Specimens are labeled in the presence of the patient?
Paper/Information with protected health information is out of view; computers and workstations are locked.
All crash cart checks are complete including log - staff can articulate performance in a code.
* Admission assessment
* education documentation
* pain management
Access of medical record for consults, labs/tests, interdisciplinary notes, advance directives, etc.
Hand off Communication procedures are performed/articulated?
Team Members are prepared through education:
National Patient Safety Goals - How are they applied in the area?
Universal Protocol for ALL invasive procedures: pre-procedure verification; site marking; time-out.
History/Physical within 24 hours, operative notes complete - immediately.
Abbreviations - Not to use
What is the Adverse Event process?
Patient c/o process?
Organ donation procedures?
Are there any alarms sounding that staff is not attending to in a timely manner.
Patients and families properly informed of their rights.
*. Rights and Responsibilities statement
Family guides provided to all families on admissions.
Point of Care testing lab controls documented and control solution labeled & dated.
*. Reagents, i Stat analyzes, glucometers, GEMS
Point of Care Testing Quality Control:
*. Consistently and correctly documented
*. Dates missing initials
*. Performed by qualified person
*. Out of range is followed
*. Logged numbers match bottle ID numbers
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.