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HOSPITAL NATIONAL PATIENT SAFETY GOALS - 2010
2010 NPSG
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GOAL 1; IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION
GOAL 1; IMPROVE THE ACCUR
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01.01.01 Use at least two patient identifiers when providing care, treatment, and services.
01.01.01
Two Pt identifiers
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EP1 Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient`s room number or physical location is not used as an identifier
Two Pt identifiers
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See also MM.05.01.09, EPs 8 and 11; NPSG.01.03.01, EP 1
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01.03.01 Eliminate transfusion errors related to patient misidentification.
01.03.01
Eliminate trans errors
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true
1
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EP1 Before initiating a blood or blood component transfusion:
Match blood/Patient
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Note: If two individuals are not available, an automated identification technology (for example, bar coding) may be used in place of one of the individuals.
2
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1
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Match the blood or blood component to the order.
Match blood or component
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1
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Match the patient to the blood or blood component.
Match pt to component
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true
1
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Use a two-person verification process (See also NPSG.01.01.01, EPs 1 and 2)
Use a two-person verifica
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EP2 When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient.
Qualif transfusionist
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true
1
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EP3 When using a two-person verification process, the second individual conducting the identification verification is qualified to participate in the process, as determined by the hospital.
Identifica verification
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GOAL 2; IMPROVE THE EFFECTIVENESS OF COMMUNICATION AMONG CAREGIVERS
IMPROVE EFFECTIVENESS
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0
11
1
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true
1
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e1dfe2a3-11eb-43db-b5b6-3198c0148a99
02.03.01 Report critical results of tests and diagnostic procedures on a timely basis.
02.03.01
Rpts critical results
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EP1 Develop written procedures for managing the critical results of tests and diagnostic procedures that address the following:
Develop procedure
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The definition of critical results of tests and diagnostic procedures
Def of critical results
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By whom and to whom critical results of tests and diagnostic procedures are reported
By whom reported
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The acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures
Acceptable length/time
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1
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EP2 Implement the procedures for managing the critical results of tests and diagnostic procedures.
Implement procedure
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true
1
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EP3 Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.
Evaluate the timeline
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GOAL 3; IMPROVE THE SAFETY OF USING MEDICATIONS
IMPROVE SAFETY
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03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
03.04.01
Label all Medications
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Note: Medication containers include syringes, medicine cups, and basins.
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EP1 In perioperative and other procedural settings both on and off the sterile field, label medications and solutions that are not immediately administered. This applies even if there is only one medication being used.
Meds not immed admin
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Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process. Refer to NPSG.03.04.01, EP 5, for information on timing of labeling.
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EP2 In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container.
Labeling when transfered
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EP3 In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the following:
Solution labels include
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Medication name
Medication name
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Strength
Strength
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Quantity
Quantity
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Diluent and volume (if not apparent from the container)
Diluent and volume
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Preparation date
Preparation date
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Expiration date when not used within 24 hours
Expiration date w/24hrs
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Expiration time when expiration occurs in less than 24 hours
Expiration time w/24hrs
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Note: The date and time are not necessary for short procedures, as defined by the hospital.
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EP4 Verify all medication or solution labels both verbally and visually. Verification is done by two individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it.
EP4 Verify all medication
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EP5 Label each medication or solution as soon as it is prepared, unless it is immediately administered.
EP5 Label each medication
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Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process.
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EP6 Immediately discard any medication or solution found unlabeled
Immed discard unlabeled
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EP7 Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.
Discard contents
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Note: This does not apply to multiuse vials that are handled according to infection control practices.
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EP8 All medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting staff responsible for the management of medications.
Labels are reviewed
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03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
03.05.01
Reduce Pt harm
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Note: This requirement applies only to hospitals that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation will remain within, or close to, normal values.
2
true
3
100
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EP1 Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available.
EP1 Use only oral unit-do
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Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children.
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EP2 Use approved protocols for the initiation and maintenance of anticoagulant therapy.
EP2 Use approved protocol
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true
3
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EP3 Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record.
Before warfarin
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3
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EP4 Use authoritative resources to manage potential food and drug interactions for patients receiving warfarin.
Authoritative resources
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0
true
3
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EP5 When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing.
Heparin is admin intrav
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true
3
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EP6 A written policy addresses baseline and ongoing laboratory tests that are required for heparin and low molecular weight heparin therapies.
Policy addresses baseline
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3
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EP7 Provide education regarding anticoagulant therapy to staff, patients, and families. Patient/family education includes the following:
Edu on anticoagulant ther
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The importance of follow-up monitoring
Follow up monitoring
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3
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Compliance
Compliance
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1
0
45
3
3
0
true
3
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54045042-d1a1-4557-babb-4422c6e508f7
Drug and food interactions
Drug and food interaction
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1
0
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3
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0
true
3
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e9d3d7d3-e849-42bc-b0f6-75b09d3198cd
The potential for adverse drug reactions and interactions
Adverse reactions
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0
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3
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0
true
3
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EP8 Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization.
Evaluate anticoag safety
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0
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GOAL 7; REDUCE THE RISK OF HEALTH CARE–ASSOCIATED INFECTIONS
REDUCE RISK OF INFECT
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1
0
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true
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003a21ca-fbdf-4ba1-80dd-f361f44e6880
07.01.01: Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
07.01.01
Comply w/the CDC & WHO
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0
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1
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2
true
1
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EP1 Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 5)
Implement program
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1
0
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2
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0
true
1
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EP2 Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 3)
Set goals for improving
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0
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true
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EP3 Improve compliance with hand hygiene guidelines based on established goals.
Improve compliance
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0
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2
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83a5003c-015a-4ac7-b500-819d406becf3
07.03.01: Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.
07.03.01
Prevent Infections
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Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria.
2
true
1
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EP1 Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug-resistant organism acquisition and transmission.
Conduct periodic risk
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0
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0
true
1
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EP2 Based on the results of the risk assessment, educate staff and licensed independent practitioners about health care–associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter.
Educate staff
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Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the hospital.
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1
100
bb50379f-c91f-40c4-b0cb-37af0f0ee7dd
EP3 Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care–associated infection strategies.
Infected or colonized
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
57
2
3
0
true
1
100
484a4405-c804-42f1-b057-144c45933846
EP4 Implement a surveillance program for multidrug-resistant organisms based on the risk assessment.
Imple surveil program
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
58
2
3
0
true
1
100
80c967ec-7d10-407d-bb0d-0fee91c0cb72
EP5 Measure and monitor multidrug-resistant organism prevention processes and outcomes, including the following:
Measure/monitor outcomes
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
59
2
3
Note: Surveillance may be targeted rather than hospital-wide.
2
true
1
100
a49c1d53-a057-45d8-bfb0-520fed6f0971
Multidrug-resistant organism infection rates using evidence-based metrics
Organism infection
0
1428903e-ff00-4067-9dc0-a659544e064b
80c967ec-7d10-407d-bb0d-0fee91c0cb72
1
0
60
3
3
0
true
1
100
ee2c6745-6c36-4130-97dd-b33863fa3d0b
Compliance with evidence-based guidelines or best practices
Compliance w/guidelines
0
1428903e-ff00-4067-9dc0-a659544e064b
80c967ec-7d10-407d-bb0d-0fee91c0cb72
1
0
61
3
3
0
true
1
100
b6c3a78b-4469-4e14-a367-227aedcbdf61
Evaluation of the education program provided to staff and licensed independent practitioners
Eval of edu program
0
1428903e-ff00-4067-9dc0-a659544e064b
80c967ec-7d10-407d-bb0d-0fee91c0cb72
1
0
62
3
3
Note: Surveillance may be targeted rather than hospital-wide.
0
true
1
100
6d721982-6f4a-4f05-b86b-ff55bc6b4838
EP6 Provide multidrug-resistant organism process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.
Provide outcome key
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
63
2
3
0
true
1
100
dcbc8d25-ebbd-4b20-afce-73503d44a535
EP7 Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).
P&P on reducing risk
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
64
2
3
0
true
1
100
3e918b6a-87f1-4633-a469-aa3f47bd0202
EP8 When indicated by the risk assessment, implement a laboratory-based alert system that identifies new patients with multidrug-resistant organisms.
Laboratory alert system
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
65
2
3
Note: The alert system may use telephones, faxes, pagers, automated and secure electronic alerts, or a combination of these methods.
0
true
1
100
164cc9b8-724a-4224-b4f9-8dac41eb231a
EP9 When indicated by the risk assessment, implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms.
Readmitted/transfered
0
1428903e-ff00-4067-9dc0-a659544e064b
83a5003c-015a-4ac7-b500-819d406becf3
1
0
66
2
3
Note 1: The alert system information may exist in a separate electronic database or may be integrated into the admission system. The alert system may be either manual or electronic or a combination of both. Note 2: Each hospital may define its own parameters in terms of time and clinical manifestation to determine which re-admitted patients require isolation.
0
true
1
100
082fd06a-4247-4e84-b62f-c707e5b70c06
07.04.01: Implement evidence-based practices to prevent central line–associated bloodstream infections.
07.04.01
Central-line infections
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
67
1
3
Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.
2
true
1
100
18bbcc1e-3d3a-44c1-bdfe-3c16c15222cb
EP1 Educate staff and licensed independent practitioners who are involved in managing central lines about central line–associated bloodstream infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities.
Educate staff involved
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
68
2
3
0
true
1
100
2708ae74-5615-4a2d-bc95-55365119d036
EP2 Prior to insertion of a central venous catheter, educate patients and, as needed, their families about central line–associated bloodstream infection prevention.
Edu on central catheter
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
69
2
3
0
true
1
100
66129629-225c-4382-a4d4-97d0dc387603
EP3 Implement policies and practices aimed at reducing the risk of central line–associated bloodstream infections. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).
P&P on reducing risk
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
70
2
3
0
true
1
100
cd9ea30a-923c-4dab-8614-fdc83e090104
EP4 Conduct periodic risk assessments for central line–associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the hospital, and this infection surveillance activity is hospital-wide, not targeted.
Periodic risk assessments
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
71
2
3
0
true
1
100
090d853f-8448-4515-8dca-3bd4d57029e7
EP5 Provide central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.
Infection rate data/prev
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
72
2
3
0
true
1
100
0aeb8609-ba48-4aa0-a3ee-10fdcb6251fe
EP6 Use a catheter checklist and a standardized protocol for central venous catheter insertion.
Use catheter checklist
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
73
2
3
0
true
1
100
e9c18279-6f46-4a2f-91bc-f19ea5c334de
EP7 Perform hand hygiene prior to catheter insertion or manipulation
Hand hygiene prior
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
74
2
3
0
true
1
100
b6483511-8c38-4819-912c-6eb555f6ea77
EP8 For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.
Adult Pts do not insert
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
75
2
3
0
true
1
100
570202ee-f2d2-4ae9-a83f-afa23644565c
EP9 Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters.
Standardized cart & kit
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
76
2
3
0
true
1
100
3ce9055e-f712-4a42-bc5b-d384307fc27e
EP10 Use a standardized protocol for sterile barrier precautions during central venous catheter insertion.
Sterile barrier precaut
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
77
2
3
0
true
1
100
eaa740fa-69ec-4d10-b1a7-ca20bd273f5b
EP11 Use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over 2 months of age, unless contraindicated.
Antiseptic for skin prep
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
78
2
3
0
true
1
100
c8cecebd-a50e-47b6-bb53-e0168539519f
EP12 Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.
Protocol to disinfect
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
79
2
3
0
true
1
100
d9c61563-7efb-4f5b-8852-bae206b97f4c
EP13 Evaluate all central venous catheters routinely and remove nonessential catheters.
Evaluate central catheter
0
1428903e-ff00-4067-9dc0-a659544e064b
082fd06a-4247-4e84-b62f-c707e5b70c06
1
0
80
2
3
0
true
1
100
17b0b01d-09a2-4ee8-af08-69791ef586ef
07.05.01: Implement evidence-based practices for preventing surgical site infections.
Surgical site infections
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
81
1
3
2
true
1
100
8fb1c189-598a-4395-b46e-0f611145801e
EP1 Educate staff and licensed independent practitioners involved in surgical procedures about surgical site infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities.
Edu on surg site infec
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
82
2
3
0
true
1
100
527eb3cb-c5b9-432b-94d3-2923c5efbf9a
EP2 Educate patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.
Educate pt and family
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
83
2
3
0
true
1
100
830080c7-8506-4d04-bcee-b03328a2b88d
EP3 Implement policies and practices aimed at reducing the risk of surgical site infections. These policies and practices meet regulatory requirements and are aligned with evidence-based guidelines (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).
P&P surgical site infect
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
84
2
3
0
true
1
100
24b2b62a-0823-4c40-903c-27a927050a81
EP4 As part of the effort to reduce surgical site infections:
Reduce surg site infect
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
85
2
3
2
true
1
100
f6f75e08-a8d3-4c03-85c4-d48df3813285
Conduct periodic risk assessments for surgical site infections in a time frame determined by the hospital.
Periodic risk assess
0
1428903e-ff00-4067-9dc0-a659544e064b
24b2b62a-0823-4c40-903c-27a927050a81
1
0
86
3
3
0
true
1
100
c601e67d-c54b-406f-a927-d78bcef01f6b
Select surgical site infection measures using best practices or evidence-based guidelines.
Site infection measures
0
1428903e-ff00-4067-9dc0-a659544e064b
24b2b62a-0823-4c40-903c-27a927050a81
1
0
87
3
3
0
true
1
100
1fa7cd6b-ccb9-482f-a5cc-0a8142bf314b
Monitor compliance with best practices or evidence-based guidelines
Monitor compliance
0
1428903e-ff00-4067-9dc0-a659544e064b
24b2b62a-0823-4c40-903c-27a927050a81
1
0
88
3
3
0
true
1
100
46b21e86-0cf8-4479-9e1f-1ab2bf58610f
Evaluate the effectiveness of prevention efforts.
Evaluate the effectivenes
0
1428903e-ff00-4067-9dc0-a659544e064b
24b2b62a-0823-4c40-903c-27a927050a81
1
0
89
3
3
Note: Surveillance may be targeted to certain procedures based on the hospital’s risk assessment.
0
true
1
100
d8cd8c9e-febe-41a3-93e7-46b85dd1790e
EP5 Measure surgical site infection rates for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices. The hospital’s measurement strategies follow evidence-based guidelines.
Measure surgical site
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
90
2
3
Note: Surveillance may be targeted to certain procedures based on the hospital`s risk assessment.
0
true
1
100
b10a64d9-20c7-4b70-a001-da91a1e6258f
EP6 Provide process and outcome (for example, surgical site infection rate) measure results to key stakeholders.
Provide process/outcome
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
91
2
3
0
true
1
100
dfbff43e-aab0-43e6-acd1-1cbcdb31fe1a
EP7 Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to evidence-based best practices.
Admin antimicrobial agent
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
92
2
3
0
true
1
100
bf04cc06-52aa-443c-b393-a6e948d21f90
EP8 When hair removal is necessary, use clippers or depilatories.
Hair removal w/clippers
0
1428903e-ff00-4067-9dc0-a659544e064b
17b0b01d-09a2-4ee8-af08-69791ef586ef
1
0
93
2
3
Note: Shaving is an inappropriate hair removal method.
0
true
1
100
5172deff-84dd-41bc-9471-bd8c2f224bca
GOAL 15; THE HOSPITAL IDENTIFIES SAFETY RISKS INHERENT IN ITS PATIENT POPULATION
IDENTIFIES SAFETY RISK
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
94
1
3
2
true
1
100
33612c8a-75df-4c3c-8c71-f22f47e2f6c1
15.01.01: Identify patients at risk for suicide.
15.01.01
Pts at risk for suicide
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
95
1
3
Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
2
true
1
100
5fb70ab8-b1d7-4cdd-a9dd-6ff8190158ed
EP1 Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
Pt charc & environment
0
1428903e-ff00-4067-9dc0-a659544e064b
33612c8a-75df-4c3c-8c71-f22f47e2f6c1
1
0
96
2
3
0
true
1
100
0d040a78-b8a4-41c5-a106-9970658959a5
EP2 Address the patient’s immediate safety needs and most appropriate setting for treatment.
Address safety needs
0
1428903e-ff00-4067-9dc0-a659544e064b
33612c8a-75df-4c3c-8c71-f22f47e2f6c1
1
0
97
2
3
0
true
1
100
8f9507a9-2ff3-4452-a649-4755a2b049a5
EP3 When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
Provide suicide prev info
0
1428903e-ff00-4067-9dc0-a659544e064b
33612c8a-75df-4c3c-8c71-f22f47e2f6c1
1
0
98
2
3
0
true
1
100
d8cb3380-ea20-4c3c-8043-522a7228a9d8
UP.01.01.01: Conduct a pre procedure verification process.
UP.01.01.01
Preprocedure verification
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
99
1
3
2
true
1
100
7c305690-b506-4f13-862f-b143b6a19eb5
EP1 Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.
Verify correct procedure
0
1428903e-ff00-4067-9dc0-a659544e064b
d8cb3380-ea20-4c3c-8043-522a7228a9d8
1
0
100
2
3
0
true
1
100
73fdc5fa-4139-4be5-b7b0-545910adf604
EP2 Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:
Standardized list
0
1428903e-ff00-4067-9dc0-a659544e064b
d8cb3380-ea20-4c3c-8043-522a7228a9d8
1
0
101
2
3
0
true
1
100
04a84b9a-9751-4271-b332-92b410956cf6
Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and preanesthesia assessment)
Relevant documentation
0
1428903e-ff00-4067-9dc0-a659544e064b
73fdc5fa-4139-4be5-b7b0-545910adf604
1
0
102
3
3
0
false
1
100
127269bb-61c8-4bcf-b4f8-6048a5b2e764
Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed
Labeled test results
0
1428903e-ff00-4067-9dc0-a659544e064b
73fdc5fa-4139-4be5-b7b0-545910adf604
1
0
103
3
3
0
false
1
100
c6563258-436c-47c1-aba6-feb611e2c513
Any required blood products, implants, devices, and/or special equipment for the procedure
Any required blood prod
0
1428903e-ff00-4067-9dc0-a659544e064b
73fdc5fa-4139-4be5-b7b0-545910adf604
1
0
104
3
3
Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the preprocedure verification. It is not necessary to document that the standardized list was used for each patient.
0
false
1
100
29bf4215-53fe-446d-9ca8-497f21ffc65a
EP3 Match the items that are to be available in the procedure area to the patient
Match items available
0
1428903e-ff00-4067-9dc0-a659544e064b
d8cb3380-ea20-4c3c-8043-522a7228a9d8
1
0
105
2
3
0
true
1
100
73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
UP.01.02.01: Mark the procedure site.
UP.01.02.01
Mark the procedure site
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
106
1
3
2
true
1
100
30007135-ec5b-4529-91f2-9a6908edeeb3
EP1 Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.
Marking of the incision
0
1428903e-ff00-4067-9dc0-a659544e064b
73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
1
0
107
2
3
Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intraoperative imaging techniques may be used for locating and marking the exact vertebral level.
0
true
1
100
b5ca5286-c66d-4b3d-ab2b-3cfb45d4e866
EP2 Mark the procedure site before the procedure is performed and, if possible, with the patient involved.
Mark site before proced
0
1428903e-ff00-4067-9dc0-a659544e064b
73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
1
0
108
2
3
0
true
1
100
eb6b7a53-7de2-42e4-9f4f-16f9a2497699
EP3 The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:
Site marked by LIP
0
1428903e-ff00-4067-9dc0-a659544e064b
73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
1
0
109
2
3
2
true
1
100
19c25ba2-eb42-41f6-ab6c-78602e931fe2
An individual in a medical residency program who is being supervised by the licensed independent practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed
Medical residency program
0
1428903e-ff00-4067-9dc0-a659544e064b
eb6b7a53-7de2-42e4-9f4f-16f9a2497699
1
0
110
3
3
0
true
1
100
c6313d47-dfa1-44d5-be46-aea6a1ee5b94
A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure (that is, an advanced practice registered nurse (A.P.R.N.) or physician assistant (P.A.)); who is familiar with the patient; and who will be present when the procedure is performed.
Collaborative agreement
0
1428903e-ff00-4067-9dc0-a659544e064b
eb6b7a53-7de2-42e4-9f4f-16f9a2497699
1
0
111
3
3
0
true
1
100
1b8f1056-9c4f-4362-9770-6c5dad977f24
EP4 The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital.
Method of marking site
0
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73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
1
0
112
2
3
Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site.
0
true
1
100
a4718a32-7f96-46a7-8e8c-bb9dec8a12b2
EP5 A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).
EP5 A written, alternativ
0
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73eafa8e-9b79-4f2b-9b98-ac2c41ebddb4
1
0
113
2
3
0
true
1
100
7514d53a-5143-4b12-89a2-c74e6a3dd0f9
UP.01.03.01: A time-out is performed before the procedure.
UP.01.03.01
Time-out before proced
0
1428903e-ff00-4067-9dc0-a659544e064b
1428903e-ff00-4067-9dc0-a659544e064b
1
0
114
1
3
2
true
1
100
4353a706-af5f-4599-9282-3a312b8f2fb6
EP1 Conduct a time-out immediately before starting the invasive procedure or making the incision.
Time-out immed before
0
1428903e-ff00-4067-9dc0-a659544e064b
7514d53a-5143-4b12-89a2-c74e6a3dd0f9
1
0
115
2
3
0
true
1
100
3925ec2c-f2ac-4ace-8451-e5ae490a40bb
EP2 The time-out has the following characteristics:
Following characteristics
0
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7514d53a-5143-4b12-89a2-c74e6a3dd0f9
1
0
116
2
3
2
true
1
100
a330ffa1-bbe0-4d57-ab37-97787ce65734
It is standardized, as defined by the hospital
Defined by the hospital
0
1428903e-ff00-4067-9dc0-a659544e064b
3925ec2c-f2ac-4ace-8451-e5ae490a40bb
1
0
117
3
3
0
true
1
100
669c73a0-74fe-4c05-83a5-bb400c8a4099
It is initiated by a designated member of the team
Initiated by team memb
0
1428903e-ff00-4067-9dc0-a659544e064b
3925ec2c-f2ac-4ace-8451-e5ae490a40bb
1
0
118
3
3
0
true
1
100
e2dd1589-1413-4215-b391-b80c57825174
It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.
Involves all members
0
1428903e-ff00-4067-9dc0-a659544e064b
3925ec2c-f2ac-4ace-8451-e5ae490a40bb
1
0
119
3
3
0
true
1
100
5ea8c709-643a-410a-8e42-59ae301a0613
EP3 When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.
Time out procedure
0
1428903e-ff00-4067-9dc0-a659544e064b
7514d53a-5143-4b12-89a2-c74e6a3dd0f9
1
0
120
2
3
0
true
1
100
4c71e213-b85b-45d0-87b5-7b36406c7e2f
EP4 During the time-out, the team members agree, at a minimum, on the following
Agreement during time-out
0
1428903e-ff00-4067-9dc0-a659544e064b
7514d53a-5143-4b12-89a2-c74e6a3dd0f9
1
0
121
2
3
2
true
1
100
9e7e1a37-36b5-4bc4-9b4c-a94bbfe7e983
Correct patient identity
Correct patient identity
0
1428903e-ff00-4067-9dc0-a659544e064b
4c71e213-b85b-45d0-87b5-7b36406c7e2f
1
0
122
3
3
0
true
1
100
042b2679-7de0-4e4b-973c-3ae74f4e8eb5
The correct site
The correct site
0
1428903e-ff00-4067-9dc0-a659544e064b
4c71e213-b85b-45d0-87b5-7b36406c7e2f
1
0
123
3
3
0
true
1
100
afa0adf3-68be-4a90-81ce-8481122b1fab
The procedure to be done
The procedure to be done
0
1428903e-ff00-4067-9dc0-a659544e064b
4c71e213-b85b-45d0-87b5-7b36406c7e2f
1
0
124
3
3
0
true
1
100
a4c09ee0-6fac-485e-9674-31acf047a9b5
EP5 Document the completion of the time-out
Doc completion time-out
0
1428903e-ff00-4067-9dc0-a659544e064b
7514d53a-5143-4b12-89a2-c74e6a3dd0f9
1
0
125
2
3
Note: The hospital determines the amount and type of documentation
0
true
1
100