Critical Path Network

JCAHO unveils national patient safety goals

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has released its 2005 National Patient Safety Goals that will apply specifically to hospitals.

The goals and associated requirements, which were approved by JCAHO’s board of commissioners at its July meeting, include five of the 2004 goals and add two new expectations. The latter focus on reconciling medications across the continuum of care and reducing the risk of patient falls.

The goals set forth evidence-based requirements that address critical aspects of care known to involve significant risk to patients.

The goals are reviewed and revised annually by the sentinel event advisory group. This panel consists of physicians, nurses, pharmacists, and patient safety experts who work closely with JCAHO staff members on a continuing basis to determine priorities for and develop goals and associated requirements. They are largely, but not exclusively, based on information from the JCAHO sentinel event database. As part of the development process, candidate goals and requirements are sent to the field for review and comment before they are finalized.

The 2005 Hospital National Patient Safety Goals are as follows:

  • Goal: Improve the accuracy of patient identification.

Use at least two patient identifiers (neither to be the patient’s physical location) when administering medications or blood products; taking blood samples and other specimens for clinical testing; or providing any other treatments or procedures.

  • Goal: Improve the effectiveness of communication among caregivers.

For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result read back the complete order or test result. Standardize a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization.

Measure, assess, and, if appropriate, take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical test results and values.

  • Goal: Improve safety of using medications.

Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care areas. Standardize and limit the number of medication concentrations available in the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike medications used in the organization and take action to prevent errors involving the interchange of these medications.

  • Goal: Improve the safety of using infusion pumps.

Ensure free-flow protection on all general-use and patient-controlled analgesia IV infusion pumps used in the organization.

  • Goal: Reduce risk of health care-associated infections.

Comply with current Centers for Disease Control and Prevention hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health care-associated infection.

  • Goal: Accurately and completely reconcile medications across the continuum of care.

During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications on the patient’s entry to the organization and with the involvement of the patient.

That process includes a comparison of the medications the organization provides to those on the list.

A complete list of the patient’s medications is communicated to the next provider of service when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

  • Goal: Reduce the risk of patient harm resulting from falls.

Assess and periodically reassess each resident’s risk for falling, including the potential risk associated with the resident’s medication regimen, and take action to address any identified risks.