some important tips for jci survey. common questions & explanation
TRANSCRIPT
Some Important Tips for JCI Survey
Common Questions & Explanation
Very ImportantTo know
• Their achievement is critical to full compliance with the JCI standards.
• Any failing goals is consider a failing in JCI ACCREDITATION.
1-What is the process of identifying patient? & when it must be used ?
Patient is identified (Hospital ID band).
• before any treatment, collection of samples, blood transfusion, drug administration, diagnostic test or procedure is conducted
• Patient’s complete Name, Hospital ID Number, National ID card/Iqama
• Patient’s Full Name: Refers to the patient’s name to the Third Level.
For infant/ child:
• Identification should be carried out by two hospital staff using identification information available in the Medical Records
Important:
• In the event identification band is lost
• it must be reported as ‘Incident Report’ to prevent using the lost band in infant/child abduction.
IPSG.1 Identify Patient’s Safety:
• 2-What is process for Telephone/Verbal Orders and when receiving Critical Values Result?
• 1-Verbal Order: • limited to urgent situations where immediate
written/ electronic communication is not feasible.
Verbal/ Telephone Order: will not be accepted for:
• Physical restraints, Starting Patient Controlled Analgesia (PCA),
• Starting Narcotic/ Scheduled medications, Initiating TPN therapy
• Category of care (Code status), Withdrawal of life support, Chemotherapy.
Critical Test Reporting (Laboratory & Radiology):
• ‘Write Down, Read-Back, Confirm/Verify’
• For Telephone Orders, responsible physicians requires to sign order within (24 ) h.
• For Verbal Orders, physicians require signing order after situation is over Or before physician leave the area.
• Handovers: See hospital wide Handover Form, used for communicating critical content between health care providers during handovers of patient care.
• IPSG.2 Improve Effective Communication:
• 3-What is your process to ensure safe identification, storage, preparation and dispensing of High Alert Medications (HAM)?
• The hospital has a list of all high-alert medications, including look-alike / sound- alike medications that is developed from hospital-specific data.
• Look-alike and Sound-Alike (LASA) medications are recommended to have Tall Man letters over the medication storage
• Examples: • • EPINEPHrine and EPHEDrine -
VinBLASTIN” and “VinCRISTINE.
• All high alert medication shall be stored in a secured cabinets and clearly labelled.
• Concentrated electrolytes are stored ONLY in areas that requires it with appropriate labelling.
• - Storage bins for HAM based on its strengths shall be segregated.
• It is the responsibility of MRP to prescribe medications within the approved formulary that includes orders and prescribing HAM.
• Verbal orders for HAM are only allowed during Emergency or Life threatening situation
• HAM orders must be double checked during preparation & before administration.
•
• IPSG.3 Improve the Safety of High-Alert Medications (HAM):
• 4-When does the Time-out conducted?
• TEAM TIME OUT- applied to some procedures /first skin incision performed for paediatric patients:
All activities should be STOPPED and all members of the
surgical/procedural team must fully participate in the TIME-OUT
• Confirms all members are present and attentive.• Addresses the following standard information:• -Correct patient identity• -Correct type of procedure to be performed• -Correct procedure site has been marked (if applicable) • -Availability of correct equipment for the procedure.• Correct and appropriate documents and diagnostic images
are available.• Any attending staff can identifies anticipated critical
events
• IPSG.4 Ensure Correct-Site, Correct Procedure, Correct Patient Surgery:
• What is the process in your department to reduce HAI’s?
• -You must be familiar with (MCWP 1-1-9415-02-003 Hand-Hygiene)
• - You must be familiar with (5-Moments of Hand Hygiene)
• Before touching a patient. • Before a procedure.• After a procedure or body fluids exposure risk.• After touching a patient.• After touching a patient surroundings
• - You may be asked to demonstrate how to do:• 1- Hand Rub Procedure.• 2- Hand Wash and Hand Disinfection
Procedure
• • IPSG.5 Reduce the Risk of Health Care-Associated Infections:
6-When is fall risk assessment/reassessment conducted ?
• ASSESSMENT: • Upon patient admission
in the unit.
REASSESSMENT:
– Transfer of patient from one unit to another within the facility
– Any changes in patients status/condition
– Following a fall
• -Patient initial fall risk nursing assessment performed Within (3) hours of admission using
• the ‘Humpty Dumpty Fall Scale’ and
• re-assessment daily or with any changes.
• - Score 6-11 is: Low Risk –
• Activate low risk prevention protocol by nursing.
• Score 12 and above is: High Risk –
• Activate high risk prevention protocol by nursing
For Paediatric in-patients ages 3 months to 14 y/o,
• Identified as high risk of fall:
• Will be fitted with yellow ID printed with “FALL RISK” and a Humpty Dumpty to be placed outside the patient’s active medical file.
- For Neonates and/or Infants ages 0 to 3 months, Identified as high risk of fall:
• Must have a • Humpty Dumpty sticker
to be placed outside the patient’s active medical file and a
• Humpty Dumpty poster placed at the bedside.
For Out-patient & ED:
• Nursing Screening for fall risk, and if parameters are positive will receive a full risk assessment.
• Use of assistive device i.e. Gait unstable, Poor balance and Focuses on apparent need.
• Patient Re-assessment at each visit.
After a Fall What is Physician’s Role?:
• 1- Assess level of injury and treat any resulting problem.
• • 2- Initiate diagnostic& treatment
interventions for contributing intrinsic & extrinsic causes
• 3- Document post-fall assessment and treatment.
• 4-Find out probable cause of fall, such as history, physical factors, medications, and laboratory values.
• 5-Refer patient to appropriate services if needed.
• Important:
• All events of patients fall: An ‘Incident Report’ must be completed.
IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls:
International Patient Safety Goals (IPSG)
• “Very ImportantTo know”
• Their achievement is critical to full compliance with the JCI standards.
• Any failing goals is consider a failing in JCI ACCREDITATION.