Regulatory,Mission Watch,

Inside UW Health,Mission Watch,Survey Readiness Resources,Survey Readiness: Questions of the Week

Week of September 18, 2017

Week of September 18, 2017 - Inside UW Health, Mission Watch, Survey Readiness Resources, Survey Readiness: Questions of the Week


Managers: Please review these Questions and Answers with your staff/teams this week.

Providers and Staff: Please review and be ready to answer these questions.

We are in the window for an unannounced site visit/survey by The Joint Commission. To access preparation resources, including the comprehensive Reference Guide, visit the Survey Readiness section.

If you have questions, please contact Lisa LeClair, Accreditation and Regulatory Specialist.

What are some risk factors for patients falling?

These include:

  • Confusion/disorientation
  • Depression
  • Altered elimination
  • Dizziness/vertigo
  • Prescribed antiepileptic
  • Prescribed benzodiazepine

What are your five moments of hand hygiene?

  1. Before patient contact
  2. Before aseptic task (e.g., dressing change, insertion of a Foley or central line)
  3. After body fluid exposure
  4. After contact with patient surroundings
  5. After patient contact

What Performance Improvement System does UW Health use that provides a systematic, organization-wide approach to quality care and service to patients?

UW Health uses FOCUS PDCA methodology as a framework:

  • F:  Find – A process that needs improvement
  • O: Organize – A team that knows the process
  • C: Clarify – Knowledge through flowcharting or data collection
  • U: Uncover – Underlying causes of variation or poor quality
  • S: Select – A (single) modification
  • P: Plan – Plan a change or test aimed at improvement
  • D: Do – Carry out the change or test (preferably on a small scale)
  • C: Check – Check or study the results
  • A: Act – Act, adopt, abandon or cycle again

What are some ways to protect patient-specific information?

  • Never talk about patients/families in public areas or in the presence of other patients, families, or visitors
  • Knock before entering a patient’s room
  • Interview patients in private areas
  • Position any items that contain patient information (e.g., paper records, computer screens, work stations on wheels (WOWs), X-ray jackets) so that identifying information cannot be readily observed by others.  This applies to all sites.
  • Never access any patient information unless it is needed to provide care or services to the patient
  • Never release patient information to another individual unless specific written permission has been granted
  • Never remove medical records from the hospital or clinics property
  • Log off computer before walking away and never allow others to use your sign-on ID and password
  • Change your computer password periodically
  • Be aware that a computerized audit trail exists which records what information was reviewed

What is the difference between an adverse drug reaction and a medication error?

An Adverse Drug Reaction (ADR) is any non-preventable response to a drug that is noxious, unintended or undesired and occurs at doses normally used in humans for prophylaxis, diagnosis, treatment of disease or modification of physiologic function.

A Medication Error is any preventable, unintended medication event that may cause or lead to inappropriate use and/or patient harm.  

All Adverse Drug Reactions and Medication Errors should be reported in Patient Safety Net (PSN).