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Fatal doses of chemotherapy. Amputations of the wrong foot. Anesthesia miscalculations that result in the death of a patient undergoing a minor procedure.
Catastrophic errors some highly publicized, some known only within the hospital walls can occur even in facilities with otherwise impeccable quality records.
That was the dilemma facing the Joint Commission on Accreditation of Healthcare Organizations, which now has devised a new policy to address the issue for facilities in good standing.
Under that policy, such adverse events will trigger an interim survey of the facility, which then will be placed on "accreditation watch" a notation available for public information until they develop a plan to prevent these errors from recurring.
During the interim survey, the Joint Commission will scrutinize the processes that resulted in the error and require the hospital to correct them. The Joint Commission will append the new "accreditation watch" status to the hospital’s existing accreditation classification until a corrective plan is in place.
"We want to get people to focus on the process and how to correct it," says Rick Croteau, MD, vice president of accreditation services at the Joint Commission.
The Joint Commission has placed about a dozen hospitals on watch since the policy was implemented in September.
Croteau says the new "watch" status should correct glitches in the old system.
Under the old policy, a hospital which committed a error that resulted in the injury or death of a patient, also known as a sentinel event, was placed on "conditional accreditation," a status which implied the facility was not meeting some Joint Commission standards.
"That might not have been true," Croteau says. "Someone can make a deadly mistake at a hospital that is meeting all of our standards." The new status erases the potential for misinterpretation.
The old policy also failed to address procedures, prompting facilities to "solve" a problem by firing someone.
"They figured that if someone was fired, the problem wouldn’t occur again," Croteau says. Under the new system, simple personnel change will not be viewed as enough to correct the problem, Croteau says.
For example, firing a resident who has slept three hours in two days for misreading a chart doesn’t prevent another tired resident from committing the same mistake, he explains.
The Joint Commission expects to learn of sentinel events the same way it does now: from the media, from patients, from hospital employees, and, preferably, from the organization itself. Croteau says there is no penalty if the hospital does not report the event themselves. But since the purpose of the new policy is to make systemwide corrections, any delay in making those amendments could put other patients at risk, he says.
"Some of them understand that if it is already public knowledge, or will be soon, then it’s better to take a proactive approach and let us know," Croteau explains.
Other events may come to light during the regularly scheduled surveys when the public can get in touch with the Joint Commission about a specific facility.
After the Joint Commission learns of a catastrophic error, they will call the facility, tell them they have been made aware of a sentinel event and send a surveyor out within two weeks.
"We try to do if faster than it has been [done] in the past," he says. The goal is to have someone on site within a week.
The surveyor determines if the organization had control over the event and can reduce the risk to patients in the future, or if the event was an "act of God" beyond the hospital’s control.
Croteau says if the error could have been prevented, then the surveyor will work with the facility to find the root cause.
"If it was human error, we have to find out if it was a problem with communications, if it was related to training, or if there was some step which broke down and how we can correct it," he says.
The facility then has 30 days to develop a plan and submit it to the Joint Commission. Once that plan is accepted, the accreditation watch is removed from the facility. After four to six months, a follow-up survey is conducted to see if the plan has been implemented.
This 30-day period is perhaps the biggest potential problem with the new policy, says Judy Houma-Lowry, RN, MSBA, CPHQ, a quality consultant based in Detroit. "If people aren’t familiar with root cause analyses, how can you expect them to find out the root of a problem and develop a plan within 30 days?" she asks.
The trick for a facility will be to bring a group of people together who all have the same understanding of a particular process. Only then, says Houma-Lowry, can a team determine what caused the error and develop a plan to ensure the situation does not repeat itself.
"But overall, this is a great thing for hospitals," she adds. "They will have to focus on the real issue, on why people make mistakes."
Croteau, says many organizations have complained that the watch is punitive.
"They see it that way because it is publicly available information," he says. "We want to reduce that perception and get people to see that if we help them improve their processes, we can eliminate sentinel events in the future."
He says the new program is better because a facility which is accredited with commendation can be under a watch, rather than hanging under the "conditional accreditation" banner for six months. Croteau, though, knows he’s fighting an uphill battle.
"Just the other day I got an irate call," he says. "It was someone put on watch. I explained the benefits to him of doing a root-cause analysis and fixing the process. Forty-seven minutes later I won’t say he was happy, but he was happier."
Documents pertaining to the new policy are being finalized and will be sent to health care organizations in the near future, he says.
[For more information about the new policy, call Rick Croteau, MD, vice president, accreditation services, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Telephone: (630) 792-5776.]