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Standard EC.04.01.01

The hospital collects information to monitor conditions in the environment.

EP 1

The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following:

• Injuries to patients or others within the hospital’s facilities.
• Occupational illnesses and staff injuries.
• Incidents of damage to its property or the property of others.
• Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.
• Hazardous materials and waste spills and exposures.
• Fire safety management problems, deficiencies, and failures.
• Medical or laboratory equipment management problems, failures, and use errors.
• Utility systems management problems, failures, or use errors.

Note 1

All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions as well as to the designated leader of the workplace violence reduction effort. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.

Note 2

Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.

Standard EC.04.01.01

The hospital collects information to monitor conditions in the environment.

EP 6

Based on its process(es), the hospital reports and investigates the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

Standard EC.04.01.01

The organization collects information to monitor conditions in the environment.

EP 1

The organization develops and implements a process(es) for continually monitoring, internally reporting, and investigating the following:

• Problems and incidents related to each of the environment of care management plans.
• Injuries to individuals served or others within the organization’s facilities.
• Occupational illnesses and staff injuries. Note: this requirement applies to issues in the workplace, such as back injuries or allergies. It does not apply to communicable diseases.
• Incidents of damage to its property or the property of others in locations it controls.
• Safety and security incidents involving individuals served, staff, or others in locations it controls, including those related to workplace violence.
• Fire safety management problems, deficiencies, and failures.

Note 1

All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions as well as to the designated leader of the workplace violence reduction effort. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.

Note 2

Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.

Standard EC.04.01.01

The organization collects information to monitor conditions in the environment.

EP 1

The organization develops and implements a process(es) for monitoring, internally reporting, investigating, and documenting the following:

• Injuries to patients, staff, or others within the organization’s facilities
• Safety and security incidents, including those related to workplace violence, involving patients, staff (including staff in the field), or others
• Hazardous materials and waste spills and exposures
• Fire safety management problems, deficiencies, and failures

Note 1

This bullet on fire safety management is applicable only for inpatient hospice, ambulatory infusion, and facility-based rehabilitation technology.

• Equipment management problems, failures, and use errors.
• Utility systems management problems, failures, or use errors.

Note 2

This bullet on utility systems management is applicable only for inpatient hospice, ambulatory infusion, and facility-based rehabilitation technology.

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