USP Drug Safety Review: Errors related to JCAHO's National Patient Safety Goals

May 15, 2005

In 2002, JCAHO formed the Sentinel Event Alert Advisory Group to help develop the first set of National Patient Safety Goals (NPSGs) that were put into effect on Jan. 1, 2003. NPSGs and their accompanying requirements represent specific actions that JCAHO-accredited organizations are expected to take in order to prevent medical errors such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups. USP has studied medication error data findings reported to the MEDMARX program in relation to the following 2005 NPSGs

In 2002, JCAHO formed the Sentinel Event Alert Advisory Group to help develop the first set of National Patient Safety Goals (NPSGs) that were put into effect on Jan. 1, 2003. NPSGs and their accompanying requirements represent specific actions that JCAHO-accredited organizations are expected to take in order to prevent medical errors such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups. USP has studied medication error data findings reported to the MEDMARX program in relation to the following 2005 NPSGs:

Selected JCAHO National Patient Safety Goals - 2005Goal 1. Improve the accuracy of patient identification
Goal 2. Improve the effectiveness of communication among caregivers
Goal 5. Improve the safety of using infusion pumps

Improving medication safety related to the NPSGs

2. Examine the admission/discharge/transfer (ADT) information system. What precautions or safeguards are in place to prevent patient mix-ups (e.g., patients with the same last name residing in the same room or within the same patient care unit)? How quickly is ADT information updated?

3. All employees who assume any level of responsibility for patient care (e.g., transportation) or who administer care (noninvasive or invasive care including transfusions and medication administration) to a patient should first verify that an ID band is attached to that patient and to confirm that information on the ID band exactly matches documented orders and/or labeled materials (e.g., medications or blood products) intended for use with that patient. Documentation may be the medical chart or medical chart surrogate.