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Accreditation Insider Patient Safety Monitor Insider
Accreditation Insider
AHAP is a community in which survey coordinators and other accreditation specialists share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth. In this e-newsletter, you'll read helpful tips and timely news items related to accreditation and survey-readiness improvement. Plus, train your staff and yourself with our weekly quiz questions included with clickable answers.
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Issue 52, December 30, 2014
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Wisconsin nurse investigated for patient infection death
A former University of Wisconsin Hospital nurse accused of stealing morphine could also face a... -
Staff Challenge: National Patient Safety Goals
Medications prepared and used in the OR and other procedural areas must be labeled. The label...
Issue 51, December 23, 2014
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CMS announces list of facilities penalized for HACs
One in five hospitals are being penalized by the CMS for hospital-acquired conditions. -
Report: U.S. is unprepared for future outbreaks
A new report found that much of the United States is not prepared for future infectious outbreaks. -
Staff Challenge: Provision of Care
True or false: A postoperative patient who is receiving pain medication should be educated about... -
Webcast: Conduct OSHA mock inspections to ensure compliance, improve safety
An upcoming HCPro webcast will help attendees ensure safety compliance in physician offices...
Issue 50, December 16, 2014
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Report: Hospital alarms are top healthcare tech hazard
A new ECRI Institute report says hospital alarm errors top the list of healthcare technology... -
Report: Superbugs could become a worldwide crisis
A new British government report warns that antimicrobial-resistant infections could lead to 10... -
Staff Challenge: National Patient Safety Goals
Fill in the blanks: A hospital ________________ should be performed on a regular basis to determine...
Issue 49, December 9, 2014
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Ohio hospital successfully reduces false alarms
A Cincinnati hospital formed a task force and substantially reduced the number of false alarms from... -
Dallas ER doc: Mistakes were made in Ebola case
The emergency room physician who initially misdiagnosed the first Ebola patient on U.S. soil now... -
Staff Challenge: Provision of Care
True or false: A postoperative patient who is receiving pain medication should be educated about...
Issue 48, December 2, 2014
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AHRQ: U.S. hospitals prevented 1.3 million adverse events since 2010
U.S. hospitals are making headway in preventing adverse events, with the Agency for Healthcare... -
CDC: ER visits at an all-time high
Emergency departments are busier than ever, with more than 136 million patient visits in 2011... -
Staff Challenge: National Patient Safety Goals
True or false: When a patient has been seen in the outpatient clinic for a minor eye infection and...
Issue 47, November 25, 2014
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California hospitals reported 6,200 adverse events since 2010
Hospitals in California reported more than 6,200 adverse events in the last four fiscal years. -
Joint Commission adds Life Safety CodeĀ® surveyor to ASC surveys
The Joint Commission will add a Life Safety Code® surveyor to the survey team for ambulatory... -
Staff Challenge: National Patient Safety Goals
What does the statement “Immediately Administered Medication” mean? -
Learn about preventing ED violence in upcoming webinar
A December 10 webinar from HCPro discusses how to prevent ED violence and design an effective...
Issue 46, November 18, 2014
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2015 National Patient Safety Goals released
The full chapter of The Joint Commission’s 2015 National Patient Safety Goals has been... -
Joint Commission: 1,200 hospitals achieved Top Performer status
The Joint Commission recognized more than 1,200 hospitals in its Top Performers on Key Quality... -
Staff Challenge: Provision of Care
Fill in the blank: A patient’s learning needs and ability to learn should be assessed...
Issue 45, November 11, 2014
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Study: Handoff improvement program reduces medical errors
Implementing a handoff improvement program has been found to reduce medical errors in nine... -
Team-based approach successful at reducing alarm fatigue
A study found that using a team-based approach can help hospitals reduce alarm fatigue. -
Staff Challenge: National Patient Safety Goals
When should staff and physicians be educated about healthcare-associated infections including...
Issue 44, November 4, 2014
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Leapfrog Group releases latest patient safety ratings
The Leapfrog Group last week released the fall 2014 update to its Hospital Safety Scores, which... -
Joint Commission clarifies pain management standard
The Joint Commission revised the language to its pain management standard to encourage healthcare... -
Staff Challenge: National Patient Safety Goals
Patient/family education on the importance of medication management is a critical component of...
Issue 43, October 28, 2014
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CDC releases new Ebola guidelines for ED workers
The Centers for Disease Control and Prevention this week released new guidelines for emergency... -
Studies: Collaboration with caregivers can help reduce readmissions
Two new research studies released this month found that better collaboration with community-based... -
Staff Challenge: Provision of Care
Fill in the blank: Each patient should have a written plan of care that has ______________ and... -
Nov. 17 webcast provides latest guidance on how hospitals can prepare for Ebola
A new HCPro webcast will help hospitals prepare a response plan in the event they receive a patient...
Issue 42, October 21, 2014
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Joint Commission makes new patient safety chapter available for download
The Joint Commission is allowing the public to download its new Patient Safety Systems chapter... -
CDC tightens up PPE guidance for Ebola patient care
The Centers for Disease Control and Prevention has released updated guidance for healthcare workers... -
Staff Challenge: Medication Management
Fill in the blank: Orders in which the dose is decreased by a particular amount with each dosing...
Issue 41, October 14, 2014
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CDC vows to change Ebola hospital procedures
In the wake of a Dallas nurse testing positive for Ebola, the director of the CDC says new... -
Hospitals, unions face off over mandatory flu vaccinations
Some hospital employees are challenging facility mandated flu vaccinations, highlighted by a...
Issue 40, October 7, 2014
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Study: C. diff infection rate levels off
A new study found that the rate of C. difficile infections in hospitals nearly doubled from 2001 to... -
Medicare levies record number of 30-day readmission fines
Hospitals are feeling the heat to reduce readmissions, with 2,610 receiving fines from Medicare for... -
Staff Challenge: Environment of Care and Life Safety
At least ___% of your fire drills should be unannounced.
Issue 39, September 30, 2014
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Unintended retention of objects after surgery tops most-reported sentinel events
The Joint Commission reviewed 394 sentinel events during the first half of 2014, according to... -
CMS offers categorical waiver allowing power strip use in hospitals
The CMS is offering a categorical waiver that permits hospitals to use power strips in patient care... -
Staff Challenge: Provision of Care
What are the time parameters for completing a history and physical?
Issue 38, September 23, 2014
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President signs executive order to fight antibiotic resistance
President Barack Obama last week announced a national strategy to prevent the spread of... -
Report: Healthcare worker flu vaccination rate is still lacking
Flu vaccinations for healthcare workers are lacking, according to a new report published in the... -
Staff Challenge: National Patient Safety Goals
Hospitals are permitted to define what medication information is necessary to be obtained from the...
Issue 37, September 16, 2014
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Joint Commission to add new patient safety chapter to manual
The Joint Commission is adding a new patient safety-focused chapter to its accreditation manual and... -
Study: Majority of U.S. hospitals overuse antibiotics
A study conducted by the Centers for Disease Control and Prevention and Premier Safety Institute... -
Staff Challenge: Provision of Care
Fill in the blank: When a patient is both in restraints AND secluded, the patient must be...
Issue 36, September 9, 2014
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Safety issues continue to dominate top-cited standards list
Eight of The Joint Commission’s top 10 standards compliance issues for the first half of 2014... -
CMS to resume releasing hospital-acquired conditions data
After it stopped public reporting data on hospital-acquired conditions, the CMS now plans to resume... -
Staff Challenge: Environment of Care and Life Safety
Fire drills are required “one per shift, per quarter” in buildings designated as... -
Webcast examines financial benefits of quality and patient safety
Upcoming HCPro webcast will describe how to build patient safety and quality programs that measure...
Issue 35, September 2, 2014
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Standards revisions align with CMS changes
New Joint Commission revisions to hospital standards have been made to align with CMS effort to... -
Los Angeles hospital agrees to pay $700,000 in patient dumping case
A Glendale, California hospital has agreed to pay $700,000 in civil penalties to settle a lawsuit... -
Staff Challenge: Environment of Care and Life Safety
The e-SOC is comprised of two basic sections. Name them.
Issue 34, August 26, 2014
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New Sentinel Event Alert warns about tubing misconnections
A new Sentinel Event Alert from The Joint Commission warns hospitals to take extra measures to... -
NC jury awards patient $1.5 million after sound-alike drug mix-up
A Durham, North Carolina ophthalmologist and hospital were found negligent by a jury after a drug... -
Staff Challenge: Provision of Care
Name key elements that should be the basis for the “written” plan of care. -
Give us your feedback and win $50 off any HCPro product!
Take this HCPro customer survey and get a chance to win $50 off any product in the HCPro...
Issue 33, August 19, 2014
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CDC warns of antibiotic overuse
The Centers for Disease Control and Prevention is urging hospitals to launch antibiotic stewardship... -
Study: Superbugs are increasing in southeastern U.S. hospitals
A new study published in Infection Control and Hospital Epidemiology found that superbugs grew at... -
Staff Challenge: National Patient Safety Goals
An important objective of medication reconciliation is to resolve discrepancies between home...
Issue 32, August 12, 2014
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2015 IPPS Final Rule focuses on healthcare quality efforts
The fiscal year 2015 IPPS final rule devotes a substantial amount of its updates to hospital... -
U.S. hospitals prepare for possible Ebola cases
As the Ebola outbreak intensifies in Africa, U.S. hospitals are bracing for a potential influx of... -
Staff Challenge: Rights, Ethics, and Communication
Name the two major federal laws that support the use of interpreters.
Issue 31, August 5, 2014
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Tennessee surgical quality collaborative touts successes
A surgical quality collaborative in Tennessee allowed 10 hospitals to reduce surgical complications... -
Report: Hospitals still need to work on medication reconciliation
A new study found that hospitals need to improve their medication reconciliation processes. -
Staff Challenge: Provision of Care
When the hospital prepares food for its patients, it must prepare the food under certain...
Issue 30, July 29, 2014
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California fines hospitals for medical errors
Eight California hospitals were fined a total of $775,000 by the state for preventable medical... -
Study: Fist bumps are more hygienic than handshakes
A new study found that fist bumps are a safer alternative to handshakes, with nearly twice as many... -
Staff Challenge: National Patient Safety Goals
Fill in the blank: Current medications include which of the following? a.  ...
Issue 29, July 22, 2014
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Experts to Senate panel: Patient safety remains a huge concern
Fifteen years after a major Institute of Medicine report, hospitals have made no progress on... -
High-volume emergency departments have lower mortality rates
A new study found that patients have a lower likelihood of in-hospital death if admitted through... -
Staff Challenge: Medication management
Fill in the blank: Medication containers should be labeled whenever a medication is prepared but...
Issue 28, July 15, 2014
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Study: OR briefings can improve teamwork, surgical outcomes
A new study found that preoperative briefings can lead to improved team communication and safety in... -
SC hospital's water investigated as source of bacterial outbreak
Officials believe water may have been the source of bacteria that infected 15 patients and may have... -
Staff Challenge: Environment of Care and Life Safety
For hospitals that use The Joint Commission for deemed status: To ensure the proper functioning of... -
Upcoming webcast provides mock tracer guidance
An HCPro webcast on August 20 will walk attendees through the mock survey process to help improve...
Issue 27, July 8, 2014
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CMS renews deeming authority for Joint Commission
The CMS has renewed deeming authority for The Joint Commission for hospital accreditation through... -
HHS awards $840 million in emergency preparedness grants
The U.S. Department of Health and Human Services has awarded more than $840 million in funding to... -
Staff Challenge: Rights, Ethics, and Communication
A patient has the right to access his or her clinical information, request a copy of his or her...
Issue 26, July 1, 2014
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Report: Problems with patient safety in military facilities
A New York Times report found that patient safety is severely lacking in U.S. military hospitals... -
Study: Anesthesia providers have poor hand hygiene compliance rates
A Dartmouth-Hitchcock Medical Center study found that anesthesia providers often fail to clean... -
Staff Challenge: Environment of Care and Life Safety
When are hospitals required to implement interim Life Safety Code® measures?
Issue 25, June 24, 2014
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Joint Commission prepublication standards aligning with CMS go into effect next week
Revised standards from The Joint Commission that align with CMS requirements go into effect on July... -
CMS punishing hospitals with worst rates of HAIs, patient injuries
The federal government this fall will cut Medicare payments for hospitals that have the worst rates... -
Staff Challenge: Provision of Care
Fill in the blank: It is essential that the handoff communication process include...
Issue 24, June 17, 2014
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Joint Commission issues Sentinel Event Alert on reuse of vials
A new Sentinel Event Alert from The Joint Commission addresses the misuse of single-dose/single-use... -
Syracuse hospital passes follow-up inspection after allegations of patient abuse
A Syracuse hospital passed an April inspection required after it was cited earlier in the year for... -
Clarification
The American Society for Healthcare Engineering clarified that the CMS has not issued a new... -
Staff Challenge: Environment of Care and Life Safety
Hospitals should have processes in place that continually monitor for specific types of events...
Issue 23, June 10, 2014
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CMS restricts use of power strips in patient care areas
The CMS is barring the use of power strips in hospital patient care spaces including operating... -
Dallas hospital uses pharmacists in ED to reduce errors
A Dallas hospital looks to reduce medication errors by having pharmacists work full-time in its... -
Staff Challenge: Rights, Ethics, and Communication
Fill in the blank: Patients are to be informed about unanticipated outcomes of care by...
Issue 22, June 3, 2014
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Joint Commission: Complete overdue PFIs by July 1
The Joint Commission now requires that accredited organizations complete or request extensions for... -
WHO: Looking towards a post-antibiotic era
A new report from the World Health Organization found that antimicrobial resistance poses a serious... -
Staff Challenge: Provision of Care
Identify three things that are monitored on a continual basis while a patient is receiving...
Issue 21, May 27, 2014
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Joint Commission postpones implementation of revised diagnostic imaging standards
The implementation of new and revised diagnostic imaging standards from The Joint Commission has... -
Study: Seven of 10 bronchitis patients are prescribed antibiotics
A new study found that physicians are overprescribing antibiotics, which researchers say are... -
Staff Challenge: Medication Management
Who should be notified when a medication has been recalled for safety reasons by the FDA or by the...
Issue 20, May 20, 2014
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HHS: Quality initiatives prevent 15,000 deaths, save $4 billion
Public-private partnerships led to decrease in patient harm during 2011 and 2012. -
Report: Sepsis connected to shocking number of patient deaths
A new report found that sepsis is present in as many as one in every two hospitalized patients who... -
Staff Challenge: Provision of Care
Fill in the blank: The Joint Commission standards that cover sedation and anesthesia apply to all...
Issue 19, May 13, 2014
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CMS rule change eliminates unnecessary requirements
A new rule from the CMS eliminates regulations seen as excessively burdensome on healthcare... -
CMS launches improved QIO program
The CMS last week announced changes to its quality improvement organization program that re... -
Staff Challenge: Environment of Care and Life Safety
Dialysis equipment must be properly maintained. ____________ and _____________ testing must be...
Issue 18, May 6, 2014
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Joint Commission clarifies organ procurement requirements
The Joint Commission has released a new clarification for organ procurement organizations as part... -
Survey: Most physicians say colleagues order unnecessary tests and procedures
According to a new survey from the ABIM Foundation, three out of four physicians say their... -
Staff Challenge: National Patient Safety Goals
What additional steps, besides the use of two patient identifiers, are required when preparing to...
Issue 17, April 29, 2014
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Joint Commission releases 2013 sentinel event stats
Treatment delays and wrong patient/wrong site/wrong procedure errors were the most frequently... -
California senator calls on hospitals to address medical errors
Sen. Barbara Boxer (D-Calif.) issued a report last week that found that medical errors cause... -
Staff Challenge: Environment of Care and Life Safety
What does the Safe Medical Device Act of 1990 require of hospitals?
Issue 16, April 22, 2014
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Study examines patient deaths tied to hospital linens
Five children died at a New Orleans hospital from a fungus infection believed to have been spread... -
California lawmakers mull workplace violence bill after attacks on nurses
A California bill has been proposed that would require stricter workplace violence prevention... -
Staff Challenge: Medication Management
A pharmacist must review all medication orders prior to the medication being dispensed except in...
Issue 15, April 15, 2014
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CMS proposes adoption of 2012 Life Safety CodeĀ®
CMS yesterday announced a proposed rule to adopt an updated edition of the Life Safety Code®... -
AORN outlines ways to improve patient safety and outcomes
Improvements must be made in handoffs, the use of PCA pumps, and postoperative orders to provide... -
Staff Challenge: Rights, Ethics, and Communication
Fill in the blank: Hospitals must provide information in an understandable format to patients who...
Issue 14, April 8, 2014
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Syracuse surgeon accused of slapping anesthetized patients
A surgeon at St. Joseph’s Hospital Health Center in Syracuse, N.Y., is accused of slapping... -
Rhode Island hospital found in violation of infection control policies
The Rhode Island Department of Health has ordered Rhode Island Hospital to make corrections after... -
Staff Challenge: National Patient Safety Goals
What are two indications for the use of anticoagulant therapy?
Issue 13, April 1, 2014
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Joint Commission releases top-cited standards of 2013
Safety issues continue to top The Joint Commission’s annual list of top standards... -
CDC: Hospital-acquired infections are declining, but still dangerous
A new study found that hospitals are making progress in reducing infection rates, but estimated... -
Staff Challenge: Infection Control
Hospitals should focus their infection control and prevention activities on the areas that pose...
Issue 12, March 25, 2014
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Study: One in five facilities doesn't provide enough hand sanitizer
A new study found that one in five U.S. health facilities doesn’t make alcohol-based... -
Webinar to focus on worker fatigue
A Joint Commission official will discuss hospital worker fatigue and its impact on patient and... -
Staff Challenge: Provision of Care
Fill in the blank: The scope and content of __________________, _____________, and...
Issue 11, March 18, 2014
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Joint Commission releases prepublication standards for EC chapter
The Joint Commission has released revised requirements for the Environment of Care chapter. -
Study: Surgical checklists may not lead to better outcomes
A Canadian study of surgical safety checklists found no significant difference in outcomes after... -
Staff Challenge: Rights, Ethics, and Communication
What are the various questions you should ask when assessing a patient to determine which...
Issue 10, March 11, 2014
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CDC report encourages antibiotic stewardship to prevent HAIs
A new CDC report provides guidance for hospitals on proper antibiotic prescribing practices. -
Study: New tool helps hospitals reduce readmissions
A new tool from the American College of Surgeons can help hospitals predict high-risk cases and... -
Staff Challenge: National Patient Safety Goals
Why is it inappropriate to use a room number as one of the two patient identifiers?
Issue 9, March 4, 2014
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CMS clarifies two-midnight rule, but hospitals still upset
The CMS last week issued another clarification of its two midnight rule, but hospitals say the... -
Study: Stethoscopes may spread bacteria
A new study found that physicians’ stethoscopes have the potential to spread germs from... -
Staff Challenge: Medication Management
Why is the risk for transcription error higher when medication orders are given verbally over the...
Issue 8, February 25, 2014
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Texas hospital declines award after lawsuits filed over botched surgeries
A Texas hospital announced it won’t accept the Malcolm Baldrige National Quality Award after... -
Stanford study finds checklist use reduces HAI rate
A study found that using a computerized safety checklist that pulls information from electronic... -
Staff Challenge: Provision of Care
True or False: The hospital has to provide its patients with a nutritious, appropriate diet. They...
Issue 7, February 18, 2014
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Joint Commission seeks comments on proposed perinatal care certification requirements
The proposed requirements of a new Joint Commission perinatal care certification program are up for... -
Kentucky VA hospital reduces MRSA rate through screening
By instituting a screening program for patients, the Louisville (Ky.) Veterans Affairs Medical... -
Kentucky VA hospital reduces MRSA rate through screening
By instituting a screening program for patients, the Louisville (Ky.) Veterans Affairs Medical... -
Staff Challenge: Leadership
For deemed status purposes, which medical services or departments require a physician leader?
Issue 6, February 11, 2014
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CMS delays two-midnight rule enforcement
After opposition from hospitals and physicians, the CMS has delayed enforcement of its... -
Study: Hospitals need to improve ICU infection control practices
A new study found that improving infection control protocols in intensive care units would have a... -
Staff Challenge: National Patient Safety Goals
Name at least three different situations where the use of two patient identifiers is required.
Issue 5, February 4, 2014
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Joint Commission clarifies gas cylinder storage requirements
The Joint Commission has added new clarifications to storage requirements for medical gas cylinders. -
Report explains clinical alarm NPSG
The Joint Commission explains how it developed its new National Patient Safety Goal on clinical... -
Staff Challenge: Infection Control
The hospital has a responsibility for communication information about the prevention and...
Issue 4, January 28, 2014
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ISMP launches new medication safety initiative
The Institute for Safe Medication Practices has begun a campaign to increase awareness of... -
Eisenberg award winners announced
The Joint Commission and the National Quality Forum have announced the 2013 recipients of the John... -
Staff Challenge: Rights, Ethics, and Communication
Fill in the blank: Hospitals are required to provide language and _________________ services.
Issue 3, January 22, 2014
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CMS requests comments on emergency preparedness rule
The CMS is seeking public comments on a new proposed rule on emergency preparedness. -
Joint Commission MM standards to apply to sample meds
Starting on July 1, many Joint Commission Medication Management standards will apply to sample... -
Staff Challenge: Provision of Care
True or False: Many patients who have a cardiopulmonary or respiratory event have signs and...
Issue 2, January 14, 2014
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Hospitals entice patients with iPads, quiet spaces
Some hospitals are kicking off the new year with plans to improve the patient experience by... -
The trouble with EHRs
Although electronic health records are known to reduce healthcare costs, concerns about accuracy... -
Staff Challenge: Medication Management
What is the best-sized packaging for medications that are being used in patient care areas?
Issue 1, January 7, 2014
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Top healthcare buzzwords for 2014, part 1
Big changes in healthcare mean big changes in the way providers and payers talk. Many terms being... -
Top quality issues for 2014, part I
The pressure to reduce readmissions and preserve reimbursements will only increase in 2014... -
Staff Challenge: Emergency Management
When an emergency requires the use of LIPs who are not current members of your medical staff, an...
Issue 51, January 2, 2014
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Seven signs providers are opening up about bad healthcare outcomes
Hospitals and physicians are increasingly working together to be more forthcoming with patients... -
Seven signs providers are opening up about bad healthcare outcomes
Hospitals and physicians are increasingly working together to be more forthcoming with patients... -
Three favorite nursing trends in 2013
Some nursing leadership trends emerged quietly this year, but are nonetheless provocative for how...