Table 1.

List of essential safety requirement codes and definitions.

Standard code	Code definition
HR.5	The hospital has a process for proper credentialing of staff members licensed to provide patient care
MS.7	Medical staff members have current delineated clinical privileges
PC.25	Policies and procedures guide the handling, use, and administrations of blood and blood products
PC.26	Patients at risk for developing venous thromboembolism are identified and managed
QM.17	The hospital has a process to ensure correct identification of patients
QM.18	The hospital had a process to prevent wrong patient, wrong site, and wrong surgery/procedure
AN.2	Anesthesia staff members have the appropriate qualifications
AN.15	Qualified staff perform moderate and deep sedation/analgesia
IPC.4	There is a designated multidisciplinary committee that provides oversight of the infection prevention and control program
IPC.15	Facility design and available supplies support isolation practices
MM.5	The hospital has a system for the safety of high-alert medications
MM.6	The hospital has a system for safety of look-alike and sound-alike (LASA) medications
MM.41	The hospital has a process for monitoring, identifying, and reporting significant medication errors, including near misses, hazardous conditions, and at-risk behaviors that have the potential to cause patient harm. potential to cause patient harm
LB.51	The blood bank develops a process to prevent disease transmission by blood/platelet transfusion
FMS.9	The hospital ensures that all occupants are safe from radiation hazards
FMS.32	The hospital ensures proper maintenance of the medical gas system
FMS.21	The hospital had an effective fire alarm system
FMS.22	The hospital has a fire suppression system available in the required area(s)
FMS.23	There are fire exits that are properly located in the hospital
FMS.24	The hospital and its occupants are safe from fire and smoke