| 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)] |