Checklist to comply with new standards

— 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:

• What are your responsibilities should a sentinel event occur on your shift?
• Whom do you contact?
• What evidence is preserved?
• What type of program is in place for individuals who may have been involved in a sentinel event?
• Is an occurrence or incident report generated?
• What facts must be documented in the medical record?

Source: Kathleen Catalano, RN, JD, Director of Administrative Projects, Children’s Medical Center of Dallas.