Secondary Logo

Journal Logo

Improving medical/surgical practice with JCAHO's 2005 National Patient Safety Goals

Salyer, Regina RN, CCRN, BSN


Follow this advice to comply with guidelines and keep your patients safe.

Follow new guidelines to keep your patients safe.

Last accessed on August 2, 2005.

BY NOW, YOU'VE probably heard about the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO's) 2005 National Patient Safety Goals (NPSGs). In development and revised yearly since 2002, the goals “highlight problematic areas in health care and describe evidence- and expert-based solutions to these problems.” They focus on systemwide solutions to deliver safe, high-quality health care. In this article, I'll review the NPSGs related to medical/surgical nursing practice and discuss what steps our facility has taken to comply.

We started a patient-safety team in our facility, which has dramatically improved communication about patient safety and the NPSGs. The team of nurses and other staff from all areas of the hospital focuses on patient safety as a shared responsibility. We encourage safety awareness and nonpunitive reporting of errors. The team has learned to be proactive and to feel comfortable talking about errors, concerns, and suggestions. Then they pass what they've learned on to their co-workers.

The 2005 Hospitals' and Critical Access to Hospitals' NPSGs are identical lists that apply to medical/surgical nursing. The goals and requirements are as follows:

  • Improve the accuracy of patient identification. According to the JCAHO, you must use at least two patient identifiers whenever you administer medications or blood products, obtain specimens for lab tests, give treatments, or perform procedures. Valid patient identifiers include the patient's full name, Social Security number, address, and medical record number. The patient's room number isn't a valid identifier.
  • At our facility, all health care personnel and medical staff are required to check ID bracelets before every patient interaction. Identification data is laser-printed on easy-to-read stickers and applied to the bracelets. We use the same stickers to label each page of the patient's chart.
  • When a patient is admitted, we confirm with her that the bracelet is accurate before we apply it. We double-check the information by asking her to state her full name, birth date, and the last four digits of her Social Security number. All of these identifiers clearly appear on the bracelet, along with her medical record number.
  • Improve communication among caregivers. When you receive orders or critical test results orally (in person or over the phone), the JCAHO requires that you document the information and then verify it by reading back the entire order or test result. At our facility, lab critical values are both phoned to the nurses' station (with documented “read back”) and printed out at the nurses' station. As soon as critical values are received, the nurse must phone the health care provider for appropriate intervention. Lab results are also entered in the computer system. All lab results are reported out within a period determined by urgency, such as stat or routine.
  • The JCAHO requires each facility to have a standardized list of unacceptable abbreviations, acronyms, and symbols. For example, “u” isn't acceptable for “units” because it can be misread as a zero. These lists of banned shortcuts are posted at all nurses' stations, listed on charts, and circulated by e-mail to hospital staff.
  • Improve medication safety. Concentrated electrolyte solutions, including potassium chloride, potassium phosphate, and sodium chloride (saline > 0.9%), must be removed from patient-care areas. Hospitals are required to standardize concentrations of electrolyte solutions and limit the amounts of these available for clinical use in the unit. They're also required to identify and, at least annually, review a list of look-alike and sound-alike drugs used and take steps to prevent mix-ups.
  • To act on these requirements, our facility has removed all concentrated potassium vials and sodium chloride from the automated medication dispenser in all patient-care units. Drug concentrations have been standardized throughout the hospital. Nurses perform double checks on all high-alert medications (such as heparin, insulin, opioids, and chemotherapeutic drugs) and two nurses co-sign whenever an intravenous (I.V.) infusion is initiated and when the rate is adjusted or an I.V. bag is added or replaced.
  • Our pharmacy has changed the type font on sound-alike and look-alike medication labels to “tall-man lettering” (for instance, DOBUTamine and DOPAmine) to emphasize differences. Look-alike and sound-alike medications are separated in the automated medication dispenser stock in each unit.
  • Improve the safety of infusion pump use. Facilities must guarantee free-flow protection on all I.V. infusion pumps, including patient-controlled analgesia equipment.
  • We examined all I.V. infusion pumps for free-flow capability and replaced free-flow-capable pumps with free-flow-protected pumps. To prevent rate changes from positional I.V. sites, we provide I.V. therapy in the hospital only by pump.
  • Reduce the risk of health-care-associated infections. The JCAHO requires hospitals to follow current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Posters and our Web site remind caregivers to wash their hands for at least 15 seconds after every patient interaction, whether or not they've worn gloves. Alcohol-based hand rubs are available in patient-care areas to clean hands that aren't visibly soiled. Under CDC guidelines, caregivers should wash visibly soiled hands with soap and water.
  • Our facility developed a tracking system to monitor urinary tract infections and bloodstream infections. We investigate these infections and all sentinel events within the hospital, then we implement risk-reduction strategies. (See What's a sentinal event?)
  • Accurately and completely reconcile medications across the continuum of care. This process must be developed during 2005 and fully implemented by January 2006; it involves working with the patient to obtain and document a complete list of his current medications on admission. These medications must then be compared with the medications provided by the hospital. Also, when the patient is referred or transferred, a complete list of medications must be conveyed to the next provider responsible for her care.
  • At our facility, when a patient is admitted, both nurses and physicians must ask the patient (or knowledgeable significant other) for an up-to-date list of all prescription and over-the-counter medications. We document this in the electronic medical record and make the medication list available to all current providers of care by password-protected access to our computerized medication administration system. Transfer forms are used to communicate current medications to providers when we receive patients and when they're transferred to other facilities.
  • Reduce the risk of falls. Assess and periodically reevaluate each patient's risk of falling, including medication-associated risks, then address any risk factors you identify.
  • We use the Morse Fall Scale for all patients on admission, then reassess daily. If the score is 45 or more, we ask for a physical therapy consult and put the patient in our “Falling Star” fall-prevention program. We identify a patient in this program with a special green bracelet and a star that's placed on the outside of her door and on her chart. Preventive measures include a night-light, frequent toileting and checks on the patient, low beds, and bed and chair exit alarms. We make sure call bells and personal items are placed within her reach. These measures have decreased the incidence of patient falls.
  • Understanding the 2005 NPSGs will not only keep you in compliance with JCAHO standards, but you also improve your ability to give top-notch care. Patient safety is everyone's responsibility. By taking a proactive approach, you can ensure continuity of care and protect your patients from avoidable mishaps.

Regina Salyer is the critical care/cardiology nurse-educator in the department of nursing education at the Penn-Presbyterian Medical Center in Philadelphia, Pa.

Back to Top | Article Outline

What's a sentinal event?

A sentinel event is defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

At least two of the following criteria must be met to fulfill the definition of a sentinel event:

  • It resulted in unanticipated death or major permanent loss of function.
  • It's associated with significant deviation from the usual process.
  • It's undermined or has significant potential for undermining public confidence.

Other events that JCAHO considers sentinel include:

  • infant abduction
  • infant discharged to the wrong family
  • rape by another patient or staff
  • hemolytic transfusion reaction
  • surgery on the wrong patient or wrong body part.
Back to Top | Article Outline


.Joint Commission on Accreditation of Healthcare Organizations
    .UPHS Office of Public Affairs News Releases
      © 2005 Lippincott Williams & Wilkins, Inc.