Can JCAHO Patient Safety Goals Have An Impact?

By Steven Chinn, DPM, MS

Everyone dreads the potential experience of making a mistake that affects patient care. However, the complexity of healthcare lends itself to these situations. Caring for patients requires a series of interconnecting steps in order to produce the desired outcome. As physicians and surgeons try to minimize the variables that arise, there are still factors, some of which we are accountable for and some not, that can add up to a bad clinical outcome. Many states have regulations that require licensed healthcare facilities, such as hospitals and nursing homes, to report any unusual patient care problems to the state licensing agency. State health inspectors would follow up with a facility to see that the facility puts corrective actions in place to remedy or prevent such an incident from occurring again. Licensed facilities would work with the state health departments to develop an acceptable plan. Unfortunately, these mistakes and subsequent correction actions typically occur in isolation. In most cases, the desire to avoid negative publicity results in the lack of disclosing or sharing this information within a facility or health system. (The exceptions are situations that are broadcast by the media.) Unfortunately, these mistakes and corrective action(s) are not shared with other facilities. Reviewing The Evolution Of Patient Safety Goals In 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) initiated the concept of “sentinel events,” which are adverse, patient care-related outcomes that could cause permanent disability or death. The list included such things as blood transfusion reaction, wrong site-wrong side-wrong patient surgery, infant abduction, assault and serious medication errors. The focus was twofold. JCAHO-accredited organizations would internally report these issues and determine the causative factors that led to the event. This is when organizations should conduct a root cause analysis (RCA), which identifies and determines the reasons that contributed or potentially could have contributed to the incident. This was the first coordinated step in health care to address the issue of patient safety and quality of care, but only JCAHO-accredited organizations were publicly mandated to address medical errors. In 1999, the Institute of Medicine (IOM) issued a report that projected medical errors lead to approximately 98,000 deaths per year and the IOM deemed that most of these errors were preventable. Given the publicity associated with this report, the healthcare industry responded with a variety of initiatives that strongly encourages healthcare organizations to ensure they reduce medical errors, if not eliminate them all together. After this report, the Leapfrog Group and the National Quality Forum issued guidelines on how to prevent medical errors. JCAHO collected sentinel events data from facilities and organizations that have voluntarily reported and have developed recommendations to help facilities prevent these types of incidents in the future. Over the years, JCAHO has issued various alerts and bulletins that have brought attention to various practices and solutions that have essentially become standard in the country. Examples of this include the evaluation of adverse outcomes attributed to delays in treatment and strategies to prevent fires in the surgical suite. A Look At The JCAHO 2004 National Patient Safety Goals Since the beginning of 2003, JCAHO-accredited organizations had to adhere to requirements for JCAHO’s National Patient Safety Goals. Earlier this year, JCAHO added a seventh requirement. 1. Improve the accuracy of patient identification. Use at least two patient identifiers (not the patient’s room number) whenever taking blood samples or administering medications or blood products. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a “time out,” to confirm the correct patient, procedure and site, using active communication techniques. 2. Improve communication between providers. Implement a process for taking verbal or telephone orders or critical test results that requires a verification “read-back” of the complete order or test result by the person receiving the order or test result. Standardize the abbreviations, acronyms and symbols used throughout the organization. This should include a list of abbreviations, acronyms and symbols not to use. 3. Improve the safety of using high-alert medications. Remove concentrated electrolytes (including but not limited to potassium chloride, potassium phosphate and sodium chloride >0.9%) from patient care units. Standardize and limit the number of drug concentrations available in the organization. 4. Eliminate wrong site, wrong patient and wrong procedure surgery. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. Implement a process to mark the surgical site and involve the patient in the marking process. 5. Improve the safety of using infusion pumps. Ensure free-flow protection on all general use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization. 6. Improve the effectiveness of clinical alarm systems. Implement regular preventive maintenance and testing of alarm systems. Ensure alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit. 7. Reduce the risk of health care-associated infections. Comply with current hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC). Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection. What Will The Guidelines Require In 2005? In addition to the current rules, the JCAHO has mandated the following new goals and requirements for 2005: • Improve the effectiveness of communication among caregivers. Measure, assess and if appropriate, improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical test results and values. • Improve the safety of using medications. Identify and annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. • Accurately and completely reconcile medications across the continuum of care. By 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes comparing the medications the organization provides to those on the list. Physicians/facilities would communicate the complete list of the patient’s medications to the next provider of service when they refer or transfer a patient to another setting, service, practitioner or level of care in or outside the organization. • Reduce the risk of patient harm resulting from falls. Assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen. Take the necessary action to address any identified risks. How Will The JCAHO Guidelines Affect Daily Operations? Compliance with the National Patient Safety Goals will affect day-to-day hospital operations. JCAHO has done extensive education of the public as well as with different healthcare groups, such as the Veterans Administration, Leapfrog Group, Institute for Healthcare Improvement and the National Quality Forum, in order to teach patients what to watch out for and what to ask their doctors and other providers. As a result, patients are better educated and are asking more questions about their care. With almost 18,000 JCAHO-accredited facilities across the country that must comply with the National Patient Safety Goals, there is less chance that one hospital or one ambulatory surgery center does not comply with these requirements. JCAHO wants these goals to establish the expectation in all of its accredited organizations. Here are some of the relevant things that you may be asked to comply with at the facilities at which you practice. 1. Avoid using certain abbreviations for documentation in the medical records. (See “Why You Should Avoid These Abbreviations, Acronyms And Symbols” and “Other Abbreviations That Could Be Misinterpreted” below.) Some of these abbreviations have been in use for years, including qd for daily, qid for four times a day and MS for morphine sulfate. One podiatrist checked on his patient, who was nowhere to be found. The nurses told the doctor he discharged the patient while the doctor said he had not. “D/C PT” was written as clear as a bell in the physician’s order form. He wanted to discontinue the physical therapy. 2. Follow a pre-procedure checklist and protocol that will verify the location, laterality and the actual patient prior to an invasive procedure. The intent is to prevent surgeons from operating on the wrong foot or ankle. How many times have surgeons explored the wrong intermetatarsal space for a neuroma? 3. Staff should take an extra minute to make sure two patient identifiers are used when performing procedures, giving medications or blood products, taking lab specimens, or providing treatments, such as physical therapy, to the patient. Keep in mind that one of the identifiers cannot be the patient’s room or bed number. A group of patients at a nursing home lined up outside the exam room waiting to see the doctor. After a while, he was done and went back to his office. Later that afternoon, the nursing home administrator called him, asking him if he was coming in to see the patients. The doctor said he did. They were still waiting for him in front of the exam room. The doctor didn’t ask patients for their names to make sure he had the right patients. 4. Practice the CDC guidelines for hand hygiene, which recommends hand washing before and after patient care. Hand washing has been identified as the number one way to control infections. Alcohol-gel based hand scrub solutions are acceptable and need to be available to everyone who has patient care duties. 5. When providing a verbal or telephone order, get a confirmatory “read back” of that order to make sure they heard it right. Nurses provide care according to your orders. At 2 a.m., are you sure the nurse got your instructions exactly right? Are you sure you gave that order correctly? Wait on the phone for the nurse to read back exactly what he or she wrote down. 6. You may be asked to evaluate the timeliness of reporting and timeliness of receipt by the responsible licensed caregiver of critical test results and values. There have been many adverse patient outcomes across the country because the right doctor did not get the lab results in a timely fashion. This could be problematic for you and your patient if you did not get aminoglycoside peaks and troughs results or if you did not get CT or MRI results in a timely fashion. 7. Document a complete list of medications that a patient may be on at the time of admission and communicate the list to all healthcare providers involved in the care of the patient. This further enhances the value of summary or problem lists that should include current medications, allergies and sensitivities, hospitalizations and current medical conditions. 8. Your facility may want to reduce the number of different drug concentrations to comply with the National Patient Safety Goals. Many medication errors occur because the facility had several concentrations of drugs to choose from. You may not be stocking the lidocaine with epinephrine in as many different concentrations as in the past because of this. 9. Re-evaluate how look-alike and sound-alike drugs are used and stored in your facility. The classic story is the Celexa® and the Celebrex® stored in a sample drug room side by side. When the wrong drug is given to the wrong patient, you either have the depressed patient who has no joint pain or the arthritic patient who is really hurting, but very happy. 10. New safety features on PCA pumps may prevent the pump from free flowing narcotics if the device malfunctions or is turned off. Also be aware tubing in some of these systems is not interchangeable with different sizes. This can potentially negate the safety feature. In Summary Given all of the different facets and processes involved in healthcare, breakdowns can occur anywhere along the way. When they do, it can be potentially catastrophic to both the patients and their caregivers. The primary purpose of the JCAHO’s National Patient Safety Goals is to prevent these types of patient injuries from occurring. Consider it a proactive insurance program. Rather than waiting for something bad to happen, you can participate in stopping or preventing it before it does. That is what the staff at the hospitals, surgery centers, clinics and nursing homes are being trained to do. With the media focused on anything that will create exposure, the last thing you want is bunch of reporters hanging out in the office’s parking lot. Compliance with programs such as JCAHO’s National Patient Safety Goals will help reduce the risk of patients suffering bad clinical outcomes. It will also help with your own personal risk reduction program. However, the most important thing is it can help prevent that situation when you have to explain to a patient, “I’m sorry to tell you this, but there was a terrible mistake ... .” Dr. Chinn is a consultant for several healthcare organizations in the United States, including academic health centers, government facilities and community hospitals. He is a certified healthcare executive, a certified professional in healthcare risk management and certified professional in healthcare quality. He is also CEO of Apex Healthcare Consulting Group, Millbrae, Calif. He can be reached at (650) 652-7943 or

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