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APPENDIX IV

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NPSG.01.01.01

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Use at least two patient identifiers when providing care, treatment, and services.

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NPSG.01.03.01

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Eliminate transfusion errors related to patient misidentification.

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NPSG.02.03.01

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Report critical results of tests and diagnostic procedures to the right staff person on a timely basis.

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NPSG.03.04.01

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Before a procedure, label medicines that are not labeled. Note: medication containers include syringes, medicine cups, and basins.

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NPSG.03.05.01

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

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NPSG.03.06.01

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Maintain and communicate accurate information about patients’ medications.

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NPSG.06.01.01

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Ensure that medical equipment alarms are audible and responded to on time.

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NPSG.07.01.01

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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.

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NPSG.07.03.01

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Implement evidence-based practices to prevent healthcare-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.

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NPSG.07.04.01

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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.

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NPSG.07.05.01

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Implement evidence-based practices for preventing surgical site infections.

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NPSG.07.06.01

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Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

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NPSG.15.01.01

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Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.

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UP.01.01.01

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Conduct a preprocedure verification process to ensure that the correct procedure is done on the correct patient at the correct site on the body.

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UP.01.02.01

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Mark the procedure site.

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UP.01.03.01

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A time out is performed before the procedure.

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© The Joint Commission, 2017. Reprinted with permission. Available at: https://www.jointcommission.org/assets/1/6/2017_NPSG_HAP_ER.pdf.

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Skipped numbers represent retired Goals (the numbers are not replaced).

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NPSG, National Patient Safety Goal; UP, Universal Protocol.

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