Audit

INFORMATION MANAGEMENT

Confidential Patient Information:
Cannot be overheard or seen by unauthorized persons:
* Computer terminals signed off when not in use.
* Patient information is not discussed in public areas.
* Labels and PHI are obliterated before discarding in the trash.

No clipboards displayed as sign-in sheets when multiple patient names on the list.

If fax machine is in public area, patient information is quickly removed.

Disclosure of confidential patient information only to those authorized by the patient.

Documentation plan for computer downtime.

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

Are PSG posted on unit.

Process/Action for sudden change/deterioration in patient's condition

Who can call a MET team?

Use of two (2) patient identifiers when administering medications, blood/blood components, and collecting specimens?

Specimens labeled in the presence of patient?

Two (2) person verification and use of bar coding for blood transfusions.

To whom are critical results/values of tests reported, and by when?

Label medications in syringes, cups on/off the sterile field.

Universal Protocol for ALL invasive procedures: pre-procedure verification, site marking, and time out.

Medication reconciliation done on admission and discharge.

Process to report adverse events.

STANDARD PERFORMANCE IMPROVEMENT

Is department's PI project data posted.

Staff are familiar with their department's PI, goals and progress.

Nursing: Use of restraints process and data collection.

Nursing: Fall reduction measures, data collection and goals, injury-related falls.

ED/Code Blue committee: Results of resuscitation, data collection and evaluation.

Pharmacy: Significant medication errors and adverse drug reactions.

DESCRIBE THE DEPARTMENTS RESPONSE TO THE TEAMS ARRIVAL

Greet the team with smiles and introductions.

Have a space designated for the team to conduct interviews and file reviews.

Promptly deliver materials required for review to the tracer team.

Any additional comments regarding positive or suboptimal issues observed during the tracer.

Surveyors Name
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.