Patient Safety Indicators WHO

8/13/2019 Patient Safety Indicators WHO

1/25

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&methodsmeasures&indicatorsdphprocess&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 highrisk for entrapment): 1) rail to mattress, 2) between split rails, 3) rail to board -either end, ) boardto mattress, or, !) within rail"

#hen beds and/or mattresses are re-ordered for pur$hase or lease are they re%iewed forentrapment 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 organiation inall $arts throughout the hospital"

&re there post-$ode, other debriefing forms that are filled out to offer feedba$k on how $odes arepreformed to allow feedba$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 standardied system (e.g. $he$klist) or method used to %erify that $ode $arts are fullysto$ked and properly e'uipped before they are sent to the units and a daily inspe$tion on ea$hunit"
http://www.who.int/patientsafety/research/methods_measures/indicators_dph_process/en/index.htmlhttp://www.who.int/patientsafety/research/methods_measures/indicators_dph_process/en/index.htmlhttp://www.who.int/patientsafety/research/methods_measures/indicators_dph_process/en/index.htmlhttp://www.who.int/patientsafety/research/methods_measures/indicators_dph_process/en/index.html


2/25

Electrical Sa#et$&re ele$tri$al re$epta$les in, or ser%ing, wet areas or beha%ioral health areas pro%ided withround 0ault ir$uit Interruption (0I) 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 eposed wiring"

&re emergen$y power re$epta$les appropriately identified and only used for e'uipment needingto be on emergen$y power $ir$uits"

&re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the fa$ilityre%entati%e aintenan$e () pro$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 etension $ords pla$ed where they are free fromme$hani$al damage, properly sied (gauge) to pre%ent o%erheating, and arranged so that they donot present a tripping haard"

En&iron'ental and ou%eeeping 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, organied, well light and temperature $ontrolled" Is all storage 167 belowfire 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 $leaningprodu$ts or medi$ation"

&re haards $learly identified and properly $ontrolled during $onstru$tion and reno%ation"

&re high haard 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 andinterstitial spa$es), et$. labeled with appropriate signage and lo$ked to pre%ent unauthoriedentran$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$e with the re%entati%e aintenan$erogram"

Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of failure and oremergen$y"

Is the e'uipment used on ea$h patient positioned in a way that it is e%ident the e'uipment is inuse for that patient"

&re alarms audible by $are staff, uni'ue in tone and pit$h to pre%ent masking9, and are limitsappropriately set to redu$e unwanted or false alarms"


3/25

&re work arounds a%oided in the use of medi$al de%i$es with alarms"Is the e'uipment designed su$h that its operation is intuiti%e to the user and does not re'uire useof adun$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/orread 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$es is keptinta$t (i.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"

an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients when theyassess for fall risk"

&s part of the orientation, are the patient and family instru$ted to get help from $lini$al staff ifthere 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 standardied throughout the patient $are areas of thefa$ility"

*as the fa$ility eliminated sterile water (in forms easily $onfused with medi$ations) from wardsto$k"

E%cape and Elope'ent +re&entionIs 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$h as wander guards are used, are methods in pla$e to ensure theyfun$tion $orre$tly"

If wander guard systems are in pla$e, are they in$luded in the pre%entati%e maintenan$einspe$tion program"

&re annual drills of the full missing patient pro$ess (grid sear$h) $ondu$ted at least annually if theplan wasn;t eer$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"

,all +re&ention


4/25

&re all patient/resident rooms, pro$edure rooms and $ommon areas pro%ided with ade'uatelighting 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 whenneeded"

&re pre%entati%e measures implemented to pre%ent falls from manual lifting and/or handlingpatients"

&re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental slipping andtripping haards"

&re shower/bathroom areas pro%ided with ade'uate lighting, proper drainage, non-slip floorsurfa$es, and installed handrails"

&re $all buttons within rea$h of the patient"

&re bed and $hair alarms used and audible, and, are they $onfigured to redu$e the number offalse/unwanted alarms"

5oes the fa$ility ha%e a 0all re%ention < anagement roto$ol or e'ui%alent"

Is a uniform tool used to assess whi$h patients are at high risk for falls, and is there $riteria todetermine: 1) #hen they are assessed, and 2) #hat triggers a reassessment, in$ludingappli$able timeframes"

Is there at least one patient lift, 8 table, radiololgy table, et$. a%ailable that has suffi$ientlifting/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"

,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"

an $lini$al staff identify smoke and fire walls in their immediate area"

Is the fire alarm signal easily distinguishable from other alarms (e.g., e'uipment, nurse $all, et$.)"

an staff des$ribe the pro$ess on how they are notified when the fire alarm system is out ofser%i$e in their area or being tested"

&re flame retardant paamas or aprons pro%ided for patients who smoke and are identified as a7smoking risk7"

If flame retardant paamas or linens are used, 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$ilities late free poli$y being followed in$luding pro%iding late free supplies andde%i$es"


5/25

&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 dayfor o$$upied, monthly for non-o$$upied)"

Is there a pro$ess in pla$e to establilsh temporary negati%e/positi%e pressure rooms if they areneeded"

Medical a% Sa#et$&re piped in oygen and $ompressed air identified by a prominent label and not merely by $oloradapters"

&re air flow meters remo%ed when not in use (for nebulied medi$ation treatments)"

5o staff know where the emergen$y oygen shut-off is, 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& (ompressed as &sso$iation) =tandards"

5o area/unit personnel know how to $orre$tly handle oygen $ylinders"

&re pins on medi$al gas regulators inta$t, and is damaged e'uipment immediately remo%ed fromser%i$e"

&re oygen $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, $lean, 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 $ontaining sterile water for ine$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 minimie thepotential 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 miing (admitures) on inpatient $are units a dis$ouraged pra$ti$e"

&re pro$edures in pla$e to pre%ent sterile produ$t use from patient to patient (in$ludingmedi$ations)"

&re I o%er-wrap bags utilied and properly labeled with manufa$turers instru$tions"


6/25

&re I bags free of markings, su$h as epiration dates, applied by staff with ink pens or feltmarkers (prior to use)"Is an independent double $he$k $ompleted for all infusion pump settings for high alertmedi$ations and look alike/sound alike drugs"

&re appropriate re%ersal agents (flumaenil, naloone, protamine, et$.) a%ailable based on thedrug being administered and $lini$al setting"

5oes the fa$ility tra$k use of re%ersal agents"

Is there a pro$ess for monitoring >&"

Is >& 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 $oded orlabeled, or ha%e labels that do not s$an"

Is there a helpdesk for >& 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, if so how"

Medication Sa#[email protected] &re up-to-date fa$ility spe$ifi$ proto$ols,

guidelines, dosing s$ales, and/or$he$klists readily a%ailable for staff"

)andat

or' Medication Sa#et$

*.+..*&respe$ifi$pre$autionsfollowedwhenhandlinglook/soun

d alikedrugs"

8e$ommended

Medication Sa#[email protected] Is a prohibited abbre%iations in effe$t"


7/25

andatory

Medication Sa#[email protected] If &utomated 5ispensing a$hines

(&5s) are used, is staff aware of awritten poli$y, and $an they eplain how

the ma$hine works"

8e$ommended

Medication Sa#[email protected] If &5s are used, are there $apabilities

to run o%erride reports that tra$kdis$repan$y and utiliation at leastmonthly"

8e$ommended

Medication Sa#et$

@.3.11.3 &re patients edu$ated regarding theirpres$ribed medi$ation, as inpatients andas part of the dis$harge pro$ess"

andatory

Medication Sa#[email protected]! 5oes the $are pro%ided by harma$ists

meet the $lini$al needs of the patients ins$ope and fre'uen$y"

andatory

Medication Sa#[email protected] Is a pro$ess in pla$e to re$on$ile patient

medi$ations upon admission, transfer ordis$harge and is a $urrent list ofmedi$ations gi%en to the patient whendis$harge from a &, and ifmedi$ations are $hanged eiting a $lini$"

andatory

eneral +atient Sa#et$ Concern%@.3.12.1 Is read-ba$k used for all %erbal order and

$riti$al %alue reports"

andatory

eneral +atient Sa#et$ Concern%


8/25

@.3.12.2 &re B= or lo$ally de%eloped $ogniti%eaids a%ailable on the floor for staff toreferen$e (+s$ape and +lopementC 0allre%ention, et$.)"

8e$ommended


@.3.12.3 &re patient/resident re$ords kept$onfidential, in$luding $omputerinformation"

andatory

eneral +atient Sa#et$ Concern%@.3.12. &re staff wearing identifi$ation badges

and are unauthoried persons kept out ofpatient $are areas"

andatory


@.3.12.! &re restraints used in a$$ordan$e withlo$al poli$y and are restraint alternati%ede%i$es a%ailable and used whenappropriate"

andatory

eneral +atient Sa#et$ Concern%@.3.12.4 &re there pra$ti$es in pla$e to de$rease

the likelihood of patient misidentifi$ation"

andatory


9/25

eneral +atient Sa#et$ Concern%@.3.12.4.1 Dpon $olle$tion of blood or blood

produ$ts is a informed $onsent obtained"

andatory

eneral +atient Sa#et$ Concern%@.3.12.4.2 Is the labeling of blood samples or

spe$imens done at the bedside, ratherthan in bulk (at the nurses station) topre%ent mislabeling"

andatory


@.3.12.4.3 Is there an eisting proto$ol for patientidentifi$ation with non-$ommuni$ati%epatients"

andatory

eneral +atient Sa#et$ Concern%@.3.12.@ &re there monitoring pro$esses in pla$e

for portable food and be%erage warmingor heating de%i$es"

8e$ommended

eneral +atient Sa#et$ Concern%@.3.12.6 &re handoffs between shifts or transfer of

$are between units standardied"

andatory



10/25

@.3.12.A Is the transfer of $are betweendis$iplines for off-unit appointmentsstandardied, in$luding the $ontinuationof monitoring patient status and patientmedi$al de%i$es su$h as I pumps andoygen le%el while the patient is %isiting,

being treated/tested, and duringtransport"

8e$ommended

eneral +atient Sa#et$ Concern%@.3.12.1E &re patients sear$hed and residents

'uestioned for $ontraband uponadmission to ea$h appli$able area/unit"

8e$ommended

eneral +atient Sa#et$ Concern%@.3.12.11 5oes the fa$ility ha%e an emergen$y

response proto$ol for dealing withdisrupti%e patients"

8e$ommended


@.3.12.11.1

Is there an assessment used todetermine if a patient is potentially%iolent"

andatoryC riority &

eneral +atient Sa#et$ Concern%@.3.12.12 #hen performing pro$edures outside of

the operating room are appropriatesedation proto$ols and pri%ilegesfollowed when appli$able"

andatory

.ue%tion

"ed Sa#et$


11/25

@..1.1 If bed rails are installed/used are they free of entrapment potential (for patientsidentified 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"

andatory

"ed Sa#[email protected] #hen beds and/or mattresses are re-ordered for pur$hase or lease are they

re%iewed for entrapment risk"

8e$ommended

"ed Sa#[email protected] &re non-$ompliant beds $learly marked as to indi$ate entrapment risk"

andatory

"ed Sa#[email protected].! Is the appropriate bed-type mat$hed to the le%el of $are needed for ea$h

patient"

8e$ommended

"ed Sa#[email protected] &re beds with built-in weight s$ales a$$urate and fun$tioning $orre$tly"

8e$ommended

"ed Sa#et$


12/25

@..1.@ &re measures in pla$e to help pre%ent fires resulting from the use of ele$tri$hospital beds"

8e$ommended

Code Cart%@..2.1 &re $ode $arts lo$ked when not in use, and is e'uipment in good $ondition $lean

and $o%ered"

andatory

Code Cart%@..2.3 &re e'uipment and drugs easily retrie%able on/in $ode $arts, and is there

standard organiation in all $arts throughout the hospital"

8e$ommended

Code Cart%

@..2.3.1 &re there post-$ode, other debriefing forms that are filled out to offer feedba$kon how $odes are preformed to allow feedba$k regarding pro$essimpro%ements"

8e$ommended

Code Cart%@..2. Is the *& modified %ersion of the + (+mergen$y ardia$ are) &*&

(&meri$an *eart &sso$iation) *andbook of ardio%as$ular are ogniti%e &idlo$ated on all $arts"

8e$ommended

Code Cart%@..2.! &re 2 dete$tors a%ailable on $ode $arts for $onfirming esophageal

intubations"


13/25

andatory

Code Cart%@..2.4 Is there a standardied 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 theunits and a daily inspe$tion on ea$h unit"

8e$ommended

Electrical Sa#[email protected] &re ele$tri$al re$epta$les in, or ser%ing, wet areas or beha%ioral health areas

pro%ided with round 0ault ir$uit Interruption (0I) prote$tion or an isolatedpower system"

andatory

Electrical Sa#[email protected] &re ele$tri$al re$epta$les fitted with $o%ers, se$ured, and free of loose or

eposed wiring"

andatory

Electrical Sa#[email protected] &re emergen$y power re$epta$les appropriately identified and only used for

e'uipment needing to be on emergen$y power $ir$uits"

andatory

Electrical Sa#[email protected]. &re ele$tri$ally powered medi$al de%i$es in good $ondition and in line with the

fa$ility re%entati%e aintenan$e () pro$ess"

andatory

Electrical Sa#et$


14/25

@..3.! &re there at least re$epta$les (4 in $riti$al $are) for ea$h patient bed"

andatory

Electrical Sa#et$

@..3.4 If used, are power $ords and ele$tri$al etension $ords pla$ed where they arefree from me$hani$al damage, properly sied (gauge) to pre%ent o%erheating,and arranged so that they do not present a tripping haard"

8e$ommended

En&iron'ental and ou%eeeping Sa#et$

@...1 &re hot water temperatures taken manually using a thermometer before patientuse or immersion (in$luding partial immersion) takes pla$e"

andatory

En&iron'ental and ou%eeeping Sa#[email protected] &re supply and return air registers $lean and free of lint and dust"

andatory

En&iron'ental and ou%eeeping Sa#[email protected] 5oes general housekeeping appear to be a priority"

andatory

En&iron'ental and ou%eeeping Sa#et$@... &re storage rooms neat, organied, well light and temperature $ontrolled" Is all

storage 167 below fire sprinklers and off the floor"

andatory

En&iron'ental and ou%eeeping Sa#et$@...! &re egress $orridors and stairways unobstru$ted and kept free of storage"

andatory

En&iron'ental and ou%eeeping Sa#et$


15/25

@...4 &re patient or resident areas free of unlabeled or unattended $ontainers, su$h as$leaning produ$ts or medi$ation"

andatory

En&iron'ental and ou%eeeping Sa#et$@...@ &re haards $learly identified and properly $ontrolled during $onstru$tion and

reno%ation"

andatory

En&iron'ental and ou%eeeping Sa#[email protected] &re steps taken to eliminate/$ontrol 7pests7 in the hospital en%ironment"

andatory

E*uip'ent Sa#et$@..!.1 Is medi$al e'uipment being inspe$ted in a$$ordan$e with the re%entati%e

aintenan$e rogram"

andatory

E*uip'ent Sa#et$@..!.2 Is ba$k up patient $are/monitoring e'uipment readily a%ailable in the e%ent of

failure and or emergen$y"

8e$ommended

E*uip'ent Sa#et$@..!.3 Is the e'uipment used on ea$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$


16/25

@..!. &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"

9asking o$$urs when the fre'uen$y and intensity of two independent separate

alarms blend together. 7

andatory

E*uip'ent Sa#et$@..!.! &re work arounds a%oided in the use of medi$al de%i$es with alarms"

8e$ommended

E*uip'ent Sa#et$@..!.4 Is the e'uipment designed su$h that its operation is intuiti%e to the user and

does not re'uire use of adun$t de%i$es to $omplete the re'uired tasks"

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

E*uip'ent Sa#et$@..!.6 &re li'uids kept away from medi$al e'uipment"

8e$ommended

E*uip'ent Sa#et$@..!.A &re disposable medi$al de%i$es/supplies stored in a way that the integrity of the

de%i$es is kept inta$t (i.e. not bent or folded)"

8e$ommended


17/25

E*uip'ent Sa#et$@..!.1E Is a reliable system used to identify whi$h tubes and $onne$tors go to whi$h

de%i$es"

8e$ommended

E*uip'ent Sa#et$@..!.1E.1 &re the tubes/$onne$tors kept out of the way to a%oid them from being

inad%ertently unplugged"

8e$ommended

E*uip'ent Sa#et$


18/25

@..!.1E.2 &re staff obser%ed to tra$e tubes and lines ba$k to points of origin in appropriate$ir$umstan$es"

8e$ommended

E*uip'ent Sa#et$@..!.1E.2($ontinued)

($ontinued)... &re staff obser%ed to tra$e tubes and lines ba$k to points of originin appropriate $ir$umstan$es"

8e$ommended

E*uip'ent Sa#et$@..!.1E. an staff des$ribe how they in$lude tubing $onsiderations for indi%idual patients

when they assess for fall risk"

8e$ommended

E*uip'ent Sa#et$


19/25

@..!.1E.! &s part of the orientation, 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 anyde%i$es or tubings"

andatory

E*uip'ent Sa#et$@..!.11 &re lo$ations of &+5s and defibrillators standardied throughout the patient $are

areas of the fa$ility"

8e$ommended

E*uip'ent Sa#et$@..!.12 &re $lo$ks syn$hronied and a$$urate"

8e$ommended

E*uip'ent Sa#et$@..!.13 *as the fa$ility eliminated sterile water (in forms easily $onfused with

medi$ations) from ward sto$k"

8e$ommended

E*uip'ent Sa#et$@..!.1 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


20/25

@..4.! Is a risk assessment for elopement $ompleted at the time of admission ortransfer and regularly during the patients stay"

andatory

E%cape and Elope'ent +re&[email protected].@ Is a system in pla$e to $learly identify high risk es$ape or elopement patients to

staff"

8e$ommended

,all +re&ention@[email protected] &re all patient/resident rooms, pro$edure rooms and $ommon areas pro%ided

with ade'uate lighting so that the patients ability to ambulate safely is notimpeded"

andatory

,all +re&ention@[email protected] &re me$hani$al assist de%i$es used to lift or transfer patients a$$essible and

used by staff when needed"

8e$ommended

,all +re&ention

@[email protected] &re pre%entati%e measures implemented to pre%ent falls from manual liftingand/or handling patients"

8e$ommended

,all +re&ention@[email protected] &re all floors in patient/resident rooms or pro$edure rooms free of en%ironmental

slipping and tripping haards"

andatory

,all +re&ention


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@..@. &re shower/bathroom areas pro%ided with ade'uate lighting, proper drainage,non-slip floor surfa$es, and installed handrails"

andatory

,all +re&ention@..@.! &re $all buttons within rea$h of the patient"

8e$ommended

,all +re&ention@[email protected] &re bed and $hair alarms used and audible, and, are they $onfigured to redu$e

the number of false/unwanted alarms"

andatory

,all +re&ention@..@.@ 5oes the fa$ility ha%e a 0all re%ention < anagement roto$ol or e'ui%alent"

andatory

,all +re&ention@[email protected] Is a uniform tool used to assess whi$h patients are at high risk for falls, and is

there $riteria to determine: 1) #hen they are assessed, and 2) #hat triggers areassessment, in$luding appli$able timeframes"

andatory

,all +re&ention@[email protected] Is there at least one patient lift, 8 table, radiololgy table, et$. a%ailable that has

suffi$ient lifting/holding $apa$ity to meet the needs of bariatri$ patients"

8e$ommended

,all +re&ention


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@[email protected] Is the load $arrying $apa$ity of the e'uipment ob%ious to $are pro%iders"

8e$ommended

,ire Sa#[email protected] &re staff members familiar with fire emergen$y pro$edures, and the fire

pre%ention plan for their ser%i$e area"

andatory

,ire Sa#[email protected] an $lini$al staff identify smoke and fire walls in their immediate area"

andatory

,ire Sa#[email protected] Is the fire alarm signal easily distinguishable from other alarms (e.g., e'uipment,

nurse $all, et$.)"

andatory

,ire Sa#[email protected]. 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"

andatory

In#ection [email protected] &re all linen $arts ($lean and soiled) kept $o%ered and the bottom of the $art is a

solid surfa$e (without openings)"

andatory

In#ection [email protected] &re sharps $ontainers a$$essible and not o%er filled"

andatory

In#ection Control


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@..A.3 Is the fa$ilities late free poli$y being followed in$luding pro%iding late freesupplies and de%i$es"

andatory

In#ection [email protected]. &re the & re$ommended hand hygiene guidelines followed"

andatoryIn#ection [email protected].!Is the integrity of negati%e/positi%e pressure isolation rooms

tested and maintained (on$e per day for o$$upied, monthly for non-o$$upied)" andatoryIn#ection [email protected].!.1Is there a pro$ess in pla$e to establilsh temporarynegati%e/positi%e pressure rooms if they are needed" 8e$ommendedMedical a% Sa#[email protected]&repiped in oygen and $ompressed air identified by a prominent label and not merely by $oloradapters" 8e$ommendedMedical a% Sa#[email protected]&re air flow meters remo%ed when not in use

(for nebulied medi$ation treatments)"8e$ommended

Medical a% Sa#[email protected]

5o staff knowwhere the emergen$y oygen shut-off is, and when and how to use it" andatory)edical as

/afet'*.0.1.02oes the storage and use of porta%le medical gas containers appear to %e in

compliance with C (Compressed as ssociation" /tandards3 )andator' )edicalas /afet'*.0.1.0.2o area&unit personnel know how to correctl' handle ox'gen

c'linders3 )andator' )edical as /afet'*.0.1.4re pins on medical gas regulators

intact, and is damaged e5uipment immediatel' removed from

service3 )andator' )edical as /afet'*.0.1.6re ox'gen c'linders with %all-t'peregulators used with the c'linder in the vertical position3 )andator' )edication

/afet'*.0..re all medication refrigerators maintained

appropriatel'3 )andator' )edication /afet'*.0..2o medication carts remainedlocked and inaccessi%le to patients when not in use3 )andator' )edication

/afet'*.0..+re the tops of medication carts, clean, free of stra' drugs, sharps and

food3 )andator' )edication /afet'*.0..0re receptacles for medication storagelocked and are controlled su%stances dou%le locked3 )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..6.!f

needle-less s'tems are used are emergenc' medication deliver' s'stems for drugs in codecarts and emergenc' drug %oxes compati%le are adaptors provided and


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availa%le3 8ecommended )edication /afet'*.0..6.!f codes are not called within a

specified duration, does the organi9ation use an alternate method (e.g. mock codes" to

maintain staff competenc' with emergenc' medication3 8ecommended )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'*.0..Have concentrated electrol'tesolutions %een removed from patient floors&care areas3 )andator' )edication

/afet'*.0..;.re onl' standard concentrations of high alert medications kept in the

area&unit to minimi9e the potential of calculation and compoundingerrors3 )andator' )edication /afet'*.0..1!s a unit dose medication s'stem used

including li5uids3 8ecommended )edication /afet'*.0..1.re single-dose

perenteral containers (with preference to pre-filed s'ringes" used when

possi%le3 )andator' )edication /afet'*.0..+!s drug preparation done primaril' in thepharmac' and not on care units3 )andator' )edication /afet'*.0..+.!s medication

mixing (admixtures" on inpatient care units a discouraged

practice3 8ecommended )edication /afet'*.0..0re procedures in place to prevent

sterile product use from patient to patient (includingmedications"3 8ecommended )edication /afet'*.0..4re !7 over-wrap %ags

utili9ed and properl' la%eled with manufacturersinstructions3 8ecommended )edication /afet'*.0..6re !7 %ags free of markings,

such as expiration dates, applied %' staff with ink pens or felt markers (prior to

use"3 8ecommended )edication /afet'*.0..*!s an independent dou%le checkcompleted for all infusion pump settings for high alert medications and look alike&sound

alike drugs3 8ecommended )edication /afet'*.0..;re appropriate reversal agents

(fluma9enil, naloxone, protamine, etc." availa%le %ased on the drug %eing administered

and clinical setting3 )andator' )edication /afet'*.0..;.2oes the facilit' trackuse of reversal agents3 8ecommended )edication /afet'*.0..!s there a process for

monitoring


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their prescri%ed medication, as inpatients and as part of the discharge

process3 )andator' )edication /afet'*.0..+42oes the care provided %' >harmacists

meet the clinical needs of the patients in scope and fre5uenc'3 )andator' )edication/afet'*.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..0!s a process in place to reconcile patient medications upon admission,transfer or discharge and is a current list of medications given to the patient when

discharge from a 7)C, and if medications are changed exiting a

clinic3 )andator' eneral >atient /afet' Concerns*.0..!s read-%ack used for allver%al order and critical value reports3 )andator' eneral >atient /afet'

Concerns*.0..re ?C>/ or locall' developed cognitive aids availa%le on the floor for

staff to reference (@scape and @lopement# Fall >revention, etc."3 8ecommended eneral

>atient /afet' Concerns*.0..+re patient&resident records kept confidential, includingcomputer information3 )andator' eneral >atient /afet' Concerns*.0..0re staff

wearing identification %adges and are unauthori9ed persons kept out of patient care

areas3 )andator' eneral >atient /afet' Concerns*.0..4re restraints used in

accordance with local polic' and are restraint alternative devices availa%le and used whenappropriate3 )andator' eneral >atient /afet' Concerns*.0..6re there practices in

place to decrease the likelihood of patient misidentification3 )andator' eneral>atient /afet' Concerns*.0..6.Apon collection of %lood or %lood products is a

informed consent o%tained3 )andator' eneral >atient /afet' Concerns*.0..6.!s the

la%eling of %lood samples or specimens done at the %edside, rather than in %ulk (at thenurses station" to prevent misla%eling3 )andator' eneral >atient /afet'

Concerns*.0..6.+!s there an existing protocol for patient identification with non-

communicative patients3 )andator' eneral >atient /afet' Concerns*.0..*re there

monitoring processes in place for porta%le food and %everage warming or heatingdevices3 8ecommended eneral >atient /afet' Concerns*.0..re handoffs %etween

shifts or transfer of care %etween units standardi9ed3 )andator' eneral >atient /afet'

Concerns*.0..;!s the transfer of care %etween disciplines for off-unit appointmentsstandardi9ed, including the continuation of monitoring patient status and patient medical

devices such as !7 pumps and ox'gen level while the patient is visiting, %eing

treated&tested, and during transport3 8ecommended eneral >atient /afet'Concerns*.0..1re patients searched and residents 5uestioned for contra%and upon

admission to each applica%le area&unit3 8ecommended eneral >atient /afet'

Concerns*.0..2oes the facilit' have an emergenc' response protocol for dealing

with disruptive patients3 8ecommended eneral >atient /afet' Concerns*.0..=henperforming procedures outside of the operating room are appropriate sedation protocols

and privileges followed when applica%le3 )andator' /urgical or !nvasive >rocedure

>recautions*.0.0.Has the 7H B8 /elf ssessment : /elf-ssessment Tool forB%serving /teps 8e5uired %' 7H 2irectives 110-1 (@nsuring Correct /urger' and

!nvasive >rocedures" and 116-1+1 (>revention of 8etained /urgical !tems, %eing

used3 )andator'

Patient Safety Indicators WHO

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