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JCAHO Update for Infection Control
2005 patient safety goals warn of sound-alike drugs
Infection control goals remain intact
New patient safety goals for 2005 by the Joint Commission on Accreditation of Healthcare Organizations include preventing patient falls and avoiding potentially fatal mix-ups with similarly named drugs.
Remaining unchanged from 2004 are the two key infection control patient safety goals:
1. Comply with current Centers for Disease Control and Prevention hand hygiene guidelines.
2. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Goals include patient falls reduction
Effective Jan. 1, 2005, the patient safety goals also include a new emphasis on reducing patient falls.
Infection control professionals have focused on this area before as an important noninfectious adverse outcome.
The Joint Commission’s new patient safety goal calls for hospitals to "assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks."
Much emphasis is placed on medication in general, with the Joint Commission adding a goal for 2005 that calls for hospitals to "accurately and completely reconcile medications across the continuum of care."
That goal states that "during 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient.
This 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 it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization."
In addition, the Joint Commission calls for hospitals to "identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs."
The Joint Commission notes that many drug names can look or sound like other drug names, which may lead to potentially harmful medication errors.
Communication issues exacerbate problem
Increasingly, pharmaceutical manufacturers and regulatory authorities are taking measures to determine if there are unacceptable similarities between proposed names and products on the market. But factors such as poor handwriting or poorly communicated oral prescriptions can exacerbate the problem, the organization states.
To prevent potentially deadly interactions or inappropriate care, the Joint Commission lists the following tips: