A Self-Assessment Guide for Health Care Organizations - IFC

Patient Safety
PS.1 Patient identification
1 Collaborative process for development of
policies/procedures
2 Use of two patient identifiers
3 Patient identified before giving medications,
blood, etc.
4 Patient identified before taking blood or
specimens
5 Patient identified before giving treatments or
procedures
PS.2 Safe communication
1 Collaborative process for development of
policies/procedures
2 Complete verbal or telephone order written
down
3 Read back of verbal or telephone order
4 Order or test result is confirmed
PS.3 High alert medications
1 Collaborative process for development of
policies/procedures
2 High alert medications not present on units
PS.4 Correct site, procedure, patient for surgery
1 Collaborative process for development of
policies/procedures
2 Clearly understood mark for surgical
identification
3 Verification of documents, equipment on-hand,
correct, functional
4 Checklist and time out procedure
PS.5 Health associated infections
1 Hand hygiene guidelines
2 Effective hand hygiene program
PS.6 Risk of falls
1 Collaborative process for development of
policies/procedures
2 Fall risk assessments
3 Measures to reduce risk of falls
Total Highest Possible = 200
Baseline
Score
Score
Score
Percent achievement % % %
82 IFC Self-Assessment Guide for Health Care Organizations