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.

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