New Joint Commission safety goals will change practice of ED nursing
Your ED will be affected by all 6 safety goals
If improving patient safety isn’t already a No. 1 priority in your emergency department (ED), there’s now another reason to put it to the top of your list: The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has announced its 2003 National Patient Safety Goals — and each one will impact the ED. The six new goals include specific recommendations for improving patient safety. Surveyors will score for the goals as of Jan. 1, 2003.
You will have to review the goals and implement them, and failure to do so will result in a Type I recommendation, warns Kathleen Catalano, director of regulatory compliance at the Dallas-based Provider HealthNet Services, a privately held company that provides information technology, medical records, transcription, coding, and business office outsourcing services to the health care industry. "This Type I will be included in the overall aggregate survey score," she adds.
Here are the safety goals identified by the Joint Commission and ways to comply with each:
1. Improve the accuracy of patient identification.
Catalano advises always using at least two patient identifiers when taking blood samples or administering medications or blood products. According to the Joint Commission, neither identifier should be the patient’s room number.
Michelle H. Pelling, MBA, RN, president of The ProPell Group, a Portland, OR-based health care consulting firm specializing in compliance, agrees and says that you should ask the patients their names and check the armbands. "For situations where the patient cannot confirm their identity, family members or friends should be queried, if available," she adds.
Accurate identification is especially important in the ED, says Catalano, because many times a patient’s identity is unknown. She gives the following example of a problem that commonly occurs in the ED: Upon arrival, a patient is given an unidentified patient number of UNI2344. All the pages of the patient’s chart have that identifier, and blood is ordered while the patient is in the ED.
Suddenly, the patient is whisked away to the operating room (OR) and needs blood. By that time, the circulating nurse has learned that the patient’s name is Mary Jane Smith, and she faxes the blood bank the request slip with that identifier. Now, the blood bank has no idea who patient UNI2344 is. "Now what do you do?" asks Catalano. Unless a formal document is received in the blood bank noting the change, the blood cannot be released to the patient, she says. She suggests having a policy that no change will be made to the unidentified patient information for at least 24 hours. "This allows for surgical procedures and infusion of blood products," she says.
2. Improve effectiveness of communication among care providers.
Pelling stresses that verbal orders should be your priority, as they are used so often in the ED. "Nurses should repeat the order to the practitioner and wait for validation before proceeding," she says. However, Catalano adds that you should have a plan in case a physician won’t wait for the "read-back." She recommends keeping track of physicians who are too busy for this and completing an incident report each time it occurs. "Eventually, the offending physicians will get the message," she says.
Catalano also advises standardizing the abbreviations, acronyms, and symbols used in the ED. "Make sure the list includes all the ones not to use," she says. "I’ve never seen these on any abbreviation list, and I think it’s a good idea to add them."
3. Use high-alert medications more safely.
Catalano notes that the Joint Commission recommends removing concentrated electrolytes such as potassium chloride, potassium phosphate, and sodium chloride > 0.9% from patient care units. "Do a walk-through of the ED and check that there are no nooks and crannies containing high-alert meds," she says. "For example, are they removed from the crash cart as well?"
She recommends checking with the pharmacy to see what actions they have taken to ensure that high-alert medications are "out of harm’s way." "Some EDs have problems because the physicians say they are physically present all the time and that they know how to administer these medications," she says. "In spite of their ability, these high-alert meds should not be available."
Catalano says that the number of drug concentrations available should be standardized throughout the facility. Included in the list should be contact information for the individual who can mix a specific drug concentration if it’s not normally stocked, she adds.
At Medical Center of Central Georgia in Macon, ED nurses routinely are given specific inservices on high-alert medications such as cardioactive and vasoactive drips, blood products, and insulin, reports Jonathan Kent, RN, CEN, assistant director of the emergency center. For example, ED nurses recently participated in a "training blitz" to review the policy for blood products, he reports. Printed material was distributed, and staff were given a test with 10 true-or-false questions, with 100% as the minimum passing score. If nurses don’t pass the test, remedial training is given, and they are retested, says Kent. "To make things more complicated, drug companies are putting out more new drugs and new indications for old drugs at a lightning pace," he says. "Each of these requires staff education and reference material to be added to the mix."
Kent says that drug company representatives often give inservices for new drugs and refreshers for medications rarely used. "They bring in demo kits and give folks hands-on practice, present the scientific data supporting the product, and go into wonderful detail on how exactly the drugs work," he says. In addition, printed drug information is compiled in an "Emergency Center Reference Book," which is kept in the critical care area, and posters for complex drugs are hung on the walls until the staff are comfortable with dosage and administration.
Take a timeout’
4. Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
Before you perform any procedure in the ED, Pelling says you should take a "timeout" to confirm correct patient, procedure, and site.
Even though the ED is not an OR, procedures often are performed there, Catalano points out. "With this in mind, make a checklist noting on which side of the body a procedure is to be performed," she says. This can be a form very similar to those used in the OR, so Catalano suggests borrowing one already developed. "Don’t reinvent the wheel," she says. She also recommends checking that the patient’s X-ray is positioned correctly on the viewing box and not backward or upside down. "To ensure compliance with this, request an inservice from the radiology department," she suggests.
5. Improve the safety of infusion pumps.
The ED should use only pumps that are free-flow protected and retire any old pumps that are not, stresses Pelling. "Also, make sure that the nursing staff are not holding old pumps in some secret place to use in the event they can’t find a free flow-protected one," she says.
At Trinity Medical Center in Rock Island, IL, high-alert drugs administered with infusion pumps are all double-checked with another nurse, says Cindy Wage, RN, BSN, ED nurse educator. "We also have drug books in each of our main cardiac rooms with all the drip rates and dosages figured out," she says. "It is easy then to set the pump in critical situations."
6. Make clinical alarm systems more effective.
Unless the patient has constant one-to-one observation, the alarm audibility should be continuous, says Pelling. She notes that it always has been a Joint Commission requirement that alarm systems receive regular preventative maintenance. "This means equipment needs to be rotated in order to ensure that all equipment is checked in a busy ED," she explains.
Resources
For more information about the patient safety goals, contact:
• Kathleen Catalano, Director of Regulatory Compliance, Provider HealthNet Services, 15851 Dallas Parkway, Suite 925, Addison, TX 75001. Telephone: (972) 701-8042, ext. 216. Fax: (972) 385-2445. E-mail: [email protected].
• Jonathan Kent, RN, CEN, Assistant Director, Emergency Center, Medical Center of Central Georgia, P.O. Box 6000, Box 142, Macon, GA 31208. Telephone: (478) 633-3038. Fax: (478) 633-7879. E-mail: [email protected].
• Michelle H. Pelling, MBA, RN, President, The ProPell Group, P.O. Box 910, Newburg, OR 97132. Telephone: (503) 641-1987. E-mail: [email protected].
• Cindy Wage, RN, BSN, Nurse Educator, Emergency Department, Trinity Medical Center, West Campus, 2701 17th St., Rock Island, IL 61201. Telephone: (309) 779-3232. Fax: (309) 779-2105. E-mail: [email protected].
The Joint Commission 2003 National Patient Safety Goals and associated recommendations can be accessed at the August 2002 JCAHOnline — Monthly News Brief from the Joint Commission on Accreditation of Healthcare Organizations at www.jcaho.org. Click on "JCAHOnline" and then "August 2002."
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