Patients have the right to receive care in a safe setting. Accreditation Commission for Health Care (ACHC) Acute Care Hospital Standards require patient care to be provided in a safe environment and that hospitals identify patients at risk of self-harm or harm to others. Maintaining a safe environment is essential for protecting patients and others.

Potential environmental risks may include, but are not limited to, ligature points, sharps, harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags (for suffocation), oxygen tubing, and electrical and call light cords. These and many other common items found in the clinical environment can be used to inflict serious harm.

Although all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk of self-harm or harm to others, and the actions being taken to minimize those risks in accordance with nationally recognized standards of practice and industry guidelines.

The ACHC Acute Care Hospital Accreditation Standards Manual addresses requirements for screening and management of all patients for risk of self-harm or harm to others.

Stay Informed

Standard 15.01.19: Privacy and Safety: Identify Patients at Risk – This standard requires hospitals to have policies and procedures that describe how to identify patients at risk systemwide and detail mitigation strategies that are in place to protect patients and others. Hospital policies and procedures should also address how continuous, visual observation or one-to-one monitoring is established should the risk assessment identify this need for a patient.

Patient Risk Assessment Tools  

Numerous patient risk assessment tools are available to identify patients at risk for harm to self or others. The patient risk assessment tool utilized should be appropriate to the patient population, care setting, and staff competency.

All hospitals are expected to implement a patient risk assessment strategy that is in accordance with evidence-based, industry-practice guidelines.

Maintain Compliance

When a Surveyor Visits

While conducting a survey, an ACHC Surveyor will ask for documentation of hospital policies and procedures that explain how at-risk patients are identified and which mitigation strategies should be implemented to protect patients from harming themselves or others. The Surveyor will also assess:

• Medical records to review each patient’s at-risk screening documentation and mitigation strategies implemented to protect them.
• Relevant policies and procedures.
• Interviews with staff to validate their practice reflects policy and to observe how risk assessment is modified based on care area and patient population.
• Patient risk assessment tools adopted by the hospital.

Tips for Compliance

• Implement patient risk assessment tools appropriate for the patient population in accordance with evidence-based, industry-practice guidelines.
• Develop hospital policies and procedures that identify the screening assessment process for patients at risk.
• Develop mitigation strategies for staff to implement to reduce the risk of harm.
• Ensure the patient risk assessment and mitigation strategies are documented in the patient’s medical record.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, or to obtain a copy of the ACH Accreditation Standards Manual, contact your Account Advisor, email [email protected], or call (855) 937-2242.