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uFFFFFFFFF1:	Gap Analysis - S 1: SSI Prevention

RecommendationActual PracticeDesired PracticeAction Plan1. *3+#19IH'" elective surgery C+II+2A%0#1)22#4@
7I-8-"H25H@46I+H223A+H5H0H21 A%0@%7H-2#H21D'H22#4@
7I-0+!D 2. D!H31H-H21 "@'I'H25H#4@'H210#'H-2#3H21  I2I-31 C+I315H-H21 A%0'#C
I electric clipper3. C+I prophylactic antibiotic @	20@!7H-!5I-H
5I B"@%7-C+I@+!20*!1@
7I-5H!10H-"*3+#12#H211IF  B"C+I2+%-@%7-3C@'%25H3C+I!5#01"2C5#1H!A%0@7I-@"7H-*9-*3+#131@
7I-B# (bactericidal concentration) @!7H-0%!5H21  C+I#1)2 therapeutic level -"2D'I%-2#H21A%0+%1H21@*#G*4I-5 2-3 
1H'B!  *3+#12#H21%-5H!5'2!@*5H"*9 0C+I antibiotic 15+%12 clamp *2"*07-



	
Gap Analysis - S 2: Safe Anesthesia

RecommendationActual PracticeDesired PracticeAction Plan1. *1*8C+I!5'4*1

5A"LCB#"22%1H'D6H!5B-2*9A%9IH'" ASA PS III-V2. *1*8C+I'4*1

5"22%CB#"22%5H!52#H213'I-"#2" DI!5B-2*4142##01'2!#9I*6D!HI-"'H25%0 50 #2"3. I-1 2'0A#I-22#C+I2##01'2!#9I*6
3.1 !5!2#2#I-1 2'0A#I-@	20-"H2 @
H 2#I-12#@4%7HD*I-2@5"3.2 !5!2#2#I-1 2'0A#I-@
4#0 DIAH
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32
 2#C+I3#6)2#5	8@	4
" 	2##0@!4'2!@*5H"5H@5H"'I-1@4C+!H : 1II2'4*1

5A%0(1%"##!
" 	2##0@!4A%0'2A2#9A% 2'0@GH'"#H'!C9IH'"5H!5'2!@*5H" +#7-9IH'"5HDI#1"22-"H2 #'!1I2#@#5"!9IH'"C+I!5* 2'05H5H-#01'2!#9I*6 C#55H9IH'"*2!2##-H21DI @G2##0@!4#H'!1-'4*1

5A"L (1%"A"L -2"8#A"L /%/ 
" 	2#C+II-!9%9IH'"A%0'2!"4"-!C2#C+I"2#01'2!#9I*6@7H-H21 @
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" 	2#*7H-*2#19I#H'!2 : 1I5!(1%"A"L 5!'4*1

5 @I2+I25H22#@%7- +I-4142# @I2+I25H#1*5@4 /%/
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" 	!52##0@!4A%0'2A2##01'2!#9I*6 B"@	20-"H2"4HC#2"5H!5B-2*@41
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Gap Analysis - S 3.2: Surgical Safety Checklist

RecommendationActual PracticeDesired PracticeAction Plan1. Sign In H-5H0@#4H!C+I2##01'2!#9I*6 !52##03C*4HH-D5I
" 	#'*-'H29IH'"C+I'2!"4"-!
" 	9IH'""7"1
7H- 2#H21 3A+H5H0H2
" 	#'*-'H2!52# mark site (I23DI)
" 	#'*-'2!%- 1"C2##01'2!#9I*6 (anesthesia safety check)
" 	#'*-'H2!5 pulse oxymeter 4C+I9IH'"A%0C
I2#DI
" 	#'*-'2!@*5H"-9IH'"C@#7H-2#AI"2, difficult airway, B-2*@*5"@%7-!2'H2 1,000 ml A%0@#5"!#I-!#11
+22. Tine Out H-5H0%!5 !52##03C*4HH-D5I
" 	(1%"A"L "22% '4*1

5 --2"7"1
7H-9IH'" 3A+H +12# 2#1H2
" 	C+I antibiotic prophylaxis C 60 25H-%!5
" 	4 2#1*55HI-C
I#0+'H2H21
" 	22#LB-2*@4@+8'4$4C+I@7H-#H'!5!#2
	-(1%"A"L: 1I-'4$4+#7-D!H2+'1, #0"0@'%25H2'H20C
I, #0!22#*9
@*5"@%7-
	- '4*1

5: critical resuscitation plan, patient-specific concern
	- "22%: sterility indicator result, @#7H-!7-, patient concern -7HF3. Sign Out H-5H0@G surgical drape C+I!52##03C*4HH-D5I
" 	(1%"A"L'11I5!
	- +12#5HDI#03D
	- @+82#L*31
5H@46I#0+'H2H21
	- A2#9A%+%1H21
" 	'4*1

5'11I5!
	- @+82#L*31
5H@46I#0+'H2H21
	- recovery plan
" 	"22%'11I5!
	- 2#1@#7H-!7-A%0I21@%7-
	- 2#@5"	%2*4H*H#'A%0
7H-9IH'"
	- @+82#L*31
5H@46I#0+'H2H21A%0 recovery plan
Gap Analysis - I 1: Hand Hygiene 

RecommendationActual PracticeDesired PracticeAction Plan1. 1C+I!5 alcohol-based handrubs 5H@I26DIH2"  85HC+I#42#9IH'" (point of patient care) 6H9I4142*2!2#C
IDI@!7H-I-2#B"D!HI---2#4@'5H34##!2#9A%9IH'" 2. 1C+I!5I3*0-2A%0*4H-3'"'2!*0'5H3@G*3+#12#%I2!7-6H@I26DIH2"3. C+I'2!#9IAH9I4142@5H"'1'452#%I2!7-5H9I- 4. A**7H-@7-CC5H32@7H-#08IC+I!52#%I2!7-5. *1@42!A%0'1#012#414 A%0C+II-!9%I-%1AH9I4142
Gap Analysis - I 2.1: CAUTI Prevention

RecommendationActual PracticeDesired PracticeAction Plan1. C*H2*2"*'1**2'0H-@!7H-3@G@H21I+%125H42#22@%7--7HF A%I', #0@!4'2!3@G5H0I-C*H*2"*'1**2'0H-D@G#0"0F A%0-*2"*'1**2'0--@#G'5H*82. @%7-#0@ -*2"*'1**2'05H@+!20*!19IH'" C
I2@%G5H*85H0C+I1**2'0D+%DI*0'3. 9IC*H*2"*'1**2'0I-DI#12#6-#!A%0!51)0@5"-, %I2!7-C+I*0-2H-C*H*2"*', C
I aseptic technique 5H9I-, 3'2!*0-2 urethral meatus I'" sterile normal saline, C
I*2#+%H-%7H5H@+!20*!2 2
05H--A*3+#1C
I#1I@5"'4. 9A%#0+'H22*2"*'1**2'0
"  	H-*2"*'1**2'01 sterile closed urinary drainage system, #6*2"*'C+I@+!20*!
"  	#1)2#0#02"1**2'0C+I@G#04
"  	%I2!7-A%0C*H8!7-*0-2H-5H0*1!1**2"*'1**2'0 A%0%I2!7-+%12-8!7-
"  	@G1'-"H21**2'02
H-5H--AD'I (sampling port) B"C
I aseptic technique
"  	1'23A+H-8@G1**2'0C+IH3'H2#01#0@201**2'0 B"D!H*1!1*17I
"  	#02"1**2'0--28@G1**2'0H-"-5H0C+I1**2'0D+%DI*0'A%0D!HD+%"I-%1 B"C
I 2
0*0-25HA"@	20*3+#19IH'"AH%0#2"A%0+%5@%5H"-"H2C+I urinary drainage tap *1!1*1 2
05HC
I#11**2'0
"  	D!H@4! antiseptic +#7- antimicrobial solutions C8@G1**2'0
"  	D!H@%5H"*2"*'1**2'0B"D!H3@G +#7-D!H@%5H"@G routine
"  	9A% meatal hygiene #03'1
"  	D!H'#3 bladder irrigation5. 6-#!@I2+I25HC2#C*H*2"*'1**2'0A%02#9A%, C+I'2!#9IAH9IH'"A%0
24@5H"'12C2#I-12#4@
7I-#02@41**2'0Gap Analysis - I 2.2: VAP Prevention

RecommendationActual PracticeDesired PracticeAction Plan1. Wean --8#LA%0@#7H-
H'"+2"C--29IH'"C+I@#G'5H*82!I-H
5I2%44A%0 weaning protocol -B#"22%2. Hand hygiene 
2.1 %I2!7-I'"*9HA%0I3+#7- alcohol-based handrubs (I2D!H!52#@7I-5H@+G
1) C#5H-D5I 
" 	H-A%0+%1*1!1*19IH'"5HC*HH-
H'"+2"C+#7-@20- 
" 	H-A%0+%1*1!1*1-8#L@#7H-
H'"+2"C6H3%1C
I19IH'" D!H'H20*'!8!7-+#7-D!HG2!
" 	+%12*1!1*1@"7H-8, *2#1+%1H22@4+2"C, +#7-'185H@7I-*2#1+%1H D!H'H20C*H8!7-+#7-D!HG2!2.2 @%5H"8!7-A%0%I2!7- C#5H-D5I
" 	#0+'H22#*1!1*9IH'"%0#2"
" 	+%121I-*2#1+%1H+#7-'185H@7I-*2#1+%1H29IH'"#2"+6H A%0H-5H0D*1!1*9IH'"#2"-7H '18 +#7-*4HA'%I-!
" 	#0+'H22#*1!1*13A+H-#H22"5H@7I- A%02@4+2"C+#7--8#L
H'"+2"CC9IH'"#2"@5"'13. Aspiration Precautions
3.1 I-12#*3%1@7H-22#C*HH-
H'"+2"C 
) C
I noninvasive positive-pressure ventilation H2 face mask @7H-%'2!3@GA%0#0"0@'%2C2#C*HH-
H'"+2"CC9IH'"2%8H!  A%0C
I@G*H'+6H- weaning process
) +%5@%5H"2#C*HH-
H'"+2"CI3
) H-5H0%H-"%!2 cuff +#7--H-
H'"+2"C C+I9@*!+0#4@'@+7- cuff --C+I+!
) #02" circuit condensate H-1H29IH'"
) #1)2#01'2!1C cuff C+I-"9H#0+'H2 20-30 cmH2O3.2 I-12#*3%1@7H-22#C+I-2+2#2*2""2
) C9IH'"5HC*H@#7H-
H'"+2"CA%0D!H!5I-+I2!22#A"L C+I"+1'@5"9IH'"*93!8! 30-45 -(2 
) #'*-3A+H-*2""2C+I-2+2#A%0'1 gastric residual volumes H-C+I tube feeding  -*2""2C+I-2+2#--C+I@#G'5H*84. Prevent Contamination
) 3'2!*0-2@#7H-!7--"H21H'6 H-5H03@#7H-!7-D3C+I#2(2@
7I-+#7-3%2"@
7I- (42#2C
I enzymatic cleaner *3+#1@#7H-!7-5H!5 lumen +#7-4'D!H#2@#5")
) I2@GDDI C
I2#6HH2@
7I-I'"D-I31@#7H-!7-+#7--8#L5H*1!1*1@"7H-8-9IH'"  #55H@#7H-!7-A%0-8#L1ID'H-'2!#I-+#7-'2!
7I C+IC
I low-temperature sterilization methods A%0 rinse I'" sterile water 
) @%5H" ventilator circuits H-@!7H-@+G'2!*#5H
1@ (B"1H'DD!H'#@%5H"H-"'H28 48 
1H'B!) A%0'#@+"I3CH-4IH-"F C+I@G routine 
) suction @H25H3@G C
I'45414@7H-I-12#@7I-5H@+!20*! A%0@GDC4(2@5"'11IB#"22%, A"-8#L5HC
I9@*!+0A%0I3%2"C
H-215HC
I9C endotrachial tube --21, C
I saline H-@!7H-@*!+0@+5"'I  5. Oral Care  % colonization - dental plaque B"2#A#1'1%0 2 #1I, 9A%'2!
8H!
7I-@"7H-8B"C
I moisturizer 8 2-4 
1H'B!

Gap Analysis - I 2.3: Central line infection Prevention

RecommendationActual PracticeDesired PracticeAction Plan1. 13 protocol I-1 central line infection: 3+C+IC
I checklist, @*#4!%1C+I"22%9A%2#4142! checklist, 1#6H!5@#7H-!7-8-"H2#I-!, 3+C+I"22%@I2
H'"C2#C*H central line2. *H@*#4!C+I!52#C
I hand hygiene 5H@+!20*!@!7H-09A% central line: H-A%0+%12#%3#3A+H5H0*-C*H*2", H-A%0+%12#*-C*H @%5H" H-! +#7-4A%, @!7H-**1"'H20!52#@7I-, H-A%0+%12#3 invasive procedures, #0+'H29IH'", H-C*HA%0+%1-8!7-, +%12C
I+I-I33. C
I maximal barrier precautions C2#@#5"!C*H central line: *3+#19I5H3+12# C+I*'!+!', mask, @*7I-2'L#2(2@
7I-A%08!7-#2(2@
7I-  *3+#19IH'"C+I%8!I2#2(2@
7I-1IAH(5#)06%2"@I2 B"!5
H-@4@%GF #3A+H5H0*-C*H central line 4. C
I chlorhexidine 2% in 70% isopropyl alcohol @
G4'+1#4@'5H0*-C*H central line @G@'%2 30 '425A%0%H-"C+IA+I*4H-@204'+15. @%7-3A+H5H@+!20*!*3+#12#*-C*H central line B"42#2'2!@*5H"H-2#@4 2'0A#I-, "2"2!+%5@%5H" femoral catheter, .C+I16@+8%5H@%7-3A+H1I, C
Icentral venous catheter 5H!53' ports +#7- lumens I-"5H*86. 13 protocol C2#9A% central line: hand hygiene A%0 aseptic technique, 2#C
I sterile transparent dressings +#7- sterile gauze @7H-43A+H5H*-C*H A%02#@%5H"@!7H-@5"
7I+#7-@7I-, D!HC
I topical antibiotic ointments +#7- creams #3A+H5H*-C*H, 2##'*-#03'1, 2#@%5H" IV set 72 
1H'B!+%12@#4H!C
I, 2#3+ port *3+#1 parenteral nutrition @G2#@	20I2C
I multi-lumen catheter, 2# cap stopcock 5HD!HDIC
I, 2#%2#@7I-H- access port B"2#@
GI'"I3"2H2@
7I-5H@+!20*!, D!H@%5H" central line @G routine @5"@7H-%'2!@*5H"H-2#4@
7I-, I22#C*H#1IA#3A	8@	4 C+I@%5H" central line  2"C 48 
1H'B!, 169I3 '15H @'%2 5H*-C*HA%0- catheter A%02#3 dressing CA16!2#27. ''2!3@G5HI-!5 central line B"3@G*H'+6H-2##'@"5H"!-5!*+*22'4
2
5 #083''15HDI*-C*H central line !2A%I'C#0+'H22##'@"5H"!'H2'15I@G'15H@H2D# A%0---155HD!H!5'2!3@GI-C
I8. C+I'2!#9IA%06-#!9I4142@5H"'12#414@7H-'8!A%0I-1 bloodstream infection #-%8!2#@%7-3A+H, 2#*-C*H, 2##0@!43A+H5H*-C*H, I-H
5I5HI-@%5H" dressing, 2#16, 2# flush 5H@+!20*!, 2#@%5H" set, I-H
5IC2#-+#7-@%5H" catheter9. #0@!4#0*44%- protocol 5HC
IB"'1-1#22#@4 central line catheter-related bloodstream infections, 2#4142! protocol, 42!1''1@7H-92#@%5H"A%5H56I A%0C+II-!9%I-%1AH9I4142@5H"'1-1#22#4@
7I--"H2*!H3@*!-
Gap Analysis - M 1.1 Control of concentrated electrolyte Solutions

RecommendationActual PracticeDesired PracticeAction Plan1. C+I'2!*31
1'2!%- 1"C2#C
I KCl #'!1I*2#%0%2" electrolyte @I!I-7HF 
Potassium phosphate solution
Hypertonic saline (> 0.9% sodium chloride solution)
Magnesium sulfate solution (e" 50%)
Sodium heparin >1,000 units/ml
Concentrated morphine +#7- opiates -7HF 5HC
I@7H-@#5"! intravenous, spinal A%0 epidural infusions.
"25HC+I2+%-@%7--7HF 6H!5'2!@I!I*9'H25H6I0@5"D'I+#7-*9'H25HB#"22%"-!#1'H2@G#015H%- 1"5H0C+IAH9IH'"2. 13A'22#C
I (protocol) 5H@#5"H2"A%0@+!20*!#-%8!  C+I414H- KCl @*!7-"25HI-'8! #'!1I2#312#*1HC
I 2#1@G A%02#163. %2#C
I-1#2*H' (ratio) A%0#I-"%0C2##08'2!@I!I-"2CA'22#C
I (protocols), @-*2#5H@5H"'I-, 2#@5"	%2 C+IC
II3+1H-#4!2#C2#A*'2!@I!I4. 17I-@'
 1L5H#I-!C+I (ready-to-administer) +#7-#I-!C
I (ready-to-use) 5HD!H3@GI-@7-2H-C
I5. I2@GDDI D!H'#@G*2#%0%2" electrolyte @I!ID'I5H+H'"9A%9IH'" '#@GD'I5H#4@'1@#5"!-@ *1
##!6HA"D'I@	20+#7-C7I5H5H9%G-6. I2D!H!5@ *1
#+#7-D!H!57I5H@#5"!"2-@ *1
##!@7H-@GA%01@#5"!*2#*0%2"@+%H25I C+I9I5H!58*!14@+!20*! (A"L "22% 9I
H'"@ *1
#) A%0DI#12#6-#!@H21I@G9I1@#5"!7. I2!52#@G+%- KCl D'IC+H'"9A%9IH'"C7I5H5HA"D'I@	20 0I-@5"	%24AH%0+%-I'"*5*0I-A*#08'H2  I-*!C+I@7-2 8. I2"1I-@GA%01@#5"! concentrated injectable medicine 5H+H'"9A%9IH'" 0I-%'2!@*5H"C2#C
I@'
 1L1%H2'B"
" 	4142! multidisciplinary policies & procedures @5H"'1'45*1HC
I, 1@G, @#5"! A%0C+I*2#%0%2"@I!I-"H2%- 1"
" 	C
IB"2"17I-5H%- 1" (purchasing for safety policies) @7H-%*2#%0%2"@I!I5H!52#@5"	%2A%02###8C%1)05H9%I2"%61
" 	A"2#@G*2#%0%2"@I!I--2"2-7HF
" 	312#@I26*2#%0%2"@I!IB"3+C+I9I41425H!58*!14@+!20*! (3'I-") @H21I5H@I26DI
" 	313'*2#%0%2"@I!IC+H'"9A%9IH'"C+I!5I-"5H*85H3@G*3+#12##1)29IH'" B"C
II-!9%'2!5H2#C+I"25HI-2# A%0#0"0@'%25H*2!2#A"25HC
IDDI
" 	4#013@7-5H
1@5H*2#%0%2"@I!IAH%0+%-
" 	1+2I-!9%2%44A%0I-!9%'4
22#5H3@G@5H"'12#1@#5"!A%02#C+I*2#%0%2"@I!IC+I9I4142*2!2#C
IDIH2"
" 	1C+I!5@#7H-!7-3'2 (dose) @
H dosage charts *3+#19IH'"5H!5I3+11'H2F 
" 	6-#!9I414285H@5H"'I-C2#C
I*2#%0%2"@I!I-"H2%- 1"9. +%121@#5"! C+I!52#'*--"H2-4*#0B"9I!58*!14@+!20*!A%0DI#12#6-#!-5+6H '#!52#13 checklist *3+#1C
IC2#'*- #0-I'"2#3''2!@I!I, -1#22#C+I, *2"5HH-@
7H-!10. C+I@5"	%2*2#%0%2"5H1@#5"!A%I'I'"@#7H-+!2"@7-'H2 C
I-"H2#0!1#0'1 H-5H03DC+I9IH'"11. C
I infusion pump @7H-C+I*2#%0%2"5H!5'2!@I!I*9  I2D!H!5 infusion pump C+IC
I-8#L-7H5H*2!2#31#4!2*2#%0%2"CAH%0
H'@'%2DI A%0C+I!52#42!#4!2*2#%0%2"5H9IH'"DI#1H-"F12. !5B#*#I27I2--L#5H*1*82#6-#!-9I4142 B"2"A%0'45414 A'24145H5 A%02#C+I#02(5"1##1#-@G#2"513. 3*1H2##1)2-A"L0I-#08-1#22#C+I*2#%0%2"I'"

	 
Gap Analysis - M 1.2: Improve the safety of High-Alert Drug

RecommendationActual PracticeDesired PracticeAction Plan1. '452#@7H-I-1-1#2"
" 	13
83*1H, preprinted order forms, A%0 clinical pathways +#7- protocols 6H*0I-'452##1)25H@G!2#2*3+#19IH'"5H!51
+2 * 2'0-B# +#7-'2!I-2#5H%I2"%61
" 	%'2!+%2+%2"B"2#3+!2#2'2!@I!IA%02"2C+I!5I-"5H*8@H25H3@G
" 	42#211I anticoagulation services 6H3@42#B""22%+#7-@ *1
#
" 	1C+I!5I-'2!@7-CA%0I-!9%@5H"'1'452#42!2#C
I"25H@+!20*!-"9HC
83*1H, protocols, A%0 flow sheets
" 	42#213 protocols *3+#1%8H!9IH'"5H!5'2!@*5H"*9 @
H 9I*9-2"82. '452#@7H-I+2'2!4%1IA%0-1#2"
" 	##8I-'2!@7-CA%0I-!9%@5H"'1 parameter 5H@+!20*!*3+#12#42!2#C
I"2C
83*1H, protocols, A%0 flow sheet
" 	*#I2'2!!1HC'H29I5HI-2#C
II-!9%%2##'*-2+I-4142#5H*31
 *2!2#@I26I-!9%1%H2'DI
" 	3A'2 double-checks B"-4*#0AH1DC
I @!7H-!5'2!@+!20*!3. '452#@7H-##@2-1#2"
" 	13 protocols -8
2C+I!52#C
I*2#I2$4L (reversal agents) B"D!HI-#-A"L
" 	*#I2'2!!1HC'H2!5 antidotes A%0*2#I2$4L (reversal agents) #I-!C
I
" 	!5A'2
H'"
5'4 (rescue protocols)2##1#8@7H-'2!%- 1"C2#C
I Anticoagulants
" 	13 anticoagulation flow sheet A%03*1HC
I"2 @7H-42!9IH'"2B#"22%D6I2
" 	1C+I!5 anticoagulant clinic C setting -9IH'"CA%09IH'"-HEPARIN
" 	C
I weight-based heparin protocol 31C+I!5D!H@4 1-2 protocols
" 	C
IA-#L!2#*1HC
I5H4!L%H'+I2 (preprinted order forms) +#7-A'22#*1HC
I"2 (ordering protocols)
" 	*#I2'2!!1HC'H2A'22##12 heparin DI42#2#-%8!62#C
I  thrombolytics and GIIg/IIIa inhibitors. I'" *#I2'2!!1HC'H2D!H!52#C+I heparin  2"C 6-12 
1H'B!H-+#7-+%12#C+I LMWH
" 	C
I'2!@I!I!2#2C OR, ER, A%0 ICU
" 	A"@'
 1L5H!5%1)0%I2"%61--21@'%2C
I+#7-1@G
" 	H2" anticoagulant 2A@ *1
##!@H21I
" 	2#@GD'I5H+H'"9A%9IH'" C+IC
I2##8 '2!@I!I A%02"25HI-"5H*8WARFARIN
" 	%#2"2#"25H!5+%2"'2!A#-"2#1#02C+I@+%7-I-"5H*8
" 	13A'22##12"25H@G!2#2C2#@#4H!C+I"2, 2#C+I"2H-@7H-, A'22##12 Vitamin K, 2#+"8"2@7H-2#H21
" 	#1#82#@I26I-!9%%2##'2+I-4142#@7H-#12"2
" 	1C+I!5+H'" anticoagulation %2@7H-42!A%012##12"2
" 	C2#42!%2#C
I"2 '#DI%2##'2+I-4142# 2"C 2 
1H'B! +#7- monitor 5HI2@5" 3H2 INR !2 plot @5"12"2 run chart +#7- control chart
" 	C+I'2!#9IAH9IH'"2!#01'2!*2!2#C2##1#9I @7H-C+I9IH'"@I2C'452#4"2 2#42!%2#C
I"2I'"@- "2A%0-2+2#5H'#@+%5@%5H"  
" 	C
I medication reconciliation @7H-#1#82#*7H-*2#*H!-I-!9%2#C
I"2 A%0#H'!19IH'"131

5"25H9IH'"C
I-"H29I-2##1#8@7H-'2!%- 1"C2#C
I Narcotics
" 	13A'2 (protocol) 5H@G!2#2*3+#12#C+I"2AI'
" 	C
I'452#5H@+!20*!C2#42!%I2@5"2 narcotic A%0 opiate 
" 	1C+I!5A'2 (protocol) 2#C+I naloxone A%0*2#I2$4L6H*2!2#C+I9IH'"DIB"D!HI-#-3*1HA"L
" 	#6)2 pain specialist (-20@G"22% @ *1
# A"L 5HDI#12#6-#!) I2A"L9I9A%D!H@
5H"'
2
C@#7H-2#'8!-22#'
" 	C
I'452##01-22#'A%0'2!1'%5HD!HC
H"2C+I!26I
" 	+%121IB#A#!2#C+I"25H infusion pump A%I' C+I!5 independent double-check B"@ *1
#+#7-"22%
" 	3 independent double-check *3+#1 PCA A%0 epidural narcotics
" 	%+#7-12#C
I"25H!5'2!A#+%2"2I2@GDDI
" 	C
IA'2 (protocols) A%03*1HC
I"25H4!LD'I%H'+I2*3+#1 PCA, 2#C+I"2AI'+%1H21, 2#C+I sedation #'!1I epidural, intrathecal pain management2##1#8@7H-'2!%- 1"C2#C
I Insulin
" 	3+C+I!5 independent double-check "2, 2"2, pump setting, '452#C+I A%0 2##081'9IH'"H-5H0!52#C+I IV insulin
" 	C
I3*1H2#+""2 insulin (infusion order) 5H4!LD'I%H'+I2
" 	A""25H
7H-I-!-%I2"B"2#@5"	%2 @'%2 A%0#0"0+H2
" 	1@#5"!*2#%0%2"H2F CA@ *1
##! A%03C+I IV-infusion insulin !5!2#2'2!@I!I@5"'1
" 	!-C+I9IH'"#4+2#"2 insulin I'"@-I2*2!2#3DI
" 	#0*2@'%25HC+I-2+2#1@'%25HC+I insulin
" 	"@%42#C
I sliding insulin dosage scale  AHI2!52#C
I-"9H C+I3@G!2#2B"2#C
IA'2 (protocol) A%03*1H5H4!LD'I%H'+I2 +#7- 
83*1HB"-!4'@-#L
" 	C
I diabetic management flow sheet
" 	*#I2'2!!1HC'H2!52#42!%2#C
I"2-"H2@+!20*!B"2##'I32%C@%7-I'"'45 rapid testing H-"6I
" 	@!7H-*1HC
I insulin C+I#08+#7--I2-46!2#25H3+D'I*3+#12##'*-2+I-4142# A%02#42!%2%445H9IH'"2##1#8@7H-'2!%- 1"C2#C
I Sedatives
" 	@G*3#-A%0*1HC
I oral moderate sedation 5H!5'2!A#@5"2@5"'@H21I
" 	133*1H5H4!LD'I%H'+I2*3+#12#*1H narcotic A%0 sedative
" 	42!%-"2C@G8#2"5HDI#1 chloral hydrate *3+#1 pre-operative sedation C#0"0H- #0+'H2 A%0+%13+12#
" 	!5@#7H-!7--8#L
H'"
5'45H@+!20*!1-2"8-9IH'" A%0*2#AI C8+H'"25H!52#C+I"2 sedative A%0#0+'H22#3+12#6H9IH'"DI#1 sedation
" 	C
IA'22##1%2"2-1B!14*3+#1 benzodiazopines, sedatives A%0 hypnotics -7H C%8H!@I2+!2"
" 	42!9IH'"@7H-9-22#A*-2#2#+2"C2#01 O2 saturation +#7- CO2 B"C
I pulse oximeter A%0 capnographer
" 	9#22#@-*2#2#C+I"21I-!9%*1

2
5-9IH'"@7H-#'*-A'BI!5H*2!2#22#LA%0I-1DIGap Analysis - M 2.1: Look-Alike Sound-Alike Medication Names

RecommendationActual PracticeDesired PracticeAction Plan1. '"2
7H-I-!-%I2" (LASA) 5H!5C
ICB#"22%@G#0385, *#I2'2!!1HC'H2C2#17I-"2C+!H !52#42#2@#7H-
7H-I-!-%I2"A%02#*-19IC
I A%0!5'2!7H1''H2"25H!5
7H-2#I21'+6H1I-20!5
7H-5HAH21C#0@(H2F2. 3A'22%44 (clinical protocol) H-D5ID414
" 	%2#C
I3*1H2##1)2I'"'22A%03*1H2##1)22B#(1L
" 	@I'2!3@G5H0I--H2	%2-"H2#0!1#0'18#1I5H+"4"2 A%0-H2I3H-5H0C+I"2 B"D!H'2C12#3 2 5H@G +#7-*4H5HD!H@20-7HF
" 	@I'2!3@G5H0I-#'*-@I2+!2"-2#C
I"2C3*1HC
I"2 A%0#'*-2#'44	1"B#5H@G1811@I2+!2"+#7-I-H
5IC2#C
I"2H-5H0C+I"2-5#1I+6H
" 	#081I
7H-*2!1
A%0
7H-2#I2C3*1HC
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7H-*2!1
!52C+
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+2D'IC*25H5HA"@	20+#7-1@GB"D!H@#5"%311'-1)# @
H B"+!2"@%%H- 
1I +#7-C@#7H-H2""2-1B!145. C
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I
7H-"2	%2 %H-A%0
1I@G +I2--!4'@-#L @#7H-H2""2-1B!14 A%0 MAR (Medication Administration Record)6. 13%"8L@7H-C+I9IH'"A%09I9A%!5*H'#H'!C2#%'2!@*5H"B"
" 	C+II-!9%5H@G%2"%1)L-1)#AH9IH'"A%09I9A%@5H"'1I-H
5IC2#C
I"2 
7H-*2!1
A%0
7H-2#I2 %I2@5"5H-2@46IDI
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+2@#7H-*2"2  2)2 A%09IH'"5H!5I-31C'2!#9I@5H"'12#9A%*8 2
" 	C+I@ *1
#'#H'!19IH'"@7H-"7"1I-H
5I #9%1)L5H2+'1-"25HH2"C+IAH9IH'" B"@	20-"H2"4H@!7H-!52#H2""25H#9I'H2!51
+2@5H"'1@#7H-
7H-7. *#I2'2!!1HC'H2#0'2#12#@5H"'1"2C81I-DI#12#414B"9I!58*!145H@+!20*!A%0!5'2!#9I'2!*2!2#, 1C+I!52#C+I'2!#9I@5H"'1"25H!5H
7H-I-!-%I2"C+%1*9#2#(6)2 2#!4@( A%02#(6)2H-@7H--9I#0-'4
2
5
 
Gap Analysis   M 3: Assuring Medication Accuracy at Transition in Care
(Medication Reconciliation)

RecommendationActual PracticeDesired PracticeAction Plan1. *#I2#05H@G!2#2C2##'#'!A%016I-!9%@5H"'1"25H9IH'"AH%0#2"3%1C
I-"9H A%0*H!-1

5#2"2#C+I19I5HC+I2#9A%H-D @!7H-!52#@%5H"8C+I#42# (2##1D'I-B#"22%, 2#"I2"/*HH-, 2#3+H2", 2#!242!#'5H OPD)  I-!9%5H'##'#'!#0-I'"
" 	"2 '42!4 -2+2#@*#4! -2+2#5H-2!5-1#4#4"21"2 *!8D# 5HA"L*1HA%05H9IH'"7I-@-
" 	2 '2!5H '45C
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" 	A+%H5H#1"2-9IH'" I2@GDDIC+I#'*-I-!9%"25H9IH'"DI#15HI219IC+I#42#! 9!4+#7-@ *1
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8!
2. !5B"2"A%0'454145H3+C@#7H-H-D5I
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1 (@
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" 	@#5"@5"1

5#2"2#"2-9IH'"1"25HA"L*1H (reconciliation) @7H-9'H2!52#%0@%" 2#*1HI3 +#7-'2!D!H*-%I-#0+'H2"2-9IH'"1* 2'02%44 '2!%2@%7H-C2"2 A%0B-2*@4-1#4#4"2  2"C#0"0@'%25H3+D'I (@
H  2"C 24 
1H'B!+%12#1D'I-B#"22% +#7-*1I'H21I*3+#1"25H!5'2!@*5H"*9 !5B-2*@4'2!AH2C2"25H!5%#8A# A%0/+#7- @'%25H0C+I"2#1IH-D)
" 	#0'2##1#81

5#2"2#"2@!7H-!53*1HC
I"2C+!H @7H-*0I-"25H9IH'"3%1DI#11I+! #'!1I"25H9IH'"3!22I2
" 	#0'2#5H*#I2'2!!1HC'H2!52##1#81

5#2"2#"2-9IH'"@!7H-3+H2" A*6#2"2#"21I+!5H9IH'"0I-C
I+%123+H2" 6H!51I"25HA"L*1HC+!H A%0"2@4!5H9IH'"@"DI#1@!7H--"9H5HI25HA"L*1HC
IH-  1

5#2"2#5I'#*7H-*2#C+I9I5H0C+I2#9A%H-@7H- A%0C+I9IH'"@G*H'+6H-2#C+I3A03@!7H-3+H2"  9IH'"'#4I"25HA"LD!H*1HC
I-5H-D
" 	2#!-+!2"2A%0'2!#14
-C1I-H2F - medication reconciliation C+IAH9I5H!58*!14@+!20*!  2"CI#4-'2!#14
-#H'!1  6H-20DIAH9IC+I#42#! 9!4 A"L "22% @ *1
# A%0%44@
5H"-7HF  
" 	2#@I26I-!9%5H@5H"'I-A%0-3#5)22@ *1
#C1I-H2F -#0'2# reconciliation 3. 32#6-#!'45414@5H"'1 medication reconciliation @I2##8C+%1*9#2#(6)2 2#!4@( A%02#(6)2H-@7H--9I#0-'4
2
5
Gap Analysis - M4: Blood Safety

RecommendationActual PracticeDesired PracticeAction Plan1. 3B"2"#01
24@5H"'12##42#B%+4 (National Blood Policy) D*9H2#414 2. #1B%+4@	2029I#426H!5'2!@*5H"H-2#4@
7I-H33. 1'-"H2B%+4#428"940I-DI#12##'2+I-4142#2!!2#22!B"2"#01
24@7H-+2#H-#-"2#4@
7I- DIAH 44%4* D'#1*1-1@*5 (HbsAg) D'#1*1-1@*5 (anti-HCV) D'#1*@-*L (anti-HIV1/2 A%0 HIV antigen) -"H2I-"I'"'45 EIA, DI#12#*-+!9HB%+4A%0#'+2A-5I-5IH-@!G@%7-A5H44H-5H03@%7-DC+IAH9IH'"@7H-I-1 serious haemolytic transfusion reactions4. @7H-C+I!1HC'H20DI#1#0B"
L*9*82B%+45HDI#1#42  '#A"B%+4--@G*H'#0-H2F  '45C
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H 2##1)2A18112##1)22@%7-)Gap Analysis - P 2.3: Communicating Critical Test Results

RecommendationActual PracticeDesired PracticeAction Plan1. C
I'452#5H@G!2#2@7H-*7H-*2#%2##'*-5H!5H2'4$4 
) #081'9I!5+I25H#14
-C2#*H!-A%0#1%2##'*-5H!5H2'4$4  9I5H!5+I25H+%1C2##1A%042!%7-A"L9I*1H#' 2##2"2%'##2"2#H-A"L5H*2!2#%!7-AI1
+29IH'"DIC15
) #081'8%5H0DI#1%2##'*-5H!5H2'4$4A@!7H-A"L9I*1H#'D!H-"9H  !5'452#5H0#08A"L@I2-DIA%0A"L5H09A%A1IAH#19IH'"D'I C+I(9"LB#(1L-B#"22%@G(9"L%2I-!9%A"L9I9A%AA%02##2"2
) 3+'H22##'*-A%0H2'4$4C#01C5H0I-!52##2"2B"15A%0@G5H@
7H-7-DI B"131

5#2"2#2##'*-A%0H2'4$45H!5'2!*31
*93'@H25H3@G
) #08#0"0@'%25H0I-#2"2%2##'*-5H!5H2'4$4AHA"L9I*1H#'-"H2@+!20*!1'2!@#HH'5H0I-AI1
+29IH'" (@
H  2"C 1 
1H'B!,  2"C@'#), I-H
5I5H0I-#2"2, '452#42!, A'2414+2D!H*2!2#4H-A"L9I*1H+#7-A"L5H09A%A5H3+D'IAHA#
) 3+'452##2"2A"L9I*1H#' B"C
I@42#*7H-*2#5H@+!20*!5H*8*3+#1AH%0*22#L  @
H C
I active  push  system *3+#1%2##'*-5HI-!52#AID1
+2C+I9IH'"15  *#I2'2!!1HC'H20#1#9I2##1#2%-A"L9I5H*2!2#%!7-4142#AID1
+2C+I9IH'"
	) 3+B"2"2#*7H-*2##H'!C+I@GDCA'2@5"'1*3+#12##'*-#0-2#'44	I"B#8#0@  *H@*#4!'2!#14
-#H'!1A%02#32@G5!#0+'H2*22H2F 3+
8I-!9%1IH35H0I-#2"2 2. --A#05H!5'2!H2@
7H-7- '2CDI
) --A#0C+I!52##081'A"L9I*1HA%0'452#5H04H-%1 C05HA"L*1H#'*-
) --A#0C+I!1HC'H23*1H#'*-!5I-!9%2%44@5"-5H0A%%2##'*-
) *#I2#042!@7H-C+I@4'2!!1HC'H2!52##2"2%C@'%25H@+!20*!A%0H2@
7H-7-
) *#I2#042!'H2@7H-#1#9I'H29IH'"DI#12#AID1
+2C@'%25H@+!20*!3. #0*1*8A%03#8#1)2
) 1C+I!52#!4@(A%02#(6)2H-@7H-@5H"'1'452#*7H-*2#%2##'*-5H!5H2'4$4
) !52#42!31#0*44%-#05H@5H"'I- (@
H -1#2'2!%I!@+%'-2#*7H-*2#, 2#*-#0B#(1L, @'%22#-*-) A%03D#1#82!'2!@+!20*!
Gap Analysis - P 2.4: Verbal or Telephone Order/ Communication

RecommendationActual PracticeDesired PracticeAction Plan1. 9I#1I-!9%163*1H+#7-%2##'2+I-4145H*!9#LC@'
#0@5"+#7--!4'@-#L2. 9I#1I-!9%-H2'%1 (read back) 3*1H+#7-%2##'2+I-4142#3. 9I#1I-!9%#12#"7"129I5H*1H2##1)2+#7-9I#2"2%2##'2+I-4142#


Gap Analysis - P 2.5: Abbreviations, Acronyms, Symbols, & Dose Designation

RecommendationActual PracticeDesired PracticeAction Plan1. -L#131

53"H- 
7H-"H- *1

%1)L A%02##082"25HD!H-8
2C+IC
I1H'1I-L#2. 1

5#2"2#3"H-5HD!H-8
2C+IC
I #'!6#2"2#H-D5I
" 	U, u
" 	IU
" 	Q.D., QD, q.d., qd
" 	Q.O.D., QOD, q.o.d, qod
" 	Trailing zero (X.0 mg) @%(9"L2!+%18(4"!@G*4H5H+I2!C
I
" 	Lack of leading zero (.X mg) 2#D!H@5"@%(9"L+I28(4"!@G*4H5HD!H9I-
" 	MS
" 	MSO4
" 	MgSO43. -L#31

5#2"2#5HD!H-8
2C+IC
ID*9H2#41413*1H83*1H A%0@-*2#5H@5H"'12#C
I"21I+! D!H'H20@G2#16C#02)+#7-16C-!4'@-#L4. A-#L!5H14!LD'I%H'+I2 (preprinted forms) 0I-D!H!5#2"2#5HD!H-8
2C+IC
I1%H2'
Gap Analysis - P 3: Proper Diagnosis

RecommendationActual PracticeDesired PracticeAction Plan1. '4@#20+L+2B-2*12 
" 	' 2#'!-2#'44	1"B#5HD!H
1AI +#7-2#'44	1"B#C9IH'"%8H!5HI-!2#12##1)2I3 +#7-I-!2-B#"22%I3 +#7-I-*HH-
" 	''2!*-%I--2#'44	1"B#-A"L12#'44	1"22#"22% 'H2'2!D!H*-%I-C9IH'"%8H!C C#0@GC
" 	C
I trigger tool @7H-I+2@'
#0@5"5H!5B-2*@+82#LD!H6#0*L 3!2''H2!5@+82#LD!H6#0*L@46I+#7-D!H A%0@+82#L1%H2'@5H"'I-12#'44	1"B#5HD!H@+!20*!+#7-D!H -"H2D#
" 	''2!@+!20*!-2#'44	1"B#-"H2*!H3@*!-2. 2##1#82#'44	1"B#
" 	C
I evidence @GA'2C2##0@!49IH'"
" 	C
IA'4 human factors @7H---AA16A%02##0!'%%2##0@!45H
H'"C2#*#8%2#'44	1"B#DIH2"6I
" 	#1#8#016@'
#0@5"@7H-C+I*2!2##'#'!I-!9% 42!'2!I2'+I2A%0#0!'%%I-!9%C9IH'"5H!5'2!1I-DIH2"6I
" 	#1#82#*7H-*2#A%0#2"2I-!9%%2##'*-#0-2#'44	1"B# @7H-C+I!1HC'H2A"L9I*1H#'0DI#1%5HH2@
7H-7-C@'%25H@+!20*!
Gap Analysis - P 4.1: Preventing Pressure Ulcers

RecommendationActual PracticeDesired PracticeAction Plan) #081'9IH'"5H!5'2!@*5H"H-2#@4A%1B"#0@!42#@%7H-D+' 2#1H2" 2#@*5"'2!#9I*6 A%0* 2'02B 
22#, #'*-4'+1-9IH'"5H!5'2!@*5H"1IAH+1'#@I2@!7H-A##1A%0#03'1, C
I8%"442%44#H'!1@#7H-!7-!2#2C2##0@!4 (@
H Braden Scale +#7- Norton Scale), #0@!4I3-"H2*!H3@*!-A%0@4H!'2!5H-2##0@!4@!7H-9IH'"!5-22#@%'%) I+2A%0#1)211"5H!5%H-2#-@7I-@"7H-H-A# (tissue tolerance to pressure) DIAH -2"8, 2#32-@*I@%7-, 2#'8!I32%C9IH'"@2+'2, I3+11',  2'08B 
22#) 13A2#9A%*3+#19IH'"AH%0#2"B"'2!#H'!!7-19IH'"A%09IC+I#42#-7HF #0811"@*5H"A%0@I2+!2"*3+#19IH'"  A2#9A%'##0-I'"
" 	2##'94'+1C3A+H5H!5'2!@*5H"*9 2#3'2!*0-2A%09A%4'+1
" 	A'22#I-1A%1C9IH'"5H%1I1**2'0D!HDI
" 	2#1H25H@+!20*! 9IH'"5HD!H*2!2#@%7H-D+'@-DI'#DI#12#%41'8 2 
1H'B! B"132#2@'%22#%41'A%0162#414
" 	C
I-8#L%A# @
H 5H-B! 5H-%! 
" 	C
I-8#L#-#1@	203A+H5H!58H!#09 @
H +!- AH#-I-(- AH#-@7H-"*I@I2
" 	#0@!4A%0'2A9A%I2B 
22#
" 	2#@4H!+#7-3#'2!*2!2#C2#@%7H-D+'A%034##!
" 	13A'2I-1*3+#19IH'"5H0DI#12##01'2!#9I*6 A%09IH'"5H!5-22#@%'% (D!H#9I*61' DI#1"2@42)
" 	C
IAH#-@7H-%A#'2#-9IH'"@5"H21
" 	C
I2#1H2 2#@%7H-"I2"A%02#%41'5H@+!20*! @7H-I-1-1#2"H-4'+122#@*5"*5+#7-A#@	7-) *#I2'2!!1HC'H2!5#1"2##I-!C
I*3+#19IH'"A%09I4142 DIAH moisturizers, skin barriers, equipment (therapeutic surfaces), A%09I5H0C+I3#6)2 (12" 231 14##!31 9I@
5H"'
2
2#9A%A% B 
2# /%/)) *#I2'2!!1HC'H2*!2
48C5!*+*22'4
2
5!5'2!#0+1H-A2#9A% A%0162#9A%H2F %C@'
#0@5") 42!2#414B"C
I22#(6)2'2!
8A%0-8142#L 2#*3#' 2##'*-5H@20	) C+I'2!#9IA%02#6-#!5H@+!20*!AH5!9IC+I#42#	
Gap Analysis - P 4.2: Preventing Patient Falls

RecommendationActual PracticeDesired PracticeAction Plan1. #081'9IH'"5H!5'2!@*5H"H-2#%1+%I!B"2#C
I@#7H-!7-#0@!4'2!@*5H"5H@G!2#2 @
H Morse Fall Risk Assessment +#7- Hendrich Fall Risk Assessment B"36611"H-D5I: #0'142#%1+%I!, -2"8 (!2'H2 65 5), 2#C
I"2%H-!#0*2 "24@'
 "2#02" A%0"2%'2!1B%+4, B##02@4+2"C B#2@4+2"C-81I@#7I-#1 B#6!@(#I2 A%0B#I--1@*,  2#@%7H-D+' 2#@4 3%1%I2!@7I-5HD!H4, $4##!!52#34##!I-", * 2'024C (*1* '2!3#H-), !5 2'0#H-2#DI"4A%02#!-@+G, 2#4#9A%0-22#@G'5H@I2@'%2@4, 2##1#9I-#0*2*1!1**H'%2"%% @
H 9IH'"@2+'2, !5-22#@'5"(5#)0 !6, !5-22#1**2'0H-"+#7-%1I1**2'0D!H-"9H2. #0@!4'2!@*5H"H-2#%1+%I!I3#0+'H2-"9HCB#"22% @7H-2* 2'0-9IH'"0@%5H"DC#0+'H2#12##1)2 @
H *12+L%0 2 #1I A%0@!7H-!52#"I2"9IH'"2+H'"+6HD"1-5+H'"+6H +#7-!52#@%5H"A%C* 2'0I2#H22"+#7-4C3. C
IA'2I-1'2!@*5H"6H42#211"+%2"F -"H2DI'"1
" 	#0@!4'2!@*5H"-9IH'"AH%0#2"A%0#0@!4I3
" 	42!*1@9IH'"5H!5'2!@*5H"H-"F
" 	C
I2@%7-H2F C2#9A%9IH'" @
H @5"5H!5#01H3 2#6--3%1A%02#@%7H-"I2"5H%- 1" -8#L*H*1

2@7-
" 	C
I-8#L@#7H-
H'"@4
" 	C+I'2!
H'"@+%7-2I2#H22"AH9IH'"5H!5'2!*9C0@4+#7-"2"2!34##!5H"2 @
H 2#1H2" 2#@%7H-"I2"@- A%0*H@*#4!C+I'8!2##1'C+I56II'"2#32" 231
" 	C+I9IH'"!5B-2*DI#12#
H'"@+%7-C+I1H2"-"H2*!H3@*!-
" 	!52##0@!4'2!@*5H"I2*4HA'%I-!B"5!*+*22'4
2
5 A%01+#7-%-1#2"C+I@+%7-I-"5H*8 
" 	'A%0#1"25H-23C+I9IH'"%1+%I!DIH2" B"@	20-"H2"4H "24@'

" 	!-+!2"+I25H@	20C+I9I4142@7H-I+2-1#2"H-2#%1+%I!A%0*H@*#4!'2!7H1'C2#I-1
" 	1@'5AI1
+22#%1+%I!19IH'" #-#1' A%09I4I42 A%0C+I2#(6)2H-@7H-4. *H@*#4!C+I9I4142#2"22#%1+%I!A%0@+8@7-%21I+! B"C
I#0#2"25H@I26A%0C
I2#DIH2"	
	
	
	
Gap Analysis - L 1: Avoiding Catheter and Tubing Mis-connections

RecommendationActual PracticeDesired PracticeAction Plan1. !5#0A%0'45414C2#
" 	@I"I319I
H'" 9IH'" A%0#-#1''H2D!H'#-+#7-H--8#LH2F I'"@-  '#-'2!
H'"@+%7-2"22%@!7H-!51
+2
" 	3+C+I!52# label high-risk catheter (@
H arterial, epidural, intrathecal). '#+%5@%5H"2#C
I catheter 6H!5 injection ports *3+#13A+H@+%H25I
" 	3+C+I9I9A% trace *2"8@*I2I2D6 connection port @7H-"7"1 attachments H-5H0!52# connect, reconnect, C+I"2 *2#%0%2" +#7-@'
 1L-7HF 
" 	C+I#0'2# line reconciliation 5H@G!2#2@G*H'+6H-2#*7H-*2#*H!-I-!9% (handover communication) B" recheck tubing connections A%0 trace tubes & catheters 8@*ID"1A+%HI2 @!7H-#19IH'"C+!H5H+H'" A%0@!7H-!52#@%5H"@'#
" 	+I2!C
I standard Luer syringes C2#C+I"24+#7--2+2#2*2""2
" 	C
I2##0@!4A%0*-'2!@*5H" (FMEA) @7H-I+2B-2*@4 misconnection @!7H-07I- catheter A%0 tube 
4C+!H2. ##82#6-#!@5H"'1-1#2"- tube & device misconnection  C2#!4@(A%02#(6)2H-@7H--9I#0-'4
2
53. *H@*#4!C+I17I- tube A%0 catheter 6H9--A@7H-'2!%- 1"A%0I-1 misconnections 1-8#L+#7- tube -7HF	
	

Gap Analysis - E 1: (Rapid) Response to the Deteriorating Patient

RecommendationActual PracticeDesired PracticeAction Plan1. @4B-2*C+I@I2+I25H5H9A%9IH'"*2!2#-'2!
H'"@+%7-28%5HDI#12#6-#!!2@G4@() C#55H-22#-9IH'"#8% B"*2!2#3DI%-@'%22. 3+@L*3+#12##I--'2!
H'"@+%7-@7H--*-H-2#@%5H"A%-22#-9IH'" +#7-@!7H-@I2+I25H 9IH'" A%0#-#1'#9I*6I-2#'2!
H'"@+%7- 6H'#!5-L#0-H-D5I
" 	2#16* 2'02*#5#'4"2@!7H-A##1 DIAH heart rate, respiratory rate, blood pressure, level of consciousness, oxygen saturation, temperature A%0-2#'!1I hourly urine output A%0 biochemical analysis C2#5
" 	13A2#42!5H#08
1@'H20I-16I-!9%C H-"@H2D# B"42#22#'44	1"B#A%0A2##1)2*3+#19IH'" 
" 	13 multi-parameter +#7- aggregate weighted scoring system *3+#12#42!@7H-C+I*2!2#-*-@G%311IDI (graded response) #'!1I2#!581+#7-0A5H
1@5H0I--'2!
H'"@+%7-
" 	C
I'452#*7H-*2#5H@G!2#2 @
H SBAR (Situation, Background, Assessment, Recommendation) 19I5H0C+I'2!
H'"@+%7-
" 	C
IA165HDI#12#--AD'I-"H2@G#0@7H-16@+82#L@!7H-9IH'"!5-22#@%'% A%0@#4H!IC+I intervention3. *#I2'2!!1HC'H2@I2+I25H5HC+I2#9A%9IH'"5H!52#@GH'"@	5"%1 !5'2!#9I'2!*2!2#5H3@GC2#42! '1 A%'2!+!2" A%0-*-B"15-"H2@+!20*!1#01-2#9A%5H3%1C+I-"9H4. C+I'2!#9IAH@I2+I25H5H-20I--'2!
H'"@+%7-A%09I5H+I25HC+I'2!
H'"@+%7- @5H"'1B"2"A%0'45414C2#-*--"H2@#HH'5. '1-1#22#@4 cardiopulmonary arrest A%0-1#22#@*5"
5'4H-A%0+%12#3@42#2!#05I  #1#8331'2!-#55H*2!2#I-1DIB"A"@-29I'"#0"0*8I2"5H2'H20I-@*5"
5'4A%09IH'"5H!53*1HD!HI-
H'"7I
5--22#3'6. #0@!4%DIA%0#0*44%- intervention 5HC
I@7H-I+2A%0#1)29IH'"5H!5-22##8% @
H 3'2#@#5" code 
H'"
5'45H%%, 3'2#"I2"9IH'"@I2 ICU 5H%%, 3'9IH'"@*5"
5'45H%%7. *H@*#4!2#'A%0'4@#20+L (@
H RCA) @+82#L5H9IH'"!5-22##8%A%0D!H!52#C+I intervention C@'%25H@+!20*!
	
	

Gap Analysis   E2 : Sepsis

RecommendationActual PracticeDesired PracticeAction PlanI. MANAGEMENT OF SEVERE SEPSISA. Early goal-directed resuscitation 
-	C+I resuscitate 9IH'" septic shock 2! protocol 155H'H2!5 hypoperfusion B"D!HI-#-@I2 ICU A%0!5@I2+!2"H-D5I 2"C 6 
1H'B!: CVP 8-12 mmHg, MAP > 65 mmHg, urine >= 0.5mL/kg/hr, central venous O2 saturation (Scvo2) >= 70% +#7- mixed venous O2 saturation (SVo2)> 65% (1C)
-	 2"C 6 
1H'B!-2# resuscitate I2 O2 saturation D!HDI2!@I2+!2"  C+I PRC @7H-C+I#01 Hct >= 30% A%0/+#7- C+I dobutamine infusion C-1#2*9*8D!H@4 20 g/kg/min @7H-C+I##%8@I2+!2"1%H2' (2C)B. Diagnosis
-	C+I3 blood culture -"H2I-" 2 specimen H-5H0C+I antibiotic  B"@20H24'+1-"H2I-" 1 specimen A%09@%7-2 vascular access device AH%08 (I2 device 1I*-C*H!2!2'H2 48 
1H'B!)  #'!1I2#@20@
7I-23A+H-7HF 5H!5B-2*@GA+%H-2#4@
7I-DI (1C)
-	H2" 2#1*5+#7-3 imaging study B"15@7H-I+2A+%H4@
7I-5H@GDDIB"42#26'2!@*5H"A%0%DIC+I*!8% (1C)C. Antibiotic therapy
-	C+I IV antibiotic C+I@#G'5H*8@H25H03DI  2"C 1 
1H'B!+%125H'H2!5 septic shock (1B) B"@%7- antibiotic 5H2'H20!5%H-@
7I-5H@GDDI81' A%0*2!2#!5'2!@I!IC-'1"'05H**1"'H20!52#4@
7I-*9- (1B)
-	C+I#0@!4 antibiotic regimen 8'1 @7H-I-12#7I-"2 % toxicity A%0%H2C
IH2" (1C)
-	'#C
I combination therapy *3+#12#4@
7I-5H#2+#7-**1"'H20@G Pseudomonas infection +#7-9IH'"5H!5@!G@%7-2'H3  AHC2#C
IA empirical D!H'#C
I combination therapy !2'H2 3-5 '1 (2D)
-	'#C+I antibiotic @G@'%2 7-10 '1 +#7-2'H25II29IH'"!52#-*-
I2 "1!5A+%H4@
7I-5H"1D!HDI@#02"-- +#7-!5 9!48I!1#H- @!G@%7-2'H3 (1D)
-	@!7H-'H2-22#-9IH'"!4DI@422#4@
7I- C+I+"82#C
I antibiotic 15@7H-I-12#4@
7I-7I-"2+#7-%I2@5"2"2 (1D)D. Source control
-	'#I+2A%0'44	1"2#4@
7I-C23A+H@GI-H
5I5H0I-32#H21@7H-'8!A+%H4@
7I-A	8@	4 @
H necrotizing fasciitis, diffuse peritonitis, cholangitis, intestinal infarction (1C) B"'#'44	1"C+IDI 2"C 6 
1H'B! (1D) #'!1IA+%H4@
7I--7HF 5H*2!2#'8!DI
-	I2**1"'H2 infected peripancreatic necrosis @GA+%H-2#4@
7I- C+I
0%-2#C+I definitive intervention D'H20!5@*IAH5H
1@#0+'H2@7I-@"7H-5H!5
5'41@7I-@"7H-5H2" (2B)
	'452#'8!A+H4@
7I- '#0'455H#0H-*#5#'4"2-9IH'"C+II-"5H*8 @
H C
I2#@209A'H2H2#02"5+- (1D)
-	I2**1"'H2 intravascular access device @GA+%H-2#4@
7I- '#---15+%125H*-C*H-8#L@*IC+!HA%I' (1C)E. Fluid therapy
-	2#C
I fluid resuscitation 0C
I natural/artificial colloids +#7- crystalloids GDI (1B) B"!5@I2+!2"5H CVP >= 8 mmHg (+#7- >=12 mmHg C9IH'"5HC
I@#7H-
H'"+2"C) (1C)
-	A03C+IC
I fluid challenge technique I2 hemodynamic (arterial pressure, heart rate, urine output) -9IH'"56I@#7H-"F (1D) 
-	C+I fluid challenges B"C
I crystalloids1000 mL +#7- colloids 300 500 mL C@'%2 30 25 +#7--20C+I@#G''H2A%0!2'H25IC#55H!5 tissue hypoperfusion (1D)
-	'#%-1#22#C+I*2#I3I2'H2 CVP @4H!6IB"5HD!H!5 hemodynamic improvement (1D)F. Vasopressors
-	#1)2#01 mean arterial pressure 5H#01 >= 65 mmHg @7H-C+I*2!2# autoregulation C vascular bed H2F DI (1C) 
-	"25HA03C+IC
I@G-11A#7- norepinephrine +#7- dopamine 2 central catheter (1C) D!H'#C
I epinephrine, phenylephrine, vasopressin C
H'A#F
-	+2D!HDI%A03C+IC
I epinephrine @G first alternative  (2B)
	D!HC
I low-dose dopamine @7H- renal protection (1A)
-	9IH'"5HI-C
I vasopressor '#DI#12#C*H arterial catheter B"@#G'5H*85H@GDDI @7H-C+I*2!2#'1 arterial pressure DI (1D)G. Inotropic therapy
-	A03C+IC
I dobutamine infusion I2!5 myocardial dysfunction (1C)H. Corticosteroids
-	42#2 IV hydrocortisone *3+#1 septic shock C9IC+
H@!7H-'2!1B%+4D!H-*-H- fluid resuscitation A%0 vasopressor therapy (2C),  D!HA03C+I3 ACTH stimulation test @7H-H
5I9IH'"5H'#DI#1 hydrocortisone(2B),  D!H'#C
I dexamethasone I2!5 hydrocortisone (2B)
-	D!HC
I corticosteroids @7H-#1)2 sepsis 5HD!H
G- -2!5I-H
5I2#0'142#@GH'"I'"B#H-!D#IH-+#7-#0'142#C
I corticosteroids (1D)I. Recombinant human activated protein C (rhAPC)
-	42#2C+I rhAPC C9IC+
K5H!5 organ dysfunction @7H-2 sepsis A%02##0@!42%44@+G'H2!5'2!@*5H"H-2#@*5"
5'4*9 (APACHE II >= 25 +#7-!5 multiple organ failure) I2D!H!5I-+I2! (2B)
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5'4H3 (@
H APACHE II < 20 +#7-!5 organ failure @5"-'1"'0@5"') D!H'#DI#1 rhAPC (1A)J. Blood Product Administration
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H erythropoietin @7H-#1)2 sepsis-related anemia AH*2!2#C
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I antithrombin therapy(1B)
-	D!HC
I FFP @7H-AID laboratory clotting abnormalities "@'IAH0!5@%7---+#7-!52#'2A3+12# (2D)
-	C+I  platelets @!7H-  platelet counts <= 5,000/mm3  D!H'H20!5@%7---+#7-D!H, +#7-@!7H- platelet counts -"9H#0+'H2  5,000 6 30,000/mm3 A%0!5'2!@*5H"5H0!5@%7---*9, 9IH'"5H03H21+#7- invasive procedure '#!5 platelet counts >= 50,000/mm3 (2D)II. SUPPORTIVE THERAPY OF SEVERE SEPSISA. Mechanical ventilation of sepsis-induced acute lung injury (ALI)/ARDS
-	1I@I2+!2"5H tidal volume 6mL/kg C9IH'"5H@G ALI/ARDS (1B), 1I@I2 initial upper limit plateau pressure d"30cmH2O B"42#2 chest wall compliance C2##0@!4 plateau pressure (1C)
-	%H-"C+I PaCO2 *9'H2#014DI I23@G@7H- minimize plateau pressures A%0 tidal volumes (1C), '#1I PEEP (positive end expiratory pressure) @7H-I-1 extensive lung collapse C
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I FiO2 +#7- plateau pressure C#015H-20@G-1#2" -'H3DI +2D!H@4'2!@*5H"22#@%5H"H2 (2C)
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-	C
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-	C
I conservative fluid strategy *3+#19IH'" ALI 6HD!H!5 tissue hypoperfusion (1C)B. Sedation, analgesia, and neuromuscular blockade
-	C
I sedation protocols B"!5 sedation goal *3+#19IH'"6H critically ill A%0C
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-	C
I intermittent bolus sedation +#7- continuous infusion sedation 6#01 sedation scale 5H3+D'I B"!5 daily interruption @7H-C+I9IH'"7H@G#0"0  32# re-titrate I23@G (1B)
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I neuromuscular blockers C+I!25H*8 I2I-C
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I IV insulin @7H-'8! hyperglycemia C9IH'" severe sepsis +%125H3C+I9IH'"  stable C ICU A%I' (1B)
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I low-dose unfractionated heparin (UFH) +#7- low-molecular weight heparin (LMWH) I2D!H!5I-+I2! (1A)F. Deep vein thrombosis prophylaxis
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I mechanical prophylactic device @
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I combination -"2A%0 mechanical therapy *3+#19IH'"5H!5'2!@*5H"H-2#@4 DVT *9 (2C)
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I LMWH A UFH C9IH'"5H!5'2!@*5H"*9!2 (2C)G. Stress ulcer prophylaxis
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I H2 blocker(1A) +#7- proton Inhibitor (1B)  1I5I0I-42#2#0B"
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RecommendationActual PracticeDesired PracticeAction Plan1. 2#I+2A%0#0@!49IH'"5H!5-22#@G+I2--"H2#'@#G' I'"-2(1"@L2#'44	1"-22#@G+I2-5H
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