Patient Safety Events

Citation

TJC APR.09.02.01

Any individual who provides care, treatment, and services can report concerns about safety or...

The hospital must educate staff and medical staff on their right to report safety or quality concerns to The Joint Commission without fear of retaliation or disciplinary action.

Citation

TJC APR.09.04.01

The hospital provides care, treatment, services, and an environment that pose no risk of an “...

The hospital is required to maintain an environment and provide services that do not pose an immediate threat to the health or safety of patients.

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 MS.16.03.01

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Citation

TJC MS.18.05.01

The medical staff develops and implements a process to identify and manage matters of individ...

The medical staff must implement a confidential process to identify, refer, monitor, and respond to physician or practitioner health and impairment concerns separately from discipline.

Citation

TJC MS.20.01.01

Physicians or other licensed practitioners who are responsible for the care, treatment, and s...

The originating hospital must credential and privilege telemedicine practitioners or include specified safeguards when relying on distant-site credentialing and privileging decisions.

Citation

TJC NPG.01.01.01

The hospital has a process in place to correctly identify patients when providing care, treat...

The hospital uses processes such as two patient identifiers, specimen container labeling in the patient’s presence, and distinct newborn identification methods to correctly identify patients.

Citation

TJC NPG.01.02.01

The hospital reports critical results of tests and diagnostic procedures on a timely basis.

The hospital maintains written procedures for defining, reporting, timing, and evaluating critical results of tests and diagnostic procedures.

Citation

TJC NPG.01.04.01

The hospital has a process for handoff communication.

The hospital has a process for sharing patient information during internal handoffs, including an opportunity for discussion between sender and receiver.

Citation

TJC NPG.01.05.01

The hospital improves the safety of clinical alarm systems.

The hospital identifies important alarm signals and establishes policies for alarm settings, authority, monitoring, response, and signal checks.

Citation

TJC NPG.01.05.02

The hospital recognizes and responds to changes in a patient’s condition.

The hospital develops and implements written criteria for early warning signs of patient deterioration and appropriate actions to take.

Citation

TJC NPG.01.06.01

The hospital conducts a preprocedure verification process.

The standard addresses verification of the correct patient, procedure, and site and availability of required procedure-related items before a procedure.

Citation

TJC NPG.01.06.02

The hospital marks the procedure site.

The standard addresses when and how procedure sites are marked, who may mark them, and alternative processes when marking is refused or impractical.

Citation

TJC NPG.01.06.03

The hospital performs a time-out before the procedure.

The standard requires a standardized team time-out immediately before invasive procedures or incisions and documentation of its completion.

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.06.03.01

The hospital collects data on pain assessment and management.

Requires the hospital to collect and analyze data on pain assessment and management to identify opportunities for improving safety and quality.

Citation

TJC NPG.08.01.01

The hospital reduces the risk for suicide.

Requires the hospital to screen, assess, document, monitor, and follow up on patients at risk for suicide, including environmental risk mitigation and discharge planning.

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.11.02.01

The hospital assesses and manages the patient's risks for falls.

The hospital assesses and manages patient fall risks and implements fall risk reduction interventions based on the patient population, setting, and individual assessed risks.

Citation

TJC NPG.12.06.01

The hospital evaluates staffing during performance improvement activities.

Requires the hospital to include staffing adequacy in performance improvement analyses, report findings to safety program leaders, and provide annual written reports to governance.

Citation

TJC NPG.13.03.01

The hospital manages imaging safety risks.

The hospital manages MRI, CT, PET, nuclear medicine, and fluoroscopy safety risks through access controls, signage, dosimetry monitoring, and annual medical physicist performance evaluations.

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 NPG.14.03.01

The hospital labels all medications, medication containers, and other solutions on and off th...

Requires labeling of all medications, containers, and solutions on and off the sterile field in perioperative and other procedural settings, including required label content and two-person verification.

Citation

TJC NPG.14.04.01

The hospital reduces the likelihood of patient harm associated with the use of anticoagulant...

Requires the hospital to reduce patient harm from anticoagulant therapy through approved reversal and perioperative protocols and use of unit-dose, prefilled, or premixed products when available.

Citation

TJC PC.13.02.13

The hospital continually monitors patients who are simultaneously restrained and secluded.

Requires the hospital to continually monitor patients who are simultaneously restrained and secluded, using trained staff in person or via close-proximity video and audio.

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 PE.05.01.01

The hospital manages imaging safety risks.

Requires the hospital to manage imaging safety risks by ensuring annual performance evaluations of nuclear medicine, PET, CT, MRI, and fluoroscopic imaging equipment by qualified medical physicists, with documented results and corrective recommendations.

Citation

TJC PI.11.01.01

The hospital has an ongoing quality assessment and performance improvement program.

Requires the hospital to maintain an ongoing QAPI program with measurable improvement on evidence-based indicators and proportionate performance improvement projects.

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 PI.13.01.01

The hospital compiles, analyzes, and uses data.

Requires the hospital to analyze internal data over time and use the results to monitor service effectiveness, safety, quality, and improvement opportunities.