Protocol Development and Quality Improvement

Patient safety–endorsed measures notable for ICU care (2015)

ADEs

ii.

Catheter-associated urinary tract infections

iii.

Central line–associated bloodstream infections

iv.

Surgical site infections

Ventilator-associated pneumonia

vi.

Ventilator-associated events

vii.

Stroke

viii.

Acute myocardial infarction

ix.

Falls

Pressure ulcer rate

Health information technology–related safety events (2016)

Aims to reduce preventable harm by first modernizing criteria for what constitutes a serious

reportable event

The Leapfrog Group – Launched in 2000

Hospital quality and safety survey is a voluntary survey of hospitals rating themselves on quality

and safety practices

Reported at www.leapfroggroup.org

ICU-related measures

CPOE

ii.

Bar code medication administration

iii.

ICU physician staffing

iv.

Hand hygiene

Air embolism

vi.

Falls and Trauma

vii.

Central line–associated bloodstream infection

viii.

Catheter-associated urinary tract infection

ix.

Health-care associated infections including surgical site infection: Colon, methicillin-resistant

Staphylococcus aureus, Clostridioides difficile

The Joint Commission (TJC) – Founded in 1951

One of three CMS accreditation organizations, TJC is an independent, not-for-profit organization

that sets the standards for accreditation in health care

Tracer methodology – Method of evaluation done during an on-site survey that traces the health

care experiences of a patient while in the hospital

Identifies, tests, and specifies standardization of performance measures

Identify patients correctly (NPSG.01.01.01).

of birth. This is done to make sure that each patient receives the correct medication and

treatment.

ii.

Improve staff communication (NPSG.02.03.01).

iii.

Use medications safely.

cups, and basins). Do this where medications and supplies are set up (NPSG.02.03.01).