Patient History and Physical is on the record within 24 hours following admission
Patients receive confirmation through at least two identifiers prior to blood tests and specimen collection
Patients receive confirmation through at least two identifiers prior to surgery initiation
Patients receive confirmation through at least two identifiers prior to diagnosis or procedure administration
Patients require identification prior to contact with infants
System in place to prevent infant abduction
Infection Control practices in place for visitors
The patient room number is never used as an identifier
Wrong site surgery precautions include:
Site protocols are followed systematically
Site marking
Patient interview and confirmation
Triple check in the surgery suite prior to surgery initiation
Family members are involved whenever possible
Blood and other specimen containers are labeled in the presence of the patient or patient's family
Privacy for reasons for tests are not communicate to unauthorized persons
Phone orders and phone test results are "read back" to confirm accuracy
The orders are written in the patient's chart at the time of the phone contact
Standardized acceptable abbreviations, acronyms, symbols and dose designations are readily available to staff
Staff is educated to sound-a-like and look-a-like drugs. A list is kept at each nursing station.
The hospital has a standardized of unacceptable abbreviations, acronyms, symbols and dose designations available to staff.
Charting is completed prior the end of each shift
Time allowances for order entry is clearly defined and enforced
Time allowance for entry of test criteria is clearly defined and enforced
A system is in place and enforced to "hand off" information between shifts
An accurate complete list of medications is compiled upon admission
All medications are labeled
Drug name
Patients Name
Expiration Date
Strength
Amount
Route
Dose
Medication administration is triple checked for order, patient, dose, route and counter indications
All unused medication open in the sterile field are discarded
Patients receiving anti-coagulant therapy are followed according to the National Patient Standards 2008
Individualized Plan
Patients having Warfin therapy have a baseline International Normalized Ratio (INR) baseline
Patients having Warfin therapy have a current International Normalized Ratio (INR) baseline to know when to adjust therapy
Dietary is notified when patients are on Warfin therapy
When Heparin is administered intravenously and continuously programmable infusion pumps are used
Lab tests are conducted to monitor anti-coagulant therapy
The patient and family members are educated regarding anti-coagulant therapy
Staff know when and how to ask for specialized assistance
Patients are educated regarding their care during the stay
Patients are educated regarding their care upon discharge
Patients are informed regarding charges for care provided
Patients are not refused care due to inability to pay
Patient's religious, cultural and ethnic differences are respected
Urgent response system is effective and implemented on all units
Patients are informed regarding staff and physician names
Restraints:
Policies and procedures outline qualified applications
Physician or Registered Nurse evaluation is completed within one hour of the emergency application of a restraint
Patients have the right to refuse care and depart AMA; such decisions are documented in the patient's record an contain the signature of the patient or surrogate
Patients receive documents written information regarding rights to refuse treatment and end of life decisions
End of life decisions are recorded in the patient's record
Patient's are informed regarding inclusion or exclusion of organ donation
Pain is assessed regularly and clearly documented per shift
Patients are assessed for needs including:
Medical history
Current medical condition
Psychological condition
Social condition
Nutritional and hydration
Functional status
Cultural variances
Admission nursing assessment is completed within 24 hours from time of admission
Nutritional screening is completed within 24 hours of admission
