Regulatory Compliance Flashcards
What is the Nursing Code of Ethics?
A guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession
focused on outlining the goals, values, and obligations to the profession of nursing.
ANA code of Ethics for nurses.
Written policies and procedures for blood transfusion services must conform to the standards of the:
American association of blood banks
takes the lead in Evidence Based Standards related to the criteria for blood donors, compatibility testing, and administration of human blood products.
A peer review
Focuses on an individual practitioner’s
strengths and weaknesses.
An associate with the same role expectations and performance description examines and evaluates the clinical practice of a peer.
Internal benchmarking
When processes within the same facility are measured against each other
Benchmarking
Continual monitoring of a competitor for performance improvement
Competitive benchmarking
Another way of saying you’re monitoring a competitor for performance improvement in your own facility
Functional benchmarking
-comparing your industry to another industry
-as you might compare a preop checklist in surgery to a preflight checklist in aviation.
Monies for larger purchases that have lasting use implications for a time defined period is called?
Capital budget
Some items might depreciate over time and need replacement as technologies change. The budget for these large expenses is called a capital budget.
US nuclear regulatory commission (NRC)
Sets radiation safety limits
Inside label of autologous tissue must include
-Patient identification using 2 unique identifiers
- Source of tissue
-Laterality if indicated
-Type of tissue
-Patient medical diagnosis, any pertinent clinical information
Outside label of autologous tissue must include
“For autologous use only”
“not evaluated for infectious substances”
“Biohazard”
Safe medical device act
Must report any incident of death or serious injury related to medical device
EPA (Environmental Protection Agency)
Recommends background noise not be more than 45 decibels
OSHA (Occupational Safety and Health Administration)
Mandatory limits on radiation exposure
Requirements on respirators
FDA (Federal Drug Administration)
-Collects medical device safety info reported by patients, manufacturers, and other stake holder
-Issue recalls
-Requirements for reprocessing
Capital budget
Typically used for purchase of large equipment (over $500) or for maintenance of assets with a “life” longer than the current year
Ex: OR beds, monitors, lasers, robots
Operational budget
Concerned with day-to-day running of the department or service line
Ex: salaries, supplies
According to AAMI and ANOR how much can pans weight?
25 lbs
Health literacy
Ability to make appropriate health decisions based on finding, understanding, and using information and services
How long do we maintain documentation related to an exposure?
The duration of the individual’s employment plus 20 years
FDA
Regulates medical and pharmaceutical devices and products
CDC
-Protect health, safety and security threats
-risk of healthcare associated infections
-Infection prevention guidelines and recommendations
CMS
-oversight of enforcing conditions of participation
-determines reimbursement fees and fees-for-services regulations; focuses on decreasing fraud
-establishes value-based incentive reimbursement; ties reimbursement to improve patient outcomes
-Enforces compliance with HIPAA
OSHA
-ensure safe and healthy work environment (staff & pts)
-managing infectious disease
-establishing a culture of safety
-Addressing workplace violence
-Performing safe patient handling
-Managing biological and chemical exposure risk
Competency
Actual application
Competence
Have the ability
Research
Generation of new information & knowledge
Evidence Based Practice (EBP)
-a systematic, thorough process to identify a clinical issue, collect and evaluate best evidence, design and implement a practice change, and evaluate the process
-Incorporation of findings into practice
-includes: literature, patient preferences, and expert judgement
-uses research to guide practice, utilizing scientific evidence
Shared governance
-Accountability of the individual practitioner
-foundation build on clinical decision making & professional accountability
-includes distributive decision making
Autologous bone grafts should be stored at a temperature of 
-4 F (-20 C)
Which type of fire extinguisher should be used in an operating room or procedure room?
Carbon dioxide or water mist extinguisher
State board of nursing
Defines the professional registered nurse’s scope of practice 
The WHO surgical safety checklist (SSC)
Improves communication
Associated with a significant reduction in postoperative complication rates and mortality 
When wearing a single dosimeter, the Perioperative RN should place the dosimeter
Outside the lead apron along the neckline 
Deviation from a standardized procedure that is hospital policy suggested the need for
An evaluation of the procedure or staff
Surgical care improvement project (SCIP) measure
Administering the prophylactic anabiotic within one hour of the surgical incision
Radiation safety important components
Time, distance, and shielding
Factors to consider when selecting products for use in the operating room
Direct costs
Indirect costs
Reimbursement potential
Group purchasing organization contract pricing
Agency for Healthcare Research and Quality
Committed to safety and quality- reduce the risk of harm
Effectiveness- improves healthcare outcomes with the use of research
Efficiency- transforms research into practice
Lead shielding used to minimize the patient exposure to ionizing radiation should be placed
Between the patient and the source of radiation but not within the path of the beam that originates from the x-ray tube
Halon extinguisher
For an electrical fire
Won’t leave residue on equipment
Health information technology for economic and clinical health (HITECH) act 
Addresses the use of electronic health information and technology to improve healthcare quality 
The importance of educating patients and family members about the prevention of wound infections postoperatively is part of the
National patient safety goals
The minimum distance between ceiling mounted sprinkler heads and sterile stored items should be 
18 inches
Surgical tissue banking records kept for
10 years
Uniform Anatomical Gift Act 1968
Guidelines
Tissue procured from suitable donors
Free from infections and diseases
What to do if tissue is dropped?
-soak in betadine, antibiotic solution, or both
-Steam sterilization of bone not recommended (cooks it)
OR discard and use artificial materials
-Always report to infection prevention personnel
Specimen Cytology
Examines cell types of fluid
Nursing process (AN I PIE)
-assessment
-Nursing diagnosis
-Identification of outcomes
-Planning
-implementation
-Evaluation
Nursing diagnosis
-Focuses on human response
-Don’t require doctor order
Identification of outcomes
Future tense
“patient will…”
Planning
Purpose is to select interventions to meet desired outcome
-ex: gathering supplies, getting room ready
Implementation
Purpose is to carry out the plan of care
Being done with the patient
Evaluation
Purpose is to identify if goal was met
Written in past tense
The regulatory agency responsible for surveying facilities’ compliance with Universal Protocol is
The Joint Commission
