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This program will cover The Joint Commission Sentinel Event (SE) policy and Patient Safety Systems chapter, which are designed to be used together to help hospitals ensure compliance and improve patient safety. The Patient Safety Systems chapter educates hospitals on structuring an integrated patient safety system by providing a framework for the accreditation standards and patient safety. It is vital for hospitals to incorporate the Patient Safety Systems chapter and the amended TJC SE alerts in their practice.
Our expert will also discuss the CMS Root Cause Analysis (RCA) tracer, which lists questions that a surveyor will ask during a validation or certification survey. Knowing TJC standards on creating a thorough and credible root cause analysis (systematic analysis) will help hospitals address a surveyor’s questions.
Anyone who works with patients, including but not limited to: CEOs, COOs, CMOs, CNOs, CMS Regulatory Staff, Compliance Officers, Consumer Advocates, In-house Legal Counsels, Nurses (all levels), Nurse Educators, Patient Safety Officers, Policy and Procedure Committee Members, Quality Improvement Directors, Regulatory Officers, Risk Managers, TJC Accreditation Officers, TJC Liaisons, and anyone responsible ensuring quality and safety of patients.
CMS QAPI Worksheet on Patient Safety, Adverse Events & Medication Errors
|- Policies & procedures on non-punitive environment||- What constitutes a medical error?|
|- Section on patient safety, AE, & medical errors||- Staff role in promoting patient safety|
|- CMS-finalized worksheets||- RCA performed on all preventable AEs|
TJC Sentinel Event Policy & Procedure
|- Amended Sentinel Event alerts||- Goals of SE policy|
|- Systematic analysis approach||- Patient safety event, close calls, etc.|
|- Reporting a SE & 4 options||- Action plan & follow up|
|- RCA requirements||- Required review of events & process|
TJC Patient Safety Systems
|- Key patient safety requirements||- Proactive approach to preventing harm|
|- Becoming a learning institution||- LD.04.04.05 Hospital Safety Program requirements|
|- Process to improve quality and patient safety||- Role of hospital leaders in patient safety|
|- Fair & just culture||- Data use & reporting systems|
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