Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Environmental of Care
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1 - How do you report an error that has occurred?<br><br>Medication error<br>Injury to employee <br>Injury to patient/visitor<br>Safety Concern<br>Near Miss Event<br><br>(refer to pg 26-27)
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2 - What do you do if someone is in a care area without an ID badge?
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3 - What are MSDS? Can you show me how you would access an MSDS sheet on a chemical?<br>(refer to pg 19)
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4 - How can you tell if equipment you are using is clean?
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5 - How do you clean equipment between patient and how long does cleaner take to work?<br>Pg 37
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6 - What is the hospital's policy<br>pg we
Emergency Management
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7. - Who is able to turn off a medical gas valve in an emergency? Where is the medical gas valve?
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8 - What should you do if there is a missing child? What measures have been implemented to reduce the risk of a patient abduction?<br><br>(Interviewee needs to be able to name at least 2 of the listed options to be in compliance)
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9 - What are the emergency codes? What is your role?<br><br>Refer pg 18
Human Resources
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10 - What do you do for continuing education?
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11 - How do you learn about new products, procedures?
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12 - What competences are required for your job?
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13 - Staff can locate physician/resident privileges?
Information Management
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14 - Locate: H&P, Falls risk assessment, pain assessment, EC record, lab results
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15 - Name 3 ways (or more) that you maintain patient privacy confidentiality?<br>
Life Safety
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16 - what type of safety training/education have you received?
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17 - In the event of a fire, what does RACE stand for?<br><br>Pg 19
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18 - When using a fire extinguisher, what does PASS stand for?
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19 - Can you show me the location of the nearest fire pull station and fire extinguisher?
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20 - What is your unit's evacuation plan and area of refuge?
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21 - How do you ensure everyone was evacuated & the area is clear?
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22 - How would you dispose of different kinds of waste? Hazardous Pharmaceutical, Biohazard-Infectious, Chemotheraphy?
Patient Safety/National patient Safety Goals
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23 - How do you promote patient safety?
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24 - What are the 3 identifiers used at ACH to ensure patients are safety? Is this in policy?
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25 - When do you check patient identifiers?<br><br>Pg 7-8 <br>(Interviewee needs to be able to name 2 to be in compliance)
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26 - Where do you label specimens?
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27 - What are the major safety risks for your patient population? (Name at least 2)
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28 - What has been done to reduce those (safety) risks?<br>(Interviewee needs to be able to name interventions to at least 2 of the examples given above to be in compliance)
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29 - How do you report critical results to the physician or ARNP?<br><br>Pg 8-9
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30 - What are your processes for giving blood transfusions? Can you walk me through the process?<br>Pg 8
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31 - When should a time out be preformed?
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32 - Can you explain how you ensure the surgery for this patient is conducted on the right patient, on the right site and is the right procedure? (Universal Protocol?)
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33 - How do you assess if a patient is at risk from falling?<br>Suicide
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34 - What do you give to the patient/family in regards to medications reconciled at discharge?
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35 - Can you explain the procedure to give warfarin?
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36 - What are some of the things you're doing at ACH to prevent surgical site infections?
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37 - What if during the time out you are unsure of something being right-what should you do?
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38 - Are you encouraged/expected to speak up to the team before the procedure begins?<br>
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39 - What are some of the things you're doing at ACH to prevent central line associated blood stream infections?
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40 - When do you call the Rapid Response Team?
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41 - Can families call them also?
Performance Improvement
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42 - Can you show me where I would fine information on your department's Quality Improvement (Performance Improvement) activities?
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43 -Can you tell me about a Quality Improvement project that you have done in your department?
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44 - How do I report a quality of care concern?<br><br>(Interviewee needs to be able to name 1 to be in compliance)
Provision of Care Treatment and Service
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45 - When does the physician/ARNP have to evaluate the child who is restrained for violent/self-destructive reason?
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46 - What are examples of alternatives you might use to avoid using restraints on a patient?<br>
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47 - Where do you document the need for an interpreter?<br>
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48 - Tell me about the process for telephone orders or verbal orders?
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49 - What is your hand-off communication?
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50 - How do you instruct families to report a safety concern?
Infection Prevention
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51 - What do you do to prevent the spread of infection?<br><br>(Interviewee needs to name Hand Hygiene and 1 other to be in compliance)
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52 - Staff is not wearing artificial nails?
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53 - Describe Standard precautions?
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54 - How do you know a patient requires isolation? Is in isolation?
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55 - How do you identify an MDR patient?
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56 - How do you know your negative pressure room is functioning?
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57 - Do you know your units infection prevention data?
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58 - When are you supposed to preform hand hygiene?
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59 - If a patient has a confirmed MRSA, what do about that?
Medication Management
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60 - Can you show me how you would access the formulary on the intranet?
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61 - What the precautions for look-alike-sound-alike drugs or high risk medications?
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62 - Where would you find info on high alert medications?<br><br>(Interviewee needs to be able to name 1 to be in compliance)
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63 - How do you report an Adverse Drug Reaction?<br><br>(Interviewee needs to be able to name 2 to be in compliance)
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64 - How do you report a medication event (error), including a "near miss"?
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65 - How are you alerted to Food and Drug Interactions (with drug prescribed for your patient)?<br><br>Interviewee needs to be able to name 2 to be in compliance)
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66 - Can you describe your medication reconciliation processes?<br><br>(Interviewee needs to be able to name 2 to be in compliance)
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67 - What resources are available if you have drug information question?<br><br>(Interviewee needs to be able to name 2 to be in compliance)
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68 - What are the rights to medication administration?
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69 - What is the procedure for wasting a narcotic drug?
Rights and Responsibilities of the Individual
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70 - What do you do if a patient or family has a grievance?
Describe the Unit's response to your arrival
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71 - Greet the team with smiles & introductions?
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72 - Have a space designated for the team to conduct interviews and file reviews?
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73 - Promptly deliver materials required for review to the tracer team?
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74 - Any additional comments regarding positive or suboptimal issues observed during this tracer?
