Environment of care
1. Manage hazardous materials and waste.
• Hazardous energy
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2. Medical equipment is maintained, tested and inspected.
• Test and maintain medical equipment on inventory
• Document testing and maintenance of sterilizers
3. Collect information to monitor conditions in the environment.
• Evaluate each environment of care plan annually
Human resources
4. Verify staff qualifications.
• Primary source verify licensed/certified/registered staff
5. Clinical privileges are granted to licensed independent practitioners.
• Primary source verify training
• Primary source verify licensure
• Query National Practitioner Data Bank
• Site-specific privileges
• Give LIP written list
Infection control
6. Identify risks for acquiring and transmitting infection.
• Identify risks based on services and populations
• Prioritize and document identified risks
7. Reduce the risk of infections associated with medical equipment, devices and supplies.
• Cleaning and performing low-level disinfection of medical equipment, devices and supplies
• Perform intermediate and high-level disinfection and sterilization
8. Evaluate effectiveness of infection prevention and control activities yearly and when risks change.
• Annually evaluate prevention and control activities and when risks change
Medication management
9. Safely manage high-alert and hazardous medications.
• Identify in writing and have process to manage
10. Address safe use of look-alike, sound-alike medications.
• Develop list and take action to prevent interchange
11. Medications are stored safely.
• Store medications per manufacturers’ recommendations
• Prevent unauthorized people from obtaining
• Label with expiration date
• Remove expired or contaminated medications and store separately
12. Safely manage emergency medications.
• Emergency medications and related supplies are readily accessible
National Patient Safety Goals and Universal Protocol
13. Use at least two patient identifiers when providing care, treatment or services.
• Two patient identifiers
• Label specimen containers in patient’s presence
14. Comply with either the Centers for Disease Control and Prevention or World Health Organization hand hygiene guidelines.
• Set goals
15. A time-out is performed before the procedure.
• Conduct and document time-out before starting procedure
Waived testing
16. Staff and LIPs performing waived testing are competent.
• At least two of four assessment methods used per person per test annually
17. Perform quality control checks for waived testing on each procedure.
• Expired reagent
• Check daily
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