IBFCSM CHEP cheat sheet

Sentinel event: an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof; the event is analyzed with a root cause analysis (RCA) within 45 calendar days of becoming aware of it under Joint Commission expectations.

RCA is retrospective and applies to sentinel events; failure mode and effects analysis (FMEA) is prospective and applies to high-risk processes before harm occurs.

The Joint Commission's Universal Protocol has three components performed in order: preprocedure verification, marking of the operative/procedure site, and a time-out immediately before the procedure begins.

National Patient Safety Goal for hand hygiene aligns with WHO "Five Moments": before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professional, patient, or consumer.

High-alert medications (e.g., concentrated electrolytes, insulin, anticoagulants, opioids) require independent double checks and standardized storage; the ISMP list is the common reference.

Sharps injury prevention follows the hierarchy of controls: eliminate unnecessary sharps, use engineered safety devices, then administrative controls (no recapping), then PPE.

Pressure injury staging: Stage 1 = intact skin with nonblanchable erythema; Stage 2 = partial-thickness loss with exposed dermis; Stage 3 = full-thickness loss; Stage 4 = full-thickness with exposed fascia, muscle, tendon, cartilage, or bone.

Hand-off communication using SBAR (Situation, Background, Assessment, Recommendation) is a structured technique to reduce communication-related adverse events.

The four phases of emergency management are mitigation, preparedness, response, and recovery; healthcare planning cycles through all four continuously.

The Joint Commission Emergency Management standards require an all-hazards approach, a hazard vulnerability analysis (HVA), and at least one exercise per year with the plan evaluated and revised.

HVA scoring typically multiplies probability x impact (or risk = probability x consequence) and ranks hazards so the organization allocates resources to the highest-scoring events.

The Hospital Incident Command System (HICS) is a scalable structure with five functions: Command, Operations, Planning, Logistics, and Finance/Administration.

Surge capacity has four components: staff, stuff, space, and systems (or structure); surge level is the ability to expand quickly beyond normal capacity.

Continuity of operations planning (COOP) focuses on maintaining critical functions (e.g., utilities, IT, pharmacy, laboratory, food service) during and after a disruption.

Evacuation decision-making considers horizontal (same-floor) vs. vertical (other floor) vs. full-building evacuation, and the decision to shelter in place vs. evacuate is made by the incident commander with life-safety input.

Decontamination planning for a healthcare facility includes a designated area with drainage control, PPE for staff, and a process to protect the emergency department from contamination.

The Hospital Emergency Response Checklist (WHO) and the CMS Emergency Preparedness Rule (for Medicare-participating providers) require an emergency plan, policies, communication plan, and training/testing.

Hierarchy of controls, most to least effective: elimination, substitution, engineering controls, administrative controls, and PPE.

Risk assessment formula: risk = severity x likelihood (or probability x consequence); residual risk is the risk remaining after controls are applied.

ALARP principle: risks should be reduced to as low as reasonably practicable, balancing cost and effort against the benefit of further risk reduction.

Job hazard analysis (JHA) breaks a task into steps, identifies hazards at each step, and defines controls before the task is performed.

Exposure limits: OSHA PELs are legal limits; NIOSH RELs are recommended; ACGIH TLVs are consensus guidelines; when limits differ, the more protective value is used for planning.

PPE is the last line of defense because it protects only the wearer and depends on correct fit, donning/doffing, and compliance; it does not eliminate the hazard.

Safety data sheets (SDS) under OSHA HazCom 2012 (GHS-aligned) have 16 sections, including hazards identification, composition, first-aid, firefighting, and exposure controls.

Incident investigation seeks root and contributing causes using tools such as the 5 Whys, fishbone (Ishikawa) diagram, and fault tree analysis; the goal is system correction, not blame.

The hierarchy of hazard control applies to bloodborne pathogens via the Needlestick Safety and Injection Safety Act: employers must evaluate and use safer medical devices with frontline input.

Medical device recall classes: Class I = reasonable probability of serious adverse health consequences or death; Class II = temporary or medically reversible harm; Class III = unlikely to cause harm.

FDA's 510(k) premarket notification requires substantial equivalence to a legally marketed predicate device; PMA (premarket approval) is required for Class III high-risk devices.

Unique Device Identification (UDI) is a unique identifier on device labels and packaging that supports traceability, recalls, and adverse event reporting.

MedWatch is the FDA adverse event reporting system; manufacturers must report deaths and serious injuries, and user facilities report device-related deaths to FDA and serious injuries to the manufacturer.

The Consumer Product Safety Commission (CPSC) can order recalls and requires reporting of substantial product hazards under the Consumer Product Safety Act.

Material safety: latex allergy prevention relies on identifying latex-containing products, providing latex-free alternatives, and labeling; powder-free low-protein gloves reduce exposure.

Sterilization assurance uses biological indicators (e.g., Geobacillus stearothermophilus for steam) and chemical indicators; a failed BI requires recall and reprocessing of loads.

Post-market surveillance includes complaint handling, MDR (Medical Device Reporting), and trend analysis; a rising complaint trend is a signal to reassess risk.

Disaster management cycle: mitigation/prevention, preparedness, response, and recovery; each phase informs the next through after-action review.

Incident Command System (ICS) is a standardized on-scene emergency management structure with common terminology, modular organization, and manageable span of control (typically 3-7 subordinates).

The National Incident Management System (NIMS) provides the framework for all levels of government and private entities to work together during incidents; ICS is a component of NIMS.

Triage in mass casualty: START (Simple Triage and Rapid Treatment) sorts by respirations, perfusion, and mental status into Immediate, Delayed, Minor, and Expectant categories.

Disaster declaration triggers resource requests through mutual aid and emergency management agencies; the Stafford Act authorizes federal assistance for state and local governments.

After-action report (AAR) and improvement plan (IP) document strengths, areas for improvement, and corrective actions following exercises and real events.

Community resilience planning includes at-risk populations (elderly, disabled, non-English speakers, homeless) and requires accessible communication and evacuation planning.

Mass fatality planning includes temporary morgue capacity, victim identification (e.g., DMORT), and family assistance centers.

Sentinel event reporting and RCA: RCA must be completed within 45 calendar days of awareness under Joint Commission expectations.

FMEA is prospective; RCA is retrospective. Use FMEA for high-risk processes before harm, RCA after a sentinel event.

Universal Protocol order: preprocedure verification, site marking, time-out immediately before the procedure.

WHO Five Moments for hand hygiene: before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after touching surroundings.

High-alert medications require independent double checks and standardized storage; ISMP maintains the reference list.

Sharps injury prevention follows the hierarchy of controls: eliminate, engineered safety devices, administrative controls, PPE.

Pressure injury staging: Stage 1 nonblanchable erythema; Stage 2 partial-thickness; Stage 3 full-thickness; Stage 4 full-thickness with exposed deep structures.

SBAR (Situation, Background, Assessment, Recommendation) is a structured hand-off technique to reduce communication-related harm.

Medication error definition: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professional, patient, or consumer.

Four phases of emergency management: mitigation, preparedness, response, recovery.

Joint Commission Emergency Management requires an all-hazards approach, an HVA, and at least one exercise per year with plan evaluation and revision.

HVA scoring: risk = probability x impact (or consequence); rank hazards to allocate resources to the highest-scoring events.

HICS five functions: Command, Operations, Planning, Logistics, Finance/Administration.

Surge capacity components: staff, stuff, space, systems (or structure).

COOP focuses on maintaining critical functions (utilities, IT, pharmacy, laboratory, food service) during and after disruption.

Evacuation types: horizontal (same floor), vertical (other floor), full-building; the incident commander decides shelter-in-place vs. evacuate with life-safety input.

Decontamination area requires drainage control, PPE for staff, and protection of the emergency department from contamination.

CMS Emergency Preparedness Rule requires an emergency plan, policies, communication plan, and training/testing for Medicare-participating providers.

Hierarchy of controls, most to least effective: elimination, substitution, engineering controls, administrative controls, PPE.

Risk = severity x likelihood (or probability x consequence); residual risk is what remains after controls.

ALARP: reduce risk to as low as reasonably practicable, balancing cost and effort against benefit.

JHA: break the task into steps, identify hazards at each step, define controls before the task is performed.

Exposure limits: OSHA PELs are legal limits; NIOSH RELs are recommended; ACGIH TLVs are consensus guidelines; use the more protective value for planning.

PPE is the last line of defense; it protects only the wearer and depends on fit, donning/doffing, and compliance.

SDS under OSHA HazCom 2012 (GHS-aligned) has 16 sections including hazards identification, composition, first-aid, firefighting, and exposure controls.

Incident investigation tools: 5 Whys, fishbone (Ishikawa) diagram, fault tree analysis; goal is system correction, not blame.

Needlestick Safety and Injection Safety Act: employers must evaluate and use safer medical devices with frontline input.

Recall classes: Class I = reasonable probability of serious adverse health consequences or death; Class II = temporary or medically reversible harm; Class III = unlikely to cause harm.

510(k) requires substantial equivalence to a legally marketed predicate; PMA is required for Class III high-risk devices.

UDI is a unique identifier on device labels and packaging that supports traceability, recalls, and adverse event reporting.

MedWatch: manufacturers report deaths and serious injuries; user facilities report device-related deaths to FDA and serious injuries to the manufacturer.

CPSC can order recalls and requires reporting of substantial product hazards under the Consumer Product Safety Act.

Latex allergy prevention: identify latex-containing products, provide latex-free alternatives, label, and use powder-free low-protein gloves.

Sterilization assurance: biological indicators (e.g., Geobacillus stearothermophilus for steam) and chemical indicators; a failed BI requires recall and reprocessing of loads.

Post-market surveillance: complaint handling, MDR, and trend analysis; a rising complaint trend is a signal to reassess risk.

Disaster management cycle: mitigation/prevention, preparedness, response, recovery; after-action review feeds the next cycle.

ICS is a standardized on-scene structure with common terminology, modular organization, and a manageable span of control (typically 3-7 subordinates).

NIMS provides the framework for all levels of government and private entities to work together; ICS is a component of NIMS.

START triage sorts by respirations, perfusion, and mental status into Immediate, Delayed, Minor, Expectant.

Disaster declaration triggers resource requests through mutual aid and emergency management agencies; the Stafford Act authorizes federal assistance for state and local governments.

AAR and improvement plan (IP) document strengths, areas for improvement, and corrective actions after exercises and real events.

Community resilience planning includes at-risk populations (elderly, disabled, non-English speakers, homeless) and requires accessible communication and evacuation planning.

Mass fatality planning includes temporary morgue capacity, victim identification (e.g., DMORT), and family assistance centers.

Sentinel event RCA must be completed within 45 calendar days of awareness under Joint Commission expectations.

FMEA is prospective; RCA is retrospective.

Universal Protocol order: preprocedure verification, site marking, time-out.

WHO Five Moments for hand hygiene cover patient contact, aseptic procedure, body fluid exposure, and surroundings.

High-alert medications require independent double checks and standardized storage; ISMP maintains the reference list.

Sharps injury prevention follows the hierarchy of controls.

Pressure injury staging: Stage 1 nonblanchable erythema through Stage 4 exposed deep structures.

SBAR is a structured hand-off technique to reduce communication-related harm.

Medication error: any preventable event that may cause or lead to inappropriate medication use or patient harm.

Four phases: mitigation, preparedness, response, recovery.

Joint Commission requires all-hazards approach, HVA, and at least one exercise per year.

HVA scoring: risk = probability x impact; rank hazards to allocate resources.

HICS five functions: Command, Operations, Planning, Logistics, Finance/Administration.

Surge capacity components: staff, stuff, space, systems.

COOP maintains critical functions during and after disruption.

Evacuation types: horizontal, vertical, full-building; incident commander decides shelter-in-place vs. evacuate.

Decontamination area requires drainage control, staff PPE, and ED protection.

CMS Emergency Preparedness Rule requires plan, policies, communication plan, training/testing.

Hierarchy of controls: elimination, substitution, engineering, administrative, PPE.

Risk = severity x likelihood; residual risk remains after controls.

ALARP: reduce risk to as low as reasonably practicable.

JHA breaks task into steps, identifies hazards, defines controls before work.

OSHA PELs are legal; NIOSH RELs recommended; ACGIH TLVs consensus; use more protective value.

PPE is last line of defense; protects only wearer.

SDS has 16 sections under HazCom 2012.

Incident investigation tools: 5 Whys, fishbone, fault tree; goal is system correction.

Needlestick Safety Act requires safer medical devices with frontline input.

Recall classes: I = serious harm or death; II = temporary/reversible; III = unlikely harm.

510(k) requires substantial equivalence to predicate; PMA for Class III.

UDI supports traceability, recalls, and adverse event reporting.

MedWatch: manufacturers report deaths/serious injuries; user facilities report deaths to FDA.

CPSC can order recalls and requires reporting of substantial product hazards.

Latex allergy prevention: identify latex products, provide alternatives, label, use powder-free gloves.

Sterilization assurance: biological and chemical indicators; failed BI requires load recall.

Post-market surveillance: complaint handling, MDR, trend analysis.

Disaster management cycle: mitigation, preparedness, response, recovery.

ICS span of control typically 3-7 subordinates.

NIMS provides framework for government and private entities; ICS is a component.

START triage uses respirations, perfusion, mental status; categories Immediate, Delayed, Minor, Expectant.

Stafford Act authorizes federal assistance for state and local governments.

AAR and improvement plan document strengths, areas for improvement, corrective actions.

Community resilience planning includes at-risk populations and accessible communication.

Mass fatality planning includes temporary morgue capacity, victim identification, family assistance centers.

Sentinel event RCA: 45 calendar days from awareness under Joint Commission expectations.

FMEA prospective; RCA retrospective.

Universal Protocol: verification, site marking, time-out.

WHO Five Moments for hand hygiene.

High-alert medications: independent double checks, standardized storage, ISMP list.

Sharps injury prevention: hierarchy of controls.

Pressure injury staging: 1 nonblanchable erythema; 2 partial-thickness; 3 full-thickness; 4 exposed deep structures.

SBAR hand-off technique.

Medication error definition: preventable event causing inappropriate use or harm.

Phases: mitigation, preparedness, response, recovery.

Joint Commission: all-hazards approach, HVA, one exercise per year.

HVA scoring: risk = probability x impact.

HICS: Command, Operations, Planning, Logistics, Finance/Administration.

Surge capacity: staff, stuff, space, systems.

COOP maintains critical functions.

Evacuation: horizontal, vertical, full-building; IC decides shelter vs. evacuate.

Decontamination: drainage control, staff PPE, ED protection.

CMS EP Rule: plan, policies, communication, training/testing.

Hierarchy: elimination, substitution, engineering, administrative, PPE.

Risk = severity x likelihood; residual risk after controls.

ALARP: as low as reasonably practicable.

JHA: steps, hazards, controls before work.

PELs legal; RELs recommended; TLVs consensus; use more protective.

PPE last line of defense.

SDS 16 sections under HazCom 2012.

Investigation: 5 Whys, fishbone, fault tree; system correction.

Needlestick Safety Act: safer devices with frontline input.

Recall classes: I serious harm/death; II temporary/reversible; III unlikely harm.

510(k) substantial equivalence; PMA for Class III.

UDI supports traceability and recalls.

MedWatch: manufacturers report deaths/serious injuries; facilities report deaths to FDA.

CPSC can order recalls; substantial product hazard reporting.

Latex allergy prevention: identify, alternatives, label, powder-free gloves.

Sterilization assurance: biological/chemical indicators; failed BI requires load recall.

Post-market surveillance: complaints, MDR, trend analysis.

Disaster cycle: mitigation, preparedness, response, recovery.

ICS span of control 3-7.

NIMS framework; ICS is a component.

START triage: respirations, perfusion, mental status; Immediate, Delayed, Minor, Expectant.

Stafford Act authorizes federal assistance.

AAR and improvement plan document corrective actions.

Community resilience planning includes at-risk populations.

Mass fatality planning: morgue capacity, victim identification, family assistance centers.

Sentinel event RCA within 45 calendar days of awareness.

FMEA prospective; RCA retrospective.

Universal Protocol: verification, site marking, time-out.

WHO Five Moments for hand hygiene.

High-alert medications require independent double checks.

Sharps injury prevention follows hierarchy of controls.

Pressure injury staging 1-4.

SBAR hand-off technique.

Medication error: preventable event causing inappropriate use or harm.

Phases: mitigation, preparedness, response, recovery.

Joint Commission requires all-hazards approach, HVA, annual exercise.

HVA scoring: risk = probability x impact.

HICS five functions.

Surge capacity: staff, stuff, space, systems.

COOP maintains critical functions.

Evacuation types: horizontal, vertical, full-building.

Decontamination area requirements.

CMS EP Rule requirements.

Hierarchy of controls: elimination, substitution, engineering, administrative, PPE.

Risk = severity x likelihood.

ALARP principle.

JHA process.

PELs legal; RELs recommended; TLVs consensus.

PPE last line of defense.

SDS 16 sections.

Investigation tools: 5 Whys, fishbone, fault tree.

Needlestick Safety Act.

Recall classes I, II, III.

510(k) vs. PMA.

UDI supports traceability.

MedWatch reporting.

CPSC recall authority.

Latex allergy prevention.

Sterilization assurance indicators.

Post-market surveillance.

Disaster cycle phases.

ICS span of control 3-7.

NIMS framework.

START triage categories.

Stafford Act.

AAR and improvement plan.

Community resilience planning.

Mass fatality planning.