2017 Joint Commission SmartBook

ENVIROMENT SERVICE BRANCH
Quality Manager, Ms. Tannia Fields: 590-5491
Hazmat, SPC Cortez: 590-7416
What we do for you & our customers
To provide a Clean, Healthy and Safe Environment for Staff,
Patients and Visitors through efficient and proper Housekeep-
ing Services, Clean Linen Supply, Vehicle Management, Medical
and Non-Medical Waste removal/disposal and soiled Linen
removal/laundering.

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UNIVERSAL PROTOCOL

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Q. What is “Alarm fatigue”?
A: Simply put, too many alarms result in desensitization, and
workers turning off alarms which can harm/kill patients.

NPSG #6: Use Alarms Safely

NPSG #6: Use Alarms Safely : Make improvements to ensure that
alarms on medical equipment are heard and responded to on
time.
Focus currently is in high risk areas.
For more information, refer to MEDCOM policy 16-102, and dis-
cuss with your Unit leadership.
Universal Protocol for Preventing Wrong Site, Wrong Proce-
dure, and Wrong Person Surgery:
Q. What are the three components for the Universal Protocol?
A. Conduct a Pre-operative Verification Process. Verify correct
procedure, for the correct patient and at the correct site.
B. Mark the Operative Site. The site is marked by the surgeon, or
responsible LIP, near site of procedure, prior to the procedure being
performed. The patient should be involved in this process if possible.
C. Conduct a Final Time-Out. Conduct a time-out immediately be-
fore starting the procedure. All team members must stop and agree
on the following: correct patient, correct site, and correct procedure
to be conducted.
ALL team members are focused on the time-out.

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ENVIROMENT SERVICE BRANCH
HAZMAT and RMW, Mr. Carl Holmgren: 590-4611

Hazmat (alternate), SPC Cortez: 590-7416
ESB Chief, CPT Wiltbank: 590-5348

Regulated Medical Waste (RMW)
BIOHAZARD bags, NOT= storage bags
“GREEN HANDTOWELS” and Regular trash DO

NOT belong in RMW!!!
 Infectious Medical Waste Green Label

080103
 Noninfectious Medical Waste RED label

080102
 Medications and x-ray contrast media

White label – no diamond

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EMERGENCY MANAGEMENT
POC: Mr. Gustavo Beltra

1. What is the LRMC Memo Number for Emergency Management?
a. LRMC MEMO 525-2
b. LRMC MEMO 500-1
c. LRMC MEMO 1-501
d. None of the above

2. The four phases of Emergency Management are:
a. Mitigation, Preparedness, Response and Clean-Up
b. Planning, Preparedness, Response and Recovery
c. Mitigation, Preparedness, Response and Recovery
d. Planning, Execution, Preparedness and Recovery

3. What does HVA stand for?
a. Hazardous Voluntary Action
b. Hazardous Variable Act
c. Hazardous Vulnerability Analysis
d. Hazardous Vulnerability Assessment

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Q. What is a sentinel event?

A. A sentinel event is an unexpected occurrence involving death or
serious physical or psychological injury or “the risk thereof”. In-
cludes loss of limb or function. Any process variation for which a
recurrence would carry a significant chance of a serious adverse
outcome falls in this category. Immediate action/investigation is
required!

Q What do you do when a sentinel event occurs?

A. Take care of the patient. Secure all equipment, supplies, etc. to
ensure everything is available for investigating the cause(s) of the
event. Notify the supervisor, nursing supervisor, Ms Kendra Bonin,
or Ms Zelma Delgado immediately once the patient is taken care of.

Q. How do you report a patent safety event (actual/near miss)?

A. Staff should submit the event in the Patient Safety Reporting
System (PSR). Please enter as much information as possible. Re-
member: the PSR is for patient events and near misses only.
Staff injuries are reported through the Safety Officer

B. For anonymous or “on-the-go” reporting: call 590-SAFE.
C. You may report directly to TJC (website)

Questions regarding 2017 NATIONAL PATIENT SAFETY GOALS
(NSPG)

Improve the Accuracy of Patient Identification

Q. What are the two patient identifiers used at LRMC?

A. The patient’s full name and date of birth.

B. Label all specimens in the presence of the patient after name
and date of birth confirmed with the patient.

Q. When the medication reconciliation is done?

A. At every patient visit, both inpatient and outpatient.

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NATIONAL PATIENT SAFETY GOALS

OVERALL MISSION OF PATIENT SAFETY

Reduce the chance that adverse effects of human error will harm
patients. Develop a Culture of Safety, in which staff willingly report
actual and near miss patient safety events without the threat of dis-
ciplinary action. Focuses on system and process design, rather than
on the individual involved in the event. Systems and processes can
be analyzed and designed to make future recurrences less likely.

Q. Who is responsible for patient safety at LRMC?

A. Everyone.

Q. How are patients involved in the patient safety program?

A. Patients are part of the healthcare team. They need to be will in-
formed about their condition, medications, and care requirements.
Patients should provide accurate and complete information to
provider(s) to assist in their care. Patients should be informed of an
unanticipated deviation from the expected outcome of their care.

Q. What is an actual/adverse event?

A. The event happened and reached the patient. This is also called
an “unusual occurrence”, “error” or “incident”.

Q. What is a near miss/good catch?

A. The event did not reach the patient; it was “caught” before it hap-
pened/reached the patient.

Q. Why is reporting near misses / good catches important?

A. Because good catches/near misses often are the easiest way to
prevent future errors. Identifying an error that could have hap-
pened but did not and reviewing how the error was prevented are
effective ways to identify safety nets that are in place and that could
prevent errors.

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4. What are the top five Hazards our organization has identified?
a. Flood, Earthquake, Wild Fire, Landslide Fire Alarm Failure
b. Supply Shortage, staff storage, Hostage Situation, Infant Ab-
duction, Rain
c. Bomb Threat, Aircraft Crash, Water System Failure, HAZMAT
Event, CBRNE Terrorist Event
d. Noise, trash, housekeeping, construction, air-conditioner
failure

5. When do most emergencies occur?
a. Morning
b. Weekend
c. Night
d. Anytime

6. Activity designed to reduce risk of a potential damage due to
an emergency is considered:
a. Preparedness
b. Mitigation
c. Recovery
d. Response

Answers: 1a, 2c, 3c, 4c, 5d, 6b

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HUMAN RESOURCES

POC: Jason Reisler
Five key areas of concern from Human Resources
I. Evaluations (HR.01.07.01: The hospital evaluates staff perfor-
mance)
a. How do you evaluate performance? “IAW military policy”
*evaluations cannot be kept in the CAF folder.
b. How often do you evaluate performance? “at least once a year”
II. Staff Functions (HR.01.02.07: The hospital determines how
staff function within the organization)
a. What are the required (vs recommended) licenses, registration and
certificates needed to work here? Should know the difference be-
tween required and recommended. * EMT is a requirement to main-
tain MOS qualification for 68W and 4N0s it is not a requirement to
work on the floors since they do not have a medical license.
b. Resuscitative Medicine requirements? IAW LRMC memo 40-48
[Intent: staff are following local policy and know how to access it]
*Wrong answer are usually because they do not know of the policy or
they are confused about the difference between required and recom-
mended.
cd. If a privileged provider is brought into your clinic how can
you verify they are working within their scope of practice?

A. Calls Credentials or asks provider to pull up their CCQAS file.

30

Call 590-SAFE or
Desktop Icon for PSR

Failure Modes and
Effects Analysis (Pro-Risk )

Root Cause Analysis
(System Approach design)

Stay Alert, Stay Safe, and

51

PATIENT SAFETY HOSPITAL GOALS

“Zero preventable harm” approach to Health Care by fol-
lowing the National Patient Safety Goals:

Patient Safety: Freedom from accidental injury (Kohn, Cor-
rigan and Donaldson 2000)

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How do you verify the current staff member’s status of licenses, cer-
tifications or registrations?

1) Provider: Credentials or CCQAS *This data cannot be kept in
the CAF folder!!!!!

2) Nurse RN/LVN: Looking for “Prime Source Verification (PSV)”
and required resuscitative med (copy) card in CAF folder. *Should
also know how to access 30/60/90 report and PSV online.

3) Medic: Copy is kept in CAF folder. Does not need to be prime
source verified since it is not a federal requirement. Should also
know how to access 68W 30/60/90 report online.

4) Other: Copy is kept in CAF folder.

III. Orientation (HR.01.04.01: The hospital provides orientation
to staff)
a. Where is your documentation of orientation to key safety (hospital
-wide and unit specific) content before staff provides care? Files
kept in CAF folder: enterprise-wide is Swank TFT or Safety Storm,
hospital-wide is proof of HNO, unit-specific is current “unit orienta-
tion” *If unit orientation is not present or has not been reviewed in
over one year the leadership must fix immediately.
b. What are some of the special areas/equipment staff need to be ori-
entated on here? Whatever is identified should be listed on the “unit
orientation” *Looking for the LRMC template for at least the last two
pages (minimum IPaC and EoC)

31

c. Where is your documentation of orientation to the Diversity,
Age-Specific Care/Population Based Care? CAF folder: Swank TFT

d. How do you document orientation of patient rights and ethical
aspects of care? CAF folder section I: ethics statement

IV. Training (HR.01.05.03: Staff participate in ongoing educa-
tion and training)

a. What training/education is provided to your staff to increase
competency? Twice a year with one being specific to the popula-
tion served [Intent: see if leadership is developing their staff]

1) How do you document it? Either in the CAF folder, skill
builder book or online *must be consistent

2) Is the training specific to the population served? At least
once in the year *Training should also either be based on team
concepts/performance or developed to meet the needs of the var-
ious job types (question I.b.)

b. How are staff trained and documented on:

1) Team communication, collaboration and coordination of
care? Is there any additional training? TeamSTEPPS (copy kept in
CAF folder) [Intent: should have a TeamSTEPPS champion and be
involved in implementing TeamSTEPPS in daily activities and
training]

2) Reporting unanticipated adverse events? At a minimum
copies kept in CAF folder: Swank TFT and HNO

3) Falls reduction? At a minimum nurses will have DoNO in
CAF folder

4) Identifying early warning signs of a change in condition? At
a minimum copies kept in CAF folder: Swank TFT

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***** KEY POINTS *****
 Opened Multi-Dose Vials are to be dated, initialed and discarded

after 28 days using standard stickers you can find in the unit
Medication Management Manual or on the Pharmacy Medshare
page.
 Multi-Dose Vials drawn up or used in patient care areas (i.e. pa-
tient treatment rooms, procedure rooms and operating rooms)
are considered patient specific or single use and should be dis-
carded after use.
*This does NOT apply to vaccines unless the vaccine is contami-
nated. Vaccines are good until the manufacturer’s expiration date.
 Drug References available to staff include LexiOnline Database
 Use the two patient-identifiers: Full Name & Date of Birth
 IAW RCHE MEMO 40-9, verbal orders are allowed only in Medical
Emergencies
 Ensure all medications are secured at all times!

Medication Management Manual

49

Improve the Safety of Using Medications.

Q. When do medication syringes/containers need to be labeled?

 A. All medications, medication containers (for example, syringes,
medicine cups, basins), or other solutions on and off the sterile
field must be labeled as soon as it is prepared.

(If the medication container (syringe, basin, etc.) is not used immedi-
ately (i.e. placed on a procedure table, used on an on-going basis,
such as anesthesia), the medication MUST be labeled. This process
applies to the operating room, and all other areas, where procedures
are done and there are pre-draws of solutions and medications. Dis-
card any medications vials/containers until after the procedure is
complete

Accurately and Completely Reconcile Medications Across the
Continuum of Care.

Q. What is the process for reconciling patient medications?

 A. During screening, the screener reviews meds on patient pro-
file, over the counter meds, vitamins and herbal supplements.
This is communicated to the provider. After making any changes
or adjustments, the updated medication list is available to the
patient to take home.

Q. What happens when a patient is transferred to a hospital?

 A. The following documents are given to the German Red Cross
ambulance or the fly team staff:

Complete medication list

A completed SBAR form

Patient’s AHLTA note as well as any other pertinent information

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V. Competency (HR.01.06.01: Staff are competent to perform
their responsibilities)
a. Who defines competencies for your staff here? Leadership (OIC,
CNOIC, NCOIC) [Intent: leadership understands they define this not
MEDCOM.]
1)What are the NEW procedures, policies, equipment, initiatives,
etc. that affect this unit? Should be listed on staff member’s compe-
tency assessment if they have been present over one year.
2) What are the CHANGES in procedures, policies, equipment, initia-
tive, etc. that affect this unit? Should be listed on staff member’s on-
going competency assessment if they have been present over one
year.
3) What are the HIGH RISK aspects/procedures here? At a minimum
will be IAW LRMC Memo 40-31. Whatever is identified must be on
the competency assessment
4) What are PROBLEMATIC aspects/areas here? At a minimum will
be IAW LRMC Memo 40-31. Whatever is identified must be on the
competency assessment Additional areas of discussion:
Does the competency assessment appear to be pencil whipped
(multiple pages done on one day); is the competency assessment
the 2006 BAMC template (tool was designed to accommodate three
orientation, training and competency assessment and is not reflec-
tive of local and Army policies anymore);

33

A2. are DoN Medics documented to use medications (reason core
competency assessments where removed in 2014); competency as-
sessments “should” be specific to the job type; difference require-
ments and intent behind the three types of competency assessments;
utilization of Mosby and other training platforms to reduce redun-
dant tasks; competency assessment must be specific to the popula-
tion served
5) When do you assess/re-assess competency? Initially and at a mini-
mum every three years. Also it is reviewed annually and any new com-
petencies are documented and validated.
6) What is your process for assessing competency? Looking for leader-
ship involvement and assigning a preceptor.
7) How do you assign preceptors? Based on education, experience, and
expertise. *NOT based on rank.
8)What do you do if a staff member’s competency does not meet expec-
tations? Take appropriate administrative or corrective training. Staff
member is prohibited from performing the task(s) until leadership has
approved the validity of their competency.

34

MEDICATION PREPARATION
The organization prepares medications.
Except in urgent situations, pharmacist non-availability, or per phar-
macy-approved protocols, the pharmacy mixes all sterile injections
administered at the clinic.
Available Drug References – The LRMC has an on-line subscription to
Lexi-Comp ONLINE .
ADVERSE DRUG REACTIONS AND MEDICATION ERRORS
The organization responds to actual or potential adverse drug events,
significant adverse drug reactions, and medication errors.
Patients are monitored for the effectiveness of medications by provid-
ers, nurses and clinical pharmacists. Assessment of the medication’s
effect on the patient includes the patient’s own perceptions and is doc-
umented in the medical record.
An Adverse Drug Reaction is an unintended/undesirable/negative re-
sponse to a drug taken at normal doses that compromises efficacy
and/or enhances toxicity.
 ADRs can be reported by submitting a PSR (Patient Safety Report),

phoning the ADR hotline at 590-SAFE, or reporting to the Depart-
ment of Pharmacy
Medication errors can be prevented by ensuring all medication orders
are reviewed by a pharmacist and using two patient identifiers (name
and DOB) before dispensing or administering medications.
 Medication incidents/errors are reported via PSR System, to in-
clude near-miss events and unsafe conditions.

47

EMERGENCY MEDICATIONS The organization safely manages any
emergency medications.

Depending on the section/MFR, the list of emergency medications
and supplies is contained in LRMC Memo 40-48: cardiopulmonary
Resuscitation and Emergency Cardiac Care or in the local SOP.

PATIENT HOME MEDICATIONS The organization safely controls
medications brought into the organization by patients, their families
or licensed independent practitioners.

 Patients are NOT allowed to bring in medications from the out-
side to be administered at the clinic/ward since the chain of cus-
tody should remain with the health care organization to ensure
integrity, potency and safety of medication.

MEDICATION ORDERS

Medication orders are clear accurate.

Prohibited abbreviations (U, u, IU, QD, qd, Q.D., q.d., QOD, qod, Q.O.D,
q.o.d., MS, MS04, MgSO4, use of a trailing zero (X.O mg) or lack of a
leading zero (.X mg), the preferred written terminology and reason
for potential problem is contained in LRMC Memo 40-56

The organization reviews the appropriateness of all medication or-
ders for medications to be dispensed in the organization.

All medication orders are entered on the patient’s electronic profile
to screen for allergies, drug interactions, appropriate dose, frequency,
route, drug/food interactions, therapeutic duplicates and
contraindications.

 All pediatric orders (< 12 years old) must contain weight

 Only one range per order
(i.e. 1-2 tabs Q3-4 hrs is NOT acceptable)

 All PRN orders must contain indication

46

CAF AUDIT TOOL

CAF Folder Management is located as a link on the Desk-
top.

35

INFECTION PREVENTION AND CONTROL
Preventing the Risk of Infections

Standard Precautions: A set to prevent the trans-
mission of diseases that can be acquired by contact
with blood, body fluid, non-intact skin (including
rashes), mucous membranes. These measures are to
be used when providing care to all individuals,
whether or not they appear infectious or symptomatic.

 Hand Hygiene
 Personal Protective Equipment (PPE)
 Needle stick and Sharps Injury Prevention
 Cleaning and Disinfection
 Respiratory Hygiene (Cough Etiquette)
 Waste Disposal
 Safe Injection Practices (One and Only Campaign)
 Isolation Signage
 Evaluations and Surveillance

LRMC PAM 40-9 Infection Prevention and Control Manual

36

RECALLED MEDICATIONS
The organization follows a process to retrieve recalled or discon-
tinued medications.
 The pharmacy notifies prescribers and nursing staff when a

medication is recalled for safety reasons by the manufacturer
of FDA via e-mail. If the recall is a patient level recall, specific
product reports can be generated from CHCS to identify pa-
tients.
Non-controlled patient turn-ins and internal expired medications
are segregated in different containers. All controls ( internal ex-
pired medications) are documented on a DA3161 Request for Is-
sue/Turn-in and added to a perpetual inventory in our Destruction
Vault (Pyxis). Medications are destroyed by pharmacy staff and a
disinterested officer at least quarterly.

MEDICATION ADMINISTRATION
The organization safely administers medications.
Staff allowed to administer medication include RN or LPN/ 68W
within their scope of practice. Orders are verified and medications
identified before being administered to patients via the five
“Rights” of medication administration: right patient, right drug,
right dose, right time and right route.

INVESTIGATIONAL MEDICATIONS
Non-FDA approved medications procured on the local economy (in
emergency situations) may be treated as investigational medica-
tions and will require consent from the patient.

45

MEDICATION SELECTION
LRMC Pharmacy & Therapeutics (P&T) recommends changes to Re-
gional Health Command Europe formulary. A list of stocked medica-
tions is available for staff and patients upon request.
If a medication is not on the formulary, a provider can submit a pa-
tient specific non-formulary drug request (NFDR) electronically with
patient information, prescription information and justification includ-
ed (i.e. formulary agent ineffective or adverse reaction experienced).
Clinical pharmacists at LRMC review request and approve or disap-
prove. Providers can request a medication be added to the formulary
by completing a DD 2081, New Drug Request and forwarding to the
Chief of Pharmacy for inclusion at the next P&T meeting.
MEDICATION STORAGE
We ensure medications are stored appropriately, available when nec-
essary and the risk of diversion is minimized by:

 Securing all medications when not under direct observation of a
health care provider or under lock and key (i.e. in locked medica-
tion room and/or Pyxis Station).

 Warranting controlled substances are double locked (in locked
medication room and locked cabinet, cart or Pyxis).

 The pharmacy conducts monthly unit inspection/staff assistance
visits to all medication storage areas to ensure proper storage,
labeling and to remove any expired medications.

44

WASH YOUR HANDS !!!!!! WASH YOUR HANDS !!!!!!
Isolation Precaution Signs

37

INFORMATION MANAGEMENT (IM)
POC: LTC Adam J. Peters & MAJ Underwood
Reference: Army Regulation 25-1 Army Knowledge Management
and
Information Technology
MEDSHARE Site: https://medsharevm.ermc.amedd.army.mil/
sites/LRMC/DCA/IMD/default.aspx
The goals of IM:
 Provide Signal Capabilities to the Force
 Enhance Cybersecurity Capabilities
 Increase Network Throughput & Ensure Sufficient Computing

Infrastructure
 Deliver IT Services to the Edge
 Strengthen Network Operations

38

 methylPROGESTERone (DepoProvera) and methylPREDNISo-
lone (DepoMedrol)

 metoprolol SUCCinate XL and metoprolol TARTrate
 Ortho Tri-Cyclen and Ortho Tri- Cyclen **LO**
 NIFEdipine and niMODipine
 PAClitaxel and DOCEtaxel
 predniSONE and prednisoLONE
 TopaMAX and TopROL XL
 vinBLAStine and vinCRIStine
 yasMIN and Yaz
 ZyPREXA and ZyPREXA XR and ZyrTEC

**Brand names always start with an uppercase letter. Some brand names incorporate
tall man letters in initial characters and may not be readily recognized as brand
names.

43

LOOK-ALIKE / SOUND-ALIKE MEDICATION
 Albuterol and LEValbuterol
 Anesthetic sprays (Pain Ease Spray and DERMOplast spray)
 ALPRAZolam and LORazepam and clonazePAM
 bupropion SR and bupropion XL
 CeleBREX and CeleXA
 CISplatin and CARBOplatin
 cloNIDine, clonazepam and klonoPIN
 cloTRImazole and cloBETasol
 Depakote SPRINKLE, Depakote ER and DR
 DILTiazem ER and DILTiazem
 DOPamine and DOBUTamine
 dtAP AND Tdap vaccines
 ePHEDrine and EPINEPHrine
 ESOmeprazole and omeprazole
 glipiZIDE and glyBURIDE
 guanFACINE and guanFACINE ER
 HYDROcodone and oxyCODONE and oxyCONTIN
 HYDROmorphone and morphine
 hydrOXYzine and hydralazine
 metFORMin and metFORMin XR and methoCARBamol

42

What is IM and what does it cover?

 APPLICATION MANAGEMENT SERVICES The Application De-
velopment and Maintenance Service includes the following out-
puts:

 Deployment Training Development Services includes capabili-
ties that address training for new solutions deployed within the
MHS environment as well as end user training for applications
and services already existing in the MHS environment.

 End User Training Services results in the optimal use of the sys-
tem by the end user through continual user experience improve-
ments, improved system adoption rates, integrated functional
voice, standardized and workflow specific role-based curricu-
lum, and Subject Matter Expert (SME) certified trainers. Product
and Curriculum Lifecycle Training Services consist of analyzing
and developing strategic training and workflow integration
planning for information systems in the MHS.

 Health Information Technology Implementation Services pro-
vide a full array of subservices to support product implementa-
tion. Activities include: conducting training events and sessions:
Train the Trainer (T3), Trainer competency validation; conduct-
ing system training Clinical Technology Consulting Services pro-
vide consulting for hardware and software for use within the
MHS clinics to include functional and technical troubleshooting
of AHLTA and other clinical applications.

 Clinical Content and Template Management Services offer evi-
dence-based best practices that can rapidly be incorporated into
enterprise-wide workflows through the creation, management,
and updates of content rich templates used in the EHR for a
wide variety of clinical users.

39

MEDICATION MANAGEMENT

HIGH ALERT MEDICATION (HAM)

Safely manage high-alert and hazardous medications.

High-alert medications are involved in a high percentage of errors,
sentinel events or at higher risk for adverse outcomes or abuse.
High risk therapeutic categories of medications include anticoagu-
lants, anti-neoplastic agents, concentrated electrolytes, epidurals
and peripheral nerve infusions, insulin, liposomal drugs, moderate
sedation agents, narcotic/opiates, neuromuscular blocking agents,
oxytocic agents, total parenteral nutrition and vitamin K products.

 The organization minimizes the risk associated with high alert
medications by identifying in writing (see following list) and
posting in patient care areas.

 High risk medications are highlighted as high risk with stickers
(high-alert and / or stop sign stickers). Medications can also be
segregated in red bins in storage areas.

SOUND ALIKE LOOK ALIKE/ MEDICATIONS (SALAD)

The organization addresses the safe use of look-alike/sound-alike
medications.

 See list of look-alike/sound-alike medications in RCHE 40-9.

 Upper case (tall man) and lower case (short man) letters are
printed on the medication label for medications identified as
look-alike/sound-alike (i.e. TopAMAX and TopROL XL).

 Pharmacy places signage in medication storage areas signifying
medication as look-alike/sound-alike. Pharmacy may also uti-
lizes red storage bins in the main department to segregate these
items from regular stock.

40

HIGH RISK / HIGH ALERT MEDICATONS
 Anticoagulants
 Anti-neoplastic Agents
 Concentrated Electrolytes
 Epidurals and Peripheral Nerve Infusions
 Insulin
 Liposomal Drugs
 Moderate sedation agents
 Narcotic/opiates

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