Patient Safety Monitor Crosswalk

Less Topics	Patient ID: Identifiers	Patient ID: Transfusions	Verbal Orders	Abbreviations More Topics
The Joint Commission	NPSG.01.01.01	NPSG.01.03.01	PC.02.03.01, EP 20	IM.02.02.01, EPs 2 and 3
The Centers for Medicare & Medicaid Services (CMS)	All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.	Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. If blood transfusions and intravenous medications are administered by personnel other than doctors of medicine or osteopathy, the personnel must have special training for this duty.	If verbal orders are used, they are to be used infrequently. The content of verbal orders must be clearly communicated. CMS expects nationally accepted read-back verification practice to be implemented for every verbal order.	The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical service.
Alabama	The only information that Alabama specifies about patient identification is that hospitals must have a specific method of identifying newborns, and linking them to their mothers.	Almost all hospital licensure regulations for the state of Alabama refer to CMS regulations, including those for quality.	Almost all hospital licensure regulations for the state of Alabama refer to CMS regulations, including those for quality.	Almost all hospital licensure regulations for the state of Alabama refer to CMS regulations, including those for quality.
Alaska	No current regulation under this topic.	No current regulation under this topic.	No current regulation under this topic.	No current regulation under this topic.
Arizona	A patient must be identified to ensure the patient receives proper medical services.	Arizona requires hospitals to have policies regarding the transfusion of blood in the clinical laboratory and pathology setting.	Arizona regulations do not specifically address this topic.	No current regulation under this topic.
Arkansas	During the admission process, each patient admitted to the hospital will receive an identification bracelet.	Arkansas regulations require that blood transfusions must be administered in accordance with state law and approved medical staff policy, but do not mention patient identification for the use of blood transfusions specifically.	Telephone and verbal orders should be used infrequently.	Although there is no current regulation under this topic, abbreviations are not acceptable in surgery records.
California	Patients must wear a wristband identification tag.	No current regulation under this topic.	Verbal orders for drugs shall be recorded promptly and given only by authorized personnel and those authorized to prescribe them.	No current regulation under this topic.
Colorado	Patients must be identified upon admission. Each patient must have some type of visible means of identification placed on his or her body, and if this is not possible due to medical or personal safety, the facility must devise another way to identify the patient. Patient identification information must also be included in the patient's medical record.	Colorado regulations require that both a registered nurse and a licensed healthcare professional to identify the patient, the specimen, blood type, crossmatch, and expiration date of the blood or blood component before a blood transfusion.	Colorado hospital regulations state that verbal orders must be received by an appropriate member of the medical staff, and documented when received. A staff member responsible for implementing the order is also responsible for writing the order in the patient's medical record. Additionally, the order must be authenticated within 48 hours.	Colorado does not currently have regulation under this topic.
Connecticut	Connecticut regulations require that at the time of patient admission to the hospital, a record should be started with complete identification data and a nurse's or other licensed practitioner's notation of condition on admission.	Although Connecticut does not have any regulations that specifically relate to identification of patients during blood transfusions, it does have other rules regarding transfusions.	Although Connecticut does not have any regulations pertaining to verbal orders for the hospital setting, in the industrial health facility setting, verbal orders are required to be confirmed in writing in the patient’s medical record.	Connecticut regulations for general hospitals do not specifically address this topic; however, Connecticut Public Health does address several other factors concerning patient safety. Click the link below for more information see 19-13-D3. Short-term hospitals, general and special.
Delaware	Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.	Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.	Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.	Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.
Florida	No current regulation under this topic.	No current regulation under this topic.	No current regulation under this topic.	No current regulation under this topic.
Georgia	Georgia regulations require each patient to have a unique identifying number.	No current regulation under this topic.	Georgia regulations require that verbal orders are limited and documented on the medical record. The order must be verbally repeated and can only be received by licensed or qualified staff members. A timeline of verbal verification is also needed.	Georgia regulations require that staff members in charge of maintaining medical records keep a list of accepted abbreviations, symbols, and terminology within the hospital to be used in entries on the medical record.
Hawaii	No current regulation under this topic.	Although there are no specific regulations concerning identification of the patient prior to a blood transfusion in Hawaii's rules, there are some general rules about blood transfusions, such as transfusions should only be done under the supervision of a pathologist or physician qualified in immunohematology and hemotherapy.	Within twenty-four hours of receiving any verbal or telephone orders for medication, they must be recorded and signed by the person receiving them and countersigned by the attending physician.	No current regulation under this topic.
Idaho	Idaho does not specifically address this topic, but does address patient identification of newborns in the maternity ward.	Idaho regulations address a blood transfusion policy under its laboratory policies.	Verbal or telephone orders shall be given from only those authorized to give medical orders.	Idaho has no current regulation under this topic.
Illinois	Identification must always be affixed to the patient.	Illinois requires that a medical staff committee review all blood transfusions and make recommendations concerning the policies of such practices.	Verbal orders must be signed by the prescriber before he/she leaves the area. Telephone orders must be signed as soon as possible and should be addressed in hospital policy.	There is no current regulation for Illinois under this topic.
Indiana	There is no current regulation under this topic.	Blood transfusions must be administered in accordance with state law and approved medical staff policy. Anyone other than a physician must have special training to give a blood transfusion.	Verbal orders must be read back and verified, signed and dated by the same person who took the order.	There is no current regulation under this topic.
Iowa	This topic is currently not addressed under Iowa regulations.	This topic is not currently addressed under Iowa regulations.	All verbal orders must be signed within 30 days of the patient's discharge. Staff members receiving the verbal order must be authorized personnel only.	Iowa regulations do not specifically address this topic, but does describe medical records and reporting.
Kansas	Kansas does not specifically address this topic, but does address patient identification of newborns and mothers in the maternity ward.	Patient identification during blood transfusions is not addressed by Kansas regulations.	According to Kansas regulation, verbal orders must be signed and dated by the receiver as soon as possible. The person entering the orders must sign and date the order as soon as possible, and the order must be authenticated within 72 hours or 30 days of a patient's discharge, whichever comes first.	This topic is not currently addressed under Kansas regulations.
Kentucky	Patients must be identified from the time of admission to the time of discharge. Identification bracelets are stated as an example by Kentucky's hospital regulations.	This topic is not currently addressed by Kentucky regulations.	Verbal orders must be repeated and verified. Kentucky requires that verbal orders be signed by a member of the medical staff as soon as possible or within 30 days in the case of a patient discharge. Regulation also requires the verbal order be immediately transcribed, repeated to the physician issuing the order, and annotated in the patient's medical record.	This topic is not currently addressed by Kentucky regulations.
Louisiana	This topic is not addressed under Louisiana's hospital regulations.	This topic is not addressed under Louisiana's hospital regulations.	Lousiana's hospital regulations requires that hospitals' staff bylaws address this topic. The regulations also require that medical staff members are to be granted up to 10 days following the date an order is transmitted verbally or electronically for a signature on the orders.	Abbreviations are not addressed in Louisiana regulations.
Maine	Maine regulations do not specifically address this topic. Standards state that all applicants and licensees must comply with federal standards and certification requirements for hospitals as adopted by the Centers for Medicare and Medicaid Services.	This topic is not addressed by Maine health regulations.	Maine regulations do not specifically address verbal orders. Standards state that all applicants and licensees must comply with federal standards and certification requirements for hospitals as adopted by the Centers for Medicare and Medicaid Services.	Maine regulations do not specifically address abbreviations. Standards state that all applicants and licensees must comply with federal standards and certification requirements for hospitals as adopted by the Centers for Medicare and Medicaid Services.
Maryland	Service standards for hospitals in Maryland include most Joint Commission standards.	Maryland regulations do not currently address this topic.	Service standards for hospitals in Maryland include most Joint Commission standards.	Service standards for hospitals in Maryland include most Joint Commission standards.
Massachusetts	Massachusetts state regulations do not address this topic. The state does require hospitals to follow Medicare's Conditions of Participation, with a few exceptions. Hospitals can also be considered for "deemed status" through Joint Commission accreditation.	Massachusetts state regulations do not address this topic. The state does require hospitals to follow Medicare's Conditions of Participation, with a few exceptions. Hospitals can also be considered for "deemed status" through Joint Commission accreditation.	Other than specific discharge planning requirements, most areas covered by the NPSGs are not addressed. Massachusetts does require hospitals to follow Medicare’s Conditions of Participation, with a few exceptions. Hospitals can also be considered for "deemed status" through Joint Commission accreditation.	Other than specific discharge planning requirements, most areas covered by the NPSGs are not addressed. Massachusetts does require hospitals to follow Medicare’s Conditions of Participation, with a few exceptions. Hospitals can also be considered for "deemed status" through Joint Commission accreditation.
Michigan	There is no current regulation on this topic.	Although Michigan does not specifically address improved identification of patients to eliminate errors related to blood transfusions, it does say that hospitals need to have a facility to perform blood transfusions.	Verbal or telephone orders shall be written into the record as such.	There is no current regulation on this topic.
Minnesota	Minnesota's regulations state that for a medical record to be complete, it should include adequate identification data.	There is no current regulation for Minnesota.	Minnesota's regulation says that any medication or treatment given to a patient must be done in the form of a written order.	There is no current regulation on this topic for Minnesota.
Mississippi	Although Mississippi does not have any regulations specifying two methods of patient identification, it does say that within a patient's medical record should be patient identification.	Although Mississippi does not have any regulations that specifically call for active patient identification prior to a blood transfusion, the state’s regulations do have rules about blood and blood products.	Although Mississippi does not have any regulations that discuss the protocol for receiving verbal orders, there is a time specification required by regulations.	There is currently no regulations concerning a necessary list of abbreviations, dose designations, acronyms, or symbols kept in each hospital for Mississippi. To find the state's general health facilities regulations, click the link below.
Missouri	Missouri does not have any specific regulations regarding this topic.	Missouri does not have any regulations that relate specifically to blood transfusions and patient identification.	Missouri requires that the medical staff along with nursing set the timeframe by which verbal orders need to be authenticated by the prescribing practitioner.	Missouri's regulations require used abbreviations to be approved, as well as there to be a list of handwritten abbreviations that should not be used.
Montana	Although Montana's regulations do not have language concerning the use of two patient identifiers, regulations do state that a core medical record should contain a form of patient identification, specifically his or her name, maiden name if relevant, address, date of birth, sex, and, if available, Social Security number.	Montana does not have any current regulation regarding identification errors with transfusions.	Montana does not have any current regulations concerning verbal orders.	Montana does not have any current regulations that concern creating a standardized list of abbreviations, symbols, acronyms, or dose designations.
Nebraska	Nebraska's regulations state that a patient's medical record and medication record must contain a method of identification for that patient.	Nebraska does not have any specific requirements for eliminating errors with blood transfusions by correctly identifying patients.	Verbal and telephone orders must be accepted, checked, and transcribed by a qualified staff member.	Nebraska does not currently have any regulations that require a list of standardized abbreviations to be used throughout a hospital.
Nevada	If passed, Assembly Bill 280 would require all Nevada hospitals to create safety checklists reminding healthcare workers how to identify a patient appropriately and make certain that the patient is provided with the specific treatment ordered by a healthcare professional.	According to Nevada regulation, blood transfusions must follow the policies and procedures developed by the hospital, with input from the medical staff.	According to Nevada regulation, when a telephone or verbal order is taken, it must be accepted only by an authorized person and signed or initialed by the practitioner in accordance with the policies of the facility.
New Hampshire	New Hampshire's hospital regulations do not currently address this topic.	New Hampshire's hospital regulations do not currently address this topic.	New Hampshire regulations do not have any specific language that addresses verbal orders.	New Hampshire regulations do not contain any specific language that addresses abbreviations, acronyms, symbols, or dose designations not to be used in a facility.
New Jersey	Hospitals need to have a patient identification system that identifies all patients from the time of admission until the patient's release from the hospital.	New Jersey does not have a current regulation under this topic.	Medical staff policies should say who can give and receive verbal orders, as well as the time period in which they need to be verified.	New Jersey does not have a regulation regarding abbreviations, acronyms, symbols, or dose designations that should not be used.
New Mexico	New Mexico does not specifically address this topic, but states that at the time of admission the patient must be given a copy of their rights and responsibilities.	New Mexico currently does not have a regulation under this topic.	Within 72 hours, all verbal orders need to be recorded and authenticated by the prescribing practicioner, or a practioner authorized to sign on behalf of the prescribing physician. All oral orders given must be transcribed into the patient's medical record by an authorized staff person.	Abbreviations and symbols are permitted in medical records as long as they are approved by a written facility policy that controls their use and allows only one meaning per symbol.
New York	Patient ID not specifically addressed.	Misidentification of patients directly relating to blood transfusions is not addressed specifically in New York regulations. However, general requirements for transfusions are provided.	Verbal orders must be addressed in policies. The hospital must implement procedures regarding use and authentication of telephone orders. They must be in accordance with federal law and be authenticated by the prescribing practitioner as soon as possible.	Abbreviations are not specifically addressed by New York hospital regulations.
North Carolina	Facilities shall maintain complete and permanent record of all patients including date, time, admission, discharge, address, date of birth, nearest of kin, provisional diagnosis, referring physicians, attending physician, identification bracelet or band.	North Carolina does not currently have a regulation under this topic.	Verbal orders shall be countersigned by a physician within five days of issuance.	North Carolina regulations do not specifically address this topic.
North Dakota	North Dakota doesn't specifically require hospitals to use at least two patient identifiers when providing care, treatment, or services. But it does require that patient identification and history of disease or injury will be kept in medical records.	North Dakota does not specifically address the topic of eliminating transfusion errors related to patient misidentification, but it does require that written policies and procedures for transfusion services be established and revised as needed.	Telephone and verbal orders may be used provided they are given only to qualified licensed personnel and put in writing, signed, or initialed by a healthcare practitioner responsible for the care of the patient.	No current regulation under this topic.
Ohio	Ohio does not specifically address patient identification, but it requires hospitals to have a quality improvement program.	Ohio doesn’t address the elimination of transfusion errors related to the misidentification of patients.	Ohio doesn’t address improving caregiver communication of verbal or telephone orders.	Ohio doesn’t address the standardization of abbreviations, acronyms, symbols, and dose designations.
Oklahoma	Adequate medical records shall be kept on every patient. Each record will include patient identification through various means.	Oklahoma does not have a current regulation under this topic.	All verbal orders must be documented and signed by the prescribing physician within 48 hours, and only by an authorized physician or practitioner.	Oklahoma does not have a current regulation under this topic.
Oregon	Systems for patient identification shall include name, date, and signature.	Oregon doesn't specify how transfusion errors should be eliminated, but it does require that there is an effective, written quality assurance program to evaluate and monitor blood transfusions.	Verbal orders will be documented and countersigned by the practitioner who gave the order no later than the date the record is closed. They will also need the signature, date, and title of the individual receiving the order.	Only abbreviations approved by the medical staff may be used in medical records. All diagnoses and operations should be expressed in standard terminology.
Pennsylvania	Pennsylvania doesn't require the use of two patient identifiers when providing care, treatment, and services, but it does require each patient at admission to wear a form of visible patient identification such as an identification bracelet.	Pennsylvania does not specifically require hospitals to eliminate transfusion errors related to patient misidentification, but it does require that hospitals have the capability of providing transfusions to meet the needs of patients.	Verbal orders must be signed and authenticated within 24 hours.	Abbreviations and symbols may only be used if they are part of a list approved by the medical staff and a legend exists to explain them.
Rhode Island	For each patient seeking emergency care, a medical record shall be maintained.	Rhode Island has no current regulation under this topic.	All telephone or verbal orders must be put in writing by the person who took the order with his or her signature and date. Identification of the practitioner who gave the order must be recorded with his or her signature no later than the end of the next calendar day.	Rhode Island has no current regulation under this topic.
South Carolina	There is no current regulation under this topic for South Carolina.	South Carolina requires hospitals to have a blood transfusion policy, but doesn't specifically addresss prevention of misidentification of patients.	South Carolina requires verbal orders to be given to registered nurses and immediately recorded, dated and signed. Verbal or telephone orders must be countersigned by the prescriber (or his designee) within 48 hours.	There is no current regulation under this topic for South Carolina.
South Dakota	South Dakota identifies twelve pieces of patient information that have to be contained within the patient's record and must show the condition of the patient or resident upon admission and through discharge.	South Dakota has a general policy on blood transfusions, but does not address the prevention of patient misidentification errors. See section 44:04:10:04.	All medical orders must be in writing and signed by the physician or the physician extender. Orders via telephone may be taken only when there is an urgent need to create or modify a medical order. The physician signs or initials the orders for nursing facility residents on the next visit to the facility. The physician should sign or initial any orders for hospital patients as soon as possible. Each patient’s or resident’s physician is responsible for documenting written orders and progress notes on the clinical record.	Those medications administered to the patient must be recorded in his or her medical record. Use of abbreviations and chemical symbols may be allowed but only if the hospital has a standard list of abbreviations and symbols approved for use by the medical staff. This list must be made available to members of both the medical and nursing staffs. Only licensed nurses, or those acting under the delegation of a licensed nurse, may administer medications.
Tennessee	Tennessee's regulations do not specifically address patient identification at admission.	Tennessee requires hospitals to report all events of blood transfusion reactions, use of wrong type of blood and/or delivery of blood to the wrong patient to be reported to the state department of public health. No specific policy addresses prevention of transfusion errors.	Verbal orders can only be accepted by those authorized to do so. Orders must be signed and initialed by the prescribing practitioner.	Tennessee regulations do not address this topic specifically.
Texas	Texas does not have specific regulations on patient identifiers.	Texas hospital regulations do not address this topic.	Texas regulations require that all verbal orders be dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient.	While Texas regulations do not specifically address the use of abbreviations, they do address the clarity of medical records, stating that medical records must be consistent with hospital policies and procedures.
Utah	Although this topic is not specifically addressed by Utah’s hospital regulations, they do state that each patient’s medical record shall contain patient identification and demographic information that at least includes the patient’s name, address, date of birth, sex, and emergency contact information.specifically addressed by Utah’s hospital regulations.	This topic is not specifically addressed by Utah's hospital regulations.	According to Utah regulations, verbal orders must be accepted and transcribed by qualified personnel and authenticated within 30 days of the patient's discharge.	This topic is not specifically addressed by Utah's hospital regulations.
Vermont	Vermont's hospital regulations do not specifically address this topic. They require hospitals to implement quality improvement programs, as well as a program for reporting and investigating adverse events.	Vermont's hospital regulations do not specifically address this topic. They require hospitals to implement quality improvement programs, as well as a program for reporting and investigating adverse events.	Vermont's hospital regulations do not specifically address this topic. They require hospitals to implement quality improvement programs, as well as a program for reporting and investigating adverse events.	Vermont's hospital regulations do not specifically address this topic. They require hospitals to implement quality improvement programs, as well as a program for reporting and investigating adverse events.
Virginia	Virginia regulations require hospitals to have a patient identification system for all patients, including newborn infants.	Virginia regulations require hospitals to have written policies and procedures for all phases of blood transfusion and storage.	Virginia regulations require that verbal and telephone orders be used in the case of emergency. These orders must be signed no later than 72 hours after the order is given.	Virginia's hospital regulations do not currently address this topic.
Washington	Under Washington's patient care regulations, located in the administrative code's hospital licensing section, hospitals are required to have a reliable method for identifying each patient.	Washington state regulations do not specifically address patient identification during blood transfusions, but does require hospital policy to ensure proper preparation and administration of blood and blood products.	Washington hospital regulations included in the administrative code under the "management of information" section do not address having a specific process for handling verbal orders, but do require that they are recorded in the patient's medical record after being transcribed by qualified personnel.	Washington does not currently have any regulation under this topic.
West Virginia	West Virginia regulations do not specifically address this topic. The only mention of patient identification within West Virginia's hospital licensure is in conjunction with the medical record, where it is stated that the inpatient medical record must contain some form of patient identification.	West Virginia regulations do not specifically address this topic.	West Virginia Hospital Licensure says that only authorized persons can give or receive verbal orders. Verbal orders must also be countersigned by a physician.	West Virginia's Hospital Licensure says only abbreviations approved by medical staff members can be used in patients' medical records.
Wisconsin	Regulations require that the medical record staff ensure each patient's medical record contain accurate patient identification data.	Wisconsin does not specifically call for identification of a patient prior to a blood transfusion. The state does have some rules surrounding blood transfusions and the processes and procedures regarding them.	Wisconsin regulations state that all verbal and telephone orders be authenticated by a member of the medical staff that can prescribe within 24 hours of the order being placed.	According to Wisconsin regulations, symbols and abbreviations may be used in medical records if the definitions and use are approved and controlled by a written facillity policy. They do not have any language about which specific abbreviations and symbols can or cannot be used, just that hospitals should have their own definitions.
Wyoming	Wyoming regulations do not address patient identification.	This topic is not addressed specifically. Wyoming regulations require that blood transfusions are performed by specially licensed individuals, but they do not specify patient identification requirements for the process.	Only registered nurses are to be given telephone orders and within 48 hours the order must be signed and initialed by the physician. Telephone orders should be used sparingly.	Wyoming health regulations do not address abbreviations.

Patient Safety Monitor Crosswalk

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