PCT Modules 4 and 5 Test

Flash cards over NHA Module 4- Patient Safety and Quality & Module 5- Documentation and Record Keeping to study for test on Friday 9/25/26

What are examples of 2 patient identifiers?

First and last name & DOB

What do you use when there is a language barrier in the communication of the care?

A organization-approved medical interpreter or translation service

Only proceed when patients can’t identify themselves if there is a _______ person to assist with identification.

“Reliable”

True or false: A patient’s room # should not be used to verify identity.

True

True or false: Discrepancies in patient identification must be reported to prevent wrong-patient errors.

True

What is ‘Technical Communication’ when it comes to handoffs?

When important information on patient care is relayed, including current conditions and task requirements.

What is ‘Relational Communication’ when it comes to handoffs?

Verbal and nonverbal behaviors that contribute to successful communication, including tone of voice, eye contact, and body language.

What does SBAR stand for?

Situation, Background, Assessment, Recommendation

What does I-PASS stand for?

Illness severity, Patient summary, Action list, Situation Awareness, Synthesis by receiver

What is HCAHPS?

A national, standardized, and publicly reported survey that captures patients’ perspectives of their hospital experience

Why are standardized handoff templates like SBAR and I-PASS used in healthcare settings?

To communication patient care information in clear and structured manner during handoffs

Organizations adopt strategies to prevent harm, striving for zero harm. Two approaches are STARR & ARCC. What do they stand for?

Stop, Think, Act, Review.

Ask a question, Request a change, voice a Concern, use the Chain of command.

OSHA, CDC, TJC, CMS, and DOH are agencies that provide guidelines and _______.

Regulations

What are the four P’s for hourly patient rounding?

Pain, Position, Possessions, Potty

When doing patient rounding the AIDET communication framework can be used. Addressing these times helps the patient not need assistance later on. What does AIDET stand for?

Acknowledge, Introduce, Duration, Explanation, Thank you

What is a ‘just culture’? And what does it aim to do?

Just culture is a concept that revolves around designing, implementing, and supporting a safe and transparent environment within an organization.

It aims to create an environment where individuals can report errors, learn from mistakes, and contribute to continuous improvement.

In risk identification, what is a ‘near miss’?

A situation where an error/mishap almost occurs but it is prevented before harm is caused.

In risk identification, what are ‘adverse events’?

Refers to unintended harm caused by medical care from errors, negligence, or system failures.

What is a RCA (Root Cause Analysis)?

A structured, team-based investigation process used to find the underlying system and process flaws that caused an error or adverse event, rather than blaming the individual.

According to NHA, what are the steps in a RCA?

Assessment → Evaluation → Analysis → Outcome/planning → Implementation

True or false: As healthcare becomes more complex patient safety & medical error prevention becomes more critical.

True

Identify what each of these NPSGs mean in healthcare: Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, improved healthcare equity, and prevent mistakes in surgery,

• Use two patient identifiers and ensure that the medication, treatment, procedure, or care is intended for that specific patient. 

• Reporting critical results promptly to the appropriate person. 

• proper labeling, taking additional care with patients on anticoagulant (blood-thinning) medications, and accuracy of medication lists & Report to a nurse or supervisor if a medication is found in an unlabeled container, such as a syringe with liquid in it that remains on the patient's bedside table. 

• To reduce the risk of harm to patients, this goal promotes the appropriate use of clinical alarm systems in healthcare settings. These audible alert devices, built into medical equipment, warn clinicians that a potentially severe event may occur or when a machine malfunctions. 

• Healthcare-associated infections (HAIs) develop when a patient is in a healthcare setting. Review topic 10 on details of HAIs.

• Requires the screening of patients who may be at risk for suicide or who have intentions of suicide. 

• TJC advisory committee determined that health-related social needs were often underreported or not assessed when a patient was admitted to a healthcare organization. 

• A pre-procedure safety check process must be used to verify the correct procedure, patient, and site.

The National Database of Nursing Quality Indicators (NDNQI) was established by the ____ to report on structural processes & outcome indicators to evaluate care provided.

American Nurses Association (ANA)

What are ‘structural indicators’? (Examples)

These include nurse turnover, patient volume, certification, staffing & skill mix, and workforce characteristics

What are ‘process indicators’? (Examples)

These include advanced care planning, care coordination, depression screening, pediatric pain assessment, restraints, and suicide risk screening

What are ‘outcome indicators’? (Examples)

These include patient falls, pressure injuries, and healthcare-associated infections (HAIs)—central line-associated bloodstream infection, catheter-associated urinary tract infection, surgical-site infection, and ventilator-associated pneumonia

True or false: Managing all tasks a clinician is expected to complete in a shift is easy to do without tools to help prioritize.

False

What is a ‘routine task/order’?

Represents duties and tasks that must be done consistently, either on a fixed or regular basis, for a particular purpose

What is a 'stat task/order’?

Medical directive that requires medical immediate action due to the urgency of the situation- within 30 minutes

‘ABCDE’ is a method to quickly determine a patient’s stability. What does it stand for?

Airway, Breathing, Circulation, Disability, Exposure

Another prioritization tool that can be used while managing competing priorities is the CURE hierarchy. What does it stand for?

Critical: Need that required immediate action

Urgent: Need that causes discomfort

Routine: Typical tasks

Extra: Activities that contribute to patient comfort but are not essential

Clinicians must continuously prioritize patient care activities based on time constraints. What is ‘group/cluster care’?

Time management techniques that are used to save time when providing patient care (For example: providing more than one of the patient’s needs at a time before having to come back time after time)

A restraint should be the last resort to ensure patient & staff safety. What are 4 reasons restraints may be used?

1) Agitation/restlessness

2) Self removal of medical device

3) Patient is aggressive or combative

4) The patient is a danger to themselves or others

What is a physical restraint?

Device that includes materials, straps, fabric, and equipment that can be fastened and limit a patient’s movement

What do you need to document when restraints are used in care?

The reason for restraint, that the family has been informed, # of restraints and location, and the patient’s vital signs

To maintain patient-centered care, what must the clinician do when a patient has restraints?

Must monitor skin integrity, hydration, ROM, and toileting when restrained

What are pathogens?

Organisms with the potential for causing disease, such as bacteria or virus

Clinicians should perform hand hygiene (either hand sanitizer or hand washing) in what circumstances?

Before touching a patient, before aseptic or clean procedures, body fluid risk, after touching a patient, and after touching the patient’s surroundings

What is the order for donning & doffing PPE?

Donning- Gown →mask → goggles → gloves

Doffing- Gloves → goggles → gown → mask

What is the definition of immunocompromised?

State in which an individuals immune system is weakened or compromised, affecting the ability to fight off infections

What are contact precautions/when are they required?

Contact precautions are required for patients with infections that spread via direct contact or contact with the environment (indirect contact). Because patients touch many items in their rooms, you should wear gloves and a gown when handling any items in the patient's room and when taking contact precautions.

What are droplet precautions/when are they required?

Droplet precautions are required for patients with infections that spread via droplets more significant than 5 microns in diameter (rubella, meningitis, mumps, pertussis, influenza, and some other respiratory infections). This means clinicians must wear a mask when interacting with these patients, especially within 3 ft of the patient.

What is airborne precautions/when are they required?

Airborne precautions are required for patients with infections that spread via droplets smaller than 5 microns in diameter. Airborne precautions require patients to be in a negative pressure room (which prevents the air in the room from entering the hallway) or an airborne infection isolation room. These patients should also wear masks when leaving their rooms to go elsewhere in the facility.

What are neutropenic precautions/when are they required?

Requires meticulous hand hygiene and PPE such as gloves, a gown, or a mask to protect patients with compromised immune systems from potential infectious threats

What is ‘medical asepsis’?

Refers to practices that prevent the transmission of micro-organisms and minimize the risk of infection (clean technique)

What is ‘surgical asepsis"‘?

Sets of practices used to create and maintain a sterile environment during medical procedures; it ensures the absence of all micro-organisms within any invasive procedure

What is the definition of sanitization?

The process of making something completely clean and free from bacteria

What is the definition of disinfection? And what is disinfectant?

The process of destroying pathogens on a surface

Chemical substances or compounds used to inactivate or destroy micro-organisms on inert surfaces

What are biological hazards?

Disease producing agent that can be transmitted to individuals through various routes of exposure

What are hazardous chemicals?

Any chemical that can be a physical health hazard

What are radiological hazards?

Radioactive material that can damage the environment or harm people

What are electrical hazards?

Dangerous condition that can cause burns, electrocution, electrical shock, or other serious injuries

What are fire or explosive hazards?

Combustible or flammable liquid that can occur and cause serious injuries to individuals

True or false: Quality Improvement (QI) is critical in healthcare for several reasons; patient safety, patient satisfaction, health outcomes, and cost reduction.

True

What is the primary goal for quality improvement in healthcare?

To enhance patient safety and reduce the risk of harm

What are the quality metrics measured through NDNQI?

Patient falls, pressure injuries, and healthcare association infections (HAIs)

A process where nurses can review current research and identify whether the skills and procedures used are the best practices for efficiency, safety, and effectiveness or not is called:

Evidence-Based Practice (EBP)

What does the PDSA model for quality improvement contain?

Plan → Do → Study → Act

What are some different quality metrics in healthcare, and what do they mean/what are examples?

Patient safety: Are you following safety practices?

Clinical outcomes: How are you providing care?

Process measures: Practicing good hygeine?

Efficiency metrics: Are you documenting and using supplies correctly?

Staff satisfaction: How are you engaging with peers?

6 core competencies of the Quality and Safety Education for Nurses (QSEN)?

1) Patient-centered care

2) Teamwork and collaboration

3) Safety

4) Evidence-based practice

5) Quality improvement

6) Informatics

What is an Electronic Health Record (EHR)?

The electronic version of a patient’s medical history maintained by a provider or providers over time

What is an Electronic Medical Record (EMR)?

The electronic version of a patient’s chart of medical records. It captures data for care provided by a provider

What is the difference between objective and subjective statements?

Objective- Represents facts or observations VS. Subjective- Data that comes from opinions, perceptions, or experiences from the patient

What does the FACT acronym stand for?

Factual, Accurate, Complete & concise, and Timely

What are the ‘five rights of documentation’?

1) Right patient

2) Right information

3) Right time

4) Right format

5) Right purpose and intent

Clinicians are legally bound to protect patient ______; handling disclosed info. in a trusted relationship.

Confidentiality

Demographic data relates to what?

A person or group of people’s name, DOB, address, phone number, or emails.

Inadequate documentation puts the clinician and organization at risk of _______.

Malpractice

What is downtimes, when it comes to EHR/EMRs?

Period (planned or unplanned) in which the EHR is not fully accessible—documentation by hand is required.