Professional Documents
Culture Documents
2013
&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)POCTRestraints
Learning AssessmentPatient EducationHandoff/SBAR
Continuum of CareBlood AdministrationFalls
Code Blue/Rapid ResponseCode Carts
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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11
> 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
12
>> 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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> Provide suicide information (i.e., crisis hotline) to the patient and
family members
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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
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
> Only access a patients 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.
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
> The following are the steps to document on the Adult Profile Flow Sheet:
>> Language AssistanceAnswer Yes or No
>> Language NeededOpen pull down menu and select language
>> Order an interpreter consult (x3801)
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 patients 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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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.
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10. What are the two types of restraints that are used at AAMC?
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> 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
> 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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These items are teaching points on the General Teaching Title in Patient Education.
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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 patients learning must be
documented in the medical record.
> 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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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 patients 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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24. What standardized tool does AAMC use in communicating hand off
patient care?
SBAR
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turn, will lead to a reduction in harm, increased satisfaction for all providers
and overall better outcomes for patients and their families.
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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.
> 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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> 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
> 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 patients environment at the time of admission and at
least every shift.
>> Remove clutter and tripping hazards from patients 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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> 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 patients 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 patients room and/or call x1111
Rapid Response: Call x1111
Who can call Rapid Response?
AnyoneStaff (nurse, PCT, dietary, etc.), family members, patients, volunteers, etc.
Why would you call Rapid Response?
> You are worried about your patientCall 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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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 months log is kept with the crash cart. A department must keep
prior months logs in a separate location on the unit for one year.
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Medication Management
1. What does AAMCs high alert acronym PPINNCH stand for?
Pitocin
Potassium concentrated IV
Insulin
Narcotics
Neuromuscular blockers
Chemotherapy
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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 patients rooms, and in med rooms. The
code carts contain medications but are secured with a tamper evident lock
and checked.
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All medications that are removed from the original manufacturers 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.
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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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.
Surgical Services
How do you label medications on and off the sterile field?
1. Medication containers include syringes, medicine cups and basins.
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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.
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.
1.
Pre-procedure verification begins when the patient is scheduled for a
procedure.
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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
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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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.
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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Fingernails are to be short (less than 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.
> Identify the appropriate isolation and hang an isolation sign on entry to
the patient room.
> Gather the correct personal protective equipment (PPE) and place at entry
to patient room.
> 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.
>
Prior to insertion of a central line (central line-associated bloodstream
infection (BSI) prevention)
>
Prior to surgery (surgical site infection (SSI) prevention)
>
PPE: sterile gloves, cap, gown, mask, eye protection for
inserter/assistant; mask with eye shield for everyone else in the room
Remember:
Physicians may also report as needed. The laboratory also reports any test
results regarding communicable diseases.
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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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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:
Pneumonia (PN)
> Re-admissions
Work with your unit leadership and/or participate in unit quality councils
and performance improvement projects.
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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.
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> 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.
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)
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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. Dont 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.
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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.
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Know and follow the guidance in the EOC 4.4.01 Emergency Operations
Plan. The main aspects for staff to follow are:
Leadership
The Leadership at AAMC is responsible for:
> 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
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Information Management
1. Do you have the necessary computer access to do your job?
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> 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.
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Notes:
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Notes:
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Notes:
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