|
Note: New Goals and Requirements are indicated in bold.
|
| Goal 1 |
Improve the accuracy of patient identification. |
| 1A |
Use at least two patient identifiers (neither to be the patient's location) whenever collecting laboratory samples or administering medications or blood products, and use two identifiers to label sample collection containers in the presence of the patient. Processes are established to maintain samples' identity throughout the pre-analytical, analytical and post-analytical processes. |
| 1B |
Immediately prior to the start of any invasive procedure, conduct a final verification process to confirm the correct patient, procedure, site, and availability of appropriate documents. This verification process uses active—not passive—communication techniques. The patient's identity is re-established if the practitioner leaves the patient's location prior to initiating the procedure. Marking the site is required unless the practitioner is in continuous attendance from the time of the decision to do the procedure and patient consent to the initiation of the procedure (for example, bone marrow collection, or fine needle aspiration). |
| 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 order or test result "read-back" the complete order or test result. |
| 2B |
Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. |
| 2C |
Measure, 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. |
| 2D |
All values defined as critical by the laboratory are reported to a responsible licensed caregiver within time frames established by the laboratory (defined in cooperation with nursing and medical staff). When the patient's responsible licensed caregiver is not available within the time frames, there is a mechanism to report the critical information to an alternative responsible caregiver. |
| 2E |
Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. |
| Goal 3 |
Not applicable. |
| Goal 4 |
Not applicable. |
| Goal 5 |
Not applicable. (Retired in 2006.) |
| Goal 6 |
Not applicable. |
| Goal 7 |
Reduce the risk of health care-associated infections. |
| 7A |
Comply with current 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 |
Not applicable. |
| Goal 9 |
Not applicable. |
| Goal 10 |
Not applicable. |
| Goal 11 |
Not applicable. |
| Goal 12 |
Not applicable. |
| Goal 13 |
Encourage the active involvement of patients and their families in the patient's 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 14 |
Not applicable. |