All JCAHO-accredited healthcare organizations are surveyed for implementation of the following safety requirements or acceptable alternatives as appropriate to the services the organization provides:
Improve the accuracy of patient identification.
Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
Improve the effectiveness of communication among caregivers.
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having that person receiving the information record and “read-back” the complete order or test result.
Standardize the abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Implement a standardized approach to “handoff” communication, including an opportunity to ask and respond to questions.
Improve the safety of using high-alert medications.
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the hospital, and take action to prevent errors involving the interchange of these drugs.
Label all medications, medication containers (e.g., syringes, medicine cups, basins) or other solutions on and off the sterile field
Reduce the likelihood of patient harm associated with the use of anticoagulation therapy
Reduce the risk of health care-acquired infections.
Comply with current CDC guidelines for hand hygiene.
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-acquired infection.
Accurately and completely reconcile medications across the continuum of care.
There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.
A complete list of the patient’s medications is communicated to the next provider of service when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.
Reduce the risk of patient harm resulting from falls.
Implement a fall prevention program and evaluate the effectiveness of the program.
Encourage patients’ active involvement in their own care as a patient safety strategy.
Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
The organization identifies safety risks inherent in its patient population.
The organization identifies individuals at risk for suicide.
Improve recognition and response to changes in a patient’s condition.
The organization selects a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.
The first National Patient Safety Goals were approved by the Joint Commission’s Board of Commissioners in July 2002. JCAHO established these goals to help accredited organizations address specific areas of concern in regards to patient safety. Each goal includes no more than two succinct, evidence- or expert-based recommendations. Each year, the goals and associated recommendations are reevaluated; some may continue while others will be replaced because of emerging new priorities. New goals and recommendations are announced in July and become effective on January 1 of the following year.
For more information, contact Lisa Corrente-Hetland, Director of Quality & Patient Safety, at 401-769-4100, Ext. 2407.