Western Kentucky University

WKUHS AAAHC Accreditation : Infection Prevention & Control & Safety

I.D. Chapter Evidence Notes

Subchapter 1 -Infection Prevention & Control 

 

 

 7.A

Infection Prevention and Control and Safety 

Infection Prevention

 

 7.B

Infection Prevention and Control and Safety 

Infection Prevention 

 

 7.B.1

Infection Prevention and Control and Safety 

 Infection Prevention

 

7.B.2 

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.B.3

Infection Prevention and Control and Safety 

 Infection Prevention

 The Clinical Nurse Services Manager oversees the Infection Prevention and Control program.

 7.B.4

Infection Prevention and Control and Safety 

 Infection Prevention

 

7.B.5 

Infection Prevention and Control and Safety 

Infection Prevention 

 

7.B.6 

Infection Prevention and Control and Safety 

Infection Prevention 

 

7.C 

Infection Prevention and Control and Safety 

Infection Prevention 

Guidelines from the CDC, WHO and other national quality organizations were referenced in the Infection Prevention and Control program.

 7.C.1

Infection Prevention and Control and Safety 

 Infection Prevention

Hand Hygiene

 See 7.C

 7.C.2

Infection Prevention and Control and Safety 

 Infection Prevention

Safe Injection Practices

 See 7.C

 7.C.3

Infection Prevention and Control and Safety 

Infection Prevention 

 

 7.D

Infection Prevention and Control and Safety 

Infection Prevention 

Instrument Sterilization

Cleaning and Disinfecting

 

7.E 

Infection Prevention and Control and Safety 

Sharps Injury Prevention 

 

 7.E.1

 Infection Prevention and Control and Safety

 Sharps Injury Prevention

 

 7.E.2

Infection Prevention and Control and Safety 

 Sharps Injury Prevention

 

7.E.3 

Infection Prevention and Control and Safety 

 Sharps Injury Prevention

 

7.E.4 

Infection Prevention and Control and Safety 

Sharps Injury Prevention 

 

7.E.5 

 Infection Prevention and Control and Safety

Sharps Injury Prevention 

 

7.F 

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.G

Infection Prevention and Control and Safety 

Infection Prevention 

 

 7.H

Infection Prevention and Control and Safety 

 Cleaning and Disinfecting

Instrument Sterilization

 

7.I 

 Infection Prevention and Control and Safety

 Instrument Sterilization

 

 7.J

Infection Prevention and Control and Safety 

 Patients with Communicable Disease

The local Health Department is notified appropriately. 

7.K 

Infection Prevention and Control and Safety 

 Cleaning and Disinfecting

 

 7.K.1

Infection Prevention and Control and Safety 

 Cleaning and Disinfecting

 

7.K.2 

Infection Prevention and Control and Safety 

Cleaning and Disinfecting 

 

7.K.3 

Infection Prevention and Control and Safety 

 Cleaning and Disinfecting

 

 7

 Subchapter 2 -Safety

 

 

7.A 

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.A.1

Infection Prevention and Control and Safety 

Infection Prevention 

Incident Reporting

The Incident Review Committee monitors and creates action plans when incidents occur.  

7.A.2 

Infection Prevention and Control and Safety 

Infection Prevention 

See 7.A.1 

7.A.3 

 Infection Prevention and Control and Safety

Infection Prevention 

Education and reminders are provided regarding look-alike sound-alike medications. 

7.A.4 

Infection Prevention and Control and Safety 

Patient Nourishment Refrigerator 

 

 7.A.5

Infection Prevention and Control and Safety 

 Product Recalls

Recalls are handled as quickly as possible once they are discovered and documentation is maintained appropriately.  

 7.A.6

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.B

Infection Prevention and Control and Safety 

Infection Prevention 

 The Clinical Nurse Services Manager and Executive Director oversee the safety program.

7.C 

Infection Prevention and Control and Safety 

Infection Prevention 

 

7.C.1 

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.C.2

Infection Prevention and Control and Safety 

 Infection Prevention

 

 7.D

 Infection Prevention and Control and Safety

 

 

7.E 

Infection Prevention and Control and Safety 

 Procedure Consent

 

 7.F

 Infection Prevention and Control and Safety

 Risk Management Plan

BEAP

Safety Handbook

 

7.G 

Infection Prevention and Control and Safety 

Risk Management Plan 

 

 7.H

Infection Prevention and Control and Safety 

 Risk Management Plan

 

7.I 

Infection Prevention and Control and Safety 

Infection Prevention 

WKUHS provides MSDS, PPE & eye wash stations to prevent and/or minimize injury from hazardous exposure.  

 7.J

Infection Prevention and Control and Safety 

Infection Prevention 

See7.I

 7.K

Infection Prevention and Control and Safety 

Infection Prevention

Patient Nourishment Refrigerator 

 

7.L 

Infection Prevention and Control and Safety 

 

Patients are educated on how to use medical devices provided by WKUHS. 

7.M 

Infection Prevention and Control and Safety 

Instrument Sterilization 

 WKUHS does not reprocess disposable devices.

7.N 

Infection Prevention and Control and Safety 

Product Recalls 

Recalls are handled as quickly as possible once they are discovered and documentation is maintained appropriately. 

 7.N.1

Infection Prevention and Control and Safety 

Product Recalls 

See 7.N 

 7.N.2

Infection Prevention and Control and Safety 

 Product Recalls

 See 7.N

7.N.3 

Infection Prevention and Control and Safety 

 Product Recalls

See 7.N 

7.N.4 

Infection Prevention and Control and Safety 

 Product Recalls

 See 7.N

 7.N.5

Infection Prevention and Control and Safety 

Product Recalls

See 7.N 

 7.N.6

Infection Prevention and Control and Safety 

 Product Recalls

 See 7.N

7.O 

 Infection Prevention and Control and Safety

Infection Prevention 

Expired Products

 

 7.P

Infection Prevention and Control and Safety 

Infection Prevention 

 Education is given to clinical staff before new products are used.

 Last Modified 11/11/13