JCAHO’s safety goals — The clock is ticking, will your ED be compliant?

ED managers share their secrets for becoming, staying compliant

ED managers and staff will face even greater responsibility for compliance under the 2006 National Patient Safety Goals just unveiled by the Joint Commission on Accreditation of Healthcare Organizations.

The goals include two major new requirements for EDs: One, under the goal, "Improve the effectiveness of communication among caregivers," addresses handoffs of patients. The other, under "Improving the safety of using medications," involves the labeling of medication containers and other solutions during perioperative procedures, including those performed in the ED.

ED Management has sought out leading ED managers across the country for their tips and advice on compliance. These EDs, some of whom already are compliant, can offer a clear roadmap for those who need to bring their departments into compliance.

Handoffs affect EDs most directly in admissions and during shift changes for nurses, says Richard J. Croteau, MD, executive director of patient safety initiatives for the Joint Commission. "If handoffs are to be done well, you must create a more formalized process," he says. "A specific requirement is to allow for questions to be asked and clarification to be provided as a part of that communication."

Many EDs already are ahead of the game in terms of compliance with this safety goal, say some ED managers, including Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, CNS, MICN, director of emergency/trauma services at the University of California, Irvine (UCI) Medical Center in Orange. "We think, for example, that EDs are much more proactive in addressing [handoffs to] the inpatient area because we are used to giving verbal communications," she says.

However, many hospitals provide audiotaped change-of-shift reports, Croteau says. In those cases, he notes, if the new nurse has questions, he or she must guess or contact the prior nurse at home. Direct verbal communications are preferred.

"The types of things to be communicated are: who the patient is, what the condition is, the current status, what is anticipated in terms of treatment over the next shift, and condition changes or complications being looked for," he explains. In admissions, that kind of information must be communicated to the inpatient staff, Croteau notes.

The labeling requirement refers to all perioperative procedures, he says. "It has been a long-standing practice to put medications on a sterile field by pouring them into a little medicine cup, which is often unlabeled," Croteau observes.

While this is "an old practice," it persists, he says, adding that Joint Commission officials contend about half of the hospitals in the United States still use this practice. "All meds have to be labeled," he asserts.

The leaders interviewed by ED Management offer a number of tips that can help you bring your ED into compliance.

At St. Anthony Community Hospital in Warwick, NY, handoffs are conducted nurse to nurse, says Jeff Reilly, RN, vice president of administration and the facility’s former ED nurse manager. "This is a very critical piece of communication," he says. "Those questions and clarifications happen as part of our policies and procedures."

There always is concern about information being omitted during admissions that occur at a shift change, Reilly concedes. "But we have procedures in place that unless there is a crisis, we do not transport patients from one department to another for about a half-hour to 40 minutes during shift changes," he says.

At UCI Medical Center, the ED staff members view shift changes as an opportunity to also increase patient involvement, which is mandated in Goal 13: "Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy."

"Between shifts, both nurses should go to the patient together and discuss the patient’s condition and what they hope to accomplish," Bradley notes. "This way, you accomplish two of those patient safety goals right there."

For transfers to critical care, where, there are greater chances for error, "we call ahead of time and file a verbal report, including things the patients will need when they arrive, like a ventilator or an IV [intravenous] pole," she explains. "When they arrive, there is once again one-to-one communication between nurses."

That communication includes such things as looking at the wounds, the IV setup, and the patient’s valuables, she says. "These are identified and counted in the ED and then by the nurse who is receiving the patient," Bradley explains.

In the ED at St. Mary’s Regional Medical Center in Lewiston, ME, the admission report is verbal via in-house phone or, in the intensive care unit, given nurse to nurse at the bedside so they have the opportunity for dialogue, questions, and clarification of orders and treatment, says Jackie Mador, RN, MHA, CEN, ED manager/clinical coordinator. "Shift changes are always handled person to person," she says.

Mador contends her facility still needs a formal policy delineating exactly what the nurses should discuss. "We do have to focus on creating a template — a standard for what is shared," she notes.

How will her staff do this? "We have a shared governance model," Mador explains. "The staff will be told what the standard and the expectations are, and then they will develop the process and the tools to meet them." While she is the ED manager, Mador says she would be present during the process only to lend support. "We foster and empower our nurses to come up with the exact process."

As for the new requirement concerning the labeling of meds, this safety goal can be addressed directly through packaging, says Bonnie Atencio, MS, RN, CEN, clinical educator in the ED at Mercy San Juan Medical Center in Carmichael, CA.

"In our ED, we have prepackaged suture kits," she explains. "They contain two plastic sterile cups, into which the nurse pours normal saline solution in one and [antiseptic] solution in the other. Everything else is brought into the room by the RN, and either the labeled bottle is held for the MD to withdraw the meds, or the medication is brought and administered by the RN."

The saline and antiseptic solutions are two distinctly different-appearing liquids, Atencio notes. Nevertheless, the Joint Commission requires that those cups also be labeled. "I suppose the providers of the suture kits could pre-label those cups to ensure compliance with the goal," she offers.

Croteau says that approach appears to be a reasonable one as long as there is a step in which the person checks the label of both containers prior to pouring, which is perhaps checked by another person.

"Pharmacy always uses a double-check process for filling, so it seems reasonable that other folks should, too," he says.

Engraving the cups allows them to be sterile and easily readable, Croteau adds.

"Repeated labeling with paper labels could leave glue or partial labels on the cup, which could cause sterility problems — in theory," he says. "So as long as there are proper steps included to make sure that what is poured into the container matches the label, the process will be acceptable."


For more information, contact:

  • Bonnie Atencio, MS, RN, CEN, Clinical Educator, Emergency Department, Mercy San Juan Medical Center, 6501 Coyle Ave., Carmichael, CA 95608. Phone: (916) 536-3140. Fax: (916) 863-6802. E-mail: batencio@chw.edu.
  • Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, CNS, MICN, Director Emergency/Trauma Services, UCI Medical Center, University of California, Irvine, 101 The City Drive, Route 128, Orange, CA 92868-3298. Phone: (714) 456-5248. Fax: (714) 456-5390. E-mail: dbradley@uci.edu.
  • Richard J. Croteau, MD, Executive Director of Patient Safety Initiatives, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000. E-mail: rcroteau@jcaho.org.
  • Jackie Mador, RN, MHA, CEN, Emergency Department Manager/Clinical Coordinator, St. Mary’s Regional Medical Center, Campus Avenue, Lewiston, ME 04243. Phone: (207) 777-8246. E-email: jmador@sochs.com.
  • Jeff Reilly, RN, Vice President, Administration, St. Anthony Community Hospital, 15 Maple Ave., Warwick, NY 10990. Phone: (845) 986-2276. E-mail: jreilly@tshs. org.

You can download a complete copy of the 2006 National Patient Goals free of charge on the web site of the Joint Commission (www.jcaho.org). Under "Top Spots," click on "National Patient Safety Goals & FAQs." Once there, scroll to the bulleted item "Critical Access Hospital and Hospital."