The hospital collects data.

(1)

The hospital tracks medical errors and adverse patient events, analyzes their causes, and implements preventive actions and mechanisms that include feedback and learning throughout the hospital. Medical errors and adverse patient events include but are not limited to the following: - Medication administration errors - Surgical errors - Equipment failure - Infection control errors - Blood transfusion–related errors - Diagnostic errors

(2)

The hospital documents what quality improvement projects it is conducting, the reasons for conducting these projects, and the measurable progress achieved on these projects.

(3)

The hospital measures, analyzes, and tracks quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service, and operations.

(4)

The hospital takes action to improve its performance. After implementing changes, the hospital measures its success and tracks performance to ensure that improvements are sustained.