1. HIPAA compliance - Is there patient information left out for passers by to view? Make sure that your monitors displaying patient info are not in public view. Paperwork should be face down if anybody can just pass by and be able to read it. Patient identification and history should be verified verbally once in the exam room (you can check the armband prior to entering, but ask the patient behind closed doors). Proper identification of patients with at least two identifiers. Proper charting of procedures and checking Physician's orders is important as well.
2. Crash cart checks - the crash cart in your department should be checked daily. There must also be proof that it was checked. A log including date, time, lock number, first drug expiration date, first equipment expiration date, who's checking the cart, and records of defibrillator tests (usually the test strips) must be available on the cart. If you're missing a day... ding!
3. Pharmaceuticals - need to be under lock and key - this includes contrast media. Techs need to know where the key is also. Make sure you do not have expired drugs/contrast. Multi-use vials and bottles need to have an "opened on" date, as well as an "expires on" date. These are usually 28 days after opening for expiration for most containers. Barium tablet bottles can be saved for one year after opening. If you see an open container that is not dated, chuck it out.
4. Waste disposal - every type of waste has its place. Sharps containers should be locked up and removed after they are 3/4 full. Contrast has its own special disposal container. Linens and trash go in separate places. You know the drill.
5. Fire drill!!! - know what to do in case of a fire... evacuation routes, how to locate and operate a fire extinguisher and alarm pull stations, and where to find the nearest gas and oxygen shut off valves.
6. Hand sanitizing - this has been a big one at every JCAHO site visit I have been a part of. Wash your hands before and after every patient, or use hand gel if your hospital provides it. Please make sure not to use the same gloves on two patients. Gloves should be used in the exam room and disposed of prior to walking out of the room with the patient. Segway to...
7. Isolation precautions - know your hospital's methods for communicating isolation protocol. Know the proper precaution per disease type, as well as the proper method for gearing up for an exam.
8. Quality Assurance - there are many things that a radiology department is responsible for regarding equipment, radiation monitoring etc. The ones that JCAHO may be interested in are probably going to involve radiation protection. Make sure you have your lead aprons cataloged and checked for cracks once a year. Make sure that your staff is wearing their radiation badges.
9. Incident response - what does your department do if an incident/occurrence report needs to be filed? How are safety concerns and policy violations reported and followed up on? Who is responsible for filling these reports out?
10. MSDS information - they might say, "what would happen if you came across an unknown chemical that was spilled on the floor and you haven't heard the name of the chemical on the label?" Know where to find your Material Safety Data Sheets... usually you can access them online, but do you know the website? Or do you know where your facility might have paper copies? This is your homework ;-)
Remember, you may not have all the answers to these questions... especially under pressure. You should know who does have the answers though. The absolute worst thing you can say is "I don't know" followed by a blank stare or an apologetic look on your face with a shoulder shrug. You can, however, say "let me ask my supervisor" or "let me find out for you."
2. Crash cart checks - the crash cart in your department should be checked daily. There must also be proof that it was checked. A log including date, time, lock number, first drug expiration date, first equipment expiration date, who's checking the cart, and records of defibrillator tests (usually the test strips) must be available on the cart. If you're missing a day... ding!
3. Pharmaceuticals - need to be under lock and key - this includes contrast media. Techs need to know where the key is also. Make sure you do not have expired drugs/contrast. Multi-use vials and bottles need to have an "opened on" date, as well as an "expires on" date. These are usually 28 days after opening for expiration for most containers. Barium tablet bottles can be saved for one year after opening. If you see an open container that is not dated, chuck it out.
4. Waste disposal - every type of waste has its place. Sharps containers should be locked up and removed after they are 3/4 full. Contrast has its own special disposal container. Linens and trash go in separate places. You know the drill.
5. Fire drill!!! - know what to do in case of a fire... evacuation routes, how to locate and operate a fire extinguisher and alarm pull stations, and where to find the nearest gas and oxygen shut off valves.
6. Hand sanitizing - this has been a big one at every JCAHO site visit I have been a part of. Wash your hands before and after every patient, or use hand gel if your hospital provides it. Please make sure not to use the same gloves on two patients. Gloves should be used in the exam room and disposed of prior to walking out of the room with the patient. Segway to...
7. Isolation precautions - know your hospital's methods for communicating isolation protocol. Know the proper precaution per disease type, as well as the proper method for gearing up for an exam.
8. Quality Assurance - there are many things that a radiology department is responsible for regarding equipment, radiation monitoring etc. The ones that JCAHO may be interested in are probably going to involve radiation protection. Make sure you have your lead aprons cataloged and checked for cracks once a year. Make sure that your staff is wearing their radiation badges.
9. Incident response - what does your department do if an incident/occurrence report needs to be filed? How are safety concerns and policy violations reported and followed up on? Who is responsible for filling these reports out?
10. MSDS information - they might say, "what would happen if you came across an unknown chemical that was spilled on the floor and you haven't heard the name of the chemical on the label?" Know where to find your Material Safety Data Sheets... usually you can access them online, but do you know the website? Or do you know where your facility might have paper copies? This is your homework ;-)
Remember, you may not have all the answers to these questions... especially under pressure. You should know who does have the answers though. The absolute worst thing you can say is "I don't know" followed by a blank stare or an apologetic look on your face with a shoulder shrug. You can, however, say "let me ask my supervisor" or "let me find out for you."
What is your view regarding the listing of in/out-patient exams (which includes the PT's last name, time, room number if applicable and the type of procedure) on a large dry erase board which is easily visible to anyone located in the radiology department? I asked this question because this situation is standard operating procedure at my current and past (3) facilities.
ReplyDeleteI have worked at many places that used to keep a paper log (usually with a patient's sticker on it) listing every patient having an exam in the department. The theme that I have noticed is concern of whether or not it can be viewed in a common area. If visitors and non-hospital employees can simply walk by and acquire information, you will be called out for it. Aside from that, I haven't seen any issues as long as the information pertains to the job at hand.
ReplyDeleteIsolation is clearly very important. I remember in my CT practice were wr had a call about a critically ill patient that needed an urgent head ct so obviously we told them to bring them, after a few minutes when they brought the patient all of them (there were 5 people...2 escorts, 2 nurses and a resident) all dressed up and masked like if they were back from an Ebola outbreak. It turned out that the patient was positive for MENINGITIS and we all had a fit! Honestly...they should had told us! There were a lot of people that day that could had been exposed to the disease...luckily everything was fine.
ReplyDeleteNice... can you say "number one patient safety goal"?
ReplyDelete