Incident Reporting

Citation

TJC IC.06.01.01

The hospital implements its infection prevention and control program through surveillance, pr...

The hospital must implement active surveillance, outbreak management, and staff health protocols to prevent the transmission of infectious diseases.

Citation

TJC MM.17.01.01

The hospital responds to actual or potential adverse drug events, significant adverse drug re...

The standard addresses hospital policies and processes for reporting and evaluating adverse drug events, adverse drug reactions, medication incompatibilities, and medication administration errors.

Citation

TJC NPG.02.03.01

The hospital’s leaders design work processes to focus individuals on safety and quality issues.

The standard requires hospital leaders to implement patient safety program structures, reporting systems, event analyses, risk assessments, communication processes, safety culture evaluation, and conduct management.

Citation

TJC NPG.07.03.01

The hospital assesses the patient who may be a victim of possible abuse, neglect, and exploit...

Requires the hospital to identify, assess, report, and refer patients who may be victims of abuse, neglect, or exploitation, and to educate staff on recognition and follow-up.

Citation

TJC NPG.09.03.01

The hospital investigates adverse events related to tissue use or donor infections.

Requires the hospital to have a written procedure for investigating tissue-related adverse events, reporting to suppliers, sequestering suspect tissue, and informing recipients of donor infection risk.

Citation

TJC NPG.11.01.01

The hospital manages security risks.

Requires the hospital to control access to security-sensitive areas, develop security incident policies including infant or pediatric abduction, monitor and investigate specified safety and security incidents, and coordinate care decisions for patients under legal or correctional restrictions.

Citation

TJC NPG.13.04.01

The hospital monitors quality improvement projects related to imaging safety.

The hospital collects, reviews, and analyzes data on MRI thermal injuries, ferromagnetic incidents, and CT radiation dose index exceedances as part of its quality improvement program.

Citation

TJC PC.13.02.19

For hospitals that use Joint Commission accreditation for deemed status purposes:

Hospitals using Joint Commission accreditation for deemed status must report deaths associated with the use of restraint or seclusion to CMS.

Citation

TJC PC.15.01.01

The hospital safely provides blood and blood components.

Requires the hospital to safely provide blood and blood components, including policies, quarantine, notification, and documentation when potentially HIV- or HCV-infectious units are identified.

Citation

TJC PI.12.01.01

The hospital collects data.

Requires the hospital to collect, analyze, and act on data regarding medical errors, adverse patient events, and quality improvement projects.

Citation

TJC RI.13.01.01

The patient has the right to be free from harassment, neglect, exploitation, and verbal, ment...

Requires the hospital to protect patients from abuse, neglect, exploitation, and harassment, and to report allegations to appropriate authorities within specified time frames.