- Rights of Patients
- Governance
- Administration
- Quality of Care Provided
- Quality Management Improvement
- Clinical Records and Health Information
- Infection Prevention and Control and Safety
- Facilities and Environment
- Anesthesia Services
- Surgical & Related Services
- Pharmaceutical Services
- Pathology & Medical Laboratory Services
- Diagnostic & Other Imaging Services
- Other Professional & Technical Services
- Health Education and Health Promotion
| I.D. | Chapter | Evidence | Notes |
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7 |
Subchapter 1 -Infection Prevention & Control |
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7.A |
Infection Prevention and Control and Safety |
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7.B |
Infection Prevention and Control and Safety |
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7.B.1 |
Infection Prevention and Control and Safety |
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7.B.2 |
Infection Prevention and Control and Safety |
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7.B.3 |
Infection Prevention and Control and Safety |
The Clinical Nurse Services Manager oversees the Infection Prevention and Control program. |
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7.B.4 |
Infection Prevention and Control and Safety |
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7.B.5 |
Infection Prevention and Control and Safety |
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7.B.6 |
Infection Prevention and Control and Safety |
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7.C |
Infection Prevention and Control and Safety |
Guidelines from the CDC, WHO and other national quality organizations were referenced in the Infection Prevention and Control program. |
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7.C.1 |
Infection Prevention and Control and Safety |
See 7.C |
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7.C.2 |
Infection Prevention and Control and Safety |
See 7.C |
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7.C.3 |
Infection Prevention and Control and Safety |
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7.D |
Infection Prevention and Control and Safety |
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7.E |
Infection Prevention and Control and Safety |
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7.E.1 |
Infection Prevention and Control and Safety |
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7.E.2 |
Infection Prevention and Control and Safety |
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7.E.3 |
Infection Prevention and Control and Safety |
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7.E.4 |
Infection Prevention and Control and Safety |
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7.E.5 |
Infection Prevention and Control and Safety |
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7.F |
Infection Prevention and Control and Safety |
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7.G |
Infection Prevention and Control and Safety |
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7.H |
Infection Prevention and Control and Safety |
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7.I |
Infection Prevention and Control and Safety |
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7.J |
Infection Prevention and Control and Safety |
The local Health Department is notified appropriately. |
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7.K |
Infection Prevention and Control and Safety |
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7.K.1 |
Infection Prevention and Control and Safety |
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7.K.2 |
Infection Prevention and Control and Safety |
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7.K.3 |
Infection Prevention and Control and Safety |
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7 |
Subchapter 2 -Safety |
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7.A |
Infection Prevention and Control and Safety |
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7.A.1 |
Infection Prevention and Control and Safety |
The Incident Review Committee monitors and creates action plans when incidents occur. |
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7.A.2 |
Infection Prevention and Control and Safety |
See 7.A.1 |
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7.A.3 |
Infection Prevention and Control and Safety |
Education and reminders are provided regarding look-alike sound-alike medications. |
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7.A.4 |
Infection Prevention and Control and Safety |
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7.A.5 |
Infection Prevention and Control and Safety |
Recalls are handled as quickly as possible once they are discovered and documentation is maintained appropriately. |
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7.A.6 |
Infection Prevention and Control and Safety |
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7.B |
Infection Prevention and Control and Safety |
The Clinical Nurse Services Manager and Executive Director oversee the safety program. |
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7.C |
Infection Prevention and Control and Safety |
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7.C.1 |
Infection Prevention and Control and Safety |
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7.C.2 |
Infection Prevention and Control and Safety |
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7.D |
Infection Prevention and Control and Safety |
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7.E |
Infection Prevention and Control and Safety |
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7.F |
Infection Prevention and Control and Safety |
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7.G |
Infection Prevention and Control and Safety |
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7.H |
Infection Prevention and Control and Safety |
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7.I |
Infection Prevention and Control and Safety |
WKUHS provides MSDS, PPE & eye wash stations to prevent and/or minimize injury from hazardous exposure. |
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7.J |
Infection Prevention and Control and Safety |
See7.I |
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7.K |
Infection Prevention and Control and Safety |
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7.L |
Infection Prevention and Control and Safety |
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Patients are educated on how to use medical devices provided by WKUHS. |
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7.M |
Infection Prevention and Control and Safety |
WKUHS does not reprocess disposable devices. |
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7.N |
Infection Prevention and Control and Safety |
Recalls are handled as quickly as possible once they are discovered and documentation is maintained appropriately. |
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7.N.1 |
Infection Prevention and Control and Safety |
See 7.N |
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7.N.2 |
Infection Prevention and Control and Safety |
See 7.N |
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7.N.3 |
Infection Prevention and Control and Safety |
See 7.N |
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7.N.4 |
Infection Prevention and Control and Safety |
See 7.N |
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7.N.5 |
Infection Prevention and Control and Safety |
See 7.N |
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7.N.6 |
Infection Prevention and Control and Safety |
See 7.N |
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7.O |
Infection Prevention and Control and Safety |
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7.P |
Infection Prevention and Control and Safety |
Education is given to clinical staff before new products are used. |
