Protocol Development and Quality Improvement
| (1) | Unless an authorized staff member prepares a medication, takes it directly to the |
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patient, and administers it without a break in the process, the medication must be
labeled.
| (2) | Medication or solution labels should include name, strength, concentration, diluent |
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and volume, and expiration date/time.
| (b) | Reduce the likelihood of patient harm associated with the use of anticoagulant therapy |
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(NPSG.03.05.01)
| (c) | Record and pass along correct information about a patient’s medications at admission, |
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transfer, and discharge. Find out what medications the patient is taking. Compare these
medications with new medications given to the patient. Make sure patients know which
medications to take when they are at home. Tell patients it is important to bring their up-
to-date list of medications each time they visit a physician (NPSG.03.06.01).
iv.
Use alarms safely. Make improvements to ensure alarms on medical equipment are heard and
responded to on time (NPSG.06.01.01).
Prevent infection (NPSG.07.01.01).
| (a) | Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or |
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the World Health Organization. Set goals for improving hand cleaning. Use the goals to
improve hand cleaning.
vi.
Identify patient safety risks: Reduce the risk of suicide (NPSG.15.01.01).
vii.
Improve health care equity (NPSG16.01.01).
| (a) | Improving health care equity is a quality and patient safety priority. Identify health care |
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disparities in the population and develop a written plan to improve this.
viii.
Prevent mistakes in surgery using pre-procedural checklist:
| (a) | Make sure that the correct surgery is done on the correct patient and at the correct place |
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on the patient’s body (UP.01.01.01).
| (b) | Mark the correct place on the patient’s body where the surgery is to be done (UP.01.02.01). |
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| (c) | Have a time-out before the surgery to make sure that a mistake is not being made and |
document the time-out (UP.01.03.01).
The Joint Commission (TJC) chart-abstracted measures for hospitals. Note that beginning with
01/01/2020 discharges, the emergency department (ED), immunization (IMM), substance use
(SUB), tobacco treatment (TOB), and venous thromboembolism (VTE) measures previously in the
aligned CMS/TJC specifications manual have been moved to the Specifications Manual for Joint
Commission National Quality Measures for hospital use.
Chart-abstracted measures from the hospital inpatient quality reporting (IQR) program;
however, the hospital may still voluntarily report (critical care-focused measures)
| (a) | Venous thromboembolism - VTE-6-Hospital-acquired, potentially preventable venous |
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thromboembolism
| (b) | Immunization - IMM-2 influenza immunization |
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ii.
Required chart-abstracted core measures from the Specifications Manual for Joint Commission
National Quality Measures, version 2022B2, posted 9/6/2022 (critical care–focused measures)
| (a) | Comprehensive stroke - CSTK-04 Procoagulant reversal agent initiation for intracerebral |
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hemorrhage (ICH)
| (b) | Comprehensive stroke - CSTK-05a Hemorrhage transformation for patients treated with |
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intravenous alteplase therapy only
| (c) | Comprehensive stroke - CSTK-05b Hemorrhage transformation for patients treated with |
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intravenous alteplase therapy or mechanical endovascular reperfusion therapy
| (d) | Comprehensive stroke - CSTK-06 Nimodipine treatment administered |
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