Accreditation & Patient Safety
JCAHO Patient Safety Practices
Click http://www.jcipatientsafety.org/show.asp?durki=11787 to connect to a wide array of Patient Safety Practices resources.
JCAHO Patient Safety Goals
In 2002 JCAHO started making Patient Safety Goals, http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ in an effort to improve health care safety and promote risk reduction activities by heath care providers. In 2004, the first standards for ambulatory care clinics were listed. Annually an updated list now occurs, based on evidence and consensus of leading health care experts, and how cost effective and practical is the goal.
JCAHO “Do Not Use list”
As part of its Patient Safety Goal work, JCAHO has issued a list of abbreviations, http://www.jointcommission.org/PatientSafety/DoNotUseList/ that are not to be used in accredited organizations because they have been implemented in medication errors.
JCAHO Universal Protocol
In 2004, JCAHO said that all accredited organizations were to follow the Universal Protocol, http://www.jointcommission.org/PatientSafety/UniversalProtocol/ which includes a pre-op verification process, marking of the operative site, a ‘time- out’ before any procedure and an adaptation of these requirements to procedures in non-operative settings like clinics and at bedsides.
Past JCAHO Patient Safety Goals by Year
(New is in bold. Repeated goals on past lists are deleted, if they are on the current year listing.)
2007 Ambulatory Care Patient Safety Goals
| Goal 1 |
Improve the accuracy of patient identification. |
| 1A |
Use at least two patient identifiers when providing care, treatment or services. |
| Goal 2 |
Improve the effectiveness of communication among caregivers. |
| 2A |
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. |
| 2B |
Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. |
| 2C |
Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. |
| 2E |
Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. |
| Goal 3 |
Improve the safety of using medications. |
| 3B |
Standardize and limit the number of drug concentrations used by the organization. |
| 3C |
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs |
| 3D |
Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. |
| Goal 7 |
Reduce the risk of health care-associated infections. |
| 7A |
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. |
| 7B |
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. |
| Goal 8 |
Accurately and completely reconcile medications across the continuum of care. |
| 8A |
There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. |
| 8B |
A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. |
| Goal 11 |
Reduce the risk of surgical fires. |
| 11A |
Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels with enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. |
| Goal 13 |
Encourage patients’ active involvement in their own care as a patient safety strategy. |
| 13A |
Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. |
2006 Ambulatory Care Patient Safety Goals
| Goal 1 |
Improve the accuracy of patient identification. |
| 1A |
Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. |
| Goal 2 |
Improve the effectiveness of communication among caregivers. |
| Goal 3 |
Improve the safety of using medications. |
| 3D |
Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. |
| Goal 7 |
Reduce the risk of health care-associated infections. |
| Goal 8 |
Accurately and completely reconcile medications across the continuum of care. |
| Goal 11 |
Reduce the risk of surgical fires. |
2005 Ambulatory Care Patient Safety Goals
| Goal 1 |
Improve the accuracy of patient identification. |
| Goal 2 |
Improve the effectiveness of communication among caregivers. |
| Goal 3 |
Improve the safety of using medications. |
| 3A |
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. |
| Goal 5 |
Improve the safety of using infusion pumps. |
| 5A |
Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization. |
| Goal 7 |
Reduce the risk of health care-associated infections. |
| Goal 8 |
Accurately and completely reconcile medications across the continuum of care. |
| Goal 11 |
Reduce the risk of surgical fires. |
2004 Ambulatory Care Patient Safety Goals
| 1 |
Improve the accuracy of patient identification. |
| a |
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. [Scored at Standard PC.13.20, EP #9] |
| 2 |
Improve the effectiveness of communication among caregivers. |
| 3 |
Improve the safety of using high-alert medications. |
| a |
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care areas. [Scored at Standard MM.2.20, EP #9] |
| 4 |
Eliminate wrong-site, wrong-patient, wrong-procedure surgery. |
| a |
Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. |
| 5 |
Improve the safety of using infusion pumps. |
| 6 |
Improve the effectiveness of clinical alarm systems. |
| a |
Implement regular preventive maintenance and testing of alarm systems in accordance with manufacturer's guidelines. |
| b |
Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the patient care area. |
| 7 |
Reduce the risk of health care-acquired infections. |
| a |
Comply with current CDC hand hygiene guidelines. |
| b |
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection. |
Montana Primary Care
Association
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Helena, MT 59601
Phone: (406) 442-2750
Fax: (406) 449-2460
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