Sparta Community Hospital aims to strengthen our culture of safety by promoting transparency and accountability throughout the organization. One way we accomplish this is by developing a monthly Safety Scorecard that tracks key metrics for both patient and workforce safety. These results are made available on our website. By monitoring our progress monthly, we can evaluate the effectiveness of our safety plan and continuously improve outcomes for our patients and staff.
Employee/Patient Safety
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Safety Events | 0 | 0 | 1 | |||||||||
| Patient Falls | 6 | 7 | 6 | |||||||||
| Employee Falls | 2 | 0 | 0 | |||||||||
| Employee Injuries | 2 | 1 | 1 | |||||||||
| Total Unlabeled/Mislabeled Specimens (Goal 0) | 2 | 2 | 3 | |||||||||
| Lab Collected (Goal 0) | 0 | 0 | 2 | |||||||||
| Non-Lab Collected (Goal 0) | 2 | 2 | 1 | |||||||||
| Med Errors Hospital (reached patient) | 1 | 2 | 0 | |||||||||
| Med Errors Clinic (reached patient) | 1 | 0 | 0 | |||||||||
| Blood Culture Contamination Rate (Goal ≤2%) | 7.70% | |||||||||||
| Employee Exposures | 0 | 0 | 0 | |||||||||
| DI Retakes | 1 | 1 | 1 | |||||||||
| Clinic Chart Completion % Within 2 Business Days (Goal ≥ 86%) | 91.2 | 91.3 | ||||||||||
| Unplanned Downtime | 0 | 0 | 0 | |||||||||
| Incident Reports | 90 | 103 | 83 | |||||||||
| Handwashing Compliance | 100 | 100 | 100 | |||||||||
| Hazardous Surveillance Rounds | ||||||||||||
| Patient Areas – Semi Annual | ||||||||||||
| Non-Patient Care-Annual |
Emergency Management
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Drills (2/year) | 0 | 0 | 1 | |||||||||
| Actual Events | 1 | 0 | 0 | |||||||||
| HOPE Coalition Meetings | 1 | 1 | 1 | |||||||||
Security Management
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Security Incidents | 1 | |||||||||||
| 911 Calls | 4 | 1 | 1 | |||||||||
| Panic Button Activations | 0 | 0 | 1 |
Life Safety
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Fire Drills (Goal 3/quarter) | 1 | 1 | 1 | |||||||||
| ILSM Events | 0 | 0 | 0 | |||||||||
| Life Safety PM | ||||||||||||
| Extinguishers (Monthly) | 1 | 1 | 1 | |||||||||
| Exit Signs (Monthly) | 1 | 1 | 1 | |||||||||
| Annual Door Inspection |
Hazardous Materials
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Spills | 0 | 0 | 0 | |||||||||
| Cleaner List |
Utility Management
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Failures (Greater than 4 hours) | 0 | 0 | 0 | |||||||||
| Generator Testing | ||||||||||||
| Weekly | 4 | 4 | 4 | |||||||||
| Monthly | 1 | 1 | 1 | |||||||||
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| ATS | 1 | 7 | 7 | |||||||||
| Water Management Plan (QTR) |
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Medical Equipment Management
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
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| Monthly Reports Received | x | x | x | |||||||||
| Semi-Annual ESI |
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| Annual ESI Clinics |
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| Recalls | 1 | 2 | 1 |
Risk
| January 2025 | February 2025 | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 | August 2025 | September 2025 | October 2025 | November 2025 | December 2025 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ED LWBS Pre-Screen (Goal ≤2%) | 0% | 0.35% | 0.001704 | |||||||||
| MedSurg Fall Risk Screening (Goal 100%) | 94% | 100% | 97% | |||||||||
| Surgery Safety Checklists (Goal 100%) | 100% | 99% | 100% | |||||||||
| EMR Potential Patient Safety Situations |
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