ED Accreditation Update: TJC cites meds labeling for poor compliance
ED Accreditation Update
TJC cites meds labeling for poor compliance
Every year The Joint Commission (TJC) identifies those standards and requirements that were most frequently identified as "not compliant" for the previous six-month period. For the most recent reporting period, Jan. 1, 2007, through June 30, 2007, the standard with the lowest compliance rate for hospitals was the National Patient Safety Goal for medication labeling, with a compliance rate of 17%.
The goal reads as follows: "Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field."
Why is compliance with this goal so low? "There have been so many other patient safety interventions out there, like hand washing and medication reconciliation, that this has just not been elevated to the highest level of attention," offers Kathy Hendershot, ED clinical director at Methodist Hospital in Indianapolis. "It has just not really hit the radar yet."
Nonetheless, this is a very important goal for ED managers to consider, says India Owens, RN, MSN, CEN, director of emergency services at Clarion West Medical Center, also in Indianapolis, and a past president of the Emergency Nurse Association. In fact, she says, while the term "sterile field" is commonly thought to apply only to the operating room, it is most definitely germane to the ED.
"The term 'sterile field' does apply to the ED," Owens asserts. For example, she offers, a patient may need suturing. A nurse has drawn up some lidocaine and left some in the syringe in the event the doctor needed more. "In that case it would be on the table within the sterile field, and the physician might or might not use it, so the commission says it has to be labeled," Owens explains.
The sterile field would apply to any type of procedural tray, such as the ones used to insert chest tubes or central lines, Hendershot says. "We also do plastics repair down here, as well as incision and drainage," she says.
Owens believes compliance is low because sterile fields come into play in the ED under emergency situations, "so you don't find people stopping to create a label or apply a label to a source."
In addition, she notes, it is a relatively new standard, "And because of the 'sterile field' scenario, a lot of people have decided it doesn't apply to the ED." But procedures such as suturing or putting in a chest tub, most definitely involve a sterile field, Owens insists. (Editor's note: ED Management contacted The Joint Commission for clarification, and a spokesperson confirmed that the term does, indeed, apply to the ED.)
When is labeling required?
Because the goal also refers to medications "off the sterile field," Owens says ED managers should be concerned any time a staff member takes medication from a dispensing unit and to a patient's room.
"It may be labeled, but not with a patient's name," she points out. "Say I'm in a busy ED and I take Vicodin for Mr. Smith, but when I get there he has been taken to X-ray. I might drop it in my pocket, go to the dispensing machine and get Augmentin for Mr. Jones. He is also out of his room, and I drop that in my pocket." In that case, she notes, the nurse would have two containers with no labels on them.
Within the past three months, Owens' ED has taken several steps to improve compliance with this goal. "What we've done is create pre-made labels that say, for example, 'lidocaine 1%,'" she shares. "They are kept in with the chest tube bundles or on the code cart so you can pull out a pre-made label and slap it on a syringe."
Her department also has plastic bags that are kept on top of the dispensing machine so they can affix a patient's name label to that bag before taking the medication to the room. "That way, if it is in my pocket, I at least have the labeled baggie," Owens explains.
Often, she notes, a nurse will have more than one medication. "If I put the patient's name label over their medicine label I couldn't do the five 'rights' at the bedside," she points out.
Hendershot also has pre-printed labels for the drugs used most often in her department, such as morphine, versed, and saline flush. "One of the things we do is have pre-labeled syringes, even saline syringes, as often as we can," she says. "We used to just pour saline in a cup, but [according to the goal], any med drawn by a nurse and handed to another nurse or doctor has to be labeled."
To emphasize safe labeling, Hendershot has met with the nurses and sent out printed information about when meds need to be labeled. It's just as important Hendershot continues, for staff to know where labeling is not required. "If you prepare a med at the patient's bedside and are administering it to them immediately, then you do not need to label it," she says.
Owens is convinced the recent changes in her department have been effective, and perhaps with good cause. "We just had a [Joint Commission] visit, and it was a success," she reports.Every year The Joint Commission (TJC) identifies those standards and requirements that were most frequently identified as "not compliant" for the previous six-month period. For the most recent reporting period, Jan. 1, 2007, through June 30, 2007, the standard with the lowest compliance rate for hospitals was the National Patient Safety Goal for medication labeling, with a compliance rate of 17%.
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