| 1. Leadership structures and systems | Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, leaders are directly accountable for those gaps and there is adequate investment in performance improvement abilities, and actions are taken to ensure safe care of every patient served. |
| 2. Culture measurement, feedback, and intervention | Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk. |
| 3. Teamwork training and skill building | Healthcare organizations must establish a proactive, systematic, organization-wide approach to developing team-based care through teamwork training, skill building, and team-led performance improvement interventions that reduce preventable harm to patients. |
| 4. Identification and mitigation of risks and hazards | Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm. |
| 5. Informed consent | Ask every patient or legal surrogate to “teach back,” in his or her own words, key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent. |
| 6. Life-sustaining treatment | Ensure that written documentation of the patient's preferences for life-sustaining treatment is prominently displayed in his or her chart. |
| 7.Disclosure | Following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, the family should receive timely, transparent, and clear communication concerning what is known about the event. |
| 8. Care of the caregiver | Following serious unintentional harm due to systems failures and/or errors that resulted from human performance failures, the involved caregivers should receive timely and systematic care—and the opportunity to fully participate in event investigation and risk identification and mitigation activities that will prevent future events. |
| 9. Nursing workforce | Implement critical components of a well-designed nursing workforce, including (a) an adequate nursing plan, (b) senior nurse administrative leaders as part of the hospital's senior management team, (c) governance board engagement in nurse staffing decisions, and (d) budget to support nursing education and skill building. |
| 10. Direct caregivers | Ensure that non-nursing direct care staffing levels are adequate, that staff are competent, and that they have had adequate orientation, training, and education. |
| 11. Intensive care unit care | All patients in general ICUs should be managed by physicians who have specific training and certification in critical care medicine. |
| 12. Patient care information | Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and to all relevant caregivers. |
| 13. Order read-back and abbreviations | Incorporate a safe, effective communication strategy, structure, and systems to include (a) record and “read-backs” for verbal orders and critical test results; (b) use of a standard “do not use” abbreviation list. |
| 14. Labeling of diagnostic studies | Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, lab specimens, and other studies to ensure accuracy. |
| 15. ... |