- Email: [email protected]
Update on the National Patient Safety Goals—Changes for 2005
Home Study Program
FEBRUARY 2005, VOL 81, NO 2
Home Study Program MANAGEMENT
Update on t h e National Patient Safety Goals-Changes for 2005
T
he article ”Update on the National Patient Safety Goalsqhanges for 2005” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 29,2008. Complete the examination answer sheet and learner evaluation found on pages 345-346 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.
You also may access this Home Study via AORN Online at http://www. aorn. org/journar/homestudy,/default.htm.
BEHAVIORAL OBJECTVIES After reading and studying the update on the National Patient Safety Goals, nurses will be able to
1. identify the current National Patient Safety Goals, 2. describe changes to the requirements of the original goals, and
3. discuss the two new goals that were added for 2005.
This program meets criteria for CNOR ond CRNFA recertification, os well as other continuing education requirements. A minimum score of 70% on the multiplechoice examination is necessary to earn I . 6 contact hours for this independent study.
Purpose/Goal: To educate perioperative nurses about the Joint Commission on Accredftation of Healthcare Organizations’ 2005
Wationol Patient Safety Goals.
AORN JOURNAL
335
FEBRUARY 2005, VOL 81, NO 2
Catalano
Home Study Program Update on t h e National Patient Safety Goals-Changes for 2005 MANAGEME~V~
Kathleen Catalano, RN
" S G s 4 and 6 from the 2003 and 2004 goaIs are not included in the 2005 goals. n February 2002, the Joint CommisNational Patient Safety Goal 4 (ie, sion on Accreditation of Healthcare eliminate wrong-site, wrong-patient, Organizations (JCAHO) formed the wrong-procedure surgery) remained in Sentinel Event Advisory Group to effect untd JCAHOs Universal Protocol develop the first National Patient Safety for Preventing Wrong Site, Wrong Goals (NPSGs)to help accredited health Procedure, Wrong Person Surgery care organizations address patient safe- became mandatory for all JCAHOty concerns. The initial six goals recom- accredited organizations on July 1,2004.' mended by the group were approved The Universal Protocol applies to all by JCAHOs Board of Commissioners surgical and other invasive procedures in July 2002 and took effect Jan 1,2003.' that expose patients to more than miniEach goal has one or more associated mal risk and includes procedures perrequirements that must be met to formed in settingsother than the OR (eg, achieve compliance. Each year, the special procedure units, endoscopy advisory group re-evaluates the NPSGs units, interventional radiology suites). and recommends additions, deletions, Compliance with the Universal Protocol or modifications to the goals and their is being surveyed by JCAHO as an specific requirements for the next year.' accreditation participation requirement. In 2004, a seventh goal was added. National Patient Safety Goal 6 (ie, For 2005, JCAHO developed program- improve the effectiveness of clinical speclfic goals for each of its accreditation alarm systems) has been incorporated programs to make the goals more rele- into JCAHO's Environment of Care vant to ddferent types of health care facil- Standards! This article recaps the curities2 Although the total number of rent NPSGs that apply to hospitals, NPSGs that apply to hospitals still is highlights changes that have been seven, two new goals have been added, made, and details how these changes and there are new requirements for some may affect perioperative services. of the original NPSGs. In addition,
I
NPSG I IMPROVE THE ACCURACY
ABSTRACT EACH YEAR SINCE 2003, the Joint Commission on Accreditation of Healthcare Organizations has established National Patient Safety Goals for accredited health care organizations. THE GOALS are developed to promote improvement in patient safety by helping health care organizations address specific safety concerns. -
discusses the CUXTentgoalSand for 2005. AoRN I (February 2005) 336-341. *Is
new
3 36
AORN JOURNAL
*'
OF PATIENT IDENTIFICATION
National Patient Safetv Goal 1 reauires staff members to confirm that they'have the correct patient and are preparing to perform the specific services and treatments that were ordered for this patient. For 2005, only one specific requirement is associated with thi goal o< improving patient identification accuracy: at least two patient-specific identifiers, neither of which can be the patient's room number, are to be used when administering medications or blood products, taking blood samples and other specimens for clinical
Catalan0
testing, or providing any other treatments or procedures.2 The two patient-specific identifiers can come from the same source (eg, a patient’s armband).A patient’s armband usually includes a wealth of information, such as the patient’s name, account number, telephone number, social security number, date of birth, and address, and each piece of data can serve as a patient-specific identifier. The patientspecific identifiers chosen should be compared to those on the medication administration record, physician order, or requisition to ascertain that h s is the correct patient. Documenting that two patient-specific identifiers were located and compared with the medication administration record, physician order, or requisition is not necessary. The Joint Commission has stated that when surveyors are on-site at a facility, they will observe staff members to ensure that the practice is in place and is being
FEBRUARY 2005, VOL 81, NO 2
test result read back the complete order or test result.2 The Joint Commission does not require the read-back to be documented; however, if the health care facility requires documentation, this policy must be followed. It is interesting to note that JCAHO states that this requirement applies to all caregivers, including physicians, so when physicians receive critical test results over the telephone, they are to read back the test results.6In the periopIn 2003, goal 1 included a second erative area, this may apply to the requirement that before the start of any postanesthesia care unit (PACU) more surgical or invasive procedure, a final than the OR. For example, if a PACU verification process, such as a time out, nurse knows that a physician is waiting be completed to confirm the correct for a particular critical test result on a patient, procedure, and site. The final recovering patient but the physician is verification was to be accomplished in the OR when the test result is using active, not passive, communica- received, the PACU nurse will call the tion technique^.^ This requirement was OR and speak with the physician, who included until July 1, 2004, when the then is expected to read back the critical test result. Universal Protocol was adopted. REQUIREMENT2B. During the first half NPSG Z-IMPROVE THE EFFEC~VENESS of 2004,31% of organizations undergoOF COMMUNICATION AMONGCAREGIVERS ing an accreditation survey received a For 2005, three requirements apply to Requirement for Improvement (ie, forthe goal of improving the effectiveness merly a Type I recommendation) for of communication. The third require- the standard covering abbreviations, ment (ie, 2C) is new for 2005. symbols, and acronyms not to be used REQUIREMENT 2A. Requirement 2A states in the medical record? Requirement 28 that for telephone orders or telephonic for NPSG 2 states that organizations reporting of critical test results, the com- must have a list of abbreviations, plete order or test must be verified by acronyms, and symbols that are not to having the person receiving the order or be used in the medical record.2 Each
A patient‘s armband contains numerous pieces of data that can be used as patientspecific identifiers.
AORN IOURNAL
33 7
Catalan0
FEBRUARY 2005, VOC 81, NO 2
TABLE1
The Joint Commission on Accreditation of Healthcare Organizations' Do-Not-Use Abbreviations' For
Write
U
unit
IU
International unit
QD
Daily
QOD
Every other day
.X mg
0.X mg (alwaysuse a leading zero)
X.0 mg
X mg (never use a trailing zero)
MS
Morphine sulfate
MSO4
Morphine sulfate
MgS04
Magnesium sulfate
1. "2004 National Patient Safety Goals-FAQs," Joint Commission on Accreditation of Healthcare Organizations, http:/ /www.jcaho.org/accredited+organizations /patient+safety/04+npsg/O4_faq~.htm (accessed 10 Dec 2004).
organization must adopt JCAHO'S published list of nine abbreviations, symbols, and acronyms not to be used (Table 1) and, as of April 2004, add three acronyms, symbols, or abbreviations of their own choosing to that list.' Use of do-not-use abbreviations, acronyms, and symbols in the perioperative area should be monitored, and corrective action should be taken if individuals continue to use them. REQUIREMENT 2c. Requirement 2 c is new for 2005, but it goes hand-in-hand with 2A. It requires an organization to measure, assess, and, if appropriate, take action to improve the timeliness of reporting and receipt of critical test results and values by the responsible licensed caregiver? If a physician does not read back orders or critical test results, perioperative staff members can document how often the read-back issue has arisen and give that information to the appropriate quality or physician
338
AORN JOURNAL
committee. That group then can determine what action, if any, to take.
NPSG
3-IMPROVE
THE
SAFETYOF USING MEDICATIONS The goal regarding medication safety has three specific requirements. Requirement 3C is new for 2005. comREQUIREMENTS 3A AND 3B. TO be pliance with requirement 3A, a facility must remove concentrated electrolytes, including, but not limited to, potassium chloride, potassium phosphate, and sodium chloride greater than 0.9%, from patient care units.' Compliance with requirement 3B requires standardizing and limiting the number of medication concentrations available in a facility.* Although in most organizations the pharmacy probably is leading efforts to remove concentrated electrolytes and limit the number of medication concentrations, it is prudent to make a thorough sweep of perioperative areas to determine if any concentrated electrolytes or excessive medication concentrations are stored somewhere that no one would expect. These medications could be used by someone unaware of their harmful potential. REQUIREMENT3C. Requirement 3C states that organizations are to identify and review at least annually a list of lookalike and sound-alike medications that are used in the facility and take action to prevent errors involving the interchange of these medications? The Joint Commission has provided three tables that list look-alike and sound-alike medications. The tables can be found on JCAHO's web site at http://www.jcaho.org /accredited+organizations/patient+safe ty/O5+npsg/lasa.pdf. To be in compliance with requirement 3C, organizations must list 10 look-alike or sound-alike medication combinations. At least five of these medication combinations are to be taken from the JCAHO document's table I (ie,
Catalan0
potentially problematic medications used in critical access hospitals, hospitals, office-based surgery) and table I1 (ie, potential problematic medications used in ambulatory care, assisted living, behavioral health care, disease-specific care, home care, long-term care) as appropriate to the type of organization. Five more medication combinations are to be selected from the JCAHO document’s tables I, 11, or I11 (ie, a supplemental list of medication pairs suggested by experts).*For example, three pairs of look-alike or sound-alike medications that might be found in the perioperative area are 0 ephedrine and epinephrine, 0 fentanyl and sufentanil, and 0 hydromorphone injection and morphine injection.
FEBRUARY 2005, VOL 81, NO 2
requirements for this goal. REQUIREMENT 7A. Requirement 7A requires organizations to comply with the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines? This involves compliance with all category I recommendations(ie, IA, IB) or requirements (ie, IC) in the NPSG 5-IMPROVETHE guidelines. Compliance with category I1 SAFETYOF INFUSION PUMPS The goal for infusion pump safety recommendations of the CDC’s hand has one specific requirement: that the hygiene guidelines is to be considered facility ensure free-flow protection on all for implementation but is not required general-use and patient-controlled anal- for accreditation purposes. The guidegesia IV infusion pumps used in the lines are available on the CDC’s web site facility.’ This goal refers to all ambulato- at http://www.cdc.gov/handhygiene/. REQUIREMENT 7B. Requirement 7B is to ry pumps, not syringe or enteral pumps. It is important to note.that as of January manage as sentinel events all identified 2004, add-on devices to achieve free- cases of unanticipated death or major flow protection no longer were accept- permanent loss of function associated with a health care-associated infection.2 able for compliance with this goal.6 In the event that an issue arises Reporting an infection of this magniregarding the safety considerations of tude has been a long-standing responinfusion pumps, a facility might consider sibility for facilities. If this becomes an consulting ECRI. The Joint Commission issue, facilities should consider involvviews ECRI as an authoritativesource on ing perioperative staff members in the the adequacy of free-flow protection for investigation of the sentinel event specific pump and administration set when performing the root cause analyconfigurations.6 The ECRI web site sis that is linked to an unanticipated death or major permanent loss of funcaddress is http://www.ecri.org. tion related to a health care-associated infection. Perioperative staff members’ NPSG T-REDUCE THE RISK OF expertise with aseptic technique and HEALTH CARE-ASSOCIATEDINFECTIONS The goal of reducing the risk of infection control may help others better health-care associated infections was understand events that could trigger added in 2004. There are two specific this type of incident.
The goal to reduce the risk of health careassociated infections requires organizations to comply with current Centers for Disease Control and Prevention hand hygiene guidelines.
AORN JOURNAL
339
FEBRUARY 2005, V0L 81, NO 2
Catalan0
communicated to the next service provider when the organization refers or transfers the patient to another setting, service, practitioner, or level of care within or outside the facility.2Tlus goal is especially applicable to the PACU and same day surgery areas because patients usually are transferred to another setting in the hospital from the PACU and discharged home after same day surgery. T h s process should not be too timeconsuming if the list is maintained electronically. If it is not, this process probably will be viewed as cumbersome and will require innovative planning to make it less onerous and more user-friendly. Facilities must develop a process for obtaining and documenting complete Lists of patients‘ current medications and be ready to implement this process by 2006.
3 40
NPSG 8-ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSSTHE CONTINUUM OF CARE The goal of reconciling patient medications is new for 2005. Facilities are to work on this goal during 2005 and be ready to implement it fully by January 2006. During 2005, JCAHO surveyors may ask facilities what steps they have taken or plan to take to comply with this goa1.j The goal has two requirements. REQUIREMENT8A. Requirement 8A is for facilities to develop a process for obtaining and documenting, with patient involvement if possible, a complete list of a patient’s current medications when the patient is admitted to the facility. This process should include a comparison of the medications the organization provides to those on the patient’s list.2For inpatients, this should not be problematic because a complete list of current medications should accompany them when they arrive in the OR for their procedure. This may not be true for same day surgery patients, however, because many of them undergo their preoperative tests and complete their paperwork on the morning of their procedure. REQUIREMENT 8B. The second requirement for this goal notes that a complete list of a patient’s medications is to be
AORN JOURNAL
NPSG R REDUCE THE RISK OF PATEINT HARMRESULTINGFROMFALLS There is only one specific requirement for the goal of reducing patient falls, which also is new for 2005. It states that organizations are to assess and periodically reassess each patient’s risk for falling, including the potential risk associated with a patient’s medication regimen, and take action to address any identified risks.z Age, physical condition, and disease processes can make patients more prone to falls even before they are wheeled into the OR. In the OR, patients may fall when they are moving to the OR bed or during a positioning change. In addition, the medications a patient receives in the OR may increase h s or her chances of falling. In many same day surgery settings, patients recover while they are sitting in a recliner. It is far easier for patients to get up unassisted from a recliner than from a bed, and patients who attempt to get up before they are fully recovered also may risk falling. Guidelines regarding potential falls should be written for the perioperative services area even if patient falls have never occurred in a facility’s perioperative area. Although the perception may
Catalano
FEBRUARY 2005, VOL 81, NO 2
be that patient falls usually do not occur in perioperative areas, it is wise to be prepared for the unexpected.
A SAFEENVIRONMENT As in the past, compliance with the NPSGs is mandatory for facilities that are or plan to become JCAHO accredited. The Joint Commission has made it clear that if one or more of its surveyors are on-site at a facility, whether for cause or to perform an accreditation survey, the NPSGs relevant to that facility will be surveyed and scored! In addition, malung the perioperative area as safe as possible for patients is a worthy objective. Health care professionals cannot eliminate all risk, but they must strive to identify possible safety hazards and lessen their effect on patients. *:*
Kathleen Catalano, RN, JD, is director of regulatory compliance, Provider Health Net Services, Addison, Tex. Editor’s note: Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill.
NOTES 1.“Facts about the 2005 National Patient Safety Goals,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+organizations/patient+ safety/05+npsgfacts.htm (accessed 7 Dec 2004). 2.”The Joint Commission announces the 2005 National Patient Safety Goals and requirements,” Joint Commission Perspectives 24 (August 2004) 1,3-10. 3. “Frequently asked questions about the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+organizations/patient +safety/universal+protocol/faqup.htm (accessed 10 Dec 2004). 4. ”This month at the Joint Commission,” (April 2004) Joint Commission on Accreditation of Healthcare Or anizations, http://
www.~caho.org/about+us~ews+letfevslthb+mo nth+&ri1+2004.htm (accessed 27 Dec 2004). 5. ”Hospital executive briefings for 2005,” Joint Commission Resources Conference, Dallas, 14 Sept 2004. 6. ”2004 National Patient Safety GoalsFAQs,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho .org/accredited+organizations/patient+safety/04+ npsg/04#aqs.htm (accessed 10 Dec 2004). 7. ”JCAHO a proves National Patient Safety Goals E r 2003,” Joint Commission Perspectives 22 (September 2002) 1-3. 8. ”Look-alike/sound-alikedru list,” Joint Commission on Accreditation o Healthcare Organizations, http://www.jcaho.org/accredit ed+organizations/patient+safety/05+npsg/lasa .pdf (accessed 27 Dec 2004).
f
Autism and Brain‘s Immune System Linked, Says Study esearchers have found evidence that the brains R of some people with autism show clear signs of inflammation, suggesting that the disease may be associated with activation of the brain’s immune system, according to a Nov 15, 2004, news release from Johns Hopkins Medicine, Baltimore. The findings support the theory t h a t immune response in the brain is involved in autism, although it is not clear whether the inflammation is a cause or a consequence of the disease. Researchers examined tissue from three regions of the brain in 11 people with autism, aged five to 44 years, who had died of injuries. They also measured levels of two immune system proteins, cytokines
and chemokines, found in the cerebrospinal fluid in six living patients with autism, aged five to 12 years. Compared with normal control brains, the brains of people with autism showed evidence of an ongoing inflammatory process i n different regions of the brain. Cytokine and chemokine levels in the cerebrospinal fluid also were elevated in patients with autism. The findings may provide a good starting point for developing new treatments. Brain’s Immune System Triggered in Autism (news release, Baltimore: Johns Hopkins Medicine, Nov 15, 2004) http:// www. hopkinsmedicine.org/Press_releases/2004/11_15a_04 .html (accessed 8 Dec 2004). AORN JOURNAL
3 41
FEBRUARY 2005, VOL 81, NO 2
Home Study Program MANAGEMENT
Update on t h e National Patient Safety Goals-Changes for 2005
T
he article ”Update on the National Patient Safety Goalsqhanges for 2005” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 29,2008. Complete the examination answer sheet and learner evaluation found on pages 345-346 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.
You also may access this Home Study via AORN Online at http://www. aorn. org/journar/homestudy,/default.htm.
BEHAVIORAL OBJECTVIES After reading and studying the update on the National Patient Safety Goals, nurses will be able to
1. identify the current National Patient Safety Goals, 2. describe changes to the requirements of the original goals, and
3. discuss the two new goals that were added for 2005.
This program meets criteria for CNOR ond CRNFA recertification, os well as other continuing education requirements. A minimum score of 70% on the multiplechoice examination is necessary to earn I . 6 contact hours for this independent study.
Purpose/Goal: To educate perioperative nurses about the Joint Commission on Accredftation of Healthcare Organizations’ 2005
Wationol Patient Safety Goals.
AORN JOURNAL
335
FEBRUARY 2005, VOL 81, NO 2
Catalano
Home Study Program Update on t h e National Patient Safety Goals-Changes for 2005 MANAGEME~V~
Kathleen Catalano, RN
" S G s 4 and 6 from the 2003 and 2004 goaIs are not included in the 2005 goals. n February 2002, the Joint CommisNational Patient Safety Goal 4 (ie, sion on Accreditation of Healthcare eliminate wrong-site, wrong-patient, Organizations (JCAHO) formed the wrong-procedure surgery) remained in Sentinel Event Advisory Group to effect untd JCAHOs Universal Protocol develop the first National Patient Safety for Preventing Wrong Site, Wrong Goals (NPSGs)to help accredited health Procedure, Wrong Person Surgery care organizations address patient safe- became mandatory for all JCAHOty concerns. The initial six goals recom- accredited organizations on July 1,2004.' mended by the group were approved The Universal Protocol applies to all by JCAHOs Board of Commissioners surgical and other invasive procedures in July 2002 and took effect Jan 1,2003.' that expose patients to more than miniEach goal has one or more associated mal risk and includes procedures perrequirements that must be met to formed in settingsother than the OR (eg, achieve compliance. Each year, the special procedure units, endoscopy advisory group re-evaluates the NPSGs units, interventional radiology suites). and recommends additions, deletions, Compliance with the Universal Protocol or modifications to the goals and their is being surveyed by JCAHO as an specific requirements for the next year.' accreditation participation requirement. In 2004, a seventh goal was added. National Patient Safety Goal 6 (ie, For 2005, JCAHO developed program- improve the effectiveness of clinical speclfic goals for each of its accreditation alarm systems) has been incorporated programs to make the goals more rele- into JCAHO's Environment of Care vant to ddferent types of health care facil- Standards! This article recaps the curities2 Although the total number of rent NPSGs that apply to hospitals, NPSGs that apply to hospitals still is highlights changes that have been seven, two new goals have been added, made, and details how these changes and there are new requirements for some may affect perioperative services. of the original NPSGs. In addition,
I
NPSG I IMPROVE THE ACCURACY
ABSTRACT EACH YEAR SINCE 2003, the Joint Commission on Accreditation of Healthcare Organizations has established National Patient Safety Goals for accredited health care organizations. THE GOALS are developed to promote improvement in patient safety by helping health care organizations address specific safety concerns. -
discusses the CUXTentgoalSand for 2005. AoRN I (February 2005) 336-341. *Is
new
3 36
AORN JOURNAL
*'
OF PATIENT IDENTIFICATION
National Patient Safetv Goal 1 reauires staff members to confirm that they'have the correct patient and are preparing to perform the specific services and treatments that were ordered for this patient. For 2005, only one specific requirement is associated with thi goal o< improving patient identification accuracy: at least two patient-specific identifiers, neither of which can be the patient's room number, are to be used when administering medications or blood products, taking blood samples and other specimens for clinical
Catalan0
testing, or providing any other treatments or procedures.2 The two patient-specific identifiers can come from the same source (eg, a patient’s armband).A patient’s armband usually includes a wealth of information, such as the patient’s name, account number, telephone number, social security number, date of birth, and address, and each piece of data can serve as a patient-specific identifier. The patientspecific identifiers chosen should be compared to those on the medication administration record, physician order, or requisition to ascertain that h s is the correct patient. Documenting that two patient-specific identifiers were located and compared with the medication administration record, physician order, or requisition is not necessary. The Joint Commission has stated that when surveyors are on-site at a facility, they will observe staff members to ensure that the practice is in place and is being
FEBRUARY 2005, VOL 81, NO 2
test result read back the complete order or test result.2 The Joint Commission does not require the read-back to be documented; however, if the health care facility requires documentation, this policy must be followed. It is interesting to note that JCAHO states that this requirement applies to all caregivers, including physicians, so when physicians receive critical test results over the telephone, they are to read back the test results.6In the periopIn 2003, goal 1 included a second erative area, this may apply to the requirement that before the start of any postanesthesia care unit (PACU) more surgical or invasive procedure, a final than the OR. For example, if a PACU verification process, such as a time out, nurse knows that a physician is waiting be completed to confirm the correct for a particular critical test result on a patient, procedure, and site. The final recovering patient but the physician is verification was to be accomplished in the OR when the test result is using active, not passive, communica- received, the PACU nurse will call the tion technique^.^ This requirement was OR and speak with the physician, who included until July 1, 2004, when the then is expected to read back the critical test result. Universal Protocol was adopted. REQUIREMENT2B. During the first half NPSG Z-IMPROVE THE EFFEC~VENESS of 2004,31% of organizations undergoOF COMMUNICATION AMONGCAREGIVERS ing an accreditation survey received a For 2005, three requirements apply to Requirement for Improvement (ie, forthe goal of improving the effectiveness merly a Type I recommendation) for of communication. The third require- the standard covering abbreviations, ment (ie, 2C) is new for 2005. symbols, and acronyms not to be used REQUIREMENT 2A. Requirement 2A states in the medical record? Requirement 28 that for telephone orders or telephonic for NPSG 2 states that organizations reporting of critical test results, the com- must have a list of abbreviations, plete order or test must be verified by acronyms, and symbols that are not to having the person receiving the order or be used in the medical record.2 Each
A patient‘s armband contains numerous pieces of data that can be used as patientspecific identifiers.
AORN IOURNAL
33 7
Catalan0
FEBRUARY 2005, VOC 81, NO 2
TABLE1
The Joint Commission on Accreditation of Healthcare Organizations' Do-Not-Use Abbreviations' For
Write
U
unit
IU
International unit
QD
Daily
QOD
Every other day
.X mg
0.X mg (alwaysuse a leading zero)
X.0 mg
X mg (never use a trailing zero)
MS
Morphine sulfate
MSO4
Morphine sulfate
MgS04
Magnesium sulfate
1. "2004 National Patient Safety Goals-FAQs," Joint Commission on Accreditation of Healthcare Organizations, http:/ /www.jcaho.org/accredited+organizations /patient+safety/04+npsg/O4_faq~.htm (accessed 10 Dec 2004).
organization must adopt JCAHO'S published list of nine abbreviations, symbols, and acronyms not to be used (Table 1) and, as of April 2004, add three acronyms, symbols, or abbreviations of their own choosing to that list.' Use of do-not-use abbreviations, acronyms, and symbols in the perioperative area should be monitored, and corrective action should be taken if individuals continue to use them. REQUIREMENT 2c. Requirement 2 c is new for 2005, but it goes hand-in-hand with 2A. It requires an organization to measure, assess, and, if appropriate, take action to improve the timeliness of reporting and receipt of critical test results and values by the responsible licensed caregiver? If a physician does not read back orders or critical test results, perioperative staff members can document how often the read-back issue has arisen and give that information to the appropriate quality or physician
338
AORN JOURNAL
committee. That group then can determine what action, if any, to take.
NPSG
3-IMPROVE
THE
SAFETYOF USING MEDICATIONS The goal regarding medication safety has three specific requirements. Requirement 3C is new for 2005. comREQUIREMENTS 3A AND 3B. TO be pliance with requirement 3A, a facility must remove concentrated electrolytes, including, but not limited to, potassium chloride, potassium phosphate, and sodium chloride greater than 0.9%, from patient care units.' Compliance with requirement 3B requires standardizing and limiting the number of medication concentrations available in a facility.* Although in most organizations the pharmacy probably is leading efforts to remove concentrated electrolytes and limit the number of medication concentrations, it is prudent to make a thorough sweep of perioperative areas to determine if any concentrated electrolytes or excessive medication concentrations are stored somewhere that no one would expect. These medications could be used by someone unaware of their harmful potential. REQUIREMENT3C. Requirement 3C states that organizations are to identify and review at least annually a list of lookalike and sound-alike medications that are used in the facility and take action to prevent errors involving the interchange of these medications? The Joint Commission has provided three tables that list look-alike and sound-alike medications. The tables can be found on JCAHO's web site at http://www.jcaho.org /accredited+organizations/patient+safe ty/O5+npsg/lasa.pdf. To be in compliance with requirement 3C, organizations must list 10 look-alike or sound-alike medication combinations. At least five of these medication combinations are to be taken from the JCAHO document's table I (ie,
Catalan0
potentially problematic medications used in critical access hospitals, hospitals, office-based surgery) and table I1 (ie, potential problematic medications used in ambulatory care, assisted living, behavioral health care, disease-specific care, home care, long-term care) as appropriate to the type of organization. Five more medication combinations are to be selected from the JCAHO document’s tables I, 11, or I11 (ie, a supplemental list of medication pairs suggested by experts).*For example, three pairs of look-alike or sound-alike medications that might be found in the perioperative area are 0 ephedrine and epinephrine, 0 fentanyl and sufentanil, and 0 hydromorphone injection and morphine injection.
FEBRUARY 2005, VOL 81, NO 2
requirements for this goal. REQUIREMENT 7A. Requirement 7A requires organizations to comply with the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines? This involves compliance with all category I recommendations(ie, IA, IB) or requirements (ie, IC) in the NPSG 5-IMPROVETHE guidelines. Compliance with category I1 SAFETYOF INFUSION PUMPS The goal for infusion pump safety recommendations of the CDC’s hand has one specific requirement: that the hygiene guidelines is to be considered facility ensure free-flow protection on all for implementation but is not required general-use and patient-controlled anal- for accreditation purposes. The guidegesia IV infusion pumps used in the lines are available on the CDC’s web site facility.’ This goal refers to all ambulato- at http://www.cdc.gov/handhygiene/. REQUIREMENT 7B. Requirement 7B is to ry pumps, not syringe or enteral pumps. It is important to note.that as of January manage as sentinel events all identified 2004, add-on devices to achieve free- cases of unanticipated death or major flow protection no longer were accept- permanent loss of function associated with a health care-associated infection.2 able for compliance with this goal.6 In the event that an issue arises Reporting an infection of this magniregarding the safety considerations of tude has been a long-standing responinfusion pumps, a facility might consider sibility for facilities. If this becomes an consulting ECRI. The Joint Commission issue, facilities should consider involvviews ECRI as an authoritativesource on ing perioperative staff members in the the adequacy of free-flow protection for investigation of the sentinel event specific pump and administration set when performing the root cause analyconfigurations.6 The ECRI web site sis that is linked to an unanticipated death or major permanent loss of funcaddress is http://www.ecri.org. tion related to a health care-associated infection. Perioperative staff members’ NPSG T-REDUCE THE RISK OF expertise with aseptic technique and HEALTH CARE-ASSOCIATEDINFECTIONS The goal of reducing the risk of infection control may help others better health-care associated infections was understand events that could trigger added in 2004. There are two specific this type of incident.
The goal to reduce the risk of health careassociated infections requires organizations to comply with current Centers for Disease Control and Prevention hand hygiene guidelines.
AORN JOURNAL
339
FEBRUARY 2005, V0L 81, NO 2
Catalan0
communicated to the next service provider when the organization refers or transfers the patient to another setting, service, practitioner, or level of care within or outside the facility.2Tlus goal is especially applicable to the PACU and same day surgery areas because patients usually are transferred to another setting in the hospital from the PACU and discharged home after same day surgery. T h s process should not be too timeconsuming if the list is maintained electronically. If it is not, this process probably will be viewed as cumbersome and will require innovative planning to make it less onerous and more user-friendly. Facilities must develop a process for obtaining and documenting complete Lists of patients‘ current medications and be ready to implement this process by 2006.
3 40
NPSG 8-ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSSTHE CONTINUUM OF CARE The goal of reconciling patient medications is new for 2005. Facilities are to work on this goal during 2005 and be ready to implement it fully by January 2006. During 2005, JCAHO surveyors may ask facilities what steps they have taken or plan to take to comply with this goa1.j The goal has two requirements. REQUIREMENT8A. Requirement 8A is for facilities to develop a process for obtaining and documenting, with patient involvement if possible, a complete list of a patient’s current medications when the patient is admitted to the facility. This process should include a comparison of the medications the organization provides to those on the patient’s list.2For inpatients, this should not be problematic because a complete list of current medications should accompany them when they arrive in the OR for their procedure. This may not be true for same day surgery patients, however, because many of them undergo their preoperative tests and complete their paperwork on the morning of their procedure. REQUIREMENT 8B. The second requirement for this goal notes that a complete list of a patient’s medications is to be
AORN JOURNAL
NPSG R REDUCE THE RISK OF PATEINT HARMRESULTINGFROMFALLS There is only one specific requirement for the goal of reducing patient falls, which also is new for 2005. It states that organizations are to assess and periodically reassess each patient’s risk for falling, including the potential risk associated with a patient’s medication regimen, and take action to address any identified risks.z Age, physical condition, and disease processes can make patients more prone to falls even before they are wheeled into the OR. In the OR, patients may fall when they are moving to the OR bed or during a positioning change. In addition, the medications a patient receives in the OR may increase h s or her chances of falling. In many same day surgery settings, patients recover while they are sitting in a recliner. It is far easier for patients to get up unassisted from a recliner than from a bed, and patients who attempt to get up before they are fully recovered also may risk falling. Guidelines regarding potential falls should be written for the perioperative services area even if patient falls have never occurred in a facility’s perioperative area. Although the perception may
Catalano
FEBRUARY 2005, VOL 81, NO 2
be that patient falls usually do not occur in perioperative areas, it is wise to be prepared for the unexpected.
A SAFEENVIRONMENT As in the past, compliance with the NPSGs is mandatory for facilities that are or plan to become JCAHO accredited. The Joint Commission has made it clear that if one or more of its surveyors are on-site at a facility, whether for cause or to perform an accreditation survey, the NPSGs relevant to that facility will be surveyed and scored! In addition, malung the perioperative area as safe as possible for patients is a worthy objective. Health care professionals cannot eliminate all risk, but they must strive to identify possible safety hazards and lessen their effect on patients. *:*
Kathleen Catalano, RN, JD, is director of regulatory compliance, Provider Health Net Services, Addison, Tex. Editor’s note: Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill.
NOTES 1.“Facts about the 2005 National Patient Safety Goals,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+organizations/patient+ safety/05+npsgfacts.htm (accessed 7 Dec 2004). 2.”The Joint Commission announces the 2005 National Patient Safety Goals and requirements,” Joint Commission Perspectives 24 (August 2004) 1,3-10. 3. “Frequently asked questions about the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery,” Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+organizations/patient +safety/universal+protocol/faqup.htm (accessed 10 Dec 2004). 4. ”This month at the Joint Commission,” (April 2004) Joint Commission on Accreditation of Healthcare Or anizations, http://
www.~caho.org/about+us~ews+letfevslthb+mo nth+&ri1+2004.htm (accessed 27 Dec 2004). 5. ”Hospital executive briefings for 2005,” Joint Commission Resources Conference, Dallas, 14 Sept 2004. 6. ”2004 National Patient Safety GoalsFAQs,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho .org/accredited+organizations/patient+safety/04+ npsg/04#aqs.htm (accessed 10 Dec 2004). 7. ”JCAHO a proves National Patient Safety Goals E r 2003,” Joint Commission Perspectives 22 (September 2002) 1-3. 8. ”Look-alike/sound-alikedru list,” Joint Commission on Accreditation o Healthcare Organizations, http://www.jcaho.org/accredit ed+organizations/patient+safety/05+npsg/lasa .pdf (accessed 27 Dec 2004).
f
Autism and Brain‘s Immune System Linked, Says Study esearchers have found evidence that the brains R of some people with autism show clear signs of inflammation, suggesting that the disease may be associated with activation of the brain’s immune system, according to a Nov 15, 2004, news release from Johns Hopkins Medicine, Baltimore. The findings support the theory t h a t immune response in the brain is involved in autism, although it is not clear whether the inflammation is a cause or a consequence of the disease. Researchers examined tissue from three regions of the brain in 11 people with autism, aged five to 44 years, who had died of injuries. They also measured levels of two immune system proteins, cytokines
and chemokines, found in the cerebrospinal fluid in six living patients with autism, aged five to 12 years. Compared with normal control brains, the brains of people with autism showed evidence of an ongoing inflammatory process i n different regions of the brain. Cytokine and chemokine levels in the cerebrospinal fluid also were elevated in patients with autism. The findings may provide a good starting point for developing new treatments. Brain’s Immune System Triggered in Autism (news release, Baltimore: Johns Hopkins Medicine, Nov 15, 2004) http:// www. hopkinsmedicine.org/Press_releases/2004/11_15a_04 .html (accessed 8 Dec 2004). AORN JOURNAL
3 41