JCAHO Update for Infection Control

2004 Patient Safety Goals include hospital infections

Reduce infections, report sentinel events

Don’t forget, new Patient Safety Goals — including reducing nosocomial infections — go into effect as of Jan 1, 2004.

Joint Commission surveyors will be looking for signs of implementation of the following:

1. Improve the accuracy of patient identification.

A. Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.

B. 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 techniques.

2. Improve the effectiveness of communication among caregivers.

A. Implement a process for taking verbal or telephone orders or critical test results that require a verification read-back of the complete order or test result by the person receiving the order or test result.

B. 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.

A. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.

B. Standardize and limit the number of drug concentrations available in the organization.

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

A. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.

B. Implement a process to mark the surgical site and involve the patient in the marking process.

5. Improve the safety of using infusion pumps.

A. Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.

6. Improve the effectiveness of clinical alarm systems.

A. Implement regular preventive maintenance and testing of alarm systems.

B. 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.

A. Comply with current hand hygiene guidelines by the Centers for Disease Control and Prevention.

B. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.