EACH YEAR the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) publishes new goals and requirements for patient safety based on input from its national accreditation surveys and from a national advisory group. (See How do safety goals take shape?)
In this article, I'll focus on goals, standards, and requirements for hospitals. I'll also give you practical tips for incorporating the safety goals into your nursing practice. Stay current on your organization's policies and procedures and check out the latest patient-safety goals on the JCAHO Web site.1
Here are the goals and requirements for 2007 with examples of how you can incorporate them into your nursing practice.
What's new for 2007?
These goals and requirements have been added for 2007:
- A complete list of medications must be provided to the patient on discharge from the facility. This requirement adds to the prior goal of medication reconciliation at each transition in the patient's treatment, such as when he's referred or transferred to another unit or setting, practitioner, or level of care.
- The JCAHO already requires that a list of the patient's home medications be obtained at admission and compared (reconciled) with the patient's ordered medications at admission, transfer within the hospital, and discharge. Such reconciliation helps prevent omissions, duplications, dosing errors, and drug interactions. Be sure to take clear, concise, and complete medication histories and document the history in a way that fosters multidisciplinary collaboration.
- Encourage patients to be actively involved in their own care as a patient-safety strategy. Establish channels for patients and their families to give input on patient-safety issues, then encourage their use. Some hospitals are empowering family members to initiate a rapid response team when the patient's condition is deteriorating. Another strategy you can use is to educate patients on admission about what they can do to reduce wrong-site surgery, fall risk, and hospital-acquired infection.
- Define and communicate the means for patients and their families to report their concerns about safety. Hospitals must encourage patients and families to be involved in these safety strategies. Establish and publicize internal reporting mechanisms such as safety hotlines. When patients and families have safety concerns, refer them to specific patient representatives. For more suggestions on best practices for this area, see National Agenda for Action: Patients and Families in Patient Safety. Nothing about Me, without Me (see Resources).
- Patients in psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals must be assessed for suicide risk. Because emotional and behavioral disorders may not be readily apparent in every patient being admitted to a general hospital, all patients should be assessed for suicide risk on admission, just as they're assessed for fall risk and pressure ulcer risk. Assess each patient's suicide risk and his safety needs in the plan of care.
Previous safety goals: Still valid
Most previous JCAHO patient-safety goals are still in effect, including these:
- Use two patient identifiers. Use the patient's full name and one other identifier such as his birth date, but never his room number. Referring to a patient by his room number is an outdated practice that has no place in a culture of safety. When verifying identity, say to the patient, “Please state your name” rather than asking, “Are you John Jones?”
- Check two identifiers each time you administer a drug or blood product, obtain a specimen, or perform a procedure or treatment. Make a habit of comparing the medication administration record or specimen labels at the point of care with the two identifiers on the patient's ID band. Label specimen containers in the patient's presence at the time they're collected.
- Write down and read back critical diagnostic values. You must first write down information that's given to you orally, then read it back to the practitioner. Be sure to clearly and correctly identify the patient during the process. Remember, practitioners often make treatment decisions based on a diagnostic value before the written report is available.
- The timely reporting of critical test results was added to the goals in 2006 because delays in reporting test results can harm patients significantly. Hospitals are now required to monitor timeliness of results reporting and have policies and procedures in place to decrease delays.
- Without critical-results read-back procedures, significant additional errors may cascade from one initial error. If lab results are reported for the wrong patient, for example, two patients can be affected: One may receive unnecessary or even dangerous treatment; the other may miss treatment he needs.
- A horrific example of this kind of error is a pathology result mix-up that caused one woman to have an unnecessary bilateral mastectomy. Meanwhile, treatment was delayed for the patient who had cancer.
- Standardize handoff communication. Effective handoffs are required when care is transferred between individuals; for example, during shift change. Hospitals must implement a standardized approach to handoff communication that gives clinicians an opportunity to ask and answer questions. The process must be standardized for shift report, transfers within the hospital, admission from the ED, and direct admissions.
- Make sure other communication also is effective. Each hospital must develop its own standardized list of unacceptable abbreviations, acronyms, and symbols. These lists commonly forbid “u” for units, “qd” for daily, and trailing zeros, such as 6.0. Unacceptable shortcuts shouldn't be permitted in the medical record, during oral orders, in progress notes, or in flow sheets. They also shouldn't be used in documentation that's handwritten, including free-text computer entry, or on preprinted forms.
- Standardize and limit the number of drug concentrations. Most hospitals have standardized their concentrations of heparin, insulin infusions, magnesium, and other high-risk medications. One exception is customized concentrations mixed for pediatric emergencies when the calculations are made using Broselow tapes. Because this practice enhances patient safety, the JCAHO supports it.
- Be careful with soundalike, look-alike drugs (SALADs). The JCAHO requires each hospital to develop and review annually a list of SALADs that it uses and take action to prevent mix-ups. The Institute for Safe Medication Practices has developed a list of over 40 combinations of drug names that have been confused, which hospitals can use as a benchmark. Be familiar with these and stay alert for potential errors.
- Improve medication labeling in perioperative and procedural settings. Tragic errors have occurred when unlabeled drugs and solutions were placed on sterile fields. Patients have been injected with topical solutions, for instance.
- When medications and solutions are removed from their original package, the syringe or container must be identified with sterile labels that include the drug name, strength, amount, expiration date (when not used within 24 hours), and expiration time. Labels for compounded admixtures should also include the date prepared and the diluent used.
- Follow Centers for Disease Control and Prevention hand hygiene guidelines. Studies show that most hospital workers are compliant with good hand hygiene practices only 30% to 50% of the time and that many hospital-acquired infections are related to inadequate hand hygiene or glove use. Use alcohol-based solutions or soap-and-water hand washing properly and use gloves correctly.
- Reduce the risk of patient harm resulting from falls. Because many patient falls in hospitals can be prevented, the JCAHO requires hospitals to implement a fall-reduction program and evaluate its effectiveness. Be familiar with your facility's program. Then assess your patients for fall risk and select appropriate interventions, including communicating the patient's fall risk to other staff.
As a nurse, you strive to protect the safety of each patient. The JCAHO National Patient Safety Goals provide a framework to help you reach this goal.
How do safety goals take shape?
Safety goals are general statements, such as “Improve accuracy of patient identification,” and requirements specify actions to support the goal, such as “Use at least two identifiers.” Based on the goals, facilities develop policies and procedures to meet the requirements. For example, a hospital can specify which two patient identifiers to use. Staff support these requirements by integrating them into practice.
1. Joint Commission on Accreditation of Healthcare Organizations, 2007 National Patient Safety Goals.. Accessed October 2, 2006.
Kohn LT, et al. Committee on Health Care in America. To Err Is Human: Building a Safer Health System
. Washington, D.C., Institute of Medicine, National Academy Press, 2000.
.Institute for Safe Medication Practices.
.Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series
. Washington, D.C., The National Academies Press, 2006.
.Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century.
Washington, D.C., The National Academies Press, 2001.
.The National Patient Safety Foundation. National Agenda for Action: Patients and Families in Patient Safety. Nothing about Me, without Me.