How We Are Keeping You Safe

Our goal at Memorial Healthcare System is to achieve the highest level of quality and safe care for those we serve. Through our Mission and Vision, Quality and Safety are core values that are embedded into our culture and daily operations. Staff undergo extensive training, and comprehensive safety policies and standard operating procedures are in place. Caregivers as well as patients are encouraged to speak up regarding safety concerns. Quality and safety data are tracked and trended and changes are implemented as needed to improve patient outcomes. We are committed to a culture of safety and have implemented evidence based practices to decrease patient harm.

Patient Identification – clinicians will ask the patient or family member the patient’s name and date of birth and check the identification bracelet before administering care.

Surgery and Procedure Safety – a safety checklist is used to prevent serious safety events before every procedure we perform in the operating room, procedural area, and at the bedside.

Pause for the Cause – immediately prior to the start of the procedure, the surgical team will pause and verbally confirm your identification, procedure, correct side/site, allergies, and any other information regarding your procedure.

Crew Resource Management – Memorial Healthcare System uses a safety initiative that is patterned after those used in commercial aviation that combines teamwork, communication and skills with tools such as checklists and handoffs to improve and enhance quality and safety.

Infection Prevention – MHS has a dedicated department for healthcare epidemiology and infection prevention. To prevent the spread of communicable diseases, the specialized Infection Preventionists perform comprehensive surveillance and implement evidence based interventions with all staff including physicians. Ongoing surveillance, analysis, performance improvement and education for preventing infections has been shown to reduce the frequency of events.

Hand Hygiene – handwashing and using alcohol based hand sanitizer are the most important ways to stop the spread of germs in healthcare settings. Hand hygiene is our number one priority at MHS to prevent healthcare associated infections and our dedication is evident in our policy, training of all staff, and how we monitor the hand hygiene compliance using trained observers.

Medication Verification Process – before giving a medication the nurse will check your identification bracelet and ask your name and date of birth. The medical team will make sure that you know the name of any new medication along with the possible side effects. You will be given a list of your medications daily for your review.

Falls – falls are a serious safety concern and may contribute to severe injuries. All patients are evaluated for risk of falling and this is communicated to the multidisciplinary team. The staff perform hourly rounding to provide assistance as needed. MHS facilities have Fall Prevention task forces in place where thorough reviews of all patient falls take place. Fall prevention strategies are in place and patients and family members are educated and encouraged to participate in our fall prevention strategies.

Pressure ulcers – Pressure injuries or bedsores are wounds that may occur when an individual is unable to reposition themselves frequently. MHS has a wound care teams with certified wound care nurse specialists dedicated to keeping patient’s skin safe while in the hospital. The members of the wound care team collaborate with the nursing teams to prevent and treat pressure injuries. Patient’s skin is assessed to determine risk for breakdown and patients are assisted with repositioning. Additionally, we utilize special beds, turning equipment, skin creams, rounding and other technologies to ensure that skin health is maintained.

Elopement – we have procedures in place to protect our patients who are at a risk of elopement in the event that they wander off of their assigned nursing unit and into the public areas of the hospital.

Safe Medical Devices – all staff members are responsible for ensuring that equipment is working properly. If a piece of equipment does not function properly, the equipment is taken out of service.

Magnetic Resonance Imaging (MRI) Safety – MRI works with a powerful magnetic force and will pull any metal object to it, very rapidly and with extreme force. The following safeguards have been put into place to ensure the safety of our patients; the department is color coded in separate MRI safety zones, the MRI zones are restricted areas all patients are pre-screened for MRI safety and then reviewed again by a second MRI technologist, patients are visually monitored with cameras while in the scanner, and the MRI staff uses detection equipment to screen for metals.

There are multiple organizations that publish quality and safety data related to healthcare. When making healthcare decisions it is important to get information from trusted resources. Memorial Healthcare System supports the efforts to make quality and safety data available to the public.

  1. AHCA – in the State of Florida, the Agency for Healthcare Administration (AHCA) provides information to consumers related to healthcare. Their consumer website includes performance data and information on selected medical conditions, hospital-acquired infections and patient satisfaction
  2. The Joint Commission – founded in 1951 and is an independent non-profit organization and is a recognized global leader for healthcare accreditation that offers an unbiased assessment of quality achievement in patient care and safety. Memorial Healthcare System facilities are accredited by The Joint Commission and adheres to their standards. The Joint Commission has developed Hospital National Patient Safety Goals to improve patient safety. Memorial Healthcare System has adopted and implemented the Hospital National Patient Safety Goals.
  3. Hospital Compare – is a consumer-oriented website developed by the Centers for Medicare & Medicaid Services that provides information on the quality of care, value of care, and patient experience provided at individual hospitals. Learn more
  4. The Leapfrog Group – is a non-profit organization that collects, analyzes and publishes data on safety and quality. There are 2 methods used to publicly report hospital data; Leapfrog Hospital Survey and the Hospital Safety Grade. Learn more at The Leapfrog Group and

Report a Patient Safety Concern or File a Complaint

Patients have the right to express concerns or complaints, verbally or in writing, about any aspect of patient care or safety.

The complaint may be directed to the attending healthcare professional, or the manager or department leader of the Hospital. The action will not result in retaliation or barriers to patient care. The Hospital will attempt to resolve your complaint to your satisfaction as soon as possible. If we cannot promptly resolve your complaint, we will consider it a grievance, and respond according to our grievance policy.

Patients have the right to express grievances to the appropriate licensing agency. 

If you have a complaint against a hospital or ambulatory surgical center:
Call the Consumer Assistance Unit at 1-888-419-3456 or write to: Agency for Health Care Administration, Consumer Assistance Unit, 2727 Mahan Drive/Bldg. 1, Tallahassee, Florida 32308.

If you have a complaint against a health care professional and want to receive a complaint form: 
Call the Consumer Service Unit at 1-888-419-3456 or write to: Agency for Health Care Administration, Consumer Services Unit, P.O. Box 14000, Tallahassee, Florida 32317-4000. 

Joint Commission Notice

Memorial Healthcare System facilities are accredited by The Joint Commission and adheres to their standards. If you would like to contact the Joint Commission to express patient safety concerns:

Go to and choose  "Report a Patient Safety Event" .
By Phone: (800) 994-6610
By Email:
By Maill:
Office of Quality and Patient Safety
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

Please be aware that The Joint Commission does not evaluate the care of an individual, or whether that care was appropriate. Instead, their evaluation focuses  performance of the organization based on Joint Commission established standards of care.

Daughter learning how to assist her mother during a Family In Training (FIT) Program session at Memorial Regional South.

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