Page 538 - eBook Version 8 Book 1 of 2 JUL 2022

6.
Staff able to articulate the process for obtaining chemical information – MSDS sheets.
Call 3-E company @ 1-800-451-8346 – this information is located on green badge buddy
Themes (Operational Assessment)
Nominal Scale Yes/No/ NA
#
The Right Thing
Why is this the right thing to do? (Rationale)
1.
All staff that enter information in EPIC are identified by correct credentials.
RC.01.02.01 EP 4 – The author of each medical record entry is identified in the medical record.
2.
Hand written orders are dated, timed, author identified, professional title identified, and authenticated either by written legible signature, electronic signature, computer key or stamp
RC 01.01.01 –Reference HIM Department Policy 4.04.
3.
Verbal/telephone orders are signed, dated, and timed by next visit.
Reference Medication Management Policy 3.20.07.
4.
All medication orders are complete with med name, dose, route, frequency, and indication for use if PRN.
Medication Management Policy 3.20.7 – Verbal, Telephone, and Written Orders
5.
Refrigerators/Freezers are clean without expired items and all brought in items are labeled appropriately.
PC.02.02.03 EP 11 – The hospital stores food and nutrition products, including those brought in by patients and their families, using proper sanitation, light, moisture, ventilation, and security.
6.
All informed consents contain the first and last name of the physician/anesthesiologist performing the procedure.
Administrative Policy 2.04 – Disclosure and Informed Consent
Safety (National Patient Safety Goals)
Nominal Scale Yes/No/ NA
#
The Right Thing
Why is this the right thing to do? (Rationale)
1.
No dangerous abbreviations in documentation.
NPSG 02.02.01 –Reference Medication Management Policy 3.20.07.
2.
Staff wearing current NPSG badge buddy, Safety badge buddy, Survey Tips/Etiquette badge buddy.
Contact Accreditation and Regulatory Readiness for additional badges.
3.
Staff observed using standard precautions (ex. hand hygiene, the use of personal protective equipment).
Reference Infection Control Policy 6.01.
4.
Staff observed using two patient identifiers when giving medications, blood administration, or collecting specimens.
NPSG.01.01.01 – Use at least two patient identifiers when providing care, treatments, and services.
5.
The staff can articulate the three steps that occur when a critical result occurs:
a. The verified results are verbally communicated to licensed personnel within 45 minutes – this is documented in EPIC
b. The critical value received is recorded in EPIC in the Critical Value Communication flow sheet and read-back to the reporting person
c. The critical value is then reported to the patient’s provider as soon as possible
To provide a process for communicating and documentinga critical test/value/result/report forall patients (inpatient and outpatient) including those who may already have been discharged from Children’s Medica l Center (Children’s). Plea se refer to CPP 4.61
Comments:
*Questions in bold are from previous clean sweeps due to non-compliance denoted in 1st Quarter clean sweep findings,, Executive Walkarounds, tracers, and Accreditation and Regulatory Readiness audits*
Clean Sweep Tool 4th Quarter 2009 Please fax to Accreditation and Regulatory Readiness at x61622