New 2005 patient safety goals are here: Don’t delay in developing strategies

A collaborative, consistent approach is key to avoiding problems

During your next survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), it’s unknown where surveyors will go, which staff members they’ll speak to, and which patients will be traced. But one thing is certain: Compliance with the National Patient Safety Goals will be a key focus.

You must be in compliance with the new goals, which include requirements for fall prevention and medication reconciliation, by Jan. 1, 2005.

"All institutions will have to make changes to meet compliance," says Leisa Oglesby, assistant hospital administrator of quality at Louisiana State University in Shreveport. "Changes will impact nursing and physician documentation; the way pharmacists access, store, and report medications; and the way risk management tracks and trends falls to identify those at risk and determine what actions should be taken to reduce the risk."

To ensure compliance, you’ll need to review the goals with an interdisciplinary team, advises Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Metamora, MI. "You need to look at all the people in the organization the goal is going to affect. Make sure you have a consistent approach before disseminating the information in terms of compliance."

In some cases, the goals are put out over an organization’s intranet or posted on bulletin boards, but that is not an effective approach if you fail to communicate a clear strategy for how to comply, Homa-Lowry says. You’ll also need a way to measure compliance with the goals, whether through performance improvement and risk management data or via feedback from observation rounds or patient tracers, she adds.

There were a few surprises in the 2005 goals, says Oglesby. "JCAHO had said the revisions in the goals would be related to Sentinel Event Alerts and/or sentinel events reported. However, the changes requested to meet compliance have not been reported through published Sentinel Event Alerts," she says. "Nor has JCAHO published definitions related to meeting compliance."

Here is a partial list of the specific requirements of the 2005 goals, with strategies for meeting each:

Define timeliness for reporting of critical test results.

At Louisiana State, a team is reviewing current organizational and departmental policies to determine "timeliness" and how it should be measured, Oglesby says. "The process will be implemented before Jan. 1 to meet compliance with the new standards," she says. "Each organization will need to define what is timely."

Identify look-alike/sound-alike medications.

The hospital’s pharmacy and therapeutics committee has spent several months working with the pharmacy to identify look-alike/sound-alike medications and to determine what additional steps, if any, should be taken, Oglesby reports.

"According to our recent survey, it is more than look-alike, sound-alike medications," says Oglesby. "The surveyor stated that different strengths of the same medication could not be stored in the same drawer."

This new goal allows room for interpretation, Oglesby adds. "I anticipate that the JCAHO will be answering a lot of questions concerning this goal," she says. "Who will define which medications look alike and sound alike, and determine what actions are appropriate? This is very subjective according to who is surveying compliance."

The hospital’s pharmacy has taken many actions over the past year to improve safety, such as separating look-alike medications, flagging bins where drugs are kept, highlighting differences in look-alike medications, and placing warning flags to alert pharmacists to sound-alike medications, says Oglesby.

"The main issue is narrowing down the list so that the pharmacist will heed the warning," she says. "If you have too many, they may get in the habit of seeing them and miss an important one."

Assess the risk of patient harm from falls.

The new goal requires not only assessment of a patient’s risk for falling, but periodic reassessment of the risk. This is a daunting challenge for large institutions due to patient volume and acuity, Oglesby says. "The more services provided by an organization, the more areas that must be included in the list for assessment," she says. "That’s not to mention the increased time it will take for documentation by staff that are already overworked."

A team is reviewing how the organization can meet this new standard. So far, areas at highest risk for patient falls have been identified, and a team of nurses has been assigned to select the tool that will be used to identify patients at risk, determine when to reassess a patient’s risk of falling, and address how falls are tracked and reported.

"We will be using the same scale for measuring falls as we do with variance reporting," Oglesby says.

At Cheshire Medical Center/Dartmouth Hitchcock Keene (NH), a falls prevention team has been in place for more than a year, and a variety of tools have been implemented to assess fall risk, says Chaele Ellsworth, RN, MBA, director of quality improvement/risk management/case management.

To comply with the new goal, falls prevention now is part of every inpatient initial nursing assessment, with various interventions implemented based on the patient’s score, Ellsworth says. "The new policy calls for the assessment to be done daily or as the patient’s condition changes," she says. "We are also changing our occurrence reporting forms to have a more detailed report completed for patient falls."

Although many organizations have purchased bed alarms or low beds for patients at risk for falling and have implemented policies for sitters to observe patients with the goal of avoiding restraints, patient education often is overlooked, says Homa-Lowry.

"Providing better documentation of education of patients about risk of falling when they get their medications is really important," she says. "Sometimes staff may say they have told the patient they are at risk for falling, but it’s often not specifically written in the medical records."

Reconcile medications across the continuum of care.

Of all the new goals, this one is the most problematic, says Tony Simek, Joint Commission coordinator at Abington (PA) Memorial Hospital. "This is a very challenging and worthwhile goal, but it requires automation to be efficient," he says. "Otherwise, it can be very, very labor-intensive — in other words, unrealistic."

Obtain list of patient’s current medications

The goal requires you to develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s entry to the organization, with the involvement of the patient. This process must allow for comparison of the medications the organization gives with those on the patient’s list. In addition, a complete list of the patient’s medications must be communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care, whether within or outside the organization.

"First of all, the whole idea of trying to get a current list of the medications a patient is on is going to be difficult," Homa-Lowry says. "Sometimes the patient is not the best resource, and the information is only going to be as good as what they give you."

Still, you should develop an approach for compliance as soon as possible, Homa-Lowry warns. "You’ve got about a year to do this," she says. She recommends doing a failure mode and effects analysis to determine the best approach. "Test what you want to do and see how effective it is. Have a group of people who really represent the continuum of care, and look at how they can come into compliance," she says.

This is a good way to work through glitches before a new process for reconciling medications is implemented, she says. "Look at what you want to do, and run it through the analysis to see how well you think it would be complied with, instead of just putting it out there," she says. "Determine each step that can fail and how it can fail, and determine the effect if it does fail."

Electronic medical record may help

The best way to meet this standard is still being discussed at Cheshire Medical/Dartmouth Hitchcock, says Ellsworth. "We hope that the electronic medical record used in our physician offices will help us with this," she says. In addition, a new medication administration check system will be implemented throughout the hospital for both inpatients and outpatients, she reports.

Two members of the organization’s medication safety committee have participated in Irving, TX-based VHA’s Medication Error Prevention Initiative since its inception, Ellsworth notes. "This collaborative of hospitals in New England has shared information and worked together on a variety of medication error reduction projects. I think this has kept us ahead of the curve on the goals related to medication use," she says.

[For more information on compliance with the Joint Commission’s 2005 National Patient Safety Goals, contact:

Chaele Ellsworth, RN, MBA, Director, Quality Improvement/Risk/Case Management, Cheshire Medical Center/Dartmouth Hitchcock Keene, 580-590 Court St., Keene, NH 03431. Telephone: (603) 354-5454, ext. 2180. E-mail:

Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 West Sutton Road, Metamora, MI 48455. Telephone: (810) 245-1535. Fax: (810) 245-1545. E-mail:

Leisa Oglesby, Assistant Hospital Administrator of Quality, 1541 Kings Highway, Shreveport, LA 71130. Telephone: (318) 675-5030. Fax: (318) 675-4646. E-mail:

Tony Simek, JCAHO Coordinator, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001-3788. E-mail:]