JCAHO Update for Infection Control: Nosocomial infections may be 2004 focus

JCAHO identifying patient safety goals

Reducing the risk of serious nosocomial infections is being considered as a 2004 national patient safety goal by the Joint Commission.

The Joint Commission’s Sentinel Event Alert Advisory Group met in March to begin identifying the 2004 National Patient Safety Goals. Identified as potential new topics for 2004 goals were preventing surgical fires, eliminating kernicterus, and reducing the risk of serious nosocomial infections.

The advisory group will evaluate and consider both the potential new topics and existing goals in developing its recommendation for 2004 goals to the board of commissioners.

The 2004 goals and recommendations are expected to be announced in July following approval by the board.

According to Joint Commission spokeswoman Charlene Hill, if preventing serious infections becomes a patient safety goal, then surveyors will ask accredited facilities about their specific programs and policies to accomplish that goal.

Nosocomial infections would appear to be a strong candidate for a patient safety goal because the Joint Commission recently advised organizations that infections that lead to patient deaths or permanent loss of function should be regarded as sentinel events and subjected to a root-cause analysis with the idea of preventing such infections in the future.1

In addition, some of the Joint Commission’s 2003 patient safety goals may continue into 2004. As of Jan. 1, 2003, JCAHO began surveying health care organizations’ compliance with the 2003 National Patient Safety Goals.

As of Feb. 21, 313 surveys were completed and most health care organizations were found to be in compliance with the patient safety goals. However, some of the recommendations are proving more challenging than others.

Seven percent of those surveyed are not complying with the goal requiring standardizing abbreviations or symbols that are used in providing care. (For example, when "u" is handwritten to indicate units, it can often look like a zero and lead to incorrect medication dosages.)

A noncompliance rate of 2.6 was found for the goal requiring at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.

In addition, 2.2% of those surveyed were not marking the site where surgery is to be performed, e.g., the left foot, and involving the patient in the process.


1. Joint Commission on Accreditation of Healthcare Organizations. Infection control-related sentinel events. Sentinel Event Alert Jan. 22, 2003; Issue 28.