New Patient Safety Guidelines Issued

These are designed to enhance patient care and reduce serious injuries and deaths, especially in emergency departments.

The recommendations were compiled by an advisory group of physicians, nurses, risk managers, and other professionals based on prior sentinel event alerts. Delays in treatment have been noted as a serious cause of patient death or permanent injury, and more than 50% of the cases involving a delay happened in emergency departments. A summary of the goals and recommendations follows.

Improve the accuracy of patient information by requiring at least two methods of patient identifiers (neither to be the room number) when taking blood samples or giving medications or blood products. Prior to any surgery or invasive procedure, conduct a final verification process to confirm the correct patient, procedure, and site. To improve communications among caregivers, implement a process for taking verbal or telephone orders that require a verifying "read-back.” Standardize all abbreviations, acronyms, and symbols used throughout the organization.

Improve the safety of high-alert medications by removing concentrated electrolytes such as potassium chloride and potassium phosphate from patient care units. Standardize and limit the number of drug concentrations available. Create and use preoperative verification, such as a checklist, to eliminate wrong-site, wrong patient, and wrong procedure surgery. Mark the surgical site and involve the patient in that process. Improve infusion pump safety by ensuring free flow protection on all general-use and patient-controlled analgesia (PCA) intravenous infusion pumps used. Improve clinical alarm systems by having regular preventative maintenance and testing.

"These recommendations were based on things we know were causes of events,” said Dennis O'Leary, M.D., president of JCAHO. "If you do these things we are recommending, the risk goes down and almost certainly the frequency.”




Related Links:
US Joint Commission on Accreditation of Healthcare Organization