SDS Accreditation Update

Improvement seen in quality measures

Prophylactic antibiotics, marking site studied

American hospitals are making measurable strides in the quality of care provided for patients with surgical conditions, according to Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007, The Joint Commission's second report on health care quality and patient safety in hospitals. The detailed report portrays the aggregate performance of accredited hospitals against The Joint Commission's standardized national performance measures and its National Patient Safety Goals.

Surgery programs showed overall improvement in administration of prophylactic antibiotics within one hour prior to surgical incision and discontinued use of antibiotic within 24 hours of surgery. The national average of 86.7% administration of antibiotics within one hour of surgery is a 4.9% improvement from the previous year's results. Hospitals reported 87% of hysterectomy patients receiving antibiotics within one hour prior to surgery, which represented an improvement of 4.7%. Knee joint replacement patients received antibiotics within one hour of surgery in 90.4% of cases, which represents an improvement of 5.3%, the most significant improvement for this measure.

Stopping antibiotics within 24 hours also is a significant factor in reducing the risk of surgical site infections, and 78.9% of hospitals surveyed by The Joint Commission for this report did stop antibiotics within 24 hours. This represents an improvement of 5.4% over the previous year.

Compliance with safety goals

Compliance with National Patient Safety Goals related specifically to surgery show high compliance rates. Ninety-one percent of surgery programs complied with Requirement 3D, which requires the labeling of all medication containers in the operating room. The study reports a 97% compliance rate with Requirement 4A, which mandates a preoperative verification process to ensure correct patient and procedure identification. More than 93% of surgery programs comply with Requirement 4B, which addresses marking the surgical site.

To see a copy of the Annual Report go to and select "Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007" on the left navigational bar under "top spots." To view individual hospitals' performance on the measures included in the study, go to and search by name, state, or zip code.