• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


Interview one staff member and ask them:

  • How do you report an error that has occurred?<br>• Medication error<br>• Injury to employee<br>• Injury to patient/visitor<br>• Safety concern<br>• Near-miss Event <br><br>Acceptable Response: Reporting is done by completing the appropriate module in Hopkins Event Reporting Online (HERO); Go to any desktop computer to the HERO icon

  • What is MSDS? Can you show me how you would access an MSDS sheet on a chemical? Acceptable Response: Material Safety Data Sheets; Can be found on Sibley’s Intranet – Quick links- MSDS Online. Staff aware of how to access MSDS.

  • How can you tell if equipment you are about to use is clean? Acceptable Response: Staff should be able to speak to the fact that only clean equipment is stored in clean utility room or storage rooms and should have a green “Clean” tag.

  • How do you clean equipment between patients and how long does cleaner take to work? Acceptable Response: Wipe equipment with appropriate cleaner:<br>• Super Sani-Cloth – 2 minutes contact time • Sani-Cloth AF3 – 3 minutes contact time • Sani-Cloth Bleach – 4 minutes contact time. Contact time = disinfectant must remain wet on the surface for a specific amount of time to kill germs

  • How can you tell if a new piece of equipment is safe to use? Acceptable Response: Equipment should have a BioMed Tag

  • What would you do if medical equipment malfunctions? Acceptable Response: Take out of use, put a note (tag) on it, and submit work order. Note: The green tag is for non-medical equipment, such as microwaves or refrigerators with initial electrical inspection and is not required any scheduled maintenance.

  • What is the hospital’s smoking policy? Acceptable Response: Sibley Memorial Hospital is a “Tobacco-Free Campus” <br>Policy 03-21-68


  • Who is able to turn off a medical gas valve in an emergency? Where is the medical gas shut-off valve located on your unit? Acceptable Response: Qualified staff: Manager, Clinical Leader or Charge Nurse as designated by unit management. In the event that piped medical gases need to be shut off to any patient care area in order to prevent a fire from intensifying, it will be the responsibility of a qualified staff to shut off the main valves that supply medical gases to the affected area. This however, will only be done at the direction of the Fire Department.

  • What should you do if there is a missing child? Acceptable Response: Activate “Code Pink” • Unit lock down • Secure all exists • Check all visitors’ bags


  • Name 3 ways (or more) that you maintain patient privacy/ confidentiality. Acceptable Responses: -Computer screens turned to restrict others from viewing.<br>-Restricted computer access -Staff log off of when leaving computers (tap N go) -Use of NexCut Shredding Boxes -Patient information not discussed in open/public areas<br>-When appropriate, knock before entering the patient's room -Speak to families in a private area


  • What type of safety training/education have you received? Acceptable Responses: <br>• Orientation<br>• Unit specific <br>• In-services

  • In the event of a fire, what does RACE stand for? Acceptable Response: R) Rescue A) Alert/Alarm C) Contain E) Evacuate / Extinguish

  • When using a fire extinguisher, what does PASS stand for? Acceptable Response: P) Pull the pin A) Aim at the base of the fire S) Squeeze the lever S) Sweep from side to side

  • How would you dispose of different kinds of waste? For example, Hazardous Pharmaceutical, Biohazard-Infectious, Chemotherapy? Acceptable Response: Biohazard: Red Bags; Sharps: Sharp Boxes; Pharmaceutical: Cactus Sink; Chemo: Yellow Box


  • What are the 2 most common identifiers used at SMH to ensure patients are safe? What do you use as the source to verify patient identity? Acceptable Response:<br> • Name<br>• Birth date<br>• VERY IMPORTANT: Check two identifiers and compare to source (patient’s armband) not procedure board or paper documentation.

  • When do you check patient identifiers? NOTE: Interviewee needs to be able to name 2 to be in compliance. Acceptable Response Options:<br>• Initial contact <br>• Giving meds <br>• Taking blood <br>• Giving blood <br>• Obtaining specimens <br>• Prior to any treatment or procedures

  • Where do you label specimens? Acceptable Response: At patient's bedside / in patient's room

  • What are the major safety risks for your patient population? (Name at least 2) Acceptable Response Options:<br>- Infection<br>- Medication Errors<br>- Abduction – Infant<br>- Falls<br>- Patient Misidentification<br>- Other _________________

  • What has been done to reduce those (safety) risks? (Interviewee needs to be able to name interventions to at least 2 of the examples given above to be in compliance) Acceptable Response Examples:<br>- Use of PPE<br>- Isolation<br>- Standardized administration process for high risk meds<br>- Tall Man lettering<br>- Code Pink drills<br>- Fall risk assessment<br>- Fall precautions <br>- Call light within reach<br>- 2 patient identifiers<br>- Other ______________

  • Can you give examples of the NPSGs and how you use them in patient care? Acceptable Response: Infection prevention – Hand hygiene; Patient identification – using 2 patient identifiers; Clinical Alarms – reducing alarm fatigue; Universal Protocol – time out before surgery


  • Can you show me where I would find information on your department's Quality Improvement (Performance Improvement) activities? Acceptable Response: All departments should post information on Quality Improvement activities

  • Can you tell me about a Quality Improvement project that you have done in your department? Acceptable Response: All departments should participate in Quality Improvement activities

  • How do I report a quality of care concern? (Interviewee needs to be able to name 1 to be in compliance) Acceptable Response Options:<br>- Contact supervisor or risk management<br>- Report through appropriate chain of command<br>- Complete a HERO Report <br>- Compliance Line 844-SPEAK 2 US


  • Can you show me where to find the restraint policy? Acceptable Response: On Sibley Intranet – Link to “Sibley Policies and Document Library” Policy 01-31-12

  • What is your Hand-Off communication? Acceptable Response: SBAR. Hand-off info includes opportunity for discussion among giver & receiver

  • What does SBAR stand for? Acceptable Response: S) Situation B) Background A) Assessment R) Recommendation


  • What do you do to prevent the spread of infection? (Interviewee needs to name Hand Hygiene and 1 other to be in compliance) Acceptable Response Options:<br>- Hand Hygiene<br>- Standard Precautions and use of Personal Protective Equipment<br>- Isolation precautions<br>- Use of negative pressure rooms when indicated<br>- Admission assessment screens of patients for exposure to communicable diseases.<br>- Using evidence-based practices and bundles to prevent infection<br>- Not working when sick<br>- Other ________________

  • Describe Standard precautions? Acceptable Response: • Hand hygiene before and after patient care<br>• Wearing PPE’s (gown, gloves, mask, faceshield) when anticipating exposure to patient’s body fluids<br>• Clean equipment before use for each patient

  • When are you supposed to perform hand hygiene? Acceptable Response: • 5 moments:<br>o Before patient care<br>o Before aseptic/sterile procedure<br>o After patient care<br>o After touching body fluids<br>o After touching patient equipment/environment


  • How do you report an Adverse Drug Reaction? (Interviewee needs to be able to name 2 to be in compliance) Acceptable Response Options:<br>- Contact Physician immediately<br>- Pharmacy/a Pharmacist<br>- Complete a HERO Report<br>- Other ______________

  • How do you report a medication event (error), including a “near miss”? Acceptable Response: Complete a HERO Report.

  • What are the 5 rights to medication administration? Acceptable Response: Right Patient, <br>Right medication, <br>Right dose, <br>Right time, <br>Right route


  • What do you do if a patient or family has a grievance? Acceptable Response: Work to resolve the grievance quickly and inform the Supervisor of the Department.

  • How do you let patients/families know about their rights? Acceptable Response: Patients Rights & Responsibilities is posted in registration and given in admission packet. Note: Patient’s Bill of Rights and Responsibilities

  • When does discharge planning begins? Acceptable Response: At admission and continues through hospital stay based on patient status.


  • Greeted with smiles & introductions?

  • Was a space designated for the team to conduct interviews and file reviews?

  • Did staff promptly answer questions or deliver materials required for review to the tracer team?

  • NO or LACK OF additional comments regarding positive or suboptimal issues observed during this tracer? Choose NO to enter response

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