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In an ED recently, Kathleen Catalano, RN, JD, was shocked to notice pharmacists refilling five vials of potassium chloride (KCl). "I asked about the fact that concentrated potassium chloride was being put out for use," she recalls. Catalano, director of administrative projects at Children’s Medical Center of Dallas, learned ED nurses had prepared an IV with KCl without calling the pharmacy, as the hospital’s policy required. To make matters worse, the IV was not prepared under the laminar airflow hood — another violation of hospital policy.
"The pharmacy technician was not the least bit alarmed about the use of concentrated KCl," she says. "There, but for the grace of God, went a medication nightmare." KCl often is mistaken for other medications such as sodium chloride, heparin, or furosemide, and direct infusion of concentrated KCl results in death, she explains.
Concentrated KCl should be removed from all medication areas, including the ED, unless specific safeguards are in place, warns Catalano, a former consultant with the Greeley Co., a firm in Marblehead, MA, specializing in health care regulatory compliance.
Dangerous situations like the above scenario have led to the development of new patient safety standards from the Joint Commission on Accreditation of Healthcare Organizations, based in Oakbrook Terrace, IL. The standards become effective July 1, 2001. The patient safety standards are broader than the sentinel event standards that became effective in 2000, according to Catalano. "The new standards look at more than just the patient who has been subject to a catastrophic event," she says.
Recent reports from the Washington, DC-based Institute of Medicine spurred the Joint Commission to focus on patient safety, she adds. (For ordering information, see "Sources and Resources," at the end of this article.)
Surveyors will ask what you’ve been doing to improve patient safety in your ED, according to Carole Patterson, MN, RN, consultant for Joint Commission Resources (JCR), an Oakbrook Terrace, IL-based provider of education and consulting services established by the Joint Commission, and former director of the Joint Commission’s Standards Interpretation Group. "Questions about how the hospital is improving patient safety by doing proactive risk identification and reduction activities will be an important part of the unit visits, including the ED," she says.
Any of the following three scenarios will get you into trouble during a Joint Commission survey, says Patterson:
"Special notice would be taken and written up in the preliminary noncompliance report given to the hospital at the end of the survey," Patterson warns.
Here are ways to comply with the patient safety standards:
• Use alternatives to restraint. You’ll need to be familiar with Joint Commission standards for the least restrictive use of restraints, both physical and chemical, and be able to answer surveyors’ questions about those standards, says Kathryn Perlman, MS, RN, clinical educator for the ED at Presbyterian Hospital of Dallas. (For more information about the new restraint standards, see ED Nursing, October 2000.)
Surveyors will ask nurses what documentation is required for a patient who is restrained, what are alternatives to restraints, and how often a patient who is restrained needs to be reassessed, she says. (For more information on alternatives to restraints, see ED Nursing, December 2000.)
At Presbyterian, ED nurses are required to complete a form showing that alternatives are being attempted. Perlman suggests decreasing stimulation by dimming lights, turning off the TV or radio, moving the patient to a room close to the nurses’ station, or using bed alarms. (To see Presbyterian’s Alternatives to Restraints/Restraints Flowsheet, click here.)
• Be involved in your hospitals’ patient safety program. Patterson advises joining the hospital’s patient safety or environment-of-care safety committee. "Bring along one of the ED physicians, too," she suggests. "Medical leaders are key to making patient safety efforts visible as well as viable."
• Order IV admixtures from pharmacy. Having the pharmacy mix IVs eliminates the need to keep the admixture drug on the unit, says Perlman. "It adds another risk-control element because the pharmacist checks it before it leaves the pharmacy," she explains.
• Do not keep bottles of multidose drugs on the counter. Examples of multidose drugs include Tylenol elixir and Prelone, says Perlman. "Joint Commission hates this, and it’s dangerous," she underscores. "Having medications lying around the room makes it easy to grab the wrong bottle, thinking that it is something else — if the bottles look alike, for example."
• Apply conscious sedation standards consistently throughout the hospital. You must apply the same protocol in any area that uses conscious sedation, says Cheryl Pinney, RN, BSN, MBA, director of emergency services at Cheshire Medical Center in Keene, NH, and the hospital’s Joint Commission coordinator. (For a copy of Cheshire Medical Center’s Conscious Sedation Documentation Flowsheet, click here. The medical center's Conscious Sedation Plan of Care appears below.) "This is not a new standard, but there still continues to be a lot of focus on this area,"’ she says. "Along with using a consistent protocol, staff must be trained to use the protocol."
The key is that all areas follow the same protocol, says Pinney. She suggests having several training sessions scheduled at various times so that all staff can attend, inservicing at staff meetings, developing self-study packets with a simple post-test, or implementing a poster campaign in a clinical area that all staff sign off on.
• Have your hospital risk manager perform an inservice for your staff. At Cheshire Medical Center, the hospital risk manager provided a half-hour presentation to ED nursing staff on sentinel events and how to perform a root-cause analysis. Pinney included information in the staff meeting minutes for staff who were unable to attend. "We will also review components of the presentation at future staff meetings," she says.
• Perform a visual inspection. Check for evidence of safety issues in your ED, recommends Pinney. Here are some examples she provides:
The ED uses a department checklist of items to review before surveyors arrive, says Pinney. (To see Cheshire Medical Center's ED checklist, click here.)
• Make sure that checklists are up to date. There should be "no holes," says Pinney. The ED staff use crash cart and trauma room checklists once every 24 hours, and obtain replacements as needed. "Staff are held accountable to make sure no day is missed in checking the lists," she says. (To see the medical center's Emergency Care Center Critical Care Room Inventory Checklist, click here.)
For more information on the patient safety standards, contact:
• Kathleen Catalano, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-8722. E-mail: email@example.com.
• Kathryn Perlman, MS, RN, Emergency Department, Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231-4496. Telephone: (214) 345-6301. Fax: (214) 345-6486. E-mail: KathrynPerlman@texashealth.org.
• Cheryl Pinney, RN, BSN, MBA, Emergency Services, Cheshire Medical Center, 580 Court St., Keene, NH 03431. Telephone: (603) 354-6601. Fax: (603) 354-6605. E-mail: Cpinney@cheshire-med.com.
The complete Revisions to the Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction can be accessed from the Joint Commission’s web site (www.jcaho.org). On the upper-right corner of the home page, click on "patient safety standards" under the "top spots" drop-down menu.
A 250-page resource guide, A Practical Guide to Avoiding Medical Errors, addresses staffing issues, sentinel events, nosocomial infections, error prevention strategies and technology, legislation, and liability. The cost is $249 plus $9.95 shipping and handling, and includes nine free nursing contact hours. To order, contact:
• American Health Consultants, P.O. Box 530161, Atlanta, GA 30352-0161. Telephone: (800) 688-2421 or (404) 262-7436. Fax: (800) 850-1232 or (404) 262-5525. E-mail: firstname.lastname@example.org. Web: www.ahcpub.com.