On-going risk assessments are conducted in each department to evaluate policies, processes and procedures with the goal of preventing risks and adverse events
A proactive system exists to identify on-going risks to patient safety, reduction of medication errors and medical errors
Wrong site surgery protocols are evaluated against surgery performance
Corrective action is initiated to deter recurrence of Sentinel Events
Root Cause Analysis is conducted for all Sentinel Events
All employees know how to report a sentinel event
The most frequent sentinel event is the focus of correction efforts for at least 12 months following initiation of plan of correction
The most frequent sentinel event is the focus of correction efforts for at least 12 months following initiation of plan of correction
Failure mode events are given high priority
Policies and Procedures are updated as changes are implemented
Policies and Procedures do not conflict with other department's Policies and Procedures
Barriers to communication are identified and remediated: interpreters are available to all patients
Hospital marketing materials accurately represent services available
Hospital identifies what constitutes a conflict of interest
Informed consent policy includes:
Which procedures require Informed Consent
The process used to obtain informed consent
How Informed Consent is documented in the patient's record
When a surrogate decision maker can grant consent
Circumstances when emergency procedures do not require Informed Consent
Informed Consent contains:
Nature of the proposed treatment, procedure, care, diagnostic test, medication
Potential benefits, risks, side effects and recovery risks and expectations
The likelihood of achieving treatment goals
Reasonable alternatives related to the treatment or care
Risks and benefits related to alternative care
End of life instructions are available for patients and patient surrogates
Documentation indicates the patient's refusal to sign Advance Directives
Organ donation policies are in place
Patients and families are informed regarding filing complaints
Complaint resolution is documented
Resolved complaints are reported to patients and families
Patients and families are informed regarding filing complaints with state agencies
Policies exist to prevent abuse, neglect and exploitation
Patients are informed regarding how to access adult and child protection agencies
Policies address when to discharge patients when treatment needs exceed the capabilities of the hospital
Contractual agreements are in place for receiving hospitals
Policies include provisions of care the hospital cannot provide
Policies are in place to evaluate victims of crimes, abuse or neglect
Policies include provisions for referral to law enforcement agencies when abuse, criminal acts or neglect is identified
Policies are in place to address patients identified with alcoholism and substance abuse disorders
Policies are in place to address patients identified with psychological, developmental and emotional disorders
Discharge planning is initiated immediately upon admission. Patients and families are included in discharge planning
Patients are informed how to obtain continuing care after discharge
The Infection Control Program is evaluated with a risk analysis at least annually
Pro-active Risk Assessments are conducted at least annually
