|
Goal 1 |
Improve
the accuracy of patient
identification. |
|
1A |
Use at
least two patient identifiers when
providing care, treatment or
services. |
|
Goal 2
|
Improve
the effectiveness of communication
among caregivers. |
|
2A |
For
verbal or telephone orders or for
telephonic reporting of critical
test results, verify the complete
order or test result by having the
person receiving the information
record and "read-back" the complete
order or test result. |
|
2B |
Standardize a list of abbreviations,
acronyms, symbols, and dose
designations that are not to be used
throughout the organization. |
|
2C |
Measure
and assess, and if appropriate, take
action to improve the timeliness of
reporting, and the timeliness of
receipt by the responsible licensed
caregiver, of critical test results
and values. |
|
2E |
Implement a standardized approach to
“hand off” communications, including
an opportunity to ask and respond to
questions. |
|
Goal 3 |
Improve
the safety of using medications. |
|
3C |
Identify
and, at a minimum, annually review a
list of look-alike/sound-alike drugs
used by the organization, and take
action to prevent errors involving
the interchange of these drugs. |
|
3D |
Label
all medications, medication
containers (for example, syringes,
medicine cups, basins), or other
solutions on and off the sterile
field. |
|
3E |
Reduce
the likelihood of patient harm
associated with the use of
anticoagulation therapy. |
|
Goal 7 |
Reduce
the risk of health care-associated
infections. |
|
7A |
Comply
with current World Health
Organization (WHO) Hand Hygiene
Guidelines or Centers for
Disease Control and Prevention (CDC)
hand hygiene guidelines. |
|
7B |
Manage
as sentinel events all identified
cases of unanticipated death or
major permanent loss of function
associated with a health
care-associated infection. |
|
Goal 8 |
Accurately and completely reconcile
medications across the continuum of
care. |
|
8A |
There is
a process for comparing the
patient’s current medications with
those ordered for the patient while
under the care of the organization. |
|
8B |
A
complete list of the patient’s
medications is communicated to the
next provider of service when a
patient is referred or transferred
to another setting, service,
practitioner or level of care within
or outside the organization. The
complete list of medications is also
provided to the patient on discharge
from the facility. |
|
Goal 9 |
Reduce
the risk of patient harm resulting
from falls. |
|
9B |
Implement a fall reduction program
including an evaluation of the
effectiveness of the program. |
|
Goal 13 |
Encourage patients’ active
involvement in their own care as a
patient safety strategy. |
|
13A |
Define
and communicate the means for
patients and their families to
report concerns about safety and
encourage them to do so. |
|
Goal 15 |
The
organization identifies safety risks
inherent in its patient population. |
|
15A |
The
organization identifies patients at
risk for suicide. [Applicable to
psychiatric hospitals and patients
being treated for emotional or
behavioral disorders in general
hospitals—NOT APPLICABLE TO CRITICAL
ACCESS HOSPITALS)] |
|
Goal
16 |
Improve recognition and response to
changes in a patient’s condition. |
|
16A |
The
organization selects a suitable
method that enables health care
staff members to directly request
additional assistance from a
specially trained individual(s) when
the patient’s condition appears to
be worsening. [Critical Access
Hospital, Hospital] |