Hospital R.Ph.s weigh in on new JCAHO patient safety goals

July 11, 2005

Communications between caregivers and medication use safety dominate the Joint Commission on Accreditation of Healthcare Organizations' 2006 National Patient Safety Goals for hospitals. Among the major additions to the 2006 goals are new requirements that "hand-offs" of patients between caregivers be standardized and that all medication containers, including syringes, medicine cups, basins, and other solutions used in perioperative areas, be labeled.

The new labeling requirement, which would apply to surgical or other invasive services, comes in the wake of several high-profile errors that occurred in surgical and radiological areas in which unlabeled clear solutions were administered to patients and caused harm.

In addition, two other goals are relevant to health systems-reducing the risk of healthcare-associated infections and reducing the risk of patient harm resulting from falls. Among the recommendations: comply with current Centers for Disease Control & Prevention hand hygiene guidelines and manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with healthcare-related infection. Health systems are encouraged to implement a fall-reduction program and evaluate the effectiveness of the program.

"Pharmacists need to take a role in facilitating this process for our colleagues in the OR suite," Begliomini said. He noted that Lehigh R.Ph.s would be meeting with anesthesia and OR staff to access the processes that go into the placing of drugs into basins. Possible solutions, he said, would be placing stickers on drug containers or allowing only prelabeled basins in perioperative areas.

In the category of improving the effectiveness of communication among caregivers, the new goal would require a standardized approach to "hand-off" communications, including an opportunity to ask and respond to questions. A hand-off is when a patient gets handed off from one hospital to another or from a nursing facility to the hospital. In those cases it must be ensured that the information about that patient comes with the patient. The goal is to have a seamless transition from one place to another.

Bill Arrington, R.Ph., director of pharmacy at Stillwater (Okla.) Medical Center, said that the hand-off issue is less problematic when a patient is coming from a nursing home or another hospital compared with when they come directly from home. "We get patients in here, and their medical histories are pretty sketchy." He said that often when patients come from home, they bring their own medications with them that they may or may not be taking.

"The goal regarding hand-off communication is one of the most important things we've done," said Rick Croteau, M.D., executive director for patient safety initiatives at JCAHO. "The most commonly cited root cause category for all types of adverse events is poor communication." He added that most breakdowns in communication occur at hand-offs.

Regarding the requirement relating to patient falls, Arrington noted that falls often have to do with medications that affect patients' balance. At his facility, bed alarms alert the nursing staff whenever a patient gets out of bed. A patient safety committee is responsible for monitoring patient falls.

In addition to the new goals, JCAHO's Sentinel Event Advisory Group recommended the following selected goals:

JCAHO's Croteau said that the new goals would kick in on Jan. 1, 2006.