Following the review, nine experts were asked to evaluate the domains identified in the literature review on relevance

and potential for improvement. This resulted in a list of nine areas:

health care-associated infection (HC !"# maternal care# adverse drug events# adverse events devices# unsafe in$ections# unsafe %lood products# misdiagnosis# surgical and anesthetic error# falls.

http:&&www.who.int&patientsafet'&research&methods(measures&indicators(dph(process&en& index.html
ACUTE CARE UNITS (Medical/Surgical/Step-Down) 7 ! "ed Sa#et$ If bed rails are installed/used are they free of entrapment potential (for patients identified as high risk for entrapment): 1) rail to mattress, 2) between split rails, 3) rail to board -either end, ) board to mattress, or, !) within rail" #hen beds and/or mattresses are re-ordered for pur$hase or lease are they re%iewed for entrapment risk" &re non-$ompliant beds $learly marked as to indi$ate entrapment risk" Is the appropriate bed-type mat$hed to the le%el of $are needed for ea$h patient" &re beds with built-in weight s$ales a$$urate and fun$tioning $orre$tly" &re measures in pla$e to help pre%ent fires resulting from the use of ele$tri$ hospital beds" Code Cart% &re $ode $arts lo$ked when not in use, and is e'uipment in good $ondition $lean and $o%ered" &re e'uipment and drugs easily retrie%able on/in $ode $arts, and is there standard organi(ation in all $arts throughout the hospital" &re there post-$ode, other debriefing forms that are filled out to offer feedba$k on how $odes are preformed to allow feedba$k regarding pro$ess impro%ements" Is the )*& modified %ersion of the +,, (+mergen$y ,ardia$ ,are) &*& (&meri$an *eart &sso$iation) *andbook of ,ardio%as$ular ,are ,ogniti%e &id lo$ated on all $arts" &re ,-2 dete$tors a%ailable on $ode $arts for $onfirming esophageal intubations" Is there a standardi(ed system (e.g. $he$klist) or method used to %erify that $ode $arts are fully sto$ked and properly e'uipped before they are sent to the units and a daily inspe$tion on ea$h unit"

Electrical Sa#et$ &re ele$tri$al re$epta$les in, or ser%ing, wet areas or beha%ioral health areas pro%ided with /round 0ault ,ir$uit Interruption (/0,I) prote$tion or an isolated power system" &re ele$tri$al re$epta$les fitted with $o%ers, se$ured, and free of loose or e1posed wiring" &re emergen$y power re$epta$les appropriately identified and only used for e'uipment needing to be on emergen$y power $ir$uits" &re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the fa$ility 2re%entati%e 3aintenan$e (23) pro$ess" &re there at least re$epta$les (4 in $riti$al $are) for ea$h patient bed"

If used, are power $ords and ele$tri$al e1tension $ords pla$ed where they are free from me$hani$al damage, properly si(ed (gauge) to pre%ent o%erheating, and arranged so that they do not present a tripping ha(ard" En&iron'ental and (ou%e)eeping Sa#et$ &re hot water temperatures taken manually using a thermometer before patient use or immersion (in$luding partial immersion) takes pla$e" &re supply and return air registers $lean and free of lint and dust" 5oes general housekeeping appear to be a priority" &re storage rooms neat, organi(ed, well light and temperature $ontrolled" Is all storage 167 below fire sprinklers and off the floor" &re egress $orridors and stairways unobstru$ted and kept free of storage" &re patient or resident areas free of unlabeled or unattended $ontainers, su$h as $leaning produ$ts or medi$ation" &re ha(ards $learly identified and properly $ontrolled during $onstru$tion and reno%ation" &re high ha(ard areas su$h as: 8oofs, ser%i$e areas, medi$ation rooms, labs, radiation areas, $onfined spa$es, high %oltage areas, laser areas, low use areas (su$h as sub-floors and interstitial spa$es), et$. labeled with appropriate signage and lo$ked to pre%ent unauthori(ed entran$e" &re steps taken to eliminate/$ontrol 7pests7 in the hospital en%ironment" E*uip'ent Sa#et$ Is medi$al e'uipment being inspe$ted in a$$ordan$e with the 2re%entati%e 3aintenan$e 2rogram" Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of failure and or emergen$y" Is the e'uipment used on ea$h patient positioned in a way that it is e%ident the e'uipment is in use for that patient" &re alarms audible by $are staff, uni'ue in tone and pit$h to pre%ent masking9, and are limits appropriately set to redu$e unwanted or false alarms"

&re work arounds a%oided in the use of medi$al de%i$es with alarms" Is the e'uipment designed su$h that its operation is intuiti%e to the user and does not re'uire use of ad:un$t de%i$es to $omplete the re'uired tasks" Is patient $are and monitoring e'uipment positioned so that $aregi%ers $an easily rea$h and/or read displays and $ontrols" &re li'uids kept away from medi$al e'uipment" &re disposable medi$al de%i$es/supplies stored in a way that the integrity of the de%i$es is kept inta$t (i.e. not bent or folded)" Is a reliable system used to identify whi$h tubes and $onne$tors go to whi$h de%i$es" &re the tubes/$onne$tors kept out of the way to a%oid them from being inad%ertently unplugged" &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es" ,an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients when they assess for fall risk" &s part of the orientation, are the patient and family instru$ted to get help from $lini$al staff if there is a real or per$ei%ed need to $onne$t or dis$onne$t any de%i$es or tubings" &re lo$ations of &+5s and defibrillators standardi(ed throughout the patient $are areas of the fa$ility" *as the fa$ility eliminated sterile water (in forms easily $onfused with medi$ations) from ward sto$k" E%cape and Elope'ent +re&ention Is the use of $ell phones or other de%i$es that $an affe$t monitoring and other medi$al e'uipment $ontrolled in appli$able areas as spe$ified in lo$al poli$y" Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff" If ele$troni$ systems su$h as wander guards are used, are methods in pla$e to ensure they fun$tion $orre$tly" If wander guard systems are in pla$e, are they in$luded in the pre%entati%e maintenan$e inspe$tion program" &re annual drills of the full missing patient pro$ess (grid sear$h) $ondu$ted at least annually if the plan wasn;t e1er$ised during a real e%ent" Is a risk assessment for elopement $ompleted at the time of admission or transfer and regularly during the patients stay" &re staff familiar with the fa$iliities elopement risk assessment pro$ess" Is a pro$esses in pla$e and used to keep tra$k of high risk patients when they are off of the unit" Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff" ,all +re&ention

&re all patient/resident rooms, pro$edure rooms and $ommon areas pro%ided with ade'uate lighting so that the patients ability to ambulate safely is not impeded" &re me$hani$al assist de%i$es used to lift or transfer patients a$$essible and used by staff when needed" &re pre%entati%e measures implemented to pre%ent falls from manual lifting and/or handling patients" &re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental slipping and tripping ha(ards" &re shower/bathroom areas pro%ided with ade'uate lighting, proper drainage, non-slip floor surfa$es, and installed handrails" &re $all buttons within rea$h of the patient" &re bed and $hair alarms used and audible, and, are they $onfigured to redu$e the number of false/unwanted alarms" 5oes the fa$ility ha%e a 0all 2re%ention < 3anagement 2roto$ol or e'ui%alent" Is a uniform tool used to assess whi$h patients are at high risk for falls, and is there $riteria to determine: 1) #hen they are assessed, and 2) #hat triggers a reassessment, in$luding appli$able timeframes" Is there at least one patient lift, -8 table, radiololgy table, et$. a%ailable that has suffi$ient lifting/holding $apa$ity to meet the needs of bariatri$ patients" Is the load $arrying $apa$ity of the e'uipment ob%ious to $are pro%iders" ,ire Sa#et$ &re staff members familiar with fire emergen$y pro$edures, and the fire pre%ention plan for their ser%i$e area" ,an $lini$al staff identify smoke and fire walls in their immediate area" Is the fire alarm signal easily distinguishable from other alarms (e.g., e'uipment, nurse $all, et$.)" ,an staff des$ribe the pro$ess on how they are notified when the fire alarm system is out of ser%i$e in their area or being tested" &re flame retardant pa:amas or aprons pro%ided for patients who smoke and are identified as a 7smoking risk7" If flame retardant pa:amas or linens are used, is a pro$ess in pla$e to ensure integrity of the flame retardant agent is maintained on these arti$les after repeated laundering" In#ection Control &re all linen $arts ($lean and soiled) kept $o%ered and the bottom of the $art is a solid surfa$e (without openings)" &re sharps $ontainers a$$essible and not o%er filled" Is the fa$ilities late1 free poli$y being followed in$luding pro%iding late1 free supplies and de%i$es"

&re the )& re$ommended hand hygiene guidelines followed" Is the integrity of negati%e/positi%e pressure isolation rooms tested and maintained (on$e per day for o$$upied, monthly for non-o$$upied)" Is there a pro$ess in pla$e to establilsh temporary negati%e/positi%e pressure rooms if they are needed" Medical -a% Sa#et$ &re piped in o1ygen and $ompressed air identified by a prominent label and not merely by $olor adapters" &re air flow meters remo%ed when not in use (for nebuli(ed medi$ation treatments)" 5o staff know where the emergen$y o1ygen shut-off is, and when and how to use it" 5oes the storage and use of portable medi$al gas $ontainers appear to be in $omplian$e with ,/& (,ompressed /as &sso$iation) =tandards" 5o area/unit personnel know how to $orre$tly handle o1ygen $ylinders" &re pins on medi$al gas regulators inta$t, and is damaged e'uipment immediately remo%ed from ser%i$e" &re o1ygen $ylinders with ball-type regulators used with the $ylinder in the %erti$al position" Medication Sa#et$ &re all medi$ation refrigerators maintained appropriately" 5o medi$ation $arts remained lo$ked and ina$$essible to patients when not in use" &re the tops of medi$ation $arts, $lean, free of stray drugs, sharps and food" &re re$epta$les for medi$ation storage lo$ked and are $ontrolled substan$es double lo$ked" Is area sto$k limited to emergen$y medi$ation and I) solutions whi$h are appropriate to patient $are in the unit" &re bags $ontaining sterile water for in:e$tion prohibited from being ordered or sto$ked on patient $are areas without spe$ial permission and pre$aution" &re only standard $on$entrations of high alert medi$ations kept in the area/unit to minimi(e the potential of $al$ulation and $ompounding errors" Is a unit dose medi$ation system used in$luding li'uids" Is drug preparation done primarily in the pharma$y and not on $are units" Is medi$ation mi1ing (admi1tures) on inpatient $are units a dis$ouraged pra$ti$e" &re pro$edures in pla$e to pre%ent sterile produ$t use from patient to patient (in$luding medi$ations)" &re I) o%er-wrap bags utili(ed and properly labeled with manufa$turers instru$tions"

&re I) bags free of markings, su$h as e1piration dates, applied by staff with ink pens or felt markers (prior to use)" Is an independent double $he$k $ompleted for all infusion pump settings for high alert medi$ations and look alike/sound alike drugs" &re appropriate re%ersal agents (fluma(enil, nalo1one, protamine, et$.) a%ailable based on the drug being administered and $lini$al setting" 5oes the fa$ility tra$k use of re%ersal agents" Is there a pro$ess for monitoring >,3&" Is >,3& used to administer medi$ation without using work arounds" #hat is the proto$ol for handling medi$ation preparations that are in$orre$tly bar $oded or labeled, or ha%e labels that do not s$an" Is there a helpdesk for >,3& a%ailable during all shifts" 5o the )I=?& modules effe$ti%ely alert to potential food/drug/herbal intera$tions and dupli$ate drug therapies" &re users prohibited from turning them off (the alerts)" Is $urrent drug referen$e information made readily a$$essible to $aregi%ers, if so how" Medication Sa#et$ &re up-to-date fa$ility spe$ifi$ proto$ols, guidelines, dosing s$ales, and/or $he$klists readily a%ailable for staff"

@.3.11.24

)andat or' *.+.,,.-*

&re spe$ifi$ pre$autio ns followed when handling look/soun d alike drugs"

Medication Sa#et$

8e$ommended

@.3.11.26

Medication Sa#et$ Is a prohibited abbre%iations in effe$t"

3andatory

@.3.11.2A

Medication Sa#et$ If &utomated 5ispensing 3a$hines (&53s) are used, is staff aware of a written poli$y, and $an they e1plain how the ma$hine works"

8e$ommended

@.3.11.32

Medication Sa#et$ If &53s are used, are there $apabilities to run o%erride reports that tra$k dis$repan$y and utili(ation at least monthly"
8e$ommended

@.3.11.3

Medication Sa#et$ &re patients edu$ated regarding their pres$ribed medi$ation, as inpatients and as part of the dis$harge pro$ess"

3andatory

@.3.11.3!

Medication Sa#et$ 5oes the $are pro%ided by 2harma$ists meet the $lini$al needs of the patients in s$ope and fre'uen$y"

3andatory

@.3.11. 2

Medication Sa#et$ Is a pro$ess in pla$e to re$on$ile patient medi$ations upon admission, transfer or dis$harge and is a $urrent list of medi$ations gi%en to the patient when dis$harge from a )&3,, and if medi$ations are $hanged e1iting a $lini$"
3andatory

@.3.12.1

-eneral +atient Sa#et$ Concern% Is read-ba$k used for all %erbal order and $riti$al %alue reports"

3andatory

-eneral +atient Sa#et$ Concern%

@.3.12.2

&re B,2= or lo$ally de%eloped $ogniti%e aids a%ailable on the floor for staff to referen$e (+s$ape and +lopementC 0all 2re%ention, et$.)"
8e$ommended

@.3.12.3

-eneral +atient Sa#et$ Concern% &re patient/resident re$ords kept $onfidential, in$luding $omputer information"
3andatory

@.3.12.

-eneral +atient Sa#et$ Concern% &re staff wearing identifi$ation badges and are unauthori(ed persons kept out of patient $are areas"

3andatory

@.3.12.!

-eneral +atient Sa#et$ Concern% &re restraints used in a$$ordan$e with lo$al poli$y and are restraint alternati%e de%i$es a%ailable and used when appropriate"

3andatory

@.3.12.4

-eneral +atient Sa#et$ Concern% &re there pra$ti$es in pla$e to de$rease the likelihood of patient misidentifi$ation"

3andatory

@.3.12.4.1

-eneral +atient Sa#et$ Concern% Dpon $olle$tion of blood or blood produ$ts is a informed $onsent obtained"

3andatory

@.3.12.4.2

-eneral +atient Sa#et$ Concern% Is the labeling of blood samples or spe$imens done at the bedside, rather than in bulk (at the nurses station) to pre%ent mislabeling"

3andatory

@.3.12.4.3

-eneral +atient Sa#et$ Concern% Is there an e1isting proto$ol for patient identifi$ation with non-$ommuni$ati%e patients"

3andatory

@.3.12.@

-eneral +atient Sa#et$ Concern% &re there monitoring pro$esses in pla$e for portable food and be%erage warming or heating de%i$es"

8e$ommended

@.3.12.6

-eneral +atient Sa#et$ Concern% &re handoffs between shifts or transfer of $are between units standardi(ed"

3andatory

-eneral +atient Sa#et$ Concern%

@.3.12.A

Is the transfer of $are between dis$iplines for off-unit appointments standardi(ed, in$luding the $ontinuation of monitoring patient status and patient medi$al de%i$es su$h as I) pumps and o1ygen le%el while the patient is %isiting, being treated/tested, and during transport"

8e$ommended

@.3.12.1E

-eneral +atient Sa#et$ Concern% &re patients sear$hed and residents 'uestioned for $ontraband upon admission to ea$h appli$able area/unit"

8e$ommended

@.3.12.11

-eneral +atient Sa#et$ Concern% 5oes the fa$ility ha%e an emergen$y response proto$ol for dealing with disrupti%e patients"

8e$ommended

@.3.12.11. 1

-eneral +atient Sa#et$ Concern% Is there an assessment used to determine if a patient is potentially %iolent"
3andatoryC 2riority &

@.3.12.12

-eneral +atient Sa#et$ Concern% #hen performing pro$edures outside of the operating room are appropriate sedation proto$ols and pri%ileges followed when appli$able"

3andatory

.ue%tion/ "ed Sa#et$

@. .1.1

If bed rails are installed/used are they free of entrapment potential (for patients identified as high risk for entrapment): 1) rail to mattress, 2) between split rails, 3) rail to board -either end, ) board to mattress, or, !) within rail"

3andatory

@. .1.2

"ed Sa#et$ #hen beds and/or mattresses are re-ordered for pur$hase or lease are they re%iewed for entrapment risk"

8e$ommended

@. .1.3

"ed Sa#et$ &re non-$ompliant beds $learly marked as to indi$ate entrapment risk"

3andatory

@. .1.!

"ed Sa#et$ Is the appropriate bed-type mat$hed to the le%el of $are needed for ea$h patient"

8e$ommended

@. .1.4

"ed Sa#et$ &re beds with built-in weight s$ales a$$urate and fun$tioning $orre$tly"

8e$ommended

"ed Sa#et$

@. .1.@

&re measures in pla$e to help pre%ent fires resulting from the use of ele$tri$ hospital beds"

8e$ommended

@. .2.1

Code Cart% &re $ode $arts lo$ked when not in use, and is e'uipment in good $ondition $lean and $o%ered"
3andatory

@. .2.3

Code Cart% &re e'uipment and drugs easily retrie%able on/in $ode $arts, and is there standard organi(ation in all $arts throughout the hospital"

8e$ommended

@. .2.3.1

Code Cart% &re there post-$ode, other debriefing forms that are filled out to offer feedba$k on how $odes are preformed to allow feedba$k regarding pro$ess impro%ements"

8e$ommended

@. .2.

Code Cart% Is the )*& modified %ersion of the +,, (+mergen$y ,ardia$ ,are) &*& (&meri$an *eart &sso$iation) *andbook of ,ardio%as$ular ,are ,ogniti%e &id lo$ated on all $arts"

8e$ommended

@. .2.!

Code Cart% &re ,-2 dete$tors a%ailable on $ode $arts for $onfirming esophageal intubations"

3andatory

@. .2.4

Code Cart% Is there a standardi(ed system (e.g. $he$klist) or method used to %erify that $ode $arts are fully sto$ked and properly e'uipped before they are sent to the units and a daily inspe$tion on ea$h unit"

8e$ommended

@. .3.1

Electrical Sa#et$ &re ele$tri$al re$epta$les in, or ser%ing, wet areas or beha%ioral health areas pro%ided with /round 0ault ,ir$uit Interruption (/0,I) prote$tion or an isolated power system"

3andatory

@. .3.2

Electrical Sa#et$ &re ele$tri$al re$epta$les fitted with $o%ers, se$ured, and free of loose or e1posed wiring"

3andatory

@. .3.3

Electrical Sa#et$ &re emergen$y power re$epta$les appropriately identified and only used for e'uipment needing to be on emergen$y power $ir$uits"

3andatory

@. .3.

Electrical Sa#et$ &re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the fa$ility 2re%entati%e 3aintenan$e (23) pro$ess"

3andatory

Electrical Sa#et$

@. .3.!

&re there at least

re$epta$les (4 in $riti$al $are) for ea$h patient bed"

3andatory

@. .3.4

Electrical Sa#et$ If used, are power $ords and ele$tri$al e1tension $ords pla$ed where they are free from me$hani$al damage, properly si(ed (gauge) to pre%ent o%erheating, and arranged so that they do not present a tripping ha(ard"

8e$ommended

@. . .1

En&iron'ental and (ou%e)eeping Sa#et$ &re hot water temperatures taken manually using a thermometer before patient use or immersion (in$luding partial immersion) takes pla$e"

3andatory

@. . .2

En&iron'ental and (ou%e)eeping Sa#et$ &re supply and return air registers $lean and free of lint and dust"
3andatory

@. . .3

En&iron'ental and (ou%e)eeping Sa#et$ 5oes general housekeeping appear to be a priority"

3andatory

@. . .

En&iron'ental and (ou%e)eeping Sa#et$ &re storage rooms neat, organi(ed, well light and temperature $ontrolled" Is all storage 167 below fire sprinklers and off the floor"

3andatory

@. . .!

En&iron'ental and (ou%e)eeping Sa#et$ &re egress $orridors and stairways unobstru$ted and kept free of storage"

3andatory

En&iron'ental and (ou%e)eeping Sa#et$

@. . .4

&re patient or resident areas free of unlabeled or unattended $ontainers, su$h as $leaning produ$ts or medi$ation"

3andatory

@. . .@

En&iron'ental and (ou%e)eeping Sa#et$ &re ha(ards $learly identified and properly $ontrolled during $onstru$tion and reno%ation"

3andatory

@. . .1E

En&iron'ental and (ou%e)eeping Sa#et$ &re steps taken to eliminate/$ontrol 7pests7 in the hospital en%ironment"

3andatory

@. .!.1

E*uip'ent Sa#et$ Is medi$al e'uipment being inspe$ted in a$$ordan$e with the 2re%entati%e 3aintenan$e 2rogram"

3andatory

@. .!.2

E*uip'ent Sa#et$ Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of failure and or emergen$y"
8e$ommended

@. .!.3

E*uip'ent Sa#et$ Is the e'uipment used on ea$h patient positioned in a way that it is e%ident the e'uipment is in use for that patient"

8e$ommended

E*uip'ent Sa#et$

@. .!.

&re alarms audible by $are staff, uni'ue in tone and pit$h to pre%ent masking9, and are limits appropriately set to redu$e unwanted or false alarms"

93asking o$$urs when the fre'uen$y and intensity of two independent separate alarms blend together. 7

3andatory

@. .!.!

E*uip'ent Sa#et$ &re work arounds a%oided in the use of medi$al de%i$es with alarms"

8e$ommended

@. .!.4

E*uip'ent Sa#et$ Is the e'uipment designed su$h that its operation is intuiti%e to the user and does not re'uire use of ad:un$t de%i$es to $omplete the re'uired tasks"

8e$ommended

@. .!.@

E*uip'ent Sa#et$ Is patient $are and monitoring e'uipment positioned so that $aregi%ers $an easily rea$h and/or read displays and $ontrols"

8e$ommended

@. .!.6

E*uip'ent Sa#et$ &re li'uids kept away from medi$al e'uipment"

8e$ommended

@. .!.A

E*uip'ent Sa#et$ &re disposable medi$al de%i$es/supplies stored in a way that the integrity of the de%i$es is kept inta$t (i.e. not bent or folded)"

8e$ommended

@. .!.1E

E*uip'ent Sa#et$ Is a reliable system used to identify whi$h tubes and $onne$tors go to whi$h de%i$es"

8e$ommended

@. .!.1E.1

E*uip'ent Sa#et$ &re the tubes/$onne$tors kept out of the way to a%oid them from being inad%ertently unplugged"

8e$ommended

E*uip'ent Sa#et$

@. .!.1E.2

&re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es"

8e$ommended

@. .!.1E.2 ($ontinued )

E*uip'ent Sa#et$ ($ontinued)... &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es"

8e$ommended

@. .!.1E.

E*uip'ent Sa#et$ ,an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients when they assess for fall risk"

8e$ommended

E*uip'ent Sa#et$

@. .!.1E.!

&s part of the orientation, are the patient and family instru$ted to get help from $lini$al staff if there is a real or per$ei%ed need to $onne$t or dis$onne$t any de%i$es or tubings"

3andatory

@. .!.11

E*uip'ent Sa#et$ &re lo$ations of &+5s and defibrillators standardi(ed throughout the patient $are areas of the fa$ility"

8e$ommended

@. .!.12

E*uip'ent Sa#et$ &re $lo$ks syn$hroni(ed and a$$urate"

8e$ommended

@. .!.13

E*uip'ent Sa#et$ *as the fa$ility eliminated sterile water (in forms easily $onfused with medi$ations) from ward sto$k"

8e$ommended

@. .!.1

E*uip'ent Sa#et$ Is the use of $ell phones or other de%i$es that $an affe$t monitoring and other medi$al e'uipment $ontrolled in appli$able areas as spe$ified in lo$al poli$y"

8e$ommended

E%cape and Elope'ent +re&ention

@. .4.!

Is a risk assessment for elopement $ompleted at the time of admission or transfer and regularly during the patients stay"

3andatory

@. .4.@

E%cape and Elope'ent +re&ention Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff"
8e$ommended

@. .@.1

,all +re&ention &re all patient/resident rooms, pro$edure rooms and $ommon areas pro%ided with ade'uate lighting so that the patients ability to ambulate safely is not impeded"

3andatory

@. .@.2

,all +re&ention &re me$hani$al assist de%i$es used to lift or transfer patients a$$essible and used by staff when needed"

8e$ommended

@. .@.2.1

,all +re&ention &re pre%entati%e measures implemented to pre%ent falls from manual lifting and/or handling patients"

8e$ommended

@. .@.3

,all +re&ention &re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental slipping and tripping ha(ards"

3andatory

,all +re&ention

@. .@.

&re shower/bathroom areas pro%ided with ade'uate lighting, proper drainage, non-slip floor surfa$es, and installed handrails"

3andatory

@. .@.!

,all +re&ention &re $all buttons within rea$h of the patient"

8e$ommended

@. .@.4

,all +re&ention &re bed and $hair alarms used and audible, and, are they $onfigured to redu$e the number of false/unwanted alarms"

3andatory

@. .@.@

,all +re&ention 5oes the fa$ility ha%e a 0all 2re%ention < 3anagement 2roto$ol or e'ui%alent"

3andatory

@. .@.6

,all +re&ention Is a uniform tool used to assess whi$h patients are at high risk for falls, and is there $riteria to determine: 1) #hen they are assessed, and 2) #hat triggers a reassessment, in$luding appli$able timeframes"

3andatory

@. .@.A

,all +re&ention Is there at least one patient lift, -8 table, radiololgy table, et$. a%ailable that has suffi$ient lifting/holding $apa$ity to meet the needs of bariatri$ patients"

8e$ommended

,all +re&ention

@. .@.A.1

Is the load $arrying $apa$ity of the e'uipment ob%ious to $are pro%iders"

8e$ommended

@. .6.1

,ire Sa#et$ &re staff members familiar with fire emergen$y pro$edures, and the fire pre%ention plan for their ser%i$e area"

3andatory

@. .6.2

,ire Sa#et$ ,an $lini$al staff identify smoke and fire walls in their immediate area"

3andatory

@. .6.3

,ire Sa#et$ Is the fire alarm signal easily distinguishable from other alarms (e.g., e'uipment, nurse $all, et$.)"

3andatory

@. .6.

,ire Sa#et$ ,an staff des$ribe the pro$ess on how they are notified when the fire alarm system is out of ser%i$e in their area or being tested"

3andatory

@. .A.1

In#ection Control &re all linen $arts ($lean and soiled) kept $o%ered and the bottom of the $art is a solid surfa$e (without openings)"

3andatory

@. .A.2

In#ection Control &re sharps $ontainers a$$essible and not o%er filled"

3andatory

In#ection Control

@. .A.3

Is the fa$ilities late1 free poli$y being followed in$luding pro%iding late1 free supplies and de%i$es"

3andatory

@. .A.

In#ection Control &re the )& re$ommended hand hygiene guidelines followed"

3andatory In#ection Control@. .A.!Is the integrity of negati%e/positi%e pressure isolation rooms tested and maintained (on$e per day for o$$upied, monthly for nono$$upied)" 3andatory In#ection Control@. .A.!.1Is there a pro$ess in pla$e to establilsh temporary negati%e/positi%e pressure rooms if they are needed" 8e$ommended Medical -a% Sa#et$@. .1E.1&re piped in o1ygen and $ompressed air identified by a prominent label and not merely by $olor adapters" 8e$ommended Medical -a% Sa#et$@. .1E.2&re air flow meters remo%ed when not in use (for nebuli(ed medi$ation treatments)" 8e$ommended Medical -a% Sa#et$@. .1E.35o staff know where the emergen$y o1ygen shut-off is, and when and how to use it" 3andatory )edical .as

/afet'*.0.,1.02oes the storage and use of porta%le medical gas containers appear to %e in compliance with C. (Compressed .as ssociation" /tandards3 )andator' )edical .as /afet'*.0.,1.0.,2o area&unit personnel know how to correctl' handle ox'gen c'linders3 )andator' )edical .as /afet'*.0.,1.4 re pins on medical gas regulators intact, and is damaged e5uipment immediatel' removed from service3 )andator' )edical .as /afet'*.0.,1.6 re ox'gen c'linders with %all-t'pe regulators used with the c'linder in the vertical position3 )andator' )edication /afet'*.0.,,., re all medication refrigerators maintained appropriatel'3 )andator' )edication /afet'*.0.,,.-2o medication carts remained locked and inaccessi%le to patients when not in use3 )andator' )edication /afet'*.0.,,.+ re the tops of medication carts, clean, free of stra' drugs, sharps and food3 )andator' )edication /afet'*.0.,,.0 re receptacles for medication storage locked and are controlled su%stances dou%le locked3 )andator' )edication /afet'*.0.,,.6!s area stock limited to emergenc' medication and !7 solutions which are appropriate to patient care in the unit3 8ecommended )edication /afet'*.0.,,.6.,!f needle-less s'tems are used are emergenc' medication deliver' s'stems for drugs in code carts and emergenc' drug %oxes compati%le are adaptors provided and

availa%le3 8ecommended )edication /afet'*.0.,,.6.-!f codes are not called within a specified duration, does the organi9ation use an alternate method (e.g. mock codes" to maintain staff competenc' with emergenc' medication3 8ecommended )edication /afet'*.0.,,.* re %ags containing sterile water for in$ection prohi%ited from %eing ordered or stocked on patient care areas without special permission and precaution3 8ecommended )edication /afet'*.0.,,.:Have concentrated electrol'te solutions %een removed from patient floors&care areas3 )andator' )edication /afet'*.0.,,.;., re onl' standard concentrations of high alert medications kept in the area&unit to minimi9e the potential of calculation and compounding errors3 )andator' )edication /afet'*.0.,,.,1!s a unit dose medication s'stem used including li5uids3 8ecommended )edication /afet'*.0.,,.,1., re single-dose perenteral containers (with preference to pre-filed s'ringes" used when possi%le3 )andator' )edication /afet'*.0.,,.,+!s drug preparation done primaril' in the pharmac' and not on care units3 )andator' )edication /afet'*.0.,,.,+.,!s medication mixing (admixtures" on inpatient care units a discouraged practice3 8ecommended )edication /afet'*.0.,,.,0 re procedures in place to prevent sterile product use from patient to patient (including medications"3 8ecommended )edication /afet'*.0.,,.,4 re !7 over-wrap %ags utili9ed and properl' la%eled with manufacturers instructions3 8ecommended )edication /afet'*.0.,,.,6 re !7 %ags free of markings, such as expiration dates, applied %' staff with ink pens or felt markers (prior to use"3 8ecommended )edication /afet'*.0.,,.,*!s an independent dou%le check completed for all infusion pump settings for high alert medications and look alike&sound alike drugs3 8ecommended )edication /afet'*.0.,,.,; re appropriate reversal agents (fluma9enil, naloxone, protamine, etc." availa%le %ased on the drug %eing administered and clinical setting3 )andator' )edication /afet'*.0.,,.,;.,2oes the facilit' track use of reversal agents3 8ecommended )edication /afet'*.0.,,.-,!s there a process for monitoring <C) 3 8ecommended )edication /afet'*.0.,,.-,.,!s <C) used to administer medication without using work arounds3 8ecommended )edication /afet'*.0.,,.-,.-=hat is the protocol for handling medication preparations that are incorrectl' %ar coded or la%eled, or have la%els that do not scan3 8ecommended )edication /afet'*.0.,,.-,.+!s there a helpdesk for <C) availa%le during all shifts3 8ecommended )edication /afet'*.0.,,.--.,2o the 7!/T modules effectivel' alert to potential food&drug&her%al interactions and duplicate drug therapies3 re users prohi%ited from turning them off (the alerts"3 8ecommended )edication /afet'*.0.,,.-4!s current drug reference information made readil' accessi%le to caregivers, if so how3 8ecommended )edication /afet'*.0.,,.-6 re up-to-date facilit' specific protocols, guidelines, dosing scales, and&or checklists readil' availa%le for staff3 )andator' )edication /afet'*.0.,,.-* re specific precautions followed when handling look&sound alike drugs3 8ecommended )edication /afet'*.0.,,.-:!s a prohi%ited a%%reviations in effect3 )andator' )edication /afet'*.0.,,.-;!f utomated 2ispensing )achines ( 2)s" are used, is staff aware of a written polic', and can the' explain how the machine works3 8ecommended )edication /afet'*.0.,,.+-!f 2)s are used, are there capa%ilities to run override reports that track discrepanc' and utili9ation at least monthl'3 8ecommended )edication /afet'*.0.,,.+0 re patients educated regarding

their prescri%ed medication, as inpatients and as part of the discharge process3 )andator' )edication /afet'*.0.,,.+42oes the care provided %' >harmacists meet the clinical needs of the patients in scope and fre5uenc'3 )andator' )edication /afet'*.0.,,.+;.,!s there a process to verif' contents of a s'ringe or container %efore drug administration to patient during a procedure or code3 8ecommended )edication /afet'*.0.,,.0-!s a process in place to reconcile patient medications upon admission, transfer or discharge and is a current list of medications given to the patient when discharge from a 7 )C, and if medications are changed exiting a clinic3 )andator' .eneral >atient /afet' Concerns*.0.,-.,!s read-%ack used for all ver%al order and critical value reports3 )andator' .eneral >atient /afet' Concerns*.0.,-.- re ?C>/ or locall' developed cognitive aids availa%le on the floor for staff to reference (@scape and @lopement# Fall >revention, etc."3 8ecommended .eneral >atient /afet' Concerns*.0.,-.+ re patient&resident records kept confidential, including computer information3 )andator' .eneral >atient /afet' Concerns*.0.,-.0 re staff wearing identification %adges and are unauthori9ed persons kept out of patient care areas3 )andator' .eneral >atient /afet' Concerns*.0.,-.4 re restraints used in accordance with local polic' and are restraint alternative devices availa%le and used when appropriate3 )andator' .eneral >atient /afet' Concerns*.0.,-.6 re there practices in place to decrease the likelihood of patient misidentification3 )andator' .eneral >atient /afet' Concerns*.0.,-.6.,Apon collection of %lood or %lood products is a informed consent o%tained3 )andator' .eneral >atient /afet' Concerns*.0.,-.6.-!s the la%eling of %lood samples or specimens done at the %edside, rather than in %ulk (at the nurses station" to prevent misla%eling3 )andator' .eneral >atient /afet' Concerns*.0.,-.6.+!s there an existing protocol for patient identification with noncommunicative patients3 )andator' .eneral >atient /afet' Concerns*.0.,-.* re there monitoring processes in place for porta%le food and %everage warming or heating devices3 8ecommended .eneral >atient /afet' Concerns*.0.,-.: re handoffs %etween shifts or transfer of care %etween units standardi9ed3 )andator' .eneral >atient /afet' Concerns*.0.,-.;!s the transfer of care %etween disciplines for off-unit appointments standardi9ed, including the continuation of monitoring patient status and patient medical devices such as !7 pumps and ox'gen level while the patient is visiting, %eing treated&tested, and during transport3 8ecommended .eneral >atient /afet' Concerns*.0.,-.,1 re patients searched and residents 5uestioned for contra%and upon admission to each applica%le area&unit3 8ecommended .eneral >atient /afet' Concerns*.0.,-.,,2oes the facilit' have an emergenc' response protocol for dealing with disruptive patients3 8ecommended .eneral >atient /afet' Concerns*.0.,-.,-=hen performing procedures outside of the operating room are appropriate sedation protocols and privileges followed when applica%le3 )andator' /urgical or !nvasive >rocedure >recautions*.0.,0.-Has the 7H B8 /elf ssessment C,: /elf- ssessment Tool for B%serving /teps 8e5uired %' 7H 2irectives -110-1-: (@nsuring Correct /urger' and !nvasive >rocedures" and -116-1+1 (>revention of 8etained /urgical !tems, %eing used3 )andator'