JCI QUESTIONS & ANSWERS

KAMC Specialist Hospital

What is IPSG # 5 Reduce the risk of health care associated infection
What is IPSG # 3 Improve the safety of high alert medication
What is IPSG # 2 Improve effective communication
What is IPSG # 4 Ensure safe surgery
What is IPSG # 6 Reduce the risk of patient harm resulting from fall
What is IPSG # 1 Identify patient correctly
What is your unit Scope of Service?
What is the age accepted in your unit? 14 and above
POLICY # PSG-001
What to use for identifying patient? MRN and Four Full Names
How do you identify patient? By asking the patient to STATE their four full names
If patient have the same four full names in the system, Mother’s maiden name
what is the other reference?
When do you identify patient? upon admission, trans-in from other unit/area, before giving blood transfusion, before
procedure/surgery, blood sampling
POLICY # PSG-002
What is the policy about telephone/verbal order? Write down, read back and confirm/verify
What is not acceptable during telephone/verbal order? Blood transfusion, TPN, Chemotherapy
Narcotics/Controlled Drugs are not allowed as telephone order
What is acceptable for verbal order? Narcotics/Controlled drugs
When do you use telephone and verbal order? Telephone order – if the doctor is not around to write the orders.
Verbal Order – during emergency OR interruption of physician involved in another client care
function
When will the doctor sign for telephone and verbal Telephone order – within 24 hours
order? Verbal order – Responsible physician shall Authenticate Verbal orders entered in TrakCare HIS as
soon as physician finished his work and before leaving unit.
What is the policy in writing telephone and verbal order? Staff nurse who accepted order in (Trakcare HIS) must document telephone/verbal orders
including Date, Time, instructions/Order, Dose, Frequency, Route, and Generic Name of Drug (for
medications), NO ABBREVIATION
POLICY # PSG - 009
What is the tool for communication? SBAR
What do we use for handover? Electronic Handover / Trakcare / Patient’s File
What is SBAR? Situation, Background, Assessment, Recommendation
Example of SBAR
POLICY # PSG-004
What are the three categories for Surgical Universal
Protocol?
What do you verify?
What is the validity of consents?
Who will do the site marking?
What mark use for site marking?
What is the marker used for site marking?
What are the indications of site marking?
If site marking is not possible, what is the reference used
by the surgeon?
If the patient refused site marking
What is TIME-OUT?
How many types of time-out?
When do they do TIME-OUT?
Who will initiate time-out?
Example for non-surgical invasive procedure time-out.
POLICY # lC-020
How to prevent HC associated infection
Demonstrate steps of Hand Hygiene.
How long does it take for HAND RUB?
How long does it take for HAND WASH?
Enumerate the 5 moments.
POLICY # PSG-006
What is the intervention for fall?
moderate Intervention above + NCP + PFE + Purple ID Band
high Intervention both for Low & Moderate + keep pt near station, maximum assistance and watcher
Pre-procedure / Pre-operative Verification, Site Marking & Time Out
Correct – patient / site marking / procedure / position. Available – implants / antibiotic /
radiological image. Secure safety belt
Surgical Consent – 6 months
Anesthesia Consent - 6 months
Blood Consent – Oncology patient- 3 months inpatient outpatient and for Regular Patient – per
admission
General Consent – per admission
Chemotherapy Consent – per cycle
Video/Photo Consent – per procedure
Hemodialysis – OPD – 1 year / Inpatient – per admission
doctor who will perform the procedure
wing arrow sign ( )
skin permanent marker
Bilateral organs, multiple structure, multiple levels.
Radiological image
Doctor will explain the importance, if patient still refuse, to look for an alternative
is also called Surgical Pause, wherein all the team members will participate in identifying:
- Correct patient, Correct procedure, Correct site, Correct position,
- Availability of implants, Availability of radiological image, Availability of antibiotic
- Secured safety bed belt
Non-surgical invasive procedure and Surgical Procedure
Before (surgery/procedure) incision
Doctor who will perform procedure
LP, parenthesis, BMA, biopsy, Thoracentesis…
HH & 5 Moments
20 seconds
40-60 seconds
Before touching the patient, Before procedure, After touching the patient, After exposure to
body fluids, After touching patient environment
lowCall light/bell at reach, good lighting, no clutters, bed in lowest position, put breaks, place phones
personal items within reach… PFE
 DocumentationsAssessment, Nurses Notes, PFE , NCP
What is your action if in case the patient fell? Assess patient for any injury
What is your action if the patient fell with/without injury?
patient will be on a HIGH RISK management until discharge.
Without Injury
Call help, assist the patient to bed, and check V/S, RBS. Carry out MRPs order; fill up Post Fall
Form, Nursing Documentations, OVAR, change ID band to purple, NCP
With INJURY do not touch patient, call help, and check VS & RBS while waiting for the MRP, assist patient to
bed unless contraindicated per MRPs order. Fill up Post Fall Form, Nursing Documentations,
OVAR, change ID band to purple, NCP
What are your documentations Post Fall Form, Nursing Documentations, OVAR, PFE,NCP
When do you assess patient for fall? Every shift, Upon admission, Trans-in from other unit/hospital, Post fall, If there is any changes in
patient conditions, Post procedure or surgery
What is the tool used for assessing patient for fall? Johns Hopkins Fall Risk Assessment Tool
What is the scoring in determining patient risk for fall? 0-5 LOW, 6-13 MODERATE, 13 above HIGH
What are the documentation for patient on Moderate to NCP, PFE, Nurses Notes
High risk for fall?
What are the basic education for newly admitted HH, Precaution of fall, Precaution of HAPU, Use of Call bell, Use of Extension number, Not to use sink behind patient
patient? room door, Pain Management

POLICY # COP-006
What are the tools use in assessing pain?
When do you initiate NCP for pain?
When do you initiate Pain Assessment and Reassessment If patient started to complaint of pain above 4
form?
When do you assess patient for pain?
When do you reassess patient for pain?
How long can you use NCP for pain?
POLICY # COP-007
When do you assess patient for pressure ulcer?
VNP or Behavioral Pain Scale
Pain 4>
Every shift, Every 4 hours, Upon admission, Trans-in from other unit/hospital, If there is any
changes in patient conditions, Post procedure or surgery after pain management
IV/rectal – 15-30 minutes,
ORAL – 30-60 minutes, whenever pain is suspected, any change in pain intervention
3 days, unless the pain is consistent then extend even up to 7 days or more
Every shift, Upon admission, Trans-in from other unit/hospital
If there is any changes in patient conditions, Post procedure or surgery

What is the intervention for patient AT RISK for pressure Skin care, Use of air mattress, Avoid head position more than 30-40 degree, NCP, PFE
ulcer?
What is the intervention for patient HIGH RISK for All interventions for AT RISK, Positioning every 2 hours, Use of gel pads, Avoid friction and shear
pressure ulcer? Wound Team assessment, Nutritional assessment
What is the intervention for patient VERY HIGH RISK for Both intervention for AT RISK and HIGH RISK
pressure ulcer? Multidisciplinary intervention which includes Plastic Surgeon and Dermatologist
What are the stages of pressure injury? STAGE 1ST, STAGE 2ND, STAGE 3RD, STAGE 4TH, UNSTAGEABLE, DTI
POLICY # COP-003
What are the types of restrain? PHYSICAL & MEDICATION INDUCED RESTRAIN
What are the content of the doctor’s order? Type of restrain, Parts to be restrain, Reason for restrain, Duration

What is the validity of the order for restrain? 12 hours

What to observe if patient with restrain? Circulation, Injury, Capillary refill…
What is the frequency of monitoring restrain? every hour
When to release restrain? every 2 hours for 15 minutes
How to secure restrain? to tie it on the bed frame
What is the responsibilities of the NURSE if the patient is To monitor patient for prevention of injury or fall
on restrain?
What are the special considerations for geriatric patient Restrain should be release every hour
is on restrain?
POLICY # HTC-001
What is the indication for BT? Symptomatic anemias, optimize level of Hgb for OR, bleeding, injury or for surgery
What is the content of the doctor’s order for BT? Clinical indications of transfusion , Number of Pack, Type and quantity of blood
Duration or rate of BT, Any premedication (if indicated)

What is the process for BT? Print doctors order of BT and sent to LAB with the blood sample for X-matching, ensure Blood
grouping available, ensure u took blood samples with a WITNESS, check in eTL blood availability,
ensure blood consent is secured, prepare materials, dependent double checking with CN or MRP
of blood before transfusion. Before transfusion, identify the patient with a witness before BT
Vital signs monitoring for BT Prior transfusion,
Every 5 minutes during the first hour
Every 10 minutes during the second hour
Then hourly
At completion of transfusion
Test dose 25-50 ml of a units to be given slowly (15-30 minutes)
Do you need a witness in extracting blood sample for X- Yes
matching?
What is the allotted time in returning blood? 30 minutes
What is your action if the patient have blood transfusion stop infusion, run IVF, verify correct unit has been given, check VS, Inform MRP, sent BT bag + BT
reaction? reaction form + blood samples from opposite arms & OVAR,
Which form to use during transfusion reaction? Manual (not in eTL)
What are the samples needed for BT reaction? 2 EDTA
AOP-001
As per policy, how much time given to complete daily within 2 hours
reassessment form?
Initial assessment form? within 12 hours
POLICY # CCC-001
What is the validity of DNR form? 6 months for OPD 1 YR
How many signature does it require to be valid? 1 consultant and 2 specialist
DNR order for reversal or revision Attending Consultant must document an order to reverse/revise DNR in the pts. DNR form
POLICY # INFECTION CONTROL
What is the process for needle stick injury? - First aid
Don’t squeeze, run under running water, clean with alcohol swab, cover with gauze or band-aid
- Inform CN or HN
- OVAR
Working Hours – go to Infection Control then Staff Clinic
Non-working Hours – inform Supervisor then ER
What is the normal pressure for negative room? (-2.5) & more negativity
What is the alarming range to call maintenance for Pressure falls less than -5
Negative Room?
What are the type of patient prohibited in negative Immunocompromised patient, Kidney donors, MAJOR SURGERIES
room?
What are cases under airborne? Critically ill MERS-CoV, Open TB, chicken pox, Measles…
What are the cases under droplet? H1N1, Mumps, Influenza, rubella…
Example of contact isolation? MRSA, CRE, VRE…
Demonstrate donning and doffing of PPEs.
What is CAUTI? catheter associated urinary tract infection
What is CLABSI? central line associated blood stream infection
What is SSI? Surgical Site Infection
Enumerate the 4 Case Definition of MERS-CoV? - Severe Pneumonia or ARDS w/ clinical or radiological evidence
- Unexplained deterioration of a chronic condition of patients w/CHF or chronic Kidney disease
on HD
- Acute febrile illness (>/= 38 C) w/ or w/o respiratory symptoms
- GI symptoms (diarrhea or vomiting), and Leukopenia or thrombocytopenia
Which color of waste bag for domestic waste? Black or blue
Which color of waste bag for chemotherapy? yellow
Color of waste bag gloves contaminated with blood. yellow
Color of waste bag gloves not contaminated with blood. Black or blue
What is the color for body parts or tissues? red
How to prevent needle stick injury? - Do not recap
- Use of Cannula/IV tray
- Dispose needles directly to sharps container after every use
- Do not leave needles in any surface
- Use of safety devices
- Vaccination
POLICY # TQM-007
What is sentinel event? unanticipated event or occurrence of death or harm or permanent loss of function not related to
patient condition
Name some incidence of Sentinel Event?
How to report Sentinel Event? Shall Report Suspected Sentinel events immediately to TQM bravo # 0515165034 then OVAR.
What is near-missed? Harm that did not happen due to timely intervention
POLICY # FMS-015
What is the extension # for internal emergency disaster? 33333
What is the number for code blue? 15555
What is the number for RRT? 14444
What is the criteria in activating Code Orange? - More than 1 liter
- Any volume of highly toxic flammable agent/materials
- Radioactive, any volume
What will you do if in case of fire? RACE
How do you confine fire? Check the room, remove O2 Cylinder, close window, place towel below door, stick ROOM tag
How to use fire extinguisher PASS
How many types of extinguisher IN YOUR UNIT?
What are the types of evacuation? - Partial evacuation – Horizontal/Vertical
Horizontal – same floor
Vertical – evacuating a floor down below
- Complete evacuation – environment of care becomes unsafe
- Shelter in evacuation - Situation it may be safer and more medically responsible for a
hospital to shelter in place than to evacuate
Who will announce horizontal evacuation? announce by HN or CN
Who will announce vertical evacuation? announced by CEO
What does it mean total evacuation? Totally evacuating the entire building announced by the CEO
Where is your assembly point? front side of both elevators
Where is your holding area? Parking area
POLICY # FMS-014
What are the external emergency codes? Code Yellow Standby and Code Yellow Active
What does code yellow standby means? A disaster within Makkah
What does code yellow active means? Casualties are on their way to KAMC
What does ‘ALL CLEAR’ means? End of code
Which mobile team your unit belong?
LABORATORY
What is the purpose of medication reconciliation? to determine if the medication will be use during hospitalization and upon discharge
How to receive critical result TrakCare -> Patient Focus -> Read Back w/Witness & will be Confirm by the Caller
What is the period for relaying critical value? 5 minutes
What is the period for relaying RBS critical value? immediately
What is TAT? Turnaround time
What are the two types of TAT?
Do you have blood test guide?
What is the content of the blood test guide
What is your POCT machine in your unit?
What is POCT? - Point of care testing
When to do Quality Control Testing?
Who is responsible when device malfunctioning
PHARMACY
What is high alert medication?
What are the example of high alert medication?
How to improve the safety of high alert medication?
LOOK ALIKE & SOUND ALIKE MEDICATIONS
What is independent double-checking?
What is dependent double-checking?
OTHERS
What is SDS?
Where can you find SDS?
What is the content of SDS?
Where can you find your Chemical Spills Kit in your unit?
What is Hazmat?
What is the available Hazmat in your unit?
What is PPM?
What is the purpose of PPM?
What is the type of delivery care system in KAMC?
Who can write OVAR?
What is the criteria in assigning patient to the nurses?
level of Oxygen (PSI) that needs replacement
When does the discharge planning starts for the patient?
Access the KAMC Medical Clinical Privilege in the policy.
Where is your Departmental Manual
What is the content of your Departmental Manual
Where is your Operational Manual?
Routine and STAT
Yes (OPEN Policy – Laboratory & Blood Bank Test’s Guide)
Preparation prior specimen extraction, proper tubing, amount blood needed, TAT
is a diagnostic test done outside the laboratory by a non-laboratory technician
- Daily
- When strip is new
- When the strip is exposed to extreme heat or cold
- When the device fell or broken
- When in doubt of the result
- When the strip container is open for a long time
POCT Coordinator
Medication that may cause harm when given incorrectly
Insulin, enoxaparin, warfarin, IV potassium chloride …
Independent double-checking, Label with red sticker, stored separately, restricted access…
Dependent double checking
Look Alike – should be stored separately
Sound Alike – usage of Tall Man Short Man Letter
2 nurses checking individually
Checking done at the same time by 2 nurses
Safety data sheet
Name of the Company, Composition or components, Hazard, First Aid
Hazardous materials
Planned preventive maintenance
determined the date for the next configuration or calibration
TOTAL care delivery system
anyone
Staff skills and knowledge, patient acuity, experience…
1000 and below
upon admission
 Dropbox -> Public -> KAMC Approved Medical Clinical Privilege
Placed in the station
Scope of Services, Educational Matrix, Unit Staff Planning, Policies and Procedures
Biomedical Equipment Room
Where is your Dietary Manual? Hard Copy -> Nurses Station / Soft Copy -> Intranet -> Nutrition department
What are the types of Shutdown? General Shutdown
Laboratory System Downtime Access the Intranet and you will find this policies
Pharmacy shutdown
What is your action after Shutdown? To utilized Manual forms then to be entered again by the respective MRPs if system is back
Where can you find this manual form in your unit?
How to access the policy Internal Website -> Policy and Procedures -> Enter your ID # & Password -> enter your query
Level of sharp containers for replacement? 3/4
Where is the unit’s RRT Kit located?
If there is a 2 RRT Case on going in your unit, where can Pharmacy
you take another RRT Kit?
Where can you find your Intubation Kit? Fridge + in Pyxis
STOCKS
What is the distance of stock off the ceiling? 50 cm
What is the distance of stock off the floor? 10 cm
What is the distance of stock from the wall? 5 cm