CYNET_SYSTEMS_MAIN_LOGO.gif   PATIENT SAFETY SPECIALIST CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) PATIENT SAFETY CULTURE 1 2 3 4  
Identification of positive patient safety culture  
Identification of safety culture needing improvement  
Assist in targeted surveys within the organization  
Assist in interpreting culture survey results  
Knowledge of Near-miss reporting  
Rating Stars (Click) LEADERSHIP 1 2 3 4  
Awareness of Organizational mission, vision, values, and goals  
Rating Stars (Click) Collaborate with the following key stakeholders: 1 2 3 4  
Executives  
Managers  
Clinicians  
Regulatory agencies  
Governing bodies  
Frontline staff  
Patients and their caregivers  
Develop improve patient safety operational plan  
Foster transparent communication throughout the organization  
Embed accountability into investigations and system improvement  
Demonstrate ability to influence decision makers in patient safety initiatives.  
Holds Certification on CPHQ, CPHRM, or Patient Safety  
Rating Stars (Click) RISK IDENTIFICATION & SOLUTIONS 1 2 3 4  
Implement a systematic approach to respond to data sources such as
safety alerts, product recalls, industry alerts) 		 
Develop a mechanism to report identified risks  
Perform activities to identify gaps and risks such as FMEA, walk-around  
Review events and near-miss reports  
Perform Root Cause Analysis (RCA)  
Rating Stars (Click) Evaluate evidence-based best practices: 1 2 3 4  
Bundles  
Checklists  
Communication techniques  
Simulation  
Training  
IT and patient safety events  
Medication safety such as barcoding, pharmacy robots, smart pumps  
Rating Stars (Click) MEASUREMENT & IMPROVEMENT 1 2 3 4  
Knowledge of the current Joint Commission standards  
Knowledge of Joint Commission survey process  
Knowledge of performance improvement  
Identify quantitative patient safety data sources.  
Develop credible internal and external event reports  
Patient feedback, patient and family advisory council)  
Collect, analyze and interpret patient safety data  
Present results of data analyses to decision makers  
Select improvement methodology  
Apply improvement methodologies  
Promote measurably improved processes  
Employ project management skills  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click)  Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)