MMH TJC - IM/NPSG/PI - Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

INFORMATION MANAGEMENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Documentation plan for computer downtime.

  Yes

  No

  N/A

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

• Are PSG posted on unit.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Who can call a MET team?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Specimens labeled in the presence of patient?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Medication reconciliation done on admission and discharge.

  Yes

  No

  N/A

• Process to report adverse events.

  Yes

  No

  N/A

STANDARD PERFORMANCE IMPROVEMENT

• Is department's PI project data posted.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Nursing: Use of restraints process and data collection.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Pharmacy: Significant medication errors and adverse drug reactions.

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO THE TEAMS ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Surveyors Name

  Sign