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JCAHO: Safety Focus

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Focus on Safety

If you’ve worked in health care for years and never met a JCAHO surveyor, this may be your year.
JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) has changed the way it conducts site visits. When surveyors visit BIDMC in October, they probably won’t be interested in speaking to a manager or a chief, or looking at written procedures.

Instead, they may ask you, a physician or nurse, to show them your patient’s chart and confidentially discuss your patient’s care. If that patient was in radiology or the lab, they may “trace” that patient to other services, asking technologists and phlebotomists about how you provided care. They may look over how you, an environment services staff member, prepared each patient’s room.

JCAHO surveyors will evaluate your work, from how often you wash your hands to the way you write notes in a chart. Nowhere will this scrutiny be more important than in the area of patient safety.

BIDMC has adopted JCAHO’s seven patient safety goals for 2004:

1. Improve the accuracy of patient identification
Use at least two patient identifiers (neither to be 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 – not passive – communication.

2. Improve the effectiveness of communication among caregivers
Implement a process for taking verbal or telephone orders or critical test results that requires a verification “read-back” of the complete order or result by the person receiving the order or result.

Standardize the abbreviations, acronyms and symbols used throughout the organization, including 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, sodium chloride >0.9 percent) from patient care units.
Standardize and limit the number of drug concentrations available in the organization.

4. Assure correct-site, correct-patient, correct-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.

6. Improve the effectiveness of clinical alarm systems
Continue and improve regular preventive maintenance and testing.

Assure that 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-acquired infections
Always comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

- Cindy Whitcome