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The IAC Standards and Guidelines
for Cardiovascular Catheterization Accreditation

 

Click here for a printer-friendly PDF of the Cardiovascular Catheterization Standards

 

Appendix C

Quality Improvement Measures

 

Requirements for safety and procedural outcomes:

 

2.2C       A policy for adherence to National Patient Safety Goals must be documented, and include at a minimum:

 

i.         Accuracy of patient identification:

a.        Use at least two patient identifiers when providing care, treatment or services.

ii.       Medication safety:

a.        Label all medication containers on and off the sterile field including syringes, medicine cups, IV bags and basins.

b.       For all containers on a sterile field, or for immediate use, the name and concentration of the medication in the container is required. For all medication containers, not on a sterile field, the medication name, concentration and expiration date must be clearly identified. 

c.        Describe the dispensing, dilution and expiration period for intravenous solutions used by the facility.

iii.     Infection control measures consistent with CDC and OSHA guidelines to include, but not limited to:

a.        hand hygiene;

b.       use of universal precautions, use of appropriate personal protection devices and practices;

c.        practices to prevent surgical site infections;

d.       development or identification of process measures and outcomes for evaluation of health care related infections;

e.        discouragement of the use of multiuse vials for dispensing medications;

f.        disinfection and sterilization practices on all surfaces contacted by the patient or any blood and body fluids after a procedure and on all instruments consistent with CDC policy; and

g.       use of sterile covers on ultrasound transducers and operator managed controls during sterile procedures are required.