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C.

Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.

D.

Reduce the likelihood of patient harm associated with the use of anticoagulation therapy

Goal 7 Reduce the risk of health care-associated infections

A.

Comply with current 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 a health care-associated infection.

Goal 8 Accurately and completely reconcile medications across the continuum of care

A.

There is a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

B.

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 upon discharge from the facility.

Goal 9 Reduce the risk of patient harm resulting from falls

A.

Implement a fall reduction program and evaluate the effectiveness of the program.

Goal 13 Encourage patient’s active involvement in their own care as patient safety strategy

A.

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 population (applies to patients who are being treated for emotional or behavioral problems)

A.

The organization identifies patients at risk for suicide.

Goal 16  Improve recognition and response to changes in a patient’s condition

A.

The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

Universal Protocols

The organization fulfills the expectations set forth in the Universal Protocol

A.

Conduct a preoperative verification process at describe in the Universal Protocol

B.

Mark the operative site as described in the Universal protocol

March 17, 2009

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