Editor's note: Each installment of Joint Commission Standards will review a chapter of the universal protocol and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print. Go to www.advanceweb.com/nurses, under Resources on the left navigation bar, click on Joint Commission.

Patient safety remains a high priority issue in the Joint Commission accreditation process. The chapter that addresses the 2007 National Patient Safety Goals (NPSGs) has been reformatted to coincide with the structure of the hospital accreditation standards.

Implementation expectations have been added to each goal requirement and are listed in the same format as elements of performance in standards. These clearly identify the steps required for compliance with each requirement and are new for 2007. The expectation is that implementation of the 2007 NPSGs and Comprehensive Accreditation Manual for Hospitals is constant throughout the organization and processes to prevent medical error are well-integrated into daily practice.

Avoiding Common Pitfalls

Goal 1 Improve Accuracy of Patient Identification

1A - Use of two patient identifiers

·  Don't skip this step in the identification process. Bring the document with the two patient identifiers (medication administration record, lab requisition slip, consent) to the patient to "match" the patient's two identifiers (stated or printed on the wristband) prior to treatment, care or service.

Goal 2 Improve Communication Among Caregivers

2A - Confirmation of verbal or telephone orders or test results

·  This is a three-step process that must be completed sequentially.

1. Write down the complete order or test results or enter it into a computer.

2. Read it back.

3. Receive confirmation from the individual giving the order.

2B - Standardize prohibited abbreviations, acronyms, symbols and dose designations (new for 2007).

·  In surveys 2003 through 2006, use of prohibited abbreviations has consistently had the highest percentage of noncompliance of all NPSGs. The Joint Commission has a new approach for 2006-2007.

a. Orders with a prohibited abbreviation require clarification with the prescriber when the order is not clear. No call is required if orders are legible and use accepted abbreviations.

b. Failure to clarify unclear orders is scored by surveyors elsewhere.

c. Use of prohibited terms are scored whenever they are used.

d. Medical staff is responsible for managing prescriber behavior, not nurses or pharmacists.

2C - Improve timeliness of reporting critical tests and critical results/values

·  Need to know: What critical tests and results/values are being measured by your organization; what are the results? Has action been taken to improve timeliness; are reporting times better?

2E - Standardize "hand-off" information

·  Ineffective communication is the most common cause for serious medical error; the most vulnerable time is during the "hand-off" process.

·  Need to know: What standardized approach to "hand-off" information is in place in your department or on your unit? When is it used? Does it allow for opportunities to ask and respond to questions? Does it include:

a. Diagnoses and current condition of the patient

b. Recent changes in condition or treatment

c. Anticipated changes in condition or treatment

d. What to watch for in the next interval of care

Goal 3 Improve the Safe Use of Medications

3B - Standardize and limit drug concentrations

·  Rule-of-6 does not comply with this goal; if in use, it must transition to standardized concentrations by the end of 2008.

3C - Manage look-alike/sound-alike drugs

·  Need to know: What look-alike/sound-alike drugs are used on your unit and what steps have been taken to avoid error in the use of these drugs?

3D - Label all medications and solutions on and off the sterile field in perioperative and other procedural settings.

·  There are nine implementation expectations for this requirement. The areas most at risk for noncompliance are those outside the operative and invasive procedural areas and in departments and care units where noninvasive procedures requiring medication and solution preparation prior to the procedure occuring.

·  The only exception to the labeling process during procedures is if the medication or solution is for immediate use:

a. Draw it up and inject.

b. Pour it and scrub patient.

Goal 7 Reduce the Risk of Healthcare-Associated Infections

7A - Comply with current CDC hand-hygiene guidelines

·  Observation is key. Many talk the talk, few walk the walk.

·  The time requirement for a soap and water wash is 15 seconds regardless of what song you are singing.

·  If using an alcohol-based rub, remember to rub your hands until dry to reduce the potential for electrostatic discharge.

7B - Sentinel events related to healthcare-associated infections

·  The intent of this requirement is to manage any unanticipated deaths or major loss of function as a sentinel event, regardless of presence or absence of a healthcare-associated infection.

Goal 8 Reconcile Medications Across Continuum of Care

8A - List of current medications on admission or entry into system

·  The key to compliance is to include all required elements on the initial list.

a. Name of all meds with dose, route, frequency, last dose (if patient is admitted)

b. Need to know the processes for:

1. completing the list when patients are unable to give needed information or when emergent care usurps list completion (know the process and follow it, no blank boxes or spaces);

2. reconciling and updating the list when new medications are ordered; and

3. communicating the updated list to the next provider of care at the time of internal transfer.

·  For brief outpatient encounters (e.g., chest X-ray), when no new meds are prescribed for use after discharge, there may not be a need to generate a complete medication list. However, if there is a potential the patient will receive medications during the encounter, a list is needed to identify potential drug interactions.

8B - A complete list of patients' medications is communicated to the next provider of service when the patient is transferred or discharged. The complete list of medications also is provided to the patient on discharge from the hospital (new for 2007).

·  A list of all the medications the patient is taking after discharge, including dose, frequency and route, is provided to both the patient and the next provider of care.

·  Outpatients seen on an ongoing basis:

a. At time of initial entry into the system develop a list of current medications; but, if you are not ordering new continuous medications, it is not necessary to give the patient a list of discharge medications following each outpatient encounter. (Nice but not necessary.)

b. Emergency department patients discharged on pain or other medications require a complete discharge medication list.

Goal 9 Reduce Risk of Patient Harm Resulting From Falls

9B - Fall-reduction program is implemented, evaluated for effectiveness

·  Need to know:

a. the relationship between fall-prevention interventions and patient-assessed needs;

b. your training and education related to the fall-reduction program;

c. how patients and families are educated; and

d. the effectiveness of the program on your unit or department.

Goal 13 Encourage Patients' Active Involvement in Their Own Care as a Patient Safety Strategy (new for 2007)

13A - Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so (new for 2007).

·  Need to know: What is your hospital's process for meeting this requirement? Does your hospital participate in the Joint Commission "Speak-Up" program?

Goal 15 The Organization Identifies Safety Risks Inherent in Its Patient Population (new for 2007)

·  Identify patients at risk for suicide (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals) (new for 2007).

·  Suicide of a patient while in a staffed, round-the-clock setting has been the most frequently reported type of sentinel event since the inception of the sentinel event policy.

·  A program to identify patients at risk includes:

a. a risk assessment specific to this patient population;

b. addressing the patient's immediate safety needs in the most appropriate setting; and

c. providing information about resources available to assist individuals and family members in crisis situations.

Universal Protocol 1 The Organization Fulfills the Expectations Set Forth in the Comprehensive Accreditation Manual for Hospitals

1A - Conduct a preoperative verification process

·  Verification of correct person, procedure and site occurs at several intervals prior to entering the operating room or procedure area and includes patient involvement whenever possible.

·  Preoperative review (preop check list) of relevant documentation, imaging, etc. is completed prior to the procedure.

1B - Mark the operative site

·  There are seven implementation expectations for this requirement. The areas most at risk for noncompliance are those outside the operative and invasive procedural areas, such as when procedures involving laterality are done at the bedside.

1C - Conduct a "time out" immediately before starting procedure

·  As with 1B, the areas most at risk for noncompliance are those outside the operative and invasive procedural areas, such as when procedures involving laterality are done at the bedside.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.