| Goal 1 |
Improve the accuracy of resident identification. |
| 1A |
Use at least two resident identifiers (neither to be the resident’s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. |
| 1B |
Prior to the start of any invasive procedure, conduct a final verification process, such as a “time out,” to confirm the correct resident, procedure and site, using active—not passive—communication techniques. |
| 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. |
| Goal 3 |
Improve the safety of using medications. |
| 3A |
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from resident care units. |
| 3B |
Standardize and limit the number of drug concentrations available in the organization. |
| 3C |
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. |
| Goal 5 |
Improve the safety of using infusion pumps. |
| 5A |
Ensure free-flow protection on all general-use and PCA (resident controlled analgesia) intravenous infusion pumps used in the organization. |
| 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 |
Accurately and completely reconcile medications across the continuum of care. |
| 8a |
During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the resident’s current medications upon the resident’s admission to the organization and with the involvement of the resident. This process includes a comparison of the medications the organization provides to those on the list. |
| 8b |
A complete list of the resident’s medications is communicated to the next provider of service when it refers or transfers a resident to another setting, service, practitioner or level of care within or outside the organization. |
| Goal 9 |
Reduce the risk of resident harm resulting from falls. |
| 9A |
Assess and periodically reassess each resident's risk for falling, including the potential risk associated with the resident's medication regimen, and take action to address any identified risks. |
| 9B |
Implement a fall reduction program, including a transfer protocol, and evaluate the effectiveness of the program. |
| Goal 10 |
Reduce the risk of influenza and pneumococcal disease in institutionalized older adults. |
| 10A |
Develop and implement a protocol for administration and documentation of the flu vaccine. |
| 10B |
Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. |
| 10C |
Develop and implement a protocol to identify new cases of influenza and to manage an outbreak. |