1. Physician Joint Commission Compliance

2. IDENTIFICATION BADGE ALWAYS, ALWAYS wear your ID
Your ID defines your role and access to certain systems and locations
Keep key contact info with your ID

3. GENERAL DOCUMENTATION
Handwriting is legible
Sign, date and time all entries

4. Patient Involvement
Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy
Educate patients and families on methods available to report concerns related to care, treatment, services and patient safety issues

5. History and Physical H&Ps are complete
All patients must have a H&P within 24 hours of admission
If an H&P is > 24 hrs but less than 30 days an interval update is acceptable
Interval updates must address any and all significant changes – USE THE FORM
If > 30 days must have new H&P

6. Pain Assessment Appropriate to the patient’s condition & treatment
Includes:
Nature
Location
Duration
Severity
Reassessment after intervention (nursing)

7. National Patient Safety Goal Medication Reconciliation
On admission: MD
List pre-admission medications on the first (white) page of med recon form; this serves as the medication section of the H&P
Reconcile on the third (pink) page – state whether each home med will be continued or not continued
Surgical patients admitted to hospital on day of surgery
List pre-admission medications on med recon form in clinic
Reconcile (pink page) at the time admit med orders are written (PACU)
On admission: RN
Review home meds with patient, alert MD of any discrepancy
Verify the CPOE orders match the reconciled list, alert MD if not consistent

8. National Patient Safety Goal Medication Reconciliation
On Discharge:
MD provides instructions for discharge meds on first (white) page
RN reviews med recon form and discharge Rx with patient
Patient is given white copy of med recon form and pink copy of discharge Rx form

9. Medication Orders Requirements
Write legibly (for non-CPOE)
RNs and/or pharmacy must clarify the order, embrace requests for clarification
PRN orders require a reason and range clarification
Avoid therapeutic duplication of orders
Distinguish between types of medication and when to use

10. Medication Orders Write your own orders
Understand the limitation of NP and PA ordering privileges. RNs cannot write orders
Verbal orders require
RN to write the order
RN to read back the order
Provider must confirm the accuracy of read back
Must be signed off within 48 hours; any physician of the treating team may sign off

11. Restraints Requires a reason which is behavioral
Requires face-to-face evaluation by MD
Must be time limited, never more than 24 hours
Type of restraint should be specified
Use CPOE restraint order set, assures compliance

12. Diagnostic Testing Requirements: Test, side/site,
Clinical condition being studied
Any specific instructions
e.g. mammogram - palpable right breast mass

13. Informed Consent
A discussion of risks and benefits as well as a signed consent is required
Consent form promotes compliance
Require date and time on the physician signature

14. Sedation & Anesthesia
Moderate sedation requires a specific DOP (delineation of privileges)
Minimum requirements:
Assessment of heart and lungs
Airway assessment
Family/patient history of anesthesia/sedation complications
Plan for Sedation/Anesthesia
CRNA’s plan must be approved by anesthesiologist

15. Sedation Documentation Tool

16. Pre-Procedure Assessment

17. Universal Protocol (Site Marking)
MUST be done for procedures with laterality, multiple structures, levels, even orifice with side
MUST involve the patient, if possible
MUST be unambiguous (no ‘x’, use initials)
MUST be visible when prepped and draped
DO NOT mark a non-operative site
SHOULD be performed by the person performing the procedure

18. Universal Protocol (Time Out)
Requirements
Immediately prior to any surgery or invasive procedure
Always includes procedure & patient ID
Includes side/site and availability of diagnostic studies or special equipment (if applicable), including implantable items
Includes bedside procedures, bronchoscopy, IR procedures

19. Safe Use of Medications
Label all medications on and off the sterile field
Drug name, strength & amount
Normal saline (even in a basin) and contrast are medications
Even if there’s only one medication in the field
Many standard kits include pre-labeled syringes

20. Physician Documentation Post Procedure
Requires post anesthesia or sedation note
Brief post op note written, in addition to any dictated note
Post op orders
Medication reconciliation for same day and same day admit surgeries/procedures

21. National Patient Safety Goal Patient Identification
Requirements
Two patient identifiers prior to medication, blood, diagnostic study, procedure, treatment
Patient Name – ask them to say their name, if conscious (don’t offer their name and wait for a ‘yes’)
Medical Record # (DOB is the second choice in areas without arm bands)
Confirm both prior to entering orders

22. National Patient Safety Goal Hand Offs
Requirements
Patient handoffs must contain standard elements, including: diagnosis, current condition, what to watch for in next interval of care
Opportunity to clarify & ask question
Contact information (pgr #)
Update who to call

23. Document Critical Results
If a nurse phones you with the critical test results (or Radiology or Laboratory call directly), repeat back the critical result to the caller. If you’re on the unit, document the result in the chart.
Document what actions you took based on the critical result. When you document the critical result, date, time and sign your entry.

24. Infection Control Requirements
No food/drink in the OR and in other patient care areas
Limited use of papers and lap top computers
Adherence to standard based and transmission precautions
TB screening and Fit testing annually

25. National Patient Safety Goal Hand Hygiene
Requirements
Alcohol-based hand gel between patients
Wash hands, soap and water, for at least 15 seconds when visibly soiled or caring for a patient on C.difficile precautions
No artificial finger nails (includes tips and wraps) for direct caregivers; polish must be intact

26. National Patient Safety Goal Unacceptable Abbreviations
DO NOT USE U IU QD
QOD
Trailing zero MS
MgSO4
Requirements
Spell out “units”, “daily”, “morphine sulfate”, etc.
Use a leading zero (0.1 mg), but not a trailing zero (5 mg)

27. Suicide Risk
Suicide is the #11 cause of death in the US (#3 in young people)
Suicide in 24-hr facilities is the #1 sentinel event reported to Joint Commission
We must
Identify patients at risk for suicide
Address immediate safety needs, provide for a safe environment
Provide info (crisis hotline) to individuals and their families for crisis situations