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— One or more qualified individuals or an interdisciplinary group must be designated to manage the organizationwide patient safety program. It is advisable that the individuals have clinical backgrounds.
— The scope of the program activities must identify the types of occurrences to be addressed, ranging from those that cause no harm to those that are serious adverse events.
— There must be a description of the mechanisms so that all components of the organization are integrated into and participate in the organizationwide program.
— There must be procedures for immediate response to medical/health care errors, including care of the affected patient(s), containment of the risk to others, and preservation of factual information for subsequent analysis.
— There will need to be clear systems for internal and external reporting of information relating to health care errors.
— The facility will have to create defined mechanisms for responding to the various occurrences, for example, performing a root-cause analysis in response to a sentinel event.
— Defined mechanisms must be created for support of staff involved in a sentinel event.
— There must be an annual report submitted to the governing body.
— All surveyors will review your hospital policy during the document review process that occurs on the first morning of any survey. Know your policy. Surveyors might ask:
Source: Kathleen Catalano, RN, JD, Director of Administrative Projects, Children’s Medical Center of Dallas.