Performance Manager
Nursing Quality & Safety Audit (through FY14 Q1)
Unit Information  
Unit
Month Completed
Year Completed
Observer Name
Observations  
Whiteboard Usage  
  Were the RN Name, PCT Name, and Plan of Care completed on patient's whiteboard?  
  Observation #1 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #2 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #3 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #4 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #5 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #6 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #7 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #8 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #9 Yes Yes with correction No
  What information was missing from the whiteboard?
  Observation #10 Yes Yes with correction No
  What information was missing from the whiteboard?
Daily Weights  
  If patient was ordered for a daily weight, was it done/documented? (Today)  
  Patient #1 Yes Yes with correction No NA
  Patient #2 Yes Yes with correction No NA
  Patient #3 Yes Yes with correction No NA
  Patient #4 Yes Yes with correction No NA
  Patient #5 Yes Yes with correction No NA
Medication Labeling  
  Were all medications, solutions and medication containers labeled as specified by hospital policy?  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
Telemetry Response  
  When a 'leads off' alarm is activated, was the patient's room responded to within 3 minutes of initiation?  
  Observation #1 Yes Yes with correction No NA
  Observation #2 Yes Yes with correction No NA
  Observation #3 Yes Yes with correction No NA
  Observation #4 Yes Yes with correction No NA
  Observation #5 Yes Yes with correction No NA
  Observation #6 Yes Yes with correction No NA
  Observation #7 Yes Yes with correction No NA
  Observation #8 Yes Yes with correction No NA
  Observation #9 Yes Yes with correction No NA
  Observation #10 Yes Yes with correction No NA
IV  
  Is the IV site dated and less than 4 days old?  
  Patient #1 Yes Yes with correction No NA
  Patient #2 Yes Yes with correction No NA
  Patient #3 Yes Yes with correction No NA
  Patient #4 Yes Yes with correction No NA
  Patient #5 Yes Yes with correction No NA
  Patient #6 Yes Yes with correction No NA
  Patient #7 Yes Yes with correction No NA
  Patient #8 Yes Yes with correction No NA
  Patient #9 Yes Yes with correction No NA
  Patient #10 Yes Yes with correction No NA
  Is the IV tubing dated and less than 4 days old?  
  Patient #1 Yes Yes with correction No NA
  Patient #2 Yes Yes with correction No NA
  Patient #3 Yes Yes with correction No NA
  Patient #4 Yes Yes with correction No NA
  Patient #5 Yes Yes with correction No
  Patient #6 Yes Yes with correction No NA
  Patient #7 Yes Yes with correction No NA
  Patient #8 Yes Yes with correction No NA
  Patient #9 Yes Yes with correction No NA
  Patient #10 Yes Yes with correction No NA
  Is there a label on the IV bag with patient's name, MRN and date and time spiked?  
  Patient #1 Yes Yes with correction No NA
  Patient #2 Yes Yes with correction No NA
  Patient #3 Yes Yes with correction No NA
  Patient #4 Yes Yes with correction No NA
  Patient #5 Yes Yes with correction No NA
  Patient #6 Yes Yes with correction No NA
  Patient #7 Yes Yes with correction No NA
  Patient #8 Yes Yes with correction No NA
  Patient #9 Yes Yes with correction No NA
  Patient #10 Yes Yes with correction No NA
  Was new tubing used for a new IV site?  
  Patient #1 Yes Yes with correction No NA
  Patient #2 Yes Yes with correction No NA
  Patient #3 Yes Yes with correction No NA
  Patient #4 Yes Yes with correction No NA
  Patient #5 Yes Yes with correction No NA
  Patient #6 Yes Yes with correction No NA
  Patient #7 Yes Yes with correction No NA
  Patient #8 Yes Yes with correction No NA
  Patient #9 Yes Yes with correction No NA
  Patient #10 Yes Yes with correction No NA
  Is there any sign of erthema, blood, or pus/drainage at the IV site?  
  Patient #1 Yes No N/A
  Patient #2 Yes No N/A
  Patient #3 Yes No N/A
  Patient #4 Yes No N/A
  Patient #5 Yes No N/A
  Patient #6 Yes No N/A
  Patient #7 Yes No N/A
  Patient #8 Yes No N/A
  Patient #9 Yes No N/A
  Patient #10 Yes No N/A
Foley Catheter  
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
  If yes, is the catheter secured in the device? Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
  For all patients with a Foley catheter, is there a securement device present? Yes Yes with correction No NA
 
If yes, is the catheter secured in the device?
Yes Yes with correction No NA
VTE  
Patient #1 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #2 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #3 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #4 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #5 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #6 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #7 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #8 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #9 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Patient #10 If patient was ordered for mechanical prevention, was it in use as ordered? Yes Yes with correction No NA
  IF NO, was there evidence in the medical record that the LIP was notified (If RN will document at end of shift, check yes)? Yes Yes with correction No NA
Equipment Cleaning  
  Did the user wipe down high frequency shared medical equipment per hospital policy BEFORE and AFTER patient contact? (ready to use Steris Germicidal Surface Wipes)  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
Hand Hygiene  
  ONLY for areas that do not participate in using Cal Stat counting.  
  Observation #1  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #2  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #3  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #4  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #5  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #6  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #7  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #8  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #9  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
  Observation #10  
  Before patient contact? Yes Yes with correction No
  After patient contact? Yes Yes with correction No
Bi-Yearly Audits  
March & September The following questions need to be completed during the months of March and September.  
Wristbands  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
Double Patient ID  
  Were two patient identifiers used to properly ID the patient?  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
5 Rights  
  The 5 Rights of Safe Medication Administration Practice are: The RIGHT Medication, Patient, Route, Time and Dose.  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
Outpatient Questions In addition to the above questions, complete the following four measures if applicable to your OUTPATIENT area:  
Preprocedure Huddles  
  Did the pre-procedure huddle occur?  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
IV Labeling  
  Observation #1 Yes Yes with correction No
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No
  Observation #4 Yes Yes with correction No
  Observation #5 Yes Yes with correction No
  Observation #6 Yes Yes with correction No
  Observation #7 Yes Yes with correction No
  Observation #8 Yes Yes with correction No
  Observation #9 Yes Yes with correction No
  Observation #10 Yes Yes with correction No
Allergy Bands  
  For a patient with a known allergy, is there an allergy band present?  
  Observation #1 Yes Yes with correction No NA
  Observation #2 Yes Yes with correction No
  Observation #3 Yes Yes with correction No NA
  Observation #4 Yes Yes with correction No NA
  Observation #5 Yes Yes with correction No NA
  Observation #6 Yes Yes with correction No NA
  Observation #7 Yes Yes with correction No NA
  Observation #8 Yes Yes with correction No NA
  Observation #9 Yes Yes with correction No NA
  Observation #10 Yes Yes with correction No NA
Safety Straps  
  If applicable, was the patient's safety strap applied on the table?  
  Observation #1 Yes Yes with correction No NA
  Observation #2 Yes Yes with correction No NA
  Observation #3 Yes Yes with correction No NA
  Observation #4 Yes Yes with correction No NA
  Observation #5 Yes Yes with correction No NA
  Observation #6 Yes Yes with correction No NA
  Observation #7 Yes Yes with correction No NA
  Observation #8 Yes Yes with correction No NA
  Observation #9 Yes Yes with correction No NA
  Observation #10 Yes Yes with correction No NA
          



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