Patient Safety Focus JCAHO 2005 Patient Safety Goals Update
BWH’s Patient Safety Team announced seven goals for the new year in response to the efforts to comply with the Joint Commission on the Accreditation of Healthcare Organizations:
1. Improve the accuracy of patient identification.
Any caregiver, who takes blood samples, administers medications or blood products, checks the patient’s wristband to compare the patient’s name and medical record number against the medication record or lab requisition.
2. Improve the effectiveness of communication among caregivers. A “read back” policy is in effect for verbal and telephone orders. A Partners-wide list of unacceptable abbreviations has been standardized, and the Laboratory and Radiology departments have developed a robust plan for communicating critical test results. Endoscopy, Cardiology, and Pulmonary are revising their practices.
3. Improve the safety of using medications. Concentrated electrolytes are not available on the floors, and a list of look-alike/sound-alike medications is available, with the additional measure of medication bar coding to help protect against look-alike/sound-alike errors.
4. Improve the safety of using infusion pumps. The Alaris IV pump is approved to ensure free-flow protection and the PCA pumps have free-flow protective tubing sets.
5. Reduce the risk of healthcare-acquired infections. Infection control measures the effectiveness of hand hygiene in ICUs. The hospital will follow the recommendations set by the JCAHO and the CDC regarding appropriate nail care. All sentinel events related to health care-acquired infections are reported to the Risk Management Department and are investigated by using the Root Cause Analysis process.
6. Accurately and completely reconcile medications across the continuum of care. A demo computer program for medication reconciliation is being piloted and will go live later this year.
7. Reduce the risk of patient harm from falls. Each patient is assessed for falls risk using a modified Heimrich scale. Patients are reassessed with any change in condition. The falls risk assessment is found on the nursing flow sheet. Medications changes are also found on the flow sheet.