JCAHO Update for Infection Control: Surveyors checking for new patient safety goals

Be advised that accreditation surveyors now are looking for signs of implementation of the six patient safety goals established for 2003.

Effective Jan. 1, 2003, all Joint Commission Accreditation of Healthcare Organization organizations will be surveyed for implementation of the recommendations or of an acceptable alternative. Alternatives must be at least as effective as the published recommendations in achieving the goals. Failure to implement any of the applicable recommendations or an acceptable alternative will result in a single special Type I recommendation (citation).

Surveyors will look for evidence of consistent implementation of the recommendations, but you don’t need to do any special documentation for the Joint Commission that you wouldn’t be doing already to implement the recommendations.

"The surveyors will look at whatever documentation you have that is relevant and will interview the organization’s leaders and direct caregivers to determine whether the recommendations have been implemented and how consistently they are being done," the Joint Commission stated in a patient safety advisory. "It’s the actual performance we are interested in, not the paperwork."

The 2003 patient safety goals are:

1. Improve the accuracy of patient identification. Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products. 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. Implement a process for taking verbal or telephone orders that requires a verification "read back" of the complete order by the person receiving the order. 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. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. Standardize and limit the number of drug concentrations available in the organization.

4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. Implement a process to mark the surgical site, and involve the patient in the marking process.

5. Improve the safety of using infusion pumps. Ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in the organization.

6. Improve the effectiveness of clinical alarm systems. Implement regular preventive maintenance and testing of alarm systems. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.