Docstoc

Sample Forms of Informed Consent and Forensic Evaluation

Document Sample
Sample Forms of Informed Consent and Forensic Evaluation Powered By Docstoc
					Patient Safety Assessment Tool
        Version 4-2005
ment Tool
 Patient Safety Assessment Tool
     Administration Elements
Element 1
Management and Leadership

Element 2
Patient Safety Program Management

Element 3
JCAHO (CAM-H)

Element 4
Procurement and Equipment Management

Element 5
Recalls and VA Alerts & Advisories

Element 6
Patient Safety Policies, Tools & Aids
                                                     NCPS Patient Safety Assessment Tool
                                                           Part I - Administrative
   MANAGEMENT AND LEADERSHIP - Element 1
                                                                                                                                                 *Not
                                                                                                                             *Met   *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                            (1)    Met (2)      (3) possible root causes
              Leadership/Support
   1.1.1      Does a non-punitive environment        Interviews and review of SPOT data.
              exist that promotes reporting of
              errors and mistakes?
              Mandatory;Priority = A                 JCAHO Std: PI.2.30, PI.3.20, LD.4.40
                                                     NCPS Handbook: 4.e.1.b (pg. 4); 5.b (pg. 5)
              Leadership/Support
   1.1.2      Are staff made available to serve on   Review RCA's looking for a mix of staff
              RCA teams including physicians         participation and interview Patient Safety
              and employees on off-tours when        Managers and upper management. Employees
              needed?                                who work on second and third shifts and
                                                     weekends should be documented in the RCA's.
                                                     The PSM should keep management abreast of
                                                     the participation status.

              Mandatory;Priority = A                 JCAHO Std: LD.4.10; LD.4.60
                                                     NCPS Handbook: 4.e.4.a (pg.4)
              Leadership/Support
   1.1.3      Is the Patient Safety Manager          Interview PSM and management.
              permitted to charter RCA teams
              based upon the SAC score without
              approval from his/her supervisor or
              top management?
              Recommended; Priority A                JCAHO Std: LD.4.50; LD.4.60
              Leadership/Support
   1.1.4      Do RCA teams meet with top             Interview PSM and management. Evidence
              management to discuss their            should show management interaction with the
              findings and recommendations?          teams, hence suggestions/recommendations
                                                     made. Nor should reports be without
                                                     justification for actions not approved.
              Mandatory;Priority = A                 JCAHO Std: LD.4.10; LD.4.40
                                                     NCPS Handbook: 4.e.4.d (pg. 5)
              Leadership/Support
   1.1.5      Are close call reports being           Review SPOT for potential SAC scores of 1, 2,
              received?                              and 3. Have PSM show specific examples of
                                                     close calls.
              Mandatory;Priority = A                 JCAHO Std: LD.3.20; LD.4.40
                                                     NCPS Handbook: 4.c-4.c.2 (pg. 3); 5.b (pg. 5); 6..a.3(pg.6);6.I(pg.7)




Mgt Ldr - 1                                                                               Version: 04.21.2005                                                                         4 of 257
                                                      NCPS Patient Safety Assessment Tool
                                                            Part I - Administrative
   MANAGEMENT AND LEADERSHIP - Element 1
                                                                                                                                   *Not
                                                                                                               *Met   *Partially   Met If score other than 'met' what are
              Question:                               Rationale/Assessment Methods:                             (1)    Met (2)      (3) possible root causes
              Leadership/Support
   1.1.6      Are lessons learned from RCAs and       Reports to VISN, or others that have been
              best practices shared with the          shared. Methods for sharing information could
              Network?                                include: meetings, conference calls, e-mail
                                                      correspondence, summaries done by PSO, etc.

              Recommended; Priority = C               JCAHO Std: LD.1.3.1
                                                      NCPS Handbook: 5.c (pg. 5)
              Leadership/Support
   1.1.7      When criminal or intentionally          Verify via interviews with key personal (PSM,
              unsafe acts are identified during the   Director, RCA team members). If systems
              RCA process, is the RCA stopped,        issues are identified a new RCA team may be
              the record sealed and top               chartered to complete the RCA following
              management notified without             completion of the AI.
              revealing team findings and
              conclusions?
              Mandatory;Priority = A                  NCPS Handbook: 6.d-h (pgs. 6-7)
              Leadership/Support
   1.1.8      Are confidentiality rules complied      Conduct interviews, review how records are
              with in the Patient Safety RCA          managed (e.g. locked office, record access,
              Process?                                etc.).
              Mandatory;Priority = A                  JCAHO Std: IM.2.10
                                                      NCPS Handbook: 4.e (pg. 3); 6.d (pg. 6)
              Leadership/Support
   1.1.9      Are RCA reports de-identified           Review a random sample of submitted RCAs in
              thoroughly prior to submission to       the SPOT database for identifiers.
              NCPS?
              Mandatory;Priority = A                  JCAHO Std: IM.2.10
                                                      38 USC 5705
              Staffing
   1.2.1      Is there a full time Patient Safety     This individual should not have any collateral
              Manager?                                duties.
              Mandatory;Priority = A                  JCAHO Std: LD.4.40; LD.4.60
                                                      USH Memo dated 12/21/2002




Mgt Ldr - 1                                                                              Version: 04.21.2005                                                            5 of 257
                                                      NCPS Patient Safety Assessment Tool
                                                            Part I - Administrative
   MANAGEMENT AND LEADERSHIP - Element 1
                                                                                                                                              *Not
                                                                                                                          *Met   *Partially   Met If score other than 'met' what are
              Question:                               Rationale/Assessment Methods:                                        (1)    Met (2)      (3) possible root causes
              Staffing
   1.2.2      If needed, is training being provided   A memorandum was sent out by the Assistant
              for the PSM to meet job                 Deputy Under Secretary for Health (10N) in
              responsibilities provided by the        December of 2001 that provided a list of PSM
              Assistant Deputy Under Secretary        job responsibilities to assist in establishing the
              for Health (in 12-2001) to enhance      PSM positions. The list captures the
              qualifications?                         fundamental activities that must be in place to
                                                      run the program. On-going training should be
                                                      sought and provided to PSMs to meet the list
                                                      criteria. See NCPS web site for memo and list
                                                      at vaww.ncps.med.va.gov/

              Recommended; Priority = A               JCAHO Std: HR.2.20
                                                      Memo from 10N: Network PSO and PSM Job Responsibilities (12-2001)
              Staffing
   1.2.3      Is clerical support personnel           A rigorous work load of RCA inputting,
              provided if deemed necessary by         maintenance, and follow up can keep the PSM
              the PSM or PSO?                         from being able to perform other duties,
                                                      therefore clerical support, if justified should be
                                                      provided.
              Recommended; Priority B
              Resources
   1.3.1      Does management support patient       Verify via training certificates, training records,
              safety staff by funding attendance at etc.
              patient safety training/conferences?

              Recommended; Priority = C
              Resources
   1.3.2      Is there dedicated space and       These items are necessary to have effective
              equipment for the Patient Safety   RCA teams.
              Program including an appropriate
              meeting space, a portable notebook
              computer, and an LCD projector?

              Recommended; Priority = B
              Resources
   1.3.3      Is Information Technology support       IT staff is often needed for SPOT help or for
              personnel provided to assist the        patient safety related upgrades to software such
              patient safety program to complete      as CPRS.
              related tasks?
              Recommended; Priority B




Mgt Ldr - 1                                                                           Version: 04.21.2005                                                                          6 of 257
                                                       NCPSPatient Safety Assessment Tool
                                                            Part I - Administrative
  PATIENT SAFETY PROGRAM MANAGEMENT - Element 2
                                                                                                                                    *Not
                                                                                                                *Met   *Partially   Met If score other than 'met' what are
                  Question:                             Rationale/Assessment Methods:                            (1)    Met (2)      (3) possible root causes
                  Root Cause Analysis Activities
  2.1.1           Are questions 1-7 consistently        Show examples of assessments including close
                  completed in SPOT (including SAC calls.
                  score) to assess all reported patient
                  safety events, including Close Calls?

                  Mandatory; Priority A                JCAHO Std: PI.3.20; PI.2.20; PI.2.30; IM.4.10
                                                       NCPS Handbook: 7.a.7 (pg. 10); 6.k (pg. 8)
                  Root Cause Analysis Activities
  2.1.1.1         Are RCAs completed as dictated by    Incidents where the Safety Report indicates an
                  SAC scoring?                         actual or potential SAC score of 3 should have a
                                                       RCA team chartered. Other incidents that score
                                                       lower than 3 receive an RCA based on a
                                                       local/network decision.
                  Mandatory; Priority A
                  Root Cause Analysis Activities
  2.1.2           Has the Patient Safety Manager       Show certificate's) of completion from attendees.
                  attended the NCPS three day
                  Patient Safety Improvement training?

                  Recommended; Priority A              JCAHO Std: HR.2.10
                  Root Cause Analysis Activities
  2.1.2.1         If individuals other than the PSMs   The appropriate training would be considered
                  serve as advisors on RCA teams       the three day Patient Safety Improvement
                  have they been appropriately         Course offered by NCPS, or the equivalent
                  trained?                             given by a trained PSM.
                  Recommended; Priority A
                  Root Cause Analysis Activities
  2.1.3           Are RCA teams orientated to the      Interview team members. Review training
                  Patient Safety Process prior to      records.
                  participating on a RCA team?
                  Recommended; Priority A              JCAHO Std: HR.4.12
                                                       RCA Team Charter memo #3
                  Root Cause Analysis Activities
  2.1.4           Is RCA team membership               Review 10 % of yearly (minimum of 4) RCA's to
                  appropriate for the adverse event    determine if appropriate personal participate
                  being evaluated?                     based on relevance to RCA content.

                  Mandatory; Priority A                JCAHO Std: LD.4.60
                                                       NCPS Handbook 4.e.1.a (pg. 3); 4.e.4.a (pg. 4)




PS Prgm Mgt - 2                                                                           Version: 04.21.2005                                                            7 of 257
                                                          NCPSPatient Safety Assessment Tool
                                                               Part I - Administrative
  PATIENT SAFETY PROGRAM MANAGEMENT - Element 2
                                                                                                                                        *Not
                                                                                                                    *Met   *Partially   Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                              (1)    Met (2)      (3) possible root causes
                  Root Cause Analysis Activities
  2.1.4.1         Does the PSM direct and advise the      Review 10 % of yearly (minimum of 4) RCA's
                  RCA/Aggregate Review teams as           and interview selective team members and the
                  necessary to produce the desired        PSM.
                  outcomes?
                  Mandatory; Priority A                   NCPS Handbook - Appendix C
                                                          JCAHO Std: LD.4.20
                  Root Cause Analysis Activities
  2.1.4.2         Does the PSM serve as an advisor        Review 10 % of yearly (minimum of 4) RCA's
                  and not as the leader, recorder or      and interview team members and the PSM.
                  team member on RCAs?
                  Recommended; Priority B                 RCA Team Charter memo #3
                  Root Cause Analysis Activities
  2.1.5           Is a follow-up and review process for Show RCA updates, review SPOT tasks, paper
                  RCA Actions and Outcome               trail, progress log, Environment of Care meeting
                  Measures being used within SPOT? minutes, etc.

                  Mandatory; Priority A                   JCAHO Std: PI.1.10
                                                          NCPS Handbook: 7.b (pg. 10)
                  Root Cause Analysis Activities
  2.1.6           Are the RCA Actions completed           Review 10 % of yearly (minimum of 4) RCA's to
                  with the specified time frame?          evaluate time frames, have PSM show results
                                                          and show tracking items to completion with
                                                          dates. Changes may also be observed on the
                                                          units in lieu of reviewing documentation.

                  Recommended; Priority B                 JCAHO Std: PI.1.10
                  Root Cause Analysis Activities
  2.1.6.1         Are Action completion and follow up Review 10 % of yearly (minimum of 4) RCA's
                  dates reasonable?                   looking for time frames and action completion
                                                      rates. In some cases it is necessary to
                                                      implement actions immediately to prevent
                                                      another occurrence.
                  Recommended; Priority B
                  Root Cause Analysis Activities
  2.1.7           Are Root Cause Contributing             Review 10 % of yearly (minimum of 4) RCA's for
                  Factors in the RCA reports              context.
                  consistently written to meet the five
                  rules of causation?
                  Recommended; Priority A                 JCAHO Std: IM.3.10
                                                          NCPS Handbook: 4.e.2, a-e (pg. 4)




PS Prgm Mgt - 2                                                                               Version: 04.21.2005                                                            8 of 257
                                                         NCPSPatient Safety Assessment Tool
                                                              Part I - Administrative
  PATIENT SAFETY PROGRAM MANAGEMENT - Element 2
                                                                                                                                     *Not
                                                                                                                 *Met   *Partially   Met If score other than 'met' what are
                  Question:                              Rationale/Assessment Methods:                            (1)    Met (2)      (3) possible root causes
                  Root Cause Analysis Activities
  2.1.8           Do the RCA reports identify            Review 10 % of yearly (minimum of 4) RCA's for
                  pertinent Root Cause Contributing      context.
                  Factors?
                  Recommended; Priority A                JCAHO Std: IM.3.10
                  Root Cause Analysis Activities
  2.1.9           Do Actions in RCA reports target       Review 10% of yearly (minimum of 4) RCA's.
                  and address the Root Cause             Also review Actions and assess if they are
                  Contributing Factors?                  obtainable.
                  Recommended; Priority A                JCAHO Std: IM.3.10
                  Root Cause Analysis Activities
  2.1.9.1         Are the action items (in Table 19 of   The identified questions should guide the RCA
                  the RCAs) aligned with the Triage      team in designing appropriate actions for the
                  Question Categories identified for     RCA. Compare the Action Items in Table 19 to
                  each Root Cause in Table 15?           the identified root causes and accompanying
                                                         triage question categories in Table 15. Each
                                                         action item must address at least 1of the 5
                                                         categories should be captured (Communication,
                                                         Training, Fatigue/Scheduling,
                                                         Environment/Equipment, Rules/Policies,
                                                         Barriers) and list as relevant factors in the root
                                                         cause.
                  Recommended; Priority A
                  Root Cause Analysis Activities
  2.1.10          Do the Outcome Measures in the      Review 10 % of yearly (minimum of 4) RCA's.
                  RCA reports effectively measure the Look for relation to Action and for numerators,
                  Actions?                            denominators, and thresholds.
                  Recommended; Priority A
                  Root Cause Analysis Activities
  2.1.11          Are RCA reports completed within       Review 10 % of yearly (minimum of 4) RCA's. If
                  45-days of the facility becoming       reports are not competed, Actions cannot be
                  aware that an RCA is required?         implemented. Reminder: Coroner dates or peer
                                                         review dates are the 'date aware' on RCAs.

                  Mandatory; Priority A                  JCAHO Std: IM.3.10
                                                         NCPS Handbook: Figure 1 (pg. 9)
                  Root Cause Analysis Activities
  2.1.11.1           RESERVED




PS Prgm Mgt - 2                                                                            Version: 04.21.2005                                                            9 of 257
                                                        NCPSPatient Safety Assessment Tool
                                                             Part I - Administrative
  PATIENT SAFETY PROGRAM MANAGEMENT - Element 2
                                                                                                                                             *Not
                                                                                                                         *Met   *Partially   Met If score other than 'met' what are
                  Question:                             Rationale/Assessment Methods:                                     (1)    Met (2)      (3) possible root causes
                  Patient Safety Reporting System
  2.2.1           Has the Patient Safety Reporting      Inquire if forms are provided in the facility where
                  System (PSRS) program been            clinicans will use and see them such as lounges
                  instituted at the facility?           and office areas.
                  Recommended; Priority B
                                                        NASA-VA inter-agency agreement for PSRS (PSRS workshop, section 3)
                  General Programmatic Functions
  2.3.1           Does the PSM collaborate with other   Interview Engineering, Safety/IH, and/or
                  entities, such as Biomedical          Infection Control. Documentation should be
                  Engineering staff, Occupational       shown such as JCAHO projects, and
                  Safety Officer and/or Industrial      participation of these disciplines on RCA and
                  Hygienist, & Infection Control?       HFMEA teams.
                  Recommended; Priority A
                  General Programmatic Functions
  2.3.2           Does the information discussed in     Review committee structure to determine if
                  committee meetings reach top          adequate information is flowing up through the
                  management for their consideration    organization.
                  and action.
                  Recommended; Priority A               JCAHO Std: PI.1, LD.4.3.1
                  General Programmatic Functions
  2.3.3           Is the PSM involved in the Patient    Show examples of Alerts/Advisories from facility,
                  Safety Alerts/Advisories/Recall       and documentation from tracking. Interview
                  process, including tracking issues to PSM.
                  resolution?
                  Recommended; Priority A               JCAHO Std: LD.4.40; LD.4.50; LD.4.60
                                                        NCPS Handbook: 5.c (pg. 5)
                  General Programmatic Functions
  2.3.4           Are Patient Safety Program            Check documentation from town meeting
                  successes publicized?                 agenda/minutes, postings, newsletters, e-mails,
                                                        or other.
                  Recommended; Priority B
                  General Programmatic Functions
  2.3.5           Is the topic of Patient Safety        Verify NEO process and materials.
                  covered in New Employee
                  Orientation?
                  Recommended; Priority A               JCAHO Std: HR.2.10




PS Prgm Mgt - 2                                                                          Version: 04.21.2005                                                                     10 of 257
                                                          NCPSPatient Safety Assessment Tool
                                                               Part I - Administrative
  PATIENT SAFETY PROGRAM MANAGEMENT - Element 2
                                                                                                                                 *Not
                                                                                                             *Met   *Partially   Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                       (1)    Met (2)      (3) possible root causes
                  General Programmatic Functions
  2.3.6           Is continuing education being           Review training methods used. Not all
                  provided for employees on Patient       employees will require the same level of
                  Safety topics?                          continuing education on Patient Safety.
                  Recommended; Priority C                 JCAHO Std: HR.3.10
                  General Programmatic Functions
  2.3.7           Does the PSM consult with experts       Intervention with, NCPS, JCAHO, ASRAM,
                  within or outside the VA when           ASHE, ISMP, ECRI, IHI, etc. The referencing of
                  needed?                                 written resources as well as telephone contact
                                                          is appropriate.
                  Recommended; Priority C
                  General Programmatic Functions
  2.3.8           Is at least one proactive risk      PSM should initiates evaluations and/or advise
                  analysis for each JCAHO accredited personnel involved with the evaluations.
                  program or has a single analysis    Assessor should review completed reports.
                  been done that covers all programs?

                  Mandatory; Priority A                   JCAHO Std: LD.4.40
                                                          NCPS Handbook: 5.d (pg. 5)
                  General Programmatic Functions
  2.3.9           Does a system exist, and is it used,    Verify via feedback documentation and interview
                  to give feedback to staff that report   facility personnel.
                  adverse event and close call
                  incidents?
                  Mandatory; Priority A                   JCAHO Std: IM.1.10
                                                          NCPS Handbook: 6.h (pg. 7)




PS Prgm Mgt - 2                                                                        Version: 04.21.2005                                                           11 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Ethics, Rights and Responsibilities
  3.1.13    Patients and, when appropriate,       At a minimum, the patient and when
            their families are informed about the appropriate, his or her family, is informed about
            outcomes of care, including           the following:
            unanticipated outcomes.               1) Outcomes of care, treatment, and services
                                                  that have been provided that the patient (or
                                                  family) must be knowledgeable about to
                                                  participate in current and future decisions
                                                  affecting the patient's care, treatment, and
                                                  service.
                                                  2) Unanticipated outcomes of care, treatment,
                                                  and services that relate to sentinel events
                                                  considered reviewable by the Joint Commission.
                                                  3) The responsible LIP or his or her designee
                                                  informs the patient (and when appropriate, his or
                                                  her family) about those unanticipated outcomes
                                                  of care, treatment, and services.

            RI.2.90                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            12 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
             Question:                           Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
             Ethics, Rights and Responsibilities
  3.1.17     The organization respects the needs 1) The organization protects confidentiality of
             of patients for confidentiality,    information about patients.
             privacy, and security.              2) The organization respects the privacy of
                                                 patients.
                                                 3) Patients who desire private telephone
                                                 conversations have access to space and
                                                 telephones appropriate to their needs and the
                                                 care, treatment, and services provided.
                                                 4) The organization provides for the safety and
                                                 security of patients and their property.
                                                 5) Not Applicable
                                                 6) Not Applicable
                                                 7) The number of patients in a room is
                                                 appropriate to the hospital’s goals and the
                                                 patients’ ages, developmental levels, clinical
                                                 conditions, or diagnosis needs. (Hospitals with
                                                 Long Term Care > 30 days)
             RI.2.130                             Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ
             Provision of Care, Treatment and Services
  3.2.4.14   Performance improvement              1) The hospital measures and assesses its
             processes seek to identify           restraint use to identify opportunities to
             opportunities to reduce the risks    introduce preventive strategies, alternatives to
             associated with restraint use        use, and process improvements that reduce the
             through preventive strategies,       risks associated with restraint use.
             innovative alternatives, and process
             improvements.
             PC.11.20                             Applies to: H




JCAHO - 3                                                                             Version: 04.21.2005                                                                            13 of 257
                                                 NCPSPatient Safety Assessment Tool
                                                      Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                        *Not
                                                                                                    *Met   *Partially   Met If score other than 'met' what are
             Question:                         Rationale/Assessment Methods:                         (1)    Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.4.15   Hospital policies and procedures  1) Policies and procedures include appropriate
             guide appropriate and safe use of details as to how the hospital does the following:
             restraint.                        Protects the patient and preserves his or her
                                               rights, dignity, and well-being during use; Bases
                                               use on the patient’s assessed needs; Makes
                                               decisions about least-restrictive methods;
                                               Ensures safe application and removal by
                                               qualified staff; Monitors and reassesses the
                                               patient during use, using qualified staff; Meets
                                               patient needs during use; Addresses risk
                                               associated with vulnerable patient populations,
                                               such as emergency, pediatric, and cognitively or
                                               physically limited patients; Makes efforts to
                                               discuss the issue of restraint, when practical,
                                               with the patient and family around the time of its
                                               use; When orders are needed, limits individual
                                               orders to licensed independent practitioners;
                                               Requires renewal of orders in accordance with
                                               applicable law and regulation; Documents
                                               restraint episodes in the medical record (see
                                               standard PC.11.100)
                                               2) The policies and procedures are developed
                                               by (continued)...
             PC.11.30                            Applies to: H




JCAHO - 3                                                                 Version: 04.21.2005                                                               14 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
              Question:                            Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Provision of Care, Treatment and Services
  3.2.4.15    (continued)... Hospital policies and ...(continued) appropriate staff and approved by
  (continued) procedures guide appropriate and     the medical staff, nursing leadership, and, as
              safe use of restraint.               appropriate, others.
             PC.11.30                              Applies to: H
             Provision of Care, Treatment and Services
  3.2.4.19   Patients in restraint are monitored. 1) Hospital policies and procedures, applicable
                                                  state law, protocols, individual orders, the
                                                  setting, and individual patient needs are used to
                                                  establish the frequency, nature, and extent of
                                                  monitoring of a patient in restraints.
                                                  2) A patient in restraints is monitored at least
                                                  every two hours or sooner according to patient
                                                  need and hospital policy.
                                                  3) Monitoring is accomplished by observation,
                                                  interaction with the patient, or related direct
                                                  examination of the patient by qualified staff.

             PC.11.70                              Applies to: H, AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ
             Provision of Care, Treatment and Services
  3.2.4.24   Staffing levels and assignments are The hospital bases its staffing levels and
             set to minimize circumstances that  assignments on a variety of factors, including
             give rise to restraint or seclusion the following:
             use and to maximize safety when     1) Staff qualifications
             restraint and seclusion are used.   2) The physical design of the environment
                                                 3) Diagnoses
                                                 4) Co-occurring conditions
                                                 5) Acuity levels
                                                 6) Age and developmental functioning of patients

             PC.12.20                              Applies to: H, BHC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            15 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
             Question:                         Rationale/Assessment Methods:                                              (1)        Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.4.25   Staff is trained and competent to 1) The hospital educates staff about minimizing
             minimize the use of restraint and the use of restraint and seclusion and, before
             seclusion and, when use is        they participate in any use of restraint or
             indicated, to use restraint or    seclusion, assesses the competence of staff to
             seclusion safely.                 use them safely.
                                               2) To minimize the use of restraint and
                                               seclusion, all direct care staff and any other staff
                                               involved in the use of restraint and seclusion
                                               receive ongoing training in and demonstrate an
                                               understanding of the following:The underlying
                                               causes of threatening behaviors exhibited by the
                                               patients; That sometimes a patient may exhibit
                                               an aggressive behavior that is related to a
                                               patient’s medical condition and not related to his
                                               or her emotional condition (for example,
                                               threatening behavior that may result from
                                               delirium in fevers or other medical conditions);
                                               How staff behaviors can affect the behaviors of
                                               the patients; De-escalation, mediation, self-
                                               protection, and other techniques such as time-
                                               out; How to recognize signs of physical distress
                                               in patients who are being held, restrained, or
                                               (continued)...


             PC.12.30                             Applies to: H, BHC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            16 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
              Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Provision of Care, Treatment and Services
  3.2.4.25    (continued)... Staff is trained and   ...(continued) secluded
  (continued) competent to minimize the use of      3) Staff members who are authorized to apply
              restraint and seclusion and, when     restraint or seclusion receive the training and
              use is indicated, to use restraint or demonstrate the competence cited in EP 2.
              seclusion safely.                     4) These direct care staff members also receive
                                                    ongoing training in and demonstrate
                                                    competence in the safe use of restraint,
                                                    including physical holding techniques, take-
                                                    down procedures, and the application and
                                                    removal of mechanical restraints.
                                                    5) Staff members who are authorized to perform
                                                    15-minute assessments of patients in restraint
                                                    or seclusion receive the training and
                                                    demonstrate the competence cited in EP 2.
                                                    6) These staff members authorized to perform
                                                    15-minute assessments receive ongoing training
                                                    and demonstrate competence in the following:
                                                    Taking vital signs and interpreting their
                                                    relevance to the physical safety of the patient in
                                                    restraint or seclusion; Recognizing nutritional
                                                    and hydration needs; Checking circulation and
                                                    range of motion in the extremities; Addressing
                                                    hygiene and elimination; Addressing physical
                                                    and psychological status and comfort; Helping
                                                    patients meet behavior criteria for discontinuing
                                                    restraint or seclusion; Recognizing readiness for
                                                    discontinuing restraint or seclusion; Recognizing
                                                    signs of any incorrect application of restraints;
                                                    Recognizing when to contact a medically trained
                                                    licensed independent practitioner or emergency
                                                    medical services to evaluate and/or treat the
                                                    patient’s physical status
              PC.12.30                              Applies to: H, BHC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                               Version: 04.21.2005                                                                            17 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
             Question:                             Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.4.28   Restraint or seclusion is limited to  1) Restraint or seclusion is used only when
             emergencies in which there is an      nonphysical interventions are ineffective or not
             imminent risk of a patient physically viable and when there is an imminent risk of a
             harming himself or herself, staff, or patient physically harming himself or herself,
             others, and nonphysical               staff, or others.
             interventions would not be effective. 2) The type of physical intervention selected
                                                   considers information learned from the patient’s
                                                   initial assessment.
                                                   3) The hospital does not permit restraint or
                                                   seclusion for any other purpose, such as
                                                   coercion, discipline, convenience, or retaliation
                                                   by staff.
                                                   4) The use of restraint or seclusion is not based
                                                   on a patient’s restraint or seclusion history or
                                                   solely on a history of dangerous behavior.

             PC.12.60                               Applies to: H, BHC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Provision of Care, Treatment and Services
  3.2.4.35   Patients in restraint or seclusion are 1) A staff member who is trained and competent
             assessed and assisted.                 in accordance with standard PC.12.30 assesses
                                                    the patient at the initiation of restraint or
                                                    seclusion and every 15 minutes thereafter.
                                                    2) This assessment includes, as appropriate to
                                                    the type of restraint or seclusion, the following:
                                                    Signs of any injury associated with applying
                                                    restraint or seclusion; Nutrition and hydration;
                                                    Circulation and range of motion in the
                                                    extremities; Vital signs; Hygiene and elimination;
                                                    Physical and psychological status and comfort;
                                                    Readiness for discontinuation of restraint or
                                                    seclusion.
                                                    3) Staff helps patients meet behavior criteria for
                                                    discontinuing restraint or seclusion.

             PC.12.130                              Applies to: H, BHC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                               Version: 04.21.2005                                                                            18 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
             Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.4.36   Patients in restraint or seclusion are 1) Monitoring is done through continuous in-
             monitored.                             person observation by an assigned staff
                                                    member who is competent and trained in
                                                    accordance with standard PC.12.30.
                                                    2) After the first hour, a patient in seclusion
                                                    without restraints may be continuously
                                                    monitored using simultaneous video and audio
                                                    equipment, if consistent with the patient’s
                                                    condition or wishes.
                                                    3) If the patient is in a physical hold, a second
                                                    staff person is assigned to observe the patient.

             PC.12.140                              Applies to: H, BHC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Provision of Care, Treatment and Services
  3.2.5.2     RESERVED
             Provision of Care, Treatment and Services
  3.2.5.3    Patients are monitored during the  1) Appropriate methods are used to
             procedure and/or administration of continuously monitor oxygenation, ventilation,
             moderate or deep sedation or       and circulation during procedures that may
             anesthesia.                        affect the patient's physiological status.
                                                2) The procedure and/or the administration of
                                                moderate or deep sedation or anesthesia for
                                                each patient are documented in the medical
                                                record.
             PC.13.30                               Applies to: H, AC*, LTC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                               Version: 04.21.2005                                                                            19 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
             Question:                          Rationale/Assessment Methods:                                             (1)        Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.5.4    Patients are monitored immediately 1) The patient's status is assessed on arrival in
             after the procedure and/or         the recovery area.
             administration of moderate or deep 2) Each patient's physiological status, mental
             sedation or anesthesia.            status, and pain level are monitored.
                                                3) Monitoring is at a level consistent with the
                                                potential effect of the procedure and/or sedation
                                                or anesthesia.
                                                4) Patients are discharged from the recovery
                                                area and the hospital by a qualified LIP
                                                according to rigorously applied criteria approved
                                                by the clinical leaders.
                                                5) Patients who have received anesthesia in the
                                                outpatient setting are discharged in the
                                                company of a responsible, designated adult.
             PC.13.40                             Applies to: H, AC*, LTC*, BHC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ
             Provision of Care, Treatment and Services
  3.2.5.5    Electroconvulsive therapy is used 1) Written policies regulate electroconvulsive
             with adequate justification,      therapy.
             documentation, and regard for     2) Whenever electroconvulsive therapy is used,
             patient safety.                   the procedure is adequately justified and
                                               documented in the patient’s medical record.
                                               3) Before initiating electroconvulsive therapy for
                                               a child or youth, two qualified, experienced
                                               child psychiatrists who are not directly involved
                                               in treating the child or youth do
                                               the following: Examine the child or youth;
                                               Consult with the psychiatrist responsible for the
                                               child or youth; Document their concurrence with
                                               the treatment in the child’s or youth’s medical
                                               record
                                               4) Written consent for any electroconvulsive
                                               therapy is obtained from the patient and
                                               documented in the clinical/case record.

             PC.13.50                             Applies to: H
             Provision of Care, Treatment and Services
  3.2.5.11     RESERVED




JCAHO - 3                                                                             Version: 04.21.2005                                                                            20 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
             Question:                           Rationale/Assessment Methods:                                              (1)        Met (2)      (3) possible root causes
             Provision of Care, Treatment and Services
  3.2.5.13   When patients are transferred or    1) The hospital communicates appropriate
             discharged, appropriate information information to any organization or provider to
             related to the care, treatment, and which the patient is transferred or discharged.
             services provided is exchanged with 2) The information shared includes the
             other service providers.            following, as appropriate to the care, treatment,
                                                 and services provided: The reason for transfer
                                                 or discharge; The patient’s physical and
                                                 psychosocial status; A summary of care,
                                                 treatment, and services provided and progress
                                                 toward goals; Community resources or referrals
                                                 provided to the patient
             PC.15.30                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.1      Patient-specific information is        1) A written policy describes the minimum
             readily accessible to those involved   amount of information about the patient that is to
             in the medication management           be available to those involved in medication
             system.                                management. Note: The hospital defines who
                                                    has this information; see standard IM.2.10. 2) At
                                                    a minimum, the information includes the
                                                    following: - The patient's age; - The patient's
                                                    sex; - The patient's current medications; - The
                                                    patient's diagnoses, comorbidities, and
                                                    concurrently occurring conditions; - The patient's
                                                    relevant laboratory values; - The patient's
                                                    allergies and past sensitivities. As appropriate
                                                    to the patient, the hospital also includes
                                                    information regarding the following: - Weight
                                                    and height; - Pregnancy and lactation status; -
                                                    Any other information required by the hospital
                                                    for safe medication management.
                                                    3) The information is accessible when needed
                                                    (except in emergency situations when time does
                                                    not permit) to LIPs, appropriate health care
                                                    professionals, and staff.
             MM.1.10                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                               Version: 04.21.2005                                                                            21 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.2     Medications available for dispensing   1. Members of the medical staff, licensed
            or administration are selected,        independent practitioners, appropriate health
            listed, and procured based on          care professionals, and staff involved in
            criteria.                              ordering, dispensing, administering, and/or
                                                   monitoring effects of medications develop
                                                   written criteria for determining what medications
                                                   are available for dispensing or administration.
                                                   2. At a minimum, the criteria include the
                                                   indication for use, effectiveness, risks (including
                                                   propensity for medication errors, abuse
                                                   potential, and sentinel events), and costs.
                                                   3. A list of medications for dispensing or
                                                   administration (including strength and dosage
                                                   form) is maintained and readily available.
                                                   Note: Sample medications are not required to be
                                                   on this list.
                                                   4. Processes and mechanisms are established
                                                   to monitor patient responses to a newly added
                                                   medication before the medication is made
                                                   available for dispensing or administration within
                                                   the hospital.
                                                   5. Medications designated as available for
                                                   dispensing or administration are reviewed at
                                                   least annually based on (continued)...


            MM.2.10                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            22 of 257
                                                     NCPSPatient Safety Assessment Tool
                                                          Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.2       (continued)... Medications available   ...(continued) emerging safety and efficacy
  (continued) for dispensing or administration are   information.
              selected, listed, and procured based   6. The hospital has processes to approve and
              on criteria.                           procure medications that are not on the
                                                     hospital’s medication list.
                                                     7. The hospital has processes to address
                                                     medication shortages and outages, including the
                                                     following:
                                                     ● Communicating with appropriate prescribers
                                                     and staff
                                                     ● Developing approved substitution protocols
                                                     ● Educating appropriate licensed independent
                                                     practitioners, appropriate health care
                                                     professionals, and staff about these protocols
                                                     ● Obtaining medications in the event of a
                                                     disaster

             MM.2.10                                 Applies to: H, AC*, LTC*, BHC*, HC*
                                                     *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                                Version: 04.21.2005                                                                            23 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.3     Medications are properly and safely   1. Only approved medications are routinely
            stored throughout the hospital.       stocked or stored.*
                                                  2. Medications are stored under necessary
                                                  conditions to ensure stability.
                                                  3. Medications are secured in accordance with
                                                  the hospital’s policy and law and regulation so
                                                  that unauthorized persons cannot obtain access
                                                  to them.
                                                  4) Controlled substances are stored to prevent
                                                  diversion and according to state and federal
                                                  laws and regulations.
                                                  5) All expired, damaged, and/or contaminated
                                                  medications are segregated until they are
                                                  removed from the hospital.
                                                  6) Medications that are easy to confuse (for
                                                  example, sound-alike and look-alike drugs or
                                                  reagents and chemicals that may be mistaken
                                                  for medications) are segregated.
                                                  7)Medications and chemicals used to prepare
                                                  medications are accurately labeled with
                                                  contents, expiration dates, and appropriate
                                                  warnings.
                                                  8) Drug concentrations available in the hospital
                                                  are standardized and limited in number.
                                                  9) Concentrated electrolytes are removed from
                                                  care units or areas, unless (continued)...
            MM.2.20                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            24 of 257
                                               NCPSPatient Safety Assessment Tool
                                                    Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                              *Not
                                                                                                                      *Met       *Partially   Met If score other than 'met' what are
              Question:                        Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.3       (continued)... Medications are   ...(continued) patient safety is at risk if the
  (continued) properly and safely stored       concentrated electrolyte is not immediately
              throughout the hospital.         available on a specific care unit or area and
                                               specific precautions are taken to prevent
                                               inadvertent administration.
                                               10) Medications in care areas are maintained in
                                               the most ready-to-administer forms available
                                               from the manufacturer or if feasible, in unit-
                                               doses that have been repackaged by the
                                               pharmacy or a licensed repackager.
                                               11) Not Applicable.
                                               12) Not Applicable.
                                               13) All medication storage areas are periodically
                                               inspected according to the hospital's policy to
                                               make sure medications are stored properly.

             MM.2.20                           Applies to: H, AC*, LTC*, BHC*, HC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                          Version: 04.21.2005                                                                            25 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.4     Emergency medications and/or           1) Not applicable.
            supplies, if any, are consistently     2) Hospital leadership, in conjunction with
            available, controlled, and secure in   members of the medical staff and LIPs, decides
            the hospital's patient care areas.     which emergency medications and/or supplies
                                                   will be readily available in patient care areas.
                                                   3) Emergency medications are available in unit-
                                                   dose, age-specific, and ready-to-administer
                                                   forms, whenever possible.
                                                   4) Not applicable.
                                                   5) Not applicable.
                                                   6) Emergency medications are stored in sealed
                                                   or in locked containers; in a locked room; or
                                                   under constant supervision (per CMS
                                                   requirements).
                                                   7) Emergency medications and supplies are
                                                   replaced as soon as possible after their use in
                                                   accordance with the hospital's policies and
                                                   procedures.

            MM.2.30                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ
            Medication Management
  3.3.5     A process is established to safely     The hospital develops a policy that addresses
            manage medications brought into        the use of medications brought into the hospital
            the hospital by patients or their      by patients or their families. The policy specifies
            families.                              the following:
                                                   1) When such medications can be used or
                                                   administered
                                                   2) A process for the identification of the
                                                   medication and the visual evaluation of its
                                                   integrity if medications brought in by the patient
                                                   or family are allowed
                                                   3) A process to inform the prescriber and
                                                   patient if medications brought into the hospital
                                                   by patients or their families are not permitted

            MM.2.40                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            26 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.6     Only medications needed to treat       There is a documented diagnosis, condition, or
            the patient’s condition are ordered.   indication-for-use for each medication ordered.

            MM.3.10                                Applies to: H, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ
            Medication Management
  3.3.7     Medication orders are written clearly Written policy(ies) address the following:
            and transcribed accurately.           1) The required elements of a complete
                                                  medication order.
                                                  2) When generic or brand names are acceptable
                                                  or required as part of a medication order.
                                                  3) Whether or when indication for use is
                                                  required on a medication order.
                                                  4) Any special precautions or procedures for
                                                  ordering drugs with look-alike or sound-alike
                                                  names.
                                                  5) Actions to take when medication orders are
                                                  incomplete, illegible, or unclear.
                                                  6) The hospital specifies the required elements
                                                  of any of the following types of orders that it
                                                  deems acceptable for use: - "As needed" (PRN)
                                                  orders; -Standing orders; - Hold orders; -
                                                  Automatic stop orders; - Resume orders (Note:
                                                  See EP 10--A blanket reinstatement of previous
                                                  orders for medications is not acceptable.); -
                                                  Titrating orders--orders in which the dose is
                                                  either progressively increased or decreased in
                                                  response to the patient's status; - Taper orders--
                                                  orders in which the dose is decreased by a
                                                  particular amount with each dosing
                                                  (continued)...


            MM.3.20                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            27 of 257
                                                     NCPSPatient Safety Assessment Tool
                                                          Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.7       (continued)... Medication orders are   ...(continued) interval; - Range orders--orders in
  (continued) written clearly and transcribed        which the dose or dosing interval varies over a
              accurately.                            prescribed range, depending on the situation or
                                                     patient's status; - Orders for compounded drugs
                                                     or drug mixtures not commercially available; -
                                                     Orders for medication-related devices (for
                                                     example, nebulizers and catheters); - Orders for
                                                     investigational medications; - Orders for herbal
                                                     products; - Orders for medications at discharge.
                                                     In addition, the hospital does the following:
                                                     7) Minimizes the use of verbal and telephone
                                                     orders.
                                                     8) Reviews and updates preprinted order sheets
                                                     as needed.
                                                     9) Specifies that blanket reinstatement of
                                                     previous orders for medications are not
                                                     acceptable.
                                                     10) Defines in writing when weight-based dosing
                                                     for pediatric populations is required.


             MM.3.20                                 Applies to: H, AC*, LTC*, BHC*, HC*
                                                     *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                                Version: 04.21.2005                                                                            28 of 257
                                               NCPSPatient Safety Assessment Tool
                                                    Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                              *Not
                                                                                                                      *Met       *Partially   Met If score other than 'met' what are
            Question:                          Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.9     Medications are prepared safely.   1) When an on-site, licensed pharmacy is
                                               available, only the pharmacy compounds or
                                               admixes all sterile medications, intravenous
                                               admixtures, or other drugs except in
                                               emergencies or when not feasible (for example,
                                               when the product's stability is short).
                                               2) Wherever medications are prepared, staff
                                               uses safety materials and equipment while
                                               preparing hazardous medications.
                                               3) Wherever medications are prepared, staff
                                               uses techniques to assure accuracy in
                                               medication preparation.
                                               4) Wherever medications are prepared, staff
                                               uses appropriate techniques to avoid
                                               contamination during medication preparation,
                                               which include but are not limited to the following:
                                               - Using clean or sterile technique as
                                               appropriate; - Maintaining clean, uncluttered,
                                               and functionally separate areas for product
                                               preparation to minimize the possibility of
                                               contamination; - Using a laminar airflow hood or
                                               other class 100 environment while preparing
                                               any intravenous (IV) admixture in the pharmacy,
                                               any sterile product made (continued)...


            MM.4.20                            Applies to: H, AC*, LTC*, BHC*, HC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                          Version: 04.21.2005                                                                            29 of 257
                                               NCPSPatient Safety Assessment Tool
                                                    Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                              *Not
                                                                                                                      *Met       *Partially   Met If score other than 'met' what are
              Question:                        Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.9       (continued)... Medications are   ...(continued) from non-sterile ingredients, or
  (continued) prepared safely.                 any sterile product that will not be used within
                                               24 hours; - Visually inspecting the integrity of
                                               the medications
             MM.4.20                           Applies to: H, AC*, LTC*, BHC*, HC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.10     Medications are appropriately     1) Medications are labeled in a standardized
             labeled.                          manner according to hospital policy, applicable
                                               law and regulation, and standards of practice.
                                               2) Any time one or more medications are
                                               prepared but are not administered immediately,
                                               the medication container must be appropriately
                                               labeled.
                                               3) At a minimum, all medications are labeled
                                               with the following: - Drug name, strength,
                                               amount (if not apparent from the container); -
                                               Expiration date when not used within 24 hours; -
                                               Expiration time when expiration occurs in less
                                               than 24 hours; - For all compounded IV
                                               admixtures and parenteral nutrition solutions,
                                               the date prepared and the diluent.
                                               4) When preparing medications for multiple
                                               patients or the person preparing the medications
                                               is not the person administering the medication,
                                               the label also includes the following: - Patient
                                               name; - Patient location; - Directions for use and
                                               any applicable cautionary statements either on
                                               the label or attached as an accessory label (for
                                               example, "requires (continued)...



             MM.4.30                           Applies to: H, AC*, LTC*, BHC*, HC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                          Version: 04.21.2005                                                                            30 of 257
                                                 NCPSPatient Safety Assessment Tool
                                                      Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                *Not
                                                                                                                        *Met       *Partially   Met If score other than 'met' what are
              Question:                          Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.10      (continued)... Medications are     ...(continued) refrigeration," "for IM use only")
  (continued) appropriately labeled.

             MM.4.30                             Applies to: H, AC*, LTC*, BHC*, HC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.11     Medications are dispensed safely.   1) Quantities of medications are dispensed
                                                 which minimize diversion yet are still consistent
                                                 with the patient's needs.
                                                 2) Dispensing adheres to law, regulation,
                                                 licensure, and professional standards of
                                                 practice, including record keeping.
                                                 3) Medications are dispensed in a timely manner
                                                 to meet patient needs.
                                                 4) Medications are dispensed in the most ready-
                                                 to-administer forms available from the
                                                 manufacturer or if feasible, in unit-doses that
                                                 have been repackaged by the pharmacy or
                                                 licensed repackager.
                                                 5) The hospital consistently uses the same dose
                                                 packaging system, or if a different system is
                                                 used, provides education about the use of the
                                                 dose packaging system.
             MM.4.40                             Applies to: H, AC*, LTC*, BHC*, HC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                            Version: 04.21.2005                                                                            31 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.12    The hospital has a system for safely   1) The hospital has a process for providing
            providing medications to meet          medications to meet patient needs when the
            patient needs when the pharmacy is     pharmacy is closed.
            closed.                                2) When nonpharmacist health care
                                                   professionals are allowed by law and regulation
                                                   to obtain medications after the pharmacy is
                                                   closed, the following safeguards are applied:-
                                                   Access is limited to a set of medications that
                                                   has been approved by the hospital. These
                                                   medications can be stored in a night cabinet,
                                                   automated storage and distribution device, or a
                                                   limited section of the pharmacy. Only trained,
                                                   designated prescribers and nurses are
                                                   permitted access to medications. Quality control
                                                   procedures (such as an independent second
                                                   check by another individual or a secondary
                                                   verification built into the system, such as bar
                                                   coding) are in place to prevent medication
                                                   retrieval errors. The hospital arranges for a
                                                   qualified pharmacist to be available either on-
                                                   call or at another location (for example, at
                                                   another organization that has 24-hour pharmacy
                                                   service) to answer questions or provide
                                                   (continued)...
            MM.4.50                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            32 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
              Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.12      (continued)... The hospital has a     ...(continued) medications beyond those
  (continued) system for safely providing           accessible to non-pharmacy staff.
              medications to meet patient needs     3) This process is evaluated on an on-going
              when the pharmacy is closed.          basis to determine the medications accessed
                                                    routinely and the causes of accessing the
                                                    pharmacy after hours.
                                                    4) Changes are implemented as appropriate to
                                                    reduce the amount of times nonpharmacist
                                                    health care professionals are obtaining
                                                    medications after the pharmacy is closed.
             MM.4.50                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.13     Medications dispensed by the           1) When the hospital has been informed of a
             hospital are retrieved when recalled   medication recall or discontinuation by the
             or discontinued by the manufacturer    manufacturer or the FDA for safety reasons,
             or the Food and Drug Administration    medications within the hospital are retrieved and
             for safety reasons.                    appropriately handled per hospital policy and
                                                    law and regulation.
                                                    2) When the hospital has been informed of a
                                                    medication recall or discontinuation by the
                                                    manufacturer or the FDA for safety reasons, all
                                                    those ordering, dispensing, and/or administering
                                                    recalled or discontinued medications are
                                                    notified.
                                                    3) When the hospital has been informed of a
                                                    medication recall or discontinuation by the
                                                    manufacturer or the FDA for safety reasons,
                                                    patients who may have received the medication
                                                    are identified and informed of the recall or
                                                    discontinuation.
             MM.4.70                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.14      RESERVED




JCAHO - 3                                                                               Version: 04.21.2005                                                                            33 of 257
                                               NCPSPatient Safety Assessment Tool
                                                    Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                              *Not
                                                                                                                      *Met       *Partially   Met If score other than 'met' what are
            Question:                          Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.16    Medications are safely and         1) Not applicable
            accurately administered.           2) Guidelines for prescriber notification in the
                                               event of an adverse drug reaction or medication
                                               error
                                               Before administering a medication, the licensed
                                               independent practitioner or appropriate
                                               healthcare professional administering the
                                               medication does the following:
                                               3) Verifies that the medication selected for
                                               administration is the correct one based on the
                                               medication order and product label
                                               4) Verifies that the medication is stable based
                                               on visual examination for particulates or
                                               discoloration and that the medication has not
                                               expired
                                               5) Verifies that there is no contraindication for
                                               administering the medication
                                               6) Verifies that the medication is being
                                               administered at the proper time, in the
                                               prescribed dose, and by the correct route
                                               7) Advises the patient or, if appropriate, the
                                               patient’s family, about any potential clinically
                                               significant adverse reaction or other concerns
                                               about administering a new medication
                                               8) Discusses any unresolved, significant
                                               concerns about (continued)...
            MM.5.10                            Applies to: H, AC*, LTC*, BHC*, HC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                          Version: 04.21.2005                                                                            34 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
              Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Medication Management
  3.3.16      (continued)... Medications are        ...(continued) the medication with the patient’s
  (continued) safely and accurately administered.   physician, prescriber (if different from the
                                                    physician), and/or relevant staff involved with
                                                    the patient’s care, treatment, and service
             MM.5.10                                Applies to: H, AC*, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ
             Medication Management
  3.3.17     Self-administered medications are      1) If self administration is allowed, procedures
             safely and accurately administered.    guide the safe and accurate self administration
                                                    of medications or administration of medications
                                                    by a person who is not a staff member and
                                                    address training, supervision, and administration
                                                    documentation.
                                                    2) Persons who administer medications but are
                                                    not staff members (for example, the patient if
                                                    self-administering) receive training and
                                                    appropriate information about the following: -
                                                    The nature of the medications to be administere.
                                                     How to administer medications, such as the
                                                    appropriate frequency, route of administration,
                                                    and dose. The expected actions and side effects
                                                    of the medications to be administered. How to
                                                    monitor the effects of the medications on the
                                                    patient.
                                                    3) Persons who administer medications but are
                                                    not staff members (including the patient if self-
                                                    administering and so forth) are determined to be
                                                    competent at medication administration before
                                                    being allowed to administer medications.



             MM.5.20                                Applies to: H, LTC*, BHC*, HC*
                                                    *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                               Version: 04.21.2005                                                                            35 of 257
                                                 NCPSPatient Safety Assessment Tool
                                                      Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                *Not
                                                                                                                        *Met       *Partially   Met If score other than 'met' what are
            Question:                            Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.18    The effects of medication(s) on      1) Each patient’s response to his or her
            patients are monitored.              medication is monitored according to the clinical
                                                 needs of the patient and addresses the patient’s
                                                 response to the prescribed medication and
                                                 actual or potential medication-related problems.
                                                 2) Monitoring a medication’s effect on a patient
                                                 includes the following: Gathering the patient’s
                                                 own perceptions about side effects, and when
                                                 appropriate, perceived efficacy; Referring to
                                                 information from the patient’s medical record,
                                                 relevant laboratory results, clinical response,
                                                 and medication profile
                                                 3) The hospital has a process for monitoring the
                                                 patient’s response to the first dose(s) of a
                                                 medication new to a patient while he or she is
                                                 under the direct care of the hospital.

            MM.6.10                              Applies to: H, AC*, LTC*, BHC*, HC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ
            Medication Management
  3.3.19    The hospital responds appropriately 1) The hospital has a process to respond to
            to actual or potential adverse drug actual or potential adverse drug events and
            events and medication errors.       medication errors.
                                                2) Appropriate action is taken when an actual or
                                                potential adverse drug event is identified (this
                                                may be limited to calling for outside assistance
                                                depending upon the hospital's services).
                                                3) The hospital or responsible individual
                                                complies with internal and external reporting
                                                requirements for actual or potential adverse
                                                drug events (for example, to the USP, the FDA,
                                                and the ISMP).

            MM.6.20                              Applies to: H, AC*, LTC*, BHC*, HC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                            Version: 04.21.2005                                                                            36 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Medication Management
  3.3.20    The hospital develops processes for   1) The hospital identifies the high-risk or high-
            managing high-risk or high-alert      alert medications used within the hospital, if any.
            medications.                          2) As appropriate to the services provided, the
                                                  hospital develops processes for procuring,
                                                  storing, ordering, transcribing, preparing,
                                                  dispensing, administering, and/or monitoring
                                                  high-risk or high-alert medications.

            MM.7.10                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ
            Medication Management
  3.3.23    Investigational medications are       1) Procedures for the use of investigational
            safely controlled and administered.   medications, when used, are implemented and
                                                  maintained including the following: Having a
                                                  written process for reviewing, approving,
                                                  supervising, and monitoring investigational
                                                  medications use; Specifying that when an
                                                  investigational medication protocol is being
                                                  conducted independent of the hospital, the
                                                  hospital will review and accommodate, as
                                                  appropriate, the patient’s continued participation
                                                  in the protocol (see standard RI.2.180);
                                                  Specifying that when pharmacy services are
                                                  provided, the pharmacy controls the storage,
                                                  dispensing, labeling, and distribution of the
                                                  investigational medication
            MM.7.40                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            37 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                           Rationale/Assessment Methods:                                             (1)        Met (2)      (3) possible root causes
            Surveillance, Prevention and Control of Infection
  3.4.1     The risk of development of a health 1. A hospitalwide IC program is implemented.
            care–associated infection is        2. Individuals and/or positions with the authority
            minimized through a hospitalwide    to take steps to prevent or control the
            infection control program.          acquisition and transmission of infectious agents
                                                are identified.
                                                3. All applicable organizational components and
                                                functions are integrated into the IC program.
                                                4. Systems are in place to communicate with
                                                licensed independent practitioners, staff,
                                                students/ trainees, volunteers, and as
                                                appropriate, visitors, patients, and families about
                                                infection prevention and control issues,
                                                including their responsibilities in preventing the
                                                spread of infection within the hospital.
                                                5. The hospital has systems for reporting
                                                infection surveillance, prevention, and control
                                                information to the following:
                                                ● The appropriate staff within the hospital
                                                ● Federal, state, and local public health
                                                authorities in accordance with law and regulation
                                                ● Accrediting bodies (see Sentinel Event
                                                Reporting, pages SE-8–SE-9, and National
                                                Patient Safety Goals, pages APR-8–APR-10)
                                                ● (continued)...


            IC.1.10                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            38 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
              Question:                          Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Surveillance, Prevention and Control of Infection
  3.4.1       (continued)... The risk of         ...(continued) The referring or receiving
  (continued) development of a health            organization when a patient was transferred or
              care–associated infection is       referred and the presence of an HAI was not
              minimized through a hospitalwide   known at the time of transfer or referral
              infection control program.         6. Systems for the investigation of outbreaks of
                                                 infectious diseases are in place.
                                                 7. Applicable policies and procedures are in
                                                 place throughout the hospital.
                                                 8. Not applicable
                                                 9. The hospital has a written IC plan* that
                                                 includes the following:
                                                 ● A description of prioritized risks
                                                 ● A statement of the goals of the IC program
                                                 ● A description of the hospital’s strategies to
                                                 minimize, reduce, or eliminate the prioritized
                                                 risks
                                                 ● A description of how the strategies will be
                                                 evaluated
             IC.1.10                              Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            39 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                             Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Surveillance, Prevention and Control of Infection
  3.4.5     Once the hospital has prioritized its 1) Interventions are designed to incorporate
            goals, strategies must be             relevant guidelines* for infection prevention and
            implemented to achieve those goals. control activities.
                                                  Interventions are implemented which include the
                                                  following (EPs 2 and 3):
                                                  2) A hospitalwide hand hygiene program that
                                                  complies with current Centers for Disease
                                                  Control and Prevention (CDC) hand hygiene
                                                  guidelines (National Patient Safety Goal 7,
                                                  requirement 7.a)
                                                  3) Methods to reduce the risks associated with
                                                  procedures, medical equipment,† and medical
                                                  devices, including the following:
                                                  ● Appropriate storage, cleaning, disinfection,
                                                  sterilization, and/or disposal of supplies and
                                                  equipment
                                                  ● Reuse of equipment designated by the
                                                  manufacturer as disposable in a manner that is
                                                  consistent with regulatory and professional
                                                  standards
                                                  ● The appropriate use of personal protective
                                                  equipment
                                                  4) Implementation of applicable precautions, as
                                                  appropriate, is based on the following:
                                                  ● The potential for transmission
                                                  ● The mechanism of transmission
                                                  ● The care, treatment, and service (continued)...
            IC.4.10                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            40 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                         (1)        Met (2)      (3) possible root causes
              Surveillance, Prevention and Control of Infection
  3.4.5       (continued)... Once the hospital has ...(continued) setting
  (continued) prioritized its goals, strategies must ● The emergence and reemergence of
              be implemented to achieve those        pathogens in the community that could affect
              goals.                                 the hospital
                                                     Interventions are implemented which include the
                                                     following (EPs 5–7):
                                                     5) Screening for exposure and/or immunity to
                                                     infectious diseases that licensed independent
                                                     practitioners, staff, student/trainees, and
                                                     volunteers may come in contact with in their
                                                     work is available as warranted
                                                     6) Referral for assessment, potential testing,
                                                     immunization and/or prophylaxis/treatment, and
                                                     counseling as appropriate of licensed
                                                     independent practitioners, staff,
                                                     students/trainees, and volunteers who are
                                                     identified as potentially having an infectious
                                                     disease or risk of infectious disease that may
                                                     put the population they serve at risk
                                                     7) Referral for assessment, potential testing,
                                                     immunization and/or prophylaxis/treatment, and
                                                     counseling as appropriate of patients,
                                                     students/trainees, and volunteers who have
                                                     been exposed to infectious disease(s) at the
                                                     hospital and licensed independent practitioners
                                                     or staff who are occupationally exposed
                                                     8) Reduction of risks associated with animals
                                                     brought into the hospital
             IC.4.10                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            41 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                            Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Surveillance, Prevention and Control of Infection
  3.4.6     The infection control program        1) The hospital formally evaluates and revises
            evaluates the effectiveness of the   the goals and program (or portions of the
            infection control interventions and, program) at least annually and whenever risks
            as necessary, redesigns the          significantly change.
            infection control interventions.     2) The evaluation addresses changes in the
                                                 scope of the IC program (for example, resulting
                                                 from the introduction of new services or new
                                                 sites of care).
                                                 3) The evaluation addresses changes in the
                                                 results of the IC program risk analysis.
                                                 4) The evaluation addresses emerging and
                                                 reemerging problems in the health care
                                                 community that potentially affect the hospital (for
                                                 example, highly infectious agents).
                                                 5) The evaluation addresses the assessment of
                                                 the success or failure of interventions for
                                                 preventing and controlling infection.
                                                 6) The evaluation addresses responses to
                                                 concerns raised by leadership and others within
                                                 the hospital.
                                                 7) The evaluation addresses the evolution of
                                                 relevant infection prevention and control
                                                 guidelines that are based on evidence or, in the
                                                 absence of evidence, expert consensus.
            IC.5.10                               Applies to: H, AC*, LTC*, BHC*, HC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ
            Surveillance, Prevention and Control of Infection
  3.4.9     The infection control process          1) At least one activity has been implemented to
            includes at least one activity aimed intervene in the potential transmission of
            at preventing transmission of          infection between patients and staff.
            epidemiologically significant
            infections between patients and staff.

            IC.6.30
            Improving Organization Performance
  3.5.3     RESERVED




JCAHO - 3                                                                             Version: 04.21.2005                                                                            42 of 257
                                                NCPSPatient Safety Assessment Tool
                                                     Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                               *Not
                                                                                                                       *Met       *Partially   Met If score other than 'met' what are
            Question:                        Rationale/Assessment Methods:                                              (1)        Met (2)      (3) possible root causes
            Improving Organization Performance
  3.5.4     Processes for identifying and    Processes for identifying and managing sentinel
            managing sentinel events are     events include the following:
            defined and implemented.         1. Defining “sentinel event” and communicating
                                             this definition throughout the hospital (At a
                                             minimum, the hospital’s definition includes those
                                             events subject to review under the Joint
                                             Commission’s Sentinel Event Policy as
                                             published in this manual and may include any
                                             process variation which does not affect the
                                             outcome or result in an adverse event, but for
                                             which a recurrence carries significant chance of
                                             a serious adverse outcome or result in an
                                             adverse event, often referred to as a “near
                                             miss.”)
                                             2. Reporting sentinel events through established
                                             channels in the hospital and, as appropriate, to
                                             external agencies in accordance with law and
                                             regulation
                                             3. Conducting thorough and credible root cause
                                             analyses that focus on process and system
                                             factors
                                             4. Creating, documenting, and implementing a
                                             risk-reduction strategy and action plan that
                                             includes measuring the effectiveness of process
                                             and system improvements to (continued)...
            PI.2.30                             Applies to: H, LTC*, BHC*, HC* & AC*
                                                *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                           Version: 04.21.2005                                                                            43 of 257
                                                 NCPSPatient Safety Assessment Tool
                                                      Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                *Not
                                                                                                                        *Met       *Partially   Met If score other than 'met' what are
              Question:                           Rationale/Assessment Methods:                                          (1)        Met (2)      (3) possible root causes
              Improving Organization Performance
  3.5.4       (continued)... Processes for        ...(continued) reduce risk
  (continued) identifying and managing sentinel   5. The processes are implemented.
              events are defined and implemented.

             PI.2.30                             Applies to: H, LTC*, BHC*, HC* & AC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ
             Improving Organization Performance
  3.5.5      Information from data analysis is   1) The hospital uses the information from data
             used to make changes that improve analysis to identify and implement changes that
             performance and patient safety and will improve the quality of care, treatment, and
             reduce the risk of sentinel events. services. 2) The hospital identifies and
                                                 implements changes that will reduce the risk of
                                                 sentinel events. 3) The hospital uses the
                                                 information from data analysis to identify
                                                 changes that will improve patient safety.
                                                 4) Changes made to improve processes or
                                                 outcomes are evaluated to ensure that they
                                                 achieve the expected results.
                                                 5) Appropriate actions are undertaken when
                                                 planned improvements are not achieved or
                                                 sustained.

             PI.3.10                             Applies to: H, LTC*, BHC*, HC* & AC*
                                                 *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                            Version: 04.21.2005                                                                            44 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                           Rationale/Assessment Methods:                                             (1)        Met (2)      (3) possible root causes
            Improving Organization Performance
  3.5.6     An ongoing, proactive program for   The following proactive activities to reduce risks
            identifying and reducing            to patients are conducted:
            unanticipated adverse events and    1) Selecting a high-risk process to be analyzed
            safety risks to patients is defined (at least one high-risk process is chosen
            and implemented.                    annually--the choice should be based in part on
                                                information published periodically by the Joint
                                                Commission about the most frequent sentinel
                                                events and risks).
                                                2) Describing the chosen process (for example,
                                                through the use of a flowchart)
                                                3) Identifying the ways in which the process
                                                could break down or fail to perform its desired
                                                function.
                                                4) Identifying the possible effects that a
                                                breakdown or failure of the process could have
                                                on patients and the seriousness of the possible
                                                effects.
                                                5) Prioritizing the potential process breakdowns
                                                or failures.
                                                6) Determining why the prioritized breakdowns
                                                or failures could occur, which may include
                                                performing a hypothetical root cause analysis.
                                                7) Redesigning the process and/or underlying
                                                systems to minimize the risk of the effects on
                                                patients.
                                                8) Testing and implementing (continued)...
            PI.3.20                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                  *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                             Version: 04.21.2005                                                                            45 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
              Question:                            Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Improving Organization Performance
  3.5.6       (continued)... An ongoing, proactive ...(continued) the redesigned process.
  (continued) program for identifying and reducing 9) Monitoring the effectiveness of the
              unanticipated adverse events and     redesigned process.
              safety risks to patients is defined
              and implemented.

             PI.3.20                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ
             Leadership
  3.6.13     Services provided by consultation,    1) The leaders approve sources for the
             contractual arrangements, or other    hospital’s services that are provided by
             agreements are provided safely and    consultation, contractual arrangements, or other
             effectively.                          agreements.
                                                   2) The medical staff advises the hospital’s
                                                   leaders on the sources of clinical services to be
                                                   provided by consultation, contractual
                                                   arrangements, or other agreements.
                                                   3) Not applicable
                                                   4) The nature and scope of services provided by
                                                   consultation, contractual arrangements, or other
                                                   agreements are defined in writing.*
                                                   5) Services provided by consultation,
                                                   contractual arrangements, or other agreements
                                                   meet applicable Joint Commission standards.
                                                   6) The hospital evaluates the contracted care,
                                                   treatment, and services to determine whether
                                                   they are being provided according to the
                                                   contract and the level of safety and quality that
                                                   the hospital expects.
                                                   7) The hospital retains overall responsibility and
                                                   authority for services furnished under a contract.
                                                   8) All reference and contract laboratory
                                                   services† meet the applicable federal
                                                   regulations for (continued)...


             LD.3.50                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            46 of 257
                                                     NCPSPatient Safety Assessment Tool
                                                          Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Leadership
  3.6.13      (continued)... Services provided by    ...(continued) clinical laboratories and maintain
  (continued) consultation, contractual              evidence of the same.
              arrangements, or other agreements
              are provided safely and effectively.

              LD.3.50                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                     *Elements of Performance are listed for Hospital program; other programs may differ
              Leadership
  3.6.14      Communication is effective             1) The leaders ensure processes are in place
              throughout the hospital.               for communicating relevant information
                                                     throughout the hospital in a timely manner.
                                                     2) Effective communication occurs in the
                                                     hospital, among the hospital’s programs, among
                                                     related hospitals, with outside organizations,
                                                     and with patients and families, as appropriate.
                                                     3) The leaders communicate the hospital’s
                                                     mission and appropriate policies, plans, and
                                                     goals to all staff.

              LD.3.60                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                     *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                                Version: 04.21.2005                                                                            47 of 257
                                               NCPSPatient Safety Assessment Tool
                                                    Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                              *Not
                                                                                                                      *Met       *Partially   Met If score other than 'met' what are
            Question:                          Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Leadership
  3.6.15    The leaders define the required    1) The leaders provide for the allocation of
            qualifications and competence of   competent qualified staff.
            those staff who provide care,      2) The leaders ensure that physician assistants
            treatment, and services, and       and advanced practice registered nurses who
            recommend a sufficient number of   practice within the hospital are credentialed and
            qualified and competent staff to   privileged and reprivileged through the medical
            provide care, treatment, and       staff process or an equivalent process that has
            services.                          been approved by the governing body. An
                                               equivalent process at a minimum does the
                                               following:
                                               ● Evaluates the applicant’s credentials
                                               ● Evaluates the applicant’s current competence
                                               ● Includes peer recommendations
                                               ● Involves communication with and input from
                                               individuals and committees, including the
                                               Medical Staff Executive Committee, to make an
                                               informed decision regarding the applicant’s
                                               request for privileges.

            LD.3.70                            Applies to: H, LTC*, BHC*, HC* & AC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ
            Leadership
  3.6.16    The leaders provide for adequate   1) The leaders provide for the arrangement and
            space, equipment, and other        allocation of space to facilitate efficient, effective
            resources.                         delivery of care, treatment, and services.
                                               2) The leaders provide for the appropriateness
                                               of interior and exterior space for the care,
                                               treatment, and services offered and for the ages
                                               and other characteristics of the patients.
                                               3) The leaders provide for the safe use,
                                               maintenance, accessibility, and supervision of
                                               grounds, equipment, and special activity areas.
                                               4) The leaders provide for adequate equipment
                                               and other resources.


            LD.3.80                            Applies to: H, LTC*, BHC*, HC* & AC*
                                               *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                          Version: 04.21.2005                                                                            48 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
            Leadership
  3.6.27    The leaders ensure that an             The patient safety program includes the
            integrated patient safety program is   following:
            implemented throughout the hospital.   1) One or more qualified individuals or an
                                                   interdisciplinary group assigned to manage the
                                                   organizationwide safety program.
                                                   2) Definition of the scope of the program's
                                                   oversight, typically ranging from no-harm,
                                                   frequently occurring "slips" to sentinel events
                                                   with serious adverse outcomes.
                                                   3) Integration into and participation of all
                                                   components of the hospital into the
                                                   organizationwide program.
                                                   4) Procedures for immediately responding to
                                                   system or process failures, including caring for
                                                   the affected individual(s), containing risk to
                                                   others, and preserving factual information for
                                                   subsequent analysis.
                                                   5) Clear systems for internal and external
                                                   reporting of information about system or process
                                                   failures.
                                                   6) Defined responses to various types of
                                                   unanticipated adverse events and processes for
                                                   conducting proactive risk assessment/risk
                                                   reduction activities.
                                                   7) Defined support systems for staff members
                                                   who have been involved in a (continued)...
            LD.4.40                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            49 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
              Question:                            Rationale/Assessment Methods:                                           (1)        Met (2)      (3) possible root causes
              Leadership
  3.6.27      (continued)... The leaders ensure    ...(continued) sentinel event.
  (continued) that an integrated patient safety    8) Reports, at least annually, to the hospital's
              program is implemented throughout    governance or authority on system or process
              the hospital.                        failures and actions taken to improve safety,
                                                   both proactively and in response to actual
                                                   occurrences
             LD.4.40                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ
             Leadership
  3.6.28     RESERVED
             Leadership
  3.6.29     The leaders allocate adequate         1) Sufficient staff is assigned to conduct
             resources for measuring, assessing,   activities for performance improvement and
             and improving the hospital's          safety improvement.
             performance and improving patient     2) Adequate time is provided for staff to
             safety.                               participate in activities for performance
                                                   improvement and safety improvement.
                                                   3) Adequate information systems are provided
                                                   to support activities for performance
                                                   improvement and safety improvement.
                                                   4) Staff is trained in performance improvement
                                                   and safety improvement approaches and
                                                   methods.
             LD.4.60                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ




JCAHO - 3                                                                              Version: 04.21.2005                                                                            50 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Leadership
  3.6.30    The leaders measure and assess         1) Leaders continually monitor the effectiveness
            the effectiveness of the performance   of the performance improvement and safety
            improvement and safety                 improvement activities.
            improvement activities.                2) The leaders develop and implement
                                                   improvements for these activities.
                                                   3) The leaders assess the adequacy of the
                                                   human, information, physical, and financial
                                                   resources allocated to support performance
                                                   improvement and safety improvement activities.


            LD.4.70                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospital program; other programs may differ.
            Management of the Enviornment of Care
  3.7.1     RESERVED
            Management of Human Resources
  3.8.1     The hospital provides an adequate       1) The hospital has an adequate number and
            number and mix of staff that are        mix of staff to meet the care, treatment, and
            consistent with the hospital’s staffing service needs of the patients.
            plan.
            HR.1.10                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                              Version: 04.21.2005                                                                             51 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
            Question:                               Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Human Resources
  3.8.2     The hospital has a process to           1) The leaders define the required competence
            ensure that a person’s qualifications   and qualifications of staff in all program(s) or
            are consistent with his or her job      service(s).
            responsibilities.                       2) The leaders define the required competence
                                                    and qualifications of staff who make decisions
                                                    about and implement and monitor restraint or
                                                    seclusion use (see standard PC.12.30).

            HR.1.20                                 Applies to: H, LTC*, BHC*, HC* & AC*
                                                    *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                               Version: 04.21.2005                                                                             52 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
             Question:                        Rationale/Assessment Methods:                                                 (1)        Met (2)      (3) possible root causes
             Management of Human Resources
  3.8.4      Orientation provides initial job As appropriate, each staff member, student, and
             training and information.        volunteer is oriented to the following (EPs 1-5):
                                              1. The hospital's mission and goals.
                                              2. Hospitalwide policies and procedures
                                              (including safety and infection control) and
                                              relevant unit, setting, or program-specific
                                              policies and procedures.
                                              3. Specific job duties and responsibilities and
                                              unit, setting, or program-specific job duties and
                                              responsibilities related to safety and infection
                                              control.
                                              4. Not applicable.
                                              5. Cultural diversity and sensitivity.
                                              6. Persons are educated about the rights of
                                              patients and ethical aspects of care, treatment,
                                              and services and the process used to address
                                              ethical issues.
                                              7. Not applicable.
                                              8. Orientation and education for forensic staff
                                              include how to interact with patients; procedures
                                              for responding to unusual clinical events and
                                              incidents; the hospital's channels of clinical,
                                              security, and administrative communication; and
                                              distinctions between administrative and clinical
                                              seclusion and (continued)...


             HR.2.10                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospitial program; other programs may differ.
              Management of Human Resources
  3.8.4       (continued)... Orientation provides   ...(continued) restraint.
  (continued) initial job training and information. 9. The hospital assesses and documents each
                                                    person's ability to carry out assigned
                                                    responsibilities safely, competently, and in a
                                                    timely manner upon completion of orientation.
             HR.2.10                               Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                              Version: 04.21.2005                                                                             53 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
            Question:                               Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Human Resources
  3.8.5     Staff members, licensed                 Staff members, licensed independent
            independent practitioners, students,    practitioners, students, and volunteers, as
            and volunteers, as appropriate, can     appropriate, can describe or demonstrate the
            describe or demonstrate their roles     following:
            and responsibilities, based on          1) Risks within the hospital’s environment
            specific job duties or                  2) Actions to eliminate, minimize, or report risks
            responsibilities, relative to safety.   3) Procedures to follow in the event of an
                                                    incident
                                                    4) Reporting processes for common problems,
                                                    failures, and user errors

            HR.2.20                                 Applies to: H, LTC*, BHC*, HC* & AC*
                                                    *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                               Version: 04.21.2005                                                                             54 of 257
                                                 NCPSPatient Safety Assessment Tool
                                                      Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                 *Not
                                                                                                                         *Met       *Partially   Met If score other than 'met' what are
            Question:                            Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Human Resources
  3.8.6     Ongoing education, including in-     The following occurs for staff, students, and
            services, training, and other        volunteers who work in the same capacity as
            activities, maintains and improves   staff providing care, treatment, and services:
            competence.                          1) Training occurs when job responsibilities or
                                                 duties change
                                                 2) Participation in ongoing in-services, training,
                                                 or other activities occurs to increase staff,
                                                 student, or volunteer knowledge of work-related
                                                 issues
                                                 3) Ongoing in-services and other education and
                                                 training are appropriate to the needs of the
                                                 population(s) served and comply with law and
                                                 regulation
                                                 4) Ongoing in-services, training, or other
                                                 activities emphasize specific job-related aspects
                                                 of safety and infection prevention and control
                                                 5) Ongoing in-services, training, or other
                                                 education incorporate methods of team training,
                                                 when appropriate
                                                 6) Ongoing in-services, training, or other
                                                 education reinforce the need and ways to report
                                                 unanticipated adverse events
                                                 7. Ongoing in-services or other education are
                                                 offered in response to learning needs identified
                                                 through performance (continued)...
            HR.2.30                              Applies to: H, LTC*, BHC*, HC* & AC*
                                                 *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                            Version: 04.21.2005                                                                             55 of 257
                                                     NCPSPatient Safety Assessment Tool
                                                          Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                     *Not
                                                                                                                             *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Human Resources
  3.8.6       (continued)... Ongoing education,      ...(continued) improvement findings and other
  (continued) including in-services, training, and   data analysis (that is, data from staff surveys,
              other activities, maintains and        performance evaluations, or other needs
              improves competence.                   assessments)
                                                     8) Ongoing education is documented
             HR.2.30                                 Applies to: H, LTC*, BHC*, HC* & AC*
                                                     *Elements of Performance are listed for Hospitial program; other programs may differ.
             Management of Information
  3.9.2      Information privacy and                 1) The hospital has developed a written process
             confidentiality are maintained.         (in one or more policies) based on and
                                                     consistent with applicable law that addresses
                                                     the privacy and confidentiality of information.
                                                     2) The hospital’s policy, including significant
                                                     changes to the policy, has been effectively
                                                     communicated to applicable staff.
                                                     3) The hospital has a process to monitor
                                                     compliance with its policy.
                                                     4) The hospital improves privacy and
                                                     confidentiality by monitoring information and
                                                     developments in technology.
                                                     5) Individuals about whom personally
                                                     identifiable health data and information may be
                                                     maintained or collected are made aware of what
                                                     uses and disclosures of the information will be
                                                     made.
                                                     6) For uses and disclosures of health
                                                     information, the removal of personal identifiers
                                                     is encouraged to the extent possible, consistent
                                                     with maintaining the usefulness of the
                                                     information.
                                                     7) Protected health information is used for the
                                                     purposes identified or as required by law and
                                                     not further disclosed without patient
                                                     (continued)...
             IM.2.10                                 Applies tor: H, LTC*, BHC*, HC* & AC*
                                                     *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                                Version: 04.21.2005                                                                             56 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
              Question:                             Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Information
  3.9.2       (continued)... Information privacy    ...(continued) authorization.
  (continued) and confidentiality are maintained.   8) The hospital preserves the confidentiality of
                                                    data and information identified as sensitive and
                                                    requires extraordinary means to preserve
                                                    patient privacy.
              IM.2.10                               Applies tor: H, LTC*, BHC*, HC* & AC*
                                                    *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                               Version: 04.21.2005                                                                             57 of 257
                                                   NCPSPatient Safety Assessment Tool
                                                        Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                   *Not
                                                                                                                           *Met       *Partially   Met If score other than 'met' what are
            Question:                              Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Information
  3.9.4     The hospital has a process for         1) The hospital has a business
            maintaining continuity of information. continuity/disaster recovery plan for information
                                                   systems, which includes the identification of the
                                                   most critical information functions for patient
                                                   care, treatment, and services and business
                                                   processes, and the impact on the hospital if
                                                   these systems
                                                   were severely interrupted, as priority areas of
                                                   the continuity/disaster recovery plan.
                                                   2) The plan is tested periodically to ensure that
                                                   the business interruption back-up techniques
                                                   are effective.
                                                   3) For electronic systems, the hospital has a
                                                   process for disaster recovery and business
                                                   continuity, as they would impact the
                                                   management of information, which includes the
                                                   following:
                                                   ● Plans for scheduled and unscheduled
                                                   interruptions, which includes end-user training
                                                   with the downtime procedures
                                                   ● Contingency procedures for operations
                                                   interruptions (hardware, software, or other
                                                   systems failure)
                                                   ● Plans for minimal interruptions as a result of
                                                   scheduled downtime
                                                   ● An emergency service plan
                                                   ● A back-up system (continued)...
            IM.2.30                                Applies to: H, LTC*, BHC*, HC* & AC*
                                                   *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                              Version: 04.21.2005                                                                             58 of 257
                                                      NCPSPatient Safety Assessment Tool
                                                           Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                      *Not
                                                                                                                              *Met       *Partially   Met If score other than 'met' what are
              Question:                               Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Information
  3.9.4       (continued)... The hospital has a       ...(continued) (electronic or manual)
  (continued) process for maintaining continuity of   ● Data retrieval and what it will address,
              information.                            including retrieval from storage and information
                                                      presently in the system, retrieval of data in the
                                                      event of system interruption, and back up of data

              IM.2.30                                 Applies to: H, LTC*, BHC*, HC* & AC*
                                                      *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                                 Version: 04.21.2005                                                                             59 of 257
                                                NCPSPatient Safety Assessment Tool
                                                     Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                *Not
                                                                                                                        *Met       *Partially   Met If score other than 'met' what are
            Question:                           Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Information
  3.9.8     The hospital has a complete and     1) Only authorized individuals make entries in
            accurate medical record for every   the medical record.
            individual assessed, cared for,     2) The hospital defines which entries made by
            treated, or served.                 nonindependent practitioners require
                                                countersigning consistent with law and
                                                regulation.
                                                3) Standardized formats are used for
                                                documenting all care, treatment, and services
                                                provided to patients.
                                                4) Every medical record entry† is dated, the
                                                author identified and, when necessary according
                                                to law or regulation and hospital policy, is
                                                authenticated.
                                                5) At a minimum, the following are authenticated
                                                either by written signature, electronic signature,
                                                or computer key or rubber stamp:
                                                ● The history and physical examination
                                                ● Operative report
                                                ● Consultations
                                                ● Discharge summary
                                                6) The medical record contains sufficient
                                                information to identify the patient; support the
                                                diagnosis/condition; justify the care, treatment,
                                                and services; document the course and results
                                                of care, treatment, and services; and promote
                                                continuity of care among providers.
                                                7) A concise discharge summary§ (continued)...



            IM.6.10                             Applies to: H, LTC*, BHC*, HC* & AC*
                                                *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                           Version: 04.21.2005                                                                             60 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
              Question:                           Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Information
  3.9.8       (continued)... The hospital has a   ...(continued) providing information to other
  (continued) complete and accurate medical       caregivers and facilitating continuity of care
              record for every individual         includes the following:
              assessed, cared for, treated, or    ● The reason for hospitalization
              served.                             ● Significant findings
                                                  ● Procedures performed and care, treatment,
                                                  and services provided
                                                  ● The patient’s condition at discharge
                                                  ● Information to the patient and family, as
                                                  appropriate
                                                  8) The hospital has a policy and procedures on
                                                  the timely entry of all significant information into
                                                  the patient’s medical record.
                                                  9) The hospital defines a complete record and
                                                  the time frame within which the record must be
                                                  completed.
                                                  10) The hospital measures medical record
                                                  delinquency at regular intervals, no less
                                                  frequently than every three months.
             IM.6.10                              Applies to: H, LTC*, BHC*, HC* & AC*
                                                  *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                             Version: 04.21.2005                                                                             61 of 257
                                                  NCPSPatient Safety Assessment Tool
                                                       Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                  *Not
                                                                                                                          *Met       *Partially   Met If score other than 'met' what are
            Question:                             Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Information
  3.9.9     Records contain patient-specific      1) Each medical record contains, as applicable,
            information, as appropriate, to the   the following clinical/case information:
            care, treatment, and services         ● Emergency care, treatment, and services
            provided.                             provided to the patient before his or her arrival,
                                                  if any
                                                  ● Documentation and findings of assessments*
                                                  ● Conclusions or impressions drawn from
                                                  medical history and physical examination
                                                  ● The diagnosis, diagnostic impression, or
                                                  conditions
                                                  ● The reason(s) for admission or care,
                                                  treatment, and services
                                                  ● The goals of the treatment and treatment plan
                                                  ● Diagnostic and therapeutic orders
                                                  ● All diagnostic and therapeutic procedures,
                                                  tests, and results
                                                  ● Progress notes made by authorized individuals
                                                  ● All reassessments and plan of care revisions,
                                                  when indicated
                                                  ● Relevant observations
                                                  ● The response to care, treatment, and services
                                                  provided
                                                  ● Consultation reports
                                                  ● Allergies to foods and medicines
                                                  ● Every medication ordered or prescribed
                                                  ● Every dose of medication administered,
                                                  including the strength, dose, or rate of
                                                  administration, administration (continued)...
            IM.6.20                               Applies tor: H, LTC*, BHC*, HC* & AC*
                                                  *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                             Version: 04.21.2005                                                                             62 of 257
                                                     NCPSPatient Safety Assessment Tool
                                                          Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                     *Not
                                                                                                                             *Met       *Partially   Met If score other than 'met' what are
              Question:                              Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Information
  3.9.9       (continued)... Records contain         ...(continued) devices used, access site or route,
  (continued) patient-specific information, as       known drug allergies, and any adverse drug
              appropriate, to the care, treatment,   reaction
              and services provided.                 ● Every medication dispensed or prescribed on
                                                     discharge
                                                     ● All relevant diagnoses/conditions established
                                                     during the course of care, treatment, and
                                                     services
                                                     2) Each medical record contains, as applicable,
                                                     the following demographic information:
                                                     ● The patient’s name, sex, address, date of
                                                     birth, and authorized representative, if any
                                                     ● Legal status of patients receiving behavioral
                                                     health care services
                                                     3) Each medical record contains, as applicable,
                                                     the following information:
                                                     ● Evidence of known advance directives
                                                     ● Evidence of informed consent patient care
                                                     ● Records of communication with the patient
                                                     regarding care, treatment, and services, for
                                                     example, telephone calls or e-mail, if applicable
                                                     ● Patient-generated information (for example,
                                                     information entered into the record over the
                                                     Web or in previsit computer systems), if
                                                     applicable


              IM.6.20                                Applies tor: H, LTC*, BHC*, HC* & AC*
                                                     *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                                Version: 04.21.2005                                                                             63 of 257
                                                NCPSPatient Safety Assessment Tool
                                                     Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                *Not
                                                                                                                        *Met       *Partially   Met If score other than 'met' what are
            Question:                           Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Information
  3.9.10    The medical record thoroughly       1) The history and physical examination, the
            documents operative or other high   results of any indicated diagnostic tests, as well
            risk procedures† and the use of     as a provisional diagnosis are recorded before
            moderate or deep sedation or        the operative or other procedures by the
            anesthesia.                         licensed independent practitioner responsible
                                                for the patient.
                                                2) Operative or other high risk procedure reports
                                                dictated or written immediately‡ after an
                                                operative or other high risk procedure record
                                                appropriate information as defined by the
                                                medical staff.
                                                3) An operative or other high risk procedure
                                                progress note is entered in the medical record
                                                immediately after the procedure, when the full
                                                operative or other high risk procedure report
                                                cannot be entered into the record immediately
                                                after the operation or procedure.
                                                4) The completed operative or other high risk
                                                procedure report is authenticated by the
                                                surgeon and made available in the medical
                                                record as soon as possible after the procedure.
                                                5) Postoperative documentation records the
                                                patient’s vital signs and level of consciousness;
                                                medications (continued)...
            IM.6.30                             Applies to: H, BHC* & AC*
                                                *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                           Version: 04.21.2005                                                                             64 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                    *Not
                                                                                                                            *Met       *Partially   Met If score other than 'met' what are
              Question:                             Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
              Management of Information
  3.9.10      (continued)... The medical record     ...(continued) (including intravenous fluids) and
  (continued) thoroughly documents operative or     blood and blood components administered, if
              other high risk procedures† and the   applicable; and any unusual events or
              use of moderate or deep sedation or   complications, including blood transfusion
              anesthesia.                           reactions and the management of those events.
                                                    6) Postoperative documentation records the
                                                    patient’s discharge from the postsedation or
                                                    postanesthesia care area by the responsible
                                                    licensed independent practitioner or according
                                                    to discharge criteria.
                                                    7) The use of approved discharge criteria to
                                                    determine the patient’s readiness for discharge
                                                    is documented in the medical record.
                                                    8) Postoperative documentation records the
                                                    name of the licensed independent practitioner
                                                    responsible for discharge.


             IM.6.30                                Applies to: H, BHC* & AC*
                                                    *Elements of Performance are listed for Hospitial program; other programs may differ.
             Management of Information
  3.9.11     For patients receiving continuing      1) The list is initiated for each patient by the
             ambulatory care services, the          third visit and maintained thereafter.
             medical record contains a summary      2) The list is always stored in the same location
             list of all significant diagnoses,     to help practitioners access needed information
             procedures, drug allergies, and        quickly and easily.
             medications.                           3) The list contains the following information:
                                                    ● Known* significant medical diagnoses and
                                                    conditions
                                                    ● Known significant operative and invasive
                                                    procedures
                                                    ● Known adverse and allergic drug reactions
                                                    ● Known long-term medications, including
                                                    current prescriptions, over-the-counter drugs,
                                                    and herbal preparations
             IM.6.40                                Applies to: H & AC*
                                                    *Elements of Performance are listed for Hospitial program; other programs may differ.




JCAHO - 3                                                                               Version: 04.21.2005                                                                             65 of 257
                                                      NCPSPatient Safety Assessment Tool
                                                           Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                                      *Not
                                                                                                                              *Met       *Partially   Met If score other than 'met' what are
            Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)      (3) possible root causes
            Management of Information
  3.9.12     RESERVED
            Management of Information
  3.9.13    The hospital can provide access to        1) There is a manual or automated mechanism
            all relevant information from a           to track the location of all components of the
            patient’s record when needed for          medical record.
            use in patient care, treatment, and       2) The hospital uses a system to assemble
            services.                                 required information or make available a
                                                      summary of information relative for patient care,
                                                      treatment, and services when the patient is seen.

            IM.6.60                                   Applies to: H, LTC*, BHC*, HC* & AC*
                                                      *Elements of Performance are listed for Hospitial program; other programs may differ.
            Medical Staff
  3.10.1     RESERVED
             Nursing
  3.11.1     RESERVED
            JCAHO Goals
  3.12.1     #1: Improve the accuracy of patient a) Use at least two patient identifiers (neither to
            identification.                      be the patient’s room number) whenever
                                                 administering medications or blood products;
                                                 taking blood samples and other specimens for
                                                 clinical testing; or providing any other treatments
                                                 or procedures.
                                                 b) For LTC, HC & Lab: Prior to the start of any
                                                 invasive procedure, conduct a final verification
                                                 process, such as a "time out," to confirm the
                                                 correct resident, procedure and site, using
                                                 active - not passive - communication
                                                 techniques. [Lab only: The patient's identiy is re-
                                                 established if the practitioner leaves the
                                                 patient's location prior to initiating the proceudre.
                                                  Marking the site is requied unless the
                                                 practitioner is in continous attendance from the
                                                 time of the decision to do the procedure and
                                                 patient consent to the initiation of the procedure
                                                 (for example, bone marrow collection or fine
                                                 needle aspiration).]
            2003-2005 for H, LTC, BHC, HC, AC & Lab




JCAHO - 3                                                                                 Version: 04.21.2005                                                                             66 of 257
                                                      NCPSPatient Safety Assessment Tool
                                                           Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                  *Not
                                                                                                              *Met   *Partially   Met If score other than 'met' what are
            Question:                                 Rationale/Assessment Methods:                            (1)    Met (2)      (3) possible root causes
            JCAHO Goals
  3.12.2     #2: Improve the effectiveness of         a) For verbal or telephone orders or for
            communication among caregivers.           telephonic reporting of critical test results, verify
                                                      the complete order or test result by having the
                                                      person receiving the order or test result "read-
                                                      back" the complete order or test result.
                                                      b) Standardize a list of abbreviations, acronyms
                                                      and symbols that are not to be used throughout
                                                      the organization.
                                                      c) Measure, assess and, if appropriate, take
                                                      action to improve the timeliness of reporting,
                                                      and the timeliness of receipt by the responsible
                                                      licensed caregiver, of critical test results and
                                                      values.
                                                      d) For Lab: All values defined as critical by the
                                                      laboratory are reported to a responsible licensed
                                                      caregiver within time frames established by the
                                                      laboratory (defined in cooperation with nursing
                                                      and medical staff). When the patient's
                                                      responsible licensed caregiver is not available
                                                      within the time frames, there is a mechanism to
                                                      report the critical information to an alternative
                                                      responsible caregiver.


            2003-2005 for H, LTC, BHC, HC, AC & Lab




JCAHO - 3                                                                        Version: 04.21.2005                                                                  67 of 257
                                                    NCPSPatient Safety Assessment Tool
                                                         Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                            *Not
                                                                                                        *Met   *Partially   Met If score other than 'met' what are
            Question:                               Rationale/Assessment Methods:                        (1)    Met (2)      (3) possible root causes
            JCAHO Goals
  3.12.3    #3: Improve the safety of using         a) Remove concentrated electrolytes (including,
            medications.                            but not limited to, potassium chloride, potassium
                                                    phosphate, sodium chloride >0.9%) from patient
                                                    care units.
                                                    b) Standardize and limit the number of drug
                                                    concentrations available in the organization.
                                                    c) Identify and, at a minimum, annually review a
                                                    list of look-alike/sound-alike drugs used in the
                                                    organization, and take action to prevent errors
                                                    involving the interchange of these drugs.

            2003 - 2005 for H, LTC, BHC, HC & AC
            JCAHO Goals
  3.12.4    #4: As of 2005 this goal is now         a) Use a pre-op verification process, such as a
            surveyed under the Universal            checklist, to confirm appropriate documents are
            Protocol: Eliminate wrong-site,         available.
            wrong-patient, wrong-procedure.         b) Implement a process to mark the surgical
                                                    site and involve the patient in the process.
            2003-2004
            JCAHO Goals
  3.12.5    2003 #5: improve the safety of          Ensure free-flow protection on all general-use
            using infusion pumps.                   and PCA (patient controlled analgesia)
                                                    intravenous infusion pumps used in the
                                                    organization
            2003-2005 for H, LTC, BHC, HC & AC
            JCAHO Goals
  3.12.6    #6: As of 2005 this goal is now         a) Implement regular preventive maintenance
            surveyed under EC standards:            and testing of alarm systems.
            Improve the effectiveness of clinical   b) Assure that alarms are activated with
            alarm systems.                          appropriate settings and are sufficiently audible
                                                    with respect to distances and competing noise
                                                    within the unit.
            2003-2004




JCAHO - 3                                                                     Version: 04.21.2005                                                               68 of 257
                                                      NCPSPatient Safety Assessment Tool
                                                           Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                                *Not
                                                                                                            *Met   *Partially   Met If score other than 'met' what are
            Question:                                 Rationale/Assessment Methods:                          (1)    Met (2)      (3) possible root causes
            JCAHO Goals
  3.12.7    #7: Reduce the risk of health care-       a) Comply with current Centers for Disease
            associated infections.                    Control and Prevention (CDC) hand-hygiene
                                                      guidelines.
                                                      b) Manage as sentinel events all identified
                                                      cases of unanticipated death or major
                                                      permanent loss of function associated with a
                                                      health care-associated infection.
            2003-2005 for H, LTC, BHC, HC, AC & Lab
            JCAHO Goals
  3.12.8    #8: Accurately and completely             a) During 2005, for full implementation by
            reconcile medications across the          January 2006, develop a process for obtaining
            continuum of care.                        and documenting a complete list of the patient's
                                                      current medications upon the patient's
                                                      admission to the organization and with the
                                                      involvement of the patient. This process
                                                      includes a comparison of the medications the
                                                      organization provides to those on the list.
                                                      b) A complete list of the patient's] medications is
                                                      communicated to the next provider of service
                                                      when it refers or transfers a patient to another
                                                      setting, service, practitioner or level of care
                                                      within or outside the organization.


            2005 for H, LTC, BHC, HC & AC
            JCAHO Goals
  3.12.9    #9: Reduce the risk of patient harm       a) Assess and periodically reassess each
            resulting from falls.                     patient's risk for falling, including the potential
                                                      risk associated with the patient's medication
                                                      regimen, and take action to address any
                                                      identified risks.
                                                      b) For LTC: Implement a fall reduction program,
                                                      including a transfer protocol, and evaluate the
                                                      effectiveness of the program.
            2005 for H, LTC, HC




JCAHO - 3                                                                        Version: 04.21.2005                                                                69 of 257
                                                NCPSPatient Safety Assessment Tool
                                                     Part I - Administrative
  JOINT COMMISSION on ACCREDITATION of HEALTHCARE ORGANIZATIONS - Element 3
  (Comprehensive Accreditation Manual for Hospitals with cross reference to other programs)
                                                                                                                    *Not
                                                                                                *Met   *Partially   Met If score other than 'met' what are
            Question:                           Rationale/Assessment Methods:                    (1)    Met (2)      (3) possible root causes
            JCAHO Goals
  3.12.10   #10: Reduce the risk of influenza   a) Develop and implement a protocol for
            and pneunococcal disease in         administration and documentation of the flu
            institutionalized older adults.     vaccine.
                                                b) Develop and implement a protocol for
                                                administration and documentation of the
                                                pneumococcus vaccine.
                                                c) Development and implement a protocol to
                                                identify new cases of influenza to manage an
                                                outbreak.
            2005 for LTC
            JCAHO Goals
  3.12.11   #11: Reduce the risk of surgical    Educate staff, including operating licensed
            fires.                              independent practitioners and anesthesia
                                                providers, on how to control heat sourses and
                                                manage fuels, and establish guidelines to
                                                minimize oxygen concentration under drapes.
            2005 for AC




JCAHO - 3                                                                Version: 04.21.2005                                                            70 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   PROCUREMENT AND EQUIPMENT MANAGEMENT - Element 4
                                                                                                                                    *Not
                                                                                                                *Met   *Partially   Met If score other than 'met' what are
                   Question:                               Rationale/Assessment Methods:                         (1)    Met (2)      (3) possible root causes
                   Procurement and Equipment
   4.1.1           Are Human Factors Engineering           The medical devices are evaluated for ease of
                   principals considered when              use; feedback to the user (verbal and visual);
                   purchasing medical devices?             level of knowledge transfer from existing
                                                           equipment; and the impact of slips or mistakes
                                                           on providing patient care. The use of informal
                                                           usability groups to test the devices is
                                                           recommended.
                   Recommended; Priority A                 JCAHO: EC.6.10, EP-2
                   Procurement and Equipment
   4.1.2           Is equipment assessed for usability     Internal and external failure rates or other past
                   and maintainability prior to            history reports should be considered when
                   procurement?                            purchasing or replacing new equipment. Look
                                                           for evidence of a usability testing process (via
                                                           an evaluation addressing such things as: Does
                                                           the equipment prominently display the mode to
                                                           the user?; Are buttons spaced far enough apart
                                                           to prevent inadvertent activation?; Is the readout
                                                           clear and unambiguous?; Will parallax be an
                                                           issue?)

                   Recommended; Priority A
                   Procurement and Equipment
   4.1.3           Is equipment inspection scope and       Show evidence of the PM inspection
                   frequency modified based on             modifications.
                   inspection results or user input?
                   Recommended; Priority A                 JCAHO Std: EC.9.10 & EC.6.10
                   Procurement and Equipment
   4.1.4           Are users and maintenance             Verify training requirements are included in
                   personnel trained on new equipment procurement contract; and interview BME and
                   prior to it being introduced into the Clinician users.
                   hospital?
                   Recommended; Priority B                 JCAHO: EC.6.10
                   Procurement and Equipment
   4.1.4.1         Is the effectiveness of this training
                   assessed?
                   Recommended; Priority B




Procure Equip Mgt - 4                                                                     Version: 04.21.2005                                                           71 of 257
                                                        NCPSPatient Safety Assessment Tool
                                                             Part I - Administrative
   PROCUREMENT AND EQUIPMENT MANAGEMENT - Element 4
                                                                                                                                *Not
                                                                                                            *Met   *Partially   Met If score other than 'met' what are
                   Question:                            Rationale/Assessment Methods:                        (1)    Met (2)      (3) possible root causes
                   Procurement and Equipment
   4.1.5           When feasible, is equipment          Limiting the number of systems/equipment
                   standardized by manufacturer and     clinicians and maintenance staff are required to
                   model?                               operate/maintain will reduce latent errors in the
                                                        system.
                   Recommended; Priority A
                   Procurement and Equipment
   4.1.5.1         Is the BPA (Blanket Purchase         A standardization group has previously
                   Agreement) followed?                 evaluated equipment and has placed them on
                                                        the BPA list. The evaluations have considered
                                                        safety and human factors.
                   Recommended; Priority B
                   Procurement and Equipment
   4.1.6           Are "user errors" or "unable to      Review documentation or log of these
                   repeat" equipment inspections        inspections or evaluations. While proficiency
                   tracked with appropriate actions     with the equipment is important, actions should
                   taken?                               be focused on the equipment and environment
                                                        and not the user. Looking at "unable to repeat"
                                                        events provides insight into equipment
                                                        design/usability issues.
                   Recommended; Priority A
                   Procurement and Equipment
   4.1.7           Is there a procurement process or  Back up emergency equipment should be
                   plan to acquire an adequate amount available in all areas, or accessible as needed
                   of back up equipment.              when primary equipment fails.




Procure Equip Mgt - 4                                                             Version: 04.21.2005                                                               72 of 257
                                                         NCPSPatient Safety Assessment Tool
                                                              Part I - Administrative
   RECALLS, ALERTS AND ADVISORIES - Element 5
                                                                                                                            *Not
                                                                                                        *Met   *Partially   Met If score other than 'met' what are
                   Question:                           Rationale/Assessment Methods:                     (1)    Met (2)      (3) possible root causes
                   Recalls and VA Patient Safety Alerts & Advisories
               5.1 Is a system in place to disseminate Facility should have a robust system to ensure
                   and track medical product, device   communication to all personnel affected. An
                   and pharmaceutical recalls, patient ideal system would be functional 24-7, and not
                   safety alerts and advisories?       dependant upon a single individual.

                     Mandatory; Priority A
                     Recalls and VA Patient Safety Alerts & Advisories
               5.2 Are recalls promptly acted upon and Review response to last recall issued and spot
                     implemented (within 8 hours)?       check during building tour to verify
                                                         device/equipment is no longer in use.
                     Recommended; Priority A             JCAHO: EC.6.10, EP-6
                   Recalls and VA Patient Safety Alerts & Advisories
               5.3 Once a recall is identified, is the    Look for evidence of communication between
                   recall information integrated into the the recall coordinators and AMMS.
                   procurement review process?
                     Recommended; Priority A
                     Recalls and VA Patient Safety Alerts & Advisories
               5.4 Are VA Patient Safety Alert and       Interview PSM on local process that tracks
                     Advisory recommendations and        completion of recommendations.
                     suggestions implemented and
                     tracked until completed?
                     Mandatory; Priority A               JCAHO: EC.6.10, EP-6




Recalls, Alerts Advis - 5                                                         Version: 04.21.2005                                                           73 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                  Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                                 *Not
                                                                                                                             *Met   *Partially   Met If score other than 'met' what are
                     Question:                               Rationale/Assessment Methods:                                    (1)    Met (2)      (3) possible root causes
                     Cognitive Aids
   6.1.1             Is the Anesthesia Cogitative Aid        Safety Staff to talk about implementation of the
                     provided on all anesthesia              aid and give feedback on how the aid was
                     machines?                               received by affected staff. Look for aid on
                                                             anesthesia machines when walking the OR.
                     Recommended; Priority C
                                                             NCPS Cognitive Aid for Anesthesiology
                     Cognitive Aids
   6.1.2             Are the American Heart Association      Safety Staff to talk about implementation of the
                     Handbooks being used and well           aid and give feedback on how the aid was
                     received on all facility crash carts?   received by affected staff. This aid should be
                                                             attached to all code carts in the facility.
                     Recommended; Priority C
                     Communication of Abnormal Results
   6.2.1             Does the facility have a written    Policy should include: 1) Description of the
                     policy for communication of         process for communication of test results to the
                     abnormal radiology, laboratory, and requesting providers (or surrogates) and how
                     pathology results?                  and when the documentation of this
                                                         communication should occur. Laboratory and
                                                         Pathology should be a separate policy, but with
                                                         similar elements.
                                                             VHA Memorandum "Interim Guidance on Communication of Abnormal
                     Mandatory; Priority A
                                                             Results 4/2/03
                     Communication of Abnormal Results
   6.2.1.1           Is there a process to address fee   Often reports from these entities do not get
                     basis and outside contract reports? placed in the electronic record due to limited or
                                                         no access. However, the facility should
                                                         recognized this vulnerability and ensure these
                                                         reports are entered with the medical record.
                     Recommended; Priority B
                     Communication of Abnormal Results
   6.2.2             Are all radiology orders and findings Documentation should include appropriate test
                     documented electronically in the      related patient history to assist radiologist or
                     patients medical record?              nuclear medicine personnel in making a
                                                           judgment call on critical findings. A standard
                                                           process should be in place to handle fee basis
                                                           and outside contract reports which often do not
                                                           get scanned in the electronic chart.

                                                             VHA Memorandum "Interim Guidance on Communication of Abnormal
                     Mandatory; Priority A
                                                             Results 4/2/03




Policies, Tools Aids - 6                                                                       Version: 04.21.2005                                                                   74 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                               *Not
                                                                                                                           *Met   *Partially   Met If score other than 'met' what are
                     Question:                          Rationale/Assessment Methods:                                       (1)    Met (2)      (3) possible root causes
                     Communication of Abnormal Results
   6.2.3             Are abnormal radiology, laboratory Direct communication is defined as face-to-face
                     and pathology findings requiring   or telephone conversation; or written as
                     urgent attention communicated      customary protocol.
                     directly?
                                                           VHA Memorandum "Interim Guidance on Communication of Abnormal
                     Mandatory; Priority A
                                                           Results 4/2/03
                     Communication of Abnormal Results
   6.2.4             Has the communication process for The issuance of pagers; maintenance of VISTA
                     contacting treating providers in the contacts; the viewing of alerts in CPRS; and /or
                     event of an abnormal report been     establishment of a system of surrogates for
                     simplified in the facility?          taking responsibility for abnormal results.

                                                           VHA Memorandum "Interim Guidance on Communication of Abnormal
                     Recommended; Priority B
                                                           Results 4/2/03
                     Patient Safety Performance Measures
   6.3.1             Has the timely reporting of radiology 2004: 70% of reports read in 4 days. 2005: 90%
                     reports been addressed                of reports read in 48 hours (2 days). Practices
                     appropriately to meet the 2004-2005 that aid in timely follow up are: Use of PACS
                     Patient Safety Performance            system; avoidance of pre-registering patients;
                     Measures (Measure 19)?                the use of voice recognition transcribing;
                                                           sending subspecialty images to facilities with
                                                           staff/capacity; using electronic transmission for
                                                           images acquired at CBOCs rather than printed
                                                           images that require manual transport via van;
                                                           Provide weekend and off-tour coverage; and,
                                                           implementing teleradiology, including VISN-wide
                                                           teleradiolgoy.

                     Mandatory; Priority A                 2004/2005 VA Patient Safety Performance Measure
                                                           VA National Radiology workgroup presentation, 2004
                     Patient Safety Performance Measures
   6.3.2             Has the prevention of surgical site Three components will be measured: a) The
                     infection been addressed            percent of patients receiving prophylactic
                     appropriately to meet (or plan to   antibiotic timely prior; b) The percent of patients
                     meet) the 2005 Patient Safety       receiving a correct prophylactic antibiotic; and,
                     Performance Measure (Measure        c) Percent of patients with prophylactic antibiotic
                     20)?                                discontinued within 24 hours after surgery.

                     Mandatory; Priority A                 2005 VA Patient Safety Performance Measure




Policies, Tools Aids - 6                                                                     Version: 04.21.2005                                                                   75 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                  Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                           *Not
                                                                                                                       *Met   *Partially   Met If score other than 'met' what are
                     Question:                         Rationale/Assessment Methods:                                    (1)    Met (2)      (3) possible root causes
                     Patient Safety Environmental Concerns
   6.4.1             Is the Domestic hot water         Verify written program and confirm with plant
                     temperature controlled via        engineering personnel. PM to include: Mixing
                     regulating hardware and           valve inspection and outlet temperature taken
                     preventative maintenance          with calibrated thermometer. Frequency of
                     inspections/checks?               inspections are determined at local level.
                     Mandatory; Priority A                   VHA Directive 2002-073
                                                             JCAHO: EC.1.20
                     Escape & Elopement Prevention
   6.5.1             Does the facility have a written plan   Facility should have a local policy that
                     to help prevent wandering and           addresses criteria listed in the related VA
                     missing patient events and a            Directive, such as the risk assessment process,
                     process to manage the events that       search procedures, and staff training
                     do occur?                               plan.Review documents to verify.
                     Mandatory; Priority A                   VHA Directive 2002-013
                                                             JCAHO: PI.3.20 & IM.4.10
                                                             vaww.ncps.med.va.gov/Elope/VHADirect2002013.pdf
                     Escape & Elopement Prevention
   6.5.2             Are Missing Patient incidents           Actual SAC score of 3 requires an individual
                     (adverse events/close calls) with a     RCA to be done. All others should be an
                     SAC potential score of 3 addressed      aggregated review (twice per FY) focusing on
                     via the Aggregate Review Process?       fixing related processes.

                     Mandatory; Priority A                   Patient Safety Handbook 1050.1 - Appendix 3
                     Escape & Elopement Prevention
   6.5.2.1           Does the missing patient event log      Review documents to verify.
                     capture the information outlined in
                     Appendix 3 of the NCPS Handbook
                     (pg C-5) for each case?
                     Mandatory; Priority A                   Patient Safety Handbook 1050.1 - Appendix 3 (pgs 25-26)
                     Escape & Elopement Prevention
   6.5.3             Are drills conducted for the search     Review documents to verify.
                     of missing patients?
                     Recommended; Priority B                 http://vaww.ncps.med.va.gov/Elope/VHADirect2002013.pdf




Policies, Tools Aids - 6                                                                       Version: 04.21.2005                                                             76 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                           *Not
                                                                                                                       *Met   *Partially   Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                                (1)    Met (2)      (3) possible root causes
                     Escape & Elopement Prevention
   6.5.4             Is there an existing patient escape   Show example of an assessment and tools. The
                     and elopement risk assessment         NCPS Cognitive Aid is one example of a tool
                     conducted for all patients? If so     that could be used.
                     what tools are used?
                     Mandatory; Priority A                 JCAHO: PC2.120 & PC.2.150
                                                           vaww.ncps.med.va.gov/CognitiveAids/EscapeElope/index.html
                                                           http://vaww.ncps.med.va.gov/Elope/VHADirect2002013.pdf
                     Escape & Elopement Prevention
   6.5.5             What measures does the facility       Examples would be: Polices on topics such as
                     have in place to prevent missing      Patient Privileging, Supervision and/or
                     patients?                             Surveillance; Conducting Drills;
                                                           Monitoring/Assessing hazardous areas (such as
                                                           maintenance/construction areas).
                     Mandatory; Priority A                 VHA Directive 2002-013
                     Escape & Elopement Prevention
   6.5.5.1           What measures are taken with high- Use of electronic devices (with comprehensive
                     risk patients?                     testing regimen - i.e. check every 24 hours;
                                                        regular PM checks, and annual performance
                                                        testing); Special precautions for field trips and
                                                        transporting; and patient identification.

                     Mandatory; Priority A                 VHA Directive 2002-013
                     Fall Prevention
   6.6.1             Are fall incidents (adverse           Review documents to verify.
                     events/close calls) with a SAC
                     potential score of 3 addressed via
                     the Aggregate review process?
                     Mandatory; Priority A                 Patient Safety Handbook 1050.1
                                                           JCAHO: EC.6.10, EP-6
                     Fall Prevention
   6.6.2             Is a Falls Aggregated Review Log      Review documents to verify.
                     kept?
                     Mandatory; Priority A                 Patient Safety Handbook 1050.1
                     Fall Prevention
   6.6.2.1           Does the falls log capture the        Review documents to verify.
                     information outlined in Appendix C
                     of the NCPS Handbook for each
                     case?
                     Mandatory; Priority A                 Patient Safety Handbook 1050.1




Policies, Tools Aids - 6                                                                    Version: 04.21.2005                                                                77 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                 Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                         *Not
                                                                                                                     *Met   *Partially   Met If score other than 'met' what are
                     Question:                         Rationale/Assessment Methods:                                  (1)    Met (2)      (3) possible root causes
                     Fall Prevention
   6.6.3             Have facility Physical Therapists Show example.
                     been involved as team members for
                     RCA's or Aggregate Reviews
                     involving Falls?
                     Recommended; Priority A                JCAHO: LD.4.10; LD.4.60
                     Fall Prevention
   6.6.4             Does a process exist to assess all     Review assessment process. Is Do all staff use
                     patients for fall risk?                the same assessment methods and/or tools?

                     Recommended; Priority A                JCAHO: PC2.120 & PC.2.150
                     Fall Prevention
   6.6.4.1           NCPS Falls Toolkit and Fall            The Falls Toolkit provides a compendium of
                     Prevention and Management              practical suggestions to improve falls programs
                     cognitive aid been distributed and     and reduce falls and injuries from falls.
                     used?                                  Templates, successful practices, cognitive aids
                                                            and advice on measuring are all included in their
                                                            resources. The Fall Prevention an Management
                                                            is an older NCPS cognitive aid that can also
                                                            helpful to determine assessment and prevention
                                                            methods.

                     Recommended; Priority B                vaww.ncps.med.va.gov/FallsToolkit/index.html
                                                            vaww.ncps.med.va.gov/CognitiveAids/FallPrev/index.html
                     Fall Prevention
   6.6.5             Are there any unique processes,        Review any and evaluate effectiveness (I.e. Hip
                     tools, or specialized equipment used   Pads, patient surveys, labeling high risk, non-
                     in the facilities fall prevention      skid socks, or Morse Fall Risk Assessment, floor
                     strategy?                              mats, walkers, canes.)
                     Recommended; Priority B
                     Fall Prevention
   6.6.5.1           Are these processes, tools or           It is important that the off shifts are given
                     equipment available to all staff on all concurrent tools and oppertunities to improve
                     shifts?                                 the care of our patients.
                     Recommended; Priority B




Policies, Tools Aids - 6                                                                      Version: 04.21.2005                                                            78 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                        *Not
                                                                                                                    *Met   *Partially   Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                             (1)    Met (2)      (3) possible root causes
                     Magnetic Resonance Imaging Safe Practices
   6.7.1             Are there multiple barriers in place  Not only should the physical environment have
                     to prevent ferrous metallic objects   barriers, such as walls to keep patients away
                     from being carried or rolled into the from the magnet, there should also be
                     Magnet Resonance room?                procedures in place, such as: requiring
                                                           patients to change clothes before the scan (in
                                                           lieu of asking them to remove all metal objects
                                                           from pockets); posted signs to notify patients of
                                                           the existing hazard at multiple points (changing
                                                           room, at entry point into the room); cognitive
                                                           aids used by staff as reminders of how to keep
                                                           the patients safe; ensure that all equipment is
                                                           MR compatible (wheelchairs, gurneys, oxygen
                                                           supply, pumps, etc.)

                     Recommended; Priority A               Related PSAT Part II question: 7.6.15.2
                     Magnetic Resonance Imaging Safe Practices
   6.7.2             Are there multiple barriers to      Types of devices that are affected by the MR
                     prevent patients with implants or   magnet include: pacemakers; metal implants;
                     prosthetic devices from being taken ferrous aneurysm clips; metal pins; foreign metal
                     into the MR room?                   objects such as shavings or particles; etc. Are
                                                         the hazards associated with tattoos and
                                                         permanent eyeliner addressed?
                     Recommended; Priority A               Related PSAT Part II question: 7.6.15.3
                     Magnetic Resonance Imaging Safe Practices
   6.7.3             Is there a process in place to    Only MR compatible oxygen cylinders or a piped
                     address the needs of patients who oxygen system should be in the vicinity of the
                     require medical devices or        MR room. Are pumps MR compatible (some
                     equipment during the MR scan      pumps can run backwards when influenced by
                     including oxygen or pumps?        strong magnetic fields).
                     Recommended; Priority A               NCPS MR Hazard Summary (2001)
                                                           Related PSAT Part II question: 7.6.15.3




Policies, Tools Aids - 6                                                                      Version: 04.21.2005                                                           79 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                        *Not
                                                                                                                    *Met   *Partially   Met If score other than 'met' what are
                     Question:                           Rationale/Assessment Methods:                               (1)    Met (2)      (3) possible root causes
                     Magnetic Resonance Imaging Safe Practices
   6.7.4             Is all equipment used or permitted  Materials and equipment that are safe for a 1.5
                     within the vicinity of the magnet   Tesla magnet may be unsafe for a 2.0 or 3.0
                     assessed for safety based upon the Tesla magnet. It is critical that devices and
                     magnets strength (Tesla rating) and equipment be assessed for environment that
                     the composition of the material.    they are used. If a new stronger magnet has
                                                         been (or will be installed) do not assume that all
                                                         of the devices and equipment may be reused.
                                                         These devices need to be reassessed for safety
                                                         and whether they will produce artifacts in the
                                                         images.
                     Recommended; Priority A               Related PSAT Part II question: 7.6.15.3
                     Magnetic Resonance Imaging Safe Practices
   6.7.5             Does the facility have a written MR Review written plan. The program should
                     Safety Program?                     include: The appointment of an MRI Officer;
                                                         how to secure MRI areas; a current list of MRI
                                                         compatible equipment in the facility; and training
                                                         requirements. Written documents should be
                                                         reviewed/updated at least annually
                     Recommended; Priority B               NCPS MRI Hazard Summary 8/01
                                                           ACR: Patient and Personnel Safety Guildlines
                                                           Related PSAT Part II question: 7.6.15.4
                     Magnetic Resonance Imaging Safe Practices
   6.7.6             Is there an on going training and    Review training materials, plan and training
                     competency program for all effected records. Check to see if that not only necessary
                     staff that covers hazard recognition clinical personnel are trained, but that
                     and policies/procedure?              emergency, transport, maintenance,
                                                          housekeeping, security, and medical
                                                          residents/fellows are included as well. If clinical
                                                          or support are not trained they should not be
                                                          allowed to work in the direct vicinity of the MR
                                                          equipment.
                     Recommended; Priority B               NCPS MRI Hazard Summary 8/01




Policies, Tools Aids - 6                                                                      Version: 04.21.2005                                                           80 of 257
                                                          NCPSPatient Safety Assessment Tool
                                                               Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                       *Not
                                                                                                                   *Met   *Partially   Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                            (1)    Met (2)      (3) possible root causes
                     Magnetic Resonance Imaging Safe Practices
   6.7.7             Are MR technicians                    Review training materials, training plan, and
                     trained/competent in the specifics of records. "Specifics of MRI Safety" include items
                     MR safety?                            such as positioning of conductive leads, cables,
                                                           sensors, and the patients' extremities; and
                                                           precautions required for unconscious patients.

                     Recommended; Priority B              NCPS MRI Hazard Summary 8/01
                                                          Related PSAT Part II question: 7.6.15.3.1
                     Magnetic Resonance Imaging Safe Practices
   6.7.8             Has the MR noise level been         MR scans can be loud with noise levels
                     assessed and patients provided with exceeding 100 dBA depending upon the type of
                     hearing protection if needed?       magnet (open or closed), the design and the
                                                         manufacturer. Interview staff, check required
                                                         policy procedure, look for posted signs.

                     Recommended; Priority B              Related PSAT Part II question: 7.6.15.2.1
                     Magnetic Resonance Imaging Safe Practices
   6.7.9             Has the MR Hazard Supplement       The Hazard Summary published by NCPS in
                     developed by NCPS been shared      2001 can serve as a guildeline and a reference
                     with all MR staff and discussed to for those working in an MR environment. This
                     determine what barriers are being  Hazard summary can be found on the NCPS
                     implemented locally to prevent     intranet and internet websites:
                     adverse events?                    vaww.ncps.med.va.gov or www.patientsafey.gov

                     Recommended; Priority B
                     Magnetic Resonance Imaging Safe Practices
   6.7.10            Has a plan been developed and       Regular code drills should be conducted in the
                     tested to address patients who need MR environment to help acclimate medical
                     emergency care (code) within the    responders to a consistent approach of
                     MR room?                            removing the patient from the magnet area.
                     Recommended; Priority B




Policies, Tools Aids - 6                                                                     Version: 04.21.2005                                                           81 of 257
                                                         NCPSPatient Safety Assessment Tool
                                                              Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                      *Not
                                                                                                                  *Met   *Partially   Met If score other than 'met' what are
                     Question:                          Rationale/Assessment Methods:                              (1)    Met (2)      (3) possible root causes
                     Medication Use Process Safety Concerns
   6.8.1             Are Medication incidents (adverse  Review documents to verify.
                     events/close calls) with a SAC
                     potential score of 3 addressed via
                     the Aggregate Review process?

                     NOTE: Actual SAC 3 require a RCA

                     Mandatory; Priority A               JCAHO: EC.6.10, EP-6
                                                         Patient Safety Handbook 1050.1
                                                         ISMP Self Assessment: #173
                     Medication Use Process Safety Concerns
   6.8.2             Is a facility-wide Medication    Review documents (database or spreadsheets)
                     Aggregated Review Log kept?      to verify.
                     Mandatory; Priority A               Patient Safety Handbook 1050.1Appendix C
                                                         JCAHO: MM.8.10
                     Medication Use Process Safety Concerns
   6.8.2.1           Does the log capture the information Review documents to verify.
                     outlined in Appendix C of the NCPS
                     Handbook for each case?

                     Mandatory; Priority A               Patient Safety Handbook 1050.1 Appendix C
                     Medication Use Process Safety Concerns
   6.8.3             Has facility Pharmacy staff been Show example in a RCA or Aggregate Review.
                     involved as team members for
                     RCA's or Aggregate Reviews
                     involving Medication use?
                     Mandatory; Priority A               Patient Safety Handbook 1050.1 , 4.e(4)(a)
                                                         ISMP Self Assessment: #171
                     Medication Use Process Safety Concerns
   6.8.4             Are patients educated regarding
                     their prescribed medication, as
                     inpatients and as part of the
                     discharge process?
                     Recommended; Priority A             JCAHO: PC.6.10
                                                         ISMP Self Assessment: N29a (similar)




Policies, Tools Aids - 6                                                                    Version: 04.21.2005                                                           82 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                 Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                     *Not
                                                                                                                 *Met   *Partially   Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                          (1)    Met (2)      (3) possible root causes
                     Medication Use Process Safety Concerns
   6.8.5             Is there a policy or SOP on the
                     provision of current drug information
                     used by clinical staff?
                     Recommended; Priority A                ISMP Safe Practice Recommendation
                                                            JCAHO: IM.5.10
                                                            ISMP Self Assessment: #17
                     Medication Use Process Safety Concerns
   6.8.6             Are local PCA protocols used,    Look for documentation via a local policy that
                     including double checks?         includes items such as standardized prescribing,
                                                      dispending , administration, and/or monitoring of
                                                      PCA medications.
                     Recommended; Priority A
                     Medication Use Process Safety Concerns
   6.8.7             Does the facility have a policy or    Examples may include: Arranging inventory
                     protocol to prevent look alike, sound alphabetically by generic name and evaluating
                     alike drug mix ups?                   which look-a-like/sound-a-likes are stored in the
                                                           same proximity based on the USP (United
                                                           States Pharmacopeia) look-a-like/sound-a-like
                                                           list; Physically separating sound-a-alike and
                                                           look-a-like medications on the shelves if they fall
                                                           close to each other; and/or Using special
                                                           caution labels or warnings.

                     Recommended; Priority B                JCAHO: 2.20, EP-6
                     Medication Use Process Safety Concerns
   6.8.8             Does the facility have contingency Review plan, interview staff.
                     plans in place for the loss of the
                     CPRS, POE, BCMA, and VISTA
                     system?
                     Mandatory; Priority A
                     Medication Use Process Safety Concerns
   6.8.8.1           Have these information system      It is important to ensure your contingency plans
                     contingency plans been tested (via are realistic and workable, it is not ideal to find
                     a drill), which included a         faults in the plan at the time of an emergency.
                     debriefing/critique?               After testing, if problems are found the plan
                                                        should be adjusted accordingly.
                     Recommended; Priority A




Policies, Tools Aids - 6                                                                   Version: 04.21.2005                                                           83 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                   *Not
                                                                                                               *Met   *Partially   Met If score other than 'met' what are
                     Question:                            Rationale/Assessment Methods:                         (1)    Met (2)      (3) possible root causes
                     Medication Use Process Safety Concerns
   6.8.9             What is the protocol for handling
                     medication preparations that are
                     incorrectly bar coded or labeled, or
                     have labels that do not scan?
                     Recommended; Priority B
                     Medication Use Process Safety Concerns
   6.8.10            What process is in place to
                     eliminate IV pumps with free flow
                     potential?
                     Mandatory; Priority A                 JCAHO: 2003 Goal # 5
                                                           ISMP Self Assessment: #108
                     Medication Use Process Safety Concerns
   6.8.11            Has a effective process begun to   JCHAO is requiring all facilites have a plan in
                     reconcile patient medications upon place by January 2006.
                     admission, transfer or discharge?

                     Mandatory; Priority A                 JCAHO: 2005 Goal #8a & 8b
                     Misidentification Prevention
   6.9.1             Is there a method in place to ensure Look for documented formal work practice,
                     patients with same or similar names interview administrate and clinical staff to verify
                     are identified as high risk for      compliance.
                     misidentification?
                     Recommended; Priority B
                     Misidentification Prevention
   6.9.2             Does a policy exist that enforces the The patient should be asked to state his/her
                     use of methods for patient            name and SS# or other identifier. Look for the
                     identification?                       elimination of the "yes" response and "knowing
                                                           and caring" methods as forms of patient
                                                           verification.
                     Recommended; Priority B
                     Misidentification Prevention
   6.9.2.1           Do caregivers use at least two        Observe patient blood draws if possible, or
                     patient identifiers when taking blood interview staff.
                     samples or administering blood,
                     blood products, or medications?

                     Mandatory; Priority A                 JCAHO: Goal 1a
                                                           ISMP Self Assessment: #11




Policies, Tools Aids - 6                                                                Version: 04.21.2005                                                            84 of 257
                                                                NCPSPatient Safety Assessment Tool
                                                                     Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                         *Not
                                                                                                                     *Met   *Partially   Met If score other than 'met' what are
                     Question:                                  Rationale/Assessment Methods:                         (1)    Met (2)      (3) possible root causes
                     Misidentification Prevention
   6.9.2.2           Is the labeling of blood samples or
                     specimens done at the bedside,
                     rather than in bulk (at the nurses
                     station) to prevent mislabeling?
                     Recommended; Priority C
                     Misidentification Prevention
   6.9.3             During patient transfers are all
                     caregivers responsible to ensure
                     correct identification of the patient in
                     question?
                     Recommended; Priority B
                     Misidentification Prevention
   6.9.4             Is there an existing protocol for          When a patient can't communicate verbally or
                     patient identification with non-           otherwise, a special protocol should be followed
                     communicative patients?                    to ensure correct identification, such as, a photo
                                                                ID or a color coded armband to flag a common
                                                                name or a name that is similar to another
                                                                admitted patient.
                     Recommended; Priority B




Policies, Tools Aids - 6                                                                  Version: 04.21.2005                                                                85 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                                Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                               *Not
                                                                                                                           *Met   *Partially   Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                                    (1)    Met (2)      (3) possible root causes
                     Medical/Surgical Resident Patient Safety Involvement (ACGME)
   6.10.1            Do you have medical/surgical          Incorporating patient safety at the prime level of
                     residents on RCA teams? Have          medical training can fulfill some requirements of
                     patient safety topics, exercises, and the Accreditation Council on Graduate Medical
                     educational opportunities been        Education (ACGME). And thereby help your
                     incorporated in the resident          university affiliate meet new and challenging
                     training/curriculum at your facility? education requirements. Having residents on
                                                           RCA teams or teaching them patient safety is an
                                                           upstream method for engraining patient safety
                                                           practices into the medical field. Other benefits
                                                           are: the learning of basic tools for root cause
                                                           analysis and human factors system design to
                                                           help them problem solve when patient safety
                                                           events occur during their practices; increase
                                                           awareness of patient safety issues; increase
                                                           participation on RCA teams; and promote
                                                           patient safety event reporting. Finally, some
                                                           state laws require medical students and
                                                           residents to learn about and participate in
                                                           patient safety (e.g., Florida).

                     Mandatory; Priority A                 NCPS web link www.patientsafety.gov/psc/pscurric.html
                                                           ACGME requirements http://www.acgme.org/outcome/comp/compFull.asp
                     Surgical and Invasive Procedures Safety
   6.11.1            Is a surgical policy or procedure in Policy should address: A counting protocol,
                     place to prevent retained objects?   maintaining continuity of staff during a single
                                                          operation; maintaining all items/packages until
                                                          the final count/closing; and special precautions
                                                          for obese patients, emergency situations, and
                                                          unplanned changes in surgical course during
                                                          surgery.
                     Recommended; Priority B               VHA Directive: 2002-070
                     Surgical and Invasive Procedures Safety
   6.11.2            Are STAT x-ray readings obtained  Radiopaque sponges and other items can be
                     before closing a surgery if an    identified via a x-ray to avoid post-surgery
                     incorrect count is determined?    complications. A protocol should require
                                                       specific action when a retained object is
                                                       suspected. Review patient records - specific
                                                       example if available.
                     Recommended; Priority C               VHA Directive: 2002-070




Policies, Tools Aids - 6                                                                     Version: 04.21.2005                                                                   86 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                  Part I - Administrative
   POLICIES, TOOLS AND AIDS - Element 6
                                                                                                                                *Not
                                                                                                            *Met   *Partially   Met If score other than 'met' what are
                     Question:                         Rationale/Assessment Methods:                         (1)    Met (2)      (3) possible root causes
                     Surgical and Invasive Procedures Safety
   6.11.3            Has the Ensuring Correct Surgery  To meet the Directive the following must be met:
                     Directive been fully implemented?  (1) A local policy is in place that incorporates
                                                       the steps as described on the correct Site
                                                       Surgery poster. (2) The execution of these steps
                                                       is documented in the patient's record. (3) The
                                                       implementation of the steps and conformance to
                                                       the local policy are monitored for compliance.

                     Mandatory; Priority A                   VHA Directive 2002-070
                     Surgical and Invasive Procedures Safety
   6.11.4            Has a program been implemented      The procedures should incorporate all of the
                     to ensure correct invasive          Correct Site Surgery steps. An exception may
                     procedures are performed outside of be made for the step requiring marking the
                     the Operating Room?                 surgical site when the privileged provider does
                                                         not leave the patient from the time of
                                                         identification of the site to the time of the
                                                         procedure start.
                     Mandatory; Priority A                   JCHAO: Goal #1b
                     Violence Prevention for Patients
   6.14.1            Is there an assessment used to          Review assessment process/documents.
                     determine if a patient is potentially
                     violent?
                     Mandatory; Priority A                   VA IL-10-97-006
                     Violence Prevention for Patients
   6.14.2            Are there existing processes,           Review written policy.
                     policies, or protocols that address
                     the handling of violent patients?
                     Mandatory; Priority A                   VA IL-10-97-006
                                                             JCAHO: EC.2.10
                     Violence Prevention for Patients
   6.14.3            Does the facility have a policy         Look for policy statement documentation.
                     statement to address the use of
                     flags in the medical record (VISTA)
                     to indicate a potentially violent
                     patient?
                     Recommended; Priority B                 VA Directive: 2003-048




Policies, Tools Aids - 6                                                              Version: 04.21.2005                                                           87 of 257
 Patient Safety Assessment Tool
   Implementation Element 7
Element 7.1
Long Term Care Untis

Element 7.2
Behavioral Health Care Units (Locked)

Element 7.3
Acute Care Units

Element 7.4
Intensive Care Units

Element 7.5
Peri-Operative Areas

Element 7.6
Radiology Areas

Element 7.7
Pharmacy (Inpatient/Outpatient)
                  Patient Safety Assessment Tool
                  Part II Implementation
                  Element: Long Term Care - 7.1
                               Categories:
                               Bed Safety                                    1-2
                               Code Carts                                    2-3
                               Electrical Safety                             3-4
                               Environmental and Housekeeping Safety         5-6
                               Equipment Safety                              6-9
                               Escape and Elopement Prevention               9 - 10
                               Fall Prevention                               10 - 12
                               Fire Safety                                   12 - 13
                               Infection Control                             14 - 15
                               Medical Gas Safety                            15 - 16
                               Medication Safety                             16 - 22
                               General Patient Safety Concerns               22 - 25
                               Psychiatric Precautions                       NA
                               Surgical or Invasive Procedures Precautions   NA
                               Imaging and X-Ray Precautions                 NA

Thursday, April 21, 2005                                                               89 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
   Revised         Bed Safety
   7.1.1.1         If bed rails are installed/used are       Entrapment can result in suffocation. Follow
                   they free of entrapment potential (for    July 2001 NCPS Patient Safety Alert Action
                   patients identified as high risk for      items including: assessing existing beds for
                   entrapment): 1) rail to mattress, 2)      horizontal gap between mattress and bed rail
                   between split rails, 3) rail to board -   must be less than 2 3/8 inches when the
                   either end, 4) board to mattress, or,     mattress is pushed to the opposite side;
                   5) within rail?                           permanently mark all non-complying bed
                                                             assemblies; fill gaps created between the
                                                             mattress and bed rail that are equal or wider
                                                             than 2 3/8 inches for high risk patients; reduce
                                                             the rail to rail openings, and openings with in rail
                                                             gaps to less than 4 3/4 inches by using rail
                                                             netting, clear padding or retrofit kits; ensure new
                                                             beds purchased meet requirements.

                   Mandatory                                 JCAHO SEA #28
                                                             VHA Patient Safety Alerts 7/12/01 & 12/12/01
                   Bed Safety
   7.1.1.2         Are bed rails easy to use, and have       Manipulate bed rails if available and interview
                   staff been trained on the usage?          staff.

                   Recommended
                   Bed Safety
   7.1.1.3         Are non-compliant beds clearly            All new beds must meet requirement, & existing
                   marked as to indicate entrapment          non-compliant beds marked.
                   risk?
                   Mandatory                                 VHA Patient Safety Alerts 7/12/01 & 12/12/00
                   Bed Safety
   7.1.1.4         Are beds designed to facilitate           Bed attributes would include: Stand assistive
                   patient transfer?                         devices to assist patients to stand, room for
                                                             base of lifting device to fit under the bed, clear
                                                             area around bed for staff and lifting equipment
                                                             access, variable position capabilities.

                   Recommended                               OSHA Guidelines for Nursing Homes




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                     90 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                            Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                   Bed Safety
   7.1.1.5         Is the appropriate bed-type matched LTC patients can acquire bed sores; cardiac
                   to the level of care needed for each patients beds designed to facilitate CPR, etc.
                   patient?
                   Recommended
                   Bed Safety
   7.1.1.6          RESERVED
   New             Bed Safety
   7.1.1.7         Are measures in place to help            In addition to facility fire prevention practices,
                   prevent fires resulting from the use     extra steps should be taken for electrical beds:
                   of electric hospital beds?               Connect the bed's power cord directly to a wall-
                                                            mounted receptacle without the use of extension
                                                            cords or power strips; Do not cover any power
                                                            cord with a rug or carpet; conduct regular
                                                            inspections for duct build up (bed frame,
                                                            motor/hardware, mattress, etc.); regularly test
                                                            bed movement and hand/panel controls; inspect
                                                            the patient control panel (if cracked liquids can
                                                            get in); check that circuits are not overloaded
                                                            with other equipment; encourage reporting of
                                                            improper functioning; and assure that
                                                            manufacturers' recalls are followed.
                                                            FDA public Health Notification: Safety Tips for Preventing Hospital
                   Recommended
                                                            Bed Fires 12-2003
                   Code Carts
   7.1.2.1         Are code carts locked when not in        Drugs have potential to be taken from
                   use, and is equipment in good            unsecured carts in common areas. Verify cart
                   condition?                               inspection records.
                   Mandatory                                 JCAHO: MM.2.30
                   Code Carts
   7.1.2.1.1 - 7.1.2.2       RESERVED
                   Code Carts
   7.1.2.3         Are equipment and drugs easily           Standardizing the location of supplies and
                   retrievable on/in code carts, and is     equipment will increase the code response
                   there standard organization in all       efficiency.
                   carts throughout the hospital?
                   Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                     91 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                   Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Code Carts
   7.1.2.4         Is the VHA modified version of the      Inspect top of cart and review checklist of
                   AHA Handbook of Cardiovascular          contents if provided.
                   Care Cognitive Aid located on all
                   carts?
                   Recommended
   Revised         Code Carts
   7.1.2.5         Are CO2 detectors available on          Inspect carts. Adjunctive devices (i.e.
                   code carts for confirming               colorimetric, syringe, or bulb devices) should be
                   esophageal intubations?                 adequately stocked and readily available for use
                                                           in all carts. Review cart checklist talk with cart
                                                           preparers in SPD (Supply Processing and
                                                           Distribution) Service.
                   Recommended
   Revised         Code Carts
   7.1.2.6         Is there a standardized system (e.g.    Cart should be locked with an integrity seal, look
                   checklist) or method used to verify     for a valid checklist or equivalent system on the
                   that code carts are fully stocked and   cart, dated with last check/update date. Items
                   properly equipped before they are       such as these should be on the checklist: O2
                   sent to the units?                      tank volume; tubing ; CO2 detectors;
                                                           appropriate medications; AED (or other
                                                           defibrillators) and suction machine functionality;
                                                           laryngoscope with batteries; cardiac board, etc.

                   Recommended
   Revised         Electrical Safety
   7.1.3.1         Are electrical receptacles in, or       All areas designated as wet locations, or areas
                   serving, wet areas or behavioral        used for behavioral health patients, require (wet)
                   health areas provided with Ground       or recommend (behavioral health) ground-fault
                   Fault Circuit Interruption (GFCI)       protection. These types of receptacles are
                   protection or an isolated power         designed to stop the flow of electrical current,
                   system?                                 preventing shock or electrocution. For
                                                           behavioral health areas, electrical receptacles
                                                           can be completely removed or covered in
                                                           patient rooms to protect patients who my try to
                                                           harm themselves.

                   Mandatory                               National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                           NFPA 99-3.3.179




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                     92 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Electrical Safety
   7.1.3.2         Are electrical receptacles fitted with    Observe conditions on unit.
                   covers, secured, and free of loose
                   or exposed wiring?
                   Mandatory                                  NFPA 99-4 3.3.2.1.2
                   Electrical Safety
   7.1.3.2.1           RESERVED
                   Electrical Safety
   7.1.3.3         Are emergency power receptacles           Staff should be able to identify emergency
                   appropriately identified and only         receptacles. Assessor should inspect locations
                   used for equipment needing to be          of these outlets.
                   on emergency power circuits?
                   Mandatory                                 NFPA 99 4.4.2.2.4.2(B)
                   Electrical Safety
   7.1.3.4         Are electrically powered medical          Cords are free of physical defects including
                   devices in good condition?                cracks, frayed ends, or missing prongs.
                   Mandatory                                 NFPA 99 8.4.1.3.1
                                                             VHA Directive 2002-030
                   Electrical Safety
   7.1.3.5         Are there at least 4 receptacles (6 in Inspect patient rooms.
                   critical care) for each patient bed?

                   Mandatory                                 NFPA 99-4.3.2.2.7.2
   Revised         Electrical Safety
   7.1.3.6         If used, are power cords and              Facilities should strive to eliminate the use of
                   electrical extension cords placed         extension cords for small working spaces such
                   where they are free from                  as the operating room, patient rooms, or exam
                   mechanical damage, properly sized         rooms. A plan should be in place to install
                   (gauge) to prevent overheating, and       permanently affixed receptacles supplied by the
                   arranged so that they do not present      appropriate electrical circuit (emergency or
                   a tripping hazard?                        critical branch) if cords are being used.

                   Recommended
                   Electrical Safety
   7.1.3.7          RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                     93 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                   Question:                           Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                   Environmental and Housekeeping Safety
   7.1.4.1         Are hot water temperatures taken    Temperature should be less than 120 F at the
                   manually using a thermometer        tap and 110F in baths.
                   before patient use or immersion
                   (including partial immersion) takes
                   place?
                   Mandatory                               VHA Directive 2002-073
                   Environmental and Housekeeping Safety
   7.1.4.2         Are supply and return air registers Observe conditions on the unit.
                   clean and free of lint and dust?
                   Recommended                             JCAHO Std: EC.8.10
                   Environmental and Housekeeping Safety
   7.1.4.3         Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                   to be a priority?
                   Recommended                             JCAHO Std: EC.8.10
   Revised         Environmental and Housekeeping Safety
   7.1.4.4         Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                   well light and temperature           rooms will help prevent mistakes. Ensuring
                   controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                   fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                        of floor keeps supplies sanitary.
                   Recommended                             JCAHO Std: EC.5.20
                   Environmental and Housekeeping Safety
   7.1.4.5         Are patient care area hallways and Observe conditions on the unit.
                   stairways unobstructed and kept
                   free of storage?
                   Mandatory                               NFPA 101 (LSC) 7.1.10
                                                            JCHAO: EC.5.20
                   Environmental and Housekeeping Safety
   7.1.4.6         Are patient areas free of unlabeled All cleaning products, medication, employee
                   or unattended containers, such as   food or drink, etc., should not be left in patient
                   cleaning products or medication?    care areas or patient rooms.
                   Mandatory                               JCAHO: EC.1.10




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                     94 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                   Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                   Question:                          Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                   Environmental and Housekeeping Safety
   7.1.4.7         Are hazards clearly identified and Pre-construction meetings should proactively
                   properly controlled during         address all necessary interventions to remediate
                   construction and renovation?       such issues. However, patient /staff concerns
                                                      may flag potential problems. Examples of
                                                      hazards: walkways maintained; marked exit
                                                      paths; guarded floor openings and overhead
                                                      hazards; dust generation; and excessive noise.

                   Mandatory                              29CFR 1926.20(b)
                                                          VA Directive 7703c(4)(a)
                                                           JCAHO: 5.50
                   Environmental and Housekeeping Safety
   7.1.4.8         Are high hazard areas such as:       High hazard areas must be locked to prevent
                   Roofs, service areas, medication     access to patients and have warning signs and
                   rooms, labs, radiation areas,        labels.
                   confined spaces, high voltage
                   areas, laser areas, low use areas
                   (such as sub-floors and interstitial
                   spaces), etc. labeled with
                   appropriate caution signage and
                   locked to prevent unauthorized
                   entrance?
                   Mandatory                              VA Directive 7703c(4)(a)
                   Environmental and Housekeeping Safety
   7.1.4.9          RESERVED
                   Environmental and Housekeeping Safety
   7.1.4.10        Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                   "pests" in the hospital environment? preventative measures or monitors. Special
                                                        considerations should be made for sterile
                                                        environments.
                   Recommended
                   Equipment Safety
   7.1.5.1         Is medical equipment being        Check inspection tags, or other identifiers on the
                   inspected in accordance with the  equipment that indicates it has been inspected.
                   Preventative Maintenance Program? Interview staff to determine how to interpret
                                                     identifiers.
                   Mandatory                              JCAHO: EC.6.20 and Goal # 6a




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                     to understand observed behavior and local norms to identify system vulnerabilities.                                                     95 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Equipment Safety
   7.1.5.2         Is back up patient care/monitoring        Uninterruptible monitoring and support should
                   equipment readily available in the        be planned for.
                   event of failure and or emergency?
                   Recommended                               JCAHO: EC.6.10
                   Equipment Safety
   7.1.5.3         Is the equipment used on each             There is no chance equipment would be
                   patient positioned in a way that it is    inadvertently shut off because it is not in sight of
                   evident the equipment is in use for       the patient.
                   that patient?
                   Recommended
                   Equipment Safety
   7.1.5.4         Are alarms audible and easily             Alarms may be broadcast to an outside room or
                   distinguished above ambient               another area such as a central nursing station.
                   background noise level?                   Interview staff as to what is done during breaks
                                                             to cover patient monitoring. Clinical alarms,
                                                             bathroom alarms, and nurse calls are included
                                                             here.
                   Mandatory                                 JCAHO: Goal # 6b
                   Equipment Safety
   7.1.5.4.1           RESERVED
                   Equipment Safety
   7.1.5.5         Are all devices that alarm                Masking is when the frequency and intensity of
                   specifically set up for each patient to   two separate alarms blend together causing
                   reduce issues such as, "masking",         heightened confusion; nuisance alarms are
                   nuisance, or altered priority due to      caused when limits are not appropriately set,
                   unwanted false or alarms?                 this can create staff complacency, annoyance to
                                                             patients, and results in a delayed staff response
                                                             (cry wolf syndrome).

                   Recommended                               JCAHO: Goal 6b
                   Equipment Safety
   7.1.5.5.1       Are work arounds avoided in the     Due to factors listed above, devices can be
                   use of medical devices with alarms? disabled, turned off, turned down, etc. Signs of
                                                       workarounds include: post it notes suck to
                                                       equipment, worn silencer buttons, and taped
                                                       down or temporally disabled buttons.
                   Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                     96 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Equipment Safety
   7.1.5.6         Is the equipment designed such that       Should not see post-it notes or permanently
                   its operation is intuitive to the user    posted signs indicating warnings about
                   and does not require use of adjunct       seemingly logical machine operation (i.e. a sign
                   devices to complete the required          reading such messages as: "Don't press
                   tasks?                                    'ENTER' key to enter data.") Interview staff and
                                                             inspect equipment in area.
                   Recommended
                   Equipment Safety
   7.1.5.7         Is patient care and monitoring            All screens/interfaces are readable and at or
                   equipment well organized in each          near eye level; key pads within reach;
                   patient/procedure room to avoid           equipment is not blocking each other; adequate
                   clutter and permit the caregivers to      space to move around, including head
                   be able to reach and read all             clearance on mounted devices.
                   equipment?
                   Recommended
                   Equipment Safety
   7.1.5.8         Are liquids kept away from medical        To prevent spillage which can result in
                   equipment?                                malfunctioning.
                   Recommended                               NFPA 70 110.11
                   Equipment Safety
   7.1.5.9         Are disposable medical                    Inspect storage rooms and other stock areas in
                   devices/supplies stored in a way          the area/unit (e.g. folding supplies like hoses
                   that the integrity of the devices is      and tubing causes kinking that has prevented
                   kept intact (i.e. not bent or folded)?    them from functioning properly).
                   Recommended
                   Equipment Safety
   7.1.5.10 - 7.1.5.10.1     RESERVED
                   Equipment Safety
   7.1.5.11        Are the location and model of AEDs The location on the code cart or within unit
                   standardized throughout the facility? should be the same from area to area.
                                                         Compare models in unit, and from unit to unit.
                   Recommended
                   Equipment Safety
   7.1.5.12           RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                     97 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised         Equipment Safety
   7.1.5.13        Does the hospital purchase               Having sterile water for injection in units on the
                   humidification devices that do not       floor creates the potential for misuse. Warnings
                   require the use of sterile water?        have been published (ISMP) regarding water
                                                            being confused with other medications resulting
                                                            in it being give intravenously resulting in fatal
                                                            hemolysis.
                   Recommended                              FDA Patient Safety News: Show #22, 12/2003
                                                            ISMP Medication Safety Alert, 9-2003
   Revised         Equipment Safety
   7.1.5.13.1      If humidification devices use sterile    If sterile water must be used it is recommend
                   water is it provided in 2 Liter bags     that it be used in 2 Liter bags. The 2 Liter bags
                   and labeled "Sterile Water"?             will help distinguish the sterile water from the 1
                                                            Liter bags of IV solutions, also pour bottles
                                                            could be considered.
                   Recommended                              FDA Patient Safety News: Show #22, 12/2003
                                                             ISMP Medication Safety Alert, 9-2003
                   Equipment Safety
   7.1.5.14        Is the use of cell phones or other       Look for signage, and ask staff about protocols.
                   devices that can affect monitoring
                   and other medical equipment
                   controlled in applicable areas?
                   Recommended
                   Escape and Elopement Prevention
   7.1.6.1         Is a system in place to clearly Look for screening processes, such as colored
                   identify high risk escape or    gowns, photos, designated identifiers for these
                   elopement patients to staff?    patients, etc.
                   Recommended
                   Escape and Elopement Prevention
   7.1.6.2         If electronic systems such as   Test wander guard system to ensure accuracy.
                   wander guards are used, are
                   methods in place to ensure they
                   function correctly?
                   Recommended
                   Escape and Elopement Prevention
   7.1.6.3         If wander guard systems are in  Observe if in use, interview appropriate staff to
                   place, are they included in the determine if properly maintained - ward staff
                   preventative maintenance        should be able to speak to reliability of system.
                   inspection program?
                   Recommended                               JCAHO: Goal #6a




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                     98 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                   Question:                       Rationale/Assessment Methods:                                                     (1)        Met (2)              (3) possible root causes
                   Escape and Elopement Prevention
   7.1.6.4         Have staff been involved in an  Interview staff.
                   elopement drill (grid search)?
                   Recommended
   New             Escape and Elopement Prevention
   7.1.6.5         Is a risk assessment for elopement      Awareness of the potential for
                   completed at the time of admission      elopement/wandering behavior is the first step in
                   or transfer and regularly during the    prevention. Review documentation or interview
                   patients stay?                          staff to verify that the assessment is being
                                                           completed. Consider using electronic flags in
                                                           CPRS to inform clinicians if the patient is a high
                                                           risk. A change in the patients care (i.e., to a
                                                           new bed/unit, or new/change in medication) is a
                                                           key time for reassessment.

                   Mandatory                               VHA Directive 2003-013
   New             Escape and Elopement Prevention
   7.1.6.5.1       If an elopement risk assessment is Discuss with ward staff the wander and
                   to be completed for patients, are  elopement policies.
                   staff familiar with the
                   wandering/elopement prevention
                   protocol or SOP?
                   Mandatory                               VHA Directive 2002-013
   New             Escape and Elopement Prevention
   7.1.6.6         Is a processes in place and used to If patient privileges are not clear this often can
                   keep track of high risk patients when lead to lack of communication on patient status
                   they are off of the unit?             and location. A tracking or documentation
                                                         system can be used to help staff know patient
                                                         habits, and is a method to communicate this
                                                         information at the shift change. Also transport
                                                         of patients off the unit should be planned and
                                                         scheduled with competent escorts who
                                                         understand the potential for a high risk patient to
                                                         elope.
                   Recommended
   Revised         Fall Prevention
   7.1.7.1         Are all patient rooms and common        Observe conditions on the unit. Patient rooms
                   areas provided with adequate            and bathrooms should be provided with
                   lighting?                               nightlights as well.
                   Recommended                             JCAHO: EC.1.10




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                     99 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Fall Prevention
   7.1.7.2         Are mechanical assist devices used        Have staff show example, and conduct
                   to lift or transfer patients accessible   interviews to determine facility consistency.
                   and used by staff when needed?

                   Recommended
                   Fall Prevention
   7.1.7.2.1       Are preventative measures                 Staff training, proper number of staff present, no
                   implemented to prevent falls from         obstructions in lift area.
                   manual lifting and/or handling
                   patients?
                   Recommended
   Revised         Fall Prevention
   7.1.7.3         Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                   slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                             create fall hazards. Patient rooms should be
                                                             free of low-lying objects that could be tripped
                                                             over causing falls.
                   Recommended                               JCAHO: EC.1.10
   Revised         Fall Prevention
   7.1.7.4         Do shower/bathroom areas have             Inspect areas specified. Bathrooms should be
                   adequate lighting, proper drainage,       provided with night lights. If a raised seats are
                   non-slip floor surfaces, and              used on toilets are they is the color of it
                   handrails installed?                      contracting to toilet to help patients see it clearly.

                   Recommended                               JCAHO: EC.1.10
                   Fall Prevention
   7.1.7.5         Are call buttons within reach of the      Inspect all areas.
                   patient?
                   Recommended
                   Fall Prevention
   7.1.7.6         Are bed and chair alarms used and         Show examples. False or unwanted alarms sets
                   audible, and, are they configured to      up the care givers for complacency.
                   reduce the number of
                   false/unwanted alarms?
                   Recommended                               JCAHO: SEA #14 & Goal #6b




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    100 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Fall Prevention
   7.1.7.7         Does the facility have a Fall            Interview staff - protocol should evaluate: 1) A
                   Prevention & Management Protocol         risk screen; 2) Protective device matched to risk
                   or equivalent?                           level; 3) First responder assessment to identify
                                                            patients for immediate physician evaluation and
                                                            4) Treatment plan for follow up, post fall.

                   Recommended
                   Fall Prevention
   7.1.7.8         Is a uniform tool used to assess         Identifying high risk patients will help care team
                   which patients are at high risk for      to put proactive and preventative measures in
                   falls, and is there criteria to          place. Assessor should look for identifiers and
                   determine: 1) When they are              interview staff.
                   assessed, and 2) What triggers a
                   reassessment?
                   Recommended
   Revised         Fall Prevention
   7.1.7.9         Does equipment (lifting equipment,       Review equipment, interview staff. Patients
                   OR tables, etc.) have sufficient         weighing in excess of 400 pounds are not
                   capacity to meet the needs of            uncommon. If equipment cannot support the
                   bariatric patients?                      weight of the patient contingency plans should
                                                            be developed to provide care.
                   Recommended
                   Fall Prevention
   7.1.7.10           RESERVED
                   Fire Safety
   7.1.8.1         Are staff members familiar with fire     Interview staff to determine familiarity.
                   emergency procedures, and the fire
                   prevention plan for their service
                   area?
                   Mandatory                                JCAHO: EC.5.20 and HR.2.20
                   Fire Safety
   7.1.8.2         Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                   fire walls in their immediate area?   must be knowledgeable regarding where to
                                                         move patients in the event of a fire.
                   Mandatory                                JCAHO: EC.5.20 and HR.2.20




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    101 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Fire Safety
   7.1.8.3         Is the fire alarm signal easily          Interview staff to determine familiarity, if alarm is
                   distinguishable from other alarms        not witnessed.
                   (e.g. equipment, nurse call, etc.)?
                   Mandatory                                 NFPA 72 1.5.4.4
                   Fire Safety
   7.1.8.4         Is the area staff notified when the    Interview staff.
                   fire alarm system is out of service or
                   being tested?
                   Mandatory                                NFPA 72 7-1.3.1
                   Fire Safety
   7.1.8.4.1       Are cognitive aids used to remind        Look for signs placed by pull stations, and
                   staff when the fire alarm system is      interview to determine if announcements are
                   not functioning?                         made on PA system, etc.
                   Recommended
                   Fire Safety
   7.1.8.5         Are flame retardant pajamas or           Smoking risk patients are patients who are
                   aprons provided for patients who         known to routinely violate the "no smoking" rules
                   smoke and are identified as a            established by the facility. They smoke in non
                   "smoking risk"?                          designated areas when unsupervised and may
                                                            have a physical or mental condition that could
                                                            lead them to drop a cigarette, ashes, or match
                                                            causing clothing or hair to ignite. Flame
                                                            retardant pajamas or aprons can be a
                                                            preventive measure for these patients.

                   Recommended                              VA MP-3, Part III, 32.36(b) & (d); VA Circ. 10-90
                   Fire Safety
   7.1.8.5.1       If flame retardant pajamas or linens     Interview staff, determine if practices are
                   are used, is a process in place to       consistent with policy.
                   ensure integrity of the flame
                   retardant agent is maintained on
                   these articles after repeated
                   laundering?
                   Recommended                              VA MP-3, Part III, 32.36(c) & (d)
                   Fire Safety
   7.1.8.6          RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    102 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Infection Control
   7.1.9.1         Are all linen carts (clean and soiled)    Observe conditions on the unit.
                   kept covered?
                   Mandatory                                 JCAHO: IC.4.10
   Revised         Infection Control
   7.1.9.2         Are sharps containers accessible          Observe conditions in unit/area. Patients and
                   and not over filled?                      employees are often stuck by sharps not
                                                             properly disposed of due to overfilling of these
                                                             containers.
                   Mandatory                                 JCAHO: IC.4.10
   Revised         Infection Control
   7.1.9.3         Is the latex allergy policy followed      Show example if available. Consider inspecting
                   and are latex free supplies and           supply and code carts. Look for latex-free
                   equipment available?                      identification on glove boxes, supply packages,
                                                             etc. Determine if the other devices are available
                                                             as latex-free such as tourniquets and medical
                                                             tubing. In pharmacy, check for a latex protocol
                                                             in IV room.
                   Mandatory                                 IL 16-97-001 Latex Information
   Revised         Infection Control
   7.1.9.4         Are the VA recommended hand               The individual products should be an alcohol rub
                   hygiene guidelines followed, such         (for disinfecting) and a hospital approved lotion
                   as having alcohol-based gel               (to prevent skin dryness). Also, staff who come
                   disinfectants located to promote use      in contact with patients or prepare sterile
                   (including inpatient rooms), and          products (such as IV drugs) should not have
                   providing individual products to all      artificial fingernails. Clinicians should also be
                   necessary staff?                          offered the small (2-4 oz.) personal containers of
                                                             hand gel. Gel should be in convenient locations
                                                             including all carts (mobile care, medication
                                                             carts, code, respiratory).

                   Mandatory                                 JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                             CDC Hand Hygiene Guidelines
                                                             VHA Directive 2005-002 July 2005




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    103 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Infection Control
   7.1.9.5         Is the integrity of negative/positive    Door remains closed if in use, Personal
                   pressure isolation rooms tested and      Protective Equipment used. Signage outside to
                   maintained (once per day for             identify hazard exists.
                   occupied, monthly for non-
                   occupied)?
                                                            CDC Guidelines for Environmental Infection Control in Health Care
                   Mandatory
                                                            Facilities
                                                            OSHA , 29 CFR 1910.145
                   Medical Gas Safety
   7.1.10.1        Are piped in oxygen and                  The use of color coding should be eliminated.
                   compressed air identified by a           Using color adapters can cause confusion
                   prominent label and not merely by        during use, mixing up the gases being
                   color adapters?                          administered. Fixes include: replacing tubing
                                                            with a type that does not use adaptors or using
                                                            only clear adaptors.
                   Recommended                              VHA Patient Safety Advisory 3/5/02
                   Medical Gas Safety
   7.1.10.2        Are air flow meters removed when         Flow meters are only used for specific
                   not in use (for nebulized medication     treatments, are not required during emergencies
                   treatments)?                             and should not be left attached to be confused
                                                            with O2 flow meter.
                   Recommended                              VHA Patient Safety Advisory 3/5/02
                   Medical Gas Safety
   7.1.10.3        Do staff know where the emergency Staff to demonstrate competency. Also verify
                   oxygen shut-off is, and when and  that labels, warnings or other signage posted at
                   how to use it?                    the shut off point in accurate and up to date.

                   Mandatory                                NFPA (National Fire Protection Association) 5.1.4.2.1
                                                            JCAHO: EC.7.50
                   Medical Gas Safety
   7.1.10.4        Does the storage and use of              If color identifies type, must be the same hue &
                   portable medical gas containers          intensity; flammables separated from oxidizers;
                   appear to be in compliance with          secured at all times (full or empty); container in
                   CGA (Compressed Gas                      good condition; only a limited quantity permitted
                   Association) Standards?                  in use area (less than 12 E-cylinders, or 1 H-
                                                            cylinder per area).
                   Mandatory                                NCGA (Compressed Gas Association) C-9, 3.7 & 4.6
                                                            NCPS O2 Cylinder Hazard Summary




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    104 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                   Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Medical Gas Safety
   7.1.10.4.1      Are all area/unit personnel                Staff to demonstrate competency.
                   competent in understanding the
                   handling procedures of oxygen
                   cylinders, including how to obtain
                   full cylinders? If so, is current
                   practices in line with the facility's
                   written procedure?
                   Mandatory                                  NCPS O2 Cylinder Hazard Summary
                   Medical Gas Safety
   7.1.10.5        Are pins on medical gas regulators         Pins should be in place and found undamaged.
                   and cylinders in good repair and is
                   damaged equipment immediately
                   removed from service?
                   Recommended                                NCPS O2 Cylinder Hazard Summary
                   Medical Gas Safety
   7.1.10.6        Are oxygen cylinders with ball-type        When placed in the horizontal position, the ball
                   regulators used with the cylinder in       valve mechanism will not function, and an
                   the vertical position?                     inaccurate reading will show on the gauge.
                   Recommended                                NCPS O2 Cylinder Hazard Summary
   New             Medical Gas Safety
   7.1.10.7        Is the facility medical gas policy or      Review the policy if available. Questions
                   procedure followed when medical            technicians to determine if policy is known and
                   gases are used in clinics and exam         followed.
                   rooms?
                   Recommended
   Revised         Medication Safety
   7.1.11.1        Are all medication refrigerators           Check floor refrigerators, ensure correct labeling
                   maintained appropriately?                  and appropriate separations from employee
                                                              food/drink. Review temperature log (or
                                                              electronic temperature monitoring device/log)
                                                              and verify that the thermometer is working.

                   Mandatory                                  JCAHO: MM.2.20, EP-13
                                                              ISMP Self Assessment: #117
                   Medication Safety
   7.1.11.2        Do medication carts remained               Randomly survey carts in the area.
                   locked and inaccessible to patients
                   when not in use?
                   Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    105 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                   Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised         Medication Safety
   7.1.11.3        Are the tops of medication carts,          Randomly survey carts in the area. Clean carts
                   clean, free of stray drugs and             will help prevent medication error by eliminating
                   syringes?                                  opportunities for mix-ups . It will also avoid drug
                                                              being taken by mental health patients or those
                                                              with cognitive impairment.
                   Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                              ISMP Self Assessment: 14
                   Medication Safety
   7.1.11.3.1      Is medication logically organized          Clearly marked labels and nametags.
                   and identified by patient?
                   Recommended                                 JCAHO: MM.4.30
   Revised         Medication Safety
   7.1.11.4        Are medication storage rooms               Door locking mechanism cannot be defeated for
                   secured at all times?                      any reason. Door should not be held open.
                   Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                              ISMP Self Assessment: 75
                   Medication Safety
   7.1.11.5           RESERVED
                   Medication Safety
   7.1.11.6        Is area stock limited to emergency     Review approved floor stock and IV solution list
                   medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                   are appropriate to patient care in the
                   unit?
   Previously      Recommended                                JCAHO: MM.3.20
   7.1.11.5                                                   ISMP Self Assessment: 82
                   Medication Safety
   7.1.11.6.1 - 7.1.11.6.2       RESERVED
   Revised         Medication Safety
   7.1.11.7        Are bags containing sterile water for Controlling the acquisition of sterile water may
                   injection prohibited from being       help to prevent it from being inadvertently given
                   ordered or stocked on patient care    intravenously.
                   areas without special permission
                   and precaution?
   Previously      Recommended                                 FDA Patient Safety News: Show #22, 12/2003
   7.1.11.46                                                   ISMP Medication Safety Alert, 9-2003




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    106 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                   Question:                           Rationale/Assessment Methods:                                                   (1)        Met (2)              (3) possible root causes
                   Medication Safety
   7.1.11.8        Have concentrated electrolyte       Such as: potassium chloride and potassium
                   solutions been removed from patient phosphate
                   floors/care areas?
   Previously
   7.1.11.16       Mandatory                                 JCAHO: MM.2.20, EP-9; Goal #3a; and SEA #1 & #11
   Revised         Medication Safety
   7.1.11.8.1      Is access limited to electrolyte          Review local policies, and interview pharmacy
                   replacement solutions (above or           staff. Show example.
                   below 0.9% sodium chloride)
                   outside the pharmacy?
   Previously
   Reserved        Recommended                               ISMP Self Assessment: 92
                   Medication Safety
   7.1.11.9           RESERVED
                   Medication Safety
   7.1.11.9.1      Are only standard concentrations of       Floor stock of high-alert drugs should be limited
                   high alert medications kept in the        to critically needed medications, with minimal
                   area/unit to minimize the potential of    number of doses, and be pre-made solutions (if
                   calculation and compounding errors?       available).

   Previously      Mandatory                                 JCAHO: MM2.20, EP-8; MM.7.10; Goal #3b & SEA #11
   7.1.11.15                                                 ISMP Self Assessment: 67.1 & 20
                   Medication Safety
   7.1.11.10       Is a unit dose medication system          Look in patient bins for bulk containers.
                   used including half tablets and
                   liquids?
   Previously      Recommended                               JCAHO: MM.2.20, EP-10
   7.1.11.6                                                  ISMP Self Assessment: 64
                   Medication Safety
   7.1.11.10.1 - 7.1.11.12       RESERVED
                   Medication Safety
   7.1.11.13       Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                   the pharmacy and not on care units? be completed in pharmacy areas.


                   Recommended                               JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.1.11.13.1 If admixtures are done in inpatient           Interview floor staff. If admixtures are done on
               care areas, is an independent                 units, the area should be a designated area that
               double-check system utilized?                 is clean and secure. It is safest for mixtures to
                                                             be completed in pharmacy areas.
                   Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    107 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   Medication Safety
   7.1.11.14       Are procedures in place to prevent       Infection control literature documents
                   sterile product use from patient to      nosocomial infections occur irrespective of
                   patient (including medications)?         changing needles or IV tubing's.
                   Recommended                              ISMP Medication Safety Alert, June 2000
   Previously                                               American Society of Anesthesiology Newsletter, 12/2000
   7.1.11.43                                                CDC MMWR Weekly, 9/26/2003
   Revised         Medication Safety
   7.1.11.15       Are premixed IV solutions kept in        The protective over-wrap for some solutions
                   over-wrap bags until they are ready      serves to control the amount of water vapor that
                   to be used (if applicable)?              escapes from an IV solution. Once unwrapped
                                                            it is best to use the solution right way.

   Previously
   7.1.11.44       Recommended                              FDA Patient Safety News: Show #22, 12/2003
                   Medication Safety
   7.1.11.16       Are IV bags free of markings, such      The volatile chemical from the ink may leach
                   as expiration dates, applied by staff into IV solutions.
                   with ink pens or felt markers (prior to
                   use)?
   Previously
   7.1.11.45       Recommended                              FDA Patient Safety News: Show #22, 12/2003
   Revised         Medication Safety
   7.1.11.17       Is an independent double check           The double check should Include patient
                   completed for all infusion pump          monitoring and verifying the number of types of
                   settings (including PCAs)?               pumps. PCA protocol should include an
                                                            independent double check of the drug, pump
                                                            setting and dosage.
   Previously
   7.1.11.12       Recommended                              JCAHO: SEA #11
                   Medication Safety
   7.1.11.18           RESERVED
                   Medication Safety
   7.1.11.19       Are appropriate reversal agents          In the event of an unusual reaction or overdose
                   (flumazenil, naloxone, protamine,        the agents need to be available.
                   etc.) available based on the drug
                   being administered?
   Previously
   7.1.11.10       Recommended                              ISMP Self Assessment: 79




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    108 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
               Question:                                   Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised     Medication Safety
   7.1.11.19.1 Is there a process to monitor the           Such as reviewing automated dispensing
               reversal agent use?                         machine records, which can be used as a tracer
                                                           order for adverse drug events. (e.g., reversal
                                                           agent s used in Endosocpy, Radiology, Acute
                                                           Care, etc., may be a signal to misadministration
                                                           or unsafe practices occurring.

   Previously
   7.1.11.10.1     Recommended
                   Medication Safety
   7.1.11.20           RESERVED
                   Medication Safety
   7.1.11.21       Is there machine readable coding    Show mechanism (i.e. BCMA) in use. Machine
                   throughout the medication           readable coding should match the electronic
                   administration process (e.g. BCMA)? medical record to the patient, allowing the
                                                       information on the patients armband to be
                                                       matched with the electronic information.

   Previously
   7.1.11.17       Recommended                             ISMP Self Assessment: 11
               Medication Safety
   7.1.11.21.1 Is BCMA used to administer                  Observe staff.
               medication without using work
               arounds?
   Previously
   7.1.11.24       Recommended
                   Medication Safety
   7.1.11.21.2 What is the protocol for handling           Interview staff and compare practices to policy
                   incorrect bar coded or labeled          of facility/Pharmacy.
                   medications?
   Previously
   7.1.11.23       Recommended                              JCHAO: MM.3.20, EP-5
               Medication Safety
   7.1.11.21.3 Is there a helpdesk for BCMA                Test hotline number available on all shifts;
               available during all shifts?                interview off-shift staff if available.
   Previously
   7.1.11.22       Recommended
                   Medication Safety
   7.1.11.22           RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                    109 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
               Question:                                   Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.1.11.22.1 Do the VISTA modules effectively            Show example, if available.
               alert to potential food/drug/herbal
               interactions and duplicate drug
               therapies?
   Previously
   Reserved        Recommended
                   Medication Safety
   7.1.11.23 - 7.1.11.24        RESERVED
                   Medication Safety
   7.1.11.25       Is drug reference information made      Interview area/unit staff, show where information
                   readily accessible to caregivers, if    is kept and how it is retrieved. One or two
                   so how?                                 reference sources should be available as well
                                                           as access to pharmacist.
   Previously      Recommended                             JCAHO: IM.3.10
   7.1.11.7                                                ISMP Self Assessment: 18.2
                   Medication Safety
   7.1.11.26       Are up-to-date facility specific        Interview unit staff, show where information is
                   protocols, guidelines, dosing scales,   kept and how it is retrieved. (e.g. use of
                   and/or checklists readily available     electrolyte replacement, aminoglycoside, and
                   for staff?                              anti-coagulant guidelines).
   Previously      Recommended                             JCHAO: IM.3.10
   7.1.11.8                                                ISMP Self Assessment: 19
   Revised         Medication Safety
   7.1.11.27       Are specific precautions followed       Discuss protocols with staff (such as insulin and
                   when handling look/sound alike          heparin vials; and hydromorphone and
                   drugs?                                  morphine). In pharmacy, discuss what is being
                                                           done with the look alike medication project.

   Previously
   7.1.11.9        Recommended                             JCAHO: MM.2.20, EP-6; SEA #19
                   Medication Safety
   7.1.11.27.1               RESERVED
                   Medication Safety
   7.1.11.28       Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                   to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                   Goal requirements?
   Previously      Mandatory                               JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
   7.1.11.25                                               ISMP Self Assessment: 40




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                    110 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised         Medication Safety
   7.1.11.29       If Automated Dispensing Machines         Written documents should include which drugs
                   (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                   written policy, and can they explain     how often drugs are inspected for expiration
                   how the machine works?                   dates, drugs not used but removed, and content
                                                            review.
   Previously
   7.1.11.27        Recommended                             JCAHO: MM.4.50
                   Medication Safety
   7.1.11.30 - 7.1.11.31.1        RESERVED
                   Medication Safety
   7.1.11.32       If ADMs are used, are there              Show example reports, where filed on units;
                   capabilities to run override reports     interview Nurse Manger. Have staff reveal how
                   that track discrepancy and utilization   reports are used and acted upon, and if there is
                   at least monthly?                        a process to deal with variances.
   Previously
   7.1.11.21       Recommended                              ISMP Self Assessment: 26
                   Medication Safety
   7.1.11.33           RESERVED
                   Medication Safety
   7.1.11.34       Are patients educated regarding          Show example.
                   their prescribed medication, as
                   inpatients and as part of the
                   discharge process?
   Previously
   7.1.11.19       Recommended                              JCAHO: PC.6.10
                   Medication Safety
   7.1.11.35       Does the care provided by           Interview clinicians to determine if Pharmacists
                   Pharmacists meet the clinical needs are available for consult, and if they participate
                   of the patients in scope and        in rounds or access patient medication history.
                   frequency?
   Previously      Recommended                              JCAHO Std: MM.4.10
   7.1.11.18                                                ISMP Self Assessment: 23
                   Medication Safety
   7.1.11.36 - 7.1.11.41.1        RESERVED
                   General Patient Safety Concerns
   7.1.12.1        Is read-back used for all verbal         Observe verbal ordering if possible, and
                   order and critical value reports?        interview staff. Verify that telephone voice mail
                                                            orders are not accepted.
                   Mandatory                                JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                            ISMP Self Assessment: 45




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    111 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                   Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   General Patient Safety Concerns
   7.1.12.2        Are NCPS or locally developed            Randomly interview nursing staff on the floor.
                   cognitive aids available on the floor    Look for aids at nurses stations.
                   for staff to reference (Escape and
                   Elopement; Fall Prevention, etc.)?
                   Recommended
                   General Patient Safety Concerns
   7.1.12.3        Are patient records kept                 Ensure records or computer screens are not left
                   confidential, including computer         unattended and openly visible.
                   information?
                   Recommended                              JCAHO Std: IM.2
                   General Patient Safety Concerns
   7.1.12.4        Are staff required to wear               Monitor patient care areas. Interview staff about
                   identification badges, and are           policies such as the handling of drug
                   unauthorized persons kept out of         manufacturer representatives that visit
                   patient care areas?                      unexpectedly.
                   Recommended                              JCAHO Std: EC.1.2 & EC.2.2
                   General Patient Safety Concerns
   7.1.12.5        Are restraints used in accordance        Randomly interview staff. Look for restraint
                   with local policy and are restraint      devices or alterative devices in the area.
                   alternative devices available and
                   used when appropriate?
                   Recommended                              JCAHO: PC.11.10 & PC.12.10 & SEA #8
                   General Patient Safety Concerns
   7.1.12.6        Are there practices in place to          Using two patient identifiers for administrations,
                   decrease the likelihood of patient       draws or procedures/images, and at outpatient
                   misidentification?                       pharmacy; record and room flags for
                                                            same/similar/common names; four or less beds
                                                            in patient rooms; bedside labeling of samples,
                                                            rather than bulk (at nurses station); special
                                                            procedure for the transporting of high risk (for
                                                            misidentification) patients.

                   Recommended                              JCAHO Goal 1a




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    112 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                   Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                   General Patient Safety Concerns
   7.1.12.7        Are there monitoring processes in       Look for a preventative maintenance log that
                   place for portable food and             periodically checks the temperature of the
                   beverage warming or heating             warming device to help prevent scalding by
                   devices?                                liquids or burns from food tray items. First and
                                                           second degree scalding can occur to patients
                                                           with cognitive or motor difficulties while being
                                                           fed in bed as well.
                   Recommended
                   General Patient Safety Concerns
   7.1.12.8        Is transfer of care between shifts      A consistent process should exist to update on-
                   standardized?                           coming staff of patient statues. Interview staff
                                                           and compare answers between units.
                   Recommended
   Revised         General Patient Safety Concerns
   7.1.12.9        Is the transfer of care between         A consistent process should occur during
                   disciplines for off-unit appointments   appointments and when patients are sent back
                   standardized, including the             and forth from units, including patient
                   continuation of monitoring patient      identification means, patient record transfer, and
                   status and patient medical devices      the monitoring of the patient's condition and
                   such as IV pumps and oxygen level       needed medical devices. Stopping and
                   while the patient is visiting, being    resumption of IV medications should be planned
                   treated/tested, and during transport?   and documented. Interview staff in all areas
                                                           compare answers to determine standardization.

                   Recommended                             US Pharmacopeia Patient Safety CAPSLink, July 2004
                   General Patient Safety Concerns
   7.1.12.10       Are patients searched for               To ensure the safety of the patients and staff
                   contraband upon admission to each       members it is essential to have a rigorous
                   applicable area/unit?                   search process of each individual patient.
                                                           Observe an admission, or interview staff to
                                                           evaluate consistency throughout the facility.
                   Recommended




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                      to understand observed behavior and local norms to identify system vulnerabilities.                                                    113 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   LONG TERM CARE UNITS - Element 7, Location 1 (7.1)                                                                   Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                   Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised         General Patient Safety Concerns
   7.1.12.11       Does the facility have an emergency    The protocol should be made up of a
                   response protocol for dealing with     mechanism for staff to communicate the
                   disruptive patients?                   emergency (via a special extension or a
                                                          separate alarm system) and a security response
                                                          when a patient, staff or visitor becomes
                                                          threatening or out of control. Staff should be
                                                          familiar with the protocol and have confidence in
                                                          how to respond.
                   Recommended
   New             General Patient Safety Concerns
   7.1.12.12       When performing procedures           The facility's Conscious Sedation protocol
                   outside of the operating room are    should be followed in all areas.
                   appropriate sedation protocols and
                   privileges followed when applicable?

                   Mandatory                              JCAHO Std: PC.13.20
                   Psychiatric Precautions
   7.1.13.1 - 7.1.13.18        RESERVED
                   Surgical or Invasive Procedure Precautions
   7.1.14.1 - 7.1.14.19        RESERVED
                   Imaging and X-rays Precautions
   7.1.15.1 - 7.1.15.9         RESERVED




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Long Term Care Units - 7.1                                     to understand observed behavior and local norms to identify system vulnerabilities.                                                    114 of 257
Patient Safety Assessment Tool
Part II Implementation
Element: Behavioral Health Care (Locked) - 7.2
             Categories:
             Bed Safety                                   NA
             Code Carts                                   1
             Electrical Safety                            2
             Environmental and Housekeeping Safety        3-4
             Equipment Safety                             4-5
             Escape and Elopement Prevention              5-6
             Fall Prevention                              6-7
             Fire Safety                                  7-8
             Infection Control                            8-9
             Medical Gas Safety                           NA
             Medication Safety                            9 - 13
             General Patient Safety Concerns              13 - 16
             Psychiatric Precautions                      16 - 19
             Surgical or Invasive Procedure Precautions   NA
             Imaging and X-Ray Precautions                NA
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                        Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Bed Safety
   7.2.1.1 - 7.2.1.7       RESERVED
                    Code Carts
   7.2.2.1          Are code carts locked when not in       Drugs have potential to be taken from
                    use, and is equipment in good           unsecured carts in common areas. Verify cart
                    condition?                              inspection records.
                    Mandatory                                JCAHO: MM.2.30
   Revised          Code Carts
   7.2.2.1.1        Are code carts secured and              If carts are missing items then they could be
                    inaccessible to patients to prevent     ineffective in when needed in an emergency.
                    tampering where appropriate (i.e.,      Check that carts are put away in affected areas.
                    Behavioral Health areas)?
                    Recommended
                    Code Carts
   7.2.2.2 - 7.2.2.3       RESERVED
                    Code Carts
   7.2.2.4          Is the VHA modified version of the      Inspect top of cart and review checklist of
                    AHA Handbook of Cardiovascular          contents if provided.
                    Care Cognitive Aid located on all
                    carts?
                    Recommended
   Revised          Code Carts
   7.2.2.5          Are CO2 detectors available on          Inspect carts. Adjunctive devices (i.e.
                    code carts for confirming               colorimetric, syringe, or bulb devices) should be
                    esophageal intubations?                 adequately stocked and readily available for use
                                                            in all carts. Review cart checklist talk with cart
                                                            preparers in SPD (Supply Processing and
                                                            Distribution) Service.
                    Recommended
                    Code Carts
   7.2.2.6           RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    117 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                          Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Electrical Safety
   7.2.3.1          Are electrical receptacles in, or         All areas designated as wet locations, or areas
                    serving, wet areas or behavioral          used for behavioral health patients, require (wet)
                    health areas provided with Ground         or recommend (behavioral health) ground-fault
                    Fault Circuit Interruption (GFCI)         protection. These types of receptacles are
                    protection or an isolated power           designed to stop the flow of electrical current,
                    system?                                   preventing shock or electrocution. For
                                                              behavioral health areas, electrical receptacles
                                                              can be completely removed or covered in
                                                              patient rooms to protect patients who my try to
                                                              harm themselves.

                    Mandatory                                 National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                              NFPA 99-3.3.179
                    Electrical Safety
   7.2.3.2          Are electrical receptacles fitted with    Observe conditions on unit.
                    covers, secured, and free of loose
                    or exposed wiring?
                    Mandatory                                  NFPA 99-4 3.3.2.1.2
   New              Electrical Safety
   7.2.3.2.1        In applicable patient care areas is       Electrical lines should not be run on the outside
                    wire molding (or other exposed            of walls and/or ceilings in areas where
                    conduit) not allowed for running          psychiatric patients can reside as inpatients, be
                    electrical lines?                         seen as outpatients or be triaged. Wire
                                                              moldings or conduit could be tampered with,
                                                              resulting in an exposed live electrical line.
                    Recommended
                    Electrical Safety
   7.2.3.3           RESERVED
                    Electrical Safety
   7.2.3.4          Are electrically powered medical          Cords are free of physical defects including
                    devices in good condition?                cracks, frayed ends, or missing prongs.
                    Mandatory                                 NFPA 99 8.4.1.3.1
                                                              VHA Directive 2002-030
                    Electrical Safety
   7.2.3.5 - 7.2.3.7       RESERVED




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    118 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                        Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                           Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                    Environmental and Housekeeping Safety
   7.2.4.1          Are hot water temperatures taken    Temperature should be less than 120 F at the
                    manually using a thermometer        tap and 110F in baths.
                    before patient use or immersion
                    (including partial immersion) takes
                    place?
                    Mandatory                               VHA Directive 2002-073
                    Environmental and Housekeeping Safety
   7.2.4.2          Are supply and return air registers Observe conditions on the unit.
                    clean and free of lint and dust?
                    Recommended                             JCAHO Std: EC.8.10
                    Environmental and Housekeeping Safety
   7.2.4.3          Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                    to be a priority?
                    Recommended                             JCAHO Std: EC.8.10
   Revised          Environmental and Housekeeping Safety
   7.2.4.4          Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                    well light and temperature           rooms will help prevent mistakes. Ensuring
                    controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                    fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                         of floor keeps supplies sanitary.
                    Recommended                             JCAHO Std: EC.5.20
                    Environmental and Housekeeping Safety
   7.2.4.5          Are patient care area hallways and Observe conditions on the unit.
                    stairways unobstructed and kept
                    free of storage?
                    Mandatory                               NFPA 101 (LSC) 7.1.10
                                                             JCHAO: EC.5.20
                    Environmental and Housekeeping Safety
   7.2.4.6          Are patient areas free of unlabeled All cleaning products, medication, employee
                    or unattended containers, such as   food or drink, etc., should not be left in patient
                    cleaning products or medication?    care areas or patient rooms.
                    Mandatory                               JCAHO: EC.1.10




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    119 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                       Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                          Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                    Environmental and Housekeeping Safety
   7.2.4.7          Are hazards clearly identified and Pre-construction meetings should proactively
                    properly controlled during         address all necessary interventions to remediate
                    construction and renovation?       such issues. However, patient /staff concerns
                                                       may flag potential problems. Examples of
                                                       hazards: walkways maintained; marked exit
                                                       paths; guarded floor openings and overhead
                                                       hazards; dust generation; and excessive noise.

                    Mandatory                              29CFR 1926.20(b)
                                                           VA Directive 7703c(4)(a)
                                                            JCAHO: 5.50
                    Environmental and Housekeeping Safety
   7.2.4.8          Are high hazard areas such as:       High hazard areas must be locked to prevent
                    Roofs, service areas, medication     access to patients and have warning signs and
                    rooms, labs, radiation areas,        labels.
                    confined spaces, high voltage
                    areas, laser areas, low use areas
                    (such as sub-floors and interstitial
                    spaces), etc. labeled with
                    appropriate caution signage and
                    locked to prevent unauthorized
                    entrance?
                    Mandatory                              VA Directive 7703c(4)(a)
                    Environmental and Housekeeping Safety
   7.2.4.9           RESERVED
                    Environmental and Housekeeping Safety
   7.2.4.10         Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                    "pests" in the hospital environment? preventative measures or monitors. Special
                                                         considerations should be made for sterile
                                                         environments.
                    Recommended
                    Equipment Safety
   7.2.5.1          Is medical equipment being        Check inspection tags, or other identifiers on the
                    inspected in accordance with the  equipment that indicates it has been inspected.
                    Preventative Maintenance Program? Interview staff to determine how to interpret
                                                      identifiers.
                    Mandatory                              JCAHO: EC.6.20 and Goal # 6a
                    Equipment Safety
   7.2.5.2 - 7.2.5.3       RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    120 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                       Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.2.5.4          Are alarms audible and easily          Alarms may be broadcast to an outside room or
                    distinguished above ambient            another area such as a central nursing station.
                    background noise level?                Interview staff as to what is done during breaks
                                                           to cover patient monitoring. Clinical alarms,
                                                           bathroom alarms, and nurse calls are included
                                                           here.
                    Mandatory                              JCAHO: Goal # 6b
                    Equipment Safety
   7.2.5.4.1 - 7.2.5.7        RESERVED
                    Equipment Safety
   7.2.5.8          Are liquids kept away from medical     To prevent spillage which can result in
                    equipment?                             malfunctioning.
                    Recommended                            NFPA 70 110.11
                    Equipment Safety
   7.2.5.9 - 7.2.5.10.1         RESERVED
                    Equipment Safety
   7.2.5.11         Are the location and model of AEDs The location on the code cart or within unit
                    standardized throughout the facility? should be the same from area to area.
                                                          Compare models in unit, and from unit to unit.
                    Recommended
                    Equipment Safety
   7.2.5.12 - 7.2.5.14          RESERVED
                    Escape and Elopement Prevention
   7.2.6.1          Is a system in place to clearly Look for screening processes, such as colored
                    identify high risk escape or    gowns, photos, designated identifiers for these
                    elopement patients to staff?    patients, etc.
                    Recommended
                    Escape and Elopement Prevention
   7.2.6.2          If electronic systems such as   Test wander guard system to ensure accuracy.
                    wander guards are used, are
                    methods in place to ensure they
                    function correctly?
                    Recommended
                    Escape and Elopement Prevention
   7.2.6.3          If wander guard systems are in  Observe if in use, interview appropriate staff to
                    place, are they included in the determine if properly maintained - ward staff
                    preventative maintenance        should be able to speak to reliability of system.
                    inspection program?
                    Recommended                             JCAHO: Goal #6a




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    121 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                        Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                       Rationale/Assessment Methods:                                                     (1)        Met (2)              (3) possible root causes
                    Escape and Elopement Prevention
   7.2.6.4          Have staff been involved in an  Interview staff.
                    elopement drill (grid search)?
                    Recommended
   New              Escape and Elopement Prevention
   7.2.6.5          Is a risk assessment for elopement      Awareness of the potential for
                    completed at the time of admission      elopement/wandering behavior is the first step in
                    or transfer and regularly during the    prevention. Review documentation or interview
                    patients stay?                          staff to verify that the assessment is being
                                                            completed. Consider using electronic flags in
                                                            CPRS to inform clinicians if the patient is a high
                                                            risk. A change in the patients care (i.e., to a
                                                            new bed/unit, or new/change in medication) is a
                                                            key time for reassessment.

                    Mandatory                               VHA Directive 2003-013
   New              Escape and Elopement Prevention
   7.2.6.5.1        If an elopement risk assessment is Discuss with ward staff the wander and
                    to be completed for patients, are  elopement policies.
                    staff familiar with the
                    wandering/elopement prevention
                    protocol or SOP?
                    Mandatory                               VHA Directive 2002-013
   New              Escape and Elopement Prevention
   7.2.6.6          Is a processes in place and used to If patient privileges are not clear this often can
                    keep track of high risk patients when lead to lack of communication on patient status
                    they are off of the unit?             and location. A tracking or documentation
                                                          system can be used to help staff know patient
                                                          habits, and is a method to communicate this
                                                          information at the shift change. Also transport
                                                          of patients off the unit should be planned and
                                                          scheduled with competent escorts who
                                                          understand the potential for a high risk patient to
                                                          elope.
                    Recommended
                    Fall Prevention
   7.2.7.1          Are all patient rooms and common        Observe conditions on the unit. Patient rooms
                    areas provided with adequate            and bathrooms should be provided with
                    lighting?                               nightlights as well.
                    Recommended                             JCAHO: EC.1.10




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    122 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                          Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Fall Prevention
   7.2.7.2 - 7.2.7.2.1        RESERVED
                    Fall Prevention
   7.2.7.3          Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                    slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                              create fall hazards. Patient rooms should be
                                                              free of low-lying objects that could be tripped
                                                              over causing falls.
                    Recommended                               JCAHO: EC.1.10
                    Fall Prevention
   7.2.7.4          Do shower/bathroom areas have             Inspect areas specified. Bathrooms should be
                    adequate lighting, proper drainage,       provided with night lights. If a raised seats are
                    non-slip floor surfaces, and              used on toilets are they is the color of it
                    handrails installed?                      contracting to toilet to help patients see it clearly.

                    Recommended                               JCAHO: EC.1.10
                    Fall Prevention
   7.2.7.5 - 7.2.7.10        RESERVED
                    Fire Safety
   7.2.8.1          Are staff members familiar with fire      Interview staff to determine familiarity.
                    emergency procedures, and the fire
                    prevention plan for their service
                    area?
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.2.8.2          Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                    fire walls in their immediate area?   must be knowledgeable regarding where to
                                                          move patients in the event of a fire.
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.2.8.3          Is the fire alarm signal easily           Interview staff to determine familiarity, if alarm is
                    distinguishable from other alarms         not witnessed.
                    (e.g. equipment, nurse call, etc.)?
                    Mandatory                                  NFPA 72 1.5.4.4
                    Fire Safety
   7.2.8.4          Is the area staff notified when the    Interview staff.
                    fire alarm system is out of service or
                    being tested?
                    Mandatory                                 NFPA 72 7-1.3.1




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    123 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Fire Safety
   7.2.8.4.1        Are cognitive aids used to remind        Look for signs placed by pull stations, and
                    staff when the fire alarm system is      interview to determine if announcements are
                    not functioning?                         made on PA system, etc.
                    Recommended
                    Fire Safety
   7.2.8.5          Are flame retardant pajamas or           Smoking risk patients are patients who are
                    aprons provided for patients who         known to routinely violate the "no smoking" rules
                    smoke and are identified as a            established by the facility. They smoke in non
                    "smoking risk"?                          designated areas when unsupervised and may
                                                             have a physical or mental condition that could
                                                             lead them to drop a cigarette, ashes, or match
                                                             causing clothing or hair to ignite. Flame
                                                             retardant pajamas or aprons can be a
                                                             preventive measure for these patients.

                    Recommended                              VA MP-3, Part III, 32.36(b) & (d); VA Circ. 10-90
                    Fire Safety
   7.2.8.5.1        If flame retardant pajamas or linens     Interview staff, determine if practices are
                    are used, is a process in place to       consistent with policy.
                    ensure integrity of the flame
                    retardant agent is maintained on
                    these articles after repeated
                    laundering?
                    Recommended                              VA MP-3, Part III, 32.36(c) & (d)
                    Fire Safety
   7.2.8.6          Are fire equipment cabinets and fire     These should be locked to prevent tampering,
                    alarm pull stations locked?              however ALL staff should carry key on their
                                                             person at all times for unlocking in an
                                                             emergency.
                    Recommended
                    Infection Control
   7.2.9.1          Are all linen carts (clean and soiled)   Observe conditions on the unit.
                    kept covered?
                    Mandatory                                JCAHO: IC.4.10
                    Infection Control
   7.2.9.2           RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    124 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                          Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Infection Control
   7.2.9.3          Is the latex allergy policy followed      Show example if available. Consider inspecting
                    and are latex free supplies and           supply and code carts. Look for latex-free
                    equipment available?                      identification on glove boxes, supply packages,
                                                              etc. Determine if the other devices are available
                                                              as latex-free such as tourniquets and medical
                                                              tubing. In pharmacy, check for a latex protocol
                                                              in IV room.
                    Mandatory                                 IL 16-97-001 Latex Information
                    Infection Control
   7.2.9.4 - 7.2.9.5       RESERVED
                    Medical Gas Safety
   7.2.10.1 - 7.2.10.7          RESERVED
   Revised          Medication Safety
   7.2.11.1         Are all medication refrigerators          Check floor refrigerators, ensure correct labeling
                    maintained appropriately?                 and appropriate separations from employee
                                                              food/drink. Review temperature log (or
                                                              electronic temperature monitoring device/log)
                                                              and verify that the thermometer is working.

                    Mandatory                                 JCAHO: MM.2.20, EP-13
                                                              ISMP Self Assessment: #117
                    Medication Safety
   7.2.11.2         Do medication carts remained              Randomly survey carts in the area.
                    locked and inaccessible to patients
                    when not in use?
                    Mandatory                                 JCAHO: MM.2.20, EP-3 & EP-4




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    125 of 257
                                                               NCPSPatient Safety Assessment Tool
                                                                   Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                           Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.2.11.3         Are the tops of medication carts,          Randomly survey carts in the area. Clean carts
                    clean, free of stray drugs and             will help prevent medication error by eliminating
                    syringes?                                  opportunities for mix-ups . It will also avoid drug
                                                               being taken by mental health patients or those
                                                               with cognitive impairment.
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                               ISMP Self Assessment: 14
                    Medication Safety
   7.2.11.3.1       Is medication logically organized          Clearly marked labels and nametags.
                    and identified by patient?
                    Recommended                                 JCAHO: MM.4.30
   Revised          Medication Safety
   7.2.11.4         Are medication storage rooms               Door locking mechanism cannot be defeated for
                    secured at all times?                      any reason. Door should not be held open.
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                               ISMP Self Assessment: 75
                    Medication Safety
   7.2.11.5            RESERVED
                    Medication Safety
   7.2.11.6         Is area stock limited to emergency     Review approved floor stock and IV solution list
                    medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                    are appropriate to patient care in the
                    unit?
   Previously       Recommended                                JCAHO: MM.3.20
   7.2.11.5                                                    ISMP Self Assessment: 82
                    Medication Safety
   7.2.11.6.1 - 7.2.11.6.2           RESERVED
   Revised          Medication Safety
   7.2.11.7         Are bags containing sterile water for Controlling the acquisition of sterile water may
                    injection prohibited from being       help to prevent it from being inadvertently given
                    ordered or stocked on patient care    intravenously.
                    areas without special permission
                    and precaution?
   Previously       Recommended                                 FDA Patient Safety News: Show #22, 12/2003
   7.2.11.46                                                    ISMP Medication Safety Alert, 9-2003
                    Medication Safety
   7.2.11.8 - 7.2.11.9.1         RESERVED




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    126 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.2.11.10        Is a unit dose medication system         Look in patient bins for bulk containers.
                    used including half tablets and
                    liquids?
   Previously       Recommended                              JCAHO: MM.2.20, EP-10
   7.2.11.6                                                  ISMP Self Assessment: 64
                    Medication Safety
   7.2.11.10.1 - 7.2.11.12            RESERVED
                    Medication Safety
   7.2.11.13        Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                    the pharmacy and not on care units? be completed in pharmacy areas.

                    Recommended                              JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.2.11.13.1 If admixtures are done in inpatient           Interview floor staff. If admixtures are done on
               care areas, is an independent                 units, the area should be a designated area that
               double-check system utilized?                 is clean and secure. It is safest for mixtures to
                                                             be completed in pharmacy areas.
                    Recommended
                    Medication Safety
   7.2.11.14 - 7.2.11.18             RESERVED
                    Medication Safety
   7.2.11.19        Are appropriate reversal agents          In the event of an unusual reaction or overdose
                    (flumazenil, naloxone, protamine,        the agents need to be available.
                    etc.) available based on the drug
                    being administered?
   Previously
   7.2.11.10        Recommended                              ISMP Self Assessment: 79
   Revised     Medication Safety
   7.2.11.19.1 Is there a process to monitor the             Such as reviewing automated dispensing
               reversal agent use?                           machine records, which can be used as a tracer
                                                             order for adverse drug events. (e.g., reversal
                                                             agent s used in Endosocpy, Radiology, Acute
                                                             Care, etc., may be a signal to misadministration
                                                             or unsafe practices occurring.

   Previously
   7.2.11.10.1      Recommended
                    Medication Safety
   7.2.11.20             RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    127 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                        Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.2.11.21        Is there machine readable coding        Show mechanism (i.e. BCMA) in use. Machine
                    throughout the medication               readable coding should match the electronic
                    administration process (e.g. BCMA)?     medical record to the patient, allowing the
                                                            information on the patients armband to be
                                                            matched with the electronic information.

   Previously
   7.2.11.17        Recommended                             ISMP Self Assessment: 11
               Medication Safety
   7.2.11.21.1 Is BCMA used to administer                   Observe staff.
               medication without using work
               arounds?
   Previously
   7.2.11.24        Recommended
                    Medication Safety
   7.2.11.21.2 What is the protocol for handling            Interview staff and compare practices to policy
                    incorrect bar coded or labeled          of facility/Pharmacy.
                    medications?
   Previously
   7.2.11.23        Recommended                              JCHAO: MM.3.20, EP-5
               Medication Safety
   7.2.11.21.3 Is there a helpdesk for BCMA                 Test hotline number available on all shifts;
               available during all shifts?                 interview off-shift staff if available.
   Previously
   7.2.11.22        Recommended
                    Medication Safety
   7.2.11.22 - 7.2.11.24             RESERVED
                    Medication Safety
   7.2.11.25        Is drug reference information made      Interview area/unit staff, show where information
                    readily accessible to caregivers, if    is kept and how it is retrieved. One or two
                    so how?                                 reference sources should be available as well
                                                            as access to pharmacist.
   Previously       Recommended                             JCAHO: IM.3.10
   7.2.11.7                                                 ISMP Self Assessment: 18.2
                    Medication Safety
   7.2.11.26        Are up-to-date facility specific        Interview unit staff, show where information is
                    protocols, guidelines, dosing scales,   kept and how it is retrieved. (e.g. use of
                    and/or checklists readily available     electrolyte replacement, aminoglycoside, and
                    for staff?                              anti-coagulant guidelines).
   Previously       Recommended                             JCHAO: IM.3.10
   7.2.11.8                                                 ISMP Self Assessment: 19




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    128 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.2.11.27        Are specific precautions followed        Discuss protocols with staff (such as insulin and
                    when handling look/sound alike           heparin vials; and hydromorphone and
                    drugs?                                   morphine). In pharmacy, discuss what is being
                                                             done with the look alike medication project.

   Previously
   7.2.11.9         Recommended                              JCAHO: MM.2.20, EP-6; SEA #19
                    Medication Safety
   7.2.11.27.1             RESERVED
                    Medication Safety
   7.2.11.28        Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                    to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                    Goal requirements?
   Previously       Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
   7.2.11.25                                                 ISMP Self Assessment: 40
                    Medication Safety
   7.2.11.29        If Automated Dispensing Machines         Written documents should include which drugs
                    (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                    written policy, and can they explain     how often drugs are inspected for expiration
                    how the machine works?                   dates, drugs not used but removed, and content
                                                             review.
   Previously
   7.2.11.27         Recommended                             JCAHO: MM.4.50
                    Medication Safety
   7.2.11.30 - 7.2.11.33             RESERVED
                    Medication Safety
   7.2.11.34        Are patients educated regarding          Show example.
                    their prescribed medication, as
                    inpatients and as part of the
                    discharge process?
   Previously
   7.2.11.19        Recommended                              JCAHO: PC.6.10




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    129 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.2.11.35        Does the care provided by                Interview clinicians to determine if Pharmacists
                    Pharmacists meet the clinical needs      are available for consult, and if they participate
                    of the patients in scope and             in rounds or access patient medication history.
                    frequency?
   Previously       Recommended                              JCAHO Std: MM.4.10
   7.2.11.18                                                 ISMP Self Assessment: 23
                    Medication Safety
   7.2.11.36 - 7.2.11.41.1           RESERVED
                    General Patient Safety Concerns
   7.2.12.1         Is read-back used for all verbal         Observe verbal ordering if possible, and
                    order and critical value reports?        interview staff. Verify that telephone voice mail
                                                             orders are not accepted.
                    Mandatory                                JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                             ISMP Self Assessment: 45
                    General Patient Safety Concerns
   7.2.12.2         Are NCPS or locally developed            Randomly interview nursing staff on the floor.
                    cognitive aids available on the floor    Look for aids at nurses stations.
                    for staff to reference (Escape and
                    Elopement; Fall Prevention, etc.)?
                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    130 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                       Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    General Patient Safety Concerns
   7.2.12.3         Are patient records kept               Ensure records or computer screens are not left
                    confidential, including computer       unattended and openly visible.
                    information?
                    Recommended                            JCAHO Std: IM.2
                    General Patient Safety Concerns
   7.2.12.4         Are staff required to wear             Monitor patient care areas. Interview staff about
                    identification badges, and are         policies such as the handling of drug
                    unauthorized persons kept out of       manufacturer representatives that visit
                    patient care areas?                    unexpectedly.
                    Recommended                            JCAHO Std: EC.1.2 & EC.2.2
                    General Patient Safety Concerns
   7.2.12.5         Are restraints used in accordance      Randomly interview staff. Look for restraint
                    with local policy and are restraint    devices or alterative devices in the area.
                    alternative devices available and
                    used when appropriate?
                    Recommended                            JCAHO: PC.11.10 & PC.12.10 & SEA #8
                    General Patient Safety Concerns
   7.2.12.6         Are there practices in place to        Using two patient identifiers for administrations,
                    decrease the likelihood of patient     draws or procedures/images, and at outpatient
                    misidentification?                     pharmacy; record and room flags for
                                                           same/similar/common names; four or less beds
                                                           in patient rooms; bedside labeling of samples,
                                                           rather than bulk (at nurses station); special
                                                           procedure for the transporting of high risk (for
                                                           misidentification) patients.

                    Recommended                            JCAHO Goal 1a
                    General Patient Safety Concerns
   7.2.12.7         Are there monitoring processes in      Look for a preventative maintenance log that
                    place for portable food and            periodically checks the temperature of the
                    beverage warming or heating            warming device to help prevent scalding by
                    devices?                               liquids or burns from food tray items. First and
                                                           second degree scalding can occur to patients
                                                           with cognitive or motor difficulties while being
                                                           fed in bed as well.
                    Recommended




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    131 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                        Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    General Patient Safety Concerns
   7.2.12.8         Is transfer of care between shifts      A consistent process should exist to update on-
                    standardized?                           coming staff of patient statues. Interview staff
                                                            and compare answers between units.
                    Recommended
   Revised          General Patient Safety Concerns
   7.2.12.9         Is the transfer of care between         A consistent process should occur during
                    disciplines for off-unit appointments   appointments and when patients are sent back
                    standardized, including the             and forth from units, including patient
                    continuation of monitoring patient      identification means, patient record transfer, and
                    status and patient medical devices      the monitoring of the patient's condition and
                    such as IV pumps and oxygen level       needed medical devices. Stopping and
                    while the patient is visiting, being    resumption of IV medications should be planned
                    treated/tested, and during transport?   and documented. Interview staff in all areas
                                                            compare answers to determine standardization.

                    Recommended                             US Pharmacopeia Patient Safety CAPSLink, July 2004
                    General Patient Safety Concerns
   7.2.12.10        Are patients searched for               To ensure the safety of the patients and staff
                    contraband upon admission to each       members it is essential to have a rigorous
                    applicable area/unit?                   search process of each individual patient.
                                                            Observe an admission, or interview staff to
                                                            evaluate consistency throughout the facility.
                    Recommended
                    General Patient Safety Concerns
   7.2.12.11        Does the facility have an emergency The protocol should be made up of a
                    response protocol for dealing with  mechanism for staff to communicate the
                    disruptive patients?                emergency (via a special extension or a
                                                        separate alarm system) and a security response
                                                        when a patient, staff or visitor becomes
                                                        threatening or out of control. Staff should be
                                                        familiar with the protocol and have confidence in
                                                        how to respond.
                    Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    132 of 257
                                                               NCPSPatient Safety Assessment Tool
                                                                   Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                           Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                            Rationale/Assessment Methods:                                                   (1)        Met (2)              (3) possible root causes
   New              General Patient Safety Concerns
   7.2.12.12        When performing procedures           The facility's Conscious Sedation protocol
                    outside of the operating room are    should be followed in all areas.
                    appropriate sedation protocols and
                    privileges followed when applicable?

                    Mandatory                                  JCAHO Std: PC.13.20
   Revised          Psychiatric Precautions
   7.2.13.1         Are all mounted fixtures designed to Breakaway rods and sprinkler heads; flush
                    prevent attachment of devices that   mounted vent covers free of louvers; no
                    could be used to inflict self-harm?  attachment points on furniture parts or doors
                                                         (i.e., hooks) or any thing fixed to the walls or
                                                         ceilings. Tamper resistant screws should be
                                                         used on all devices the patient has access to.
                    Recommended                                JCAHO SEA #7
   Revised          Psychiatric Precautions
   7.2.13.2         Are light fixtures flush-mounting          Inspect ward and patient rooms. Tamper
                    type, and indicated for use in             resistant screws/attachment devices should be
                    psychiatric areas used?                    used.
                    Recommended
                    Psychiatric Precautions
   7.2.13.3         Are observation, restroom, and             Mirrors should be stainless steel, not glass.
                    patient room mirrors shatter-
                    resistive?
                    Recommended
                    Psychiatric Precautions
   7.2.13.4         Is the psychiatric ward and patient        If cords are present, should be shortened to 4
                    rooms free of cords?                       inches or less. Any length of cord is not
                                                               recommended for seclusion rooms.
                    Recommended
                    Psychiatric Precautions
   7.2.13.5         Is the psychiatric ward and patient        Inspect ward and patient rooms.
                    rooms free of coat hangers, lamps,
                    steel trash cans or other items that
                    could be used as weapons?

                    Recommended




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    133 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Psychiatric Precautions
   7.2.13.6         Is furniture that could be tipped over   Inspect ward and patient rooms. Often even
                    secured to the walls or floor and free   small furniture parts can be disassembled and
                    of removable parts/drawers?              misused by patties, such as chair leg pads
                                                             (fixed with nails) and springs used to keep
                                                             things open or closed.
                    Recommended
   Revised          Psychiatric Precautions
   7.2.13.7         Are ceilings in bathrooms, sleeping      Ceilings and walls should be constructed of dry-
                    rooms and other spaces not in direct     wall board, plaster/lath or metal panel.
                    line of sight of the nursing station     Fasteners (such as screws and brackets) should
                    constructed of permanent fixed           be tamper-resistant, meaning they cannot be
                    material with no exposed piping and      removed without use of a special tool.
                    are fixtures or access panels
                    attached with tamper-resistant
                    fasteners?
                    Recommended
                    Psychiatric Precautions
   7.2.13.8         Are trash receptacles free of plastic    Inspect ward and patient rooms.
                    trash bags in patient rooms and
                    other areas not in sight of the
                    nursing station?
                    Recommended
                    Psychiatric Precautions
   7.2.13.9         Are sharps containers tamper proof Inspect ward and patient rooms.
                    and installed for specifications within
                    psychiatric wards?

                    Recommended                              See question 7.2.9.2
                    Psychiatric Precautions
   7.2.13.10        Are rooms free of combustibles?          Excluding items such as beds, linens, furniture.
                                                             Mattresses should be fire-resistive, however.

                    Recommended
   Revised          Psychiatric Precautions
   7.2.13.11        Are electric and manually adjustable Platform beds are the safest for an acute
                    beds been eliminated unless clinical psychiatric environment. If electrical beds are
                    need indicates?                      necessary, power cords should be shortened
                                                         and securely fastened. All beds should be
                                                         secured to walls or floor.
                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    134 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                          Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Psychiatric Precautions
   7.2.13.12        Have necessary precautions been           Breakaway or flush mount fixtures; no exposed
                    taken in the design of bath/shower        piping; flush electrical fixtures; shatter proof
                    areas, including toilets?                 mirrors; electrical fixture covers; institutional
                                                              toilet and fixtures; doors cannot lock. Shelves
                                                              used as an alternative to assist bars.

                    Recommended                               JCAHO: SEA #7
                                                              Also see question 7.2.7.4
   Revised          Psychiatric Precautions
   7.2.13.13        Are all doors constructed and             Doors open outward; no hold open devices
                    installed for psychiatric areas?          attached; handle type openers (no knobs). Door
                                                              windows are made of wired, laminated or plexi-
                                                              glass. Hinge guards applied.
                    Recommended
   Revised          Psychiatric Precautions
   7.2.13.14        Are windows constructed and               Windows should be fixed, remain locked or have
                    installed for psychiatric areas?          maximum opening of 6"; have no or minimal
                                                              window treatments, with cords shortened if any;
                                                              breakaway rods; glass should be wired,
                                                              laminated or plexi-glass; and weather stripping,
                                                              if provided, shall be permanently affixed or shall
                                                              not be capable of being removed with the use of
                                                              a special tool.
                    Recommended
                    Psychiatric Precautions
   7.2.13.15        Is alcohol-based sanitation gel kept      Inspect ward and patient rooms. Interview staff
                    in areas not accessible to patients?      to determine if vulnerability has been identified.

                    Recommended
                    Psychiatric Precautions
   7.2.13.16             RESERVED




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    135 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   BEHAVIORAL HEALTH CARE UNITS (Locked) - Element 7, Location 2 (7.2)                                                         Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Psychiatric Precautions
   7.2.13.17        Are special precautions in place for     All fixtures (covers/vents/windows) secured with
                    seclusion rooms?                         tamper-proof screws; all furniture is free of
                                                             separate pieces/parts, and secured; room free
                                                             of decorations; solid ceilings and walls;
                                                             institutional sprinklers; laminated glazing or
                                                             wired glass in windows; mirrors that are non-
                                                             breakable yet provide a true image (not
                                                             distorted).
                    Recommended
                    Psychiatric Precautions
   7.2.13.18        Are seclusion room beds free of          No protrusions, posts, or sharp edges/corners;
                    potential hazards to patients?           head/foot boards removed or secured; bed
                                                             secured to the floor.
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.2.14.1 - 7.2.14.19         RESERVED
                    Imaging and X-rays Precautions
   7.2.15.1 - 7.2.15.9         RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Behavioral Health Care Units - 7.2                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    136 of 257
                Patient Safety Assessment Tool
                Part II Implementation
                Element: Acute Care Units (Medical/Surgical/Step-down) - 7.3
                             Categories:
                             Bed Safety                                    1-2
                             Code Carts                                    2-3
                             Electrical Safety                             4-5
                             Environmental and Housekeeping Safety         5-6
                             Equipment Safety                              7-9
                             Escape and Elopement Prevention               9 - 11
                             Fall Prevention                               11 - 13
                             Fire Safety                                   13 - 14
                             Infection Control                             14 - 15
                             Medical Gas Safety                            15 - 17
                             Medication Safety                             17 - 23
                             General Patient Safety Concerns               23 - 25
                             Psychiatric Precautions                       NA
                             Surgical or Invasive Procedures Precautions   NA
                             Imaging and X-Ray Precautions                 NA

Thursday, April 21, 2005                                                             137 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
   Revised          Bed Safety
   7.3.1.1          If bed rails are installed/used are       Entrapment can result in suffocation. Follow
                    they free of entrapment potential (for    July 2001 NCPS Patient Safety Alert Action
                    patients identified as high risk for      items including: assessing existing beds for
                    entrapment): 1) rail to mattress, 2)      horizontal gap between mattress and bed rail
                    between split rails, 3) rail to board -   must be less than 2 3/8 inches when the
                    either end, 4) board to mattress, or,     mattress is pushed to the opposite side;
                    5) within rail?                           permanently mark all non-complying bed
                                                              assemblies; fill gaps created between the
                                                              mattress and bed rail that are equal or wider
                                                              than 2 3/8 inches for high risk patients; reduce
                                                              the rail to rail openings, and openings with in rail
                                                              gaps to less than 4 3/4 inches by using rail
                                                              netting, clear padding or retrofit kits; ensure new
                                                              beds purchased meet requirements.

                    Mandatory                                 JCAHO SEA #28
                                                              VHA Patient Safety Alerts 7/12/01 & 12/12/01
                    Bed Safety
   7.3.1.2          Are bed rails easy to use, and have       Manipulate bed rails if available and interview
                    staff been trained on the usage?          staff.

                    Recommended
                    Bed Safety
   7.3.1.3          Are non-compliant beds clearly            All new beds must meet requirement, & existing
                    marked as to indicate entrapment          non-compliant beds marked.
                    risk?
                    Mandatory                                 VHA Patient Safety Alerts 7/12/01 & 12/12/00
                    Bed Safety
   7.3.1.4          Are beds designed to facilitate           Bed attributes would include: Stand assistive
                    patient transfer?                         devices to assist patients to stand, room for
                                                              base of lifting device to fit under the bed, clear
                                                              area around bed for staff and lifting equipment
                                                              access, variable position capabilities.

                    Recommended                               OSHA Guidelines for Nursing Homes




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    138 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                            Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                    Bed Safety
   7.3.1.5          Is the appropriate bed-type matched LTC patients can acquire bed sores; cardiac
                    to the level of care needed for each patients beds designed to facilitate CPR, etc.
                    patient?
                    Recommended
                    Bed Safety
   7.3.1.6          Are beds with built-in weight scales    Preventative maintenance tags should be up to
                    accurate and functioning correctly?     date. Interview nurses if any double checks are
                                                            in place for weight of patients.
                    Recommended
   New              Bed Safety
   7.3.1.7          Are measures in place to help           In addition to facility fire prevention practices,
                    prevent fires resulting from the use    extra steps should be taken for electrical beds:
                    of electric hospital beds?              Connect the bed's power cord directly to a wall-
                                                            mounted receptacle without the use of extension
                                                            cords or power strips; Do not cover any power
                                                            cord with a rug or carpet; conduct regular
                                                            inspections for duct build up (bed frame,
                                                            motor/hardware, mattress, etc.); regularly test
                                                            bed movement and hand/panel controls; inspect
                                                            the patient control panel (if cracked liquids can
                                                            get in); check that circuits are not overloaded
                                                            with other equipment; encourage reporting of
                                                            improper functioning; and assure that
                                                            manufacturers' recalls are followed.
                                                            FDA public Health Notification: Safety Tips for Preventing Hospital
                    Recommended
                                                            Bed Fires 12-2003
                    Code Carts
   7.3.2.1          Are code carts locked when not in       Drugs have potential to be taken from
                    use, and is equipment in good           unsecured carts in common areas. Verify cart
                    condition?                              inspection records.
                    Mandatory                                JCAHO: MM.2.30
                    Code Carts
   7.3.2.1.1 - 7.3.2.2      RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    139 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Code Carts
   7.3.2.3          Are equipment and drugs easily           Standardizing the location of supplies and
                    retrievable on/in code carts, and is     equipment will increase the code response
                    there standard organization in all       efficiency.
                    carts throughout the hospital?
                    Recommended
                    Code Carts
   7.3.2.4          Is the VHA modified version of the       Inspect top of cart and review checklist of
                    AHA Handbook of Cardiovascular           contents if provided.
                    Care Cognitive Aid located on all
                    carts?
                    Recommended
   Revised          Code Carts
   7.3.2.5          Are CO2 detectors available on           Inspect carts. Adjunctive devices (i.e.
                    code carts for confirming                colorimetric, syringe, or bulb devices) should be
                    esophageal intubations?                  adequately stocked and readily available for use
                                                             in all carts. Review cart checklist talk with cart
                                                             preparers in SPD (Supply Processing and
                                                             Distribution) Service.
                    Recommended
   Revised          Code Carts
   7.3.2.6          Is there a standardized system (e.g.     Cart should be locked with an integrity seal, look
                    checklist) or method used to verify      for a valid checklist or equivalent system on the
                    that code carts are fully stocked and    cart, dated with last check/update date. Items
                    properly equipped before they are        such as these should be on the checklist: O2
                    sent to the units?                       tank volume; tubing ; CO2 detectors;
                                                             appropriate medications; AED (or other
                                                             defibrillators) and suction machine functionality;
                                                             laryngoscope with batteries; cardiac board, etc.

                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    140 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Electrical Safety
   7.3.3.1          Are electrical receptacles in, or         All areas designated as wet locations, or areas
                    serving, wet areas or behavioral          used for behavioral health patients, require (wet)
                    health areas provided with Ground         or recommend (behavioral health) ground-fault
                    Fault Circuit Interruption (GFCI)         protection. These types of receptacles are
                    protection or an isolated power           designed to stop the flow of electrical current,
                    system?                                   preventing shock or electrocution. For
                                                              behavioral health areas, electrical receptacles
                                                              can be completely removed or covered in
                                                              patient rooms to protect patients who my try to
                                                              harm themselves.

                    Mandatory                                 National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                              NFPA 99-3.3.179
                    Electrical Safety
   7.3.3.2          Are electrical receptacles fitted with    Observe conditions on unit.
                    covers, secured, and free of loose
                    or exposed wiring?
                    Mandatory                                  NFPA 99-4 3.3.2.1.2
                    Electrical Safety
   7.3.3.2.1             RESERVED
                    Electrical Safety
   7.3.3.3          Are emergency power receptacles           Staff should be able to identify emergency
                    appropriately identified and only         receptacles. Assessor should inspect locations
                    used for equipment needing to be          of these outlets.
                    on emergency power circuits?
                    Mandatory                                 NFPA 99 4.4.2.2.4.2(B)
                    Electrical Safety
   7.3.3.4          Are electrically powered medical          Cords are free of physical defects including
                    devices in good condition?                cracks, frayed ends, or missing prongs.
                    Mandatory                                 NFPA 99 8.4.1.3.1
                                                              VHA Directive 2002-030
                    Electrical Safety
   7.3.3.5          Are there at least 4 receptacles (6 in Inspect patient rooms.
                    critical care) for each patient bed?

                    Mandatory                                 NFPA 99-4.3.2.2.7.2




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    141 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                               Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Electrical Safety
   7.3.3.6          If used, are power cords and           Facilities should strive to eliminate the use of
                    electrical extension cords placed      extension cords for small working spaces such
                    where they are free from               as the operating room, patient rooms, or exam
                    mechanical damage, properly sized      rooms. A plan should be in place to install
                    (gauge) to prevent overheating, and    permanently affixed receptacles supplied by the
                    arranged so that they do not present   appropriate electrical circuit (emergency or
                    a tripping hazard?                     critical branch) if cords are being used.

                    Recommended
                    Electrical Safety
   7.3.3.7           RESERVED
                    Environmental and Housekeeping Safety
   7.3.4.1          Are hot water temperatures taken    Temperature should be less than 120 F at the
                    manually using a thermometer        tap and 110F in baths.
                    before patient use or immersion
                    (including partial immersion) takes
                    place?
                    Mandatory                              VHA Directive 2002-073
                    Environmental and Housekeeping Safety
   7.3.4.2          Are supply and return air registers Observe conditions on the unit.
                    clean and free of lint and dust?
                    Recommended                            JCAHO Std: EC.8.10
                    Environmental and Housekeeping Safety
   7.3.4.3          Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                    to be a priority?
                    Recommended                            JCAHO Std: EC.8.10
   Revised          Environmental and Housekeeping Safety
   7.3.4.4          Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                    well light and temperature           rooms will help prevent mistakes. Ensuring
                    controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                    fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                         of floor keeps supplies sanitary.
                    Recommended                            JCAHO Std: EC.5.20
                    Environmental and Housekeeping Safety
   7.3.4.5          Are patient care area hallways and Observe conditions on the unit.
                    stairways unobstructed and kept
                    free of storage?
                    Mandatory                              NFPA 101 (LSC) 7.1.10
                                                            JCHAO: EC.5.20




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    142 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                           Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                    Environmental and Housekeeping Safety
   7.3.4.6          Are patient areas free of unlabeled All cleaning products, medication, employee
                    or unattended containers, such as   food or drink, etc., should not be left in patient
                    cleaning products or medication?    care areas or patient rooms.
                    Mandatory                               JCAHO: EC.1.10
                    Environmental and Housekeeping Safety
   7.3.4.7          Are hazards clearly identified and Pre-construction meetings should proactively
                    properly controlled during         address all necessary interventions to remediate
                    construction and renovation?       such issues. However, patient /staff concerns
                                                       may flag potential problems. Examples of
                                                       hazards: walkways maintained; marked exit
                                                       paths; guarded floor openings and overhead
                                                       hazards; dust generation; and excessive noise.

                    Mandatory                               29CFR 1926.20(b)
                                                            VA Directive 7703c(4)(a)
                                                             JCAHO: 5.50
                    Environmental and Housekeeping Safety
   7.3.4.8          Are high hazard areas such as:       High hazard areas must be locked to prevent
                    Roofs, service areas, medication     access to patients and have warning signs and
                    rooms, labs, radiation areas,        labels.
                    confined spaces, high voltage
                    areas, laser areas, low use areas
                    (such as sub-floors and interstitial
                    spaces), etc. labeled with
                    appropriate caution signage and
                    locked to prevent unauthorized
                    entrance?
                    Mandatory                               VA Directive 7703c(4)(a)
                    Environmental and Housekeeping Safety
   7.3.4.9           RESERVED
                    Environmental and Housekeeping Safety
   7.3.4.10         Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                    "pests" in the hospital environment? preventative measures or monitors. Special
                                                         considerations should be made for sterile
                                                         environments.
                    Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    143 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.3.5.1          Is medical equipment being                Check inspection tags, or other identifiers on the
                    inspected in accordance with the          equipment that indicates it has been inspected.
                    Preventative Maintenance Program?         Interview staff to determine how to interpret
                                                              identifiers.
                    Mandatory                                 JCAHO: EC.6.20 and Goal # 6a
                    Equipment Safety
   7.3.5.2          Is back up patient care/monitoring        Uninterruptible monitoring and support should
                    equipment readily available in the        be planned for.
                    event of failure and or emergency?
                    Recommended                               JCAHO: EC.6.10
                    Equipment Safety
   7.3.5.3          Is the equipment used on each             There is no chance equipment would be
                    patient positioned in a way that it is    inadvertently shut off because it is not in sight of
                    evident the equipment is in use for       the patient.
                    that patient?
                    Recommended
                    Equipment Safety
   7.3.5.4          Are alarms audible and easily             Alarms may be broadcast to an outside room or
                    distinguished above ambient               another area such as a central nursing station.
                    background noise level?                   Interview staff as to what is done during breaks
                                                              to cover patient monitoring. Clinical alarms,
                                                              bathroom alarms, and nurse calls are included
                                                              here.
                    Mandatory                                 JCAHO: Goal # 6b
                    Equipment Safety
   7.3.5.4.1        Is the unit layout/configuration          Observe conditions and interview staff.
                    conducive to hearing all alarms,
                    especially for isolation rooms?
                    Recommended
                    Equipment Safety
   7.3.5.5          Are all devices that alarm                Masking is when the frequency and intensity of
                    specifically set up for each patient to   two separate alarms blend together causing
                    reduce issues such as, "masking",         heightened confusion; nuisance alarms are
                    nuisance, or altered priority due to      caused when limits are not appropriately set,
                    unwanted false or alarms?                 this can create staff complacency, annoyance to
                                                              patients, and results in a delayed staff response
                                                              (cry wolf syndrome).

                    Recommended                               JCAHO: Goal 6b




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    144 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                           Rationale/Assessment Methods:                                                   (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.3.5.5.1        Are work arounds avoided in the     Due to factors listed above, devices can be
                    use of medical devices with alarms? disabled, turned off, turned down, etc. Signs of
                                                        workarounds include: post it notes suck to
                                                        equipment, worn silencer buttons, and taped
                                                        down or temporally disabled buttons.
                    Recommended
                    Equipment Safety
   7.3.5.6          Is the equipment designed such that       Should not see post-it notes or permanently
                    its operation is intuitive to the user    posted signs indicating warnings about
                    and does not require use of adjunct       seemingly logical machine operation (i.e. a sign
                    devices to complete the required          reading such messages as: "Don't press
                    tasks?                                    'ENTER' key to enter data.") Interview staff and
                                                              inspect equipment in area.
                    Recommended
                    Equipment Safety
   7.3.5.7          Is patient care and monitoring            All screens/interfaces are readable and at or
                    equipment well organized in each          near eye level; key pads within reach;
                    patient/procedure room to avoid           equipment is not blocking each other; adequate
                    clutter and permit the caregivers to      space to move around, including head
                    be able to reach and read all             clearance on mounted devices.
                    equipment?
                    Recommended
                    Equipment Safety
   7.3.5.8          Are liquids kept away from medical        To prevent spillage which can result in
                    equipment?                                malfunctioning.
                    Recommended                               NFPA 70 110.11
                    Equipment Safety
   7.3.5.9          Are disposable medical                    Inspect storage rooms and other stock areas in
                    devices/supplies stored in a way          the area/unit (e.g. folding supplies like hoses
                    that the integrity of the devices is      and tubing causes kinking that has prevented
                    kept intact (i.e. not bent or folded)?    them from functioning properly).
                    Recommended
                    Equipment Safety
   7.3.5.10         Is a reliable system used to identify     Examples: Color coding or directional arrows
                    which tubes and connectors go to          for input jacks. If color labeling is used it must
                    which devices?                            be consistent throughout the unit.
                    Recommended




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    145 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                            Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.3.5.10.1       Are the tubes/connectors kept out of Taped down, or use of a hanger or device can
                    the way to avoid them from being     help to lead them away from the patient.
                    inadvertently unplugged?
                    Recommended
                    Equipment Safety
   7.3.5.11         Are the location and model of AEDs The location on the code cart or within unit
                    standardized throughout the facility? should be the same from area to area.
                                                          Compare models in unit, and from unit to unit.
                    Recommended
                    Equipment Safety
   7.3.5.12              RESERVED
   Revised          Equipment Safety
   7.3.5.13         Does the hospital purchase               Having sterile water for injection in units on the
                    humidification devices that do not       floor creates the potential for misuse. Warnings
                    require the use of sterile water?        have been published (ISMP) regarding water
                                                             being confused with other medications resulting
                                                             in it being give intravenously resulting in fatal
                                                             hemolysis.
                    Recommended                              FDA Patient Safety News: Show #22, 12/2003
                                                             ISMP Medication Safety Alert, 9-2003
   Revised          Equipment Safety
   7.3.5.13.1       If humidification devices use sterile    If sterile water must be used it is recommend
                    water is it provided in 2 Liter bags     that it be used in 2 Liter bags. The 2 Liter bags
                    and labeled "Sterile Water"?             will help distinguish the sterile water from the 1
                                                             Liter bags of IV solutions, also pour bottles
                                                             could be considered.
                    Recommended                              FDA Patient Safety News: Show #22, 12/2003
                                                              ISMP Medication Safety Alert, 9-2003
                    Equipment Safety
   7.3.5.14         Is the use of cell phones or other       Look for signage, and ask staff about protocols.
                    devices that can affect monitoring
                    and other medical equipment
                    controlled in applicable areas?
                    Recommended
                    Escape and Elopement Prevention
   7.3.6.1          Is a system in place to clearly Look for screening processes, such as colored
                    identify high risk escape or    gowns, photos, designated identifiers for these
                    elopement patients to staff?    patients, etc.
                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    146 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                              Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                    Question:                       Rationale/Assessment Methods:                                                   (1)        Met (2)              (3) possible root causes
                    Escape and Elopement Prevention
   7.3.6.2          If electronic systems such as   Test wander guard system to ensure accuracy.
                    wander guards are used, are
                    methods in place to ensure they
                    function correctly?
                    Recommended
                    Escape and Elopement Prevention
   7.3.6.3          If wander guard systems are in  Observe if in use, interview appropriate staff to
                    place, are they included in the determine if properly maintained - ward staff
                    preventative maintenance        should be able to speak to reliability of system.
                    inspection program?
                    Recommended                            JCAHO: Goal #6a
                    Escape and Elopement Prevention
   7.3.6.4          Have staff been involved in an  Interview staff.
                    elopement drill (grid search)?
                    Recommended
   New              Escape and Elopement Prevention
   7.3.6.5          Is a risk assessment for elopement     Awareness of the potential for
                    completed at the time of admission     elopement/wandering behavior is the first step in
                    or transfer and regularly during the   prevention. Review documentation or interview
                    patients stay?                         staff to verify that the assessment is being
                                                           completed. Consider using electronic flags in
                                                           CPRS to inform clinicians if the patient is a high
                                                           risk. A change in the patients care (i.e., to a
                                                           new bed/unit, or new/change in medication) is a
                                                           key time for reassessment.

                    Mandatory                              VHA Directive 2003-013
   New              Escape and Elopement Prevention
   7.3.6.5.1        If an elopement risk assessment is Discuss with ward staff the wander and
                    to be completed for patients, are  elopement policies.
                    staff familiar with the
                    wandering/elopement prevention
                    protocol or SOP?
                    Mandatory                              VHA Directive 2002-013




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    147 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   New              Escape and Elopement Prevention
   7.3.6.6          Is a processes in place and used to       If patient privileges are not clear this often can
                    keep track of high risk patients when     lead to lack of communication on patient status
                    they are off of the unit?                 and location. A tracking or documentation
                                                              system can be used to help staff know patient
                                                              habits, and is a method to communicate this
                                                              information at the shift change. Also transport
                                                              of patients off the unit should be planned and
                                                              scheduled with competent escorts who
                                                              understand the potential for a high risk patient to
                                                              elope.
                    Recommended
   Revised          Fall Prevention
   7.3.7.1          Are all patient rooms and common          Observe conditions on the unit. Patient rooms
                    areas provided with adequate              and bathrooms should be provided with
                    lighting?                                 nightlights as well.
                    Recommended                               JCAHO: EC.1.10
                    Fall Prevention
   7.3.7.2          Are mechanical assist devices used        Have staff show example, and conduct
                    to lift or transfer patients accessible   interviews to determine facility consistency.
                    and used by staff when needed?

                    Recommended
                    Fall Prevention
   7.3.7.2.1        Are preventative measures                 Staff training, proper number of staff present, no
                    implemented to prevent falls from         obstructions in lift area.
                    manual lifting and/or handling
                    patients?
                    Recommended
   Revised          Fall Prevention
   7.3.7.3          Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                    slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                              create fall hazards. Patient rooms should be
                                                              free of low-lying objects that could be tripped
                                                              over causing falls.
                    Recommended                               JCAHO: EC.1.10




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    148 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Fall Prevention
   7.3.7.4          Do shower/bathroom areas have            Inspect areas specified. Bathrooms should be
                    adequate lighting, proper drainage,      provided with night lights. If a raised seats are
                    non-slip floor surfaces, and             used on toilets are they is the color of it
                    handrails installed?                     contracting to toilet to help patients see it clearly.

                    Recommended                              JCAHO: EC.1.10
                    Fall Prevention
   7.3.7.5          Are call buttons within reach of the     Inspect all areas.
                    patient?
                    Recommended
                    Fall Prevention
   7.3.7.6          Are bed and chair alarms used and        Show examples. False or unwanted alarms sets
                    audible, and, are they configured to     up the care givers for complacency.
                    reduce the number of
                    false/unwanted alarms?
                    Recommended                              JCAHO: SEA #14 & Goal #6b
                    Fall Prevention
   7.3.7.7          Does the facility have a Fall            Interview staff - protocol should evaluate: 1) A
                    Prevention & Management Protocol         risk screen; 2) Protective device matched to risk
                    or equivalent?                           level; 3) First responder assessment to identify
                                                             patients for immediate physician evaluation and
                                                             4) Treatment plan for follow up, post fall.

                    Recommended
                    Fall Prevention
   7.3.7.8          Is a uniform tool used to assess         Identifying high risk patients will help care team
                    which patients are at high risk for      to put proactive and preventative measures in
                    falls, and is there criteria to          place. Assessor should look for identifiers and
                    determine: 1) When they are              interview staff.
                    assessed, and 2) What triggers a
                    reassessment?
                    Recommended
   Revised          Fall Prevention
   7.3.7.9          Does equipment (lifting equipment,       Review equipment, interview staff. Patients
                    OR tables, etc.) have sufficient         weighing in excess of 400 pounds are not
                    capacity to meet the needs of            uncommon. If equipment cannot support the
                    bariatric patients?                      weight of the patient contingency plans should
                                                             be developed to provide care.
                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    149 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Fall Prevention
   7.3.7.10              RESERVED
                    Fire Safety
   7.3.8.1          Are staff members familiar with fire     Interview staff to determine familiarity.
                    emergency procedures, and the fire
                    prevention plan for their service
                    area?
                    Mandatory                                JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.3.8.2          Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                    fire walls in their immediate area?   must be knowledgeable regarding where to
                                                          move patients in the event of a fire.
                    Mandatory                                JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.3.8.3          Is the fire alarm signal easily          Interview staff to determine familiarity, if alarm is
                    distinguishable from other alarms        not witnessed.
                    (e.g. equipment, nurse call, etc.)?
                    Mandatory                                 NFPA 72 1.5.4.4
                    Fire Safety
   7.3.8.4          Is the area staff notified when the    Interview staff.
                    fire alarm system is out of service or
                    being tested?
                    Mandatory                                NFPA 72 7-1.3.1
                    Fire Safety
   7.3.8.4.1        Are cognitive aids used to remind        Look for signs placed by pull stations, and
                    staff when the fire alarm system is      interview to determine if announcements are
                    not functioning?                         made on PA system, etc.
                    Recommended
                    Fire Safety
   7.3.8.5          Are flame retardant pajamas or           Smoking risk patients are patients who are
                    aprons provided for patients who         known to routinely violate the "no smoking" rules
                    smoke and are identified as a            established by the facility. They smoke in non
                    "smoking risk"?                          designated areas when unsupervised and may
                                                             have a physical or mental condition that could
                                                             lead them to drop a cigarette, ashes, or match
                                                             causing clothing or hair to ignite. Flame
                                                             retardant pajamas or aprons can be a
                                                             preventive measure for these patients.

                    Recommended                              VA MP-3, Part III, 32.36(b) & (d); VA Circ. 10-90
                    Fire Safety




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    150 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   7.3.8.5.1        If flame retardant pajamas or linens    Interview staff, determine if practices are
                    are used, is a process in place to      consistent with policy.
                    ensure integrity of the flame
                    retardant agent is maintained on
                    these articles after repeated
                    laundering?
                    Recommended                             VA MP-3, Part III, 32.36(c) & (d)




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    151 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Fire Safety
   7.3.8.6           RESERVED
                    Infection Control
   7.3.9.1          Are all linen carts (clean and soiled)    Observe conditions on the unit.
                    kept covered?
                    Mandatory                                 JCAHO: IC.4.10
   Revised          Infection Control
   7.3.9.2          Are sharps containers accessible          Observe conditions in unit/area. Patients and
                    and not over filled?                      employees are often stuck by sharps not
                                                              properly disposed of due to overfilling of these
                                                              containers.
                    Mandatory                                 JCAHO: IC.4.10
   Revised          Infection Control
   7.3.9.3          Is the latex allergy policy followed      Show example if available. Consider inspecting
                    and are latex free supplies and           supply and code carts. Look for latex-free
                    equipment available?                      identification on glove boxes, supply packages,
                                                              etc. Determine if the other devices are available
                                                              as latex-free such as tourniquets and medical
                                                              tubing. In pharmacy, check for a latex protocol
                                                              in IV room.
                    Mandatory                                 IL 16-97-001 Latex Information




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    152 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Infection Control
   7.3.9.4          Are the VA recommended hand             The individual products should be an alcohol rub
                    hygiene guidelines followed, such       (for disinfecting) and a hospital approved lotion
                    as having alcohol-based gel             (to prevent skin dryness). Also, staff who come
                    disinfectants located to promote use    in contact with patients or prepare sterile
                    (including inpatient rooms), and        products (such as IV drugs) should not have
                    providing individual products to all    artificial fingernails. Clinicians should also be
                    necessary staff?                        offered the small (2-4 oz.) personal containers of
                                                            hand gel. Gel should be in convenient locations
                                                            including all carts (mobile care, medication
                                                            carts, code, respiratory).

                    Mandatory                               JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                            CDC Hand Hygiene Guidelines
                                                            VHA Directive 2005-002 July 2005
                    Infection Control
   7.3.9.5          Is the integrity of negative/positive   Door remains closed if in use, Personal
                    pressure isolation rooms tested and     Protective Equipment used. Signage outside to
                    maintained (once per day for            identify hazard exists.
                    occupied, monthly for non-
                    occupied)?
                                                            CDC Guidelines for Environmental Infection Control in Health Care
                    Mandatory
                                                            Facilities
                                                            OSHA , 29 CFR 1910.145
                    Medical Gas Safety
   7.3.10.1         Are piped in oxygen and                 The use of color coding should be eliminated.
                    compressed air identified by a          Using color adapters can cause confusion
                    prominent label and not merely by       during use, mixing up the gases being
                    color adapters?                         administered. Fixes include: replacing tubing
                                                            with a type that does not use adaptors or using
                                                            only clear adaptors.
                    Recommended                             VHA Patient Safety Advisory 3/5/02
                    Medical Gas Safety
   7.3.10.2         Are air flow meters removed when        Flow meters are only used for specific
                    not in use (for nebulized medication    treatments, are not required during emergencies
                    treatments)?                            and should not be left attached to be confused
                                                            with O2 flow meter.
                    Recommended                             VHA Patient Safety Advisory 3/5/02




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    153 of 257
                                                               NCPSPatient Safety Assessment Tool
                                                                   Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                   Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medical Gas Safety
   7.3.10.3         Do staff know where the emergency          Staff to demonstrate competency. Also verify
                    oxygen shut-off is, and when and           that labels, warnings or other signage posted at
                    how to use it?                             the shut off point in accurate and up to date.

                    Mandatory                                  NFPA (National Fire Protection Association) 5.1.4.2.1
                                                               JCAHO: EC.7.50
                    Medical Gas Safety
   7.3.10.4         Does the storage and use of                If color identifies type, must be the same hue &
                    portable medical gas containers            intensity; flammables separated from oxidizers;
                    appear to be in compliance with            secured at all times (full or empty); container in
                    CGA (Compressed Gas                        good condition; only a limited quantity permitted
                    Association) Standards?                    in use area (less than 12 E-cylinders, or 1 H-
                                                               cylinder per area).
                    Mandatory                                  NCGA (Compressed Gas Association) C-9, 3.7 & 4.6
                                                               NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.3.10.4.1       Are all area/unit personnel                Staff to demonstrate competency.
                    competent in understanding the
                    handling procedures of oxygen
                    cylinders, including how to obtain
                    full cylinders? If so, is current
                    practices in line with the facility's
                    written procedure?
                    Mandatory                                  NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.3.10.5         Are pins on medical gas regulators         Pins should be in place and found undamaged.
                    and cylinders in good repair and is
                    damaged equipment immediately
                    removed from service?
                    Recommended                                NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.3.10.6         Are oxygen cylinders with ball-type        When placed in the horizontal position, the ball
                    regulators used with the cylinder in       valve mechanism will not function, and an
                    the vertical position?                     inaccurate reading will show on the gauge.
                    Recommended                                NCPS O2 Cylinder Hazard Summary




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    154 of 257
                                                               NCPSPatient Safety Assessment Tool
                                                                   Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                   Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medical Gas Safety
   7.2.10.7              RESERVED
   Revised          Medication Safety
   7.3.11.1         Are all medication refrigerators           Check floor refrigerators, ensure correct labeling
                    maintained appropriately?                  and appropriate separations from employee
                                                               food/drink. Review temperature log (or
                                                               electronic temperature monitoring device/log)
                                                               and verify that the thermometer is working.

                    Mandatory                                  JCAHO: MM.2.20, EP-13
                                                               ISMP Self Assessment: #117
                    Medication Safety
   7.3.11.2         Do medication carts remained               Randomly survey carts in the area.
                    locked and inaccessible to patients
                    when not in use?
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
   Revised          Medication Safety
   7.3.11.3         Are the tops of medication carts,          Randomly survey carts in the area. Clean carts
                    clean, free of stray drugs and             will help prevent medication error by eliminating
                    syringes?                                  opportunities for mix-ups . It will also avoid drug
                                                               being taken by mental health patients or those
                                                               with cognitive impairment.
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                               ISMP Self Assessment: 14
                    Medication Safety
   7.3.11.3.1       Is medication logically organized          Clearly marked labels and nametags.
                    and identified by patient?
                    Recommended                                 JCAHO: MM.4.30
   Revised          Medication Safety
   7.3.11.4         Are medication storage rooms               Door locking mechanism cannot be defeated for
                    secured at all times?                      any reason. Door should not be held open.
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                               ISMP Self Assessment: 75
                    Medication Safety
   7.3.11.5              RESERVED




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    155 of 257
                                                              NCPSPatient Safety Assessment Tool
                                                                  Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                  Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.3.11.6         Is area stock limited to emergency     Review approved floor stock and IV solution list
                    medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                    are appropriate to patient care in the
                    unit?
   Previously       Recommended                               JCAHO: MM.3.20
   7.3.11.5                                                   ISMP Self Assessment: 82
                    Medication Safety
   7.3.11.6.1 - 7.3.11.6.2        RESERVED
   Revised          Medication Safety
   7.3.11.7         Are bags containing sterile water for Controlling the acquisition of sterile water may
                    injection prohibited from being       help to prevent it from being inadvertently given
                    ordered or stocked on patient care    intravenously.
                    areas without special permission
                    and precaution?
   Previously       Recommended                                FDA Patient Safety News: Show #22, 12/2003
   7.3.11.46                                                   ISMP Medication Safety Alert, 9-2003
                    Medication Safety
   7.3.11.8         Are up-to-date facility specific          Interview unit staff, show where information is
                    protocols, guidelines, dosing scales,     kept and how it is retrieved. (e.g. use of
                    and/or checklists readily available       electrolyte replacement, amino glycoside, and
                    for staff?                                anti-coagulant guidelines).
   Previously
   7.3.11.16        Recommended                                JCHAO: IM.3.10
                    Medication Safety
   7.3.11.8.1       Is access limited to electrolyte          Review local policies, and interview pharmacy
                    replacement solutions (above or           staff. Show example.
                    below 0.9% sodium chloride)
                    outside the pharmacy?
   Previously
   7.3.11.30        Recommended                               ISMP Self Assessment: 92
                    Medication Safety
   7.3.11.9              RESERVED
                    Medication Safety
   7.3.11.9.1       Are only standard concentrations of       Floor stock of high-alert drugs should be limited
                    high alert medications kept in the        to critically needed medications, with minimal
                    area/unit to minimize the potential of    number of doses, and be pre-made solutions (if
                    calculation and compounding errors?       available).

   Previously       Mandatory                                 JCAHO: MM2.20, EP-8; MM.7.10; Goal #3b & SEA #11
   7.3.11.15                                                  ISMP Self Assessment: 67.1 & 20




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    156 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.3.11.10        Is a unit dose medication system         Look in patient bins for bulk containers.
                    used including half tablets and
                    liquids?
   Previously       Recommended                              JCAHO: MM.2.20, EP-10
   7.3.11.6                                                  ISMP Self Assessment: 64
                    Medication Safety
   7.3.11.10.1 - 7.3.11.12        RESERVED
                    Medication Safety
   7.3.11.13        Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                    the pharmacy and not on care units? be completed in pharmacy areas.

                    Recommended                              JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.3.11.13.1 If admixtures are done in inpatient           Interview floor staff. If admixtures are done on
               care areas, is an independent                 units, the area should be a designated area that
               double-check system utilized?                 is clean and secure. It is safest for mixtures to
                                                             be completed in pharmacy areas.
                    Recommended
                    Medication Safety
   7.3.11.14        Are procedures in place to prevent       Infection control literature documents
                    sterile product use from patient to      nosocomial infections occur irrespective of
                    patient (including medications)?         changing needles or IV tubing's.
                    Recommended                              ISMP Medication Safety Alert, June 2000
   Previously                                                American Society of Anesthesiology Newsletter, 12/2000
   7.3.11.43                                                 CDC MMWR Weekly, 9/26/2003
   Revised          Medication Safety
   7.3.11.15        Are premixed IV solutions kept in        The protective over-wrap for some solutions
                    over-wrap bags until they are ready      serves to control the amount of water vapor that
                    to be used (if applicable)?              escapes from an IV solution. Once unwrapped
                                                             it is best to use the solution right way.

   Previously
   7.3.11.44        Recommended                              FDA Patient Safety News: Show #22, 12/2003
                    Medication Safety
   7.3.11.16        Are IV bags free of markings, such      The volatile chemical from the ink may leach
                    as expiration dates, applied by staff into IV solutions.
                    with ink pens or felt markers (prior to
                    use)?
   Previously
   7.3.11.45        Recommended                              FDA Patient Safety News: Show #22, 12/2003




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    157 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.3.11.17        Is an independent double check           The double check should Include patient
                    completed for all infusion pump          monitoring and verifying the number of types of
                    settings?                                pumps.
   Previously
   7.3.11.12        Recommended                              JCAHO: SEA #11
                    Medication Safety
   7.3.11.18             RESERVED
   Revised          Medication Safety
   7.3.11.19        Are appropriate reversal agents          In the event of an unusual reaction or overdose
                    (flumazenil, naloxone, protamine,        the agents need to be available.
                    etc.) available based on the drug
                    being administered?
   Previously
   7.3.11.10        Recommended                              ISMP Self Assessment: 79
               Medication Safety
   7.3.11.19.1 Is there a process to monitor the             Such as reviewing automated dispensing
               reversal agent use?                           machine records, which can be used as a tracer
                                                             order for adverse drug events. (e.g., reversal
                                                             agent s used in Endosocpy, Radiology, Acute
                                                             Care, etc., may be a signal to misadministration
                                                             or unsafe practices occurring.
   Previously
   7.3.11.10.1      Recommended
                    Medication Safety
   7.3.11.20             RESERVED
                    Medication Safety
   7.3.11.21        Is there machine readable coding    Show mechanism (i.e. BCMA) in use. Machine
                    throughout the medication           readable coding should match the electronic
                    administration process (e.g. BCMA)? medical record to the patient, allowing the
                                                        information on the patients armband to be
                                                        matched with the electronic information.

   Previously
   7.3.11.17        Recommended                              ISMP Self Assessment: 11
               Medication Safety
   7.3.11.21.1 Is BCMA used to administer                    Observe staff.
               medication without using work
               arounds?
   Previously
   7.3.11.24        Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    158 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
               Question:                                    Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.3.11.21.2 What is the protocol for handling            Interview staff and compare practices to policy
               incorrect bar coded or labeled               of facility/Pharmacy.
               medications?
   Previously
   7.3.11.23        Recommended                              JCHAO: MM.3.20, EP-5
               Medication Safety
   7.3.11.21.3 Is there a helpdesk for BCMA                 Test hotline number available on all shifts;
               available during all shifts?                 interview off-shift staff if available.
   Previously
   7.3.11.22        Recommended
                    Medication Safety
   7.3.11.22             RESERVED
               Medication Safety
   7.3.11.22.1 Do the VISTA modules effectively             Show example, if available.
               alert to potential food/drug/herbal
               interactions and duplicate drug
               therapies?
   Previously
   7.3.11.20        Recommended
                    Medication Safety
   7.3.11.23 - 7.3.11.24     RESERVED
                    Medication Safety
   7.3.11.25        Is drug reference information made      Interview area/unit staff, show where information
                    readily accessible to caregivers, if    is kept and how it is retrieved. One or two
                    so how?                                 reference sources should be available as well
                                                            as access to pharmacist.
   Previously       Recommended                             JCAHO: IM.3.10
   7.3.11.7                                                 ISMP Self Assessment: 18.2
                    Medication Safety
   7.3.11.26        Are up-to-date facility specific        Interview unit staff, show where information is
                    protocols, guidelines, dosing scales,   kept and how it is retrieved. (e.g. use of
                    and/or checklists readily available     electrolyte replacement, aminoglycoside, and
                    for staff?                              anti-coagulant guidelines).
   Previously       Recommended                             JCHAO: IM.3.10
   7.3.11.8                                                 ISMP Self Assessment: 19
   Revised          Medication Safety
   7.3.11.27        Are specific precautions followed       Discuss protocols with staff (such as insulin and
                    when handling look/sound alike          heparin vials; and hydromorphone and
                    drugs?                                  morphine). In pharmacy, discuss what is being
                                                            done with the look alike medication project.

   Previously
   7.3.11.9         Recommended                             JCAHO: MM.2.20, EP-6; SEA #19


                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    159 of 257
                                                             NCPSPatient Safety Assessment Tool
                                                                 Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                 Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.3.11.27.1            RESERVED
                    Medication Safety
   7.3.11.28        Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                    to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                    Goal requirements?
   Previously       Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
   7.3.11.25                                                 ISMP Self Assessment: 40
   Revised          Medication Safety
   7.3.11.29        If Automated Dispensing Machines         Written documents should include which drugs
                    (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                    written policy, and can they explain     how often drugs are inspected for expiration
                    how the machine works?                   dates, drugs not used but removed, and content
                                                             review.
   Previously
   7.3.11.27        Recommended                              JCAHO: MM.4.50
                    Medication Safety
   7.3.11.30 - 7.3.11.31.1        RESERVED
                    Medication Safety
   7.3.11.32        If ADMs are used, are there              Show example reports, where filed on units;
                    capabilities to run override reports     interview Nurse Manger. Have staff reveal how
                    that track discrepancy and utilization   reports are used and acted upon, and if there is
                    at least monthly?                        a process to deal with variances.
   Previously
   7.3.11.21        Recommended                              ISMP Self Assessment: 26
                    Medication Safety
   7.3.11.33             RESERVED
                    Medication Safety
   7.3.11.34        Are patients educated regarding          Show example.
                    their prescribed medication, as
                    inpatients and as part of the
                    discharge process?
   Previously
   7.3.11.19        Recommended                              JCAHO: PC.6.10
                    Medication Safety
   7.3.11.35        Does the care provided by           Interview clinicians to determine if Pharmacists
                    Pharmacists meet the clinical needs are available for consult, and if they participate
                    of the patients in scope and        in rounds or access patient medication history.
                    frequency?
   Previously       Recommended                              JCAHO Std: MM.4.10
   7.3.11.18                                                 ISMP Self Assessment: 23
                    Medication Safety
   7.3.11.36 - 7.3.11.41.1        RESERVED
                    General Patient Safety Concerns

                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    160 of 257
                                                               NCPSPatient Safety Assessment Tool
                                                                   Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                   Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   7.3.12.1         Is read-back used for all verbal           Observe verbal ordering if possible, and
                    order and critical value reports?          interview staff. Verify that telephone voice mail
                                                               orders are not accepted.
                    Mandatory                                  JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                               ISMP Self Assessment: 45
                    General Patient Safety Concerns
   7.3.12.2         Are NCPS or locally developed              Randomly interview nursing staff on the floor.
                    cognitive aids available on the floor      Look for aids at nurses stations.
                    for staff to reference (Escape and
                    Elopement; Fall Prevention, etc.)?
                    Recommended
                    General Patient Safety Concerns
   7.3.12.3         Are patient records kept                   Ensure records or computer screens are not left
                    confidential, including computer           unattended and openly visible.
                    information?
                    Recommended                                JCAHO Std: IM.2
                    General Patient Safety Concerns
   7.3.12.4         Are staff required to wear                 Monitor patient care areas. Interview staff about
                    identification badges, and are             policies such as the handling of drug
                    unauthorized persons kept out of           manufacturer representatives that visit
                    patient care areas?                        unexpectedly.
                    Recommended                                JCAHO Std: EC.1.2 & EC.2.2




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    161 of 257
                                                           NCPSPatient Safety Assessment Tool
                                                               Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                               Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    General Patient Safety Concerns
   7.3.12.5         Are restraints used in accordance      Randomly interview staff. Look for restraint
                    with local policy and are restraint    devices or alterative devices in the area.
                    alternative devices available and
                    used when appropriate?
                    Recommended                            JCAHO: PC.11.10 & PC.12.10 & SEA #8
                    General Patient Safety Concerns
   7.3.12.6         Are there practices in place to        Using two patient identifiers for administrations,
                    decrease the likelihood of patient     draws or procedures/images, and at outpatient
                    misidentification?                     pharmacy; record and room flags for
                                                           same/similar/common names; four or less beds
                                                           in patient rooms; bedside labeling of samples,
                                                           rather than bulk (at nurses station); special
                                                           procedure for the transporting of high risk (for
                                                           misidentification) patients.

                    Recommended                            JCAHO Goal 1a
                    General Patient Safety Concerns
   7.3.12.7         Are there monitoring processes in      Look for a preventative maintenance log that
                    place for portable food and            periodically checks the temperature of the
                    beverage warming or heating            warming device to help prevent scalding by
                    devices?                               liquids or burns from food tray items. First and
                                                           second degree scalding can occur to patients
                                                           with cognitive or motor difficulties while being
                                                           fed in bed as well.
                    Recommended
                    General Patient Safety Concerns
   7.3.12.8         Is transfer of care between shifts     A consistent process should exist to update on-
                    standardized?                          coming staff of patient statues. Interview staff
                                                           and compare answers between units.
                    Recommended




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    162 of 257
                                                            NCPSPatient Safety Assessment Tool
                                                                Part II - Implementation
   ACUTE CARE UNITS (Medical/Surgical/Step-Down) - Element 7, Location 3 (7.3)                                                Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    General Patient Safety Concerns
   7.3.12.9         Is the transfer of care between         A consistent process should occur during
                    disciplines for off-unit appointments   appointments and when patients are sent back
                    standardized, including the             and forth from units, including patient
                    continuation of monitoring patient      identification means, patient record transfer, and
                    status and patient medical devices      the monitoring of the patient's condition and
                    such as IV pumps and oxygen level       needed medical devices. Stopping and
                    while the patient is visiting, being    resumption of IV medications should be planned
                    treated/tested, and during transport?   and documented. Interview staff in all areas
                                                            compare answers to determine standardization.

                    Recommended                             US Pharmacopeia Patient Safety CAPSLink, July 2004
   Revised          General Patient Safety Concerns
   7.3.12.10        Are patients searched for               To ensure the safety of the patients and staff
                    contraband upon admission to each       members it is essential to have a rigorous
                    applicable area/unit?                   search process of each individual patient.
                                                            Observe an admission, or interview staff to
                                                            evaluate consistency throughout the facility.
                    Recommended
   Revised          General Patient Safety Concerns
   7.3.12.11        Does the facility have an emergency The protocol should be made up of a
                    response protocol for dealing with  mechanism for staff to communicate the
                    disruptive patients?                emergency (via a special extension or a
                                                        separate alarm system) and a security response
                                                        when a patient, staff or visitor becomes
                                                        threatening or out of control. Staff should be
                                                        familiar with the protocol and have confidence in
                                                        how to respond.
                    Recommended
   New              General Patient Safety Concerns
   7.3.12.12        When performing procedures           The facility's Conscious Sedation protocol
                    outside of the operating room are    should be followed in all areas.
                    appropriate sedation protocols and
                    privileges followed when applicable?

                    Mandatory                               JCAHO Std: PC.13.20
                    Psychiatric Precautions
   7.3.13.1 - 7.3.13.18         RESERVED
                    Surgical or Invasive Procedure Precautions
   7.3.14.1 - 7.3.14.19         RESERVED
                    Imaging and X-rays Precautions
   7.3.15.1 - 7.3.15.9          RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Acute Care Units - 7.3                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    163 of 257
                 Patient Safety Assessment Tool
                 Part II Implementation
                 Element: Intensive Care Units - 7.4
                              Categories:
                              Bed Safety                                    1-2
                              Code Carts                                    2-3
                              Electrical Safety                             4-5
                              Environmental and Housekeeping Safety         5-6
                              Equipment Safety                              6-9
                              Escape and Elopement Prevention               9 - 10
                              Fall Prevention                               10 - 12
                              Fire Safety                                   12
                              Infection Control                             12 - 13
                              Medical Gas Safety                            14 - 15
                              Medication Safety                             15 - 22
                              General Patient Safety Concerns               22 - 24
                              Psychiatric Precautions                       NA
                              Surgical or Invasive Procedures Precautions   NA
                              Imaging and X-Ray Precautions                 NA

Thursday, April 21, 2005                                                              164 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
   Revised           Bed Safety
   7.4.1.1           If bed rails are installed/used are       Entrapment can result in suffocation. Follow
                     they free of entrapment potential (for    July 2001 NCPS Patient Safety Alert Action
                     patients identified as high risk for      items including: assessing existing beds for
                     entrapment): 1) rail to mattress, 2)      horizontal gap between mattress and bed rail
                     between split rails, 3) rail to board -   must be less than 2 3/8 inches when the
                     either end, 4) board to mattress, or,     mattress is pushed to the opposite side;
                     5) within rail?                           permanently mark all non-complying bed
                                                               assemblies; fill gaps created between the
                                                               mattress and bed rail that are equal or wider
                                                               than 2 3/8 inches for high risk patients; reduce
                                                               the rail to rail openings, and openings with in rail
                                                               gaps to less than 4 3/4 inches by using rail
                                                               netting, clear padding or retrofit kits; ensure new
                                                               beds purchased meet requirements.

                    Mandatory                                  JCAHO SEA #28
                                                               VHA Patient Safety Alerts 7/12/01 & 12/12/01
                     Bed Safety
   7.4.1.2           Are bed rails easy to use, and have       Manipulate bed rails if available and interview
                     staff been trained on the usage?          staff.

                    Recommended
                     Bed Safety
   7.4.1.3           Are non-compliant beds clearly            All new beds must meet requirement, & existing
                     marked as to indicate entrapment          non-compliant beds marked.
                     risk?
                    Mandatory                                  VHA Patient Safety Alerts 7/12/01 & 12/12/00
                     Bed Safety
   7.4.1.4           Are beds designed to facilitate           Bed attributes would include: Stand assistive
                     patient transfer?                         devices to assist patients to stand, room for
                                                               base of lifting device to fit under the bed, clear
                                                               area around bed for staff and lifting equipment
                                                               access, variable position capabilities.

                    Recommended                                OSHA Guidelines for Nursing Homes




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    165 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                       Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                     Question:                            Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                     Bed Safety
   7.4.1.5           Is the appropriate bed-type matched LTC patients can acquire bed sores; cardiac
                     to the level of care needed for each patients beds designed to facilitate CPR, etc.
                     patient?
                    Recommended
                     Bed Safety
   7.4.1.6           Are beds with built-in weight scales    Preventative maintenance tags should be up to
                     accurate and functioning correctly?     date. Interview nurses if any double checks are
                                                             in place for weight of patients.
                    Recommended
   New               Bed Safety
   7.4.1.7           Are measures in place to help           In addition to facility fire prevention practices,
                     prevent fires resulting from the use    extra steps should be taken for electrical beds:
                     of electric hospital beds?              Connect the bed's power cord directly to a wall-
                                                             mounted receptacle without the use of extension
                                                             cords or power strips; Do not cover any power
                                                             cord with a rug or carpet; conduct regular
                                                             inspections for duct build up (bed frame,
                                                             motor/hardware, mattress, etc.); regularly test
                                                             bed movement and hand/panel controls; inspect
                                                             the patient control panel (if cracked liquids can
                                                             get in); check that circuits are not overloaded
                                                             with other equipment; encourage reporting of
                                                             improper functioning; and assure that
                                                             manufacturers' recalls are followed.
                                                             FDA public Health Notification: Safety Tips for Preventing Hospital
                    Recommended
                                                             Bed Fires 12-2003
                     Code Carts
   7.4.2.1           Are code carts locked when not in       Drugs have potential to be taken from
                     use, and is equipment in good           unsecured carts in common areas. Verify cart
                     condition?                              inspection records.
                    Mandatory                                 JCAHO: MM.2.30
                     Code Carts
   7.4.2.1.1 - 7.4.2.2       RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    166 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Code Carts
   7.4.2.3           Are equipment and drugs easily           Standardizing the location of supplies and
                     retrievable on/in code carts, and is     equipment will increase the code response
                     there standard organization in all       efficiency.
                     carts throughout the hospital?
                    Recommended
                     Code Carts
   7.4.2.4           Is the VHA modified version of the       Inspect top of cart and review checklist of
                     AHA Handbook of Cardiovascular           contents if provided.
                     Care Cognitive Aid located on all
                     carts?
                    Recommended
   Revised           Code Carts
   7.4.2.5           Are CO2 detectors available on           Inspect carts. Adjunctive devices (i.e.
                     code carts for confirming                colorimetric, syringe, or bulb devices) should be
                     esophageal intubations?                  adequately stocked and readily available for use
                                                              in all carts. Review cart checklist talk with cart
                                                              preparers in SPD (Supply Processing and
                                                              Distribution) Service.
                    Recommended
   Revised           Code Carts
   7.4.2.6           Is there a standardized system (e.g.     Cart should be locked with an integrity seal, look
                     checklist) or method used to verify      for a valid checklist or equivalent system on the
                     that code carts are fully stocked and    cart, dated with last check/update date. Items
                     properly equipped before they are        such as these should be on the checklist: O2
                     sent to the units?                       tank volume; tubing ; CO2 detectors;
                                                              appropriate medications; AED (or other
                                                              defibrillators) and suction machine functionality;
                                                              laryngoscope with batteries; cardiac board, etc.

                    Recommended




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    167 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Electrical Safety
   7.4.3.1           Are electrical receptacles in, or         All areas designated as wet locations, or areas
                     serving, wet areas or behavioral          used for behavioral health patients, require (wet)
                     health areas provided with Ground         or recommend (behavioral health) ground-fault
                     Fault Circuit Interruption (GFCI)         protection. These types of receptacles are
                     protection or an isolated power           designed to stop the flow of electrical current,
                     system?                                   preventing shock or electrocution. For
                                                               behavioral health areas, electrical receptacles
                                                               can be completely removed or covered in
                                                               patient rooms to protect patients who my try to
                                                               harm themselves.

                    Mandatory                                  National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                               NFPA 99-3.3.179
                     Electrical Safety
   7.4.3.2           Are electrical receptacles fitted with    Observe conditions on unit.
                     covers, secured, and free of loose
                     or exposed wiring?
                    Mandatory                                   NFPA 99-4 3.3.2.1.2
                     Electrical Safety
   7.4.3.2.1             RESERVED
                     Electrical Safety
   7.4.3.3           Are emergency power receptacles           Staff should be able to identify emergency
                     appropriately identified and only         receptacles. Assessor should inspect locations
                     used for equipment needing to be          of these outlets.
                     on emergency power circuits?
                    Mandatory                                  NFPA 99 4.4.2.2.4.2(B)
                     Electrical Safety
   7.4.3.4           Are electrically powered medical          Cords are free of physical defects including
                     devices in good condition?                cracks, frayed ends, or missing prongs.
                    Mandatory                                  NFPA 99 8.4.1.3.1
                                                               VHA Directive 2002-030
                     Electrical Safety
   7.4.3.5           Are there at least 4 receptacles (6 in Inspect patient rooms.
                     critical care) for each patient bed?

                    Mandatory                                  NFPA 99-4.3.2.2.7.2




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    168 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                      Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                     Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Electrical Safety
   7.4.3.6           If used, are power cords and           Facilities should strive to eliminate the use of
                     electrical extension cords placed      extension cords for small working spaces such
                     where they are free from               as the operating room, patient rooms, or exam
                     mechanical damage, properly sized      rooms. A plan should be in place to install
                     (gauge) to prevent overheating, and    permanently affixed receptacles supplied by the
                     arranged so that they do not present   appropriate electrical circuit (emergency or
                     a tripping hazard?                     critical branch) if cords are being used.

                    Recommended
                     Electrical Safety
   7.4.3.7            RESERVED
                     Environmental and Housekeeping Safety
   7.4.4.1           Are hot water temperatures taken    Temperature should be less than 120 F at the
                     manually using a thermometer        tap and 110F in baths.
                     before patient use or immersion
                     (including partial immersion) takes
                     place?
                    Mandatory                               VHA Directive 2002-073
                     Environmental and Housekeeping Safety
   7.4.4.2           Are supply and return air registers Observe conditions on the unit.
                     clean and free of lint and dust?
                    Recommended                             JCAHO Std: EC.8.10
                     Environmental and Housekeeping Safety
   7.4.4.3           Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                     to be a priority?
                    Recommended                             JCAHO Std: EC.8.10
   Revised           Environmental and Housekeeping Safety
   7.4.4.4           Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                     well light and temperature           rooms will help prevent mistakes. Ensuring
                     controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                     fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                          of floor keeps supplies sanitary.
                    Recommended                             JCAHO Std: EC.5.20
                     Environmental and Housekeeping Safety
   7.4.4.5           Are patient care area hallways and Observe conditions on the unit.
                     stairways unobstructed and kept
                     free of storage?
                    Mandatory                               NFPA 101 (LSC) 7.1.10
                                                             JCHAO: EC.5.20




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    169 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                       Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                     Question:                           Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                     Environmental and Housekeeping Safety
   7.4.4.6           Are patient areas free of unlabeled All cleaning products, medication, employee
                     or unattended containers, such as   food or drink, etc., should not be left in patient
                     cleaning products or medication?    care areas or patient rooms.
                    Mandatory                                JCAHO: EC.1.10
                     Environmental and Housekeeping Safety
   7.4.4.7           Are hazards clearly identified and Pre-construction meetings should proactively
                     properly controlled during         address all necessary interventions to remediate
                     construction and renovation?       such issues. However, patient /staff concerns
                                                        may flag potential problems. Examples of
                                                        hazards: walkways maintained; marked exit
                                                        paths; guarded floor openings and overhead
                                                        hazards; dust generation; and excessive noise.

                    Mandatory                                29CFR 1926.20(b)
                                                             VA Directive 7703c(4)(a)
                                                              JCAHO: 5.50
                     Environmental and Housekeeping Safety
   7.4.4.8 - 7.4.4.9         RESERVED
                     Environmental and Housekeeping Safety
   7.4.4.10          Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                     "pests" in the hospital environment? preventative measures or monitors. Special
                                                          considerations should be made for sterile
                                                          environments.
                    Recommended
                     Equipment Safety
   7.4.5.1           Is medical equipment being        Check inspection tags, or other identifiers on the
                     inspected in accordance with the  equipment that indicates it has been inspected.
                     Preventative Maintenance Program? Interview staff to determine how to interpret
                                                       identifiers.
                    Mandatory                                JCAHO: EC.6.20 and Goal # 6a
                     Equipment Safety
   7.4.5.2           Is back up patient care/monitoring      Uninterruptible monitoring and support should
                     equipment readily available in the      be planned for.
                     event of failure and or emergency?
                    Recommended                              JCAHO: EC.6.10




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    170 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Equipment Safety
   7.4.5.3           Is the equipment used on each             There is no chance equipment would be
                     patient positioned in a way that it is    inadvertently shut off because it is not in sight of
                     evident the equipment is in use for       the patient.
                     that patient?
                    Recommended
                     Equipment Safety
   7.4.5.4           Are alarms audible and easily             Alarms may be broadcast to an outside room or
                     distinguished above ambient               another area such as a central nursing station.
                     background noise level?                   Interview staff as to what is done during breaks
                                                               to cover patient monitoring. Clinical alarms,
                                                               bathroom alarms, and nurse calls are included
                                                               here.
                    Mandatory                                  JCAHO: Goal # 6b
                     Equipment Safety
   7.4.5.4.1         Is the unit layout/configuration          Observe conditions and interview staff.
                     conducive to hearing all alarms,
                     especially for isolation rooms?
                    Recommended
                     Equipment Safety
   7.4.5.5           Are all devices that alarm                Masking is when the frequency and intensity of
                     specifically set up for each patient to   two separate alarms blend together causing
                     reduce issues such as, "masking",         heightened confusion; nuisance alarms are
                     nuisance, or altered priority due to      caused when limits are not appropriately set,
                     unwanted false or alarms?                 this can create staff complacency, annoyance to
                                                               patients, and results in a delayed staff response
                                                               (cry wolf syndrome).

                    Recommended                                JCAHO: Goal 6b
                     Equipment Safety
   7.4.5.5.1         Are work arounds avoided in the     Due to factors listed above, devices can be
                     use of medical devices with alarms? disabled, turned off, turned down, etc. Signs of
                                                         workarounds include: post it notes suck to
                                                         equipment, worn silencer buttons, and taped
                                                         down or temporally disabled buttons.
                    Recommended




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    171 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Equipment Safety
   7.4.5.6           Is the equipment designed such that       Should not see post-it notes or permanently
                     its operation is intuitive to the user    posted signs indicating warnings about
                     and does not require use of adjunct       seemingly logical machine operation (i.e. a sign
                     devices to complete the required          reading such messages as: "Don't press
                     tasks?                                    'ENTER' key to enter data.") Interview staff and
                                                               inspect equipment in area.
                    Recommended
                     Equipment Safety
   7.4.5.7           Is patient care and monitoring            All screens/interfaces are readable and at or
                     equipment well organized in each          near eye level; key pads within reach;
                     patient/procedure room to avoid           equipment is not blocking each other; adequate
                     clutter and permit the caregivers to      space to move around, including head
                     be able to reach and read all             clearance on mounted devices.
                     equipment?
                    Recommended
                     Equipment Safety
   7.4.5.8           Are liquids kept away from medical        To prevent spillage which can result in
                     equipment?                                malfunctioning.
                    Recommended                                NFPA 70 110.11
                     Equipment Safety
   7.4.5.9           Are disposable medical                    Inspect storage rooms and other stock areas in
                     devices/supplies stored in a way          the area/unit (e.g. folding supplies like hoses
                     that the integrity of the devices is      and tubing causes kinking that has prevented
                     kept intact (i.e. not bent or folded)?    them from functioning properly).
                    Recommended
                     Equipment Safety
   7.4.5.10          Is a reliable system used to identify     Examples: Color coding or directional arrows
                     which tubes and connectors go to          for input jacks. If color labeling is used it must
                     which devices?                            be consistent throughout the unit.
                    Recommended
                     Equipment Safety
   7.4.5.10.1        Are the tubes/connectors kept out of Taped down, or use of a hanger or device can
                     the way to avoid them from being     help to lead them away from the patient.
                     inadvertently unplugged?
                    Recommended




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    172 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                             Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                     Equipment Safety
   7.4.5.11          Are the location and model of AEDs The location on the code cart or within unit
                     standardized throughout the facility? should be the same from area to area.
                                                           Compare models in unit, and from unit to unit.
                    Recommended
                     Equipment Safety
   7.4.5.12          Are clocks synchronized and              During codes the monitoring equipment has a
                     accurate?                                clock and the room or unit has a clock and the
                                                              times on all clocks should be the same.
                    Recommended
   Revised           Equipment Safety
   7.4.5.13          Does the hospital purchase               Having sterile water for injection in units on the
                     humidification devices that do not       floor creates the potential for misuse. Warnings
                     require the use of sterile water?        have been published (ISMP) regarding water
                                                              being confused with other medications resulting
                                                              in it being give intravenously resulting in fatal
                                                              hemolysis.
                    Recommended                               FDA Patient Safety News: Show #22, 12/2003
                                                              ISMP Medication Safety Alert, 9-2003
   Revised           Equipment Safety
   7.4.5.13.1        If humidification devices use sterile    If sterile water must be used it is recommend
                     water is it provided in 2 Liter bags     that it be used in 2 Liter bags. The 2 Liter bags
                     and labeled "Sterile Water"?             will help distinguish the sterile water from the 1
                                                              Liter bags of IV solutions, also pour bottles
                                                              could be considered.
                    Recommended                               FDA Patient Safety News: Show #22, 12/2003
                                                               ISMP Medication Safety Alert, 9-2003
                     Equipment Safety
   7.4.5.14          Is the use of cell phones or other       Look for signage, and ask staff about protocols.
                     devices that can affect monitoring
                     and other medical equipment
                     controlled in applicable areas?
                    Recommended
                     Escape and Elopement Prevention
   7.4.6.1 - 7.4.6.4         RESERVED




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    173 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   New               Escape and Elopement Prevention
   7.4.6.5           Is a risk assessment for elopement        Awareness of the potential for
                     completed at the time of admission        elopement/wandering behavior is the first step in
                     or transfer and regularly during the      prevention. Review documentation or interview
                     patients stay?                            staff to verify that the assessment is being
                                                               completed. Consider using electronic flags in
                                                               CPRS to inform clinicians if the patient is a high
                                                               risk. A change in the patients care (i.e., to a
                                                               new bed/unit, or new/change in medication) is a
                                                               key time for reassessment.

                    Mandatory                                  VHA Directive 2003-013
                     Escape and Elopement Prevention
   7.4.6.5.1 - 7.4.6.6       RESERVED
   Revised           Fall Prevention
   7.4.7.1           Are all patient rooms and common          Observe conditions on the unit. Patient rooms
                     areas provided with adequate              and bathrooms should be provided with
                     lighting?                                 nightlights as well.
                    Recommended                                JCAHO: EC.1.10
                     Fall Prevention
   7.4.7.2           Are mechanical assist devices used        Have staff show example, and conduct
                     to lift or transfer patients accessible   interviews to determine facility consistency.
                     and used by staff when needed?

                    Recommended
                     Fall Prevention
   7.4.7.2.1         Are preventative measures                 Staff training, proper number of staff present, no
                     implemented to prevent falls from         obstructions in lift area.
                     manual lifting and/or handling
                     patients?
                    Recommended
   Revised           Fall Prevention
   7.4.7.3           Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                     slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                               create fall hazards. Patient rooms should be
                                                               free of low-lying objects that could be tripped
                                                               over causing falls.
                    Recommended                                JCAHO: EC.1.10




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    174 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Fall Prevention
   7.4.7.4           Do shower/bathroom areas have            Inspect areas specified. Bathrooms should be
                     adequate lighting, proper drainage,      provided with night lights. If a raised seats are
                     non-slip floor surfaces, and             used on toilets are they is the color of it
                     handrails installed?                     contracting to toilet to help patients see it clearly.

                    Recommended                               JCAHO: EC.1.10
                     Fall Prevention
   7.4.7.5           Are call buttons within reach of the     Inspect all areas.
                     patient?
                    Recommended
                     Fall Prevention
   7.4.7.6           Are bed and chair alarms used and        Show examples. False or unwanted alarms sets
                     audible, and, are they configured to     up the care givers for complacency.
                     reduce the number of
                     false/unwanted alarms?
                    Recommended                               JCAHO: SEA #14 & Goal #6b
                     Fall Prevention
   7.4.7.7           Does the facility have a Fall            Interview staff - protocol should evaluate: 1) A
                     Prevention & Management Protocol         risk screen; 2) Protective device matched to risk
                     or equivalent?                           level; 3) First responder assessment to identify
                                                              patients for immediate physician evaluation and
                                                              4) Treatment plan for follow up, post fall.

                    Recommended
                     Fall Prevention
   7.4.7.8           Is a uniform tool used to assess         Identifying high risk patients will help care team
                     which patients are at high risk for      to put proactive and preventative measures in
                     falls, and is there criteria to          place. Assessor should look for identifiers and
                     determine: 1) When they are              interview staff.
                     assessed, and 2) What triggers a
                     reassessment?
                    Recommended
   Revised           Fall Prevention
   7.4.7.9           Does equipment (lifting equipment,       Review equipment, interview staff. Patients
                     OR tables, etc.) have sufficient         weighing in excess of 400 pounds are not
                     capacity to meet the needs of            uncommon. If equipment cannot support the
                     bariatric patients?                      weight of the patient contingency plans should
                                                              be developed to provide care.
                    Recommended




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    175 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Fall Prevention
   7.4.7.10             RESERVED
                     Fire Safety
   7.4.8.1           Are staff members familiar with fire     Interview staff to determine familiarity.
                     emergency procedures, and the fire
                     prevention plan for their service
                     area?
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                     Fire Safety
   7.4.8.2           Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                     fire walls in their immediate area?   must be knowledgeable regarding where to
                                                           move patients in the event of a fire.
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                     Fire Safety
   7.4.8.3           Is the fire alarm signal easily          Interview staff to determine familiarity, if alarm is
                     distinguishable from other alarms        not witnessed.
                     (e.g. equipment, nurse call, etc.)?
                    Mandatory                                  NFPA 72 1.5.4.4
                     Fire Safety
   7.4.8.4           Is the area staff notified when the    Interview staff.
                     fire alarm system is out of service or
                     being tested?
                    Mandatory                                 NFPA 72 7-1.3.1
                     Fire Safety
   7.4.8.4.1         Are cognitive aids used to remind        Look for signs placed by pull stations, and
                     staff when the fire alarm system is      interview to determine if announcements are
                     not functioning?                         made on PA system, etc.
                    Recommended
                     Fire Safety
   7.4.8.5 - 7.4.8.6         RESERVED
                     Infection Control
   7.4.9.1           Are all linen carts (clean and soiled)   Observe conditions on the unit.
                     kept covered?
                    Mandatory                                 JCAHO: IC.4.10




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    176 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Infection Control
   7.4.9.2           Are sharps containers accessible          Observe conditions in unit/area. Patients and
                     and not over filled?                      employees are often stuck by sharps not
                                                               properly disposed of due to overfilling of these
                                                               containers.
                    Mandatory                                  JCAHO: IC.4.10
   Revised           Infection Control
   7.4.9.3           Is the latex allergy policy followed      Show example if available. Consider inspecting
                     and are latex free supplies and           supply and code carts. Look for latex-free
                     equipment available?                      identification on glove boxes, supply packages,
                                                               etc. Determine if the other devices are available
                                                               as latex-free such as tourniquets and medical
                                                               tubing. In pharmacy, check for a latex protocol
                                                               in IV room.
                    Mandatory                                  IL 16-97-001 Latex Information
   Revised           Infection Control
   7.4.9.4           Are the VA recommended hand               The individual products should be an alcohol rub
                     hygiene guidelines followed, such         (for disinfecting) and a hospital approved lotion
                     as having alcohol-based gel               (to prevent skin dryness). Also, staff who come
                     disinfectants located to promote use      in contact with patients or prepare sterile
                     (including inpatient rooms), and          products (such as IV drugs) should not have
                     providing individual products to all      artificial fingernails. Clinicians should also be
                     necessary staff?                          offered the small (2-4 oz.) personal containers of
                                                               hand gel. Gel should be in convenient locations
                                                               including all carts (mobile care, medication
                                                               carts, code, respiratory).

                    Mandatory                                  JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                               CDC Hand Hygiene Guidelines
                                                               VHA Directive 2005-002 July 2005
                     Infection Control
   7.4.9.5           Is the integrity of negative/positive     Door remains closed if in use, Personal
                     pressure isolation rooms tested and       Protective Equipment used. Signage outside to
                     maintained (once per day for              identify hazard exists.
                     occupied, monthly for non-
                     occupied)?
                                                               CDC Guidelines for Environmental Infection Control in Health Care
                    Mandatory
                                                               Facilities
                                                               OSHA , 29 CFR 1910.145




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    177 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                          Facility unit/area name:
                                                                                                                                                                         *Not
                                                                                                                                         *Met       *Partially           Met If score other than 'met' what are
                     Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Medical Gas Safety
   7.4.10.1          Are piped in oxygen and                    The use of color coding should be eliminated.
                     compressed air identified by a             Using color adapters can cause confusion
                     prominent label and not merely by          during use, mixing up the gases being
                     color adapters?                            administered. Fixes include: replacing tubing
                                                                with a type that does not use adaptors or using
                                                                only clear adaptors.
                    Recommended                                 VHA Patient Safety Advisory 3/5/02
                     Medical Gas Safety
   7.4.10.2          Are air flow meters removed when           Flow meters are only used for specific
                     not in use (for nebulized medication       treatments, are not required during emergencies
                     treatments)?                               and should not be left attached to be confused
                                                                with O2 flow meter.
                    Recommended                                 VHA Patient Safety Advisory 3/5/02
                     Medical Gas Safety
   7.4.10.3          Do staff know where the emergency Staff to demonstrate competency. Also verify
                     oxygen shut-off is, and when and  that labels, warnings or other signage posted at
                     how to use it?                    the shut off point in accurate and up to date.

                    Mandatory                                   NFPA (National Fire Protection Association) 5.1.4.2.1
                                                                JCAHO: EC.7.50
                     Medical Gas Safety
   7.4.10.4          Does the storage and use of                If color identifies type, must be the same hue &
                     portable medical gas containers            intensity; flammables separated from oxidizers;
                     appear to be in compliance with            secured at all times (full or empty); container in
                     CGA (Compressed Gas                        good condition; only a limited quantity permitted
                     Association) Standards?                    in use area (less than 12 E-cylinders, or 1 H-
                                                                cylinder per area).
                    Mandatory                                   NCGA (Compressed Gas Association) C-9, 3.7 & 4.6
                                                                NCPS O2 Cylinder Hazard Summary
                     Medical Gas Safety
   7.4.10.4.1        Are all area/unit personnel                Staff to demonstrate competency.
                     competent in understanding the
                     handling procedures of oxygen
                     cylinders, including how to obtain
                     full cylinders? If so, is current
                     practices in line with the facility's
                     written procedure?
                    Mandatory                                   NCPS O2 Cylinder Hazard Summary




                                                         *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    178 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                          Facility unit/area name:
                                                                                                                                                                         *Not
                                                                                                                                         *Met       *Partially           Met If score other than 'met' what are
                     Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Medical Gas Safety
   7.4.10.5          Are pins on medical gas regulators         Pins should be in place and found undamaged.
                     and cylinders in good repair and is
                     damaged equipment immediately
                     removed from service?
                    Recommended                                 NCPS O2 Cylinder Hazard Summary
                     Medical Gas Safety
   7.4.10.6          Are oxygen cylinders with ball-type        When placed in the horizontal position, the ball
                     regulators used with the cylinder in       valve mechanism will not function, and an
                     the vertical position?                     inaccurate reading will show on the gauge.
                    Recommended                                 NCPS O2 Cylinder Hazard Summary
                     Medical Gas Safety
   7.4.10.7              RESERVED
   Revised           Medication Safety
   7.4.11.1          Are all medication refrigerators           Check floor refrigerators, ensure correct labeling
                     maintained appropriately?                  and appropriate separations from employee
                                                                food/drink. Review temperature log (or
                                                                electronic temperature monitoring device/log)
                                                                and verify that the thermometer is working.

                    Mandatory                                   JCAHO: MM.2.20, EP-13
                                                                ISMP Self Assessment: #117
                     Medication Safety
   7.4.11.2          Do medication carts remained               Randomly survey carts in the area.
                     locked and inaccessible to patients
                     when not in use?
                    Mandatory                                   JCAHO: MM.2.20, EP-3 & EP-4
   Revised           Medication Safety
   7.4.11.3          Are the tops of medication carts,          Randomly survey carts in the area. Clean carts
                     clean, free of stray drugs and             will help prevent medication error by eliminating
                     syringes?                                  opportunities for mix-ups . It will also avoid drug
                                                                being taken by mental health patients or those
                                                                with cognitive impairment.
                    Mandatory                                   JCAHO: MM.2.20, EP-3 & EP-4
                                                                ISMP Self Assessment: 14




                                                         *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    179 of 257
                                                               NCPS Patient Safety Assessment Tool
                                                                    Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                          Facility unit/area name:
                                                                                                                                                                         *Not
                                                                                                                                         *Met       *Partially           Met If score other than 'met' what are
                     Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Medication Safety
   7.4.11.3.1        Is medication logically organized          Clearly marked labels and nametags.
                     and identified by patient?
                    Recommended                                  JCAHO: MM.4.30
   Revised           Medication Safety
   7.4.11.4          Are medication storage rooms               Door locking mechanism cannot be defeated for
                     secured at all times?                      any reason. Door should not be held open.
                    Mandatory                                   JCAHO: MM.2.20, EP-3 & EP-4
                                                                ISMP Self Assessment: 75
                     Medication Safety
   7.4.11.5             RESERVED
                     Medication Safety
   7.4.11.6          Is area stock limited to emergency     Review approved floor stock and IV solution list
                     medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                     are appropriate to patient care in the
                     unit?
   Previously       Recommended                                 JCAHO: MM.3.20
   7.4.11.5                                                     ISMP Self Assessment: 82
                     Medication Safety
   7.4.11.6.1        Do emergency medications                   Example of needle-less systems: blunt tip, pre-
                     provided in code carts and/or              dawn syringes, etc.
                     emergency drug boxes "fit" with
                     needle-less systems used in the
                     area such that treatments can be
                     safely and promptly initiated?
   Previously
   7.4.11.5.1       Recommended
                     Medication Safety
   7.4.11.6.2        Do staff periodically practice with        Conducting mock drills will facilitate use during
                     the emergency equipment and                emergencies when seconds count.
                     supplies or participate in mock
                     codes to increase familiarity with
                     these devices?
   Previously
   7.4.11.5.2       Recommended                                 ISMP Self Assessment: N27




                                                         *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    180 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                         Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                     Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Medication Safety
   7.4.11.7          Are bags containing sterile water for     Controlling the acquisition of sterile water may
                     injection prohibited from being           help to prevent it from being inadvertently given
                     ordered or stocked on patient care        intravenously.
                     areas without special permission
                     and precaution?
   Previously       Recommended                                 FDA Patient Safety News: Show #22, 12/2003
   7.4.11.46                                                    ISMP Medication Safety Alert, 9-2003
                     Medication Safety
   7.4.11.8          Have concentrated electrolyte       Such as: potassium chloride and potassium
                     solutions been removed from patient phosphate
                     floors/care areas?
   Previously
   7.4.11.16        Mandatory                                  JCAHO: MM.2.20, EP-9; Goal #3a; and SEA #1 & #11
                     Medication Safety
   7.4.11.8.1        Is access limited to electrolyte          Review local policies, and interview pharmacy
                     replacement solutions (above or           staff. Show example.
                     below 0.9% sodium chloride)
                     outside the pharmacy?
   Previously
   7.4.11.30        Recommended                                ISMP Self Assessment: 92
                     Medication Safety
   7.4.11.9             RESERVED
                     Medication Safety
   7.4.11.9.1        Are only standard concentrations of       Floor stock of high-alert drugs should be limited
                     high alert medications kept in the        to critically needed medications, with minimal
                     area/unit to minimize the potential of    number of doses, and be pre-made solutions (if
                     calculation and compounding errors?       available).

   Previously       Mandatory                                  JCAHO: MM2.20, EP-8; MM.7.10; Goal #3b & SEA #11
   7.4.11.15                                                   ISMP Self Assessment: 67.1 & 20
                     Medication Safety
   7.4.11.10         Is a unit dose medication system          Look in patient bins for bulk containers.
                     used including half tablets and
                     liquids?
   Previously       Recommended                                JCAHO: MM.2.20, EP-10
   7.4.11.6                                                    ISMP Self Assessment: 64
               Medication Safety
   7.4.11.10.1 Are single-dose containers (with                For infection control and medication safety
               preference to pre-filed syringes)               purposes. This may be a future JCAHO PS
               exclusively used?                               Goal.
   Previously
   7.4.11.31        Recommended                                ISMP Self Assessment: 84




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    181 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Medication Safety
   7.4.11.11 - 7.4.11.12       RESERVED
                     Medication Safety
   7.4.11.13         Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                     the pharmacy and not on care units? be completed in pharmacy areas.

                    Recommended                               JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.4.11.13.1 If admixtures are done in inpatient            Interview floor staff. If admixtures are done on
               care areas, is an independent                  units, the area should be a designated area that
               double-check system utilized?                  is clean and secure. It is safest for mixtures to
                                                              be completed in pharmacy areas.
                    Recommended
                     Medication Safety
   7.4.11.14         Are procedures in place to prevent       Infection control literature documents
                     sterile product use from patient to      nosocomial infections occur irrespective of
                     patient (including medications)?         changing needles or IV tubing's.
                    Recommended                               ISMP Medication Safety Alert, June 2000
   Previously                                                 American Society of Anesthesiology Newsletter, 12/2000
   7.4.11.43                                                  CDC MMWR Weekly, 9/26/2003
   Revised           Medication Safety
   7.4.11.15         Are premixed IV solutions kept in        The protective over-wrap for some solutions
                     over-wrap bags until they are ready      serves to control the amount of water vapor that
                     to be used (if applicable)?              escapes from an IV solution. Once unwrapped
                                                              it is best to use the solution right way.

   Previously
   7.4.11.44        Recommended                               FDA Patient Safety News: Show #22, 12/2003
                     Medication Safety
   7.4.11.16         Are IV bags free of markings, such      The volatile chemical from the ink may leach
                     as expiration dates, applied by staff into IV solutions.
                     with ink pens or felt markers (prior to
                     use)?
   Previously
   7.4.11.45        Recommended                               FDA Patient Safety News: Show #22, 12/2003
                     Medication Safety
   7.4.11.17         Is an independent double check           The double check should Include patient
                     completed for all infusion pump          monitoring and verifying the number of types of
                     settings?                                pumps.
   Previously
   7.4.11.12        Recommended                               JCAHO: SEA #11
                     Medication Safety
   7.4.11.18             RESERVED



                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    182 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                       Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                     Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Medication Safety
   7.4.11.19         Are appropriate reversal agents         In the event of an unusual reaction or overdose
                     (flumazenil, naloxone, protamine,       the agents need to be available.
                     etc.) available based on the drug
                     being administered?
   Previously
   7.4.11.10        Recommended                              ISMP Self Assessment: 79
   Revised     Medication Safety
   7.4.11.19.1 Is there a process to monitor the             Such as reviewing automated dispensing
               reversal agent use?                           machine records, which can be used as a tracer
                                                             order for adverse drug events. (e.g., reversal
                                                             agent s used in Endosocpy, Radiology, Acute
                                                             Care, etc., may be a signal to misadministration
                                                             or unsafe practices occurring.
   Previously
   7.4.11.10.1      Recommended
                     Medication Safety
   7.4.11.20             RESERVED
                     Medication Safety
   7.4.11.21         Is there machine readable coding    Show mechanism (i.e. BCMA) in use. Machine
                     throughout the medication           readable coding should match the electronic
                     administration process (e.g. BCMA)? medical record to the patient, allowing the
                                                         information on the patients armband to be
                                                         matched with the electronic information.

   Previously
   7.4.11.17        Recommended                              ISMP Self Assessment: 11
               Medication Safety
   7.4.11.21.1 Is BCMA used to administer                    Observe staff.
               medication without using work
               arounds?
   Previously
   7.4.11.24        Recommended
                     Medication Safety
   7.4.11.21.2 What is the protocol for handling             Interview staff and compare practices to policy
                     incorrect bar coded or labeled          of facility/Pharmacy.
                     medications?
   Previously
   7.4.11.23        Recommended                               JCHAO: MM.3.20, EP-5
               Medication Safety
   7.4.11.21.3 Is there a helpdesk for BCMA                  Test hotline number available on all shifts;
               available during all shifts?                  interview off-shift staff if available.
   Previously
   7.4.11.22        Recommended


                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    183 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                       Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                     Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Medication Safety
   7.4.11.22         Do the VISTA modules effectively        Show example, if available.
                     alert to potential food/drug/herbal
                     interactions and duplicate drug
                     therapies?
   Previously
   7.4.11.20        Recommended
                     Medication Safety
   7.4.11.23 - 7.4.11.24        RESERVED
                     Medication Safety
   7.4.11.25         Is drug reference information made      Interview area/unit staff, show where information
                     readily accessible to caregivers, if    is kept and how it is retrieved. One or two
                     so how?                                 reference sources should be available as well
                                                             as access to pharmacist.
   Previously       Recommended                              JCAHO: IM.3.10
   7.4.11.7                                                  ISMP Self Assessment: 18.2
                     Medication Safety
   7.4.11.26         Are up-to-date facility specific        Interview unit staff, show where information is
                     protocols, guidelines, dosing scales,   kept and how it is retrieved. (e.g. use of
                     and/or checklists readily available     electrolyte replacement, aminoglycoside, and
                     for staff?                              anti-coagulant guidelines).
   Previously       Recommended                              JCHAO: IM.3.10
   7.4.11.8                                                  ISMP Self Assessment: 19
   Revised           Medication Safety
   7.4.11.27         Are specific precautions followed       Discuss protocols with staff (such as insulin and
                     when handling look/sound alike          heparin vials; and hydromorphone and
                     drugs?                                  morphine). In pharmacy, discuss what is being
                                                             done with the look alike medication project.

   Previously
   7.4.11.9         Recommended                              JCAHO: MM.2.20, EP-6; SEA #19
                     Medication Safety
   7.4.11.27.1               RESERVED
                     Medication Safety
   7.4.11.28         Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                     to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                     Goal requirements?
   Previously       Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
   7.4.11.25                                                 ISMP Self Assessment: 40




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    184 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                     Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           Medication Safety
   7.4.11.29         If Automated Dispensing Machines         Written documents should include which drugs
                     (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                     written policy, and can they explain     how often drugs are inspected for expiration
                     how the machine works?                   dates, drugs not used but removed, and content
                                                              review.
   Previously
   7.4.11.27         Recommended                              JCAHO: MM.4.50
                     Medication Safety
   7.4.11.30 - 7.4.11.31.1         RESERVED
                     Medication Safety
   7.4.11.32         If ADMs are used, are there              Show example reports, where filed on units;
                     capabilities to run override reports     interview Nurse Manger. Have staff reveal how
                     that track discrepancy and utilization   reports are used and acted upon, and if there is
                     at least monthly?                        a process to deal with variances.
   Previously
   7.4.11.21        Recommended                               ISMP Self Assessment: 26
                     Medication Safety
   7.4.11.33             RESERVED
                     Medication Safety
   7.4.11.34         Are patients educated regarding          Show example.
                     their prescribed medication, as
                     inpatients and as part of the
                     discharge process?
   Previously
   7.4.11.19        Recommended                               JCAHO: PC.6.10
                     Medication Safety
   7.4.11.35         Does the care provided by           Interview clinicians to determine if Pharmacists
                     Pharmacists meet the clinical needs are available for consult, and if they participate
                     of the patients in scope and        in rounds or access patient medication history.
                     frequency?
   Previously       Recommended                               JCAHO Std: MM.4.10
   7.4.11.18                                                  ISMP Self Assessment: 23
                     Medication Safety
   7.4.11.36 - 7.4.11.39       RESERVED




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    185 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                        Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
               Question:                                      Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   New         Medication Safety
   7.4.11.39.1 Is there a mechanism to verify                 Safe labeling of medications and solutions
               contents of a syringe or container             (including contrast media) in perioperative
               before drug administration to patient          settings, operating rooms, ambulatory surgery,
               during a procedure or code?                    clinics, cardiac catheterization area, endoscopy,
                                                              radiology, dental, or other areas where
                                                              operative and invasive procedures may be
                                                              performed an independent double check should
                                                              be confirmed by the person who administers the
                                                              agent.
                    Recommended                               ISMP Medication Safety Alert December 2004
                     Medication Safety
   7.4.11.40 - 7.4.11.41.1        RESERVED
                     General Patient Safety Concerns
   7.4.12.1          Is read-back used for all verbal         Observe verbal ordering if possible, and
                     order and critical value reports?        interview staff. Verify that telephone voice mail
                                                              orders are not accepted.
                    Mandatory                                 JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                              ISMP Self Assessment: 45
                     General Patient Safety Concerns
   7.4.12.2          Are NCPS or locally developed            Randomly interview nursing staff on the floor.
                     cognitive aids available on the floor    Look for aids at nurses stations.
                     for staff to reference (Escape and
                     Elopement; Fall Prevention, etc.)?
                    Recommended
                     General Patient Safety Concerns
   7.4.12.3          Are patient records kept                 Ensure records or computer screens are not left
                     confidential, including computer         unattended and openly visible.
                     information?
                    Recommended                               JCAHO Std: IM.2
                     General Patient Safety Concerns
   7.4.12.4          Are staff required to wear               Monitor patient care areas. Interview staff about
                     identification badges, and are           policies such as the handling of drug
                     unauthorized persons kept out of         manufacturer representatives that visit
                     patient care areas?                      unexpectedly.
                    Recommended                               JCAHO Std: EC.1.2 & EC.2.2




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    186 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                      Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                     Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     General Patient Safety Concerns
   7.4.12.5          Are restraints used in accordance      Randomly interview staff. Look for restraint
                     with local policy and are restraint    devices or alterative devices in the area.
                     alternative devices available and
                     used when appropriate?
                    Recommended                             JCAHO: PC.11.10 & PC.12.10 & SEA #8
                     General Patient Safety Concerns
   7.4.12.6          Are there practices in place to        Using two patient identifiers for administrations,
                     decrease the likelihood of patient     draws or procedures/images, and at outpatient
                     misidentification?                     pharmacy; record and room flags for
                                                            same/similar/common names; four or less beds
                                                            in patient rooms; bedside labeling of samples,
                                                            rather than bulk (at nurses station); special
                                                            procedure for the transporting of high risk (for
                                                            misidentification) patients.

                    Recommended                             JCAHO Goal 1a
                     General Patient Safety Concerns
   7.4.12.7          Are there monitoring processes in      Look for a preventative maintenance log that
                     place for portable food and            periodically checks the temperature of the
                     beverage warming or heating            warming device to help prevent scalding by
                     devices?                               liquids or burns from food tray items. First and
                                                            second degree scalding can occur to patients
                                                            with cognitive or motor difficulties while being
                                                            fed in bed as well.
                    Recommended
                     General Patient Safety Concerns
   7.4.12.8          Is transfer of care between shifts     A consistent process should exist to update on-
                     standardized?                          coming staff of patient statues. Interview staff
                                                            and compare answers between units.
                    Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                       to understand observed behavior and local norms to identify system vulnerabilities.                                                    187 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                       Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                     Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised           General Patient Safety Concerns
   7.4.12.9          Is the transfer of care between         A consistent process should occur during
                     disciplines for off-unit appointments   appointments and when patients are sent back
                     standardized, including the             and forth from units, including patient
                     continuation of monitoring patient      identification means, patient record transfer, and
                     status and patient medical devices      the monitoring of the patient's condition and
                     such as IV pumps and oxygen level       needed medical devices. Stopping and
                     while the patient is visiting, being    resumption of IV medications should be planned
                     treated/tested, and during transport?   and documented. Interview staff in all areas
                                                             compare answers to determine standardization.

                    Recommended                              US Pharmacopeia Patient Safety CAPSLink, July 2004
                     General Patient Safety Concerns
   7.4.12.10         Are patients searched for               To ensure the safety of the patients and staff
                     contraband upon admission to each       members it is essential to have a rigorous
                     applicable area/unit?                   search process of each individual patient.
                                                             Observe an admission, or interview staff to
                                                             evaluate consistency throughout the facility.
                    Recommended
   Revised           General Patient Safety Concerns
   7.4.12.11         Does the facility have an emergency The protocol should be made up of a
                     response protocol for dealing with  mechanism for staff to communicate the
                     disruptive patients?                emergency (via a special extension or a
                                                         separate alarm system) and a security response
                                                         when a patient, staff or visitor becomes
                                                         threatening or out of control. Staff should be
                                                         familiar with the protocol and have confidence in
                                                         how to respond.
                    Recommended
   New               General Patient Safety Concerns
   7.4.12.12         When performing procedures           The facility's Conscious Sedation protocol
                     outside of the operating room are    should be followed in all areas.
                     appropriate sedation protocols and
                     privileges followed when applicable?

                    Mandatory                                JCAHO Std: PC.13.20
                     Psychiatric Precautions
   7.4.13.1 - 7.4.13.18         RESERVED
                     Surgical or Invasive Procedure Precautions
   7.4.14.1 - 7.4.14.19         RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                        to understand observed behavior and local norms to identify system vulnerabilities.                                                    188 of 257
                                                       NCPS Patient Safety Assessment Tool
                                                            Part II - Implementation
   INTENSIVE CARE UNITS - Element 7, Location 4 (7.4)                                                                  Facility unit/area name:
                                                                                                                                                                 *Not
                                                                                                                                 *Met       *Partially           Met If score other than 'met' what are
                     Question:                          Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                     Imaging and X-rays Precautions
   7.4.15.1 - 7.4.15.9       RESERVED




                                                 *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Intensive Care Units - 7.4                                   to understand observed behavior and local norms to identify system vulnerabilities.                                                    189 of 257
                 Patient Safety Assessment Tool
                 Part II Implementation
                 Element: Peri-Operative Care Areas - 7.5
                              Categories:
                              Bed Safety                                    1
                              Code Carts                                    1
                              Electrical Safety                             2-3
                              Environmental and Housekeeping Safety         3-4
                              Equipment Safety                              5-7
                              Escape and Elopement Prevention               NA
                              Fall Prevention                               8-9
                              Fire Safety                                   9 - 10
                              Infection Control                             10 - 11
                              Medical Gas Safety                            11 - 12
                              Medication Safety                             13 - 19
                              General Patient Safety Concerns               19 - 20
                              Psychiatric Precautions                       NA
                              Surgical or Invasive Procedures Precautions   21 - 24
                              Imaging and X-Ray Precautions                 NA

Thursday, April 21, 2005                                                              190 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Bed Safety
   7.5.1.1 - 7.5.1.3      RESERVED
                    Bed Safety
   7.5.1.4          Are beds designed to facilitate          Bed attributes would include: Stand assistive
                    patient transfer?                        devices to assist patients to stand, room for
                                                             base of lifting device to fit under the bed, clear
                                                             area around bed for staff and lifting equipment
                                                             access, variable position capabilities.

                    Recommended                              OSHA Guidelines for Nursing Homes
                    Bed Safety
   7.5.1.5 - 7.5.1.7      RESERVED
                    Code Carts
   7.5.2.1 - 7.5.2.2      RESERVED
                    Code Carts
   7.5.2.3          Are equipment and drugs easily           Standardizing the location of supplies and
                    retrievable on/in code carts, and is     equipment will increase the code response
                    there standard organization in all       efficiency.
                    carts throughout the hospital?
                    Recommended
                    Code Carts
   7.5.2.4          Is the VHA modified version of the       Inspect top of cart and review checklist of
                    AHA Handbook of Cardiovascular           contents if provided.
                    Care Cognitive Aid located on all
                    carts?
                    Recommended
                    Code Carts
   7.5.2.5 - 7.5.2.6      RESERVED




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    191 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Electrical Safety
   7.5.3.1          Are electrical receptacles in, or         All areas designated as wet locations, or areas
                    serving, wet areas or behavioral          used for behavioral health patients, require (wet)
                    health areas provided with Ground         or recommend (behavioral health) ground-fault
                    Fault Circuit Interruption (GFCI)         protection. These types of receptacles are
                    protection or an isolated power           designed to stop the flow of electrical current,
                    system?                                   preventing shock or electrocution. For
                                                              behavioral health areas, electrical receptacles
                                                              can be completely removed or covered in
                                                              patient rooms to protect patients who my try to
                                                              harm themselves.

                    Mandatory                                 National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                              NFPA 99-3.3.179
                    Electrical Safety
   7.5.3.2          Are electrical receptacles fitted with    Observe conditions on unit.
                    covers, secured, and free of loose
                    or exposed wiring?
                    Mandatory                                  NFPA 99-4 3.3.2.1.2
                    Electrical Safety
   7.5.3.2.1              RESERVED
                    Electrical Safety
   7.5.3.3          Are emergency power receptacles           Staff should be able to identify emergency
                    appropriately identified and only         receptacles. Assessor should inspect locations
                    used for equipment needing to be          of these outlets.
                    on emergency power circuits?
                    Mandatory                                 NFPA 99 4.4.2.2.4.2(B)
                    Electrical Safety
   7.5.3.4          Are electrically powered medical          Cords are free of physical defects including
                    devices in good condition?                cracks, frayed ends, or missing prongs.
                    Mandatory                                 NFPA 99 8.4.1.3.1
                                                              VHA Directive 2002-030
                    Electrical Safety
   7.5.3.5           RESERVED




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    192 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Electrical Safety
   7.5.3.6          If used, are power cords and           Facilities should strive to eliminate the use of
                    electrical extension cords placed      extension cords for small working spaces such
                    where they are free from               as the operating room, patient rooms, or exam
                    mechanical damage, properly sized      rooms. A plan should be in place to install
                    (gauge) to prevent overheating, and    permanently affixed receptacles supplied by the
                    arranged so that they do not present   appropriate electrical circuit (emergency or
                    a tripping hazard?                     critical branch) if cords are being used.

                    Recommended
                    Electrical Safety
   7.5.3.7          If provided are electrical isolation   NCPS has observed increasing number of
                    transformers and switchgear serving    electrical blackouts and brownouts in operating
                    the operating rooms properly sized     suites due to the increased power demand of
                    to carry the maximum expected          new equipment being used in the OR's.
                    electrical load?                       Facilities Engineering should conduct an
                                                           analysis to verify the adequacy of these
                                                           devices/equipment.
                    Recommended
                    Environmental and Housekeeping Safety
   7.5.4.1           RESERVED
                    Environmental and Housekeeping Safety
   7.5.4.2          Are supply and return air registers Observe conditions on the unit.
                    clean and free of lint and dust?
                    Recommended                            JCAHO Std: EC.8.10
                    Environmental and Housekeeping Safety
   7.5.4.3          Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                    to be a priority?
                    Recommended                            JCAHO Std: EC.8.10
   Revised          Environmental and Housekeeping Safety
   7.5.4.4          Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                    well light and temperature           rooms will help prevent mistakes. Ensuring
                    controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                    fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                         of floor keeps supplies sanitary.
                    Recommended                            JCAHO Std: EC.5.20




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    193 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                          Rationale/Assessment Methods:                                                  (1)        Met (2)              (3) possible root causes
                    Environmental and Housekeeping Safety
   7.5.4.5          Are patient care area hallways and Observe conditions on the unit.
                    stairways unobstructed and kept
                    free of storage?
                    Mandatory                               NFPA 101 (LSC) 7.1.10
                                                             JCHAO: EC.5.20
                    Environmental and Housekeeping Safety
   7.5.4.6          Are patient areas free of unlabeled All cleaning products, medication, employee
                    or unattended containers, such as   food or drink, etc., should not be left in patient
                    cleaning products or medication?    care areas or patient rooms.
                    Mandatory                               JCAHO: EC.1.10
                    Environmental and Housekeeping Safety
   7.5.4.7          Are hazards clearly identified and Pre-construction meetings should proactively
                    properly controlled during         address all necessary interventions to remediate
                    construction and renovation?       such issues. However, patient /staff concerns
                                                       may flag potential problems. Examples of
                                                       hazards: walkways maintained; marked exit
                                                       paths; guarded floor openings and overhead
                                                       hazards; dust generation; and excessive noise.

                    Mandatory                               29CFR 1926.20(b)
                                                            VA Directive 7703c(4)(a)
                                                             JCAHO: 5.50
                    Environmental and Housekeeping Safety
   7.5.4.8           RESERVED
                    Environmental and Housekeeping Safety
   7.5.4.9          Are battery operated lights provided
                    in the Operating Room?
                    Recommended                             NFPA 99 13.4.1.2.5(E)
                    Environmental and Housekeeping Safety
   7.5.4.10         Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                    "pests" in the hospital environment? preventative measures or monitors. Special
                                                         considerations should be made for sterile
                                                         environments.
                    Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    194 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.5.5.1          Is medical equipment being                Check inspection tags, or other identifiers on the
                    inspected in accordance with the          equipment that indicates it has been inspected.
                    Preventative Maintenance Program?         Interview staff to determine how to interpret
                                                              identifiers.
                    Mandatory                                 JCAHO: EC.6.20 and Goal # 6a
                    Equipment Safety
   7.5.5.2          Is back up patient care/monitoring        Uninterruptible monitoring and support should
                    equipment readily available in the        be planned for.
                    event of failure and or emergency?
                    Recommended                               JCAHO: EC.6.10
                    Equipment Safety
   7.5.5.3           RESERVED
                    Equipment Safety
   7.5.5.4          Are alarms audible and easily             Alarms may be broadcast to an outside room or
                    distinguished above ambient               another area such as a central nursing station.
                    background noise level?                   Interview staff as to what is done during breaks
                                                              to cover patient monitoring. Clinical alarms,
                                                              bathroom alarms, and nurse calls are included
                                                              here.
                    Mandatory                                 JCAHO: Goal # 6b
                    Equipment Safety
   7.5.5.4.1              RESERVED
                    Equipment Safety
   7.5.5.5          Are all devices that alarm                Masking is when the frequency and intensity of
                    specifically set up for each patient to   two separate alarms blend together causing
                    reduce issues such as, "masking",         heightened confusion; nuisance alarms are
                    nuisance, or altered priority due to      caused when limits are not appropriately set,
                    unwanted false or alarms?                 this can create staff complacency, annoyance to
                                                              patients, and results in a delayed staff response
                                                              (cry wolf syndrome).

                    Recommended                               JCAHO: Goal 6b
                    Equipment Safety
   7.5.5.5.1        Are work arounds avoided in the     Due to factors listed above, devices can be
                    use of medical devices with alarms? disabled, turned off, turned down, etc. Signs of
                                                        workarounds include: post it notes suck to
                                                        equipment, worn silencer buttons, and taped
                                                        down or temporally disabled buttons.
                    Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    195 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.5.5.6          Is the equipment designed such that       Should not see post-it notes or permanently
                    its operation is intuitive to the user    posted signs indicating warnings about
                    and does not require use of adjunct       seemingly logical machine operation (i.e. a sign
                    devices to complete the required          reading such messages as: "Don't press
                    tasks?                                    'ENTER' key to enter data.") Interview staff and
                                                              inspect equipment in area.
                    Recommended
                    Equipment Safety
   7.5.5.7          Is patient care and monitoring            All screens/interfaces are readable and at or
                    equipment well organized in each          near eye level; key pads within reach;
                    patient/procedure room to avoid           equipment is not blocking each other; adequate
                    clutter and permit the caregivers to      space to move around, including head
                    be able to reach and read all             clearance on mounted devices.
                    equipment?
                    Recommended
                    Equipment Safety
   7.5.5.8           RESERVED
                    Equipment Safety
   7.5.5.9          Are disposable medical                    Inspect storage rooms and other stock areas in
                    devices/supplies stored in a way          the area/unit (e.g. folding supplies like hoses
                    that the integrity of the devices is      and tubing causes kinking that has prevented
                    kept intact (i.e. not bent or folded)?    them from functioning properly).
                    Recommended
                    Equipment Safety
   7.5.5.10         Is a reliable system used to identify     Examples: Color coding or directional arrows
                    which tubes and connectors go to          for input jacks. If color labeling is used it must
                    which devices?                            be consistent throughout the unit.
                    Recommended
                    Equipment Safety
   7.5.5.10.1       Are the tubes/connectors kept out of Taped down, or use of a hanger or device can
                    the way to avoid them from being     help to lead them away from the patient.
                    inadvertently unplugged?
                    Recommended
                    Equipment Safety
   7.5.5.11         Are the location and model of AEDs The location on the code cart or within unit
                    standardized throughout the facility? should be the same from area to area.
                                                          Compare models in unit, and from unit to unit.
                    Recommended




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    196 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Equipment Safety
   7.5.5.12         Are clocks synchronized and               During codes the monitoring equipment has a
                    accurate?                                 clock and the room or unit has a clock and the
                                                              times on all clocks should be the same.
                    Recommended
   Revised          Equipment Safety
   7.5.5.13         Does the hospital purchase                Having sterile water for injection in units on the
                    humidification devices that do not        floor creates the potential for misuse. Warnings
                    require the use of sterile water?         have been published (ISMP) regarding water
                                                              being confused with other medications resulting
                                                              in it being give intravenously resulting in fatal
                                                              hemolysis.
                    Recommended                               FDA Patient Safety News: Show #22, 12/2003
                                                              ISMP Medication Safety Alert, 9-2003
   Revised          Equipment Safety
   7.5.5.13.1       If humidification devices use sterile     If sterile water must be used it is recommend
                    water is it provided in 2 Liter bags      that it be used in 2 Liter bags. The 2 Liter bags
                    and labeled "Sterile Water"?              will help distinguish the sterile water from the 1
                                                              Liter bags of IV solutions, also pour bottles
                                                              could be considered.
                    Recommended                               FDA Patient Safety News: Show #22, 12/2003
                                                               ISMP Medication Safety Alert, 9-2003
                    Equipment Safety
   7.5.5.14         Is the use of cell phones or other        Look for signage, and ask staff about protocols.
                    devices that can affect monitoring
                    and other medical equipment
                    controlled in applicable areas?
                    Recommended
                    Escape and Elopement Prevention
   7.5.6.1 - 7.5.6.6      RESERVED
                    Fall Prevention
   7.5.7.1           RESERVED
                    Fall Prevention
   7.5.7.2          Are mechanical assist devices used        Have staff show example, and conduct
                    to lift or transfer patients accessible   interviews to determine facility consistency.
                    and used by staff when needed?

                    Recommended
                    Fall Prevention
   7.5.7.2.1        Are preventative measures                 Staff training, proper number of staff present, no
                    implemented to prevent falls from         obstructions in lift area.
                    manual lifting and/or handling
                    patients?
                    Recommended


                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    197 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Fall Prevention
   7.5.7.3          Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                    slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                              create fall hazards. Patient rooms should be
                                                              free of low-lying objects that could be tripped
                                                              over causing falls.
                    Recommended                               JCAHO: EC.1.10
                    Fall Prevention
   7.5.7.4 - 7.5.7.8        RESERVED
   Revised          Fall Prevention
   7.5.7.9          Does equipment (lifting equipment,        Review equipment, interview staff. Patients
                    OR tables, etc.) have sufficient          weighing in excess of 400 pounds are not
                    capacity to meet the needs of             uncommon. If equipment cannot support the
                    bariatric patients?                       weight of the patient contingency plans should
                                                              be developed to provide care.
                    Recommended
                    Fall Prevention
   7.5.7.10               RESERVED
                    Fire Safety
   7.5.8.1          Are staff members familiar with fire      Interview staff to determine familiarity.
                    emergency procedures, and the fire
                    prevention plan for their service
                    area?
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.5.8.2          Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                    fire walls in their immediate area?   must be knowledgeable regarding where to
                                                          move patients in the event of a fire.
                    Mandatory                                 JCAHO: EC.5.20 and HR.2.20
                    Fire Safety
   7.5.8.3          Is the fire alarm signal easily           Interview staff to determine familiarity, if alarm is
                    distinguishable from other alarms         not witnessed.
                    (e.g. equipment, nurse call, etc.)?
                    Mandatory                                  NFPA 72 1.5.4.4
                    Fire Safety
   7.5.8.4          Is the area staff notified when the    Interview staff.
                    fire alarm system is out of service or
                    being tested?
                    Mandatory                                 NFPA 72 7-1.3.1




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    198 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                       Facility unit/area name:
                                                                                                                                                                       *Not
                                                                                                                                       *Met       *Partially           Met If score other than 'met' what are
                    Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Fire Safety
   7.5.8.4.1        Are cognitive aids used to remind         Look for signs placed by pull stations, and
                    staff when the fire alarm system is       interview to determine if announcements are
                    not functioning?                          made on PA system, etc.
                    Recommended
                    Fire Safety
   7.5.8.5 - 7.5.8.5.2      RESERVED
                    Infection Control
   7.5.9.1          Are all linen carts (clean and soiled)    Observe conditions on the unit.
                    kept covered?
                    Mandatory                                 JCAHO: IC.4.10
   Revised          Infection Control
   7.5.9.2          Are sharps containers accessible          Observe conditions in unit/area. Patients and
                    and not over filled?                      employees are often stuck by sharps not
                                                              properly disposed of due to overfilling of these
                                                              containers.
                    Mandatory                                 JCAHO: IC.4.10
   Revised          Infection Control
   7.5.9.3          Is the latex allergy policy followed      Show example if available. Consider inspecting
                    and are latex free supplies and           supply and code carts. Look for latex-free
                    equipment available?                      identification on glove boxes, supply packages,
                                                              etc. Determine if the other devices are available
                                                              as latex-free such as tourniquets and medical
                                                              tubing. In pharmacy, check for a latex protocol
                                                              in IV room.
                    Mandatory                                 IL 16-97-001 Latex Information




                                                       *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                            to understand observed behavior and local norms to identify system vulnerabilities.                                                    199 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Infection Control
   7.5.9.4          Are the VA recommended hand            The individual products should be an alcohol rub
                    hygiene guidelines followed, such      (for disinfecting) and a hospital approved lotion
                    as having alcohol-based gel            (to prevent skin dryness). Also, staff who come
                    disinfectants located to promote use   in contact with patients or prepare sterile
                    (including inpatient rooms), and       products (such as IV drugs) should not have
                    providing individual products to all   artificial fingernails. Clinicians should also be
                    necessary staff?                       offered the small (2-4 oz.) personal containers of
                                                           hand gel. Gel should be in convenient locations
                                                           including all carts (mobile care, medication
                                                           carts, code, respiratory).

                    Mandatory                              JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                           CDC Hand Hygiene Guidelines
                                                           VHA Directive 2005-002 July 2005
                    Infection Control
   7.5.9.5           RESERVED
                    Medical Gas Safety
   7.5.10.1         Are piped in oxygen and                The use of color coding should be eliminated.
                    compressed air identified by a         Using color adapters can cause confusion
                    prominent label and not merely by      during use, mixing up the gases being
                    color adapters?                        administered. Fixes include: replacing tubing
                                                           with a type that does not use adaptors or using
                                                           only clear adaptors.
                    Recommended                            VHA Patient Safety Advisory 3/5/02
                    Medical Gas Safety
   7.5.10.2               RESERVED
                    Medical Gas Safety
   7.5.10.3         Do staff know where the emergency Staff to demonstrate competency. Also verify
                    oxygen shut-off is, and when and  that labels, warnings or other signage posted at
                    how to use it?                    the shut off point in accurate and up to date.

                    Mandatory                              NFPA (National Fire Protection Association) 5.1.4.2.1
                                                           JCAHO: EC.7.50




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    200 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                        Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medical Gas Safety
   7.5.10.4         Does the storage and use of                If color identifies type, must be the same hue &
                    portable medical gas containers            intensity; flammables separated from oxidizers;
                    appear to be in compliance with            secured at all times (full or empty); container in
                    CGA (Compressed Gas                        good condition; only a limited quantity permitted
                    Association) Standards?                    in use area (less than 12 E-cylinders, or 1 H-
                                                               cylinder per area).
                    Mandatory                                  NCGA (Compressed Gas Association) C-9, 3.7 & 4.6
                                                               NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.5.10.4.1       Are all area/unit personnel                Staff to demonstrate competency.
                    competent in understanding the
                    handling procedures of oxygen
                    cylinders, including how to obtain
                    full cylinders? If so, is current
                    practices in line with the facility's
                    written procedure?
                    Mandatory                                  NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.5.10.5         Are pins on medical gas regulators         Pins should be in place and found undamaged.
                    and cylinders in good repair and is
                    damaged equipment immediately
                    removed from service?
                    Recommended                                NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.5.10.6         Are oxygen cylinders with ball-type        When placed in the horizontal position, the ball
                    regulators used with the cylinder in       valve mechanism will not function, and an
                    the vertical position?                     inaccurate reading will show on the gauge.
                    Recommended                                NCPS O2 Cylinder Hazard Summary
                    Medical Gas Safety
   7.5.10.7               RESERVED




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    201 of 257
                                                              NCPS Patient Safety Assessment Tool
                                                                   Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                        Facility unit/area name:
                                                                                                                                                                        *Not
                                                                                                                                        *Met       *Partially           Met If score other than 'met' what are
                    Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.5.11.1         Are all medication refrigerators           Check floor refrigerators, ensure correct labeling
                    maintained appropriately?                  and appropriate separations from employee
                                                               food/drink. Review temperature log (or
                                                               electronic temperature monitoring device/log)
                                                               and verify that the thermometer is working.

                    Mandatory                                  JCAHO: MM.2.20, EP-13
                                                               ISMP Self Assessment: #117
                    Medication Safety
   7.5.11.2         Do medication carts remained               Randomly survey carts in the area.
                    locked and inaccessible to patients
                    when not in use?
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                    Medication Safety
   7.5.11.3               RESERVED
                    Medication Safety
   7.5.11.3.1       Is medication logically organized          Clearly marked labels and nametags.
                    and identified by patient?
                    Recommended                                 JCAHO: MM.4.30
   Revised          Medication Safety
   7.5.11.4         Are medication storage rooms               Door locking mechanism cannot be defeated for
                    secured at all times?                      any reason. Door should not be held open.
                    Mandatory                                  JCAHO: MM.2.20, EP-3 & EP-4
                                                               ISMP Self Assessment: 75
                    Medication Safety
   7.5.11.5               RESERVED
                    Medication Safety
   7.5.11.6         Is area stock limited to emergency     Review approved floor stock and IV solution list
                    medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                    are appropriate to patient care in the
                    unit?
   Previously       Recommended                                JCAHO: MM.3.20
   7.5.11.5                                                    ISMP Self Assessment: 82




                                                        *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                             to understand observed behavior and local norms to identify system vulnerabilities.                                                    202 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.5.11.6.1       Do emergency medications                 Example of needle-less systems: blunt tip, pre-
                    provided in code carts and/or            dawn syringes, etc.
                    emergency drug boxes "fit" with
                    needle-less systems used in the
                    area such that treatments can be
                    safely and promptly initiated?
   Previously
   7.5.11.5.1       Recommended
                    Medication Safety
   7.5.11.6.2       Do staff periodically practice with      Conducting mock drills will facilitate use during
                    the emergency equipment and              emergencies when seconds count.
                    supplies or participate in mock
                    codes to increase familiarity with
                    these devices?
   Previously
   7.5.11.5.2       Recommended                              ISMP Self Assessment: N27
   Revised          Medication Safety
   7.5.11.7         Are bags containing sterile water for Controlling the acquisition of sterile water may
                    injection prohibited from being       help to prevent it from being inadvertently given
                    ordered or stocked on patient care    intravenously.
                    areas without special permission
                    and precaution?
   Previously       Recommended                               FDA Patient Safety News: Show #22, 12/2003
   7.5.11.46                                                  ISMP Medication Safety Alert, 9-2003
                    Medication Safety
   7.5.11.8 - 7.5.11.9          RESERVED
                    Medication Safety
   7.5.11.9.1       Are only standard concentrations of      Floor stock of high-alert drugs should be limited
                    high alert medications kept in the       to critically needed medications, with minimal
                    area/unit to minimize the potential of   number of doses, and be pre-made solutions (if
                    calculation and compounding errors?      available).

   Previously       Mandatory                                JCAHO: MM2.20, EP-8; MM.7.10; Goal #3b & SEA #11
   7.5.11.15                                                 ISMP Self Assessment: 67.1 & 20
                    Medication Safety
   7.5.11.10              RESERVED
               Medication Safety
   7.5.11.10.1 Are single-dose containers (with              For infection control and medication safety
               preference to pre-filed syringes)             purposes. This may be a future JCAHO PS
               exclusively used?                             Goal.
   Previously
   7.5.11.31        Recommended                              ISMP Self Assessment: 84




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    203 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.5.11.11        Are the sizes of injectable drugs in     Helps to prevent overdose and reduces the
                    vials or ampoules matched to the         hazard associated with multi-dose vials. This
                    clinical situation?                      may be a future JCAHO PS Goal.
   Previously
   7.5.11.42        Recommended
                    Medication Safety
   7.5.11.12              RESERVED
                    Medication Safety
   7.5.11.13        Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                    the pharmacy and not on care units? be completed in pharmacy areas.

                    Recommended                              JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.5.11.13.1 If admixtures are done in inpatient           Interview floor staff. If admixtures are done on
               care areas, is an independent                 units, the area should be a designated area that
               double-check system utilized?                 is clean and secure. It is safest for mixtures to
                                                             be completed in pharmacy areas.
                    Recommended
                    Medication Safety
   7.5.11.14        Are procedures in place to prevent       Infection control literature documents
                    sterile product use from patient to      nosocomial infections occur irrespective of
                    patient (including medications)?         changing needles or IV tubing's.
                    Recommended                              ISMP Medication Safety Alert, June 2000
   Previously                                                American Society of Anesthesiology Newsletter, 12/2000
   7.5.11.43                                                 CDC MMWR Weekly, 9/26/2003
   Revised          Medication Safety
   7.5.11.15        Are premixed IV solutions kept in        The protective over-wrap for some solutions
                    over-wrap bags until they are ready      serves to control the amount of water vapor that
                    to be used (if applicable)?              escapes from an IV solution. Once unwrapped
                                                             it is best to use the solution right way.

   Previously
   7.5.11.44        Recommended                              FDA Patient Safety News: Show #22, 12/2003
                    Medication Safety
   7.5.11.16        Are IV bags free of markings, such      The volatile chemical from the ink may leach
                    as expiration dates, applied by staff into IV solutions.
                    with ink pens or felt markers (prior to
                    use)?
   Previously
   7.5.11.45        Recommended                              FDA Patient Safety News: Show #22, 12/2003




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    204 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    Medication Safety
   7.5.11.17        Is an independent double check           The double check should Include patient
                    completed for all infusion pump          monitoring and verifying the number of types of
                    settings?                                pumps.
   Previously
   7.5.11.12        Recommended                              JCAHO: SEA #11
                    Medication Safety
   7.5.11.18              RESERVED
                    Medication Safety
   7.5.11.19        Are appropriate reversal agents          In the event of an unusual reaction or overdose
                    (flumazenil, naloxone, protamine,        the agents need to be available.
                    etc.) available based on the drug
                    being administered?
   Previously
   7.5.11.10        Recommended                              ISMP Self Assessment: 79
               Medication Safety
   7.5.11.19.1 Is there a process to monitor the             Such as reviewing automated dispensing
               reversal agent use?                           machine records, which can be used as a tracer
                                                             order for adverse drug events. (e.g., reversal
                                                             agent s used in Endosocpy, Radiology, Acute
                                                             Care, etc., may be a signal to misadministration
                                                             or unsafe practices occurring.
   Previously
   7.5.11.10.1      Recommended
                    Medication Safety
   7.5.11.20 - 7.5.11.24      RESERVED
                    Medication Safety
   7.5.11.25        Is drug reference information made       Interview area/unit staff, show where information
                    readily accessible to caregivers, if     is kept and how it is retrieved. One or two
                    so how?                                  reference sources should be available as well
                                                             as access to pharmacist.
   Previously       Recommended                              JCAHO: IM.3.10
   7.5.11.7                                                  ISMP Self Assessment: 18.2
                    Medication Safety
   7.5.11.26        Are up-to-date facility specific         Interview unit staff, show where information is
                    protocols, guidelines, dosing scales,    kept and how it is retrieved. (e.g. use of
                    and/or checklists readily available      electrolyte replacement, aminoglycoside, and
                    for staff?                               anti-coagulant guidelines).
   Previously       Recommended                              JCHAO: IM.3.10
   7.5.11.8                                                  ISMP Self Assessment: 19




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    205 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.5.11.27        Are specific precautions followed        Discuss protocols with staff (such as insulin and
                    when handling look/sound alike           heparin vials; and hydromorphone and
                    drugs?                                   morphine). In pharmacy, discuss what is being
                                                             done with the look alike medication project.

   Previously
   7.5.11.9         Recommended                              JCAHO: MM.2.20, EP-6; SEA #19
                    Medication Safety
   7.5.11.27.1             RESERVED
                    Medication Safety
   7.5.11.28        Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                    to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                    Goal requirements?
                    Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
                                                             ISMP Self Assessment: 40
   Revised          Medication Safety
   7.5.11.29        If Automated Dispensing Machines         Written documents should include which drugs
                    (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                    written policy, and can they explain     how often drugs are inspected for expiration
                    how the machine works?                   dates, drugs not used but removed, and content
                                                             review.
   7.5.11.27
                    Recommended                              JCAHO: MM.4.50
                    Medication Safety
   7.5.11.30 - 7.5.11.33        RESERVED
                    Medication Safety
   7.5.11.34        Are patients educated regarding          Show example.
                    their prescribed medication, as
                    inpatients and as part of the
                    discharge process?
   Previously
   7.5.11.19        Recommended                              JCAHO: PC.6.10
                    Medication Safety
   7.5.11.35              RESERVED
                    Medication Safety
   7.5.11.36        Are medications used in surgical         Standardization is an important patient safety
                    cases organized and standardized         principle.
                    per case type to minimize inter-
                    provider variation?
   Previously
   7.5.11.40        Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    206 of 257
                                                             NCPS Patient Safety Assessment Tool
                                                                  Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised          Medication Safety
   7.5.11.37        Are chemical products and                If appropriate sizes are acquired for each clinical
                    medications (including contract          situation it eliminates the transfer of containers,
                    media) used in the operative suite,      omitting the vulnerability of mislabeling or mis-
                    treatment areas, pharmacy or clinics     administration. Labels are required on all
                    purchased in sizes appropriate for       medications, solutions, etc. on and off the sterile
                    their clinical situation (single dose,   field, even if only one medication/solution is
                    single patient, individually labeled)    given. If pre-made single dose containers are
                    and kept in a labeled state to the       not available for sterile procedures, sterile
                    point of administration?                 markers with blank labels and/or pre-printed
                                                             labels should be made available to include in
                                                             pre-made sterile packs.

   Previously       Mandatory                                 JCAHO MM.4.30
   7.5.11.39                                                  ISMP Self Assessment C.C.6 & #66
                    Medication Safety
   7.5.11.38        Are barriers in place to prevent        Pre-drawing and mass spiking create infection
                    mass pre-drawing of sterile products control concerns and vulnerability of products
                    (e.g., lidocaine) or mass spiking of    being mixed up when used.
                    IV solutions in anticipation of patient
                    use?
   Previously
   7.5.11.37        Recommended
                    Medication Safety
   7.5.11.39        Are medications drawn up for use in Eliminate the use of unlabeled sterile basins.
                    the sterile field accurately and    Encourage the use of sterile-packed unit dose
                    consistently labeled?               medications.
   Previously
   7.5.11.38        Recommended




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    207 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
               Question:                                   Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   New         Medication Safety
   7.5.11.39.1 Is there a mechanism to verify              Safe labeling of medications and solutions
               contents of a syringe or container          (including contrast media) in perioperative
               before drug administration to patient       settings, operating rooms, ambulatory surgery,
               during a procedure or code?                 clinics, cardiac catheterization area, endoscopy,
                                                           radiology, dental, or other areas where
                                                           operative and invasive procedures may be
                                                           performed an independent double check should
                                                           be confirmed by the person who administers the
                                                           agent.
                    Recommended                            ISMP Medication Safety Alert December 2004
                    Medication Safety
   7.5.11.40        Do respiratory care professionals      Having these individuals give the medication is
                    administer pre-operative and post-     a barrier against improper administration.
                    operative respiratory drugs?
   Previously
   7.5.11.41        Recommended                            ISMP Self Assessment: 69
                    Medication Safety
   7.5.11.41        Are emergency medications to treat     These cases are rare, however, the medication
                    malignant hyperthermia readily         to treat it can expire before it is needed. There
                    available?                             should be mechanism to check the expiration
                                                           date and availability on a periodic basis.

   Previously
   7.5.11.47        Recommended
                    Medication Safety
   7.5.11.41.1 If sterile water is used to dilute IV      1 L bags of water can be confused for IV bags
                    dantrolene in emergency boxes in      and inadvertently infused.
                    treating of malignant hyperthermia is
                    it provided in 50 mL vials vs. 1 L
                    bags?
   Previously       Recommended                            FDA Patient Safety News: Show #22, 12/2003
   Reserved                                                ISMP Medication Safety Alert, 9-2003
                    General Patient Safety Concerns
   7.5.12.1         Is read-back used for all verbal       Observe verbal ordering if possible, and
                    order and critical value reports?      interview staff. Verify that telephone voice mail
                                                           orders are not accepted.
                    Mandatory                              JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                           ISMP Self Assessment: 45
                    General Patient Safety Concerns
   7.5.12.2               RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    208 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                    General Patient Safety Concerns
   7.5.12.3         Are patient records kept               Ensure records or computer screens are not left
                    confidential, including computer       unattended and openly visible.
                    information?
                    Recommended                            JCAHO Std: IM.2
                    General Patient Safety Concerns
   7.5.12.4         Are staff required to wear             Monitor patient care areas. Interview staff about
                    identification badges, and are         policies such as the handling of drug
                    unauthorized persons kept out of       manufacturer representatives that visit
                    patient care areas?                    unexpectedly.
                    Recommended                            JCAHO Std: EC.1.2 & EC.2.2
                    General Patient Safety Concerns
   7.5.12.5               RESERVED
                    General Patient Safety Concerns
   7.5.12.6         Are there practices in place to        Using two patient identifiers for administrations,
                    decrease the likelihood of patient     draws or procedures/images, and at outpatient
                    misidentification?                     pharmacy; record and room flags for
                                                           same/similar/common names; four or less beds
                                                           in patient rooms; bedside labeling of samples,
                                                           rather than bulk (at nurses station); special
                                                           procedure for the transporting of high risk (for
                                                           misidentification) patients.

   Previously
   Reserved         Recommended                            JCAHO Goal 1a
                    General Patient Safety Concerns
   7.5.12.7 - 7.5.12.10       RESERVED
   Revised          General Patient Safety Concerns
   7.5.12.11        Does the facility have an emergency The protocol should be made up of a
                    response protocol for dealing with  mechanism for staff to communicate the
                    disruptive patients?                emergency (via a special extension or a
                                                        separate alarm system) and a security response
                                                        when a patient, staff or visitor becomes
                                                        threatening or out of control. Staff should be
                                                        familiar with the protocol and have confidence in
                                                        how to respond.
                    Recommended
                    General Patient Safety Concerns
   7.5.12.12              RESERVED
                    Psychiatric Precautions
   7.5.13.1 - 7.5.13.18       RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    209 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                    Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                    Question:                           Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                    Surgical or Invasive Procedure Precautions
   7.5.14.1         Is there physical evidence that the Observe a pre-op team "time out"; or interview
                    VHA Ensuring Correct Surgery        clinicians who participate on surgical teams.
                    Directive is being followed?        Look for posters, use of a white board, review
                                                        documentation if available. View surgical
                                                        package software to see if steps are
                                                        documented.
                    Mandatory                               VHA Directive 2002-070
                                                            JCAHO: Goal #4
                    Surgical or Invasive Procedure Precautions
   7.5.14.2         Does redundancy exist in the
                    Informed Consent process to help
                    prevent misidentification of patients,
                    and ensure the correct
                    site/procedure for surgery?
                    Mandatory                               VHA Directive 2002-070
                                                            JCAHO: Goal #1
                    Surgical or Invasive Procedure Precautions
   7.5.14.3         Does a viable process exist to     Interview staff. Compare practice to written
                    ensure sponge and instrument       documentation review in PSAT Element 6.
                    counts before surgical wound
                    closure?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.3.1       Are STAT X-rays available during all
                    shifts and every day of the week
                    when a retained foreign body is
                    suspected?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.3.2       If not, what is the protocol in the   One example is a radiology follow-up policy or
                    operating room for incorrect surgical protocol.
                    sponge and instrument counts?

                    Recommended




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                         to understand observed behavior and local norms to identify system vulnerabilities.                                                    210 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                            Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                    Surgical or Invasive Procedure Precautions
   7.5.14.4         Does each surgical team conduct a Talk with staff to determine if successes are
                    post-operative debriefing to discuss acknowledged, if miscommunications occurred,
                    recently completed surgical cases? or improvements are discussed.

                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.5         Does the staff that makes up the   Reducing staff change over helps to eliminate
                    surgical team remain consistent    errors.
                    during a procedure including the
                    physician/surgical residents and
                    other operating room staff?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.5.1       If staff changeover occurs is there a Show written protocol, and interview clinicians
                    standardized protocol to brief        who participate on surgical teams.
                    oncoming staff regarding current
                    surgical procedure status?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.6         Are all members of the surgical    Interview staff to determine if professional or
                    team encouraged to, and feel       organizational barriers exist between team
                    comfortable, speaking up if they   members which can impede patient care.
                    recognize a potential problem?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.7         If ESU's (Electro-surgical units) are Ask staff of protocol; look for use of an insolated
                    used, is there a standardized         holster or device.
                    protocol of where the unit is placed
                    during a surgical procedure to
                    prevent inadvertent fire or burns?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.8         Is the use of ESU's or lasers      This type of equipment is dangerous if used with
                    avoided for surgical procedures of oxygen, or oxygen gas mixtures.
                    the mouth, throat and lungs?
                    Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    211 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                      Facility unit/area name:
                                                                                                                                                                      *Not
                                                                                                                                      *Met       *Partially           Met If score other than 'met' what are
                    Question:                           Rationale/Assessment Methods:                                                  (1)        Met (2)              (3) possible root causes
                    Surgical or Invasive Procedure Precautions
   7.5.14.9         Do guidelines exist for using flash
                    sterilizers, and is the associated
                    equipment standardized in all
                    Operating Rooms?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.10        Are blood and blood products that       Interview staff.
                    are earmarked and prepared for a
                    specific patient verified (via protocol
                    for double checks) for type and
                    cross-match before the surgical
                    procedure begins?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.11        Is the temporary storage and/or        An 'OR central storage' should be avoided;
                    labeling of blood and blood products rather, the use of separate bins, or local storage
                    in the surgical suite set up to avoid in each operating room is optimal.
                    potential mix-ups?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.12        Are procedures in place to help    A patient pre-op evaluation should be done and
                    prevent intra-operative myocardial preventive medication regimen given or other
                    ischemia in high risk patients?    intervention for high risk patients.
                    Recommended                              2003 TMIT Leapfrog Survey 1.0
                    Surgical or Invasive Procedure Precautions
   7.5.14.13        Is a pre-operative evaluation      If patients are determined to be at significant
                    completed for each patient to      risk, it may be necessary to give peri-operative
                    determine the risk of acquiring a  antibiotics. Postpone elective procedures,
                    Surgical Site Infection (SSI)?     remove hair for surgical site by clipping (not
                                                       shaving), etc.
                    Recommended                              2003 TMIT Leapfrog Survey 1.0
                    Surgical or Invasive Procedure Precautions
   7.5.14.14        Has a protocol been defined for the Ensure proper fit; keep inflation time and
                    use of pneumatic tourniquets?       pressure to minimum; require continuous
                                                        monitoring of the time and pressure display;
                                                        ensure manufactures recommendations are
                                                        followed for use and maintenance; and require
                                                        staff training on device.
                    Recommended                              2003 TMIT Leapfrog Survey 1.0




                                                      *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                           to understand observed behavior and local norms to identify system vulnerabilities.                                                    212 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PERIOPERATIVE AREAS - Element 7, Location 5 (7.5)                                                                     Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                    Question:                             Rationale/Assessment Methods:                                               (1)        Met (2)              (3) possible root causes
                    Surgical or Invasive Procedure Precautions
   7.5.14.15        Is there a system in place to verify  Vulnerabilities can exist in the acquiring and
                    that prosthetic devices are available placement of these devices.
                    in the correct size and properly
                    sterilized prior to surgery?
   Previously
   Reserved         Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.16        Is there a system in place to ensure NCPS is aware of battery operated saws that
                    that battery operated surgical       have stopped working during surgery and
                    equipment is fully charged and has manual hand saws were not available.
                    a manual back up if needed?

                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.17        Are environmental distractions     Radio volume, checking pagers, answering cell
                    minimized during surgical          phones, etc.
                    procedures?
                    Recommended
                    Surgical or Invasive Procedure Precautions
   7.5.14.18        Is the VA Anesthesia Cognitive Aid Inspect machines.
                    attached to all anesthesia
                    machines?
                    Recommended
   New              Surgical or Invasive Procedure Precautions
   7.5.14.19        Does the OR service specific fire  Lasers are an ignition source and can cause
                    plan address the use of lasers in  fire, explosion and consequently serious burns
                    and around O2 enriched             to patients or staff in an oxygen enriched
                    atmospheres and/or flammable       environment.
                    preparations?
                    Recommended
                    Imaging and X-rays Precautions
   7.5.15.1 - 7.5.15.9     RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Perioperative Area- 7.5                                          to understand observed behavior and local norms to identify system vulnerabilities.                                                    213 of 257
                   Patient Safety Assessment Tool
                   Part II Implementation
                   Element: Radiology Areas - 7.6
                                Categories:
                                Bed Safety                                    NA
                                Code Carts                                    1
                                Electrical Safety                             2-3
                                Environmental and Housekeeping Safety         3-4
                                Equipment Safety                              4-6
                                Escape and Elopement Prevention               6
                                Fall Prevention                               6-7
                                Fire Safety                                   7-8
                                Infection Control                             8-9
                                Medical Gas Safety                            9 - 10
                                Medication Safety                             10 - 15
                                General Patient Safety Concerns               15 - 17
                                Psychiatric Precautions                       NA
                                Surgical or Invasive Procedures Precautions   NA
                                Imaging and X-Ray Precautions                 18 - 22

Thursday, April 21, 2005                                                                214 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                  Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  Bed Safety
   7.6.1.1 - 7.6.1.7     RESERVED
                  Code Carts
   7.6.2.1        Are code carts locked when not in        Drugs have potential to be taken from
                  use, and is equipment in good            unsecured carts in common areas. Verify cart
                  condition?                               inspection records.
                  Mandatory                                 JCAHO: MM.2.30
                  Code Carts
   7.6.2.1.1 - 7.6.2.2    RESERVED
                  Code Carts
   7.6.2.3        Are equipment and drugs easily           Standardizing the location of supplies and
                  retrievable on/in code carts, and is     equipment will increase the code response
                  there standard organization in all       efficiency.
                  carts throughout the hospital?
                  Recommended
                  Code Carts
   7.6.2.4        Is the VHA modified version of the       Inspect top of cart and review checklist of
                  AHA Handbook of Cardiovascular           contents if provided.
                  Care Cognitive Aid located on all
                  carts?
                  Recommended
   Revised        Code Carts
   7.6.2.5        Are CO2 detectors available on           Inspect carts. Adjunctive devices (i.e.
                  code carts for confirming                colorimetric, syringe, or bulb devices) should be
                  esophageal intubations?                  adequately stocked and readily available for use
                                                           in all carts. Review cart checklist talk with cart
                                                           preparers in SPD (Supply Processing and
                                                           Distribution) Service.
                  Recommended
                  Code Carts
   7.6.2.6         RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    215 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Electrical Safety
   7.6.3.1        Are electrical receptacles in, or         All areas designated as wet locations, or areas
                  serving, wet areas or behavioral          used for behavioral health patients, require (wet)
                  health areas provided with Ground         or recommend (behavioral health) ground-fault
                  Fault Circuit Interruption (GFCI)         protection. These types of receptacles are
                  protection or an isolated power           designed to stop the flow of electrical current,
                  system?                                   preventing shock or electrocution. For
                                                            behavioral health areas, electrical receptacles
                                                            can be completely removed or covered in
                                                            patient rooms to protect patients who my try to
                                                            harm themselves.

                  Mandatory                                 National Fire Protection Guidebooks (NFPA) 99-4.3.2.2.9.1
                                                            NFPA 99-3.3.179
                  Electrical Safety
   7.6.3.2        Are electrical receptacles fitted with    Observe conditions on unit.
                  covers, secured, and free of loose
                  or exposed wiring?
                  Mandatory                                  NFPA 99-4 3.3.2.1.2
                  Electrical Safety
   7.6.3.2.1         RESERVED
                  Electrical Safety
   7.6.3.3        Are emergency power receptacles           Staff should be able to identify emergency
                  appropriately identified and only         receptacles. Assessor should inspect locations
                  used for equipment needing to be          of these outlets.
                  on emergency power circuits?
                  Mandatory                                 NFPA 99 4.4.2.2.4.2(B)
                  Electrical Safety
   7.6.3.4        Are electrically powered medical          Cords are free of physical defects including
                  devices in good condition?                cracks, frayed ends, or missing prongs.
                  Mandatory                                 NFPA 99 8.4.1.3.1
                                                            VHA Directive 2002-030
                  Electrical Safety
   7.6.3.5         RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    216 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                        Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Electrical Safety
   7.6.3.6        If used, are power cords and            Facilities should strive to eliminate the use of
                  electrical extension cords placed       extension cords for small working spaces such
                  where they are free from                as the operating room, patient rooms, or exam
                  mechanical damage, properly sized       rooms. A plan should be in place to install
                  (gauge) to prevent overheating, and     permanently affixed receptacles supplied by the
                  arranged so that they do not present    appropriate electrical circuit (emergency or
                  a tripping hazard?                      critical branch) if cords are being used.

                  Recommended
                  Electrical Safety
   7.6.3.7         RESERVED
                  Environmental and Housekeeping Safety
   7.6.4.1         RESERVED
                  Environmental and Housekeeping Safety
   7.6.4.2        Are supply and return air registers Observe conditions on the unit.
                  clean and free of lint and dust?
                  Recommended                             JCAHO Std: EC.8.10
                  Environmental and Housekeeping Safety
   7.6.4.3        Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                  to be a priority?
                  Recommended                             JCAHO Std: EC.8.10
   Revised        Environmental and Housekeeping Safety
   7.6.4.4        Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                  well light and temperature           rooms will help prevent mistakes. Ensuring
                  controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                  fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                       of floor keeps supplies sanitary.
                  Recommended                             JCAHO Std: EC.5.20
                  Environmental and Housekeeping Safety
   7.6.4.5        Are patient care area hallways and Observe conditions on the unit.
                  stairways unobstructed and kept
                  free of storage?
                  Mandatory                               NFPA 101 (LSC) 7.1.10
                                                           JCHAO: EC.5.20
                  Environmental and Housekeeping Safety
   7.6.4.6        Are patient areas free of unlabeled All cleaning products, medication, employee
                  or unattended containers, such as   food or drink, etc., should not be left in patient
                  cleaning products or medication?    care areas or patient rooms.
                  Mandatory                               JCAHO: EC.1.10




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    217 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                       Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                  Question:                          Rationale/Assessment Methods:                                                 (1)        Met (2)              (3) possible root causes
                  Environmental and Housekeeping Safety
   7.6.4.7        Are hazards clearly identified and Pre-construction meetings should proactively
                  properly controlled during         address all necessary interventions to remediate
                  construction and renovation?       such issues. However, patient /staff concerns
                                                     may flag potential problems. Examples of
                                                     hazards: walkways maintained; marked exit
                                                     paths; guarded floor openings and overhead
                                                     hazards; dust generation; and excessive noise.

                  Mandatory                              29CFR 1926.20(b)
                                                         VA Directive 7703c(4)(a)
                                                          JCAHO: 5.50
                  Environmental and Housekeeping Safety
   7.6.4.8        Are high hazard areas such as:       High hazard areas must be locked to prevent
                  Roofs, service areas, medication     access to patients and have warning signs and
                  rooms, labs, radiation areas,        labels.
                  confined spaces, high voltage
                  areas, laser areas, low use areas
                  (such as sub-floors and interstitial
                  spaces), etc. labeled with
                  appropriate caution signage and
                  locked to prevent unauthorized
                  entrance?
                  Mandatory                              VA Directive 7703c(4)(a)
                  Environmental and Housekeeping Safety
   7.6.4.9         RESERVED
                  Environmental and Housekeeping Safety
   7.6.4.10       Are steps taken to eliminate/control Infestations can occur, such as myiasis, without
                  "pests" in the hospital environment? preventative measures or monitors. Special
                                                       considerations should be made for sterile
                                                       environments.
                  Recommended
                  Equipment Safety
   7.6.5.1        Is medical equipment being        Check inspection tags, or other identifiers on the
                  inspected in accordance with the  equipment that indicates it has been inspected.
                  Preventative Maintenance Program? Interview staff to determine how to interpret
                                                    identifiers.
                  Mandatory                              JCAHO: EC.6.20 and Goal # 6a
                  Equipment Safety
   7.6.5.2 - 7.6.5.5.1    RESERVED




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    218 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  Equipment Safety
   7.6.5.6        Is the equipment designed such that       Should not see post-it notes or permanently
                  its operation is intuitive to the user    posted signs indicating warnings about
                  and does not require use of adjunct       seemingly logical machine operation (i.e. a sign
                  devices to complete the required          reading such messages as: "Don't press
                  tasks?                                    'ENTER' key to enter data.") Interview staff and
                                                            inspect equipment in area.
                  Recommended
                  Equipment Safety
   7.6.5.7        Is patient care and monitoring            All screens/interfaces are readable and at or
                  equipment well organized in each          near eye level; key pads within reach;
                  patient/procedure room to avoid           equipment is not blocking each other; adequate
                  clutter and permit the caregivers to      space to move around, including head
                  be able to reach and read all             clearance on mounted devices.
                  equipment?
                  Recommended
                  Equipment Safety
   7.6.5.8        Are liquids kept away from medical        To prevent spillage which can result in
                  equipment?                                malfunctioning.
                  Recommended                               NFPA 70 110.11
                  Equipment Safety
   7.6.5.9        Are disposable medical                    Inspect storage rooms and other stock areas in
                  devices/supplies stored in a way          the area/unit (e.g. folding supplies like hoses
                  that the integrity of the devices is      and tubing causes kinking that has prevented
                  kept intact (i.e. not bent or folded)?    them from functioning properly).
                  Recommended
                  Equipment Safety
   7.6.5.10 - 7.6.5.10.1   RESERVED
                  Equipment Safety
   7.6.5.11       Are the location and model of AEDs The location on the code cart or within unit
                  standardized throughout the facility? should be the same from area to area.
                                                        Compare models in unit, and from unit to unit.
                  Recommended
                  Equipment Safety
   7.6.5.12 - 7.6.5.13.1   RESERVED




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    219 of 257
                                                            NCPS Patient Safety Assessment Tool
                                                                 Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  Equipment Safety
   7.6.5.14       Is the use of cell phones or other        Look for signage, and ask staff about protocols.
                  devices that can affect monitoring
                  and other medical equipment
                  controlled in applicable areas?
                  Recommended
                  Escape and Elopement Prevention
   7.6.6.1 - 7.6.6.5.1   RESERVED
   New            Escape and Elopement Prevention
   7.6.6.6        Is a processes in place and used to If patient privileges are not clear this often can
                  keep track of high risk inpatients  lead to lack of communication on patient status
                  when they are off of the unit?      and location. A tracking or documentation
                                                      system can be used to help staff know patient
                                                      habits, and is a method to communicate this
                                                      information at the shift change. Also transport
                                                      of patients off the unit should be planned and
                                                      scheduled with competent escorts who
                                                      understand the potential for a high risk patient to
                                                      elope.
                  Recommended
   Revised        Fall Prevention
   7.6.7.1        Are all patient or procedure rooms        Observe conditions on the unit. Patient sleeping
                  and common areas provided with            rooms and private bathrooms should be
                  adequate lighting?                        provided with nightlights.
                  Recommended                               JCAHO: EC.1.10
                  Fall Prevention
   7.6.7.2        Are mechanical assist devices used        Have staff show example, and conduct
                  to lift or transfer patients accessible   interviews to determine facility consistency.
                  and used by staff when needed?

                  Recommended
                  Fall Prevention
   7.6.7.2.1      Are preventative measures                 Staff training, proper number of staff present, no
                  implemented to prevent falls from         obstructions in lift area.
                  manual lifting and/or handling
                  patients?
                  Recommended




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    220 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Fall Prevention
   7.6.7.3        Are the floors clean and free of          Floors should be free of liquids, electrical cords,
                  slipping and tripping hazards?            wires, tubes, or other connectors which can
                                                            create fall hazards. Patient rooms should be
                                                            free of low-lying objects that could be tripped
                                                            over causing falls.
                  Recommended                               JCAHO: EC.1.10
   Revised        Fall Prevention
   7.6.7.4        Do shower/bathroom areas have             Inspect areas specified. Bathrooms should be
                  adequate lighting, proper drainage,       provided with night lights. If a raised seats are
                  non-slip floor surfaces, and              used on toilets are they is the color of it
                  handrails installed?                      contracting to toilet to help patients see it clearly.

                  Recommended                               JCAHO: EC.1.10
                  Fall Prevention
   7.6.7.5 - 7.6.7.8    RESERVED
   Revised        Fall Prevention
   7.6.7.9        Does equipment (lifting equipment,        Review equipment, interview staff. Patients
                  OR tables, etc.) have sufficient          weighing in excess of 400 pounds are not
                  capacity to meet the needs of             uncommon. If equipment cannot support the
                  bariatric patients?                       weight of the patient contingency plans should
                                                            be developed to provide care.
                  Recommended
   Revised        Fall Prevention
   7.6.7.10       Are fall prevention mechanisms in         Consider using floor mats on slippery floors for
                  places in exam/procedure rooms in         negotiating on and off procedure/exam tables,
                  that tables and equipment are             provide adequate lighting and use mechanical
                  configured in such a way that is          devices (e.g., straps) to prevent patients from
                  conducive to safe maneuvering, and        rolling off the table.
                  is there adequate lighting, assist
                  bars and floor mats where
                  applicable?
                  Recommended
                  Fire Safety
   7.6.8.1        Are staff members familiar with fire      Interview staff to determine familiarity.
                  emergency procedures, and the fire
                  prevention plan for their service
                  area?
                  Mandatory                                 JCAHO: EC.5.20 and HR.2.20




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    221 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                  Question:                             Rationale/Assessment Methods:                                                (1)        Met (2)              (3) possible root causes
                  Fire Safety
   7.6.8.2        Can clinical staff identify smoke and Interview staff to determine familiarity. Staff
                  fire walls in their immediate area?   must be knowledgeable regarding where to
                                                        move patients in the event of a fire.
                  Mandatory                                JCAHO: EC.5.20 and HR.2.20
                  Fire Safety
   7.6.8.3        Is the fire alarm signal easily          Interview staff to determine familiarity, if alarm is
                  distinguishable from other alarms        not witnessed.
                  (e.g. equipment, nurse call, etc.)?
                  Mandatory                                 NFPA 72 1.5.4.4
                  Fire Safety
   7.6.8.4        Is the area staff notified when the    Interview staff.
                  fire alarm system is out of service or
                  being tested?
                  Mandatory                                NFPA 72 7-1.3.1
                  Fire Safety
   7.6.8.4.1      Are cognitive aids used to remind        Look for signs placed by pull stations, and
                  staff when the fire alarm system is      interview to determine if announcements are
                  not functioning?                         made on PA system, etc.
                  Recommended
                  Fire Safety
   7.6.8.5 - 7.6.8.6    RESERVED
                  Infection Control
   7.6.9.1        Are all linen carts (clean and soiled)   Observe conditions on the unit.
                  kept covered?
                  Mandatory                                JCAHO: IC.4.10
   Revised        Infection Control
   7.6.9.2        Are sharps containers accessible         Observe conditions in unit/area. Patients and
                  and not over filled?                     employees are often stuck by sharps not
                                                           properly disposed of due to overfilling of these
                                                           containers.
                  Mandatory                                JCAHO: IC.4.10




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    222 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Infection Control
   7.6.9.3        Is the latex allergy policy followed      Show example if available. Consider inspecting
                  and are latex free supplies and           supply and code carts. Look for latex-free
                  equipment available?                      identification on glove boxes, supply packages,
                                                            etc. Determine if the other devices are available
                                                            as latex-free such as tourniquets and medical
                                                            tubing. In pharmacy, check for a latex protocol
                                                            in IV room.
                  Mandatory                                 IL 16-97-001 Latex Information
   Revised        Infection Control
   7.6.9.4        Are the VA recommended hand               The individual products should be an alcohol rub
                  hygiene guidelines followed, such         (for disinfecting) and a hospital approved lotion
                  as having alcohol-based gel               (to prevent skin dryness). Also, staff who come
                  disinfectants located to promote use      in contact with patients or prepare sterile
                  (including inpatient rooms), and          products (such as IV drugs) should not have
                  providing individual products to all      artificial fingernails. Clinicians should also be
                  necessary staff?                          offered the small (2-4 oz.) personal containers of
                                                            hand gel. Gel should be in convenient locations
                                                            including all carts (mobile care, medication
                                                            carts, code, respiratory).

                  Mandatory                                 JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                            CDC Hand Hygiene Guidelines
                                                            VHA Directive 2005-002 July 2005
                  Infection Control
   7.6.9.5         RESERVED
                  Medical Gas Safety
   7.6.10.1       Are piped in oxygen and                   The use of color coding should be eliminated.
                  compressed air identified by a            Using color adapters can cause confusion
                  prominent label and not merely by         during use, mixing up the gases being
                  color adapters?                           administered. Fixes include: replacing tubing
                                                            with a type that does not use adaptors or using
                                                            only clear adaptors.
                  Recommended                               VHA Patient Safety Advisory 3/5/02
                  Medical Gas Safety
   7.6.10.2       Are air flow meters removed when          Flow meters are only used for specific
                  not in use (for nebulized medication      treatments, are not required during emergencies
                  treatments)?                              and should not be left attached to be confused
                                                            with O2 flow meter.
                  Recommended                               VHA Patient Safety Advisory 3/5/02




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    223 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                  Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  Medical Gas Safety
   7.6.10.3       Do staff know where the emergency        Staff to demonstrate competency. Also verify
                  oxygen shut-off is, and when and         that labels, warnings or other signage posted at
                  how to use it?                           the shut off point in accurate and up to date.

                  Mandatory                                NFPA (National Fire Protection Association) 5.1.4.2.1
                                                           JCAHO: EC.7.50
                  Medical Gas Safety
   7.6.10.4 - 7.6.10.4.1      RESERVED
                  Medical Gas Safety
   7.6.10.5       Are pins on medical gas regulators       Pins should be in place and found undamaged.
                  and cylinders in good repair and is
                  damaged equipment immediately
                  removed from service?
                  Recommended                              NCPS O2 Cylinder Hazard Summary
                  Medical Gas Safety
   7.6.10.6       Are oxygen cylinders with ball-type      When placed in the horizontal position, the ball
                  regulators used with the cylinder in     valve mechanism will not function, and an
                  the vertical position?                   inaccurate reading will show on the gauge.
                  Recommended                              NCPS O2 Cylinder Hazard Summary
                  Medical Gas Safety
   7.6.10.7       Is the facility medical gas policy or    Review the policy if available. Questions
                  procedure followed when medical          technicians to determine if policy is known and
                  gases are used in clinics and exam       followed.
                  rooms?
                  Recommended
                  Medication Safety
   7.6.11.1 - 7.6.11.3.1      RESERVED
   Revised        Medication Safety
   7.6.11.4       Are medication storage rooms             Door locking mechanism cannot be defeated for
                  secured at all times?                    any reason. Door should not be held open.
                  Mandatory                                JCAHO: MM.2.20, EP-3 & EP-4
                                                           ISMP Self Assessment: 75
                  Medication Safety
   7.6.11.5 - 7.6.11.6.2      RESERVED




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    224 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                  Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Medication Safety
   7.6.11.7       Are bags containing sterile water for    Controlling the acquisition of sterile water may
                  injection prohibited from being          help to prevent it from being inadvertently given
                  ordered or stocked on patient care       intravenously.
                  areas without special permission
                  and precaution?
   Previously     Recommended                               FDA Patient Safety News: Show #22, 12/2003
   7.6.11.46                                                ISMP Medication Safety Alert, 9-2003
                  Medication Safety
   7.6.11.8       Have concentrated electrolyte       Such as: potassium chloride and potassium
                  solutions been removed from patient phosphate
                  floors/care areas?
   Previously
   7.6.11.16      Mandatory                                JCAHO: MM.2.20, EP-9; Goal #3a; and SEA #1 & #11
                  Medication Safety
   7.6.11.8.1 - 7.6.11.9      RESERVED
                  Medication Safety
   7.6.11.9.1     Are only standard concentrations of      Floor stock of high-alert drugs should be limited
                  high alert medications kept in the       to critically needed medications, with minimal
                  area/unit to minimize the potential of   number of doses, and be pre-made solutions (if
                  calculation and compounding errors?      available).

   Previously     Mandatory                                JCAHO: MM2.20, EP-8; MM.7.10; Goal #3b & SEA #11
   7.6.11.15                                               ISMP Self Assessment: 67.1 & 20
                  Medication Safety
   7.6.11.10          RESERVED
               Medication Safety
   7.6.11.10.1 Are single-dose containers (with            For infection control and medication safety
               preference to pre-filed syringes)           purposes. This may be a future JCAHO PS
               exclusively used?                           Goal.
   Previously
   7.6.11.31      Recommended                              ISMP Self Assessment: 84
                  Medication Safety
   7.6.11.11 - 7.6.11.12      RESERVED
                  Medication Safety
   7.6.11.13      Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                  the pharmacy and not on care units? be completed in pharmacy areas.

                  Recommended                              JCAHO: MM.4.20 & SEA #11




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    225 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
               Question:                                   Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.6.11.13.1 If admixtures are done in inpatient         Interview floor staff. If admixtures are done on
               care areas, is an independent               units, the area should be a designated area that
               double-check system utilized?               is clean and secure. It is safest for mixtures to
                                                           be completed in pharmacy areas.
                  Recommended
                  Medication Safety
   7.6.11.14         RESERVED
   Revised        Medication Safety
   7.6.11.15      Are premixed IV solutions kept in        The protective over-wrap for some solutions
                  over-wrap bags until they are ready      serves to control the amount of water vapor that
                  to be used (if applicable)?              escapes from an IV solution. Once unwrapped
                                                           it is best to use the solution right way.

   Previously
   7.6.11.44      Recommended                              FDA Patient Safety News: Show #22, 12/2003
                  Medication Safety
   7.6.11.16      Are IV bags free of markings, such      The volatile chemical from the ink may leach
                  as expiration dates, applied by staff into IV solutions.
                  with ink pens or felt markers (prior to
                  use)?
   Previously
   7.6.11.45      Recommended                              FDA Patient Safety News: Show #22, 12/2003
                  Medication Safety
   7.6.11.17      Is an independent double check           The double check should Include patient
                  completed for all infusion pump          monitoring and verifying the number of types of
                  settings?                                pumps.
   Previously
   7.6.11.12      Recommended                              JCAHO: SEA #11
                  Medication Safety
   7.6.11.18        RESERVED
                  Medication Safety
   7.6.11.19      Are appropriate reversal agents          In the event of an unusual reaction or overdose
                  (flumazenil, naloxone, protamine,        the agents need to be available.
                  etc.) available based on the drug
                  being administered?
   Previously
   7.6.11.10      Recommended                              ISMP Self Assessment: 79




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    226 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                        Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
               Question:                                  Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.6.11.19.1 Is there a process to monitor the          Such as reviewing automated dispensing
               reversal agent use?                        machine records, which can be used as a tracer
                                                          order for adverse drug events. (e.g., reversal
                                                          agent s used in Endosocpy, Radiology, Acute
                                                          Care, etc., may be a signal to misadministration
                                                          or unsafe practices occurring.
   Previously
   7.6.11.10.1    Recommended
                  Medication Safety
   7.6.11.20 - 7.6.11.22   RESERVED
               Medication Safety
   7.6.11.22.1 Do the VISTA modules effectively           Show example, if available.
               alert to potential food/drug/herbal
               interactions and duplicate drug
               therapies?
   Previously
   7.6.11.20      Recommended
                  Medication Safety
   7.6.11.23 - 7.6.11.24   RESERVED
                  Medication Safety
   7.6.11.25      Is drug reference information made      Interview area/unit staff, show where information
                  readily accessible to caregivers, if    is kept and how it is retrieved. One or two
                  so how?                                 reference sources should be available as well
                                                          as access to pharmacist.
   Previously     Recommended                             JCAHO: IM.3.10
   7.6.11.7                                               ISMP Self Assessment: 18.2
                  Medication Safety
   7.6.11.26      Are up-to-date facility specific        Interview unit staff, show where information is
                  protocols, guidelines, dosing scales,   kept and how it is retrieved. (e.g. use of
                  and/or checklists readily available     electrolyte replacement, aminoglycoside, and
                  for staff?                              anti-coagulant guidelines).
   Previously     Recommended                             JCHAO: IM.3.10
   7.6.11.8                                               ISMP Self Assessment: 19




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    227 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                         Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                  Question:                                Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Medication Safety
   7.6.11.27      Are specific precautions followed        Discuss protocols with staff (such as insulin and
                  when handling look/sound alike           heparin vials; and hydromorphone and
                  drugs?                                   morphine). In pharmacy, discuss what is being
                                                           done with the look alike medication project.

   Previously
   7.6.11.9       Recommended                              JCAHO: MM.2.20, EP-6; SEA #19
                  Medication Safety
   7.6.11.27.1          RESERVED
                  Medication Safety
   7.6.11.28      Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                  to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                  Goal requirements?
   Previously     Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
   7.6.11.28                                               ISMP Self Assessment: 40
                  Medication Safety
   7.6.11.29 - 7.6.11.31.1      RESERVED
                  Medication Safety
   7.6.11.32      If ADMs are used, are there              Show example reports, where filed on units;
                  capabilities to run override reports     interview Nurse Manger. Have staff reveal how
                  that track discrepancy and utilization   reports are used and acted upon, and if there is
                  at least monthly?                        a process to deal with variances.
                  Recommended                              ISMP Self Assessment: 26
                  Medication Safety
   7.6.11.33          RESERVED
                  Medication Safety
   7.6.11.34      Are patients educated regarding          Show example.
                  their prescribed medication, as
                  inpatients and as part of the
                  discharge process?
   Previously
   7.6.11.19      Recommended                              JCAHO: PC.6.10
                  Medication Safety
   7.6.11.35 - 7.6.11.37      RESERVED
                  Medication Safety
   7.6.11.38      Are barriers in place to prevent        Pre-drawing and mass spiking create infection
                  mass pre-drawing of sterile products control concerns and vulnerability of products
                  (e.g., lidocaine) or mass spiking of    being mixed up when used.
                  IV solutions in anticipation of patient
                  use?
   Previously
   Reserved       Recommended
                  Medication Safety

                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    228 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                       Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                  Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   7.6.11.39      Are medications drawn up for use in    Eliminate the use of unlabeled sterile basins.
                  the sterile field accurately and       Encourage the use of sterile-packed unit dose
                  consistently labeled?                  medications.
   Previously
   Reserved       Recommended
   New            Medication Safety
   7.6.11.39.1 Is there a mechanism to verify           Safe labeling of medications and solutions
                  contents of a syringe or container    (including contrast media) in perioperative
                  before drug administration to patient settings, operating rooms, ambulatory surgery,
                  during a procedure or code?           clinics, cardiac catheterization area, endoscopy,
                                                        radiology, dental, or other areas where
                                                        operative and invasive procedures may be
                                                        performed an independent double check should
                                                        be confirmed by the person who administers the
                                                        agent.
                  Recommended                            ISMP Medication Safety Alert December 2004
                  Medication Safety
   7.6.11.40 - 7.6.11.41.1      RESERVED
                  General Patient Safety Concerns
   7.6.12.1       Is read-back used for all verbal       Observe verbal ordering if possible, and
                  order and critical value reports?      interview staff. Verify that telephone voice mail
                                                         orders are not accepted.
                  Mandatory                              JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                         ISMP Self Assessment: 45
                  General Patient Safety Concerns
   7.6.12.2         RESERVED




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    229 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                       Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                  Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  General Patient Safety Concerns
   7.6.12.3       Are patient records kept               Ensure records or computer screens are not left
                  confidential, including computer       unattended and openly visible.
                  information?
                  Recommended                            JCAHO Std: IM.2
                  General Patient Safety Concerns
   7.6.12.4       Are staff required to wear             Monitor patient care areas. Interview staff about
                  identification badges, and are         policies such as the handling of drug
                  unauthorized persons kept out of       manufacturer representatives that visit
                  patient care areas?                    unexpectedly.
                  Recommended                            JCAHO Std: EC.1.2 & EC.2.2
                  General Patient Safety Concerns
   7.6.12.5       Are restraints used in accordance      Randomly interview staff. Look for restraint
                  with local policy and are restraint    devices or alterative devices in the area.
                  alternative devices available and
                  used when appropriate?
                  Recommended                            JCAHO: PC.11.10 & PC.12.10 & SEA #8
                  General Patient Safety Concerns
   7.6.12.6       Are there practices in place to        Using two patient identifiers for administrations,
                  decrease the likelihood of patient     draws or procedures/images, and at outpatient
                  misidentification?                     pharmacy; record and room flags for
                                                         same/similar/common names; four or less beds
                                                         in patient rooms; bedside labeling of samples,
                                                         rather than bulk (at nurses station); special
                                                         procedure for the transporting of high risk (for
                                                         misidentification) patients.

                  Recommended                            JCAHO Goal 1a
                  General Patient Safety Concerns
   7.6.12.7 - 7.6.12.8   RESERVED




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    230 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                        Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        General Patient Safety Concerns
   7.6.12.9       Is the transfer of care between         A consistent process should occur during
                  disciplines for off-unit appointments   appointments and when patients are sent back
                  standardized, including the             and forth from units, including patient
                  continuation of monitoring patient      identification means, patient record transfer, and
                  status and patient medical devices      the monitoring of the patient's condition and
                  such as IV pumps and oxygen level       needed medical devices. Stopping and
                  while the patient is visiting, being    resumption of IV medications should be planned
                  treated/tested, and during transport?   and documented. Interview staff in all areas
                                                          compare answers to determine standardization.

                  Recommended                             US Pharmacopeia Patient Safety CAPSLink, July 2004
                  General Patient Safety Concerns
   7.6.12.10          RESERVED
   Revised        General Patient Safety Concerns
   7.6.12.11      Does the facility have an emergency The protocol should be made up of a
                  response protocol for dealing with  mechanism for staff to communicate the
                  disruptive patients?                emergency (via a special extension or a
                                                      separate alarm system) and a security response
                                                      when a patient, staff or visitor becomes
                                                      threatening or out of control. Staff should be
                                                      familiar with the protocol and have confidence in
                                                      how to respond.
                  Recommended
   New            General Patient Safety Concerns
   7.6.12.12      When performing procedures           The facility's Conscious Sedation protocol
                  outside of the operating room are    should be followed in all areas.
                  appropriate sedation protocols and
                  privileges followed when applicable?

                  Mandatory                               JCAHO Std: PC.13.20
                  Psychiatric Precautions
   7.6.13.1 - 7.6.13.18       RESERVED
                  Surgical or Invasive Procedure Precautions
   7.6.14.1 - 7.6.14.19       RESERVED




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    231 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                       Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                  Question:                              Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Imaging and X-rays Precautions
   7.6.15.1       In Magnetic Resonance (MR)             Any objects which contain ferrous metals (from
                  areas, do physical barriers separate   watches to floor buffers) have the potential of
                  the magnet area from waiting           being drawn into/towards the MR equipment due
                  rooms, changing rooms, reception       to the powerful magnets used. MR machines
                  areas, etc. and does adequate          are always "on", creating a continuous hazard.
                  signage exist to warn of associated    The suites/areas which house this equipment
                  hazards?                               should be configured to keep the procedure
                                                         area separate from other associated areas
                                                         (changing, waiting, etc.). Also, signage should
                                                         be placed in all areas, on doors and other
                                                         thresholds to warn of present hazards. The 5
                                                         Gauss line should fall within the magnet room,
                                                         but if it does not there should be posted signage
                                                         to identify it. Providing technicians with a
                                                         cognitive aid can also help create reminders.

                  Mandatory                              NCPS MR Hazard Summary (2001)
                                                         FDA's MRI Workgroup Report (1997)




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    232 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                        Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Imaging and X-rays Precautions
   7.6.15.2       In MR areas, are staff able to          Before the MR procedure, each patient should
                  explain the patient assessment          be assessed for all associated risk factors.
                  process to the patient or patient's     There may be different assessments during the
                  family before or at the time of         course of scheduling and conducting the tests.
                  scheduling the exam?                    Some risk factors include: implants (such as a
                                                          pacemakers/defibrillators), insulin medication
                                                          pumps, neurostimulators, intracranial aneurysm
                                                          clips, prosthetics/orthopedic repairs, ocular
                                                          metal/fragments; stents less than 6 weeks old;
                                                          electrodes and wires including PA lines;
                                                          transdermal medication patches; pregnancy;
                                                          the need for having an oxygen tank, IV, or other
                                                          device during the procedure; history of shrapnel
                                                          injuries or piercings. Also, having
                                                          claustrophobia or tattoos is good to check for, it
                                                          may not affect the need for MRI, but the staff
                                                          can then be aware the condition exists. A
                                                          standardized checklist of all possible risk factors
                                                          should be available for review.


                  Mandatory                               ACR: Patient and Personnel Safety Guidelines
                                                          www.newmri.com
   Revised        Imaging and X-rays Precautions
   7.6.15.2.1     In MR areas, are patients briefed       Before the procedure, the patient should be
                  before the procedure regarding the      educated about the MR test, again asked about
                  hazards/risk factors, provided with a   implants, instructed to change clothes including
                  patient alarm, and offered hearing      removing all metal from his/her person (jewelry,
                  protection?                             hairpins/barrettes, wire bras, zippers, etc.). A
                                                          personal alarm that patient keep with them can
                                                          allow them to alert staff if they are experiencing
                                                          discomfort, and hearing protection can reduce
                                                          anxiety and provide extra comfort if the machine
                                                          is loud (over 80 Decibels at machine - consult
                                                          Industrial Hygienist).

                  Recommended                             NCPS MR Hazard Summary (2001)




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    233 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                      Facility unit/area name:
                                                                                                                                                                 *Not
                                                                                                                                 *Met       *Partially           Met If score other than 'met' what are
                  Question:                             Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Imaging and X-rays Precautions
   7.6.15.3       Are all devices, equipment, and       Each MR machine has a magnet strength rating
                  products assumed to be unsafe for     (e.g., 1.5T), and all equipment should be tested
                  the MR environment unless proven      and rated based in compatibility in Tesla (by the
                  otherwise?                            medical equipment manufacturer). Equipment
                                                        includes but is not limited to: sandbags,
                                                        gurneys, stretches, wheelchairs, oxygen and fire
                                                        extinguishing cylinders, floor buffers, office
                                                        chairs, IV pumps, monitoring devices, AEDs and
                                                        other emergency equipment. A MR compatible
                                                        label affixed by the manufacturer will meet this
                                                        requirement.

                  Mandatory                             NCPS MR Hazard Summary (2001)
                                                        FDA's MRI Workgroup Report (1997)
   New            Imaging and X-rays Precautions
   7.6.15.3.1     Does a cognitive aid or other         Patients should be positioned to avoid crossing
                  guidance exist for MR Technicians     leads and creating loops (i.e., as if when a hand
                  on patient positioning?               a touches leg); sensors should be placed away
                                                        from the RF coils; and periodic checks of the
                                                        senor sites should be made on unconscious
                                                        patients. Also, sandbags used in patient
                                                        positioning should be labeled with "non-ferrous"
                                                        to identify its compatibility.

                  Recommended                           NCPS MR Hazard Summary (2001)
                                                        FDA's MRI Workgroup Report (1997)
   Revised        Imaging and X-rays Precautions
   7.6.15.4       In MR areas, does the clinical and    Interview staff. Look for use of cognitive aids
                  technical staff demonstrate           (equipment lists, patient checklists, procedure
                  competency in the facility's policy   checklist, etc.). Compare current practices with
                  requirements (such as: MR             written policy. Inquire if emergency drills are
                  equipment compatibility, associated   conducted for fire, medical, and civil
                  MR hazards, and emergency             disturbances.
                  procedures) and are they able to
                  name the MR Safety Officer
                  assigned for the facility?
                  Recommended                           NCPS MR Hazard Summary (2001)
                                                        ACR: Patient and Personnel Safety Guidelines




                                                 *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                              to understand observed behavior and local norms to identify system vulnerabilities.                                                    234 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                        Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                  Question:                               Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
   Revised        Imaging and X-rays Precautions
   7.6.15.5       Can staff describe contraindications    The clinical status, medication history and lab
                  to using contrast media, and how to     results of the patient should be known before
                  manage adverse reactions?               the administration of any contrast media. Staff
                                                          should readily be able to recognize the signs of
                                                          a reaction and be familiar with how to manage
                                                          an adverse reaction. Appropriate emergency
                                                          drugs should be readily available in an
                                                          emergency drug box or code cart.

                  Recommended                             US Pharmacopeia Patient Safety CAPSLink, July 2004
   Revised        Imaging and X-rays Precautions
   7.6.15.6       Are policies, guidelines, charts or     For example neurotoxic or ionic contrast agents
                  other cognitive aids available to       should not be administered intrathecally (may
                  inform staff about the proper use,      cause death). All contrast media
                  indication, and routes of each type     administrations should require a redundant
                  of contrast agent in use or any other   check. High alert medication administered upon
                  drugs administered in radiology         transfer into radiology require the same
                  which require monitoring (e.g., pain    standard of care regarding monitoring.
                  medicine, sedation, anti-
                  coagulants)?
                  Recommended                             ISMP Medication Safety Alert, 11-27-03
                  Imaging and X-rays Precautions
   7.6.15.7       Are different types of contrast media   All contrast agents should secured and stored
                  agents stored separately (ionic and     separately based on its use and provided with
                  non-ionic) from one another in the      warning labels such as "not for intrathecal use,"
                  departments and/or in the               or kits should be packaged by pharmacy for
                  pharmacy, and are they labeled with     specific procedures such as myelography.
                  applicable warnings?                    Beware of look-alikes as well with contrast
                                                          agents (for example, ionic Hypaque and non-
                                                          ionic Omipaque 300 are in similar looking vials
                                                          from same manufacturer).
                  Recommended                             ISMP Medication Safety Alert, 11-27-03
                                                          US Pharmacopeia Patient Safety CAPSLink, July 2004
   New            Imaging and X-rays Precautions
   7.6.15.8       Are physician orders for contrast   All "drugs" require a physician order, even if
                  media or nuclear medicines formally they are not distributed by pharmacy, and
                  documented in the patients record? access to this information is required by others
                                                      (e.g., to evaluate renal failure, rash,
                                                      anaphylaxis, etc.).

                  Recommended




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    235 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   RADIOLOGY AREAS - Element 7, Location 6 (7.6)                                                                          Facility unit/area name:
                                                                                                                                                                     *Not
                                                                                                                                     *Met       *Partially           Met If score other than 'met' what are
                  Question:                                 Rationale/Assessment Methods:                                             (1)        Met (2)              (3) possible root causes
                  Imaging and X-rays Precautions
   7.6.15.9       If the facility uses teleradiology via    ACR has criteria recommendations including the
                  PACS (Picture Archiving and               following: display monitors, identification
                  Communications System) are ACR            (patient id, date, facility, body part/side, data
                  (American College of Radiology)           compression, patient history), transmission, data
                  recommendations being followed?           archive and retrieval, data security, system
                                                            reliability and redundancy, and licensing. If
                                                            equipment does not meet the standards
                                                            diagnosis's could be affected.
   Previously
   7.6.15.11      Recommended                               American College of Radiology




                                                     *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Radiology - 7.6                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    236 of 257
               Patient Safety Assessment Tool
               Part II Implementation
               Element: Pharmacy (Inpatient/Outpatient) - 7.7
                            Categories:
                            Bed Safety                                    NA
                            Code Carts                                    1
                            Electrical Safety                             NA
                            Environmental and Housekeeping Safety         1-2
                            Equipment Safety                              2
                            Escape and Elopement Prevention               NA
                            Fall Prevention                               NA
                            Fire Safety                                   NA
                            Infection Control                             2-3
                            Medical Gas Safety                            3
                            Medication Safety                             3 - 12
                            General Patient Safety Concerns               12 - 13
                            Psychiatric Precautions                       NA
                            Surgical or Invasive Procedures Precautions   NA
                            Imaging and X-Ray Precautions                 13

Thursday, April 21, 2005                                                            237 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                          Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                 Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Bed Safety
   7.7.1.1 - 7.7.1.7     RESERVED
                 Code Carts
   7.7.2.1 - 7.7.2.1.1    RESERVED
                 Code Carts
   7.7.2.2       Is there a standard method for            Expired medications could cause delays in code
                 rotating stock in code carts before it    responses.
                 has expired, or replacing stock after
                 it has expired?
                 Recommended
                 Code Carts
   7.7.2.3       Are equipment and drugs easily            Standardizing the location of supplies and
                 retrievable, and is there standard        equipment will increase the code response
                 organization in all carts throughout      efficiency.
                 the hospital?
                 Recommended
                 Code Carts
   7.7.2.4 - 7.7.2.5     RESERVED
                 Code Carts
   7.7.2.6       Is there a standardized system (e.g.      Cart should be locked with an integrity seal, look
                 checklist) or method used to verify       for a valid checklist or equivalent system on the
                 that code carts are fully stocked and     cart, dated with last check/update date. Items
                 properly equipped before they are         such as these should be on the checklist: O2
                 sent to the units?                        tank volume; tubing ; CO2 detectors;
                                                           appropriate medications; AED (or other
                                                           defibrillators) and suction machine functionality;
                                                           laryngoscope with batteries; cardiac board, etc.

                 Recommended
                 Electrical Safety
   7.7.3.1 - 7.7.3.7     RESERVED
                 Environmental and Housekeeping Safety
   7.7.4.1 - 7.7.4.2     RESERVED
                 Environmental and Housekeeping Safety
   7.7.4.3       Does general housekeeping appear Cleanliness, sanitation, odor, etc.
                 to be a priority?
                 Recommended                               JCAHO Std: EC.8.10




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    238 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                           Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                 Question:                            Rationale/Assessment Methods:                                                  (1)        Met (2)              (3) possible root causes
                 Environmental and Housekeeping Safety
   7.7.4.4       Are storage rooms neat, organized, Inspect storage areas. Organized, well light
                 well light and temperature           rooms will help prevent mistakes. Ensuring
                 controlled? Is all storage 18" below extreme temperatures do not occur will uphold
                 fire sprinklers and off the floor?   the integrity of the supplies. Keeping boxes off
                                                      of floor keeps supplies sanitary.
                 Recommended                                JCAHO Std: EC.5.20
                 Environmental and Housekeeping Safety
   7.7.4.5 - 7.7.4.10    RESERVED
                 Equipment Safety
   7.7.5.1 - 7.7.5.8     RESERVED
                 Equipment Safety
   7.7.5.9       Are disposable medical                     Inspect storage rooms and other stock areas in
                 devices/supplies stored in a way           the area/unit (e.g. folding supplies like hoses
                 that the integrity of the devices is       and tubing causes kinking that has prevented
                 kept intact (i.e. not bent or folded)?     them from functioning properly).
                 Recommended
                 Equipment Safety
   7.7.5.10 - 7.7.5.14       RESERVED
                 Escape and Elopement Prevention
   7.7.6.1 - 7.7.6.6     RESERVED
                 Fall Prevention
   7.7.7.1 - 7.7.7.10    RESERVED
                 Fire Safety
   7.7.8.1 - 7.7.8.6     RESERVED
                 Infection Control
   7.7.9.1        RESERVED
                 Infection Control
   7.7.9.2       Are sharps containers accessible           Observe conditions in unit/area. Patients and
                 and not over filled?                       employees are often stuck by sharps not
                                                            properly disposed of due to overfilling of these
                                                            containers.
                 Mandatory                                  JCAHO: IC.4.10




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    239 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                           Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                 Question:                                  Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Infection Control
   7.7.9.3       Is the latex allergy policy followed       Show example if available. Consider inspecting
                 and are latex free supplies and            supply and code carts. Look for latex-free
                 equipment available?                       identification on glove boxes, supply packages,
                                                            etc. Determine if the other devices are available
                                                            as latex-free such as tourniquets and medical
                                                            tubing. In pharmacy, check for a latex protocol
                                                            in IV room.
                 Mandatory                                  IL 16-97-001 Latex Information
                 Infection Control
   7.7.9.4       Are the VA recommended hand                The individual products should be an alcohol rub
                 hygiene guidelines followed, such          (for disinfecting) and a hospital approved lotion
                 as having alcohol-based gel                (to prevent skin dryness). Also, staff who come
                 disinfectants located to promote use       in contact with patients or prepare sterile
                 (including inpatient rooms), and           products (such as IV drugs) should not have
                 providing individual products to all       artificial fingernails. Clinicians should also be
                 necessary staff?                           offered the small (2-4 oz.) personal containers of
                                                            hand gel. Gel should be in convenient locations
                                                            including all carts (mobile care, medication
                                                            carts, code, respiratory).

                 Mandatory                                  JCAHO: IC.4.10, SEA 28, and Goal #7a
                                                            CDC Hand Hygiene Guidelines
                                                            VHA Directive 2005-002 July 2005
                 Infection Control
   7.7.9.5        RESERVED
                 Medical Gas Safety
   7.7.10.1 - 7.7.10.7       RESERVED
                 Medication Safety
   7.7.11.1      Are all medication refrigerators           Check floor refrigerators, ensure correct labeling
                 maintained appropriately?                  and appropriate separations from employee
                                                            food/drink. Review temperature log (or
                                                            electronic temperature monitoring device/log)
                                                            and verify that the thermometer is working.

                 Mandatory                                  JCAHO: MM.2.20, EP-13
                                                            ISMP Self Assessment: #117




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    240 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                        Facility unit/area name:
                                                                                                                                                                 *Not
                                                                                                                                 *Met       *Partially           Met If score other than 'met' what are
                 Question:                               Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.2      Do medication carts remained            Randomly survey carts in the area.
                 locked and inaccessible to patients
                 when not in use?
                 Mandatory                               JCAHO: MM.2.20, EP-3 & EP-4
                 Medication Safety
   7.7.11.3 - 7.7.11.3.1     RESERVED
                 Medication Safety
   7.7.11.4      Are medication storage rooms            Door locking mechanism cannot be defeated for
                 secured at all times?                   any reason. Door should not be held open.
                 Mandatory                               JCAHO: MM.2.20, EP-3 & EP-4
                                                         ISMP Self Assessment: 75
                 Medication Safety
   7.7.11.5      Is the storage methods of               Sufficient space, lighting, etc.
                 medication neat and organized
                 within the pharmacy?
                 Recommended                             ISMP Self Assessment: 53
                 Medication Safety
   7.7.11.6      Is area stock limited to emergency     Review approved floor stock and IV solution list
                 medication and IV solutions which      (e.g. 3% NaCl should not generally be available).
                 are appropriate to patient care in the
                 unit?
                 Recommended                             JCAHO: MM.3.20
                                                         ISMP Self Assessment: 82
                 Medication Safety
   7.7.11.6.1    Do emergency medications                Example of needle-less systems: blunt tip, pre-
                 provided in code carts and/or           dawn syringes, etc.
                 emergency drug boxes "fit" with
                 needle-less systems used in the
                 area such that treatments can be
                 safely and promptly initiated?
                 Recommended
                 Medication Safety
   7.7.11.6.2        RESERVED




                                                 *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    241 of 257
                                                           NCPS Patient Safety Assessment Tool
                                                                Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                           Facility unit/area name:
                                                                                                                                                                    *Not
                                                                                                                                    *Met       *Partially           Met If score other than 'met' what are
                 Question:                                  Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.7      Are bags containing sterile water for      Controlling the acquisition of sterile water may
                 injection prohibited from being            help to prevent it from being inadvertently given
                 ordered or stocked on patient care         intravenously.
                 areas without special permission
                 and precaution?
                 Recommended                                FDA Patient Safety News: Show #22, 12/2003
                                                            ISMP Medication Safety Alert, 9-2003
                 Medication Safety
   7.7.11.8      Have concentrated electrolyte       Such as: potassium chloride and potassium
                 solutions been removed from patient phosphate
                 floors/care areas?
                 Mandatory                                  JCAHO: MM.2.20, EP-9; Goal #3a; and SEA #1 & #11
                 Medication Safety
   7.7.11.8.1    Is access limited to electrolyte           Review local policies, and interview pharmacy
                 replacement solutions (above or            staff. Show example.
                 below 0.9% sodium chloride) on
                 nursing units?
                 Recommended                                ISMP Self Assessment: 92
                 Medication Safety
   7.7.11.9      Are high alert drug IV                     Facility should have local established standards
                 solutions/concentrations                   for IV admixtures and administration of high alert
                 standardized?                              medications (look for standardized
                                                            concentrations, drip charts or cognitive aids for
                                                            titratable or frequently changing drugs, and pre-
                                                            made solutions when commercially available).

                 Recommended                                JCAHO: MM2.20, EP-8
                 Medication Safety
   7.7.11.9.1        RESERVED
                 Medication Safety
   7.7.11.10     Is a unit dose medication system           Look in patient bins for bulk containers.
                 used including half tablets and
                 liquids?
                 Recommended                                JCAHO: MM.2.20, EP-10
                                                            ISMP Self Assessment: 64




                                                    *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                  to understand observed behavior and local norms to identify system vulnerabilities.                                                    242 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                          Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
               Question:                                   Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.7.11.10.1 Are single-dose containers (with            For infection control and medication safety
               preference to pre-filed syringes)           purposes. This may be a future JCAHO PS
               exclusively used?                           Goal.
                 Recommended                               ISMP Self Assessment: 84
                 Medication Safety
   7.7.11.11     Are the sizes of injectable drugs in      Helps to prevent overdose and reduces the
                 vials or ampoules matched to the          hazard associated with multi-dose vials. This
                 clinical situation?                       may be a future JCAHO PS Goal.
                 Recommended
                 Medication Safety
   7.7.11.12     Has the facility prospectively            To reduce the danger of accidental free flow, it
                 analyzed which medications can            is safer to prepare smaller bags.
                 have smaller total dose bag sizes?
                 Recommended
                 Medication Safety
   7.7.11.13     Is drug preparation done primarily in Interview floor staff. It is safest for mixtures to
                 the pharmacy and not on care units? be completed in pharmacy areas.

                 Recommended                               JCAHO: MM.4.20 & SEA #11
               Medication Safety
   7.7.11.13.1 If admixtures are done in inpatient         Interview floor staff. If admixtures are done on
               care areas, is an independent               units, the area should be a designated area that
               double-check system utilized?               is clean and secure. It is safest for mixtures to
                                                           be completed in pharmacy areas.
                 Recommended
                 Medication Safety
   7.7.11.14     Are procedures in place to prevent        Infection control literature documents
                 sterile product use from patient to       nosocomial infections occur irrespective of
                 patient (including medications)?          changing needles or IV tubing's.
                 Recommended                               ISMP Medication Safety Alert, June 2000
                                                           American Society of Anesthesiology Newsletter, 12/2000
                                                           CDC MMWR Weekly, 9/26/2003
                 Medication Safety
   7.7.11.15     Are premixed IV solutions kept in         The protective over-wrap for some solutions
                 over-wrap bags until they are ready       serves to control the amount of water vapor that
                 to be used (if applicable)?               escapes from an IV solution. Once unwrapped
                                                           it is best to use the solution right way.

                 Recommended                               FDA Patient Safety News: Show #22, 12/2003




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    243 of 257
                                                        NCPS Patient Safety Assessment Tool
                                                             Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                        Facility unit/area name:
                                                                                                                                                                 *Not
                                                                                                                                 *Met       *Partially           Met If score other than 'met' what are
                 Question:                               Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.16     Are IV bags free of markings, such      The volatile chemical from the ink may leach
                 as expiration dates, applied by staff into IV solutions.
                 with ink pens or felt markers (prior to
                 use)?
                 Recommended                             FDA Patient Safety News: Show #22, 12/2003
                 Medication Safety
   7.7.11.17 - 7.7.11.18   RESERVED
                 Medication Safety
   7.7.11.19     Are appropriate reversal agents         In the event of an unusual reaction or overdose
                 (flumazenil, naloxone, protamine,       the agents need to be available.
                 etc.) available based on the drug
                 being administered?
                 Recommended                             ISMP Self Assessment: 79
               Medication Safety
   7.7.11.19.1 Is there a process to monitor the         Such as reviewing automated dispensing
               reversal agent use?                       machine records, which can be used as a tracer
                                                         order for adverse drug events. (e.g., reversal
                                                         agent s used in Endosocpy, Radiology, Acute
                                                         Care, etc., may be a signal to misadministration
                                                         or unsafe practices occurring.

                 Recommended
                 Medication Safety
   7.7.11.20     Are adverse drug reactions entered      Review ten entries of admitted patients, it
                 (in VISTA) for each patient?            should be shown that 100% have a valid entry in
                                                         the adverse drug reaction package.
                 Recommended
                 Medication Safety
   7.7.11.21     Is there machine readable coding    Show mechanism (i.e. BCMA) in use. Machine
                 throughout the medication           readable coding should match the electronic
                 administration process (e.g. BCMA)? medical record to the patient, allowing the
                                                     information on the patients armband to be
                                                     matched with the electronic information.

                 Recommended                             ISMP Self Assessment: 11




                                                 *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                               to understand observed behavior and local norms to identify system vulnerabilities.                                                    244 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                         Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
               Question:                                  Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
               Medication Safety
   7.7.11.21.1 Is BCMA used to administer                 Observe staff.
               medication without using work
               arounds?
                 Recommended
                 Medication Safety
   7.7.11.21.2 What is the protocol for handling          Interview staff and compare practices to policy
                 incorrect bar coded or labeled           of facility/Pharmacy.
                 medications?
                 Recommended                              JCHAO: MM.3.20, EP-5
               Medication Safety
   7.7.11.21.3 Is there a helpdesk for BCMA               Test hotline number available on all shifts;
               available during all shifts?               interview off-shift staff if available.
                 Recommended
                 Medication Safety
   7.7.11.22     Does the ordering system have            Requires allergy info first; safety alerts cannot
                 added safe guards as a forcing           be bypassed; previous orders discontinued
                 function?                                before new added; RPh varies all orders before
                                                          processing.
                 Recommended                              ISMP Self Assessment: 39a
               Medication Safety
   7.7.11.22.1 Do the VISTA modules effectively           Show example, if available.
               alert to potential food/drug/herbal
               interactions and duplicate drug
               therapies?
                 Recommended
                 Medication Safety
   7.7.11.23     Does the facility have a contingency Review plan, interview staff.
                 plan for the loss of the CPRS
                 system? If so, explain what
                 happens.
                 Recommended
                 Medication Safety
   7.7.11.24     Does the Information Management          Review written documents. Interview pharmacy
                 Service have a mirror test account       and engineering staff familiar with procedure.
                 to test patch installations in VISTA?

                 Recommended




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    245 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                         Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                 Question:                                Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.25     Is drug reference information made       Interview area/unit staff, show where information
                 readily accessible to caregivers, if     is kept and how it is retrieved. One or two
                 so how?                                  reference sources should be available as well
                                                          as access to pharmacist.
                 Recommended                              JCAHO: IM.3.10
                                                          ISMP Self Assessment: 18.2
                 Medication Safety
   7.7.11.26     Are up-to-date facility specific         Interview unit staff, show where information is
                 protocols, guidelines, dosing scales,    kept and how it is retrieved. (e.g. use of
                 and/or checklists readily available      electrolyte replacement, aminoglycoside, and
                 for staff?                               anti-coagulant guidelines).
                 Recommended                              JCHAO: IM.3.10
                                                          ISMP Self Assessment: 19
                 Medication Safety
   7.7.11.27     Are specific precautions followed        Discuss protocols with staff (such as insulin and
                 when handling look/sound alike           heparin vials; and hydromorphone and
                 drugs?                                   morphine). In pharmacy, discuss what is being
                                                          done with the look alike medication project.

                 Recommended                              JCAHO: MM.2.20, EP-6; SEA #19
               Medication Safety
   7.7.11.27.1 Is the purpose (indication) of the         If the pharmacy staff is told the indication of the
               medication order/prescription              medication it can serve as another method to
               communicated to the pharmacy?              minimize confusion between look/sound alike
                                                          drugs.
                 Recommended                              ISMP Self Assessment: 58
                 Medication Safety
   7.7.11.28     Do prohibited abbreviations conform For example "u" in unit may be mistaken for "0"
                 to minimum JCHAO Patient Safety     resulting in ten fold over dosage.
                 Goal requirements?
                 Mandatory                                JCAHO: MM.3.20; IM.3.10; Goal # 2b; and SEA #11 & #23
                                                          ISMP Self Assessment: 40
                 Medication Safety
   7.7.11.29     If Automated Dispensing Machines         Written documents should include which drugs
                 (ADMs) are used, is staff aware of a     are available - including strengths and doses,
                 written policy, and can they explain     how often drugs are inspected for expiration
                 how the machine works?                   dates, drugs not used but removed, and content
                                                          review.
                 Recommended                              JCAHO: MM.4.50




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    246 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                          Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                 Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.30     If ADMs are used, is there a staff        Interview staff.
                 education and competency review
                 program?
                 Recommended
                 Medication Safety
   7.7.11.31     If ADMs are used, do Pharmacists          Review policy and interview staff.
                 check drugs before restocking, is a
                 bar coding system used?
                 Recommended                               JCHAO: MM.4.50, EP-3
                                                           ISMP Self Assessment: 72
               Medication Safety
   7.7.11.31.1 If ADMs are used, does the system           Review policy and interview staff.
               have pharmacy profile interface?

                 Recommended
                 Medication Safety
   7.7.11.32     If ADMs are used, are there               Show example reports, where filed on units;
                 capabilities to run override reports      interview Nurse Manger. Have staff reveal how
                 that track discrepancy and utilization    reports are used and acted upon, and if there is
                 at least monthly?                         a process to deal with variances.
                 Recommended                               ISMP Self Assessment: 26
                 Medication Safety
   7.7.11.33     Do prescription labels include both       This helps with non-VA medications to alert
                 the generic and brand names?              patients and providers of duplicate therapy.
                                                           Most VA facilities dispense only generic
                                                           medications, but having the brand names listed
                                                           can serve this purpose.
                 Recommended                               JCAHO: MM.2.20, EP-7
                                                           ISMP Self Assessment: 41
                 Medication Safety
   7.7.11.34     Are patients educated regarding           Show example.
                 their prescribed medication, as
                 inpatients and as part of the
                 discharge process?
                 Recommended                               JCAHO: PC.6.10




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    247 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                         Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                 Question:                                Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.35     Does the care provided by                Interview clinicians to determine if Pharmacists
                 Pharmacists meet the clinical needs      are available for consult, and if they participate
                 of the patients in scope and             in rounds or access patient medication history.
                 frequency?
                 Recommended                              JCAHO Std: MM.4.10
                                                          ISMP Self Assessment: 23
                 Medication Safety
   7.7.11.36         RESERVED
                 Medication Safety
   7.7.11.37     Are chemical products and                If appropriate sizes are acquired for each clinical
                 medications (including contract          situation it eliminates the transfer of containers,
                 media) used in the operative suite,      omitting the vulnerability of mislabeling or mis-
                 treatment areas, pharmacy or clinics     administration. Labels are required on all
                 purchased in sizes appropriate for       medications, solutions, etc. on and off the sterile
                 their clinical situation (single dose,   field, even if only one medication/solution is
                 single patient, individually labeled)    given. If pre-made single dose containers are
                 and kept in a labeled state to the       not available for sterile procedures, sterile
                 point of administration?                 markers with blank labels and/or pre-printed
                                                          labels should be made available to include in
                                                          pre-made sterile packs.

                 Mandatory                                JCAHO MM.4.30
                                                          ISMP Self Assessment C.C.6 & #66
                 Medication Safety
   7.7.11.37.1 - 7.7.11.39     RESERVED
               Medication Safety
   7.7.11.39.1 Is there a mechanism to verify             Safe labeling of medications and solutions
               contents of a syringe or container         (including contrast media) in perioperative
               before drug administration to patient      settings, operating rooms, ambulatory surgery,
               during a procedure or code?                clinics, cardiac catheterization area, endoscopy,
                                                          radiology, dental, or other areas where
                                                          operative and invasive procedures may be
                                                          performed an independent double check should
                                                          be confirmed by the person who administers the
                                                          agent.
                 Recommended                              ISMP Medication Safety Alert December 2004
                 Medication Safety
   7.7.11.40         RESERVED




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    248 of 257
                                                          NCPS Patient Safety Assessment Tool
                                                               Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                          Facility unit/area name:
                                                                                                                                                                   *Not
                                                                                                                                   *Met       *Partially           Met If score other than 'met' what are
                 Question:                                 Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 Medication Safety
   7.7.11.41     Are emergency medications to treat        These cases are rare, however, the medication
                 malignant hyperthermia readily            to treat it can expire before it is needed. There
                 available?                                should be mechanism to check the expiration
                                                           date and availability on a periodic basis.

                 Recommended
                 Medication Safety
   7.7.11.41.1 If sterile water is used to dilute IV   1 L bags of water can be confused for IV bags
                 dantrolene in emergency boxes in      and inadvertently infused.
                 treating of malignant hyperthermia is
                 it provided in 50 mL vials vs. 1 L
                 bags?
                 Recommended                               FDA Patient Safety News: Show #22, 12/2003
                                                           ISMP Medication Safety Alert, 9-2003
                 General Patient Safety Concerns
   7.7.12.1      Is read-back used for all verbal          Observe verbal ordering if possible, and
                 order and critical value reports?         interview staff. Verify that telephone voice mail
                                                           orders are not accepted.
                 Mandatory                                 JCAHO: MM.3.20, EP-7; Goal #2a - see note
                                                           ISMP Self Assessment: 45
                 General Patient Safety Concerns
   7.7.12.2        RESERVED
                 General Patient Safety Concerns
   7.7.12.3      Are patient records kept                  Ensure records or computer screens are not left
                 confidential, including computer          unattended and openly visible.
                 information?
                 Recommended                               JCAHO Std: IM.2
                 General Patient Safety Concerns
   7.7.12.4      Are staff required to wear                Monitor patient care areas. Interview staff about
                 identification badges, and are            policies such as the handling of drug
                 unauthorized persons kept out of          manufacturer representatives that visit
                 patient care areas?                       unexpectedly.
                 Recommended                               JCAHO Std: EC.1.2 & EC.2.2
                 General Patient Safety Concerns
   7.7.12.5        RESERVED




                                                   *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                 to understand observed behavior and local norms to identify system vulnerabilities.                                                    249 of 257
                                                         NCPS Patient Safety Assessment Tool
                                                              Part II - Implementation
   PHARMACY (Inpatient/Outpatient) - Element 7, Location 7 (7.7)                                                         Facility unit/area name:
                                                                                                                                                                  *Not
                                                                                                                                  *Met       *Partially           Met If score other than 'met' what are
                 Question:                                Rationale/Assessment Methods:                                            (1)        Met (2)              (3) possible root causes
                 General Patient Safety Concerns
   7.7.12.6      Are there practices in place to          Using two patient identifiers for administrations,
                 decrease the likelihood of patient       draws or procedures/images, and at outpatient
                 misidentification?                       pharmacy; record and room flags for
                                                          same/similar/common names; four or less beds
                                                          in patient rooms; bedside labeling of samples,
                                                          rather than bulk (at nurses station); special
                                                          procedure for the transporting of high risk (for
                                                          misidentification) patients.

                 Recommended                              JCAHO Goal 1a
                 General Patient Safety Concerns
   7.7.12.7 - 7.7.12.11      RESERVED
                 General Patient Safety Concerns
   7.7.12.12     When performing procedures           The facility's Conscious Sedation protocol
                 outside of the operating room are    should be followed in all areas.
                 appropriate sedation protocols and
                 privileges followed when applicable?

                 Mandatory                                JCAHO Std: PC.13.20
                 Psychiatric Precautions
   7.7.13.1 - 7.7.13.18      RESERVED
                 Surgical or Invasive Procedure Precautions
   7.7.14.1 - 7.7.14.19      RESERVED
                 Imaging and X-rays Precautions
   7.7.15.1 - 7.7.15.6       RESERVED
                 Imaging and X-rays Precautions
   7.7.15.7      Are different types of contrast media    All contrast agents should secured and stored
                 agents stored separately (ionic and      separately based on its use and provided with
                 non-ionic) from one another in the       warning labels such as "not for intrathecal use,"
                 departments and/or in the                or kits should be packaged by pharmacy for
                 pharmacy, and are they labeled with      specific procedures such as myelography.
                 applicable warnings?                     Beware of look-alikes as well with contrast
                                                          agents (for example, ionic Hypaque and non-
                                                          ionic Omipaque 300 are in similar looking vials
                                                          from same manufacturer).
                 Recommended                              ISMP Medication Safety Alert, 11-27-03
                                                          US Pharmacopeia Patient Safety CAPSLink, July 2004
                 Imaging and X-rays Precautions
   7.7.15.8 - 7.7.15.9       RESERVED




                                                  *Measure safety culture by direct or indirect methods such as conversation or observation. Look for the why's
Pharmacy - 7.7                                                to understand observed behavior and local norms to identify system vulnerabilities.                                                    250 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.01.01.00             a                      a         a
  07.XX.01.02.00             a                      a         a
  07.XX.01.03.00             a                      a         a
  07.XX.01.04.00             a                      a         a           a
  07.XX.01.05.00             a                      a         a
  07.XX.01.06.00                                    a         a
  07.XX.01.07.00             a                      a         a
  07.XX.02.01.00             a           a          a         a                       a
  07.XX.02.01.01                         a
  07.XX.02.02.00                                                                                  a
  07.XX.02.03.00             a                      a         a           a           a           a
  07.XX.02.04.00             a           a          a         a           a           a
  07.XX.02.05.00             a           a          a         a                       a
  07.XX.02.06.00             a                      a         a                                   a
  07.XX.03.01.00             a           a          a         a           a           a
  07.XX.03.02.00             a           a          a         a           a           a
  07.XX.03.02.01                         a
  07.XX.03.03.00             a                      a         a           a           a
  07.XX.03.04.00             a           a          a         a           a           a
  07.XX.03.05.00             a                      a         a
  07.XX.03.06.00             a                      a         a           a           a
  07.XX.03.07.00                                                          a
  07.XX.04.01.00             a           a          a         a
  07.XX.04.02.00             a           a          a         a           a           a
  07.XX.04.03.00             a           a          a         a           a           a           a
  07.XX.04.04.00             a           a          a         a           a           a           a
  07.XX.04.05.00             a           a          a         a           a           a
  07.XX.04.06.00             a           a          a         a           a           a
  07.XX.04.07.00             a           a          a         a           a           a
  07.XX.04.08.00             a           a          a                                 a
  07.XX.04.09.00                                                          a
  07.XX.04.10.00             a           a          a         a           a           a
  07.XX.05.01.00             a           a          a         a           a           a

Tuesday, April 26, 2005                                                                            251 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.05.02.00             a                      a         a           a
  07.XX.05.03.00             a                      a         a
  07.XX.05.04.00             a           a          a         a           a
  07.XX.05.04.01                                    a         a
  07.XX.05.05.00             a                      a         a           a
  07.XX.05.05.01             a                      a         a           a
  07.XX.05.06.00             a                      a         a           a           a
  07.XX.05.07.00             a                      a         a           a           a
  07.XX.05.08.00             a           a          a         a                       a
  07.XX.05.09.00             a                      a         a           a           a           a
  07.XX.05.10.00                                    a         a           a
  07.XX.05.10.01                                    a         a           a
  07.XX.05.11.00             a           a          a         a           a           a
  07.XX.05.12.00                                              a           a
  07.XX.05.13.00             a                      a         a           a
  07.XX.05.13.01             a                      a         a           a
  07.XX.05.14.00             a                      a         a           a           a
  07.XX.06.01.00             a           a          a
  07.XX.06.02.00             a           a          a
  07.XX.06.03.00             a           a          a
  07.XX.06.04.00             a           a          a
  07.XX.06.05.00             a           a          a         a           a
  07.XX.06.05.01             a           a          a
  07.XX.06.06.00             a           a          a                     a           a
  07.XX.07.01.00             a           a          a         a                       a
  07.XX.07.02.00             a                      a         a           a           a
  07.XX.07.02.01             a                      a         a           a           a
  07.XX.07.03.00             a           a          a         a           a           a
  07.XX.07.04.00             a           a          a         a                       a
  07.XX.07.05.00             a                      a         a
  07.XX.07.06.00             a                      a         a
  07.XX.07.07.00             a                      a         a
  07.XX.07.08.00             a                      a         a

Tuesday, April 26, 2005                                                                            252 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.07.09.00             a                      a         a           a           a
  07.XX.07.10.00                                                                      a
  07.XX.08.01.00             a           a          a         a           a           a
  07.XX.08.02.00             a           a          a         a           a           a
  07.XX.08.03.00             a           a          a         a           a           a
  07.XX.08.04.00             a           a          a         a           a           a
  07.XX.08.04.01             a           a          a         a           a           a
  07.XX.08.05.00             a           a          a
  07.XX.08.05.01             a           a          a
  07.XX.08.06.00                         a
  07.XX.09.01.00             a           a          a         a           a           a
  07.XX.09.02.00             a                      a         a           a           a           a
  07.XX.09.03.00             a           a          a         a           a           a           a
  07.XX.09.04.00             a                      a         a           a           a           a
  07.XX.09.05.00             a                      a         a
  07.XX.10.01.00             a                      a         a           a           a
  07.XX.10.02.00             a                      a         a                       a
  07.XX.10.03.00             a                      a         a           a           a
  07.XX.10.04.00             a                      a         a           a
  07.XX.10.04.01             a                      a         a           a
  07.XX.10.05.00             a                      a         a           a           a
  07.XX.10.06.00             a                      a         a           a           a
  07.XX.10.07.00             a                                                        a
  07.XX.11.01.00             a           a          a         a           a                       a
  07.XX.11.02.00             a           a          a         a           a                       a
  07.XX.11.03.00             a           a          a         a
  07.XX.11.03.01             a           a          a         a           a
  07.XX.11.04.00             a           a          a         a           a           a           a
  07.XX.11.05.00                                                                                  a
  07.XX.11.06.00             a           a          a         a           a                       a
  07.XX.11.06.01                                              a           a                       a
  07.XX.11.06.02                                              a           a
  07.XX.11.07.00             a           a          a         a           a           a           a

Tuesday, April 26, 2005                                                                            253 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.11.08.00             a                                a                       a           a
  07.XX.11.08.01             a                      a         a                                   a
  07.XX.11.09.00                                                                                  a
  07.XX.11.09.01             a                      a         a           a           a
  07.XX.11.10.00             a           a          a         a                                   a
  07.XX.11.10.01                                              a           a           a           a
  07.XX.11.11.00                                                          a                       a
  07.XX.11.12.00                                                                                  a
  07.XX.11.13.00             a           a          a         a           a           a           a
  07.XX.11.13.01             a           a          a         a           a           a           a
  07.XX.11.14.00             a                      a         a           a                       a
  07.XX.11.15.00             a                      a         a           a           a           a
  07.XX.11.16.00             a                      a         a           a           a           a
  07.XX.11.17.00             a                      a         a           a           a
  07.XX.11.18.00
  07.XX.11.19.00             a           a          a         a           a           a           a
  07.XX.11.19.01             a           a          a         a           a           a           a
  07.XX.11.20.00                                                                                  a
  07.XX.11.21.00             a           a          a         a                                   a
  07.XX.11.21.01             a           a          a         a                                   a
  07.XX.11.21.02             a           a          a         a                                   a
  07.XX.11.21.03             a           a          a         a                                   a
  07.XX.11.22.00                                                                                  a
  07.XX.11.22.01             a                      a         a                       a           a
  07.XX.11.23.00                                                                                  a
  07.XX.11.24.00                                                                                  a
  07.XX.11.25.00             a           a          a         a           a           a           a
  07.XX.11.26.00             a           a          a         a           a           a           a
  07.XX.11.27.00             a           a          a         a           a           a           a
  07.XX.11.27.01                                                                                  a
  07.XX.11.28.00             a           a          a         a           a           a           a
  07.XX.11.29.00             a           a          a         a           a                       a
  07.XX.11.30.00                                                                                  a

Tuesday, April 26, 2005                                                                            254 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.11.31.00                                                                                  a
  07.XX.11.31.01                                                                                  a
  07.XX.11.32.00             a           a          a         a                       a           a
  07.XX.11.33.00                                                                                  a
  07.XX.11.34.00             a           a          a         a           a           a           a
  07.XX.11.35.00             a           a          a         a                                   a
  07.XX.11.36.00                                                          a
  07.XX.11.37.00                                                          a                       a
  07.XX.11.37.01                                                          a
  07.XX.11.38.00                                                          a           a
  07.XX.11.39.00                                                          a           a
  07.XX.11.39.01                                              a           a           a           a
  07.XX.11.40.00                                                          a
  07.XX.11.41.00                                                          a                       a
  07.XX.11.41.01                                                          a                       a
  07.XX.12.01.00             a           a          a         a           a           a           a
  07.XX.12.02.00             a           a          a         a
  07.XX.12.03.00             a           a          a         a           a           a           a
  07.XX.12.04.00             a           a          a         a           a           a           a
  07.XX.12.05.00             a           a          a         a                       a
  07.XX.12.06.00             a           a          a         a           a           a           a
  07.XX.12.07.00             a           a          a         a
  07.XX.12.08.00             a           a          a         a
  07.XX.12.09.00             a           a          a         a                       a
  07.XX.12.10.00             a           a          a         a
  07.XX.12.11.00             a           a          a         a           a           a
  07.XX.12.12.00             a           a          a         a                       a           a
  07.XX.13.01.00                         a
  07.XX.13.02.00                         a
  07.XX.13.03.00                         a
  07.XX.13.04.00                         a
  07.XX.13.05.00                         a
  07.XX.13.06.00                         a

Tuesday, April 26, 2005                                                                            255 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.13.07.00                         a
  07.XX.13.08.00                         a
  07.XX.13.09.00                         a
  07.XX.13.10.00                         a
  07.XX.13.11.00                         a
  07.XX.13.12.00                         a
  07.XX.13.13.00                         a
  07.XX.13.14.00                         a
  07.XX.13.15.00                         a
  07.XX.13.16.00
  07.XX.13.17.00                         a
  07.XX.13.18.00                         a
  07.XX.14.01.00                                                          a
  07.XX.14.02.00                                                          a
  07.XX.14.03.00                                                          a
  07.XX.14.03.01                                                          a
  07.XX.14.03.02                                                          a
  07.XX.14.04.00                                                          a
  07.XX.14.05.00                                                          a
  07.XX.14.05.01                                                          a
  07.XX.14.06.00                                                          a
  07.XX.14.07.00                                                          a
  07.XX.14.08.00                                                          a
  07.XX.14.09.00                                                          a
  07.XX.14.10.00                                                          a
  07.XX.14.11.00                                                          a
  07.XX.14.12.00                                                          a
  07.XX.14.13.00                                                          a
  07.XX.14.14.00                                                          a
  07.XX.14.15.00                                                          a
  07.XX.14.16.00                                                          a
  07.XX.14.17.00                                                          a
  07.XX.14.18.00                                                          a

Tuesday, April 26, 2005                                                                            256 of 257
                              PSAT SubElement Usage Matrix
                           Element 1
 Master Element                        Element 2 Element 3 Element 4   Element 5   Element 6   Element 7
                          Long Term
      Code                             Psyc Care Acute Care   ICU         OR       Radiology   Pharmacy
                              Care

  07.XX.14.19.00                                                          a
  07.XX.15.01.00                                                                      a
  07.XX.15.02.00                                                                      a
  07.XX.15.02.01                                                                      a
  07.XX.15.03.00                                                                      a
  07.XX.15.03.01                                                                      a
  07.XX.15.04.00                                                                      a
  07.XX.15.05.00                                                                      a
  07.XX.15.06.00                                                                      a
  07.XX.15.07.00                                                                      a           a
  07.XX.15.08.00                                                                      a
  07.XX.15.09.00                                                                      a
  07.XX.15.10.00
  07.XX.15.11.00
  07.XX.15.12.00
  07.XX.15.13.00




Tuesday, April 26, 2005                                                                            257 of 257

				
DOCUMENT INFO
Description: Sample Forms of Informed Consent and Forensic Evaluation document sample