Prevention Of Medical Errors for RNs and LPNs

in Online Classes, Online Training, Prevention of Medical Errors

JCAHO Patient Safety Goals for 2012

JCAHO set the first National Patient Safety Goals (NPSGs) in January 2003. Since that time these NPSGs have undergone many revisions, with the last one in 2012. Instead of releasing new goals for 2011 JCAHO has refined and clarified the goals and standards from year 2010. As of January 1^st 2012, all JCAHO and the Disease-Specific Care certified programs will be surveyed for implementation of applicable 2011 goals and requirements – or acceptable alternatives – as appropriate to the services the organization or program provides. The new goal for the hospital and critical hospital accreditation programs that JCAHO has approved for 2012 focuses on the prevention of catheter-associated urinary tract infection (CAUTI).

The 2011 JCAHO goals that will continue to be monitored in 2012.

1. Improve the accuracy of patient/ resident/ client identification.

a) Conduct a verification process before the procedures. Use at least two client identifiers when providing care, treatment, and services before the procedure (neither of which is the client’s room number).

b) Eliminate the transfusion errors result of miscommunication.

Goal #1 requires that at least two patient identifiers be used when administering medications; when providing treatments or procedures; when collecting blood, or blood components; and when collecting blood samples and other specimens. The patient’s room number or physical location is never to be used as an identifier. Additionally, all containers used for blood and other specimens are to be labeled in the presence of the patient.

2. Improve the effectiveness of communication among caregivers.

a) Report critical results of tests and diagnostic procedures on a timely basis.

3. Improve the safety of using medications.

a) Label all medications, medication containers, and other solutions on the sterile field in perioperative and other procedural settings.

b) Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

This Goal address how the medication is prepared and distributed, the use of approved protocols, baseline and ongoing coagulation tests, programming of pumps for consistent and accurate dosing, and education of the patient and families regarding compliance, drug-food interactions and the potential for adverse drug reactions and interactions. Most of these requirements will be fulfilled by actions taken by the pharmacy and the nursing units which is why elaboration is not considered necessary.

4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

a) Now, the main goals of the UP are to perform surgery on the correct patient, at the correct site, and with the correct procedure.

b) Conduct a Pre-procedure Verification Process

c) According to the Joint Commission, the rationale for this UP is that, “Hospitals should make sure that any procedure is what the patient needs and is performed on the right person. The frequency and scope of the verification process will depend on the type and complexity of the procedure. ”

d) Mark the Procedure Site.

e) In the commentary regarding the “marking of the procedure site”, the Joint Commission notes that while marking of the procedure site is a hotly debated topic, the LIP who will be performing the procedure should mark the site.

f) Time-Out is performed before the Procedure.

Of course the purpose of the time-out is to be certain that the correct patient is about to undergo the correct procedure, and that the correct site will be used. A designated member of the perioperative team must be responsible for initiating and conducting the time-out and ALL members of the perioperative team must participate through the use of active communication.

5. Impove the safety of using infusion pumps.

6. Improve the effectiveness of clinical alarm systems.

One of the goals is building of a septic shock alarm.

7. Reduce the risk of health care-associated infections.

a) Comply with either current Centers for Disease Control and Prevention (CDC) or World Health Organizations (WHO) hand hygiene guidelines.

b) Prevent multi-drug resistant organism infections.

This Goal is only required for the Acute care hospital accreditation program and requires risk assessments, surveillance, measurement and monitoring of prevention processes and outcomes, and education of all staff and licensed independent practitioners (LIPs) regarding health care-associated infections: multidrug-resistant organisms (meticillin-resistant staphylococcus aureus – MRSA, clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria).

c) Prevent central-line associated blood stream infections.

Prevent surgical site infections.

8. Accurately and completely reconcile medications across the continuum of care.

a) Use a protocol for comparing the patient’s current medications with those ordered from the previous health care provider.

b) Document the medication transfer between different health care providers.

c) Use modified medication reconciliation protocol in settings where the medication is used minimally.

9. Reduce the risk of patient/resident/client harm resulting from falls.

10 Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.

11. Reduce the risk of surgical fires.

12. Implementation of applicable National Patient Safety Goalsl and associated requirements by components and practitioner sites.

13. The psychiatric hospitals identify safety risks (risk for suicide) inherent in its patient population.

14. Prevent health care-associated pressure ulcers (decubitus ulcers).

Conclusion

Since the IOM’s To Err Is Human presented its dramatic findings of preventable death and injury in US hospitals in 2000, notable advances have been made. They include the development of performance standards, an increase in error reporting, integration of information technology and improved safety systems. However, more is still needed to improve safety and reduce errors, including the development of data standards for patient safety information, the establishment of a national health information infrastructure and a need for comprehensive patient safety programs in healthcare organizations. The reduction of medical errors must remain a top priority for all healthcare professionals.

Reference/Bibliography

Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err Is Human: Building A Safer Health System. NationalAcademy Press,Washington,DC. M

Martin, S. (2000). Senate Continues Search for Solutions to Medical Errors. http://www.webmd.lycos.com/contet/article/21/1728_54385.

National Council on Patient Information and Education. (2000). “Educate before you medicate” is resounding take-away message following medical errors report. http://www.talkaboutrx.org/educate.html.

FloridaHospitalAssociation (FHA). (2001). Building the Foundations for Patient Safety. http://www.fha.org/acrobat/patientsafety2.pdf.

Johnson, C. & Horton, S. (2001). Owning up to errors. Putting an end to the blame game. RN, 31 (6), 54-55.

Agency for Healthcare Research and Quality. (2001). Five Steps to Safer Healthcare. Patient Fact Sheet. http://www.ahrq.gov/consumer/5steps.htm.

Agency for Healthcare Research and Quality. (2002). 20 Tips to Help Prevention of Medical Errors in Children: Patient Fact Sheet. AHRQ Publication No. 02-P034. http://www.ahrq.gov/consumer/20tipkid.htm.

Agency for Healthcare Research and Quality. (2003). Ways You Can Help Your Family Prevent Medical Errors! http://www.ahrq.gov/consumer/5tipeng/5tips.htm..