JCAHO Patient Safety Goals for 2002-2003
JCAHO periodically sends Sentinel Event Alerts to each hospital’s patient safety team, risk manager, and/or compliance office based on increased numbers of reported events related to high-risk processes, in order to facilitate shared learning from adverse events. These alerts are accompanied by JCAHO improvement recommendations.
The Patient Safety Team works with Corporate Compliance/Risk Management and other hospital committees to ensure BWH compliance. The Patient Safety goals and BWH’s status for 2002-2003 are as follows:
1 Improve the accuracy of patient identification
1A. Use at least two identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
Current approach:
Current practice for administering blood products is to check the medical record number name on the patient ID band against the transfusion bag. The patient should state their name as well. If both conditions can’t be met, then the nurse must contact the physician for positive identification. Blood transfusion practices are reviewed as an annual nursing competency. For medications or blood samples, the criteria for patient identification are not in the nursing policies but in their competency checklist. The lab policies for phlebotomists are clearly stated to include two forms of patient identification.
Plan:
Bar-code wrist bands for inpatients will provide 2 identifiers; bar-code and patient name. Implementation is scheduled for fall 2003. Plans are in progress to potentially include a photo ID on the hospital card and the bar-coded wristband. Until this time, the nursing policies will be updated to include two forms of ID.1B. 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, not passive, communication techniques.
Current approach:
There is currently a site verification checklist that is completed prior to surgery, but no standardized final verification process prior to incision.
Plan:
Develop a verification process as a part of a three-pronged correct site/side policy improvement plan. Prior to the incision, the team including the operating physician, circulating nurse and the anesthesiologist will perform a “team pause” where all actively confirm the patient, procedure, site/side against the medical record, patient site marking, consent form and any images available. The circulating nurse will record the team pause on the OR record. This process will be initiated by June 2003.
2 Improve the effectiveness of communication among caregivers
2A. Implement a process for taking verbal orders that requires verification “read back” of the complete order by the person receiving the order.
Current approach:
Outpatient pharmacy has a policy that includes a “read back” process.
Plan:
Develop and implement a universal “read back “ policy for taking verbal/telephone orders for all providers (not just pharmacy) where appropriate. 2B. Standardize abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols NOT to use.
Current approach:
There is a current list of approved terminology including abbreviations, acronyms and symbols that are allowed in the medical record. The medical records committee must approve all forms for appropriate terminology. A list of terms NOT to use was generated from patient safety changes made to Order Entry and from the ISMP best practices. Medical Records Committee has recently approved this list of terms NOT to use.
Plan:
The Medical Records Committee plans to put the list on line. All pre-printed pathways are being checked for these terms as well as the LMR and order entry.
3. Improve the safety of using high-alert medications
3A. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride>0.9%) from patient care units.
Current approach:
High-alert medications including potassium chloride, potassium phosphate and sodium chloride>0.9% have been removed from patient care areas.
Plan:
Develop an inclusive list of high-alert medications that have been removed from patient care areas. 3B. Standardize and limit the number of drug concentrations available in the organization.
Current approach:
BWH standardizes and limits the drug concentrations in the organization. This is supported through Order Entry. All additions need approval by the Pharmacy and Therapeutics Committee.
Plan:
Continue current approach.
4 Eliminate wrong-site, wrong-patient, and wrong procedure surgery
4A. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents,(e.g. medical records, imaging studies) are available.
Current approach:
There is a preoperative checklist to confirm that appropriate documents are available.
Plan: The checklist has been revised and simplified by the OR committee, with a plan to put it on the back of the consent form to avoid extra paperwork. The operating team, prior to the incision, will be required to review the preoperative checklist. . Implement a process to mark the surgical site and involve the patient in the marking process.
Current approach: There is a policy change to mark all surgical sites, not just those of laterality. This policy does include the patient in the marking process. The policy will be implemented by June 2003.
Plan:
Fully comply with the standards by requiring that the surgeon mark all sites, involving the patient whenever possible.
5 Improve the safety of using infusion pumps
Ensure free-flow protection on all general-use and PCA intravenous infusion pumps.
Current approach: BWH is replacing all IV pumps and PCA) to the Alaris pump, which has free-flow protection.
Plan: Monitor for adverse events/near misses with the new pump.
6 Improve the effectiveness of clinical alarm systems
6A. Implement regular preventative maintenance and testing of alarm systems.
Current approach: Biomedical Engineering performs regular maintenance and testing of alarm systems. All preventative maintenance is recorded in a database for reference. 6B. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distance and competing noise within the unit.
Current approach:
Product manufacturers list default alarms. Hospital policies and procedures also list safe alarm limits. However, recent reported events reveal that there are not standardized user performance checks of alarms.
Plan:
Biomedical Engineering developed a list of all equipment with alarms, and will determine which alarms are “critical alarms.” Nursing and other departments that use this equipment will check their policies around alarm education and setting appropriate parameters. Sound capabilities with respect to distance of caregivers will also be tested.