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& ">>

G@ ? &J? C>>>H>? %?=>

A=??"=>>

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Tab"e %f C%$)e$)(I. ">> & J?

C>>..............................4II. A != & J?

C>>..............................7

III. F@> "?? %?............9 %? E?> ......................10 Seninel E"en Alers ..............10 ? "?? %? G> 11 & '=> "=? ..........13

I. H>? %?=> ..................14. & %?=> D?

"=>> ....................................24I. & !-%? %@= "=>> ....25II. "== M>@=? ?

I= "?? C=................28III.& F@?@= "?? %? ....29I*. C?= = &=>=

H?= ................................30

*. F= M= I=? ................31

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I. P-(!c!a$( a$d Te

J%!$) C%##!((!%$

"> => ?= =? =?? ? ? >@>> ?? = ?? >?

=? =?>. ">> @>? @ ?? >? <@? @> ?= ,>>, = = >>? ?>@= >? ?? =

=>.

&> G@ > = > =>@== >> > ?? ? ? ??= @=>? ?

J? C>>> = @? >= ? = =?> =? =? ? >>?? ?? =.

E$a$c!$g P-(!c!a$I$+%"+e#e$) !$ Acc'ed!)a)!%$

">> = =>> = ?=? ? = >?>?=? == 1918 ? A= C %@=>, ?=@=>= ? ? =? &

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J? C>> ?> >?

=?? == 1951.&=@ ? >@=? ? A=C ">>, A=H>? A>>?, A=M A>>?, A= D?

 A>>? ? A= C %@=>, & J? C>>>, = >? 60 =>, ? = ==?> ? <@? >?

= = ? ? @.">> = >? & J?C>>, > =>? ?= >= => ? =?, >

>@==>, > >?=?=> =  => J? C>>??> >?=> ?.C@==?, 16 & J?C>>> 29 B= => =

>>.

B@ ?> >?= =?? >> & J?C>>, & J? C>>>

B= C>>=> > > ? =?? ?= <@?=? ??> ?>? >?=? ==?>.

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6

&= = > ?? & J?

C>> > >>,>@ > ?=@ >?=> =, ?->? >@= =>>, ?"?? %? G>, ? =>@?>, >? Seninel 

E"en Aler ?>. & P(!c!a$E$gage#e$) Ad+!(%' G'%*&,>?> 2005, > ?==?? @ >@>> ? @? = >>. &> =@

>> & J? C>> > =?? ? =?? =>> = > ? <@? = ?? >?

??>. M=> ? ">E? A>= G=@ @> <@? =?=> @?=>, =>,=? =? >>, ?= 

> => = @= =@= =>.

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7

II. A$ O+e'+!e, %f Te J%!$)C%##!((!%$

& J? C>> > ? ? ? = =?> ??>, ? ?? > = ?>

>> > >???:

Mission: To conin!o!sl% impro"e

healh care for he p!blic, in

collaboraion #ih oher sakeholders,

b% e"al!aing healh care

organi&aions and inspiring hem o

e$cel in pro"iding safe and effeci"e

care of he highes q!ali% and "al!e.

Vision statement:  All people al#a%s

e$perience he safes, highes q!ali%,

bes-"al!e healh care across all

seings.

 A ?-=-=? =?, & J?C>> =?> =?>= ? 18,000 ? ==?> ==> ?

'? %??>. &> @ =,>?=, =>, =?? >?> =?>> >?>.

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& J? C>> > =?> ? >, <@? >=>, > >=>, ?= = =?>;@=> > ?= ?== ?>; = ? ==?> ? >=>;=?? ?=>, =@ =?>,-> >@== ?=> ?= @?= = ==>; ? = =>? =?=>.

& J? C>> =>D>>-% C= C=?? ?== >?= ?=>, ??

?> ==>, = >> ==>, >?? ==>, ?= = >> ==>.C=?? > > = = =>

= ? = >? >=>.

J? C>> =?? >= ? > >  <@? ?? =?> =?>

?? ? >>?? .& = ? & J?C>>> G %  A=, =? @>?@= ->? >@= = =

& J? C>> ? >?= ?= => (? => ==?=> =??==>). & J? C>>>=> =?? =>>

@?> =?> ? >??--?-=?>?=>, ? "?? %?G>, ?= =??=<@=?>.

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9

III. F%c*( %$ Pa)!e$) Safe)-

& J? C>>> ?@@>,?-= =?? =>>@>> =? >>?> =?- ? ?? >? <@? ??=. & >? ?

=?? > @>?=? 2007>?@ @> ? Jo!rnal of 

Healhcare Managemen. & >?@@ ??:

(Join Commission accrediaion #ashe ke% predicor of hospial paien 

safe% s%sem implemenaion. [Join 

Commission] accrediaion sa!s #as

he onl% organi&aional characerisic 

ha consisenl% emerged inidenif%ing #hich hospials ha"e more

e$ensi"el% implemened paien 

safe% s%sems. Join Commission

accrediaion #as !niforml%, srongl%,

and consisenl% associaed #ih moree$ensi"e implemenaion of paien 

safe% s%sems'.) 

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& J? C>>> @>

>? ?> =?? >?=> >>?= @= ??>? ??> @ ?> >?? ==? , ? @? Seninel E"en Alers, =<@=

= ? ? "?? %?G>.

Sentinel Events

& J? C>> > >? ? > @?@== ? = >=@>> = > @=, = ?=> ?=. &> ?> =

>?K @> ? > ? = ? >?? =>>. A ? >? ?@=>, J? C>>-=?=?> = ? ?

? =? @> >>,? =?> ? =@? => =@==, ?= ? ?>> ?>=?>. % J@= 1995

(?=@ %?= 30, 2010), &J? C>> > ===?> = ? 7,147 >??> ? =? =?>.

Sentinel Event AlertsI=? = ?> ==?> =>@? =? @> >> > =?? >@= =? = >>> =K ?? =?

>= => ?> = @==.

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& J? C>>> ?? >?

>=, Seninel E"en Aler , >= = = ? J?C>>> %? E?D?> > > ? =?> ==> =@

? =@ ?> ===> ??=. & Alers => =>>@? > ?> ?> > ?? ? =?.&> =?> =

@ ? "?? %? A>=G=@, =@ >>, @=>>,=>?>, ?= ?? >?=?>. %??>?> @? ? ?> @>> >? ?> ==? ?

& J? C>> >>@> Seninel E"en Aler = ?.?>>.= @=&>.

National Patient Safety Goals& J? C>> ?"?? %? G> =? >=?> ?? >? = ? = =?>? = >@?> ? =>>???? >? =>. &> G> ? ? = ? 18,000 J?C>>-=? ? ==?>. & G> ==>?

=?@?> = =??? ? ? ??>.B ? ? ? >>?? ?? G>, >> ? ?= =?> ?

=?, >@>?? = ?>? = = ? ?=??>.

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G> = ? = >?? > =?> = ? "??%? A>= G=@. F= 2011,

>?> @>? ?? :

I? ??> ==? I= >? @? '> > >?

"=? ? C ?? > I? ?? >? =>> '=> "=?

 A ? >=? ? G>,

? ? ? =<@=?>, @ & J?C>> >?,.?>>.=, @=%?=>.

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The Universal Protocol 

= >@= =@=> = >@== ? = => = = =? >@ = @=. +?, ?>?> ?@ ? @= ? ?.

% ? ? ? J?C>>> %? E? " ==? =<@=?, 908 =>?, =>, = =@= =?>? ?> ==?:

149 >> (14.4 =? ==? ?>) = ==? @=2009.

& ? = =>>>

? = =?> =??> >?? ===>, & J?C>> >?> ? '=>"=? = "=? = %?,= "=@= = "=>

%@==. & '=> "=?, > => = ? 50 =>> >>?> =?> >@ > ? A=M A>>? A=

C %@=>, > ? >@= ->@= >=@=>. & ?> ?=? @:

"=-=? =? =>>

M= ? =? >? & ? @?K ?= >?=? ? =@=

& ?= "=? @ & J? C>> >?,

.?>>.=, @=%?=>.

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IV. H%(&!)a" S)a$da'd(

 A >?= @> ?? >? > ?? ?= ? J? C>>>

>?=>. M= ? =?? >?=> = =?=? ? >?, =>> >>@>>@ > ? @>, ??=, >@== >?>,?=>@>>, =>?=? >@>,>? >? ?, =>?, <@?, =?, >@=?. M==,?= = >?=> =? ?=> ? =? =>?>, =>@= ?? >>?> ? =?? =, =??> @? ? @?> ?= = ( = ). A J?C>> >?=> =? ==? ?=@? ? -<@?,> ?? = =.

H>? >?=> = = ?=? ? = > ?@=: ?=@ =?,=? =? =@>=>>>.

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15

& >> ?> =?->

= -> >?=> > ?? = @? ?> ? ?= @? >>, @=>>, =>=>, ? = =>, ?= =?> = ? =?

?? =.

& J? C>> >?=> =>???> ?? ==??>, >?=@?@=> = =>>>

?? @>? = >? ?= >, <@? =.%?=> = ? 16 ==> = ?=> =?? ?? =. &

>@= => = =   ? >?=> =>:

Med!ca" S)aff: & = >? >? > =?= ? =>> ==>? >, -<@? =.& = >?, > >-= , > = ?=> ? <@? == =??=> ==? = ?=@? >? =>>. &=>>?> @?> ?= >? @=? = > ? =??=>.(A @ =?? ?= = = >=> ?@?=? = >@=> ? ?> ?= > =>.)& M %? >?=> =>>? =>:

!= >? >?=@?@= M @? ?? M >? >

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16

M? ?? =

G=@? @? ==> "== =? C=? = A>> @> =? F@> =>> =?

@? E? =?

= =>> ! =>> =?

@? (? =>) F= = =>>

= => = >> A?? ? =>

? >? 

"= =? L> ? =??= ?

&== => &

C?@ @?

R!g)( a$d Re(&%$(!b!"!)!e( %f )e

I$d!+!d*a": &> >?=> @> ? =? =>? ?

>> ??> @?@>>> ? =. &>>?=>, = , ?>>@> >@ > -- >>,@? ? ??>

> ?= @ = = =  = = = >?. A?, ? >?=> =>>?? ??, =>?>, ?.

& >?=> > = ?=? ??> ?=>>? > => ?? = ?.

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P'%+!(!%$ %f Ca'e, T'ea)#e$), a$d

Se'+!ce(: & @= = =>>> ?> >? = >>>>

?? >, =,= ? = ?? ? ??>, =? =. ?? @= = ?>, ?= ??>@ ? >?=> @

= >> ? ? ==?> = = ??>, =?=?> > ? = ,? ??> ? ? ? @? ?= =,

=? = ? ?? > ===, ?=>==, = >=. &> >?=> =>>? ?= =? ?? =??==? ??> = >>= ?

? ?? > ??@? =.

Med!ca)!%$ Ma$age#e$): &I>??@? M > @ ??? ===> = ? >? ? = ===>, ?400,000 =? =@-=?@=> @== >?> =. M? ===> = > ? >? =<@? ==?

?> => ?> ? ? J?C>>> %? E?D?>. M? ?>?=> >?> >@=?

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?? >? = ? <@?

= =? >>? =>? =@=, >?=,== ?=>=, == >>, >?=, ?= ?>. &

>?=> = > ? =@=? =?>, ===>, >@> @= ?= ?, <@? >? ? ? =>>>,

> > ? @> -> =?> >?==>>> ?=@@? ? >?.

I$fec)!%$ P'e+e$)!%$ a$d C%$)'%":"=? ? =->>??> (HAI>) ==>?> ?= >? ??> >? @=?. & C?=> = D>>C?= "=? (CDC)>??> ?? =? 2

??> ?? @ ? @?= >?> ? '.%. <@=?> ?? = ? =? ? ?? = ? =>?. &> ?> =>@?

=? 99,000 ?> ? $4.5 ? $5.7 = = ? ?? >?>. & J?C>>> ? =? ?= >?=> = ?

== = >?> ? ? > ? =? ?= ?> @> ?=? = =>> ==>, >=>, >??>. &

>?=> >?> ? @? =? ? =>?=@@? ? >?, @>>, ? =?? ? > ?? ?

? ?= ==.

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Pe'f%'#a$ce I#&'%+e#e$): &>

>?=> @> >>??= ? @> ? ? >@===, >>>> @==?==, ===. &> ?@@> =>>

@>> @?> =, @>? @ =@ ?@ ?? =>> ? ?? >?. & ?> , ? >?=>> =>>> >>?>

@ => ?? =@? @?? =>?>. ">> >@ >?> =?. & > ?? =

=>>>, ? ? >>= ?>@= == ?> ?, >@>? ? =>> =?>.

Leade'(!&: &> >?=>= ? >?=@?@= ? =>? = ??= ? =? ==. & ??= ?> ?, =>

@>? =?, >= ??= >=? ? ? .G =?>> ?= => = ??= ? ?

>>, >, > ?=?, @= >? @?, =>>?> ?=>?.

M >?> ?= =>=@>? >= =>,= , =

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>? = ??= ?

= >, <@? =. &L=> >?=> =>> ?>>@ > =? @?@= ?? >?=>>? > ==?; =- >=> ?? ?

?? >; >@= ? ? ? @, , >=>@=> >>= ? = =;= ?? >? ?= ==>;

== =?. &>?=> = ??? ?> @?> > ?=? =>>? ?=> ?? -@?

=?> ? =>=@> > ? = ? >?=> ? ??>.

Rec%'d %f Ca'e, T'ea)#e$), a$d

Se'+!ce(: &> >?=> =>>? ?> ? ==, ? @??? ?> ? =??= @? ?? = ?

? = > ?=> ? >?? ? ? >= =?=>=. &> == > =??@> ? => >?= = >=> > ? =

@? ? =??=> >? ?? > =@ ? ?@? = >-.

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E$+!'%$#e$) %f Ca'e: H>?> @>? E=? C= >?=> ?=? > ? >?? ?= =. & =? => @ ?= >?>: @>, <@?, . E? ?  ? =? = @> @>=>>> ??>, >@ >=@ ?=

=? => =>>,=? ?> @=> ? > ?> =??>, >?, ?=> ?? >?> ?>. C=?

=? ?? ?> ?? >= =? > ?=? >=?? ? >@= >??? = =. %?=>? ? E=

M? L %? ?=>> =? ? =? >=?. & E=M? >?=> = =? >?> ? ? => ?

? ?> => ?? == >=@?> ? >>?=>. & L%? ?= =>>> ==??, > = @>??> = ? @ ? ?

>? ?>>.

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H*#a$ Re(%*'ce(: &  

H@ >@=> >?=> > ?>@= ?? ? >? ?=>? <@?> ?>= >? >?> ?? ? ?=?> >>, ??

@?, ?? = >.H>?> @>? > = ? =?@= ?? >? ? ??? = =<@=?>. & ??> , ? >?=> =<@=

>?> ? = >?, =?? >?, =?, @?, ?= >?, >>>>, ?, = >? ?, =? >-?

=.

I$f%'#a)!%$ Ma$age#e$): &I=? M? >?=>> ? ? ?? ?? = >

? @ =?, ?? ? = >> >? ?=@@? ? >? @>? ?? ? @=?=? ? = =?,

?=? =. I ?, ? >=?? ? =?? ? = ?? ? ? ?@@?= >>. @?=? ?=

?> = => @> ? ? ,?>>, >?, ? <@?  =, ? >?=> = > ? <@ ? ? =->

>>?>, ?= >>?>, = =>>?>.

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N*'(!$g: &> >?=> =

? =?? = @=> @?>,=?? @=> =>, >? @=>> >?>. &>?=> =<@= @=> @? (>, =>> =>?= @=>

<@ @? ? =) ? =? ?>?> @=> >=> >?> @=> > =@=>, @=> >?=>,

@=> >? >.

Wa!+ed Te()!$g a$d T'a$(&"a$)

Safe): F, ? >?=?? @ ?>

>?=> = &>? =>> ? => ? ?? >? ?>? > == == &=>? %?, @> ? ? ??

> =@=> = >= ?>>@ ?,=@=?, ?=>??.

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V. Te S)a$da'd( De+e"%&#e$)

P'%ce((">> @ ? >?=>? =>> @=  >: >= =? >,= =? , =?? ?= =?? =>.

& >? >> =@? > ?=@ H?C=, =? = ? ?? =?? =?? >?=> ??@=> =@ = >@>> @>=> ?=>? = ?= <@?.

%?=> = =? ? =>> <@? >?=>, ? ? = @?  ?> ? >= K ?=. &> =?? ?> ? =? > ? = >@=>?? >?=> = ?==,=?, =?->.

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>?=> = ?

=? ? ?? >? = <@?  =, >? ? ?@?>, @=? = >@=. F= , &J? C>> =? ?=@

=<@=?> = @@?> = ? ==>>>, =? >?=> ? =? -=> = ?? >@=>

=? =>>, =@> = =>?> ? = ?> ? = =??. I ?> ? >? >?=>, & J? C>>

>> ? >? >@ > -> >?@> =? ? >@= =.

VI. Te O$-S!)e S*'+e P'%ce((

& J? C>> @@>@= =>> > ?-= ??-?=, >

=?? ? >@= > =?=?? ? ? @? ?<@? ? = ?? ??> =? =?.

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">> J? C>>

>@==> ?=? >= >:

E >> =@?@ > =, =,@= ?= ? ->?

=?? =>>. & J?C>> >@==> @??= =?> =??=>>> =@=> =?@ == @? = ?

? >? ??>. &>> ?? >@==> @>> ?=? ? = = >??>, >@>> => ?@ =. (%@==> =

? > ? @? ? >>, =?>>>?> = ? @? = >, ? ?=??.) & J?C>> ?> ? = @?

> ==?> >?=?> = = ? <@? >?  = = ? ?= ??>. &>@? => >?=?=?? =?=> ?

>> & J? C>>.

 A> =? ? ->? =>>,>@==> @> !$d!+!d*a" )'ace'/

#e)%d%"%g ? ?= ??> =

=> ? =?>>>?> = = = >=>. &> =>> > ??>@==> > =? ?= ? ? ? =? ==>,

@ >>, >==? =.

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L>> ? > ? ?

=?? > =@=>. B ? = >? ??> >>>> >? = =@>>> = ??= @? =>> >=>,

>@==> = ? @? =?> @> =??=<@=?> ? = >,-<@? =. I ? ?@ ?==>, >@==> > @>

>>?> ?==> ? =? >>?> ?? =? ?? <@? >? ?? =.S()e# )'ace'( >@>> @? @? ? @> ?

== =?, ??, ? ?=,= ? ?= @==? ?> ?=>? ? ?=?. B? ?> ?==>

= =?@?> ? >= >?=?> = ?= ? ==?>, >@>>> ? >? =>.

 A> =? ? ?== ?,>@==> ? ? >> @??= ? ??> >@ >? ? ? "?? %?G>, ? ? '=>

"=? = "=? = %?,= "=@=, = "=>%@==, ==>@=?/=? ??>.

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%@==> ? ? =??  

=?? >?=> ?>?> >> >???. I>?,? ? ? >@>> ? >>?> =>>> ?? = =? >> = @?

= > =? ?= = ? ?=?. %@==> @=>??? == ? >>? ? > > ?? ?=??> = -<@?, >

?? =.

VII. Pe'f%'#a$ce Mea(*'e#e$)

)% I#&'%+e Pa)!e$) Ca'e

"== >@=? > ?= =? J? C>>=??. % 1997, & J?C>> > ? =?? = ? ?=> ? =?? =. & J? C>> CM% @==? = ??= ?? ? >?= = =K>@=> >?> =? ? =???, =? @=, @, >@= =.

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'> ? ? @ ==

=? ??> > =?, @?? >@= @> ==>@=? =>@?>. C>@=>,>@==>, @>>> @=>=>, ?= >?=> = =>

=?= ?=>= @?? = ==.#@? =? > ? >>>??> >?=> ? = ? = >>. &

J? C>> > >?== =? ?@ ?> #@? C >?(.<@?.=) > > ?> @ ==? >?

== I= A=>H>?>K(.?>>.=/@==?.>).

VIII. Te F*)*'e %f Pa)!e$)Safe)-

& >? =?@? = =? ? = ? > ? =>>?  

?? >? =>. & J?C>>> > > ? >?@?=?> ?? ? ?=>=? ? = ? -=? @>?= =

> = ? >>?,>? <@?, >?-@ ? ==>> >??>.K & >?=> @>? ? = ?= >>? ? =,

@= =?. "@? >, ?? ??= > ? @.

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30

IX. Ce$)e' f%' T'a$(f%'#!$g

Hea")ca'e

M= ===> ? -? >? =@? ?=? >=@> => ?>. &>

@ ? > >?= -=> ?? ? =?,? ? ? @? =@>?=>> =? ?>, ? @= ? ? >? @?@=.

@>? =>> =? === =@? = >>? ?=@ ? = >>?? >>. A?@ ? = 

>@ =?> ? =>>? > ?, & J?C>> > ?=? ? ?? = =,>= ?

? =, =>@?> ?= ==> ??=>> ?> ?? >?>. &=@ ?> Ce$)e' f%' 

T'a$(f%'#!$g Hea")ca'e, & J?

C>> > >?? =@ ?>? @ >? =?> ? ?=>> <@? ?? >?=> >@ >

, - @?> >@= >? ?> (.?==?=>=?=.=).

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X. F%' M%'e I$f%'#a)!%$

F= = =? @? ??> =>> ?> @?,> >? .?>>.=.& >? > >> ?

= >-> =? ?= =? @? ??>?, >> ? ->?, >@?> =? ? =>>???? <@? >? =>,

= ?? => ?= > ?>.

 A ? & J?C>>> >? >?=>

? =? = ?==? ?=@ J? C>>>@=> ? ??://.=./= (877) 223-6866.

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