The new 2004 National Patient Safety Goals released recently by the Joint Commission on Accreditation of Healthcare Organizations continue all of the 2003 goals and add one to reduce health care-acquired infections.
When the 2004 goals were announced, JCAHO president Dennis S. O’Leary, MD, said the panel that developed the recommendations "felt strongly that the current six National Patient Safety Goals require the continued close attention of America’s health care organizations." He went on to say that "reduction of unanticipated deaths related to nosocomial infections must become a top priority for hospital and other health care organization leaders."
There are evidence-based requirements for each goal that set forth clear expectations for health care organizations to address specific types of health care errors. The 2003 requirement to "read back" verbal and telephone orders in order to confirm their accuracy has been expanded for 2004 to include the read-back of critical test results that are communicated verbally.
JCAHO-accredited providers will be evaluated on the 2004 goals beginning Jan. 1, 2004. Organizations still will be able to seek prior approval by the Joint Commission of suitable alternatives to the requirements.
Goals and requirements
These are the 2004 National Patient Safety Goals and Requirements:
Goal 1: Improve the accuracy of patient identification.
Requirements:
- Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
- Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active — not passive — communication techniques.
Goal 2: Improve the effectiveness of communication among caregivers.
Requirements:
- Implement a process for taking verbal or telephone orders or critical test results that requires a verification "read-back" of the complete order or test result by the person receiving the order or test result.
- Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use.
Goal 3: Improve the safety of using high-alert medications.
Requirements:
- Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.
- Standardize and limit the number of drug concentrations available in the organization.
Goal 4: Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
Requirements:
- Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents, (e.g., medical records, imaging studies) are available.
- Implement a process to mark the surgical site, and involve the patient in the marking process.
Goal 5: Improve the safety of using infusion pumps.
Requirements:
- Ensure free-flow protection on all general-use and PCA intravenous infusion pumps used in the organization.
Goal 6: Improve the effectiveness of clinical alarm systems.
Requirements:
- Implement regular preventive maintenance and testing of alarm systems.
- Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
Goal 7: Reduce the risk of health care-acquired infections.
Requirements:
- Comply with current CDC hand-hygiene guidelines.
- Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.
Organizations that wish to submit alternative approaches to the recommendations associated with the National Patient Safety Goals can do so by filling out a "Request for Review of an Alternative Approach" form available at the JCAHO web site, www.jcaho.org. A form should be submitted for each alternative must be submitted by the accredited organization or health care system. Forms submitted by consultants will not be accepted for consideration. The form should be submitted to JCAHO no fewer than 60 days prior to a scheduled survey.
Members of the Sentinel Event Alert Advisory Group will review each form and advise JCAHO on the acceptability of the alternative. The organization will be notified prior to its scheduled survey whether its alternative is acceptable or not. If not accepted, the organization will be provided with the rationale and will need to revise the alternative until it is approved or implement the recommendation issued by JCAHO.
If an organization is surveyed and has implemented an alternative that has yet to be reviewed, the surveyor will record a score of 3 for the relevant Accreditation Participation Requirement, include a description of the alternative and identify that an alternative needs to be reviewed.
When the report is received at JCAHO’s central office, the organization’s account representative will begin or follow-up on the process for review of the alternative. Upon disposition by JCAHO, the organization’s score will be changed to reflect either acceptance (score of 1) or rejection (score of 5) of the alternative. If the alternative is rejected, the organization will receive a special Type I recommendation and will be required to submit a written progress report.
The new 2004 National Patient Safety Goals released recently by the Joint Commission on Accreditation of Healthcare Organizations continue all of the 2003 goals and add one to reduce health care-acquired infections.
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