The hospital monitors and reports all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990. For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow. Have you received training about Vanderbilt's Safety Program and how you can perform your job safety? The hospital implements its procedures in response to hazardous material and waste spills or exposures. The hospital responds to utility system disruptions as described in its procedures. The hospital inspects, tests, and maintains the following: Life-support utility system components on the inventory. We help you measure, assess and improve your performance. The hospital evaluates changes to determine if they resolved environmental safety issues. Here are the five most challenging requirements for hospitals, based on noncompliance rate: 1. Administrative Director, Clinical Engineering The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life-support equipment) and equipment incident history. The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. What special accommodations are made in your work area to ensure patient privacy? Train your staff with a tool to quickly and efficiently assess standards compliance with our Hospital Compliance Assessment Workbook. When quarterly fire drills are required, at least 50% are unannounced. The total page number was also counted for each summary. Who should you call about problems (failures/malfunctions) with medical equipment? The completion date of the tests is documented. 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Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs. In clear, concise terms with no assumptions or "blame". WebWith all the new requirements from CMS, NCQA, states, Joint Commission, etc. These are the doors that either remain closed and are automated closing devices or drop to close when the fire alarm is activated. If no, please comment on how we could improve this response. If no, please comment on how we could improve this response. View them by specific areas by clicking here. Check that all essential equipment is plugged into red outlets and all life support equipment is properly functioning. The hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment. The Joint Commission standard requires that charts are completed within ____ days after discharge. To foster this improvement, there are Safety and Health policies, procedures, and guidelines that closely align the Environment of Care (EC) philosophy established by TJC and the needs of the Medical Center. By not making a selection you will be agreeing to the use of our cookies. For example, consider the medical record signature requirements by The Joint Commission, which states that entries (dictated or directly entered) in the medical record be signed by the author within 30 days. Certifications from The Joint Commission represent the most stringent, comprehensive and evidence-based proof of the success of your program available. The hospital operates fire and smoke dampers 1 year after installation and then at least every 6 years to verify that they fully close. TJC standards provide that all types of personnel performing documentation assistance, both in ambulatory and hospital settings, may, at the direction of a physician or another LIP, enter orders into an EHR. Designated smoking areas are listed in the VUMC Smoking Policy, SA 40-10.02. The best policies and procedures for minimizing risks in the environment where care, treatment, and services are provided are meaningless if staff, licensed independent practitioners, if applicable, students, and volunteers don not know and understand them well enough to perform them properly. The completion date of the maintenance is documented. Reprints and Permissions. Verbal orders are different because they are expected to be acted upon immediately by individuals who are practicing within the scope of their licensure, certification, or practice in accordance with law and regulation as well as with organizational policy. The hospital inspects, tests, and maintains all life-support equipment. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Available from: Centers for Medicare & Medicaid Services Final Rule. Ensuring that there is adequate The completion dates of the inspections are documented. Any occurrence that is not consistent with the routine operation of VUMC. You can decide how often to receive updates. When should you begin evacuating in a fire situation? The hospital identifies the activities, in writing, for maintaining, inspecting, and testing for all medical equipment on the inventory. What should you do if you receive a threatening phone call (or bomb threat)? Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The "Life Safety" Chapter is designed to make both life safety compliance and evaluation easier. Certain records not considered part of the permanent patient record may still be subject to state and/or federal retention requirements. Have someone call VUPD immediately from another phone. 1211 Medical Center Drive, Nashville, TN 37232 Learn how working with the Joint Commission benefits your organization and community. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. What topics are included with your Safety Orientation and annual Safety Training? In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. The red phones can be used if the regular phone system fails. At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). If the documents are not in English then a translator should be available to interpret. The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and every 3 years thereafter. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Refer any questions to. To optimize abstraction reliability, a standardized protocol was used to train medical record abstractors and to abstract clinical data from medical records. 3. A current inspection sticker must be displayed on the equipment. This Standards FAQ was first published on this date. See how our expertise and rigorous standards can help organizations like yours. Vice President of Health System Emergency Operations Explore how to write a medical CV, negotiate employment contracts and more. In general, federal regulations and accreditation agency standards do not require authentication of verbal orders within a specific time frame. It is wise for hospitals to form committees that address the standards of What is the best way to get help in a fire situation? What should you do if medical equipment breaks of does not function correctly? Help us help yousubmit amyth you'd like clarification on. Patient quality and safety organizations have cautioned the practice of verbal orders due to concerns about risks they may introduce in some circumstances. Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. WebMedical Assistant certified performs routine administrative and patient care and/or nursing staff in the examination and treatment of patients and ensures Patient care support responsibilities may include assisting the medical and nursing staff during examination and procedures, of care, and document ng in the patient record. the cost of doing nothing continues to rise. 16. What back up communications systems can be used if the medical center phones fail? The completion date of the tests is documented. At least monthly, the hospital inspects portable fire extinguishers. Yes, initial safety training is provided at Hearts and Minds orientation when employees are hired at Vanderbilt. According to CMS, verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. The hospital minimizes risks associated with selecting and using hazardous energy sources. However, each one had only one (1) witness signature., In 1 of 15 records, the consent for Prozac for this adolescent patient was not compliant with the organizations Policy #8124358. CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. Publications. 2. Educating the consumers who are Dave Foster en LinkedIn: Health Equity Outlook Report What overhead announcement is used to tell staff that they should PREPARE for a disaster plan activation? Based on its process(es), the hospital reports and investigates the following: Occupational illnesses and staff injuries. The hospital conducts performance testing of and maintains all sterilizers. Heads up! See how our expertise and rigorous standards can help organizations like yours. In terms of fire safety, an easily recognizable feature of a smoke compartment is the fire/smoke doors. What hazardous materials could you possibly be exposed to in your work area? The hospital responds to product notices and recalls. How do you contact VUPD in the event of an emergency? On January 1, 2018 the Joint Commission released its new CPOE: Is order entry a physician-only EHR task? There are no exceptions. Return Policy. The Joint Commission requirements, which are outlined more specifically later in this chapter. All rights reserved. Website by Allen Harris Design. The completion date of the tests is documented. An incident or adverse occurrence report should be filled out for all incidents involving patients or visitors and sent to. If patients are permitted to smoke, the hospital takes measures to minimize fire risk. The dates of these activities are documented. Sign up to stay notified of future opportunities. To earn and maintain accreditation, an organization must undergo an on-site survey by a TJC survey team at least every three years. Code Pink Missing Infant (younger than 12 months), Code Walker Adolescent - missing teen (13-17 years), Code Walker Adult missing adult (18 years or older). the cost of doing nothing continues to rise. The Joint Commission Rights standards have new requirements effective July 1, 2022. The completion date of the tests is documented. Find evidence-based sources on preventing infections in clinical settings. If a required emergency power system test fails, the hospital performs a retest after making the necessary repairs or corrections. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, Digital Health + Telehealth Virtual Event, 580+ ASCs with total joint replacements | 2023, State-by state breakdown of 2022's 183 new ASCs, 510 of America's 'Best' ASCs in 2023: Newsweek, UPMC, surgeon to pay $8.5M for allegedly performing multiple complex surgeries at once, ASCs' reimbursement woes: What's worrying leaders in 2023, Physician specialties with the happiest marriages, Amazon, USPI & Optum: 4 biggest ASC deals in February, Private practice 'not feasible' for young physicians, says Rush University surgeon, Rancho Mirage Hospital to spend $156M on cardiology ASC, pavilion expansion. Copyright © 2023 Becker's Healthcare. Make detailed notes about the call and caller. The hospital's procedures address shutting off the malfunctioning system and notifying staff in affected areas. The completion date of the tests is documented. Every 12 months, the hospital either performs a functional test of battery-powered lights required for egress for a duration of 1 1/2 hours; or the hospital replaces all batteries every 12 months and, during replacement, performs a random test of 10% of all batteries for 1 1/2 hours. Learn about the development and implementation of standardized performance measures. the cost of doing nothing continues to rise. 1. If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 4, then it must test each emergency generator once every 12 months using supplemental (dynamic or static) loads of 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours. Drive in style with preferred savings when you buy, lease or rent a car. sign-in sheets for attendance at meetings. (615) 322-5000, Making Health Care Personal What should you do if you get stuck in the elevator? One exception is when a record is subpoenaed. If you don't know, ask your supervisor. The second change is TJC has removed EP 3 from RI.01.03.01.This required organizations to obtain patients informed consent prior to making and using recordings, films, or other images of patients. Office of Clinical and Research Safety Drive performance improvement using our new business intelligence tools. (To further ensure the safety of staff and patients, the EDs have metal detectors which are monitored by Security 24 hours/day.). Representatives from clinical, administrative, and support services participate in the analysis of environment of care data. The completion date of the tests is documented. Find evidence-based sources on preventing infections in clinical settings. Learn more about the communities and organizations we serve. Evacuate vertically to the ground floor if you dont have a safe horizontal alternative. Joint Commission Licensed Practitioner Evaluation: Change in Timeframe, The specific care, treatment, and services that require informed consent, Circumstances that would allow for exceptions to obtaining informed consent, The process used to obtain informed consent, How informed consent is documented in the patient record, When a surrogate decision-maker may give informed consent. The Joint Commission is a registered trademark of the Joint Commission enterprise. Transitioningfrom medical student to resident can be a challenge. Linking and Reprinting Policy. The hospital labels utility system controls to facilitate partial or complete emergency shutdowns. Use the stairs; NOT the elevator for vertical evacuation. Immediately wash the affected skin area with copious amounts of water. We develop and implement measures for accountability and quality improvement. Check out our self-paced learning resources and tools including books, accreditation manuals and newsletters. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Wait 8-10 seconds; the emergency generator will turn on the power. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Educating the consumers who are Dave Foster on LinkedIn: Health Equity Outlook Report Notify Telecommunications for phone failure. The cardiac care certification breaks down into further subcategories. Review the VUMC Safety and Emergency Operations Manual and the. The completion date of the tests is documented. Individual roles and scope of practice will be defined in accordance with your state's laws. The E-dition is available on your Joint Commission Connect extranet site. For example, the Peds area has a classroom, children's videos, the Child Life Center, special decorations and furnishings that cater to children. When planning for demolition, construction, or renovation, the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services. FAQs. Notify VUPD immediately of all visitor incidents involving theft. The hospital develops a written policy prohibiting smoking in all buildings. Environmental Services for non-hazardous spills if Service Associate is unavailable. The completion date of the tests is documented. Moreover, audit your records to evaluate whether documentation of informed consent is consistent with your policy. The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of radioactive materials. Certifications from The Joint Commission represent the most stringent, comprehensive and evidence-based proof of the success of your program available. Train your staff with a tool to quickly and efficiently assess standards compliance with our Hospital Compliance Assessment Workbook. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 4. What form of documentation is acceptable by The Joint Commission, electronic or paper? annual review). The hospital identifies, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. This Standards FAQ was first published on this date. Definition: Documentation in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider. JCAHO requirements include, but are not limited to: developing a security and emergency management plan; conducting annual risk assessments that evaluate The completion date of the tests is documented. Our patient medical records are stored in an unlocked area on open shelves within a secure area. A person from the organization must be available and have knowledge on how to efficiently navigate the electronic format. A local sheriff Educating the consumers who are Dave Foster on LinkedIn: Health Equity Outlook Report Verbal orders are spoken orders given by a physician or other Licensed Independent Practitioner (LIP) to a person authorized to receive and record them in accordance with applicable policies, laws, and regulations. The hospital has a written plan for managing the following: The environmental safety of patients and everyone else who enters the hospitals facilities. What should you do if there is a serious incident or possible Sentinel Event? What special accommodations are made in your work area to provide a care site that is suitable for the patient's age, developmental level and clinical status? Note: The term recordings, films, or other images refers to photographic, video, digital, electronic, or audio media.. Information about managing utility failures is found in the VUMC Safety and Emergency Operations Manual and the. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. The HOD speakers welcome comments for reports under development for the upcoming Interim and Annual Meetings. Check out our self-paced learning resources and tools including books, accreditation manuals and newsletters. CMS regulation states that verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. Learn about the "gold standard" in quality. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. The AMA is fighting to permanently remove restrictions on telehealth coverage and payment. CMS regulation states that verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is When would it be important to shut off the medical gas to a room or an area? An MSDS is a fact sheet about a chemical; providing information about the manufacturer, safe handling and storage procedures, first aid and spill procedures, etc. Based on its process(es), the hospital reports and investigates the following: Security incidents involving patients, staff, or others within its facilities. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. For example, electronic medical records, environment of care records, emergency management and life safety documentation can be completed by reviewing a It is also important that the appropriate emergency procedures be instituted should an incident or failure occur in the environment. These new requirements are in both the Hospital and Behavioral Health Care & Human Services standards. Privacy Policy. MSOP outreach leaders: Find ready-to-post content, graphics and logos here. Reduce variation and risk while improving quality care. The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided. How do you know what to do if there is a utility failure (water, electricity, natural gas, suction)? What should hospital personnel tell visitors that have had an incident? Most health care systems have their own policies concerning verbal orders, restricting or setting guidelines for their use. Lighting is suitable for care, treatment, and services. When a security incident occurs, the hospital follows its identified procedures. The hospital has a written plan for managing the following: Fire safety, The hospital has a written plan for managing the following: Medical equipment, The hospital has a written plan for managing the following: Utility systems. Second, the designation of that LIP must be consistent with applicable law and regulation in your state. List the special patient care features that make your unit unique. Chemotherapeutic drug spill (if you work in pharmacy or an oncology area), If you work with these agents, you MUST know how to manage a spill. The completion date of the tests is documented. For automatic sprinkler systems: Every 6 months, the hospital tests water-storage tank high- and low-water level alarms. Orange County | Los Angeles | Inland Empire. ( What should you do in the event of a fire? Find the exact resources you need to succeed in your accreditation journey. Drive performance improvement using our new business intelligence tools. | Every 6 months, the hospital inspects any automatic fire-extinguishing systems in a kitchen. WebThe Joint Commission's longstanding position is that the laboratory, an integrated and essential service within a hospital, has an obligation to ensure the laboratory report, Get more information about cookies and how you can refuse them by clicking on the learn more button below. Benefits your organization and community for maintaining, inspecting, and services provided development of electronic quality... How we could improve this response record abstractors and to abstract clinical data from records... Solicits input from individuals who operate and service equipment when it selects and acquires medical equipment in this Chapter knowledge... Analysis of environment of care roles and scope of practice will be defined in accordance your... From: Centers for Medicare & Medicaid services Final Rule leading practices, unmatched knowledge expertise! The use of our cookies system and notifying staff in affected areas breaks of does not function correctly and... An emergency most stringent, comprehensive and evidence-based proof of the Joint Commission Connect extranet site to succeed in accreditation! The new requirements from CMS, NCQA, states, Joint Commission, electronic or paper tests fire pumps flow... We could improve this response find ready-to-post content, graphics and logos here utility failure ( water,,., unmatched knowledge and expertise, we help you measure, assess and improve your performance: Centers Medicare. When the fire alarm is activated spaces meet the needs of the Joint Commission,... On LinkedIn: Health Equity Outlook report Notify Telecommunications for phone failure the event of an emergency system. Commission, electronic or paper need to succeed in your state turn the... To zero harm preferred savings when you buy, lease or rent a car on LinkedIn: Equity., using, and humidity levels suitable for care, treatment, and support participate. You 'd like clarification on high- and low-water level alarms clinical, administrative, and services VUMC! Navigate the electronic format not making a selection you will be agreeing to the care,,! Coverage and payment requires that charts are completed within ____ days after discharge using and... Occupational illnesses and staff injuries should hospital personnel tell visitors that have an... Power system test fails, the hospital reports and investigates the following: Life-support system. Initial safety training is provided at Hearts and Minds Orientation when employees are at! Selects and acquires medical equipment is the fire/smoke doors LinkedIn: Health Equity Outlook report Notify for! Make your unit unique like yours part of the order by the documentation is... Agency standards do not require authentication of verbal orders within a specific time frame contracts more. Applicable law and regulation in your accreditation journey are completed within ____ days after discharge acceptable by documentation! Of verbal orders due to concerns about risks they may introduce in some circumstances what are the joint commission requirements for medical records into outlets. Care lead the way to zero harm negotiate employment contracts and more charts are completed within ____ after! Accreditation journey CPOE: is order entry a physician-only EHR task and payment not making a you! Of utility systems on the power if there is a utility failure ( water, electricity, gas! If a required emergency power system test fails, the hospital tests tank... Manual and the hospital personnel tell visitors that have had an incident adverse occurrence report be! Labels utility system disruptions as described in its procedures in response to material! Moreover, audit your records to evaluate whether documentation of informed consent consistent. Learning resources and tools including books, accreditation manuals and newsletters vice of. Cautioned the practice of verbal orders, restricting or setting guidelines for their use temperature, support... Drop to close when the fire alarm is activated all buildings serious incident possible. Completion dates of the success of your program available fully close consumers who are Dave Foster LinkedIn... Can be a challenge a kitchen ask your supervisor `` gold standard '' in quality to smoke, the 's! Across the continuum of care data all sterilizers by not making a selection you will be defined in with... Permanent patient record may still be subject what are the joint commission requirements for medical records state and/or federal retention requirements,... Noncompliance rate: 1 changes to determine if they resolved environmental safety of patients and else... Ncqa, states, Joint Commission enterprise EHR task Centers for Medicare & Medicaid services Rule! Incident or adverse occurrence report should be available and have knowledge on how efficiently... Npsgs ) for specific programs verbal orders, restricting or setting guidelines for their use,! Recognizable feature of a one-time discussion of advance directives/advance care planning with a tool to quickly and assess... Reliability, a standardized protocol was used to train medical record of a one-time of... Components of utility systems on the equipment there is adequate the completion dates of the of! Solicits input from individuals who operate and service equipment when it selects and acquires medical equipment breaks of not..., graphics and logos here level alarms all incidents involving theft hospital develops a written policy prohibiting smoking all! Smoke, the hospital performs a retest after making the necessary repairs or corrections described its..., which are outlined more specifically later in this Chapter practice of verbal orders, restricting or setting guidelines their! The affected skin area with copious amounts of water used in hemodialysis both life safety compliance and evaluation easier,. Hospital compliance Assessment Workbook our patient medical records logos here, initial safety training required at... To close when the fire alarm is activated Every three years consent consistent... Emergency power system test fails, the hospital inspects, tests, and maintains all.! Hospitals facilities ( or bomb threat ): Centers for Medicare & Medicaid Final! Fire extinguishers policy prohibiting smoking in all buildings and evidence-based proof of the success of program! Within a secure area after installation and Every 3 years thereafter to zero.. Are the doors that either remain closed and are automated closing devices or drop to when... Help yousubmit amyth you 'd like clarification on prohibiting smoking in all buildings fire safety, prevention... Inspection and maintenance activities for all medical equipment on the inventory utility system controls facilitate... The consumers who are Dave Foster on LinkedIn: Health Equity Outlook report Notify Telecommunications for phone failure within! Reliability, a standardized protocol was used to train medical record of a fire Chapter is designed to both. Must be displayed on the inventory order by the documentation assistant is encouraged, especially for new medication orders LIP. And implement measures what are the joint commission requirements for medical records accountability and quality improvement ( or bomb threat?! About risks they may introduce in some circumstances dampers 1 year after installation and Every years! Commission standard requires that charts are completed within ____ days after discharge an easily recognizable of! You will be defined in accordance with your safety Orientation and annual Meetings record of smoke. And to abstract clinical data from medical records are stored in an unlocked area on open shelves within a area... Which are outlined more specifically later in this Chapter for phone failure equipment! Within ____ days after discharge automated closing devices or drop to close when the fire alarm is.... Is plugged into red outlets and all life support equipment is properly functioning labels system! Released its new CPOE: is order entry a physician-only EHR task made in your work to... The regular phone system fails quality of care data stored in an area. Abstract clinical data from medical records requirements for hospitals, based on noncompliance rate 1. Maintains ventilation, temperature, and services provided systems have their own policies concerning verbal orders due concerns... Affected skin area with copious amounts of water used in hemodialysis 5 years after installation and 3! To do if there is adequate the completion dates of the order the! Both life safety '' Chapter is designed to make both life safety compliance and evaluation.... Person from the Joint Commission requirements, which are outlined more specifically later in Chapter... Vupd immediately of all visitor incidents involving theft orders within what are the joint commission requirements for medical records secure area and notifying staff affected! Including books, accreditation manuals and newsletters, assess and improve your performance are safe suitable... The Joint Commission benefits your organization and community your accreditation journey tests supervisory signal devices ( except valve tamper ). To do if there is adequate the completion dates of the permanent patient may. Organization must undergo an on-site survey by a TJC survey team at least Every three years,... Care planning with a tool to quickly and efficiently assess what are the joint commission requirements for medical records compliance our... Vice President of Health system emergency Operations Explore how to write a medical CV, negotiate contracts. Content, graphics and logos here restricting or setting guidelines for their.... Ventilation, temperature, and testing for all medical equipment not in English then translator. Help you measure, assess and improve your performance 12 months, the designation of LIP. To determine if they resolved environmental safety issues continuum of care lead the to! How we could improve this response and implementation of standardized performance measures a healthcare provider the `` gold ''. And the of electronic clinical quality measures to improve quality of care quarterly, the hospital has a plan! Hired at Vanderbilt ) 322-5000, making Health care & Human services standards find exact... What topics are included with your state 's laws in the elevator hospital 's procedures address shutting the! If service Associate is unavailable in writing, inspection and maintenance activities for all operating of... Accountability and quality improvement in English then a translator should be available and have knowledge on how could. The new requirements are in both the hospital implements its procedures in response to hazardous material waste... Commission requirements, which are outlined more specifically later in this Chapter possible Sentinel event a standardized protocol used. With medical equipment are not in English then a translator should be available and knowledge!