The hospital develops a standardized list of abbreviations, acronyms, symbols and dosage designations that should not be used A throughout the hospital. The hospital does not include any abbreviations, acronyms, symbols, and dose designations identified as not being used on A preprinted forms. Elements of Performance for NPSG.02.03.01 The hospital defines critical tests and critical outcomes and values.
The hospital defines the acceptable length of time between the availability of critical tests and critical results and values and receipt A by the responsible licensed caregiver. The hospital collects data on the timeliness of reporting critical test results and critical results and values of routine tests. The hospital assesses the data on the timeliness of reporting critical test results and critical results and values of routine tests A and determines whether a need for improvement exists.
The hospital takes appropriate measures to improve the timeliness of reporting critical test results and critical results and values from A routine tests and measures the effectiveness of these actions. The hospital's process for effective handover communication includes the following: Updated information about the patient's C condition, care, treatment, medications, benefits, and any recent or anticipated changes. The hospital's process for effective handover communication includes the following: A method of verifying the information received, C including repetition or readback techniques.
The hospital takes action to prevent errors when mixing up the medications on the list with similar/sounding A medications.
NPSG.07.01.01
NPSG.07.02.01
NPSG.07.03.01
As of January 1, 2010, the hospital is educating patients and their families, as needed, who are infected or colonized with a multidrug-C resistant organism about healthcare-associated infection strategies. From January 1, 2010, the hospital implements a surveillance program for multi-drug resistant organisms based on the risk A assessment. Multidrug-resistant organism infection rates using evidence-based measures - Adherence to evidence-based guidelines or best practices.
As of January 1, 2010, the hospital provides multidrug-resistant organism surveillance data to key stakeholders, including managers, licensed independent A practitioners, nursing staff, and other clinicians. Since January 1, 2010, the hospital has implemented policies and practices aimed at reducing the risk of transmission of multidrug-resistant C organisms that meet regulatory requirements and are consistent with evidence-based standards (for example, Centers for Disease Control and Prevention (CDC ) and/or professional organization guidelines). Since January 1, 2010, when indicated by risk assessment, the hospital has implemented a laboratory-based alert system that A identifies new patients with multidrug-resistant organisms.
The alarm system can be either manual or electronic or a combination of both of these methods. Note: The warning system may use telephones, faxes, pagers, automatic and secure electronic alarms, or a combination of these methods. From January 1, 2010, when the risk assessment indicates it, the hospital implements an alert system that identifies readmitted or A-transmitted multidrug-resistant organism-positive patients.
Note: Warning system information may reside in a separate electronic database or may be integrated into the receiving system.
NPSG.07.04.01
As of January 1, 2010, use a standardized cart or all-inclusive kit to insert central venous catheters. As of January 1, 2010, use a standardized protocol for the greatest possible sterile barrier during central venous catheter insertion. From January 1, 2010, use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in C patients older than two months, unless contraindicated.
NPSG.07.05.01
As of January 1, 2010, antimicrobial agents for prophylaxis used for a specific procedure or disease are administered under C according to evidence-based standards and best practice guidelines.
NPSG.08.01.01
NPSG.08.02.01
NPSG.08.03.01
NPSG.08.04.01
NPSG.09.02.01
NPSG.13.01.01
NPSG.15.01.01
NPSG.16.01.01
Universal Protocol
Marking the procedure site allows staff to unambiguously identify the intended site of the procedure. The procedure site is initially marked before the patient is moved to the place where the procedure is to be performed, and C takes place with the patient involved, awake and alert if possible. The intervention site is marked by a licensed independent practitioner or other provider who is privileged or permitted by Hospital C to perform the intended surgical or non-surgical invasive procedure.
This individual will be directly involved in the procedure and will be present when the procedure is performed. Note: Final confirmation and verification of the site mark takes place during the timeout. It is made with a marker that is sufficiently permanent to remain visible after completion of skin preparation and sterile drape.
For example, a hospital can place a temporary, unique wristband at the side of the procedure that contains the patient's name and use a different identifier for the intended procedure and site. For minimal access procedures intended to treat a lateralized internal organ, either percutaneously or through a natural opening, the intended side is marked at or near the insertion site and remains visible after completion of skin preparation and sterile drape. Documentation, pictures and/or diagrams are available in the procedure room before the procedure begins.
The purpose of the time-out immediately prior to the start of the procedure is to perform a final assessment that the correct [patient], site, positioning and procedure have been identified and that, as applicable, all relevant documents, related information and necessary equipment is available. The time-out is consistently initiated by a designated member of the team and includes active communication between all relevant members of the procedural team. The time-out is performed before the start of the procedure and, ideally, before the introduction of the anesthesia process (including A general/regional anesthesia, local anesthesia and spinal anesthesia), unless contraindicated.
It involves the immediate members of the procedural team, including the proceduralist(s), the anesthesia providers, the circulating nurse, the operating room technician, and other active participants, as appropriate to the procedure, who will participate in the procedure at its inception. It involves interactive verbal communication between all team members and any team member is able to express concerns about the procedure verification. During the time-out, other activities are suspended to the extent possible without compromising patient safety so that all relevant A members of the team are focused on the active confirmation of the correct patient, procedure, site and other critical elements.
