| 1 |
Improve the accuracy of patient identification. |
| a |
Use at least two patient identifiers whenever taking blood samples or administering medications or blood products. [Scored at Standard PC.5.10, EP #4] |
| b |
Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active—not passive—communication techniques. [Scored at Standard PC.13.20, EP #9] |
| 2 |
Improve the effectiveness of communication among caregivers. |
| a |
Implement a process for taking verbal or telephone orders or critical test results that require a verification “read-back” of the complete order or test result by the person receiving the order or test result. [Scored at Standard IM.6.50, EP #4] |
| b |
Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use. [Scored at Standard IM.3.10, EP #2] |
| 3 |
Improve the safety of using high-alert medications. |
| a |
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care areas. [Scored at Standard MM.2.20, EP #9] |
| b |
Standardize and limit the number of drug concentrations used by the organization. [Scored at Standard MM.2.20, EP #8] |
| 4 |
Not applicable. |
| 5 |
Improve the safety of using infusion pumps. |
| a |
Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used by the organization. |
| 6 |
Improve the effectiveness of clinical alarm systems. |
| a |
Implement regular preventive maintenance and testing of alarm systems in accordance with manufacturer’s guidelines. |
| b |
Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the patient care area. |
| 7 |
Reduce the risk of health care-acquired infections |
| a |
Comply with current U.S. Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. |
| b |
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health-care acquired infection. |