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JCAHO puts teeth into patient safety goals

Healthcare organizations that don't focus on patient safety are about to come up short. Starting next January, the Joint Commission on Accreditation of Healthcare Organizations will add six patient safety goals to its survey standards. Organizations that are not taking concrete action to meet the goals could lose their JCAHO accreditation.

"We have a requirement now that hospitals adhere to these National Patient Safety Goals," said Darryl Rich, associate director, surveyor development and management for JCAHO. "We absolutely expect organizations to be in compliance by Jan. 1, 2003." That's when JCAHO surveyors start evaluating healthcare organizations on specific steps taken to improve the safety of high-alert medications, reduce miscommunication between caregivers, improve the safety of infusion pumps, improve the accuracy of patient identification, eliminate wrong-site surgery, and improve the effectiveness of clinical alarm systems.

The six National Patient Safety Goals (NPSGs) were adopted by a JCAHO advisory committee headed by Henri Manasse, executive v.p. and CEO of ASHP. New goals will be identified during 2003 for implementation during 2004, Rich said. Surveyor findings on compliance with the new goals will be incorporated into accreditation reviews immediately. Compliance data on individual organizations that have been surveyed will be made public starting in mid-2004 when JCAHO reformats its organization performance report.

Meeting the new goals should not be a problem or even a significant expense. None of the six safety issues is new, noted Kasey Thompson, director of ASHP's Center on Patient Safety. And none of the steps JCAHO suggests to meet the goals requires major changes in equipment or even workflow for most institutions. The biggest change is that hospitals no longer have any excuses not to take what safety experts call obvious steps to correct safety problems that the profession has known about for years.

Each of the six JCAHO goals includes specific recommendations to help organizations reduce certain types of errors. "The commission is finally putting teeth into patient safety recommendations that have been around for decades," said Michael Cohen, president of the Institute for Safe Medication Practices. Cohen is also a member of the JCAHO advisory panel. "ISMP is a reporting organization, not an enforcement agency. We need support from groups like JCAHO. Their support gives safety some clout," he said.

Not all pharmacists are convinced that JCAHO can change institutional behavior. "These goals are givens," warned Steve Meisel, director of medication safety at Fairview Health System in Minneapolis. "Any institution in modern times should have done all of these things years ago, but clearly not all have. Changing policy does not necessarily change practice."

The new program includes two recommendations to improve the safety of high-alert medications. Organizations should remove all concentrated electrolytes from patient care units. The recommendation includes, but is not limited to, potassium chloride, potassium phosphate, and sodium chloride solutions greater than 0.9%.

Surveyors will also expect to see groups standardizing and limiting the number of drug concentrations available in the organization. "We've been talking about these issues for 30 years, but patients are still dying from concentrated electrolytes," sighed Thompson. "Making these mandates explicit means they will have an impact."

Cohen said he hopes to see the swift disappearance of all concentrated electrolytes from floor stocks. Most institutions have already pulled concentrated potassium chloride, he said, but many still keep concentrated sodium chloride and similar electrolytes in open stocks. ISMP is still reporting fatalities from the accidental use of 23.4% sodium chloride, instead of the 0.9% solutions normally used for intravenous administration. "You need restraints on the availability of these concentrates," he said. "It will mean more IV admixture preparation in pharmacy, which will provide more double checks and improve safety."

Improving communication between caregivers also includes two pharmacy-related suggestions. All verbal orders, including drug orders, should be verified by reading the order back to the person giving it. And to clarify written orders, every group should standardize all of the abbreviations, acronyms, and symbols used and create a list of abbreviations, acronyms, and symbols that should never be used. JACHO recommends groups follow ISMP's list of unsafe abbreviations, Rich said.

One common problem is the use of the letter "u" to mean units, especially in handwritten orders. In insulin orders, for example, "6u" can be misread for "60," which means the patient gets a 10-fold overdose. The most direct solution? Ban the use of "u" as an abbreviation and insist that "units" be written out in full on all orders, according to ISMP.

Another common problem is "OD," which can mean right eye (oculus dexter) or "once daily." ISMP has recorded numerous cases of oral meds being administered in the right eye rather than being given daily. Again, the solution is to stop using the potentially confusing abbreviation and write out "right eye" or "daily" on all orders.

Common drug name mix-ups include HCl (hydrochloric acid confused with potassium chloride), MSO₄ (morphine sulfate confused with magnesium sulfate), and ZnSO₄ (zinc sulfate confused with morphine sulfate).

ISMP's complete list of unsafe abbreviations and dose designations can be found on-line at www.ismp.org/msaarticles/specialissuetable.html .

JACHO is also pushing organizations to improve the safety of IV infusion pumps. The problem is that about 20% of infusion pumps in current use lack an automatic clamp to prevent free flows. The recommended solution is to provide free-flow protection on all infusion pumps. "We've been advocating that for years," Thompson said. "It places a different emphasis when you make it a stated goal for accreditation."

Organizations can also go beyond JCAHO's basic recommendations or they can implement their own safety programs. Hospitals that want to chart their own course must submit a "Request for Review of an Alternative Approach to a NPSG Recommendation" to JCAHO for approval. The form will be available on-line at www.jcaho.org and can be submitted electronically, by fax, or by mail.

Fred Gebhart

Fred Gebhart. JCAHO puts teeth into patient safety goals.

Drug Topics

2002;20:HSE1.