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Areas for Review for Nightingale

Nightingale is 13 months away from its anticipated next Joint Commission visit.

These are the areas for review that Nightengale wants to focus on prior to the Joint Commission visit.

Review Area Joint Commission Standard Standard Description

1 Information Management

IM.02.02.01 The hospital effectively manages the collection of health information.

RC.01.01. 01

The hospital maintains complete and accurate medical records for each individual patient.

RC.01.04.01 The hospital audits its medical records.

2 Medication Management

MM.01.01.01 The hospital plans its medication management processes.

NPSG 03.04.01 Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

3 Communication UP.01.01.01 Conduct a preprocedure verification process.

UP.01.02.01 Mark the procedure site.

UP.01.03.01 A time-out is performed before the procedure.

4 Infection Control IC.02.01.01 The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.

NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

NPSG.07.03.01 Implement evidence-based practices to prevent health care– associated infections due to multidrug-resistant organisms in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin- resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria.

NPSG.07.04.01 Implement evidence-based practices to prevent central line– associated bloodstream infections. Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.

NPSG.07.05.01 Implement evidence-based practices for preventing surgical site infections.