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5-Diamond Patient Safety Program Application

Five diamond logo

Please complete the application below. Participants must complete the Patient Safety Principles module first, however once completed, you may complete other modules in any order. We encourage you to submit your outcomes upon completion of each individual activity. If you have any questions, please contact us by email at 5diamondsafety@nw11.esrd.net or by phone at 651-644-9877.

Applicant Information

Facility Information
Facility Name
CMS Provider Number
NPI#
# of Staff
Participating
Project Contact at Facility
Name
Title
Email
Phone
Selected Modules

Check all that apply.
 Patient Safety Principles (required)
Communication
Constant Site Cannulation
 Decreasing Patient Provider Conflict
 Emergency Preparedness
 Hand Hygiene (Infection Control)
 Health Literacy
 Missed Treatments
 Patient Self-Managed Care
 Sharps Safety
 Slips, Trips, and Falls
 Influenza Vaccination
 Medication Reconciliation
 Stenosis Monitoring
 Transplantation