NPSG
Mix
Life Safety/EOC
Record of Care
Provision of Care
100
Improve the accuracy of patient identification (give 2 examples of when/how).
Two identifiers; checking patients in, lab specimens, medication administration
100
RI: The hospital respects, protects, and promotes patients rights.
Patient Bill of Rights in waiting rooms, support and maintain dignity, communicate effectively, religious preferences, right to pain management.
100
The hospital maintains the integrity of the means of egress (how).
Doors swing in flow of egress, not blocked, egress doors not locked
100
The hospital maintains complete and accurate medical records for each individual patient (give examples).
dated, signed, standard forms/processes, tracks locations of records, justify treatment plans, etc.
100
The hospital assesses and manages the patient's pain (give two examples of how).
writes orders, no duplication/overlap (tylenol), reassess per med type, pain scale, assess with pain scale per age/condition.
200
Improve the effectiveness of communication among caregivers (give 2 examples of when/how)
patient handoffs, calling report, critical results
200
RI: The hospital honors the patient's right to give or withhold informed consent.
written policy (command instruction), who to get consent from, consent includes discussion of proposed treatment and risks/benefits, alternatives in care, obtained prior to surgery (ex emergencies).
200
The hospital manages safety and security risks (examples).
takes actions to minimize, controls access; identifies those coming and going; hospital ID badges current, cameras, manages MRI risks, respond to product recalls, defined security procedures to risks.
200
The hospital audits medical records (how).
MRRC, peer review (nurse and providers), etc.
200
The hospital assesses the patient who may be a victim of possible abuse and neglect (give examples).
listening, injuries not consistent with story, behaviors of those who accompany them, staff education, reports to authorities, list of agencies.
300
Improve the safety of using medications (give 2 examples of when/how).
label syringes/administration devices, 2 verifiers with high alert, handoffs with meds verbalized, etc.
300
PI: The hospital collects data to monitor its performance.
which data to collect, what you do with the data, staff surveys, important data (blood usage, ADE, CPR)
300
Hospital manages fire risks (examples).
fire response plan, no smoking near building, minimize combustibles, maintains egress routes--clear of clutter), etc.
300
The hospital retains its medical records (how).
retain per laws, accurate tracking, double locks.
300
The hospital recognizes and responds to changes in patient's condition (give examples).
process for recognizing, training staff, what to do when deteriorating, seek assistance (RRT), educate family when to alert staff.
400
Reduce the harm associated with clinical alarm systems (give 2 examples of how/when).
do not mute alarms, validate parameters set, alert team with parameters changed, establish policies of actions needed when alarms alert
400
MM: The hospital safely stores medications.
Omnicell, locked, limited access, nothing left out, high risk meds locked, pharmacy mixes and prepares ready made meds to protect staff from errors, etc.
400
The hospital inspects, tests, and maintains medical equipment (examples).
Med Repair, PMs current, no frayed cords, maintains sterilizers, maintains CT/MRI scanner
400
Medical record contains a summary list.
initiated by 3rd visit, contains complete list (with allergies), readily available to all who care for the patient, updated when needed
400
The patient's personal hygiene is maintained (give examples).
oral care, offering towels and soap, educating patients/families, assist those with toiling and cleaning
500
Reduce the risk of health-care associated infections (give 2 examples of how/when).
hand washing, policies for MDRO, report SSI, remove foley catheters within 48 hours (or reevaluate, write an order to continue), etc.
500
MM: The hospital addresses the safe use of LASA meds.
posters of lists of meds, takes action to prevent (tall man), reviews list.
500
The hospital provides and maintains equipment for extinguishing fires (examples).
fire extinguishers checked and maintained, sprinkler heads free of clutter
500
The medical record contains information that reflects the patient's care, treatment, services (what content).
demographics, clinical diagnosis, allergies, PMH, consult reports, emergency services, orders, medications, ADE, advance directives, etc.
500
The hospital provides patient education and training based on each patient's needs and abilities (give examples).
conduct learning assessment based off of age, education to patients, educate staff,
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