SDS Accreditation Update
Three National Patient Safety Goals present compliance challenge in outpatient surgery
Abbreviation standards not met in more than 17% of surveys
Ambulatory programs' compliance rate for 13 of the 16 applicable National Safety Patient Goals exceeded 93% in 2005. However, the remaining three goals met compliance requirements less than 89% of the time. Timeout before the start of a procedure, read-back of verbal orders, and standardization of abbreviations are all challenges for organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations, according to 2005 compliance data.
Hospital compliance rates for the three categories were 82.7% with timeout requirement, 87.7% with read-back of verbal orders, and 61.4% for standardization of abbreviations.
Compliance for the goal that requires a timeout in the operating or procedure room immediately before the procedure to verify the patient's identity, the surgical site, and the procedure was only 86.1% at ambulatory facilities. "We tend to see higher compliance in settings that involve more major procedures, so ambulatory surgery is vulnerable to a breakdown in this process," says Richard Croteau, MD, executive director for patient safety initiatives for the Joint Commission.
While the organization may have a written policy and may have educated staff members on the process, because the procedures are minor, staff members don't always conduct timeouts consistently, he explains. "Orthopedics is probably the specialty area that most consistently verifies site and procedure, but no specialty is exempt from performing a timeout," he points out.
Using visual reminders
At SurgiCenter Services of Pitt in Greenville, NC, staff members always remember to perform timeouts, says Ann Purvis, RN, BSN, CNOR, surgical services clinical director and director of nursing. "In our educational sessions, we stress the fact that every staff member must stop what they are doing for the timeout, and we not only perform a verbal verification of patient name, procedure, and site, but we also have a visual reminder for staff members," she explains.
A staff member writes the patient and procedure information on a whiteboard in the operating room as the information is verified, Purvis adds.
Timing of this process is important, she points out. "You can mark the site at any time, but the timeout to verify the site must be done after the patient is prepped and draped and immediately before the procedure," she says. Waiting until the patient is draped is critical because you want to make sure that staff can see the marked site after the drapes are on the patient, Purvis adds.
Only 89.3% of ambulatory programs complied with the patient safety goal that requires the read-back of verbal or telephone orders to ensure accuracy, Croteau says. While outpatient surgery managers may have the policies in place, the actual read-back is not happening, he explains.
It is important that staff members understand that repeat-back and read-back are different things, Croteau points out. "When receiving a telephone or verbal order, the staff member should write the order, then read what is written back to the physician to make sure the order was heard correctly," he says. Too many times, a staff member will just repeat what was said, then invert numbers when he or she writes the order, Croteau says. "A true read back will prevent this error from occurring."
At SurgiCenter Services of Pitt, staff write and read back all verbal orders, even those given to the nurse during surgery, Purvis reports. While some staff members initially may believe that writing and reading back standard orders is not necessary, she emphasizes that it must take place for every order.
The manager of an outpatient surgery program in the Southeast, who asked not to be identified, admits, "We got gigged on this part of the patient safety goals."
During one of the procedures that the surveyor observed, the surgeon asked the nurse to administer an antibiotic, she says. Because the nurse worked with the surgeon every day on the same type of procedure, she administered the medication without reading back the order. "The nurse told me that because the surgeon asked for the same medication for every patient undergoing this procedure, she just thought of it as a standing order," the source says. "We now know that even routine, recurring instructions must be read back."
Abbreviations pose problems
The goal that posted the lowest compliance rate for both ambulatory and hospital organizations is the requirement to standardize abbreviations. Only 82.1% of ambulatory organizations and 61.4% of hospitals complied with this goal.
"I'm not surprised that all organizations are having trouble with this safety goal," admits Croteau. "You are asking people to change behavior that they learned many years ago in medical or nursing school."
In addition to continuous education and monitoring, programs might consider automated order systems that will not accept improper abbreviations, suggests Croteau. "Other surgery programs have had success with pre-printed order sheets on which none of the prohibited terms are included," he adds.
The do-not-use abbreviations that most frequently appear in the charts reviewed by surveyors are "QD" and "U," says Croteau. "We are seeing more people accepting the fact that they need to write 'units,' but many practitioners don't want to give up 'QD,'" he admits.
In addition to these three problem areas identified in 2005, Croteau points out a few 2006 National Patient Safety Goals that are presenting challenges to organizations surveyed this year. "Hand-off communications, medication reconciliation, and labeling medications in the sterile field are all tough goals for outpatient surgery programs," he says. "We don't have a full year of data yet on these goals, but they appear to be presenting the most problems for our surveyed organizations," Croteau adds.
Sources/Resource
For more information about meeting patient safety goal requirements, contact:
- Richard Croteau, MD, Executive Director for Patient Safety Initiatives, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, IL 60181. Phone: (630) 792-5776. Fax: (630) 792-5005. E-mail: [email protected].
- Ann Purvis, RN, BSN, CNOR, Surgical Ser-vices Clinical Director and Director of Nursing, SurgiCenter Services of Pitt, 102 Bethesda Drive, Greenville, NC 27834. Telephone: (252) 847-7700. E-mail: [email protected].
A list of abbreviations, symbols, and dose designations most often associated with medication errors is available at the Institute for Safe Medication Practices (ISMP) web site: www.ismp.org/PDF/ErrorProne.pdf. Some of those notations are included in the current National Patient Safety Goal 2B, a do-not-use list of error-pone abbreviations and dose designations; however, ISMP's listing includes additional abbreviations that have been associated with medication errors reported to the USP-ISMP Medication Errors Reporting Program. For more information, contact:
- ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Phone: (215) 947-7797. Fax: (215) 914-1492. E-mail: [email protected].
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