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Following the review, nine experts were asked to evaluate the domains identified in the literature review on relevance

and potential for improvement. This resulted in a list of nine areas:
• • • • • • • • •

health care-associated infection (HC !"# maternal care# adverse drug events# adverse events devices# unsafe in$ections# unsafe %lood products# misdiagnosis# surgical and anesthetic error# falls.

http:&&www.who.int&patientsafet'&research&methods(measures&indicators(dph(process&en& index.html
ACUTE CARE UNITS (Medical/Surgical/Step-Down) 7 ! "ed Sa#et$ If bed rails are installed/used are they free of entrapment potential (for patients identified as high risk for entrapment): 1) rail to mattress, 2) between split rails, 3) rail to board -either end, ) board to mattress, or, !) within rail" #hen beds and/or mattresses are re-ordered for pur$hase or lease are they re%iewed for entrapment risk" &re non-$ompliant beds $learly marked as to indi$ate entrapment risk" Is the appropriate bed-type mat$hed to the le%el of $are needed for ea$h patient" &re beds with built-in weight s$ales a$$urate and fun$tioning $orre$tly" &re measures in pla$e to help pre%ent fires resulting from the use of ele$tri$ hospital beds" Code Cart% &re $ode $arts lo$ked when not in use, and is e'uipment in good $ondition $lean and $o%ered" &re e'uipment and drugs easily retrie%able on/in $ode $arts, and is there standard organi(ation in all $arts throughout the hospital" &re there post-$ode, other debriefing forms that are filled out to offer feedba$k on how $odes are preformed to allow feedba$k regarding pro$ess impro%ements" Is the )*& modified %ersion of the +,, (+mergen$y ,ardia$ ,are) &*& (&meri$an *eart &sso$iation) *andbook of ,ardio%as$ular ,are ,ogniti%e &id lo$ated on all $arts" &re ,-2 dete$tors a%ailable on $ode $arts for $onfirming esophageal intubations" Is there a standardi(ed system (e.g. $he$klist) or method used to %erify that $ode $arts are fully sto$ked and properly e'uipped before they are sent to the units and a daily inspe$tion on ea$h unit"

Electrical Sa#et$ &re ele$tri$al re$epta$les in, or ser%ing, wet areas or beha%ioral health areas pro%ided with /round 0ault ,ir$uit Interruption (/0,I) prote$tion or an isolated power system" &re ele$tri$al re$epta$les fitted with $o%ers, se$ured, and free of loose or e1posed wiring" &re emergen$y power re$epta$les appropriately identified and only used for e'uipment needing to be on emergen$y power $ir$uits" &re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the fa$ility 2re%entati%e 3aintenan$e (23) pro$ess" &re there at least re$epta$les (4 in $riti$al $are) for ea$h patient bed"

If used, are power $ords and ele$tri$al e1tension $ords pla$ed where they are free from me$hani$al damage, properly si(ed (gauge) to pre%ent o%erheating, and arranged so that they do not present a tripping ha(ard" En&iron'ental and (ou%e)eeping Sa#et$ &re hot water temperatures taken manually using a thermometer before patient use or immersion (in$luding partial immersion) takes pla$e" &re supply and return air registers $lean and free of lint and dust" 5oes general housekeeping appear to be a priority" &re storage rooms neat, organi(ed, well light and temperature $ontrolled" Is all storage 167 below fire sprinklers and off the floor" &re egress $orridors and stairways unobstru$ted and kept free of storage" &re patient or resident areas free of unlabeled or unattended $ontainers, su$h as $leaning produ$ts or medi$ation" &re ha(ards $learly identified and properly $ontrolled during $onstru$tion and reno%ation" &re high ha(ard areas su$h as: 8oofs, ser%i$e areas, medi$ation rooms, labs, radiation areas, $onfined spa$es, high %oltage areas, laser areas, low use areas (su$h as sub-floors and interstitial spa$es), et$. labeled with appropriate signage and lo$ked to pre%ent unauthori(ed entran$e" &re steps taken to eliminate/$ontrol 7pests7 in the hospital en%ironment" E*uip'ent Sa#et$ Is medi$al e'uipment being inspe$ted in a$$ordan$e with the 2re%entati%e 3aintenan$e 2rogram" Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of failure and or emergen$y" Is the e'uipment used on ea$h patient positioned in a way that it is e%ident the e'uipment is in use for that patient" &re alarms audible by $are staff, uni'ue in tone and pit$h to pre%ent masking9, and are limits appropriately set to redu$e unwanted or false alarms"

e. not bent or folded)" Is a reliable system used to identify whi$h tubes and $onne$tors go to whi$h de%i$es" &re the tubes/$onne$tors kept out of the way to a%oid them from being inad%ertently unplugged" &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es" .&re work arounds a%oided in the use of medi$al de%i$es with alarms" Is the e'uipment designed su$h that its operation is intuiti%e to the user and does not re'uire use of ad:un$t de%i$es to $omplete the re'uired tasks" Is patient $are and monitoring e'uipment positioned so that $aregi%ers $an easily rea$h and/or read displays and $ontrols" &re li'uids kept away from medi$al e'uipment" &re disposable medi$al de%i$es/supplies stored in a way that the integrity of the de%i$es is kept inta$t (i.an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients when they assess for fall risk" &s part of the orientation. are methods in pla$e to ensure they fun$tion $orre$tly" If wander guard systems are in pla$e.t e1er$ised during a real e%ent" Is a risk assessment for elopement $ompleted at the time of admission or transfer and regularly during the patients stay" &re staff familiar with the fa$iliities elopement risk assessment pro$ess" Is a pro$esses in pla$e and used to keep tra$k of high risk patients when they are off of the unit" Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff" . are the patient and family instru$ted to get help from $lini$al staff if there is a real or per$ei%ed need to $onne$t or dis$onne$t any de%i$es or tubings" &re lo$ations of &+5s and defibrillators standardi(ed throughout the patient $are areas of the fa$ility" *as the fa$ility eliminated sterile water (in forms easily $onfused with medi$ations) from ward sto$k" E%cape and Elope'ent +re&ention Is the use of $ell phones or other de%i$es that $an affe$t monitoring and other medi$al e'uipment $ontrolled in appli$able areas as spe$ified in lo$al poli$y" Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff" If ele$troni$ systems su$h as wander guards are used.all +re&ention . are they in$luded in the pre%entati%e maintenan$e inspe$tion program" &re annual drills of the full missing patient pro$ess (grid sear$h) $ondu$ted at least annually if the plan wasn.

a%ailable that has suffi$ient lifting/holding $apa$ity to meet the needs of bariatri$ patients" Is the load $arrying $apa$ity of the e'uipment ob%ious to $are pro%iders" . and. non-slip floor surfa$es. -8 table. and installed handrails" &re $all buttons within rea$h of the patient" &re bed and $hair alarms used and audible. and 2) #hat triggers a reassessment.g. pro$edure rooms and $ommon areas pro%ided with ade'uate lighting so that the patients ability to ambulate safely is not impeded" &re me$hani$al assist de%i$es used to lift or transfer patients a$$essible and used by staff when needed" &re pre%entati%e measures implemented to pre%ent falls from manual lifting and/or handling patients" &re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental slipping and tripping ha(ards" &re shower/bathroom areas pro%ided with ade'uate lighting. et$.&re all patient/resident rooms. e'uipment. is a pro$ess in pla$e to ensure integrity of the flame retardant agent is maintained on these arti$les after repeated laundering" In#ection Control &re all linen $arts ($lean and soiled) kept $o%ered and the bottom of the $art is a solid surfa$e (without openings)" &re sharps $ontainers a$$essible and not o%er filled" Is the fa$ilities late1 free poli$y being followed in$luding pro%iding late1 free supplies and de%i$es" . nurse $all. in$luding appli$able timeframes" Is there at least one patient lift.an $lini$al staff identify smoke and fire walls in their immediate area" Is the fire alarm signal easily distinguishable from other alarms (e.an staff des$ribe the pro$ess on how they are notified when the fire alarm system is out of ser%i$e in their area or being tested" &re flame retardant pa:amas or aprons pro%ided for patients who smoke and are identified as a 7smoking risk7" If flame retardant pa:amas or linens are used. are they $onfigured to redu$e the number of false/unwanted alarms" 5oes the fa$ility ha%e a 0all 2re%ention < 3anagement 2roto$ol or e'ui%alent" Is a uniform tool used to assess whi$h patients are at high risk for falls.. radiololgy table.ire Sa#et$ &re staff members familiar with fire emergen$y pro$edures. and the fire pre%ention plan for their ser%i$e area" . and is there $riteria to determine: 1) #hen they are assessed. et$. proper drainage.)" .

/& (. and when and how to use it" 5oes the storage and use of portable medi$al gas $ontainers appear to be in $omplian$e with . $lean. monthly for non-o$$upied)" Is there a pro$ess in pla$e to establilsh temporary negati%e/positi%e pressure rooms if they are needed" Medical -a% Sa#et$ &re piped in o1ygen and $ompressed air identified by a prominent label and not merely by $olor adapters" &re air flow meters remo%ed when not in use (for nebuli(ed medi$ation treatments)" 5o staff know where the emergen$y o1ygen shut-off is.ompressed /as &sso$iation) =tandards" 5o area/unit personnel know how to $orre$tly handle o1ygen $ylinders" &re pins on medi$al gas regulators inta$t.&re the )& re$ommended hand hygiene guidelines followed" Is the integrity of negati%e/positi%e pressure isolation rooms tested and maintained (on$e per day for o$$upied. and is damaged e'uipment immediately remo%ed from ser%i$e" &re o1ygen $ylinders with ball-type regulators used with the $ylinder in the %erti$al position" Medication Sa#et$ &re all medi$ation refrigerators maintained appropriately" 5o medi$ation $arts remained lo$ked and ina$$essible to patients when not in use" &re the tops of medi$ation $arts. free of stray drugs. sharps and food" &re re$epta$les for medi$ation storage lo$ked and are $ontrolled substan$es double lo$ked" Is area sto$k limited to emergen$y medi$ation and I) solutions whi$h are appropriate to patient $are in the unit" &re bags $ontaining sterile water for in:e$tion prohibited from being ordered or sto$ked on patient $are areas without spe$ial permission and pre$aution" &re only standard $on$entrations of high alert medi$ations kept in the area/unit to minimi(e the potential of $al$ulation and $ompounding errors" Is a unit dose medi$ation system used in$luding li'uids" Is drug preparation done primarily in the pharma$y and not on $are units" Is medi$ation mi1ing (admi1tures) on inpatient $are units a dis$ouraged pra$ti$e" &re pro$edures in pla$e to pre%ent sterile produ$t use from patient to patient (in$luding medi$ations)" &re I) o%er-wrap bags utili(ed and properly labeled with manufa$turers instru$tions" .

-* &re spe$ifi$ pre$autio ns followed when handling look/soun d alike drugs" Medication Sa#et$ 8e$ommended @. guidelines.3&" Is >. nalo1one.3& a%ailable during all shifts" 5o the )I=?& modules effe$ti%ely alert to potential food/drug/herbal intera$tions and dupli$ate drug therapies" &re users prohibited from turning them off (the alerts)" Is $urrent drug referen$e information made readily a$$essible to $aregi%ers.3& used to administer medi$ation without using work arounds" #hat is the proto$ol for handling medi$ation preparations that are in$orre$tly bar $oded or labeled.&re I) bags free of markings.3.24 )andat or' *. or ha%e labels that do not s$an" Is there a helpdesk for >.26 Medication Sa#et$ Is a prohibited abbre%iations in effe$t" .3.+. and/or $he$klists readily a%ailable for staff" @.11.) a%ailable based on the drug being administered and $lini$al setting" 5oes the fa$ility tra$k use of re%ersal agents" Is there a pro$ess for monitoring >. protamine. et$... if so how" Medication Sa#et$ &re up-to-date fa$ility spe$ifi$ proto$ols.. applied by staff with ink pens or felt markers (prior to use)" Is an independent double $he$k $ompleted for all infusion pump settings for high alert medi$ations and look alike/sound alike drugs" &re appropriate re%ersal agents (fluma(enil.11. su$h as e1piration dates. dosing s$ales.

2A Medication Sa#et$ If &utomated 5ispensing 3a$hines (&53s) are used.3. and $an they e1plain how the ma$hine works" 8e$ommended @.3 Medication Sa#et$ &re patients edu$ated regarding their pres$ribed medi$ation.11. are there $apabilities to run o%erride reports that tra$k dis$repan$y and utili(ation at least monthly" 8e$ommended @.11. is staff aware of a written poli$y.11.11.1 -eneral +atient Sa#et$ Concern% Is read-ba$k used for all %erbal order and $riti$al %alue reports" 3andatory -eneral +atient Sa#et$ Concern% . and if medi$ations are $hanged e1iting a $lini$" 3andatory @.32 Medication Sa#et$ If &53s are used.3.11.3andatory @.3.3. as inpatients and as part of the dis$harge pro$ess" 3andatory @..3! Medication Sa#et$ 5oes the $are pro%ided by 2harma$ists meet the $lini$al needs of the patients in s$ope and fre'uen$y" 3andatory @.3.12.3. transfer or dis$harge and is a $urrent list of medi$ations gi%en to the patient when dis$harge from a )&3. 2 Medication Sa#et$ Is a pro$ess in pla$e to re$on$ile patient medi$ations upon admission.

12.)" 8e$ommended @. in$luding $omputer information" 3andatory @.3.2= or lo$ally de%eloped $ogniti%e aids a%ailable on the floor for staff to referen$e (+s$ape and +lopementC 0all 2re%ention.3 -eneral +atient Sa#et$ Concern% &re patient/resident re$ords kept $onfidential.12. et$.3. -eneral +atient Sa#et$ Concern% &re staff wearing identifi$ation badges and are unauthori(ed persons kept out of patient $are areas" 3andatory @.4 -eneral +atient Sa#et$ Concern% &re there pra$ti$es in pla$e to de$rease the likelihood of patient misidentifi$ation" 3andatory .2 &re B.3.3.3.12.12.12.@.! -eneral +atient Sa#et$ Concern% &re restraints used in a$$ordan$e with lo$al poli$y and are restraint alternati%e de%i$es a%ailable and used when appropriate" 3andatory @.

4. rather than in bulk (at the nurses station) to pre%ent mislabeling" 3andatory @.12.3.1 -eneral +atient Sa#et$ Concern% Dpon $olle$tion of blood or blood produ$ts is a informed $onsent obtained" 3andatory @.12.@ -eneral +atient Sa#et$ Concern% &re there monitoring pro$esses in pla$e for portable food and be%erage warming or heating de%i$es" 8e$ommended @.3 -eneral +atient Sa#et$ Concern% Is there an e1isting proto$ol for patient identifi$ation with non-$ommuni$ati%e patients" 3andatory @.12.12.3.12.4.3.3.6 -eneral +atient Sa#et$ Concern% &re handoffs between shifts or transfer of $are between units standardi(ed" 3andatory -eneral +atient Sa#et$ Concern% .@.4.3.2 -eneral +atient Sa#et$ Concern% Is the labeling of blood samples or spe$imens done at the bedside.

1E -eneral +atient Sa#et$ Concern% &re patients sear$hed and residents 'uestioned for $ontraband upon admission to ea$h appli$able area/unit" 8e$ommended @.3. being treated/tested.A Is the transfer of $are between dis$iplines for off-unit appointments standardi(ed.3.3.3.12.3. and during transport" 8e$ommended @. in$luding the $ontinuation of monitoring patient status and patient medi$al de%i$es su$h as I) pumps and o1ygen le%el while the patient is %isiting.11.@.12.11 -eneral +atient Sa#et$ Concern% 5oes the fa$ility ha%e an emergen$y response proto$ol for dealing with disrupti%e patients" 8e$ommended @.12.12 -eneral +atient Sa#et$ Concern% #hen performing pro$edures outside of the operating room are appropriate sedation proto$ols and pri%ileges followed when appli$able" 3andatory .12.ue%tion/ "ed Sa#et$ .12. 1 -eneral +atient Sa#et$ Concern% Is there an assessment used to determine if a patient is potentially %iolent" 3andatoryC 2riority & @.

1.3 "ed Sa#et$ &re non-$ompliant beds $learly marked as to indi$ate entrapment risk" 3andatory @. !) within rail" 3andatory @.1.2 "ed Sa#et$ #hen beds and/or mattresses are re-ordered for pur$hase or lease are they re%iewed for entrapment risk" 8e$ommended @. . .! "ed Sa#et$ Is the appropriate bed-type mat$hed to the le%el of $are needed for ea$h patient" 8e$ommended @. .1 If bed rails are installed/used are they free of entrapment potential (for patients identified as high risk for entrapment): 1) rail to mattress. .1. 3) rail to board -either end. . or.1.1. 2) between split rails.4 "ed Sa#et$ &re beds with built-in weight s$ales a$$urate and fun$tioning $orre$tly" 8e$ommended "ed Sa#et$ .@. ) board to mattress.

ogniti%e &id lo$ated on all $arts" 8e$ommended @.are) &*& (&meri$an *eart &sso$iation) *andbook of .1 Code Cart% &re $ode $arts lo$ked when not in use. and is e'uipment in good $ondition $lean and $o%ered" 3andatory @. . .2.@ &re measures in pla$e to help pre%ent fires resulting from the use of ele$tri$ hospital beds" 8e$ommended @. Code Cart% Is the )*& modified %ersion of the +. other debriefing forms that are filled out to offer feedba$k on how $odes are preformed to allow feedba$k regarding pro$ess impro%ements" 8e$ommended @. .1 Code Cart% &re there post-$ode.2. .1.-2 dete$tors a%ailable on $ode $arts for $onfirming esophageal intubations" .2. .@.ardio%as$ular .2. ..are .3. (+mergen$y .2. and is there standard organi(ation in all $arts throughout the hospital" 8e$ommended @.! Code Cart% &re .ardia$ .3 Code Cart% &re e'uipment and drugs easily retrie%able on/in $ode $arts.

3andatory @. se$ured.3 Electrical Sa#et$ &re emergen$y power re$epta$les appropriately identified and only used for e'uipment needing to be on emergen$y power $ir$uits" 3andatory @.4 Code Cart% Is there a standardi(ed system (e.ir$uit Interruption (/0. $he$klist) or method used to %erify that $ode $arts are fully sto$ked and properly e'uipped before they are sent to the units and a daily inspe$tion on ea$h unit" 8e$ommended @. and free of loose or e1posed wiring" 3andatory @.3.3. . .3. .2 Electrical Sa#et$ &re ele$tri$al re$epta$les fitted with $o%ers. . .2. wet areas or beha%ioral health areas pro%ided with /round 0ault . or ser%ing. Electrical Sa#et$ &re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the fa$ility 2re%entati%e 3aintenan$e (23) pro$ess" 3andatory Electrical Sa#et$ .1 Electrical Sa#et$ &re ele$tri$al re$epta$les in.I) prote$tion or an isolated power system" 3andatory @.g.3.

properly si(ed (gauge) to pre%ent o%erheating. organi(ed. . are power $ords and ele$tri$al e1tension $ords pla$ed where they are free from me$hani$al damage.1 En&iron'ental and (ou%e)eeping Sa#et$ &re hot water temperatures taken manually using a thermometer before patient use or immersion (in$luding partial immersion) takes pla$e" 3andatory @. . . . .2 En&iron'ental and (ou%e)eeping Sa#et$ &re supply and return air registers $lean and free of lint and dust" 3andatory @.! &re there at least re$epta$les (4 in $riti$al $are) for ea$h patient bed" 3andatory @. En&iron'ental and (ou%e)eeping Sa#et$ &re storage rooms neat.3.@.! En&iron'ental and (ou%e)eeping Sa#et$ &re egress $orridors and stairways unobstru$ted and kept free of storage" 3andatory En&iron'ental and (ou%e)eeping Sa#et$ . .4 Electrical Sa#et$ If used.3 En&iron'ental and (ou%e)eeping Sa#et$ 5oes general housekeeping appear to be a priority" 3andatory @. . .3. and arranged so that they do not present a tripping ha(ard" 8e$ommended @. . . . well light and temperature $ontrolled" Is all storage 167 below fire sprinklers and off the floor" 3andatory @. .

. . .!. . .!.2 E*uip'ent Sa#et$ Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of failure and or emergen$y" 8e$ommended @.3 E*uip'ent Sa#et$ Is the e'uipment used on ea$h patient positioned in a way that it is e%ident the e'uipment is in use for that patient" 8e$ommended E*uip'ent Sa#et$ .1E En&iron'ental and (ou%e)eeping Sa#et$ &re steps taken to eliminate/$ontrol 7pests7 in the hospital en%ironment" 3andatory @. . su$h as $leaning produ$ts or medi$ation" 3andatory @. .4 &re patient or resident areas free of unlabeled or unattended $ontainers. .@ En&iron'ental and (ou%e)eeping Sa#et$ &re ha(ards $learly identified and properly $ontrolled during $onstru$tion and reno%ation" 3andatory @.1 E*uip'ent Sa#et$ Is medi$al e'uipment being inspe$ted in a$$ordan$e with the 2re%entati%e 3aintenan$e 2rogram" 3andatory @. .!.@.

.4 E*uip'ent Sa#et$ Is the e'uipment designed su$h that its operation is intuiti%e to the user and does not re'uire use of ad:un$t de%i$es to $omplete the re'uired tasks" 8e$ommended @. .!.A E*uip'ent Sa#et$ &re disposable medi$al de%i$es/supplies stored in a way that the integrity of the de%i$es is kept inta$t (i. . .e. 7 3andatory @.!.!. . &re alarms audible by $are staff. .!.! E*uip'ent Sa#et$ &re work arounds a%oided in the use of medi$al de%i$es with alarms" 8e$ommended @.!. and are limits appropriately set to redu$e unwanted or false alarms" 93asking o$$urs when the fre'uen$y and intensity of two independent separate alarms blend together.6 E*uip'ent Sa#et$ &re li'uids kept away from medi$al e'uipment" 8e$ommended @.!.@. not bent or folded)" 8e$ommended .@ E*uip'ent Sa#et$ Is patient $are and monitoring e'uipment positioned so that $aregi%ers $an easily rea$h and/or read displays and $ontrols" 8e$ommended @. uni'ue in tone and pit$h to pre%ent masking9.

. .1 E*uip'ent Sa#et$ &re the tubes/$onne$tors kept out of the way to a%oid them from being inad%ertently unplugged" 8e$ommended E*uip'ent Sa#et$ .!.!.1E.@.1E E*uip'ent Sa#et$ Is a reliable system used to identify whi$h tubes and $onne$tors go to whi$h de%i$es" 8e$ommended @.

.2 ($ontinued ) E*uip'ent Sa#et$ ($ontinued).1E..!.@.an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients when they assess for fall risk" 8e$ommended E*uip'ent Sa#et$ . .2 &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es" 8e$ommended @. .!. &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate $ir$umstan$es" 8e$ommended @. .1E.!. E*uip'ent Sa#et$ .1E.

!.!. .11 E*uip'ent Sa#et$ &re lo$ations of &+5s and defibrillators standardi(ed throughout the patient $are areas of the fa$ility" 8e$ommended @.!. .@. .12 E*uip'ent Sa#et$ &re $lo$ks syn$hroni(ed and a$$urate" 8e$ommended @.13 E*uip'ent Sa#et$ *as the fa$ility eliminated sterile water (in forms easily $onfused with medi$ations) from ward sto$k" 8e$ommended @. .!. .!. are the patient and family instru$ted to get help from $lini$al staff if there is a real or per$ei%ed need to $onne$t or dis$onne$t any de%i$es or tubings" 3andatory @.1 E*uip'ent Sa#et$ Is the use of $ell phones or other de%i$es that $an affe$t monitoring and other medi$al e'uipment $ontrolled in appli$able areas as spe$ified in lo$al poli$y" 8e$ommended E%cape and Elope'ent +re&ention .! &s part of the orientation.1E.

.3 .4.1 .all +re&ention &re pre%entati%e measures implemented to pre%ent falls from manual lifting and/or handling patients" 8e$ommended @. .2 .@. pro$edure rooms and $ommon areas pro%ided with ade'uate lighting so that the patients ability to ambulate safely is not impeded" 3andatory @.! Is a risk assessment for elopement $ompleted at the time of admission or transfer and regularly during the patients stay" 3andatory @.all +re&ention .@.all +re&ention &re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental slipping and tripping ha(ards" 3andatory .@ E%cape and Elope'ent +re&ention Is a system in pla$e to $learly identify high risk es$ape or elopement patients to staff" 8e$ommended @.4.all +re&ention &re all patient/resident rooms.all +re&ention &re me$hani$al assist de%i$es used to lift or transfer patients a$$essible and used by staff when needed" 8e$ommended @.@. . .@. . .@.2.1 .

@. a%ailable that has suffi$ient lifting/holding $apa$ity to meet the needs of bariatri$ patients" 8e$ommended . .all +re&ention 5oes the fa$ility ha%e a 0all 2re%ention < 3anagement 2roto$ol or e'ui%alent" 3andatory @. .all +re&ention Is a uniform tool used to assess whi$h patients are at high risk for falls. -8 table.! .@. and 2) #hat triggers a reassessment.all +re&ention .@.@. . in$luding appli$able timeframes" 3andatory @. are they $onfigured to redu$e the number of false/unwanted alarms" 3andatory @.4 .@.@ .6 . .all +re&ention &re $all buttons within rea$h of the patient" 8e$ommended @. proper drainage. and. non-slip floor surfa$es.all +re&ention &re bed and $hair alarms used and audible.@. &re shower/bathroom areas pro%ided with ade'uate lighting.A . and installed handrails" 3andatory @. .all +re&ention Is there at least one patient lift. . and is there $riteria to determine: 1) #hen they are assessed. radiololgy table.@. et$.

6.ire Sa#et$ .an $lini$al staff identify smoke and fire walls in their immediate area" 3andatory @.6.2 In#ection Control &re sharps $ontainers a$$essible and not o%er filled" 3andatory In#ection Control . .3 .A.ire Sa#et$ &re staff members familiar with fire emergen$y pro$edures..6.A.ire Sa#et$ . .1 . e'uipment.an staff des$ribe the pro$ess on how they are notified when the fire alarm system is out of ser%i$e in their area or being tested" 3andatory @. et$. . .ire Sa#et$ Is the fire alarm signal easily distinguishable from other alarms (e.1 In#ection Control &re all linen $arts ($lean and soiled) kept $o%ered and the bottom of the $art is a solid surfa$e (without openings)" 3andatory @.@. nurse $all.@.1 Is the load $arrying $apa$ity of the e'uipment ob%ious to $are pro%iders" 8e$ommended @.g.6.A. .)" 3andatory @. and the fire pre%ention plan for their ser%i$e area" 3andatory @. . . .2 .

1&re piped in o1ygen and $ompressed air identified by a prominent label and not merely by $olor adapters" 8e$ommended Medical -a% Sa#et$@. free of stra' drugs.+ re the tops of medication carts..6.0.0. (Compressed . .as ssociation" /tandards3 )andator' )edical ..1E.1. monthly for nono$$upied)" 3andatory In#ection Control@.02oes the storage and use of porta%le medical gas containers appear to %e in compliance with C. and when and how to use it" 3andatory )edical . ... re all medication refrigerators maintained appropriatel'3 )andator' )edication /afet'*. ..0.3 Is the fa$ilities late1 free poli$y being followed in$luding pro%iding late1 free supplies and de%i$es" 3andatory @...0.as /afet'*..2o area&unit personnel know how to correctl' handle ox'gen c'linders3 )andator' )edical .A.6 re ox'gen c'linders with %all-t'pe regulators used with the c'linder in the vertical position3 )andator' )edication /afet'*. In#ection Control &re the )& re$ommended hand hygiene guidelines followed" 3andatory In#ection Control@.A.0 re receptacles for medication storage locked and are controlled su%stances dou%le locked3 )andator' )edication /afet'*. sharps and food3 )andator' )edication /afet'*.0..6!s area stock limited to emergenc' medication and !7 solutions which are appropriate to patient care in the unit3 8ecommended )edication /afet'*.0..0..1.0.1..1.as /afet'*. clean. .A.1Is there a pro$ess in pla$e to establilsh temporary negati%e/positi%e pressure rooms if they are needed" 8e$ommended Medical -a% Sa#et$@.4 re pins on medical gas regulators intact.0.as /afet'*.A.1E..!.0.0. .1E.. .@. ....2&re air flow meters remo%ed when not in use (for nebuli(ed medi$ation treatments)" 8e$ommended Medical -a% Sa#et$@...as /afet'*.!Is the integrity of negati%e/positi%e pressure isolation rooms tested and maintained (on$e per day for o$$upied.!f needle-less s'tems are used are emergenc' medication deliver' s'stems for drugs in code carts and emergenc' drug %oxes compati%le are adaptors provided and .35o staff know where the emergen$y o1ygen shut-off is......-2o medication carts remained locked and inaccessi%le to patients when not in use3 )andator' )edication /afet'*.. and is damaged e5uipment immediatel' removed from service3 )andator' )edical .

.1!s a unit dose medication s'stem used including li5uids3 8ecommended )edication /afet'*. applied %' staff with ink pens or felt markers (prior to use"3 8ecommended )edication /afet'*. re single-dose perenteral containers (with preference to pre-filed s'ringes" used when possi%le3 )andator' )edication /afet'*.-4!s current drug reference information made readil' accessi%le to caregivers..." availa%le %ased on the drug %eing administered and clinical setting3 )andator' )edication /afet'*..-... dosing scales.. re appropriate reversal agents (fluma9enil. re onl' standard concentrations of high alert medications kept in the area&unit to minimi9e the potential of calculation and compounding errors3 )andator' )edication /afet'*..0.* re %ags containing sterile water for in$ection prohi%ited from %eing ordered or stocked on patient care areas without special permission and precaution3 8ecommended )edication /afet'*.....-:!s a prohi%ited a%%reviations in effect3 )andator' )edication /afet'*...6. guidelines..-..2oes the facilit' track use of reversal agents3 8ecommended )edication /afet'*....0... does the organi9ation use an alternate method (e.4 re !7 over-wrap %ags utili9ed and properl' la%eled with manufacturers instructions3 8ecommended )edication /afet'*...0..:Have concentrated electrol'te solutions %een removed from patient floors&care areas3 )andator' )edication /afet'*..0.+0 re patients educated regarding .0....0.0..-!f codes are not called within a specified duration.0...1....0.-6 re up-to-date facilit' specific protocols.0. is staff aware of a written polic'.. protamine.availa%le3 8ecommended )edication /afet'*. are there capa%ilities to run override reports that track discrepanc' and utili9ation at least monthl'3 8ecommended )edication /afet'*..-.-. and&or checklists readil' availa%le for staff3 )andator' )edication /afet'*....6 re !7 %ags free of markings.. and can the' explain how the machine works3 8ecommended )edication /afet'*...+!s there a helpdesk for <C) availa%le during all shifts3 8ecommended )edication /afet'*. mock codes" to maintain staff competenc' with emergenc' medication3 8ecommended )edication /afet'*.....!f utomated 2ispensing )achines ( 2)s" are used.. such as expiration dates..0.g..*!s an independent dou%le check completed for all infusion pump settings for high alert medications and look alike&sound alike drugs3 8ecommended )edication /afet'*...0.0.+!s drug preparation done primaril' in the pharmac' and not on care units3 )andator' )edication /afet'*...0..2o the 7!/T modules effectivel' alert to potential food&drug&her%al interactions and duplicate drug therapies3 re users prohi%ited from turning them off (the alerts"3 8ecommended )edication /afet'*.........0..... or have la%els that do not scan3 8ecommended )edication /afet'*..0.!s <C) used to administer medication without using work arounds3 8ecommended )edication /afet'*..0..-.0..--......0.+-!f 2)s are used. if so how3 8ecommended )edication /afet'*...0 re procedures in place to prevent sterile product use from patient to patient (including medications"3 8ecommended )edication /afet'*.0.0.!s there a process for monitoring <C) 3 8ecommended )edication /afet'*....-* re specific precautions followed when handling look&sound alike drugs3 8ecommended )edication /afet'*...-=hat is the protocol for handling medication preparations that are incorrectl' %ar coded or la%eled.. naloxone.0.+........!s medication mixing (admixtures" on inpatient care units a discouraged practice3 8ecommended )edication /afet'*.....0. etc..0...0...0....

.-.-.0..0.!s there a process to verif' contents of a s'ringe or container %efore drug administration to patient during a procedure or code3 8ecommended )edication /afet'*..0 re staff wearing identification %adges and are unauthori9ed persons kept out of patient care areas3 )andator' .ssessment Tool for B%serving /teps 8e5uired %' 7H 2irectives -110-1-: (@nsuring Correct /urger' and !nvasive >rocedures" and -116-1+1 (>revention of 8etained /urgical !tems.eneral >atient /afet' Concerns*.-.0.+..-.-. transfer or discharge and is a current list of medications given to the patient when discharge from a 7 )C. and during transport3 8ecommended .+!s there an existing protocol for patient identification with noncommunicative patients3 )andator' .0. including the continuation of monitoring patient status and patient medical devices such as !7 pumps and ox'gen level while the patient is visiting..eneral >atient /afet' Concerns*.-...0..0.: /elf.eneral >atient /afet' Concerns*..eneral >atient /afet' Concerns*.eneral >atient /afet' Concerns*.: re handoffs %etween shifts or transfer of care %etween units standardi9ed3 )andator' .0-!s a process in place to reconcile patient medications upon admission.0.+42oes the care provided %' >harmacists meet the clinical needs of the patients in scope and fre5uenc'3 )andator' )edication /afet'*..-... including computer information3 )andator' ..-..eneral >atient /afet' Concerns*.6.0.."3 8ecommended .* re there monitoring processes in place for porta%le food and %everage warming or heating devices3 8ecommended .-=hen performing procedures outside of the operating room are appropriate sedation protocols and privileges followed when applica%le3 )andator' /urgical or !nvasive >rocedure >recautions*.1 re patients searched and residents 5uestioned for contra%and upon admission to each applica%le area&unit3 8ecommended . as inpatients and as part of the discharge process3 )andator' )edication /afet'*.-..Apon collection of %lood or %lood products is a informed consent o%tained3 )andator' .0.+ re patient&resident records kept confidential..eneral >atient /afet' Concerns*.-.!s the transfer of care %etween disciplines for off-unit appointments standardi9ed.eneral >atient /afet' Concerns*.eneral >atient /afet' Concerns*. etc.....eneral >atient /afet' Concerns*..-.6..re ?C>/ or locall' developed cognitive aids availa%le on the floor for staff to reference (@scape and @lopement# Fall >revention.0.eneral >atient /afet' Concerns*.. %eing used3 )andator' .2oes the facilit' have an emergenc' response protocol for dealing with disruptive patients3 8ecommended .-.0.0.eneral >atient /afet' Concerns*.-.eneral >atient /afet' Concerns*.6 re there practices in place to decrease the likelihood of patient misidentification3 )andator' .-.0... %eing treated&tested.-.-Has the 7H B8 /elf ssessment C. rather than in %ulk (at the nurses station" to prevent misla%eling3 )andator' ..eneral >atient /afet' Concerns*.0.0...0..0.4 re restraints used in accordance with local polic' and are restraint alternative devices availa%le and used when appropriate3 )andator' .0..eneral >atient /afet' Concerns*...6.0..-!s the la%eling of %lood samples or specimens done at the %edside. and if medications are changed exiting a clinic3 )andator' .their prescri%ed medication..!s read-%ack used for all ver%al order and critical value reports3 )andator' .0.