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Standards Chapter
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Ranking by Most Noncompliant Standards Found
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Most Frequently Noncompliant Standard in Chapter
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Subject Matter of Most Frequently Noncompliant Standard
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Facility Management and Safety (FMS)
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1
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FMS.7.1
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Fire safety—safe exit from the facility
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Medication Management and Use (MMU)
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2
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MMU.3
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Labeling medications
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Assessment of Patients (AOP)
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3
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AOP.1.2
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Medical assessment contains health history and physical exam
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Staff Qualifications and Education (SQE)
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4
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SQE.11
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Ongoing professional practice evaluation
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Prevention and Control of Infections (PCI)
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5
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PCI.7.1
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Equipment cleaning, disinfection, and sterilization
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Management of Communication and Information (MCI)
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6
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MCI.19.3
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Clinical record entries identify the author, when entered, and, if required, time of entry
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International Patient Safety Goal (IPSG)
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7
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IPSG.4
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Correct-patient, correct-procedure, and correct-site surgery—use of a checklist and time out
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Care of Patients (COP)
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8
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COP.2.1
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Care plan
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Patient and Family Rights (PFR)
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9
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PFR.6.4
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Informed consent
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Anesthesia and Surgical Care (ASC)
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10
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ASC.3
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Pre-sedation assessment
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Access to Care and Continuity of Care (ACC)
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11
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ACC.3.2
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Discharge summary
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Quality Improvement and Patient Safety (QPS)
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12
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QPS.6
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Data analyzed when undesirable trends or patterns are found
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Governance, Leadership, and Direction (GLD)
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13
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GLD.1
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Governance performance evaluation
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Patient and Family Education (PFE)
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14
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PFE.2
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Educational needs assessment and documentation of education
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