Joint Commission's 2007 safety goals will revamp ED nursing practice

New goals require you to involve patients in their care

Do you identify patients at risk for suicide? Do you give patients a list of their medications? And do you encourage patients to report safety risks? These are some of the changes you'll need to make to comply with the 2007 National Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations.

"To be safe, health care has to be done as a team activity, and the patient is arguably the most important member of the team," says Richard J. Croteau, MD, the Joint Commission's executive director for strategic initiatives.

Here are the new requirements with strategies for each:

• Encourage patients to report concerns about safety.

At McKay-Dee Hospital Center in Ogden, UT, "We urge patients to be involved with their own care and to report safety concerns by statements in their discharge instructions, which are reviewed with them," says Kayleen L. Paul, RN, CEN, care center director for emergency, critical care, and trauma services. "We also include the name and phone number of our care manager on every discharge instruction and urge them to give us feedback about any issue they might have."

The statement invites questions about ED care, medications, follow-up instructions, or aftercare. "We are considering adding the specific word 'safety,'" she says. For example, the statement may be changed to read, "If you have any questions or concerns about your care or safety in the ED or about your follow-up care, please call . . ."

Patients have called the ED to confirm that they received the correct medication, says Paul. "The prescription medication may look different in size and color than the dose we gave, and patients have called to clarify that it's the right medicine," she says. "It's always been a case of the pharmacy using a generic and not a medication error, but I always praise people for their attention to important details."

Invite patients to report safety concerns by handing out a brochure, posting a sign, or discussing this at triage, recommends Darlene Bradley, RN, CNS, CCRN, CEN, MICN, FAEN, director of emergency/ trauma services at University of California-Irvine Medical Center in Orange.

"Inform the patient that health care staff are interested in safety and will listen to any concern the patient would like to address," she says. "Letting the patient know that the organization wants to provide a safe and secure environment opens the door for that discussion to continue."

Patients have voiced safety concerns about wet floors and the risk of infection if an infiltration occurs with intravenous infusion, says Bradley. "Patients also question blood transfusions, disease transmission, and fear of receiving the wrong blood," she adds. "When patients witness caregivers complete the double-check to validate the right blood for the right patient, the anxiety subsides."

• Involve patients in their care.

At Barnes-Jewish Hospital in St. Louis, ED nurses explain that they need to ensure that the correct patient is getting the correct treatment, says Jennifer Williams, MSN, RN, BC, M-S CNS, CEN, CCRN, clinical nurse specialist for emergency services. "We inform the patients on arrival that care providers will ask them their name and date of birth while confirming it with their armband many times, specifically before medications and procedures," she explains.

• Identify patients at risk for suicide.

If your ED is caring for psychiatric patients, surveyors will expect to see that patients are assessed for risk of suicide, says Croteau. "The fact is that patients sometimes do commit suicide in the ED itself." In addition, if patients aren't admitted, there is a risk of suicide after they leave the ED, he adds.

Many EDs are reporting significant increases in the number of psychiatric patients, notes Croteau. "Any time the volume goes up, it puts pressure on available resources, but that is not a reason to do the right thing," he says.

Don't miss suicide risk

Assessment of suicide risk may be a major challenge for many EDs, says Kathleen A. Catalano, RN, JD, director of health care transformation support for Perot Systems, a Plano, TX-based provider of information technology services and business solutions.

"EDs are prepared for that if they are one of the behavioral health receiving centers, but otherwise, they may not know how to deal effectively with the issue."

At McKay Dee, the ED collaborated with the psychiatry department to put crisis workers in the ED to help with assessment of psychiatric patients. "Some patients are clearly brought in for a crisis evaluation by family, police, or themselves," says Paul. "For other patients, especially trauma and those involving medication 'mistakes,' the nurses are trained to have a high index of suspicion and frequently consult the crisis worker."

Suicide risks often are identified by the person accompanying the patient, says Bradley.

To assess suicide risk, she suggests using quick assessment tools such as "SAD," an acronym standing for:

Sex, because women attempt suicide three times more often than men;

Age, because individuals 19 years or younger and 45 years or older are at greater risk;

Depression, which is a good indicator of suicide risk.

"The presence of the three criteria may warrant a closer assessment by the nurse," says Bradley. She also recommends the "PERSONS" assessment:

— P, previous attempts at suicide;

— E, ETOH (alcohol abuse);

— R, an inability to think rationally;

— S, a lack of social support;

— O, an organized plan for the suicide;

— N, no spouse;

— S, a chronic or disabling sickness.

ED nurses routinely screen patients for violence and abuse at Barnes-Jewish Hospital, says Williams. "Perhaps the biggest challenge is continuing to ensure consistency in screening our patients," she says. "We need to ensure that every patient is provided the same level of screening from every ED nurse."

• Give patients a complete list of medications on discharge.

"Provisions for listing all medications at discharge may be a challenge for many EDs," says Bradley. Give patients a wallet-size card with the medications, dose, frequency, and purpose for each medication listed, she recommends. "All patients should be encouraged to carry such tools," Bradley says.

A medication list could be given to patients with discharge instructions or as a wallet-sized card, says Paul. "If given as a pocket card, there needs to be some way to change doses, or add and subtract medications," says Paul. (To download a wallet-sized medication card at no charge, go to the Utah Department of Health web site: Click on "Patient Safety." Under "Consumer Information," click on "Patient safety materials you can use in your facility." Under "Using Your Medication Safely — a Guide to Prescription health," choose English or Spanish version.)

Having an electronic medical record that can update medication lists with each visit is key to doing this list effectively, says Bradley. The University of California-Irvine's ED uses a "problem list" in which care problems and medications are listed.

Upon arrival to the ED, the listing is updated and verified with the patient. At registration, the list is automatically printed for every patient. As the care is completed, changes to the list are entered and validated.

"The list is available to all health care providers in the hospital and the clinics who are caring for the patient," says Bradley. "The printout at discharge is then used to evaluate the drugs, review side effects, and analyze for drug interactions." Errors, potentially harmful drug interactions, and discrepancies are identified through this process, she says.

Patients don't realize that vitamins, minerals, and herbal supplements can interact with other medications and can be hazardous, and these often are not reported to ED nurses, says Bradley. "Patients that frequent multiple institutions including doctor's offices and hospitals generally get a medication for each complaint," she says. "The failure to report these and document the types, doses, and frequency of use can be a significant hazard to the health of the individual."