Critical Path Network
Improve patient safety to comply with new standards
Demonstrate evidence to JCAHO surveyors
In one emergency department (ED) recently, Kathleen Catalano, RN, JD, was shocked to notice pharmacists refilling five vials of potassium chloride (KCl). "I asked about the fact that concentrated potassium chloride was being put out for use," she recalls. Catalano, who is director of administrative projects at Children’s Medical Center of Dallas, learned that ED nurses had prepared an IV with KCl without calling in pharmacy, as the hospital’s policy required. To make matters worse, the IV was not prepared under the laminar airflow hood — another violation of hospital policy.
"The pharmacy technician was not the least bit alarmed about the use of concentrated KCl," she says. "There, but for the grace of God, went a medication nightmare." KCl is often mistaken for other medications such as sodium chloride, heparin, or furosemide, and direct infusion of concentrated KCl results in death, she explains. Concentrated KCl should be removed from all medication areas, including the ED unless specific safeguards are in place, warns Catalano, a former consultant with the Greeley Co., a firm in Marblehead, MA, specializing in health care regulatory compliance.
Dangerous situations like the above scenario have led to the development of new patient safety standards from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The standards become effective July 1, 2001. The patient safety standards are broader than the sentinel event standards which became effective in 2000, according to Catalano. "The new standards look at more than just the patient who has been subject to a catastrophic event," she says.
Recent reports from the Washington, DC-based Institute of Medicine spurred the Joint Commission to focus on patient safety, she adds.
Warning: Avoid these scenarios
Surveyors will be asking what you’ve been doing to improve patient safety in your ED, according to Carole Patterson, MN, RN, consultant for Joint Commission Resources (JCR), an Oakbrook Terrace, IL-based provider of education and consulting services established by the Joint Commission, and former director of the Joint Commission’s Standards Interpretation Group. "Questions about how the hospital is improving patient safety by doing proactive risk identification and reduction activities will be an important part of the unit visits, including the ED," Patterson points out.
Any of the following three scenarios will get you into trouble during a Joint Commission survey, says Patterson:
- Staff members fail to respond appropriately to surveyor questions about patient safety-related questions.
- There is no evidence of efforts to reduce safety risks to patients in the ED.
- The ED is not involved in hospitalwide efforts to improve patient safety.
"Special notice would be taken and written up in the preliminary noncompliance report given to the hospital at the end of the survey," Patterson warns.
Here are ways to comply with the patient safety standards:
— Use alternatives to restraint. You’ll need to be familiar with Joint Commission standards for the least restrictive use of restraints, both physical and chemical, and be able to answer surveyor’s questions about those standards, says Kathryn Perlman, MS, RN, clinical educator for the ED at Presbyterian Hospital of Dallas. Surveyors will ask nurses what documentation is required for a patient who is restrained, what are alternatives to restraints, and how often a patient who is restrained needs to be reassessed, she says. At Presbyterian, ED nurses are required to complete a form showing that alternatives are being attempted. Perlman suggests decreasing stimulation by dimming lights, turning off the TV or radio, moving the patient to a room close to the nurses’ station, or using bed alarms. (To see Alternatives to Restraints/Restraints Flowsheet, click here.)
— Be involved in your hospitals’ patient safety program. Patterson advises joining the hospital’s patient safety or environment of care safety committee. "Bring along one of the ED physicians, too," she suggests. "Medical leaders are key to making patient safety efforts visible as well as viable."
— Order IV admixtures from pharmacy. Having the pharmacy mix IVs eliminates the need to keep the admixture drug on the unit, says Perlman. "It adds another risk-control element because the pharmacist checks it before it leaves the pharmacy," she explains.
— Do not keep bottles of multidose drugs on the counter. Examples of multidose drugs include Tylenol elixir and Prelone, says Perlman. "Joint Commission hates this, and it’s dangerous," she underscores. "Having medications lying around the room makes it easy to grab the wrong bottle, thinking that it is something else, if the bottles look alike, for example," adds Perlman.
— Apply conscious sedation standards consistently throughout the hospital. You must apply the same protocol in any area that uses conscious sedation, says Cheryl Pinney, RN, BSN, MBA, director of emergency services at Cheshire Medical Center in Keene, NH, and the hospital’s Joint Commission coordinator. (To see Conscious Sedation Documentation Flow Sheet, click here.) "This is not a new standard, but there still continues to be a lot of focus on this area,"’ she says. "Along with using a consistent protocol, staff must be trained to use the protocol."
The key is that all areas follow the same protocol, says Pinney. She suggests having several training sessions scheduled at various times that all staff attend, inservicing at staff meetings, developing self-study packets with a simple post-test, or implementing a poster campaign in a clinical area that all staff sign off on.
— Have your hospital risk manager perform an inservice for your staff. At Cheshire Medical Center, the hospital risk manager provided a half-hour presentation to ED nursing staff on sentinel events and how to perform a root-cause analysis. Pinney included information in the staff meeting minutes for staff who were unable to attend. "We also will review components of the presentation at future staff meetings," she says.
— Perform a visual inspection. Check for evidence of safety issues in your ED, recommends Pinney. Here are some examples she provides:
- Look around for mishandled items, such as a syringe left in an inappropriate place.
- Make sure that supply cabinets and crash carts are locked.
- Be sure that cabinets and storage areas are clean and items are appropriately stored.
- Inspect white boards to see if there is any breach of confidentiality.
The ED uses a department checklist of items to review before surveyors arrive, says Pinney.
— Make sure that checklists are up to date. There should be "no holes," says Pinney. The ED staff use crash cart and trauma room checklists once every 24 hours, and obtain replacements as needed. "Staff are held accountable to make sure no day is missed in checking the lists," she says.
[For more information on the patient safety standards, contact:
• Kathleen Catalano, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-8722. E-mail: [email protected].
• Kathryn Perlman, MS, RN, Emergency Department, Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231-4496. Telephone: (214) 345-6301. Fax: (214) 345-6486. E-mail: [email protected].
• Cheryl Pinney, RN, BSN, MBA, Emergency Services, Cheshire Medical Center, 580 Court St., Keene, NH 03431. Telephone: (603) 354-6601. Fax: (603) 354-6605. E-mail: [email protected].]
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