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Archive for the ‘JCAHO’ Category

Joint Commission Preparation Focus on Safety Resource Guide

Written by reuben

March 18th, 2012 at 8:26 pm

Posted in JCAHO

Correct Antibiotics for immunosuppressed patients going to ICU

(PNA core measure)

B-lactam (IV) + Macrolide (IV)

B-lactam (IV) + Antipneumococcal Quinolone (IV)

If documented B-lactam allergy: Antipneumoccal Quinlone(IV) + Aztreonam

B-lactam = Ceftriaxone, Cefotaxime, Ampicillin/ Sulbactam

Macrolide = Erythromycin, Clarithromycin, Azithromycin

Antipneumococcal Quinolones = Levofloxacin, Moxifloxaxin

B-lactam (IV + Macrolide (IV)
B-lactam (IV + Antipneumococcal Quinolone (IV)
If documented B-lactam allergy: Antipneumoccal Quinlone(IV) + Aztreonam
B-lactam = Ceftriaxone, Cefotaxime, Ampicillin/ Sulbactam
Macrolide = Erythromycin, Clarithromycin, Azithromycin
Antipneumococcal Quinolones = Levofloxacin, Moxifloxaxin

Written by reuben

April 28th, 2010 at 3:03 am

No more blood cultures for PNA patients

Just to be clear- blood cultures are NO LONGER NEEDED for core measure compliance in pneumonia patients.
This is consistent with available evidence so you are no longer faced with deciding between good medicine and core measure compliance.
Continue to order blood cultures on the patients you believe are septic (regardless of source) just please, please, please… no more blood cultures on the routine PNA admit.

One additional point:
If you order and draw blood cultures after antibiotics are given the case becomes a core measure outlier so please discourage your medicine colleagues from ordering late blood cultures on admitted pneumonia patients…

Written by reuben

January 23rd, 2009 at 8:58 am

Posted in ID,JCAHO

Annual OSHA & NYS Infection Control Tests

Compliance with Infection Control training requirements is very important from both the patient safety and regulatory standpoints.  Compliance with these requirements is federally and/or state mandated and subject to review and enforcement by OSHA and accrediting agencies, including JCAHO.

1.  OSHA Bloodborne Pathogen Training:

All employees with the potential for exposure to blood and/or other body fluids (designated “category A” employees) are required to complete this training annually. The attached report indicates the date upon which each employee’s current certificate for OSHA Bloodborne Pathogen Training expires.  Employees with expired certificates are indicated by a comment in the far right column of the table.  Department administrators should notify these employees so that the renewal process can be completed immediately.

OSHA Training opportunities:

The OSHA retraining course lasts approximately one hour and is offered by the Department of Infection Control throughout the year.  The schedule of course dates, times, and locations is available on the Infection Control website (<> >>Medical Services>> Infection Control).  Pre-registration is not required.

Licensed health care professionals also have the option to complete the OSHA retraining course online.  The online course is available on the Infection Control website (<> >>Medical Services>>Infection Control).  In order to receive credit for the online course, the post-test must be successfully completed after review of the slide presentation.  The confirmation certificate generated after successful completion should be printed for the employee’s records.

2. New York State Infection Control Training:

New York State requires that certain healthcare professionals receive training in infection control every four years.  Information regarding an employee’s NYS certification status can be obtained from the appropriate Mount Sinai credentialing office.

For a list of other approved New York State Infection Control course providers, visit  Licensed health professionals can also fulfill the course requirements online at

Written by phil

December 2nd, 2008 at 3:35 pm

Posted in ID,JCAHO


If a patient arrives with LVAD; Call Director on call 24/7-212-241-1000 immediately.

  • Plug in external battery pack into AC outlet
  • No chest compressions

Left Ventricular Assist Device

What is a left ventricular assist device (LVAD)?

The left ventricle is the large, muscular chamber of the heart that pumps blood out to the body. A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that’s surgically implanted. It helps maintain the pumping ability of a heart that can’t effectively work on its own.

These devices are available in most heart transplant centers.

When is an LVAD used?

This device is sometimes called a “bridge to transplant.” People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. During this wait, the patient’s already-weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can help a weak heart and “buy time” for the patient.

How does an LVAD work?

A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump’s battery and control system. LVADs are now portable and are often used for weeks to months. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.

LVAD SetupLVAD Setup

Written by phil

November 21st, 2008 at 2:34 pm

Posted in Cardiology,JCAHO

JCAHO Stroke Designation Visit

We are pleased to share the following Quick Tips with
management, faculty and staff in preparation for the
planned Joint Commission visit on March 10th and 11th in
conjunction with Mount Sinai’s application for a
special “Stroke Designation.”

Below are basic reminders of safety regulations that all
staff should know and keep in mind at all times, to ensure
that we promote a safe, secure and ideal environment for
the BEST in patient care.

If you have a JCAHO-related question, please call Ext. 4-

1. When and where should employees wear their hospital
ID badge?
At all times, above the waist and in plain sight.

2. What’s the best way to prevent the spread of
Hand hygiene. With soap and water, wash hands vigorously
for at least 15 seconds. Or, apply Purell, rub hands until
hands are dry.

3. How do all of us protect patient confidentiality?
By maintaining HIPAA compliance at all times. No
unnecessary or unauthorized disclosure or access of PHI
(Protected Health Information) is acceptable.

4. What should you do when you see fire or smoke?
R.A.C.E. [Rescue, Alarm (alarm box or call Ext. 4-3473),
Confine, Extinguish]; know specific plans for your area,
including but not limited to: location of nearest fire
alarm box, location of fire exit stairways, location of
extinguishers, evacuation plan.

5. What are the phone numbers to call in case the
following issues occur?
a. Spills
b. Holes in / repairs to ceiling, leaks, floods,
– Spills: Building Services at Ext. 4-6125.
– Holes in / repairs to ceiling, leaks, floods etc.:
Engineering at
Ext. 4-6201.

6. Whom do you go to in the case of an
emergency “event”?
Department-specific “Chain of Command.”

7. What does “Code Adam” mean?
Infant abduction from unit. Department-specific actions

8. What is “Plan E,” and what’s the first thing you
should do?
Plan E outlines how personnel are to be deployed in the
event of an internal or external emergency involving more
than 15 medical casualties. Staff are required to report
to their assigned areas, which are department-specific.

9. How do you accurately identify the patient you are
caring for?
Patient Name and Date of Birth.

10. What is “Universal Protocol”?
It is a set of steps that are designed to prevent Wrong
Site, Wrong Procedure and Wrong Patient Surgery. The
protocol applies to OR and NON-OR settings, including
bedside procedures.

11. Is there a listing of Do Not Use symbols and
abbreviations in the institution? Why is this list
Lists are posted on units to remind employees not to use
those symbols and abbreviations, as they can easily be
misread and can lead to medication errors, potentially
causing patient harm.

12. How do you effectively hand-off a patient to another
provider, caregiver or service?
Follow SBAR: Situation, Background, Assessment,

13. Provide some examples involving “Environment of
Stored items must be 6” from floor and 18” from ceiling;
doors cannot be propped or tied open; door lock
combinations shouldn’t be posted next to the door.

14. What are “Look Alike / Sound Alike” Drugs?
They are drug pairs that require special attention because
they look or sound very similar and can be confused one for
the other. When a Look Alike / Sound Alike drug is
dispensed by the pharmacy, it is labeled in TALL MAN
lettering (e.g., DOPamine vs. DOBUTamine OR hydrALAZINE
vs. hydrOXYzine).

Written by phil

August 12th, 2008 at 12:49 pm

Posted in JCAHO