Care of Patients (COP)

Measurable Elements of COP.3.5

q 1. The hospital establishes criteria for which patients are screened for suicide and self-harm, as clinically

Care of Patients (COP)

indicated.
q 2. The hospital uses evidence-based tools to assess patients for suicidal ideation based on established
criteria. Patients who screen positive, are identified as “at risk” for suicide and/or self-harm based on
the established criteria.
q 3. The hospital conducts an environmental risk assessment that identifies features in the physical envi-
ronment that could be used in a suicide or self-harm attempt; the hospital takes necessary action to
minimize the risk(s).
q 4. The hospital implements protocols and procedures to mitigate the risk of patient suicide and/or
self-harm.
q 5. The hospital monitors implementation and effectiveness of protocols and procedures for the pre-
vention of patient suicide and/or self-harm by analyzing data regarding self-harm, the incidents, or
deaths
q 6. Staff are trained on screening criteria, screening tools, and suicide and self-harm risk reduction proto-
cols and procedures.

Management of Lasers

Standard COP.4
The hospital establishes and implements a program for the safe use of lasers and other optical radiation devices
used for performing procedures and treatments. 𝖯

Standard COP.4.1
Adverse events resulting from the use of lasers and other optical radiation devices are reported, and action plans
to prevent recurrence are implemented and monitored.

Intent of COP.4 and COP.4.1

Lasers are a source of optical radiation, which includes ultraviolet radiation, high-intensity visible light, and
infrared radiation. The narrow beam of high-intensity light from a laser can be targeted and focused for precise
surgical procedures. Laser surgeries are generally minimally invasive with less blood loss than conventional
surgery, and patients typically experience shorter recovery times. The use of lasers is becoming more common
in health care as laser technology evolves and the clinical applications broaden. Lasers are used in many surgical
procedures and treatments. For example, lasers are used to perform LASIK and cataract surgery; they are
used to remove skin lesions and treat varicose veins; and in dentistry, they are used to remove tooth decay and
recontour soft tissue.
Lasers are used for noninvasive treatments as well, and other medical devices that use optical radiation are
becoming more popular for patient treatments. Examples include intense pulsed light therapy to treat skin
conditions such as acne, ultraviolet radiation to treat psoriasis, lasers to whiten teeth, high-intensity visible
light for curing composites and adhesives during dental procedures, light therapy for treatment of pain and
inflammation, and infrared radiation to treat strained muscles and tissues.
Nearly all lasers and optical radiation devices that are used in the clinical setting pose potential hazards for
patients and staff if safety procedures and guidelines are not established and followed. Lasers and optical
radiation devices can generate intense concentrations of heat, light, and reflected light. When the skin and

119
 Joint Commission International Accreditation Standards for Hospitals, 7th Edition

eyes are exposed to the heat and light without adequate protection, skin burns and eye injuries, such as retinal
burns, cataracts, and macular degeneration, may result. Injuries can come from direct contact with the light or
Care of Patients (COP)

with the reflected light from the laser.

Laser plumes are another potential hazard. These are the vapors, smoke, and particles produced during some
surgical procedures. Laser plumes introduce a potential respiratory hazard for patients and staff, as they may
contain irritants, toxins, tissue, bacteria, viruses, blood fragments, and other particles, depending on the type
of procedure.
To prevent these hazards and address safety risks to patients and staff, the hospital establishes and implements a
program for the safe use of lasers and other optical radiation devices using industry standards and professional
guidelines. The program complies with laws and regulations and includes the following:
• A qualified and trained individual who has oversight and supervision of the laser and optical radiation
safety program
• Training in safety practices and procedures for all staff who are involved in the use of lasers and
optical radiation devices; in addition, ongoing education and training is provided for new procedures,
practices, devices, and equipment; the training and ongoing education are documented (Also see
SQE.3 and SQE.8)
• Administrative and engineering controls to promote safety and prevent injury; some examples include
0 criteria and processes developed for authorizing staff who enter and/or work in the areas (hazard
zones) where lasers and other optical radiation is used; in addition to health care practitioners
who perform the laser procedures, staff who operate the lasers, and other staff who are part of the
surgical/clinical care team, the hospital identifies staff who may also require access;
0 warning signs outside the procedure room(s) to alert staff, patients, families, and visitors when a
treatment or procedure is being performed;
0 appropriate ventilation to help manage smoke plumes;
0 use of nonreflective instruments to prevent exposures to reflected light; and
0 use of drapes and other barriers to prevent staff, patients, families, and visitors from inadvertently
being exposed to direct or reflected light
• Availability of personal protective equipment for staff and patients appropriate to the type of lasers
and optical radiation devices used and type of procedures performed in the hospital (for example,
goggles, corneal shields, masks, gloves, and gowns, as applicable) (Also see SQE.8.2)
• A maintenance program for lasers and optical radiation devices and a process for routine performance
checks such as calibration and alignment (Also see FMS.9 and FMS.9.1)
• Coordination with the facility management and infection prevention and control programs; any
facility safety events and infection control events are reported (Also see PCI.4 and FMS.5)
• Detecting and reporting adverse health effects and identifying and implementing improvements to
prevent recurrence (Also see QPS.7.1)

120
 Care of Patients (COP)

Measurable Elements of COP.4

q 1. The hospital’s program for the safe use of lasers and optical radiation devices is based on industry

Care of Patients (COP)

standards and professional guidelines and complies with applicable laws and regulations.
q 2. A qualified individual with the appropriate training and experience has oversight and supervision of
the laser and optical radiation safety program.
q 3. All staff involved in the use of lasers and optical radiation devices receive safety training and continu-
ing education; the training and ongoing education are documented.
q 4. The hospital establishes and implements administrative and engineering controls for the laser and
optical radiation safety program to promote safety and prevent injury for patients and staff.
q 5. Personal protective equipment appropriate to the type of lasers and optical radiation devices and type
of procedures is available for staff and patients, and staff use it correctly and ensure that patients are
protected during procedures.
q 6. The hospital has processes for inspection, testing, and maintenance of lasers and optical radiation
devices, including routine calibration and alignment checks of lasers, and these activities are per-
formed by qualified and trained individuals.

Measurable Elements of COP.4.1

q 1. The laser safety and optical radiation program is part of the hospital’s facility management and safety
structure and provides reports to the facility management and safety structure at least annually and
when any safety events occur.
q 2. The laser safety and optical radiation program is part of the hospital’s infection prevention and con-
trol program and provides reports to the infection prevention and control program at least annually
and when any infection control events occur.
q 3. When adverse events result from the use of lasers and/or optical radiation devices, the adverse events
are reported, and action plans are identified and implemented to prevent recurrence.

Food and Nutrition Therapy

Standard COP.5
A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical
care, is available.

Intent of COP.5
Appropriate food and nutrition are important to patients’ well-being and recovery. Food choices take into
consideration the patient’s age, cultural and dietary preferences, and planned care, which may include special
dietary needs such as low cholesterol, diabetic diet, and clear liquids, depending on the patient’s diagnosis.
Based on the patient’s assessed needs and plan of care, the patient’s physician or other qualified caregiver orders
food or other nutrients for the patient. (Also see AOP.1.4)
The patient participates in planning and selecting foods. When possible, patients are offered a variety of food
choices consistent with their nutritional status. The patient’s family may, when appropriate, participate in
providing food, consistent with cultural, religious, and other traditions and practices and compatible with the
patient’s diagnosis. When the patient’s family or others provide food to the patient, they are educated about
foods that are contraindicated according to the patient’s care needs and plans, including information about

121