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Medication errors have become the No. 1 priority in hospitals now that JCAHO's patient safety standards went into effect on July 1
New standards on patient safety from the Joint Commission on Accreditation of Healthcare Organizations have created few initial problems for pharmacy. The biggest change: Medication safety programs that pharmacy directors once fought for jumped to the top of administrators' priority lists when the new standards took effect on July 1.
"The responsibility for patient safety now lies at the top of the organization," said Kasey Thompson, director of the Center on Patient Safety at ASHP. "These new standards give pharmacy more ammunition to create safer medication systems. Now pharmacy has a formal backup from JCAHO surveyors. The heat is on for hospitals to do it right."
The new standards focus on four areas: organizational leadership; improving performance; information management; and patient rights, staff training, and care delivery. That translates into formal collection of patient safety data, annual safety reports to the institution's governing board, prompt disclosure of errors to patients, and reengineering of care delivery systems to prevent errors before they occur. The burden of making it all happen lies squarely in the executive suite.
Hospital leaders are directly responsible for improving patient safety, said JCAHO president Dennis O'Leary, M.D. Their task is to create a culture that values safety more than blame. "Patient safety must be job one," he said. "We have to create a culture of safety, not blame and punishment. Caregivers must feel comfortable reporting errors and rebuilding systems that deliver care more safely."
Draft versions of the new standards have been available since 1999, noted Don Nielson, M.D., senior v.p. for quality leadership at the American Hospital Association. For most healthcare systems, he said, "the new standards formalize procedures they have already been working with. The biggest changes are more formal data collection and an annual safety report to the governing board of the institution."
A third major change is patient notification. As of July 1, patients must be notified of what JCAHO calls an "unanticipated outcome." Some hospitals already tell patients of errors, but Nielson said all institutions now need a formal policy. "This really means close collaboration among all staff," he said. "Disclosure must occur for any error."
There are no prescriptions for patient disclosure, O'Leary told a teleconference just before the new standards went into effect, but it should happen as soon as possible. At the very least, he said, patients must be advised of errors before they are discharged. "This is not an attempt to force caregivers to admit errors themselves," he said. "You simply share with the patient the fact that there has been harm."
Three key areas for hospitals to watch are communications, teamwork, and training, O'Leary said. He called lack of communication among caregivers the leading contributor to adverse events. Inadequate training is a close second. A team approach to patient care could reduce both problems. "Teamwork needs to be emphasized in an industry where solitary effort has been the norm," he said. "We must identify vulnerable care systems before a problem happens. It's a matter of getting ahead of the curve instead of reacting to an adverse event after the fact."
Sheldon Sones, independent pharmacy consultant and safe medication officer at St. Francis Hospital Medical Center in Hartford, is already trying to jump the curve. "I'm behaving like a surveyor," he said. "But I work for the facility. I don't look at who [committed the error]; I look at what breach of policy or system has occurred. It almost always is a cascade of events rather than a singular breach" that leads to an error.
Thompson noted that technology could play a major role in strengthening medication systems. In mid-July, ASHP called on the Food & Drug Administration to require that all drug packages, including unit-dose products, be bar-coded to ensure proper identification. The National Coordinating Council for Medication Error Reporting & Prevention made a similar plea to the FDA and the U.S. Pharmacopeia.
Uniform bar-coding will encourage hospitals to invest in drug administration systems to reduce errors, said ASHP CEO Henri Manasse. The 1999 Institute of Medicine report To Err Is Human noted that bar-coding can help ensure that the right drug is being administered to the right patient.
Veterans Affairs has all but eliminated drug administration errors with a bar code-based system developed in-house. Bridge Medical, a healthcare automation company, has released a similar commercial product called MedPoint. Combining bar codes on the drug, patient, and nurse with bedside scanners and computers, MedPoint verifies what the company calls the Five Rights: right drug, right patient, right dose, right route of administration, and right time.
"Forty percent of errors happen during ordering, and 40% at administration," said Bridge president and CEO John Grotting. "That makes the bedside a point of high leverage to reduce errors. Technology is logically part of the action a hospital might take" in response to the new patient safety standards.
Fred Gebhart. Hospital leaders must advance JCAHO patient safety standards.