NPSGs are grouped separately as they are the only standards that affect multiple departments in the hospital

C

38. The written procedures for compliance with NPSG.02.03.01 to get important test results to the right person at the right time must include all of the following except: a. The definition of critical results of tests and diagnostic procedures b. By whom and to whom critical results are reported c. The acceptable distance and proximity of laboratories to patient care areas d. The acceptable length of time between the availability and reporting of critical results

C

45. Which of the following is not an element of performance for NPSG.03.06.01 on Medication Reconciliation? a. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital b. Resolve discrepancies such as omissions, duplications, contraindications, unclear information, and changes c. A good faith effort to gather the information that results in an inadvertent omission of important drug therapy due to patient memory deficits will not meet the intent of the goal d. Provide the patient or family with written information on the medications the patient should be taking when he or she is discharged

C

47. Which of the following violates handwashing NPSG.07.01.01? a. Compliance with current CDC hand hygiene guidelines b. Compliance with current WHO hand hygiene guidelines c. Engaging in handwashing technique that ends with turning the faucet off with your freshly washed hands instead of a paper towel d. Addressing the patient safety threat of health care-associated infections by improving the hand hygiene of health care staff

C

48. What is a way a hospital can comply with NPSG.07.03.01 to prevent infections from multidrug resistant organisms like MRSA? a. Bypass periodic risk assessments for multidrug resistant organism acquisition and transmission. b. Educate staff and licensed independent practitioners about health care-associated infections, multidrug-resistant organisms, and prevention strategies only at hire - annual education is unnecessary c. When indicated by the risk assessment, implement a laboratory-based alert system (possibly using telephones, faxes, pagers, automated and secure electronic alerts, or a combination of these methods) that identifies new patients with multidrug-resistant organisms. d. Provide multidrug-resistant organism process and outcome data to licensed health care professionals, but never to leadership - they don't care about details

C

52. The three standards for Universal Protocol are: a. Stopping, Dropping, Rolling b. Chest Compressions, Airway, Breathing c. A preprocedure verification process, Marking of the procedure site, A time-out performed before the procedure d. Stopping, Collaborating, Listening

C

54. Under Universal Protocol a time-out refers to: a. Mandatory breaks for medical residents who have been on call all night and represent a patient safety risk due to fatigue b. Ceasing of all iv room activities when a pharmacist double checks a chemotherapy admixture in the chemo hood c. The pause before surgery begins when the surgical team double checks to ensure they have the correct patient, correct, site, and correct procedure d. The preselected dates when an organization can designate they are exempt from compliance with Universal Protocol

C

6. Under eligibility requirements, the minimum number of patients served required for an organization seeking Joint Commission accreditation for the first time is: a. 20 patients served, with 2 active at the time of the survey b. 1 patient served and active at the time of the survey c. 10 patients served, with 1 active at the time of the survey d. 5 patients served, with 1 active at the time of the survey

C

61. The top two MM standards that were scored noncompliant at the most hospitals in 2011 were: a. MM.05.01.09 Medication Labeling & MM.01.01.03 High Alert Medications b. MM.04.01.01 Medication Orders & MM.05.01.01 Pharmacist Review c. MM.03.01.01 Medication Storage & MM.04.01.01 Medication Orders d. MM.05.01.09 Medication Labeling & MM.04.01.01 Medication Orders

C

1. The Joint Commission is: a. An expert panel of patient safety experts, as well as nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings b. The lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care c. A multidisciplinary, nonprofit organization devoted entirely to medication error prevention and safe medication use d. An independent, not-for-profit organization that accredits health care organizations and is the nation's oldest and largest standards-setting and accrediting body in health care

D

15. These Joint Commission surveys are among the few surveys that are announced, with the exception of: a. First survey of the Early Survey Process b. Second survey of the Early Survey Process c. The initial survey for an organization d. The annual survey for an organization that has been awarded accreditation for five years

D

21. The critical processes around which the Medication Management standards are organized are: a. Planning, Purchasing, Storage, Ordering, Dispensing, Administration, Monitoring, & Evaluation b. Planning, Storage, Ordering, Preparation, Dispensing, Monitoring, & Evaluation c. Planning, Selection and Procurement, Ordering, Preparing and Dispensing, Administration, Monitoring, & Evaluation d. Planning, Selection and Procurement, Storage, Ordering, Preparing and Dispensing, Administration, Monitoring, & Evaluation

D

24. Under the standard addressing high alert and hazardous medications, abuse and loss of controlled substances must be reported to: a. The director of pharmacy (DOP) b. The CEO c. The COO d. The DOP & the CEO e. The DOP, CEO, & COO

D

27. All are examples of non compliant practices with regards to the medication storage standard MM.03.01.01 except: a. The presence of expired medications in stock on pharmacy shelves b. A patient's medications left unsupervised on a med cart at the nursing station c. A hanger propping open the door to the medication room on a nursing unit d. Medications dispensed only in ready-to-administer and unit dose forms

D

30. For standard MM.05.01.01 Pharmacist Review of Medication Orders Prior to Dispensing, pharmacists must review medication orders with the following exceptions: a. There are no exceptions - pharmacists must review all medication orders prior to dispensing b. If a licensed practitioner is in control of the medication process c. If the delay caused by review would harm a patient in an emergency situation d. B & C

D

36. When an NPSG is retired: a. The Goal number is also retired and no longer used b. NPSGs are never retired from spotlighted status c. The NPSG may be recategorized under another standard category as a regular standard d. A & C

D

39. Pharmacist Walt failed to label the medications he had drawn up in the procedural setting. Through his failure to label the medications, he was non compliant with which standards? a. He was actually compliant with the minimum requirements of both standards b. NPSG.03.04.01 Medication Labeling (requires labeling of all medications in perioperative and all procedural settings) c. MM.05.01.09 Medication Labeling (requires a standardized label format and labeling of all prepared meds that are not immediately administered) d. Both NPSG.03.04.01 and MM.05.01.09

D

46. In compliance with the element of performance for NPSG.03.06.01 on Medication Reconciliation that requires health care professionals to explain to patients the importance of managing medication information upon discharge, all of the following are suggestions pharmacists can make to patients except: a. Instructing the patient to give a list of her medications to her primary care physician b. Instructing the patient to update the information on her list when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added c. Instruct the patient to carry her medication information at all times in the event of an emergency situation d. Instruct the patient that health care providers have a centralized database where they can obtain her complete current medication information without her assistance, so it is not necessary to make a separate list herself

D

53. Universal Protocol applies to what practice area? a. Drug Delivery Procedures b. Medication Management Procedures c. Controlled Substance Dispensing Procedures d. Surgical and Nonsurgical Invasive Procedures

D

57. All of the following are true about individual tracers except: a. Patients are selected off an active patient list b. Patients typically are those who have received multiple or complex services c. The tracer may last from 90 minutes to 3 hours d. Surveyors are not permitted to speak with patient at any time during the tracer to prevent disruption of services and preserve continuity of care

D

59. Pharmacy staff may be approached by a surveyor during a visit to answer questions. As the pharmacy's medication safety manager, you would advise them to: a. Explain answers in great detail including volunteering extra information and going off on tangents - the surveyors will be impressed with your knowledge b. Instead of physically showing the surveyor how your department handles medication issues, you should limit it to just telling them - surveyors don't have time and show and tell is for kindergartners c. Practice evasive maneuvers when mock surveyors enter the pharmacy department for practice sessions- you'll have charted out your exit strategy for when the real surveyors show up and your coworkers can handle the questions d. Be able to explain how the pharmacy handles high-risk and hazardous medications as well as two patient identifiers the pharmacy department uses, such as name and date of birth

D

60. All of the following are ways pharmacy management and staff can prepare medication related areas for a survey except: a. Check medications for expiration dates, storage requirements, b. Ensure temperature logs for refrigerators, freezers, and warmers are properly utilized and recorded c. Examine the nursing units, including med rooms, and medication carts, to look for unsecured medications and stashed meds d. Refraining from straightening up the appearance of the pharmacy - as long as you are in compliance with all requirements, it doesn't matter how organized or disorganized the pharmacy appears

D

22. When creating a written policy to comply with MM.01.01.01 which requires specific patient information to be made available to staff, all of the following are examples of required information except: a. Age b. Allergies c. Current Medications d. Height & Weight e. Marital Status

E

25. Measures pharmacies can take to prevent errors involving look-alike/sound-alike medications that would enable them to comply with MM.01.02.01 include: a. Using tall man lettering when labeling medication storage bins on shelves b. Using bright colors when on medication storage bins to draw attention c. Attaching warning stickers to the medication storage bin d. Storing look-alike/sound-alike medications in distinct, separate locations e. All of the above

E

33. Specific MM standards are established for all these categories of medications except: a. Recalled or Discontinued Medications b. Returned Medications c. Investigational Drugs d. Self-Administered Medications e. Biosimilars and Biologics

E

55. As a pharmacy medication safety manager, you can engage in many activities to maintain the pharmacy at a constant level of readiness for Joint Commission surveys. Which of the following are tools you have at your disposal? a. Mock surveys performed by consultants b. Staff education on tracer methodology and questions asked by surveyors c. Hospital Management walk arounds and unit/department sweeps d. Internal emails for managers and Joint Commission tools for purchase e. All of the above

E

7. The Joint Commission evaluates an organization's compliance with the standards based on an assessment of: a. Tracing the care delivered to patients b. Verbal and written information provided to The Joint Commission c. On-site observations and interviews by Joint Commission surveyors d. Documents provided by the organization e. All of the above

E

11. T or F: Contingent accreditation is awarded to organizations that have never been accredited before and elect to undergo an early survey process for selected standards prior to having to demonstrate full compliance with all Joint Commission standards under Joint Commission's Early Survey Policy.

F

31. T or F: Even if a product is stable for only a short period of time, it must always be compounded in the pharmacy to comply with the requirements for MM.05.01.07 Safe Preparation of Medications

F

35. T or F: Unlike other standard categories, NPSGs remain the same year after year with no changes or additions.

F

40. T or F: According to NPSG.03.04.01 on Medication Labeling, if a medication is transferred from its original packaging to another container and it is not being administered immediately, but it is the only medication being used for that particular procedure, it does not need to be labeled.

F

43. Which of the following are non-compliant behaviors to NPSG.03.05.01 on Anticoagulation? a. A patient's baseline coagulation status was not assessed b. The pharmacist did not provide patient education to the patient concerning food and drug interactions, compliance, monitoring, and adverse effects of the medication c. The pharmacist does not use any authoritative resources to manage potential food and drug interactions d. The pharmacist did not use a programmable pump with heparin to ensure consistent dosing e. The pharmacist did not perform an evaluation of anticoagulation safe practices and had no safe practices in place f. All of the above behaviors are non-compliant

F

5. T or F: Concerning eligibility, to receive Joint Commission accreditation, a health care organization must be located in the United States.

F

62. Common noncompliance issues include all of the following except: a. Expired drugs not removed b. Failure to store medications according to manufacturer recommendations c. Situations where compounded sterile products are not made in the pharmacy and do not fall under an urgency or short stability exception d. Not all medications/solutions labeled when not immediately administered e. Failure to keep locked carts in a locked room or in view of nursing station f. All of these are noncompliance issues

F

58. Match the category of system tracer to its definition which includes pharmacy & NPSG issues ____ Medication Management System Tracer ____ Data Use System Tracer ____ Infection Control System Tracer ____ Patient Flow System Tracer a. Patient records are reviewed and then the patient is followed through the organization to determine how staff complies with processes that reduce the risk of health care-associated infections. Staff can expect surveyors to observe and discuss processes relating to the NPSGs (e.g., continuous compliance with CDC or WHO hand hygiene guidelines, practices to prevent health care-associated infections due to multidrug-resistant organisms [MDROs], and appropriate and correct use of antimicrobial agents). Pharmacy personnel must be ready to respond to surveyor questions relating to procedures for compounding sterile preparations, risk points in the process for compounding sterile preparations, education and training in compounding sterile preparations, and environmental monitoring of sterile preparation compounding areas. b. This tracer evaluates the potential for treatment delays, medical errors, and unsafe practices due to periods of patient congestion and disruptions in the flow. When a problem exists, it can affect the entire organization. This can lead to noncompliance with multiple Joint Commission standards, NPSGs, and core measures. The organization must evaluate all areas (e.g., emergency department, laboratory, and diagnostic imaging) where the flow of patients may have a negative effect on the care, treatment, or services provided. c. Patient records are reviewed to identify high-risk patients and/or patients on high-alert and other specified medications. The activity traces the path of medications through the organization and addresses medication processes (i.e., selection and procurement, storage, ordering and transcribing, preparing and dispensing, administering, and monitoring). Areas handling medications are visited and evaluated; processes for reporting errors, system breakdowns, close calls (near misses); other issues relating to safe and effective use of medications; and implementation of NPSGs relating to medications. d. Surveyors may review data relating to medication errors, adverse drug events, staffing effectiveness, and infection control. Staff can expect surveyors to discuss and evaluate how the organization uses data associated with the NPSGs (e.g., accurate patient identification, effective communication, safe use of medications, reduced risk of health care-associated infections, the safe use of anticoagulants, reconciliation of medications, and reduced risk of patient falls). Organizations must be able to show how they use data to monitor adherence to CDC or WHO hand hygiene guidelines. Pharmacy personnel must be ready to respond to questions relating to ensuring data security and integrity, methods for tracking pharmacy interventions, methods for monitoring overrides of automated distribution cabinets, and methods for tracking adverse drug events.

Medication Management - C; Infection Control - A; Data Use - D; Patient Flow - B

14. T or F: The ORYX initiative is a data-driven, continuous survey and accreditation process that complements the standards-based assessment where accredited hospitals gather and report data continuously to the Joint Commission on specified performance measures.

T

17. T or F: Joint Commission standards address the organization's performance in specific areas and specify requirements to ensure patient care is provided in a safe manner and in a secure environment.

T

28. T or F: Hospitals will have to ensure emergency department medications are restocked promptly and patient home medications are inspected as part of compliance requirements under the MM standards.

T

32. T or F: Under the Administration of Medication standard MM.06.01.01, the patient or the patient's family is to be informed of potential adverse reactions with new medication prior to administration

T

44. T or F: Evaluation of anticoagulation safe practices is an element of performance for NPSG.03.05.01 on Anticoagulation.

T