Joint Commission/Medicare survey – Santa Ana, CA
A pleasure of a surveyor who was open to different ideas of how to approach standards so was not stuck on only their “way” of doing things. A fresh take. Surveyor had some great sayings, such as:
“Can’t accept if you don’t inspect” – Surveyor was referring to nurses receiving medications from someone else. This reduces medication error in terms of wrong medication, wrong dose, expired medication, etc. I’ve seen nurses accept expired medications in the middle of a survey and the surveyor asked to see the vial. Embarrassing.
“(Medications) Must have a label to hit the table” – Again, this is to avoid medication errors and, at the same time, comply with CMS requirements regarding labeling of syringes. It is a CONDITION level deficiency if there is an unmarked vial or syringe in the OR.
“Juices is not worth the squeeze.” – Some other surveyors would disagree, but the point was that staff doesn’t need to search for QI and benchmarking activities. There is low hanging fruit somewhere. No center is perfect.
Other items:
- Even if a patient has had a tubal ligation, if they are still menstruating, do a pregnancy test. Hmmm.
- If you receive tissue from an outside source, log the temperature when received (most deliveries have a device inside) and the time. Make sure the temperature matches the recommended/required temperature. This has come up at other surveys, especially for ophthalmology.
- Suggested bringing in “dolls” to make emergency drills more interesting and memorable.