JCAHO alters its patient safety goal requirements

Recent action by JCAHO of interest to risk managers:

• After hosting the recent National Summit on Medical Abbreviations with several other organizations, JCAHO modified the 2005 requirements for meeting National Patient Safety Goal 2b — "Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use."

Now the goal applies only to all orders and all medication-related documents (a reduced requirement). It also applies to pre-printed forms, for which 100% compliance is expected (extends the requirement beyond handwritten documentation, but is a reduced requirement from that planned for 2005).

The minimum expected level of compliance for handwritten documentation remains at 90%, JCAHO reports.

Rule of 6 on its way out

• After consulting safety experts, JCAHO reaffirmed the requirement that pediatric hospitals and services which currently use the "Rule of 6" convert to standardized concentrations, as required by National Patient Safety Goal 3b, no later than Dec. 31, 2008.

The Rule of 6 is a methodology used in pediatrics to simplify intravenous preparation of weight-based drugs. JCAHO notes that a significant number of pediatric hospitals have requested permission to continue to use the Rule of 6 as an alternative approach to the requirement during some or all of the interim period.

Requests for alternative approaches to National Patient Safety Goal 3b "will continue to be considered and will require ongoing evidence of progress toward full implementation by Dec. 31, 2008, of the use of standardized drug concentrations," JCAHO reports. To be considered for the exceptions process, JCAHO requires a provider to meet these criteria:

  • The exception applies only to neonatal or pediatric acute care services.
  • All (emergent and nonemergent) admixtures are prepared only by pharmacy staff in a sterile environment.
  • Calculations of the drug solutions are validated during the preparation.
  • The labeling of solution concentration and drug per milliliter are clear to all caregivers, and the solution concentration (amount of drug per unit volume of solution) is clearly indicated on the label.
  • If the Rule of 6 is used in a pediatric setting, but standardized drug concentrations are used in other parts of the hospital, guidance aids are made available to caregivers who may not be familiar with one of these systems.
  • If the organization has a Neonatal Intensive Care Unit, the pharmacy is open 24 hours a day to support the admixture service.
  • The facility uses smart pumps designed to recognize prescription errors, dose misinterpretations and keypad programming errors.

Free-flow protection now scored

• The Sentinel Event Advisory Group has begun the process of identifying potential 2006 National Patient Safety Goals and the group recently provided advice on current goals.

With regard to "free-flow" protection for infusion pumps, the group confirmed that all organizations should be scored for compliance beginning Jan. 1, 2005. Also, the interpretive guideline on the JCAHO web site will clarify that, in relation to intravenous administration sets used with infusion pumps, it will be acceptable to have "pre-assembled" free-flow protective mechanisms instead of "intrinsic" free-flow protection.

Concerning the requirement to report critical test results "directly" to physicians, the group advised that for 2006, the word "directly" should be deleted from Requirement 2d for laboratories. Beginning Jan. 1, 2005, JCAHO changed the interpretive guidelines for Requirement 2d for laboratories to say that "directly" reporting critical test results can include reporting to an authorized agent of the responsible licensed caregiver.

The Sentinel Event Advisory Group also recommended these topics for field review as potential 2006 Patient Safety Goals: culture of safety; patient involvement in safety; multidose medication vials; wrong-line connections; health care worker fatigue; delays in treatment; anticoagulant, insulin and narcotic use; and decubitus ulcers.

Must measure quality of organ procurement

• JCAHO also revised a requirement concerning organ procurement. Effective July 2005, standard PI.1.10 will require hospitals and critical access hospitals to "measure the effectiveness of their organ procurement efforts: The conversion rate data are collected and analyzed and, when possible, steps are taken to improve the rate. The conversion rate is the number of actual organ donors over the number of eligible donors as defined by the organ procurement organization. The intent of the requirement is to optimize the conversion of potential donors to become actual donors."