2013 JCAHO Patient Safety Goals

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JCAHOJCAHO
Hospital National Patient Safety GoalsHospital National Patient Safety Goals
Effective January 1, 2013Effective January 1, 2013
JCAHO Mandatory
Annual Competency
Chesapeake Medical Staffing

The purpose of the National Patient Safety Goals is toThe purpose of the National Patient Safety Goals is to
improve patient safety. The goals focus on problems inimprove patient safety. The goals focus on problems in
health care safety and how to solve them.health care safety and how to solve them.

Full Implementation of Policies & Procedures to DecreaseFull Implementation of Policies & Procedures to Decrease
or Eliminate Catheter Associated Urinary Tract Infectionsor Eliminate Catheter Associated Urinary Tract Infections
Effective January 1. 2013Effective January 1. 2013
• While there are no new NPSG for 2013, hospitals areWhile there are no new NPSG for 2013, hospitals are
expected to have this goal implemented by January 1,expected to have this goal implemented by January 1,
2013. This particular patient safety goal focuses on2013. This particular patient safety goal focuses on
catheter-associated urinary tract infection (CAUTI),catheter-associated urinary tract infection (CAUTI),
requires organizations to fully implement the requirementsrequires organizations to fully implement the requirements
of the goal by January 1, 2013.of the goal by January 1, 2013.
• In order to comply with this goal, organizations must useIn order to comply with this goal, organizations must use
evidence based guidelines to develop policies andevidence based guidelines to develop policies and
procedures aimed at decreasing or eliminating catheter-procedures aimed at decreasing or eliminating catheter-
associated urinary tract infections. TJC refersassociated urinary tract infections. TJC refers
organizations to two evidence based guidelines fororganizations to two evidence based guidelines for
CAUTI:CAUTI:
Compendium of Strategies to Prevent Healthcare-Associated InfeCompendium of Strategies to Prevent Healthcare-Associated Infe
and theand the
Center for Disease Control’s Guideline for Prevention of CatheterCenter for Disease Control’s Guideline for Prevention of Catheter
..

According to the evidence-basedAccording to the evidence-based
research, a comprehensive CAUTIresearch, a comprehensive CAUTI
prevention program should include:prevention program should include:
• Education on evidence-based best practices forEducation on evidence-based best practices for
licensed independent practitioners and clinicallicensed independent practitioners and clinical
staff inserting and or maintaining urinary tractstaff inserting and or maintaining urinary tract
catheters.catheters.
• Performance feedback, when possible, on thePerformance feedback, when possible, on the
proportion of catheters placed by individualproportion of catheters placed by individual
clinicians and whether the placement met facility-clinicians and whether the placement met facility-
based criteria and other aspects related tobased criteria and other aspects related to
catheter care and maintenance.catheter care and maintenance.
• The appropriate supplies necessary for asepticThe appropriate supplies necessary for aseptic
technique for catheter insertion.technique for catheter insertion.

• A standardized documentation system whichA standardized documentation system which
includes indications for catheter insertion, dateincludes indications for catheter insertion, date
and time of catheter insertion, individual whoand time of catheter insertion, individual who
inserted catheter, and date and time of catheterinserted catheter, and date and time of catheter
removal.removal.
• Policies and procedures should encouragePolicies and procedures should encourage
minimal urinary catheter use and duration of useminimal urinary catheter use and duration of use
in all patients, particularly those at higher risk forin all patients, particularly those at higher risk for
CAUTI or mortality from catheterization, such asCAUTI or mortality from catheterization, such as
women, the elderly and patients with impairedwomen, the elderly and patients with impaired
immunity.immunity.
• Performance improvement monitoring to assessPerformance improvement monitoring to assess
appropriate use of indwelling catheters and toappropriate use of indwelling catheters and to
reduce the risk of CAUTI.reduce the risk of CAUTI.

National Patient Safety Goal 01.01.01National Patient Safety Goal 01.01.01
Use at least two patient identifiersUse at least two patient identifiers
when providing care, treatment, and serviceswhen providing care, treatment, and services
Wrong-patient errors occur in virtually all stages ofWrong-patient errors occur in virtually all stages of
diagnosis and treatment. The intent for this goal isdiagnosis and treatment. The intent for this goal is
• to reliably identify the individual as the person forto reliably identify the individual as the person for
whom the service or treatment is intended;whom the service or treatment is intended;
• to match the service or treatment to that individual.to match the service or treatment to that individual.
Acceptable identifiers may be the individual’s name, anAcceptable identifiers may be the individual’s name, an
assigned identification number, telephone number, orassigned identification number, telephone number, or
other person-specific identifier.other person-specific identifier.

Elements of Performance for NPSG.01.01.01Elements of Performance for NPSG.01.01.01
• Use at least two patient identifiersUse at least two patient identifiers when administeringwhen administering
medications, blood, or blood components; whenmedications, blood, or blood components; when
collecting blood samples and other specimens forcollecting blood samples and other specimens for
clinical testing; and when providing treatments orclinical testing; and when providing treatments or
procedures.procedures. The patient's room number or physicalThe patient's room number or physical
location is NOT used as an identifierlocation is NOT used as an identifier..
• Label containers used for blood and other specimens inLabel containers used for blood and other specimens in
the presence of the patient.the presence of the patient.

Eliminate transfusion errors relatedEliminate transfusion errors related
to patient misidentificationto patient misidentification
Before initiating a blood or blood component transfusion:Before initiating a blood or blood component transfusion:
• Match the blood or blood component to the order.Match the blood or blood component to the order.
• Match the patient to the blood or blood component.Match the patient to the blood or blood component.
• Use a two-person verification process or a one-Use a two-person verification process or a one-
person verification process accompanied byperson verification process accompanied by
automated identification technology, such as barautomated identification technology, such as bar
coding.coding.

• When using a two-person verification process, oneWhen using a two-person verification process, one
individual conducting the identification verification isindividual conducting the identification verification is
the qualified transfusionist who will administer thethe qualified transfusionist who will administer the
blood or blood component to the patient.blood or blood component to the patient.
• When using a two-person verification process, theWhen using a two-person verification process, the
second individual conducting the identificationsecond individual conducting the identification
verification is qualified to participate in the process,verification is qualified to participate in the process,
as determined by the hospital.as determined by the hospital.

Report critical results of tests andReport critical results of tests and
diagnostic procedures on a timely basisdiagnostic procedures on a timely basis
Critical results of tests and diagnostic procedures fallCritical results of tests and diagnostic procedures fall
significantly outside the normal range and maysignificantly outside the normal range and may
indicate a life-threatening situation. The objective isindicate a life-threatening situation. The objective is
to provide the responsible licensed caregiver theseto provide the responsible licensed caregiver these
results within an established time frame so that theresults within an established time frame so that the
patient can be promptly treated.patient can be promptly treated.

Develop written procedures for managing the criticalDevelop written procedures for managing the critical
results of tests and diagnostic procedures that addressresults of tests and diagnostic procedures that address
the following:the following:
• the definition of critical results of tests and diagnosticthe definition of critical results of tests and diagnostic
procedures;procedures;
• by whom and to whom critical results of tests andby whom and to whom critical results of tests and
diagnostic procedures are reported;diagnostic procedures are reported;
• the acceptable length of time between the availabilitythe acceptable length of time between the availability
and reporting of critical results of tests and diagnosticand reporting of critical results of tests and diagnostic
procedures.procedures.

• Implement the procedures for managing the criticalImplement the procedures for managing the critical
results of tests and diagnostic procedures.results of tests and diagnostic procedures.
• Evaluate the timeliness of reporting the critical resultsEvaluate the timeliness of reporting the critical results
of tests and diagnostic procedures.of tests and diagnostic procedures.

Label all medications, medication containers, andLabel all medications, medication containers, and
other solutions, on and off the sterile field, inother solutions, on and off the sterile field, in
perioperative and other procedural settingsperioperative and other procedural settings
Medications or other solutions in unlabeled containers areMedications or other solutions in unlabeled containers are
unidentifiable. Errors, sometimes tragic, have resulted fromunidentifiable. Errors, sometimes tragic, have resulted from
medications and other solutions removed from their originalmedications and other solutions removed from their original
containers and placed into unlabeled containers. This unsafecontainers and placed into unlabeled containers. This unsafe
practice neglects basic principles of safe medicationpractice neglects basic principles of safe medication
management, yet it is routine in many organizations.management, yet it is routine in many organizations.

The labeling of all medications, medication containers, andThe labeling of all medications, medication containers, and
other solutions is a risk-reduction activity consistent with safeother solutions is a risk-reduction activity consistent with safe
medication management.This practice addresses amedication management.This practice addresses a
recognized risk point in the administration of medications inrecognized risk point in the administration of medications in
perioperative and other procedural settings.perioperative and other procedural settings.

In perioperative and other procedural settings both on andIn perioperative and other procedural settings both on and
off the sterile field, label medications and solutions that areoff the sterile field, label medications and solutions that are
not immediately administered. This applies even if there isnot immediately administered. This applies even if there is
only one medication being used.only one medication being used.
Note: An immediately administered medication is one that anNote: An immediately administered medication is one that an
authorized staff member prepares or obtains, takes directly to aauthorized staff member prepares or obtains, takes directly to a
patient, and administers to that patient without any break in thepatient, and administers to that patient without any break in the
process.process.

In perioperative and other procedural settings both on and offIn perioperative and other procedural settings both on and off
the sterile field, labeling occurs when any medication orthe sterile field, labeling occurs when any medication or
solution is transferred from the original packaging to anothersolution is transferred from the original packaging to another
container.container.
In perioperative and other procedural settings both on and offIn perioperative and other procedural settings both on and off
the sterile field, medication or solution labels include thethe sterile field, medication or solution labels include the
medication name, strength, quantity, diluent and volume (ifmedication name, strength, quantity, diluent and volume (if
not apparent from the container), expiration date when notnot apparent from the container), expiration date when not
used within 24 hours, and expiration time when expirationused within 24 hours, and expiration time when expiration
occurs in less than 24 hours.occurs in less than 24 hours.
Note: The date and time are not necessary for short procedures, asNote: The date and time are not necessary for short procedures, as
defined by the hospital.defined by the hospital.

Verify all medication or solution labels both verbally andVerify all medication or solution labels both verbally and
visually. Verification is done by two individuals qualified tovisually. Verification is done by two individuals qualified to
participate in the procedure whenever the person preparingparticipate in the procedure whenever the person preparing
the medication or solution is not the person who will bethe medication or solution is not the person who will be
administering it.administering it.
Label each medication or solution as soon as it is prepared,Label each medication or solution as soon as it is prepared,
unless it is immediately administered.unless it is immediately administered.
Immediately discard any medication or solution foundImmediately discard any medication or solution found
unlabeled.unlabeled.

Remove all labeled containers on the sterile field andRemove all labeled containers on the sterile field and
discard their contents at the conclusion of the procedure.discard their contents at the conclusion of the procedure.
Note: This does not apply to multiuse vials that are handledNote: This does not apply to multiuse vials that are handled
according to infection control practices.according to infection control practices.
All medications and solutions both on and off the sterileAll medications and solutions both on and off the sterile
field and their labels are reviewed by entering andfield and their labels are reviewed by entering and
exiting staff responsible for the management ofexiting staff responsible for the management of
medications.medications.

Reduce the likelihood of patient harmReduce the likelihood of patient harm
associated with the use ofassociated with the use of
anticoagulant therapy.anticoagulant therapy.
Note: This requirement applies only to hospitals that provide anticoagulantNote: This requirement applies only to hospitals that provide anticoagulant
therapy and/or long-term anticoagulation prophylaxis (for example, atrialtherapy and/or long-term anticoagulation prophylaxis (for example, atrial
fibrillation) where the clinical expectation is that the patient’s laboratoryfibrillation) where the clinical expectation is that the patient’s laboratory
values for coagulation will remain outside normal values. This requirementvalues for coagulation will remain outside normal values. This requirement
does not apply to routine situations in which short term prophylacticdoes not apply to routine situations in which short term prophylactic
anticoagulation is used for venous thrombo-embolism prevention (foranticoagulation is used for venous thrombo-embolism prevention (for
example, related to procedures or hospitalization) and the clinicalexample, related to procedures or hospitalization) and the clinical
expectation is that the patient’s laboratory values for coagulation willexpectation is that the patient’s laboratory values for coagulation will
remainremain
within, or close to, normal values.within, or close to, normal values.

Anticoagulation therapy can be used as therapeuticAnticoagulation therapy can be used as therapeutic
treatment for a number of conditions, the most common oftreatment for a number of conditions, the most common of
which are atrial fibrillation, deep vein thrombosis, pulmonarywhich are atrial fibrillation, deep vein thrombosis, pulmonary
embolism, and mechanical heart valve implant. However, it isembolism, and mechanical heart valve implant. However, it is
important to note that anticoagulation medications areimportant to note that anticoagulation medications are
more likely than others to cause harm due to complexmore likely than others to cause harm due to complex
dosing, insufficient monitoring, and inconsistent patientdosing, insufficient monitoring, and inconsistent patient
compliance. This National Patient Safety Goal has greatcompliance. This National Patient Safety Goal has great
potential to positively impact the safety of patients on thispotential to positively impact the safety of patients on this
class of medications and result in better outcomes.class of medications and result in better outcomes.

To achieve better patient outcomes, patient education is aTo achieve better patient outcomes, patient education is a
vital component of an anticoagulation therapy program.vital component of an anticoagulation therapy program.
Effective anticoagulation patient education includes face-to-Effective anticoagulation patient education includes face-to-
face interaction with a trained professional who works closelyface interaction with a trained professional who works closely
with patients to be sure that they understand the riskswith patients to be sure that they understand the risks
involved with anticoagulation therapy, the precautions theyinvolved with anticoagulation therapy, the precautions they
need to take, and the need for regular Internationalneed to take, and the need for regular International
Normalized Ratio (INR) monitoring. The use of standardizedNormalized Ratio (INR) monitoring. The use of standardized
practices for anticoagulation therapy that include patientpractices for anticoagulation therapy that include patient
involvement can reduce the risk of adverse drug eventsinvolvement can reduce the risk of adverse drug events
associated with heparin (unfractionated), low molecularassociated with heparin (unfractionated), low molecular
weight heparin, and warfarin.weight heparin, and warfarin.

• Use only oral unit-dose products, prefilled syringes, orUse only oral unit-dose products, prefilled syringes, or
premixed infusion bags when these types of products arepremixed infusion bags when these types of products are
available.available. Note: For pediatric patients, prefilled syringe productsNote: For pediatric patients, prefilled syringe products
should be used only if specifically designed for children.should be used only if specifically designed for children.
• Use approved protocols for the initiation and maintenance ofUse approved protocols for the initiation and maintenance of
anticoagulant therapy.anticoagulant therapy.
• Before starting a patient on warfarin, assess the patient’sBefore starting a patient on warfarin, assess the patient’s
baseline coagulation status; for all patients receivingbaseline coagulation status; for all patients receiving
warfarin therapy, use a current International Normalizedwarfarin therapy, use a current International Normalized
Ratio (INR) to adjust this therapy. The baseline status andRatio (INR) to adjust this therapy. The baseline status and
current INR are documented in the medical record.current INR are documented in the medical record.
Note: The patient’s baseline coagulation status can be assessedNote: The patient’s baseline coagulation status can be assessed
in a number of ways, including through a laboratory test or byin a number of ways, including through a laboratory test or by
identifying risk factors such as age, weight, bleeding tendency,identifying risk factors such as age, weight, bleeding tendency,
and genetic factors.and genetic factors.

• Use authoritative resources to manage potential food andUse authoritative resources to manage potential food and
drug interactions for patients receiving warfarin.drug interactions for patients receiving warfarin.
• When heparin is administered intravenously andWhen heparin is administered intravenously and
continuously, use programmable pumps in order to providecontinuously, use programmable pumps in order to provide
consistent and accurate dosing.consistent and accurate dosing.
• A written policy addresses baseline and ongoing laboratoryA written policy addresses baseline and ongoing laboratory
tests that are required for heparin and low molecular weighttests that are required for heparin and low molecular weight
heparin therapies.heparin therapies.

• Provide education regarding anticoagulant therapy to staff,Provide education regarding anticoagulant therapy to staff,
patients, and families. Patient/family education includespatients, and families. Patient/family education includes
the following:the following:
 the importance of follow-up monitoringthe importance of follow-up monitoring
 compliancecompliance
 drug-food interactionsdrug-food interactions
 the potential for adverse drug reactions and interactionsthe potential for adverse drug reactions and interactions
• Evaluate anticoagulation safety practices, take action toEvaluate anticoagulation safety practices, take action to
improve practices, and measure the effectiveness of thoseimprove practices, and measure the effectiveness of those
actions in a time frame determined by the organizationactions in a time frame determined by the organization

Maintain and communicate accurateMaintain and communicate accurate
patient medication informationpatient medication information
There is evidence that medication discrepancies can affect patient
outcomes. Medication reconciliation is intended to identify and resolve
Discrepancies - it is a process of comparing the medications a patient is
taking (and should be taking) with newly ordered medications. The
comparison addresses duplications, omissions, and interactions, and the
need to continue current medications. The types of information that
clinicians use to reconcile medications include (among others) medication
name, dose, frequency, route, and purpose. Organizations should identify
the information that needs to be collected to reconcile current and newly
ordered medications and to safely prescribe medications in the future.

Obtain information on the medications the patient is currentlyObtain information on the medications the patient is currently
taking when he or she is admitted to the hospital or is seen intaking when he or she is admitted to the hospital or is seen in
an outpatient setting. This information is documented in a listan outpatient setting. This information is documented in a list
Or other format that is useful to those who manageOr other format that is useful to those who manage
medications.medications.
Note 1:Note 1: Current medications include those taken atCurrent medications include those taken at
scheduled times and those taken on an as needed basis.scheduled times and those taken on an as needed basis.
Note 2:Note 2: It is often difficult to obtain complete information onIt is often difficult to obtain complete information on
current medications from a patient. A good faith effort tocurrent medications from a patient. A good faith effort to
obtain this information from the patient and/or other sourcesobtain this information from the patient and/or other sources
will be considered as meeting the intent of the EP.will be considered as meeting the intent of the EP.

Define the types of medication information to be collected inDefine the types of medication information to be collected in
non–24-hour settings and different patient circumstances.non–24-hour settings and different patient circumstances.
Note 1:Note 1: Examples of non–24-hour settings include theExamples of non–24-hour settings include the
emergency department, primary care, outpatient radiology,emergency department, primary care, outpatient radiology,
ambulatory surgery, and diagnostic settings.ambulatory surgery, and diagnostic settings.
Note 2:Note 2: Examples of medication information that may beExamples of medication information that may be
collected include name, dose, route, frequency, and purpose.collected include name, dose, route, frequency, and purpose.

Compare the medication information the patient brought toCompare the medication information the patient brought to
the hospital with the medications ordered for the patient bythe hospital with the medications ordered for the patient by
the hospital in order to identify and resolve discrepancies.the hospital in order to identify and resolve discrepancies.
Note: Discrepancies include omissions, duplications,Note: Discrepancies include omissions, duplications,
contraindications, unclear information, and changes. Acontraindications, unclear information, and changes. A
qualified individual, identified by the hospital, does thequalified individual, identified by the hospital, does the
comparison.comparison.

Provide the patient (or family as needed) with writtenProvide the patient (or family as needed) with written
information on the medications the patient should be takinginformation on the medications the patient should be taking
when he or she is discharged from the hospital or at the endwhen he or she is discharged from the hospital or at the end
of an outpatient encounter (for example, name, dose, route,of an outpatient encounter (for example, name, dose, route,
frequency, purpose).frequency, purpose).
Note: When the only additional medications prescribed areNote: When the only additional medications prescribed are
for a short duration, the medication information the hospitalfor a short duration, the medication information the hospital
provides may include only those medications.provides may include only those medications.

Explain the importance of managing medication informationExplain the importance of managing medication information
to the patient when he or she is discharged from the hospitalto the patient when he or she is discharged from the hospital
or at the end of an outpatient encounter.or at the end of an outpatient encounter.
Note: Examples include instructing the patient to give a list toNote: Examples include instructing the patient to give a list to
his or her primary care physician; to update the informationhis or her primary care physician; to update the information
when medications are discontinued, doses are changed, orwhen medications are discontinued, doses are changed, or
new medications (including over-the-counter products) arenew medications (including over-the-counter products) are
added; and to carry medication information at all times in theadded; and to carry medication information at all times in the
event of emergency situations.event of emergency situations.

Comply with either the current CDCComply with either the current CDC
hand hygiene guidelines or the currenthand hygiene guidelines or the current
WHO hand hygiene guidelinesWHO hand hygiene guidelines
According to the Centers for Disease Control andAccording to the Centers for Disease Control and
Prevention, each year, millions of people acquire anPrevention, each year, millions of people acquire an
infection while receiving care, treatment, and services ininfection while receiving care, treatment, and services in
a health care organization. Consequently, health care-a health care organization. Consequently, health care-
associated infections (HAIs) are a patient safety issueassociated infections (HAIs) are a patient safety issue
affecting all types of health care organizations. One ofaffecting all types of health care organizations. One of
the most important ways to address HAIs is bythe most important ways to address HAIs is by
improving the hand hygiene of health care staff.improving the hand hygiene of health care staff.

Compliance with the World Health Organization (WHO)Compliance with the World Health Organization (WHO)
or Centers for Disease Control and Prevention (CDC)or Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines will reduce the transmission ofhand hygiene guidelines will reduce the transmission of
infectious agents by staff to patients, therebyinfectious agents by staff to patients, thereby
decreasing the incidence of HAIs. To ensuredecreasing the incidence of HAIs. To ensure
compliance with this National Patient Safety Goal, ancompliance with this National Patient Safety Goal, an
organization should assess its compliance with the CDCorganization should assess its compliance with the CDC
and/or WHO guidelines through a comprehensiveand/or WHO guidelines through a comprehensive
program that provides a hand hygiene policy, fosters aprogram that provides a hand hygiene policy, fosters a
culture of hand hygiene, and monitors compliance andculture of hand hygiene, and monitors compliance and
provides feedback.provides feedback.

• Implement a program that follows categories IA, IB,Implement a program that follows categories IA, IB,
and IC of either the current CDC or the current WHOand IC of either the current CDC or the current WHO
hand hygiene guidelines.hand hygiene guidelines.
• Set goals for improving compliance with handSet goals for improving compliance with hand
hygiene guidelines.hygiene guidelines.
• Improve compliance with hand hygiene guidelinesImprove compliance with hand hygiene guidelines
based on established goals.based on established goals.

Implement evidence-based practices toImplement evidence-based practices to
prevent health care–associated infectionsprevent health care–associated infections
due to multidrug-resistant organisms indue to multidrug-resistant organisms in
acute care hospitals.acute care hospitals.
Note: This requirement applies to, but is not limited to,Note: This requirement applies to, but is not limited to,
epidemiologically important organisms such asepidemiologically important organisms such as
Methicillin resistant staphylococcus aureus (MRSA),Methicillin resistant staphylococcus aureus (MRSA),
clostridium difficile (CDI), vancomycin-resistantclostridium difficile (CDI), vancomycin-resistant
enterococci (VRE), and multidrug-resistant gram-enterococci (VRE), and multidrug-resistant gram-
negative bacteria.negative bacteria.

Patients continue to acquire health care–associatedPatients continue to acquire health care–associated
infections at an alarming rate. Risks and patientinfections at an alarming rate. Risks and patient
populations, however, differ between hospitals.populations, however, differ between hospitals.
Therefore, prevention and control strategies must beTherefore, prevention and control strategies must be
tailored to the specific needs of each hospital based ontailored to the specific needs of each hospital based on
its risk assessment. The elements of performance forits risk assessment. The elements of performance for
this requirement are designed to help reduce or preventthis requirement are designed to help reduce or prevent
health care–associated infections fromhealth care–associated infections from
epidemiologically important multidrug-resistantepidemiologically important multidrug-resistant
organisms (MDROs).organisms (MDROs).

Hand hygiene, contact precautions, as well as cleaningHand hygiene, contact precautions, as well as cleaning
and disinfecting patient care equipment and theand disinfecting patient care equipment and the
patient’s environment are essential strategies forpatient’s environment are essential strategies for
preventing the spread of health care–associatedpreventing the spread of health care–associated
infections.infections. Implement evidence-based practices toImplement evidence-based practices to
prevent health care–associated infections due toprevent health care–associated infections due to
multidrug-resistant organisms in critical accessmultidrug-resistant organisms in critical access
hospitals.This requirement applies to, but is not limitedhospitals.This requirement applies to, but is not limited
to, epidemiologically important organisms such asto, epidemiologically important organisms such as
• methicillin-resistant staphylococcus aureus(MRSA)methicillin-resistant staphylococcus aureus(MRSA)
• clostridium difficile(CDI)clostridium difficile(CDI)
• vancomycin-resistant enterococci (VRE)vancomycin-resistant enterococci (VRE)
• multidrug-resistant gram-negative bacteria.multidrug-resistant gram-negative bacteria.

Elements of Performance for NPSG.07.03.01:Elements of Performance for NPSG.07.03.01:
• Conduct periodic risk assessments for multidrug-Conduct periodic risk assessments for multidrug-
resistant organism acquisition and transmission.resistant organism acquisition and transmission.
• Based on the results of the risk assessment, educateBased on the results of the risk assessment, educate
staff and licensed independent practitioners aboutstaff and licensed independent practitioners about
health care–associated infections, multidrug-resistanthealth care–associated infections, multidrug-resistant
organisms, and prevention strategies at hire andorganisms, and prevention strategies at hire and
annually thereafter.annually thereafter.
• Note: The education provided recognizes the diverseNote: The education provided recognizes the diverse
roles of staff and licensed independent practitionersroles of staff and licensed independent practitioners
and is consistent with their roles within the hospital.and is consistent with their roles within the hospital.

• Educate patients, and their families as needed, whoEducate patients, and their families as needed, who
are infected or colonized with a multidrug-resistantare infected or colonized with a multidrug-resistant
organism about health care–associated infectionorganism about health care–associated infection
strategies.strategies.
• Implement a surveillance program for multidrug-Implement a surveillance program for multidrug-
resistant organisms based on the risk assessment.resistant organisms based on the risk assessment.
Note: Surveillance may be targeted rather thanNote: Surveillance may be targeted rather than
hospital-wide.hospital-wide.

• Measure and monitor multidrug-resistant organismMeasure and monitor multidrug-resistant organism
prevention processes and outcomes, including theprevention processes and outcomes, including the
following:following:
 Multidrug-resistant organism infection rates usingMultidrug-resistant organism infection rates using
evidence-based metricsevidence-based metrics
 Compliance with evidence-based guidelines or bestCompliance with evidence-based guidelines or best
practicespractices
 Evaluation of the education program provided to staffEvaluation of the education program provided to staff
and licensed independent practitionersand licensed independent practitioners
Note: Surveillance may be targeted rather than hospital-Note: Surveillance may be targeted rather than hospital-
wide.wide.
• Provide multidrug-resistant organism process andProvide multidrug-resistant organism process and
outcome data to key stakeholders, including leaders,outcome data to key stakeholders, including leaders,
licensed independent practitioners, nursing staff, andlicensed independent practitioners, nursing staff, and
other clinicians.other clinicians.

• Implement policies and practices aimed at reducing theImplement policies and practices aimed at reducing the
risk of transmitting multidrug-resistant organisms. Theserisk of transmitting multidrug-resistant organisms. These
policies and practices meet regulatory requirements andpolicies and practices meet regulatory requirements and
are aligned with evidence-based standards (for example,are aligned with evidence-based standards (for example,
the CDC and/or professional organization guidelines).the CDC and/or professional organization guidelines).
• When indicated by the risk assessment, implement aWhen indicated by the risk assessment, implement a
laboratory-based alert system that identifies new patientslaboratory-based alert system that identifies new patients
with multidrug-resistant organisms.with multidrug-resistant organisms.
Note: The alert system may use telephones, faxes,Note: The alert system may use telephones, faxes,
pagers, automated and secure electronic alerts, or apagers, automated and secure electronic alerts, or a
combination of these methods.combination of these methods.

• When indicated by the risk assessment, implement anWhen indicated by the risk assessment, implement an
alert system that identifies readmitted or transferredalert system that identifies readmitted or transferred
patients who are known to be positive for multidrug-patients who are known to be positive for multidrug-
resistant organisms.resistant organisms.
Note 1: The alert system information may exist in aNote 1: The alert system information may exist in a
separate electronic database or may be integrated into theseparate electronic database or may be integrated into the
admission system. The alert system may be either manualadmission system. The alert system may be either manual
or electronic or a combination of both.or electronic or a combination of both.
Note 2: Each hospital may define its own parameters inNote 2: Each hospital may define its own parameters in
terms of time and clinical manifestation to determine whichterms of time and clinical manifestation to determine which
re-admitted patients require isolation.re-admitted patients require isolation.

prevent central line–associatedprevent central line–associated
bloodstream infections.bloodstream infections.
Note: This requirement covers short and long-termNote: This requirement covers short and long-term
central venous catheters and peripherally insertedcentral venous catheters and peripherally inserted
central catheter (PICC) lines.central catheter (PICC) lines.

• Educate staff and licensed independent practitionersEducate staff and licensed independent practitioners
who are involved in managing central lines aboutwho are involved in managing central lines about
central line–associated bloodstream infections andcentral line–associated bloodstream infections and
the importance of prevention. Education occurs uponthe importance of prevention. Education occurs upon
hire, annually thereafter, and when involvement inhire, annually thereafter, and when involvement in
these procedures is added to an individual’s jobthese procedures is added to an individual’s job
responsibilities.responsibilities.
• Prior to insertion of a central venous catheter,Prior to insertion of a central venous catheter,
educate patients and, as needed, their families abouteducate patients and, as needed, their families about
central line–associated bloodstream infectioncentral line–associated bloodstream infection
prevention.prevention.

• Implement policies and practices aimed at reducingImplement policies and practices aimed at reducing
the risk of central line–associated bloodstreamthe risk of central line–associated bloodstream
infections. These policies and practices meetinfections. These policies and practices meet
regulatory requirements and are aligned withregulatory requirements and are aligned with
evidence-based standards (for example, the CDC)evidence-based standards (for example, the CDC)
and/or professional organization guidelines).and/or professional organization guidelines).
• Conduct periodic risk assessments for central line–Conduct periodic risk assessments for central line–
associated bloodstream infections, monitorassociated bloodstream infections, monitor
compliance with evidence-based practices, andcompliance with evidence-based practices, and
evaluate the effectiveness of prevention efforts. Theevaluate the effectiveness of prevention efforts. The
risk assessments are conducted in time framesrisk assessments are conducted in time frames
defined by the hospital, and this infection surveillancedefined by the hospital, and this infection surveillance
activity is hospital-wide, not targeted.activity is hospital-wide, not targeted.

• Provide central line–associated bloodstream infectionProvide central line–associated bloodstream infection
rate data and prevention outcome measures to keyrate data and prevention outcome measures to key
stakeholders, including leaders, licensed independentstakeholders, including leaders, licensed independent
practitioners, nursing staff, and other clinicians.practitioners, nursing staff, and other clinicians.
• Use a catheter checklist and a standardized protocolUse a catheter checklist and a standardized protocol
for central venous catheter insertion.for central venous catheter insertion.
• Perform hand hygiene prior to catheter insertion orPerform hand hygiene prior to catheter insertion or
manipulation.manipulation.
• For adult patients, do not insert catheters into theFor adult patients, do not insert catheters into the
femoral vein unless other sites are unavailable.femoral vein unless other sites are unavailable.

• Use a standardized supply cart or kit that contains allUse a standardized supply cart or kit that contains all
necessary components for the insertion of central venousnecessary components for the insertion of central venous
catheters.catheters.
• Use a standardized protocol for sterile barrier precautionsUse a standardized protocol for sterile barrier precautions
during central venous catheter insertion.during central venous catheter insertion.
• Use an antiseptic for skin preparation during centralUse an antiseptic for skin preparation during central
venous catheter insertion that is cited in scientific literaturevenous catheter insertion that is cited in scientific literature
or endorsed by professional organizations.or endorsed by professional organizations.
• Use a standardized protocol to disinfect catheter hubs andUse a standardized protocol to disinfect catheter hubs and
injection ports before accessing the ports.injection ports before accessing the ports.
• Evaluate all central venous catheters routinely andEvaluate all central venous catheters routinely and
remove nonessential catheters.remove nonessential catheters.

Implement evidence-based practice forImplement evidence-based practice for
preventing surgical site infectionspreventing surgical site infections
Educate staff and licensed independent practitionersEducate staff and licensed independent practitioners
involved in surgical procedures about surgical site infectionsinvolved in surgical procedures about surgical site infections
and the importance of prevention. Education occurs uponand the importance of prevention. Education occurs upon
hire, annually thereafter, and when involvement in surgicalhire, annually thereafter, and when involvement in surgical
procedures is added to an individual’s job responsibilities.procedures is added to an individual’s job responsibilities.
Educate patients, and their families as needed, who areEducate patients, and their families as needed, who are
undergoing a surgical procedure about surgical site infectionundergoing a surgical procedure about surgical site infection
prevention.prevention.

• Implement policies and practices aimed at reducing theImplement policies and practices aimed at reducing the
risk of surgical site infections. These policies andrisk of surgical site infections. These policies and
practices meet regulatory requirements and are alignedpractices meet regulatory requirements and are aligned
with evidence-based guidelines (for example, the CDCwith evidence-based guidelines (for example, the CDC
and/or professional organization guidelines).and/or professional organization guidelines).
• As part of the effort to reduce surgical site infections:As part of the effort to reduce surgical site infections:
 Conduct periodic risk assessments for surgical siteConduct periodic risk assessments for surgical site
infections in a time frame determined by the hospital.infections in a time frame determined by the hospital.
 Select surgical site infection measures using best practicesSelect surgical site infection measures using best practices
or evidence-based guidelines.or evidence-based guidelines.
 Monitor compliance with best practices or evidence-basedMonitor compliance with best practices or evidence-based
guidelines.guidelines.
 Evaluate the effectiveness of prevention efforts.Evaluate the effectiveness of prevention efforts.
Note: Surveillance may be targeted to certain procedures based onNote: Surveillance may be targeted to certain procedures based on
the hospital’s risk assessment.the hospital’s risk assessment.

• Measure surgical site infection rates for the first 30 daysMeasure surgical site infection rates for the first 30 days
following procedures that do not involve insertingfollowing procedures that do not involve inserting
implantable devices and for the first year followingimplantable devices and for the first year following
procedures involving implantable devices. The hospital’sprocedures involving implantable devices. The hospital’s
measurement strategies follow evidence-basedmeasurement strategies follow evidence-based
guidelines.guidelines. Note: Surveillance may be targeted to certainNote: Surveillance may be targeted to certain
procedures based on the hospital's risk assessment.procedures based on the hospital's risk assessment.
• Provide process and outcome (for example, surgical siteProvide process and outcome (for example, surgical site
infection rate) measure results to key stakeholders.infection rate) measure results to key stakeholders.
• Administer antimicrobial agents for prophylaxis for aAdminister antimicrobial agents for prophylaxis for a
particular procedure or disease according to evidence-particular procedure or disease according to evidence-
based best practices.based best practices.
• When hair removal is necessary, use clippers orWhen hair removal is necessary, use clippers or
depilatories.depilatories. Note: Shaving is an inappropriate hairNote: Shaving is an inappropriate hair
removal method.removal method.

prevent indwelling catheter-associatedprevent indwelling catheter-associated
urinary tract infections (CAUTI)urinary tract infections (CAUTI)
Note: This NPSG isNote: This NPSG is newnew for 2012 and not applicable tofor 2012 and not applicable to
pediatric populations.pediatric populations.
During 2012, plan for the full implementation of this
NPSG by January 1, 2013. Note: Planning may include
a number of different activities, such as assigning
responsibility for implementation activities, creating time
lines, identifying resources, and pilot testing.

Insert indwelling urinary catheters according toInsert indwelling urinary catheters according to
established evidence-based guidelines that address theestablished evidence-based guidelines that address the
• limiting use and duration to situations necessary forlimiting use and duration to situations necessary for
patient carepatient care
• using aseptic techniques for site preparation,using aseptic techniques for site preparation,
equipment, and suppliesequipment, and supplies

Manage indwelling urinary catheters according toManage indwelling urinary catheters according to
established evidence-based guidelines that address theestablished evidence-based guidelines that address the
• securing catheters for unobstructed urine flow andsecuring catheters for unobstructed urine flow and
drainagedrainage
• maintaining the sterility of the urine collection systemmaintaining the sterility of the urine collection system
• replacing the urine collection system when requiredreplacing the urine collection system when required
• collecting urine samplescollecting urine samples

Measure and monitor catheter-associated urinary tractMeasure and monitor catheter-associated urinary tract
infection prevention processes and outcomes in high-infection prevention processes and outcomes in high-
volume areas by doing the following:volume areas by doing the following:
• selecting measures using evidence-based guidelinesselecting measures using evidence-based guidelines
or best practicesor best practices
• monitoring compliance with evidence-basedmonitoring compliance with evidence-based
guidelines or best practicesguidelines or best practices
• evaluating the effectiveness of prevention effortsevaluating the effectiveness of prevention efforts

Identify patients at risk for suicideIdentify patients at risk for suicide
Note: This requirement applies only to psychiatric hospitalsNote: This requirement applies only to psychiatric hospitals
and patients being treated for emotional or behavioraland patients being treated for emotional or behavioral
disorders in general hospitals.disorders in general hospitals.
Suicide of a patient while in a staffed, round-the-clock careSuicide of a patient while in a staffed, round-the-clock care
setting is a frequently reported type of sentinel event.setting is a frequently reported type of sentinel event.
Identification of individuals at risk for suicide while under theIdentification of individuals at risk for suicide while under the
care of or following discharge from a health care organizationcare of or following discharge from a health care organization
is an important step in protecting these at-risk individuals.is an important step in protecting these at-risk individuals.

Elements of Performance for NPSG.10.01.01:Elements of Performance for NPSG.10.01.01:
• Conduct a risk assessment that identifies specific patientConduct a risk assessment that identifies specific patient
characteristics and environmental features that maycharacteristics and environmental features that may
increase or decrease the risk for suicide.increase or decrease the risk for suicide.
• Address the patient’s immediate safety needs and mostAddress the patient’s immediate safety needs and most
appropriate setting for treatment.appropriate setting for treatment.
• When a patient at risk for suicide leaves the care of theWhen a patient at risk for suicide leaves the care of the
hospital, provide suicide prevention information (such as ahospital, provide suicide prevention information (such as a
crisis hotline) to the patient and his or her family.crisis hotline) to the patient and his or her family.

Introduction to the Universal ProtocolIntroduction to the Universal Protocol
for Preventing Wrong Site, Wrongfor Preventing Wrong Site, Wrong
Procedure, and Wrong PersonProcedure, and Wrong Person
Surgery™Surgery™
The Universal Protocol applies to all surgical andThe Universal Protocol applies to all surgical and
non-surgical invasivenon-surgical invasive procedures.procedures. Evidence indicatesEvidence indicates
that procedures that place the patient at the most riskthat procedures that place the patient at the most risk
include those that involve general anesthesia or deepinclude those that involve general anesthesia or deep
sedation,sedation, although other procedures may also affectalthough other procedures may also affect
patient safety. Hospitals can enhance safety bypatient safety. Hospitals can enhance safety by
correctly identifying the patient, the appropriatecorrectly identifying the patient, the appropriate
procedure, and the correct site of the procedure.procedure, and the correct site of the procedure.

The Universal Protocol is based on the followingThe Universal Protocol is based on the following
principles:principles:
• Wrong-person, wrong-site, and wrong-procedure surgeryWrong-person, wrong-site, and wrong-procedure surgery
can and must be prevented.can and must be prevented.
• A robust approach using multiple, complementaryA robust approach using multiple, complementary
strategies is necessary to achieve the goal of alwaysstrategies is necessary to achieve the goal of always
conducting the correct procedure on the correct person, atconducting the correct procedure on the correct person, at
the correct site.the correct site.
• Active involvement and use of effective methods toActive involvement and use of effective methods to
improve communication among all members of theimprove communication among all members of the
procedure team are important for success.procedure team are important for success.
• To the extent possible, the patient and, as needed, theTo the extent possible, the patient and, as needed, the
family are involved in the process.family are involved in the process.
• Consistent implementation of a standardized protocol isConsistent implementation of a standardized protocol is
most effective in achieving safety.most effective in achieving safety.

The Universal Protocol is implemented most successfully inThe Universal Protocol is implemented most successfully in
hospitals with a culture that promotes teamwork and wherehospitals with a culture that promotes teamwork and where
all individuals feel empowered to protect patient safety. Aall individuals feel empowered to protect patient safety. A
hospital should consider its culture when designinghospital should consider its culture when designing
processes to meet the Universal Protocol. In some hospitals,processes to meet the Universal Protocol. In some hospitals,
it may be necessary to be more prescriptive on certainit may be necessary to be more prescriptive on certain
elements of the Universal Protocol or to create processeselements of the Universal Protocol or to create processes
that are not specifically addressed within these requirements.that are not specifically addressed within these requirements.

Hospitals should identify the timing and location of the pre-Hospitals should identify the timing and location of the pre-
procedure verification and site marking based on what worksprocedure verification and site marking based on what works
best for their own unique circumstances. The frequency andbest for their own unique circumstances. The frequency and
scope of the pre-procedure verification will depend on the typescope of the pre-procedure verification will depend on the type
and complexity of the procedure. The three components of theand complexity of the procedure. The three components of the
Universal Protocol are not necessarily presented inUniversal Protocol are not necessarily presented in
chronological order (although the pre-procedure verification andchronological order (although the pre-procedure verification and
site marking precede the final verification in the time out). Pre-site marking precede the final verification in the time out). Pre-
procedure verification, site marking, and the time-outprocedure verification, site marking, and the time-out
procedures should be as consistent as possible throughout theprocedures should be as consistent as possible throughout the
hospital.hospital. Note: Site marking is not required when the individualNote: Site marking is not required when the individual
doing the procedure is continuously with the patient from thedoing the procedure is continuously with the patient from the
time of the decision to do the procedure through to thetime of the decision to do the procedure through to the
performance of the procedure.performance of the procedure.

Universal Precautions 01.01.01Universal Precautions 01.01.01
Conduct a Pre-Procedure VerificationConduct a Pre-Procedure Verification
ProcessProcess
Hospitals should always make sure that any procedureHospitals should always make sure that any procedure
is what the patient needs and is performed on the rightis what the patient needs and is performed on the right
person. The frequency and scope of the verificationperson. The frequency and scope of the verification
process will depend on the type and complexity of theprocess will depend on the type and complexity of the
procedure.procedure.

The pre-procedure verification is an ongoing process ofThe pre-procedure verification is an ongoing process of
information gathering and confirmation. The purpose ofinformation gathering and confirmation. The purpose of
the pre-procedure verification process is to make surethe pre-procedure verification process is to make sure
that all relevant documents and related information orthat all relevant documents and related information or
equipment are:equipment are:
• available prior to the start of the procedureavailable prior to the start of the procedure
• correctly identified, labeled, and matched to thecorrectly identified, labeled, and matched to the
patient’s identifierspatient’s identifiers
• reviewed and are consistent with the patient’sreviewed and are consistent with the patient’s
expectations and with the team’s understanding ofexpectations and with the team’s understanding of
the intended patient, procedure and site.the intended patient, procedure and site.

Pre-procedure verification may occur at more than onePre-procedure verification may occur at more than one
time and place before the procedure. It is up to thetime and place before the procedure. It is up to the
hospital to decide when this information is collected andhospital to decide when this information is collected and
by which team member, but it is best to do it when theby which team member, but it is best to do it when the
patient can be involved. Possibilities include thepatient can be involved. Possibilities include the
• when the procedure is scheduledwhen the procedure is scheduled
• at the time of preadmission testing and assessmentat the time of preadmission testing and assessment
• at the time of admission or entry into the facility for aat the time of admission or entry into the facility for a
procedureprocedure
• before the patient leaves the preprocedure area or entersbefore the patient leaves the preprocedure area or enters
the procedure roomthe procedure room
• missing information or discrepancies are addressedmissing information or discrepancies are addressed
before starting the procedure.before starting the procedure.

Elements of Performance for Universal Protocol.01.01.01Elements of Performance for Universal Protocol.01.01.01
Implement a pre-procedure process to verify the correct procedure,Implement a pre-procedure process to verify the correct procedure,
for the correct patient, at the correct site.for the correct patient, at the correct site. Note: The patient isNote: The patient is
involved in the verification process when possible.involved in the verification process when possible.
Identify the items that must be available for the procedure and useIdentify the items that must be available for the procedure and use
a standardized list to verify their availability. At a minimum, thesea standardized list to verify their availability. At a minimum, these
items include the following:items include the following:
• relevant documentation (for example, history & physical,relevant documentation (for example, history & physical,
signed procedure consent form, nursing assessment, and pre-signed procedure consent form, nursing assessment, and pre-
anesthesia assessment)anesthesia assessment)
• labeled diagnostic and radiology test results (for example,labeled diagnostic and radiology test results (for example,
radiology images and scans, or pathology and biopsy reports)radiology images and scans, or pathology and biopsy reports)
that are properly displayedthat are properly displayed

Any required blood products, implants, devices, and/orAny required blood products, implants, devices, and/or
special equipment for the procedure. Note: The expectationspecial equipment for the procedure. Note: The expectation
of this element of performance is that the standardized list isof this element of performance is that the standardized list is
available and is used consistently during the pre-procedureavailable and is used consistently during the pre-procedure
verification. It is not necessary to document that theverification. It is not necessary to document that the
standardized list was used for each patient.standardized list was used for each patient.
Match the items that are to be available in the procedureMatch the items that are to be available in the procedure
area to the patient.area to the patient.

Universal Protocol 01.02.01Universal Protocol 01.02.01
Mark the procedure siteMark the procedure site
Elements of Performance for UP.01.02.01Elements of Performance for UP.01.02.01
Identify those procedures that require marking of the incision orIdentify those procedures that require marking of the incision or
insertion site. At a minimum, sites are marked when there isinsertion site. At a minimum, sites are marked when there is
more than one possible location for the procedure and whenmore than one possible location for the procedure and when
performing the procedure in a different location would negativelyperforming the procedure in a different location would negatively
affect quality or safety.affect quality or safety. Note: For spinal procedures, in addition toNote: For spinal procedures, in addition to
preoperative skin marking of the general spinal region, special intra-preoperative skin marking of the general spinal region, special intra-
operative imaging techniques may be used for locating and markingoperative imaging techniques may be used for locating and marking
thethe
exact vertebral level.exact vertebral level. Mark the procedure site before the procedureMark the procedure site before the procedure
is performed and, if possible, with the patient involved.is performed and, if possible, with the patient involved.

The procedure site is marked by a licensed independentThe procedure site is marked by a licensed independent
practitioner who is ultimately accountable for the procedurepractitioner who is ultimately accountable for the procedure
and will be present when the procedure is performed. Inand will be present when the procedure is performed. In
limited circumstances, the licensed independent practitionerlimited circumstances, the licensed independent practitioner
may delegate site marking to an individual who is permittedmay delegate site marking to an individual who is permitted
by the organization to participate in the procedure and hasby the organization to participate in the procedure and has
the following qualifications:the following qualifications:
• An individual in a medical residency program who is beingAn individual in a medical residency program who is being
supervised by the licensed independent practitioner performing thesupervised by the licensed independent practitioner performing the
procedure, who is familiar with the patient, and who will be presentprocedure, who is familiar with the patient, and who will be present
when the procedure is performedwhen the procedure is performed
• A licensed individual who performs duties requiring a collaborativeA licensed individual who performs duties requiring a collaborative
agreement or supervisory agreement with the licensed independentagreement or supervisory agreement with the licensed independent
practitioner performing the procedure; that is, an advanced practicepractitioner performing the procedure; that is, an advanced practice
registered nurse (A.P.R.N.) or physician assistant (P.A.), who isregistered nurse (A.P.R.N.) or physician assistant (P.A.), who is
familiar with the patient, and who will be present when thefamiliar with the patient, and who will be present when the
procedure is performed.procedure is performed.

The method of marking the site and the type of mark isThe method of marking the site and the type of mark is
unambiguous and is used consistently throughout theunambiguous and is used consistently throughout the
hospital. Note: The mark is made at or near the procedurehospital. Note: The mark is made at or near the procedure
site and is sufficiently permanent to be visible after skinsite and is sufficiently permanent to be visible after skin
preparation and draping. Adhesive markers are not the solepreparation and draping. Adhesive markers are not the sole
means of marking the site.means of marking the site.
A written, alternative process is in place for patients whoA written, alternative process is in place for patients who
refuse site marking or when it is technically or anatomicallyrefuse site marking or when it is technically or anatomically
impossible or impractical to mark the site (for example,impossible or impractical to mark the site (for example,
mucosal surfaces or perineum).mucosal surfaces or perineum).

Examples of other situations that involve alternativeExamples of other situations that involve alternative
processes include:processes include:
• minimal access procedures treating a lateralizedminimal access procedures treating a lateralized
internal organ, whether percutaneous or through ainternal organ, whether percutaneous or through a
natural orificenatural orifice
• interventional procedure cases for which theinterventional procedure cases for which the
catheter/instrument insertion site is notcatheter/instrument insertion site is not
predetermined (for example, cardiacpredetermined (for example, cardiac
catheterization, pacemaker insertion)catheterization, pacemaker insertion)
• teethteeth
• premature infants, for whom the mark may cause apremature infants, for whom the mark may cause a
permanent tattoo.permanent tattoo.

Universal Protocol Goal 01.03.01Universal Protocol Goal 01.03.01
A time-out if performed before the procedureA time-out if performed before the procedure
The purpose of the time-out is to conduct a finalThe purpose of the time-out is to conduct a final
assessment that the correct patient, site, and procedureassessment that the correct patient, site, and procedure
are identified. This requirement focuses on those minimumare identified. This requirement focuses on those minimum
features of the time-out. Some believe that it is important tofeatures of the time-out. Some believe that it is important to
conduct the time-out before anesthesia for several reasons,conduct the time-out before anesthesia for several reasons,
including involvement of the patient.including involvement of the patient.

A hospital may conduct the time-out before anesthesiaA hospital may conduct the time-out before anesthesia
or may add another time-out at that time. During aor may add another time-out at that time. During a
timeout, activities are suspended to the extent possibletimeout, activities are suspended to the extent possible
so that team members can focus on active confirmationso that team members can focus on active confirmation
of the patient, site, and procedure. A designatedof the patient, site, and procedure. A designated
member of the team initiates the time-out and it includesmember of the team initiates the time-out and it includes
active communication among all relevant members ofactive communication among all relevant members of
the procedure team. The procedure is not started untilthe procedure team. The procedure is not started until
all questions or concerns are resolved. The time-out isall questions or concerns are resolved. The time-out is
most effective when it is conducted consistently acrossmost effective when it is conducted consistently across
the hospital.the hospital.

Elements of Performance for UP.01.03.01Elements of Performance for UP.01.03.01
Conduct a time-out immediately before starting theConduct a time-out immediately before starting the
invasive procedure or making the incision. The time-outinvasive procedure or making the incision. The time-out
has the following characteristics:has the following characteristics:
• It is standardized, as defined by the hospital.It is standardized, as defined by the hospital.
• It is initiated by a designated member of the team.It is initiated by a designated member of the team.
• It involves the immediate members of the procedureIt involves the immediate members of the procedure
team, including the individual performing theteam, including the individual performing the
procedure, the anesthesia providers, the circulatingprocedure, the anesthesia providers, the circulating
nurse, the operating room technician, and othernurse, the operating room technician, and other
active participants who will be participating in theactive participants who will be participating in the
procedure from the beginning.procedure from the beginning.

When two or more procedures are being performed onWhen two or more procedures are being performed on
the same patient, and the person performing thethe same patient, and the person performing the
procedure changes, perform a time-out before eachprocedure changes, perform a time-out before each
procedure is initiated. During the time-out, the teamprocedure is initiated. During the time-out, the team
members agree, at a minimum, on the following:members agree, at a minimum, on the following:
• correct patient identitycorrect patient identity
• the correct sitethe correct site
• the procedure to be donethe procedure to be done
Document the completion of the time-out.Document the completion of the time-out.
Note: The hospital determines the amount and type ofNote: The hospital determines the amount and type of
documentation.documentation.

JCAHO Official “Do Not Use” ListJCAHO Official “Do Not Use” List
Do Not UseDo Not Use Potential ProblemPotential Problem Use InsteadUse Instead
U, u (unit)U, u (unit) Mistaken for “0” (zero),Mistaken for “0” (zero), Write “unit”Write “unit”
the number “4” (four) or “cc”the number “4” (four) or “cc”
IU (International Unit)IU (International Unit) Mistaken for IV (intravenous)Mistaken for IV (intravenous) Write “InternationalWrite “International
or the number 10 (ten)or the number 10 (ten) Unit”Unit”
Q.D., QD, q.d., qd (daily)Q.D., QD, q.d., qd (daily) Mistaken for each otherMistaken for each other Write “daily”Write “daily”
Q.O.D., QOD, q.o.d, qodQ.O.D., QOD, q.o.d, qod Period after the Q mistaken forPeriod after the Q mistaken for Write “every otherWrite “every other
(every other day)(every other day) “I” and the “O” mistaken for “I”“I” and the “O” mistaken for “I” day”day”
Trailing zero (X.0 mg)*Trailing zero (X.0 mg)* Decimal point is missedDecimal point is missed Write X mgWrite X mg
Lack of leading zero (.X mg)Lack of leading zero (.X mg) Write 0.X mgWrite 0.X mg
MSMS Can mean morphine sulfate orCan mean morphine sulfate or Write "morphineWrite "morphine
magnesium sulfatemagnesium sulfate sulfate"sulfate"
MSO4 and MgSO4MSO4 and MgSO4 Confused for one anotherConfused for one another Write "magnesiumWrite "magnesium
sulfate"sulfate"

JCAHO Official “Do Not Use” ListJCAHO Official “Do Not Use” List
Applies to all orders and all medication-related documentation that isApplies to all orders and all medication-related documentation that is
handwritten (including free-text computer entry) or on pre-printedhandwritten (including free-text computer entry) or on pre-printed
forms.forms.
Exception:Exception: A “trailing zero” may be used only whereA “trailing zero” may be used only where
required to demonstrate the level of precision of therequired to demonstrate the level of precision of the
value being reported, such as for laboratory results,value being reported, such as for laboratory results,
imaging studies that report size of lesions, orimaging studies that report size of lesions, or
catheter/tube sizes.catheter/tube sizes. It may not be used in medicationIt may not be used in medication
orders or other medication-related documentation.orders or other medication-related documentation.

Additional Abbreviations, Acronyms and SymbolsAdditional Abbreviations, Acronyms and Symbols
Do Not UseDo Not Use Potential ProblemPotential Problem Use InsteadUse Instead
> (greater than)> (greater than) Misinterpreted as the number Write “greater than”Misinterpreted as the number Write “greater than”
< (less than)< (less than) “7” (seven) or the letter “L”“7” (seven) or the letter “L” Write “less than”Write “less than”
Confused for one anotherConfused for one another
Abbreviations forAbbreviations for Misinterpreted due to Write drug names in fullMisinterpreted due to Write drug names in full
drug namesdrug names similar abbreviations forsimilar abbreviations for
multiple drugsmultiple drugs
Apothecary unitsApothecary units Unfamiliar to many practitioners Use metric unitsUnfamiliar to many practitioners Use metric units
Confused with metric unitsConfused with metric units
@@ Mistaken for the number “2” (two) Write “at”Mistaken for the number “2” (two) Write “at”
cccc Mistaken for U (units)Mistaken for U (units) Write “mL” or “ml”Write “mL” or “ml”
when poorly writtenwhen poorly written or “milliliters”or “milliliters”
(“mL” is preferred)(“mL” is preferred)
μgμg Mistaken for mg (milligrams)Mistaken for mg (milligrams) Write "mcg" orWrite "mcg" or
resulting in one thousand-fold overdose “micrograms”resulting in one thousand-fold overdose “micrograms”

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