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Patient Safety

Dignity Health has a number of patient safety initiatives in process. Patient safety is an integral part of our operations, and we're proud of our efforts.


Our Greater Sacramento Service Area hospitals, Mercy General Hospital, Mercy Hospital of Folsom, Mercy San Juan Medical Center, Methodist Hospital of Sacramento, Sierra Nevada Memorial Hospital and Woodland Healthcare, all work to identify and enhance patient safety efforts. You, as the patient, also play a vital role in making your care safe by becoming an active, involved and informed member of your care.


  • We encourage you and your family to be involved in your care and your treatment decisions.

  • Let us know if you have questions about your care.

  • There are no wrong or bad questions.

  • If you are scheduled for surgery, you will receive instructions for antimicrobial showers or wipes to be done at home the night before and the morning of surgery. This process reduces the amount of bacteria on your body.

  • You may receive safety instructions while in the hospital.


  • You have the right to conduct health care discussions in your preferred language.

  • Please let staff know if you prefer to conduct health care discussions in a language other than English, and a translator will be provided at no cost.

Patient Rights

At Dignity Health facilities, each patient is entitled to compassionate and professionally competent care delivered with respect for individual dignity. All personnel must comply with the following rights of patients:


  1. Considerate and respectful care, and to be made comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences.

  2. Have a family member (or other representative of your choosing) and your own physician notified promptly of your admission to the hospital.

  3. Know the name of the licensed health care practitioner acting within the scope of his or her professional licensure, who has primary responsibility for coordinating your care, and the names and professional relationships of physicians and nonphysicians who will see you.

  4. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.

  5. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or nontreatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.

  6. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of members of the medical staff, to the extent permitted by law.

  7. Be advised if the hospital/licensed health care practitioner acting within the scope of his or her professional licensure proposes to engage in or perform human experimentation affecting your care or treatment. You have the right to refuse to participate in such research projects.

  8. Reasonable responses to any reasonable requests made for service.

  9. Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. You may request or reject the use of any or all modalities to relieve pain, including opiate medication, if you suffer from severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform you that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates.

  10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf.

  11. Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms.

  12. Confidential treatment of all communications and records pertaining to your care and stay in the hospital. You will receive a separate “Notice of Privacy Practices” that explains your privacy rights in detail and how we may use and disclose your protected health information.

  13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse.

  14. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff.

  15. Reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care.

  16. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from the hospital. You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also.

  17. Know which hospital rules and policies apply to your conduct while a patient.

  18. Designate visitors of your choosing, if you have decision-making capacity, whether or not the visitor is related by blood or marriage, unless:

    • No visitors are allowed.
    • The facility reasonably determines that the presence of a particular visitor would endanger the health or safety of a patient, a member of the health facility staff or other visitor to the health facility, or would significantly disrupt the operations of the facility.
    • You have told the health facility staff that you no longer want a particular person to visit. However, a health facility may establish reasonable restrictions upon visitation, including restrictions upon the hours of visitation and number of visitors.
    • The health facility must inform you (or your support person, where appropriate) of your visitation rights, including any clinical restrictions or limitations. The health facility is not permitted to restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

  19. Have your wishes considered, if you lack decision-making capacity, for the purposes of determining who may visit. The method of that consideration will comply with federal law and be disclosed in the hospital policy on visitation. At a minimum, the hospital shall include any persons living in your household and any support person pursuant to federal law.

  20. Examine and receive an explanation of the hospital’s bill regardless of the source of payment.

  21. Exercise these rights without regard to sex, race, color, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, educational background, economic status or the source of payment for care.

  22. File a grievance. If you want to file a grievance with this hospital, you may do so by writing or by calling:
    Quality, Risk, Safety and Customer Services
    Mercy San Juan Medical Center Quality Management
    6501 Coyle Avenue
    Carmichael, CA 95608
    (916) 537-5240
    The grievance committee will review each grievance and provide you with a written response within seven days. The written response will contain the name of a person to contact at the hospital, the steps taken to investigate the grievance, the results of the grievance process and the date of completion of the grievance process. Concerns regarding quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Control Peer Review Organization (PRO).

  23. File a complaint with the state Department of Health Services regardless of whether you use the hospital’s grievance process.
    California Department of Public Health
    Licensing and Certification Program
    Sacramento District Office
    3901 Lennane Drive, Suite 210
    Sacramento, CA 95843
    (916) 263-5800 or (800) 554-0354
    Fax: 916.263.5840

  24. Contact The Joint Commission if concerns about patient care and safety cannot be resolved by the complaint/grievance
    process at the hospital.
    The Joint Commission
    One Renaissance Boulevard
    Oakbrook Terrace, IL 60181
    (630) 792-5000

    Patients with concerns related to doctors may share their issues with the Medical Board of California, Central Complaint Unit, at (800) 633-2322. Health and Safety Code Sections 1262.6, 1288.4, and 124960; and 42 C.F.R. Section 482.13 (Medicare Conditions of Participation).

  25. If you have been diagnosed with a terminal illness, you have the right to receive comprehensive information and counseling regarding legal end-of-life options from your provider.

Children/Adolescent Rights:

Your child or adolescent has the right to …

  • Respect as a unique individual.
  • Respect of the care-taking role and individual response of their parent(s).
  • Normal physical and physiological needs including: nutrition, rest, sleep, warmth, activity and freedom to move and explore.
  • Consistent, supportive and nurturing care which:
  1. Meets their emotional and psychosocial needs;
  2. Fosters open communication;
  3. Encourages human relationships.
  • Self-esteem needs which will be met by attempts to give your child:
  1. The reassuring presence of a caring person, especially a parent;
  2. Freedom to express feelings or fears with appropriate reactions;
  3. As much control as possible, over both self and situation;
  4. Opportunities to work through an experience before and after they occur, verbally, in play, or in other appropriate ways;
  5. Recognition and reward for coping well during difficult situations
  • Varied and normal stimuli of life, which contributes to cognitive, social, emotional and physical developmental, needs – play, educational and social activities essential to all children and adolescents.
  • Information about what to expect prior to, during and following a procedure or experience and support in coping with it.
  • Participate, in addition to their family, in decisions affecting their own medical treatment.
  • Minimization of hospital stay duration by recognizing discharge planning needs.

Patient Responsibilities:

Your general responsibilities are:

  • Providing, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health.
  • Reporting unexpected changes in your condition to the responsible practitioner.
  • Asking questions when you do not understand what you have been told about your care or what you are expected to do.
  • Cooperating in the treatment program developed with your doctor or other caregivers. You should express any concerns you have about your ability to follow the proposed course of treatment.
  • Accepting the consequences of refusing treatment, failing to follow the recommended course of treatment or using other treatments.
  • Notifying appropriate persons in the institution of those situations where, in your opinion, your rights are not being respected.
  • Respecting the rights of other patients who are also receiving treatment in the facility.
  • Assuring that the financial obligations of your health care are fulfilled as promptly as possible.
  • Following hospital rules and regulations affecting patient care and conduct, including those related to visiting, smoking, discharge time and the care of valuables.

Spiritual Care Program

  • The Spiritual Services Department provides support for patients and families.
  • Chaplains are skilled at helping patients and families identify and use their spiritual resources, regardless of their faith tradition.
  • Each facility has a chapel. In addition, Mercy San Juan Medical Center has a healing garden located just off the McAuley lobby, Mercy General Hospital has a chapel and healing garden that is open to the public in between the historic part of the hospital and the Alex G. Spanos Heart & Vascular Center and Mercy Hospital of Folsom’s chapel is located on the main floor of the hospital.
  • Dignity Health is a not-for-profit organization, rooted in the Catholic tradition, but is not an official ministry of the Catholic Church. Mercy General Hospital, Mercy Hospital of Folsom and Mercy San Juan Medical Center are all Catholic Healthcare Ministries.

National Patient Safety Goals

  • National Patient Safety Goals (NPSG) are defined by The Joint Commission.
  • Consistent implementation of the NPSGs are a core component of the Patient Safety Programs at Mercy General Hospital, Mercy Hospital of Folsom, Mercy San Juan Medical Center and Methodist Hospital of Sacramento.
  • Internal monitoring of compliance shows high level of adoption and ongoing compliance.

Executive Rounding and Hazard Surveillance

  • Leaders round in patient care departments Monday through Friday.
  • Rounding allows leaders to talk with front-line staff and patients and helps identify safety issues.
  • Following daily rounding, leaders meet together to discuss what was learned and assign accountability for addressing any issues identified.
  • Leader rounding also supports a culture of caring and safety.

Families and Visitors

  • All hospitalized patients have the right to have visitors of their choice during their stay, unless visitation interferes with the well-being, rights or safety of others, or is not medically indicated in the patient’s care.
  • Families/ partners in care are welcome 24 hours a day according to patient preference. Due to nature of the labor and delivery process, the number of families/Partners in Care is limited to four (4).
  • Visitation privileges will not be denied based on race, religion, ethnicity, language, culture, size, gender, sexual orientation, gender identity or expression, socioeconomic status, physical or mental ability or disability.
  • Families/partners in care enjoy full and equal visitation privileges consistent with patient preferences.
  • Visitation may be modified or restricted for patient preference, treatment priorities or patient safety.
  • We use the term family to mean, any person(s) who plays a significant role in an individual’s life. This may include a person(s) not legally related to the individual. Members of “family” include spouses, domestic partners, partners in civil union and both different-sex and same-sex significant others. “Family” includes a minor patient’s parents, regardless of the gender of either parent. Solely for purposes of visitation policy, the concept of parenthood is to be liberally construed without limitation as encompassing legal parents, foster parents, same-sex parent, step-parents, those serving in loco parentis, and other persons operating in caretaker roles.

Influenza and Pneumonia Vaccination Programs

  • Patients are screened for seasonal influenza vaccination during each admission during between October and March.
  • Patients are screened for pneumonia vaccinations during each admission, year round.
  • Each year employees, physicians, students, contractors and volunteers are required to participate in our influenza vaccination program. Flu vaccines are provided free of charge.
  • The 2015/2016 participation rate was over 95%.


  • In spite of our best efforts to serve, sometimes a patient or family member may become dissatisfied. Our staff are trained to take a five step approach when addressing challenging situations:
    • Hear the concern
    • Empathize with the way the person is feeling
    • Apologize for the experience the person is having
    • Respond with action to the problem
    • Thank the person for giving you an opportunity to make things right
  • While the focus is on meeting your medical and nursing care needs, we are committed to also addressing how you feel about your care experience.

Electronic Medical Record and Patient Portal

  • We use a Cerner Electronic Health Record (EHR). The EHR was implemented in 2009.
  • Use of the EHR makes compliance with national standards including the National Patient Safety Goals easier and improves clinical reliability.
  • My Care - Dignity Health is a convenient and secure platform that will allow you to view your personal health records, clinical summaries and laboratory results. You can also schedule appointments through the patient portal.
  • Access My Care - Dignity Health at and look for My Care.

Medication Safety

  • Computerized physician order entry (CPOE) is in most areas of our hospitals.
  • Nearly 80% of all medication orders entered use CPOE.
  • Active interdisciplinary Medication Safety Team are focused on reducing medication errors and improving medication safety processes.

Staffing Effectiveness

  • Critical Care
    • All ICU patients are managed or co-managed by one or more physicians who are certified in critical care medicine.
    • When physicians are not present or available by telemedicine, telephone calls/pages are returned 95% of the time
    • Mercy General Hospital has 48 critical care beds at 48, Mercy San Juan Medical Center has 56 and Mercy Hospital of Folsom has 8.
  • Nursing
    • Comply with State Regulations for nurse staffing
    • Staffing adjusted based on patient acuity
    • Met or exceeded safe staffing targets per the ratio law in California.


    • Actively recruit qualified nursing personnel
    • Clinical site for several pre-licensure and graduate nursing program

Infection Control and Fall Prevention

  • Active flu immunization program.
  • Greater than 90% participation rate in 2015/2016.
  • Active surveillance and team planning to reduce surgical site and other infections (link to instructions for CHG skin prep and home and other information)
  • Fall prevention program including rigorous and ongoing evaluation of fall risk and fall mats for every patient room.

Perinatal Safety

  • Dedicated provider group of neonatal specialists at Mercy San Juan Medical Center and Methodist Hospital.
  • 100% of physicians and full-time nursing staff have completed APS modules at Mercy San Juan Medical Center.
  • Level III Neonatal Intensive Care Unit at Mercy San Juan Medical Center and a Level II NICU at Methodist Hospital
  • Key favorable VON data at both Mercy San Juan Medical Center and Methodist Hospital
  • Ventilator Associated Pneumonia rate is zero at both Mercy San Juan Medical Center and Methodist Hospital

Patient Advisory Council

  • Organized around service lines.
  • Serves as an advisory resource to administration and staff.
  • Provides a venue for patients and families to provide input into program development.
  • Results in more efficient planning to ensure that services really meet patient/family needs and priorities.
  • Serves a forum for hearing the voice of the patient.