Main

I.B.04

The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. 

W.

During the pre-procedure time out, the following items are verified:

1. Patient identification.

2. Intended procedure.

3. Correct surgical site.

4. All equipment necessary for performing the scheduled procedure is immediately available in the operating/procedure room.

5. Any implantable devices intended to be used during the procedure are prepared before the procedure and available.

Notes: 
P&P

J.2.

The design, construction, and equipment comply with applicable state and local codes. 

J.1.

The design and equipment facilitate the physical safety of all persons in the area. 

H.2.

The organization obtains written informed consent from the patient or the patient’s representative before the procedure or surgery is performed. 

H.1.

There is documentation that the necessity or appropriateness of the proposed procedure or surgery, as well as alternative treatment techniques, have been discussed with the patient. 

F.

Electronic data management is continually assessed as a tool for facilitating the Standards above. 

Q.

High level disinfection processes adhere to equipment and chemical manufacturers’ instructions. 

I.H.

At a minimum, all settings where sedation or anesthesia is administered should have the following equipment for resuscitation purposes:

I.Q.

A written policy outlines appropriate hand hygiene using products according to the product manufacturer’s instructions for use 

Location: 
P&P
Policy: 
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