Reducing harm to patients (PDF) is a report of 10 case studies of health care organizations with
innovations that hold promise for improving patient safety: promoting an organizational culture of safety,
improving teamwork and communication, enhancing rapid response to prevent heart attacks and
other crises in the hospital, preventing health care associated infectinos in the intensive care unit,
and preventing adverse drug events throughout the hospital.
Lesson Learned
Starting July 1, 2001, JCAHO began asking organizations what actions
they have taken in response to the problems and suggestions highlighted in the Alerts.
Organizations must show implementation of the suggestions or reasonable alternatives
taken to respond to the potential risks.
In the issues of Sentinel Event Alert, healthcare organizations,
the Joint Commission and various experts have provided
recommendations on how other healthcare organizations can prevent the
adverse events from happening in the future.
Risk reduction strategies required: The emphasis has been on "recommendations,"
but some readers have interpreted these suggestions as being Joint Commission requirements.
The Joint Commission stresses that the suggestions should be considered for implementation,
but if not appropriate for the individual healthcare organization,
alternatives should be selected.
The Joint Commission recognizes that other acceptable practices or approaches exist.
Nineteen issues of Sentinel Event Alerts have been issued over the past 3 years;
details on the events are available at the JCAHO website.
The Joint Commission will portray a hospital’s response as part
of a "Sentinel Event Strategies" safety profile.
Risk reduction strategies that reflect reported Sentinel Events to date are
likely to include the following:
- Restricting access to concentrated potassium chloride
- Reducing the risk of inpatient suicide
- Eliminating wrong-site surgery
- Eliminating the use of inappropriate & unsafe restraints
- Reducing the risk of infant abduction
- Reducing the risk of adverse transfusion-related events
- Minimizing operative/post-operative complications
- Reducing the risk of fatal falls
- Reducing the risk of intravenous infusion pump errors
- Managing "high alert" medications
JCAHO - National patient safety goals:
In April 2002, the Joint Commission (JCAHO) appointed a panel of physicians, nurses, pharmacists, and other patient safety experts to advise the organization on developing its first set of national patient safety goals.
The first six goals and measures were announced after final voting at the July 18-19 JCAHO Board of Commissioners meeting. Each goal includes one or two evidence- or expertise-based recommendations. In the following years, certain goals are to be retained, while others are replaced as a result of emerging new priorities. To ensure a greater focus on safe practices, no more than six goals—and their associated recommendations—will be established for any given year. The first six goals are listed below.
1.Improve the accuracy of patient identification.
2.Improve the effectiveness of communication among caregivers.
3.Improve the safety of using high-alert medications.
4.Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
5.Improve the safety of using infusion pumps.
6.Improve the effectiveness of clinical alarm systems.
In January 2003 the JCAHO survey process included compliance with these goals and associated recommendations or implementation of acceptable alternatives, as appropriate for the services that the healthcare organization provides. Non-compliance will result in "accreditation with requirements for improvement." Download the current NSPGs for 2007 (.pdf) (94 KB) as well as the draft 2008 NPSG (.pdf) (58 KB).
JCAHO approach to improving safety: In July of 2002, JCAHO began enforcing a set of standards on Staffing Effectiveness; these were recently tested and approved by the JCAHO board. However, on July 1 2001, the JCAHO already began enforcing a broad set of standards that focus on patient safety. These include revisions to a number of current standards to more clearly support medical/healthcare error reduction programs in accredited organizations, as well as new patient safety standards. The final standards describe the requirements for establishing ongoing patient safety programs in organizations accredited under the Comprehensive Accreditation Manual for Hospitals within the Managing Human Resources standards.