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Bringing Safety into our Culture
by: LAWRENCE M. SHUER
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is coming to pay us a visit next spring, and as physicians we have two compelling reasons to get involved.
A positive visit showcases that we are a great hospital for patients - a place to support the services our medical staff offers. A negative outcome from the visit, of course, has the opposite effect.
Preparing for the visit gives us an opportunity to review our safety procedures.
I'm hoping that we are successful with the first goal but I'm also confident that the second goal offers a genuine opportunity to achieve some benefits for our patients and ourselves. Just because an organization mandates that we "do something," doesn't mean that the effort is simply an administrative necessity. Of course we do need to comply with JCAHO standards. But this process has a value-added benefit: the JCAHO has set up a template that can help us achieve maximum safety with a minimum of difficulty.
One of the items on JCAHO's list of things to assess will be how well we have adopted the commission's National Patient Safet Ideals. As part of this process we have set seven Stanford-specific goals for 2004. The JCAHO surveyors will be talking with the medical staff to assess how well we have disseminated information regarding these goals and how well we are meeting them. We will have gone a long way toward showing the JCAHO that the medicine we practice at Stanford Hospital is good, safe medicine if we follow - and articulate to the surveyors - these seven goals:
1. Improve the accuracy of patient information. The aim of this goal is to make certain that patients are properly identified so that we avoid errors in interpreting lab results or administering blood products and procedures. To accomplish this goal we must verify each patient's name and medical record number with that recorded on the armband. (If the patient does not have an armband then the patient must verify his or her name and date of birth.) Our "time out" and boarding pass processes in the operating rooms and other procedural areas also contribute to this goal. These processes "backstop" our efforts to verify the patient's name with consent information and radiological studies to make certain that the right procedure is being performed on the correct patient.
2. Effective communication among caregivers. Any verbal order taken by a nurse is to be written down and then read back to the ordering practitioner to verify the order. This will help avoid misunderstandings. Good communication also mandates that we avoid using unapproved abbreviations in the medical record. Stanford has compiled a list of potentially confusing abbreviations to avoid. (For example, we cannot use MSO4 or MS for morphine sulfate, because these abbreviations can be misinterpreted as magnesium sulfate. The abbreviation ug should not be used for microgram; cc should not be used for ml; and q.d. and q.o.d. should not be used instead of q. day or q every other day.)
3. Safe use of high-alert medications. We have removed all supplies of undiluted injectable potassium chloride, sodium chloride and potassium acetate from all patient care areas of SHC, because these are dangerous. We are supplying all high alert IV medications in standard concentrations. If a non-standard concentration is ordered the bag will have a blue sticker stating, "This IV is a non-standard concentration." This will be placed over the port access along with a green sticker on the label noting "Check IV concentration."
4. Eliminate wrong-site, wrong-patient, wrong procedure surgery. I discussed the process for how we are striving to accomplish this goal in my column in the August/September issue of the Medical Staff Update. Essentially, this mandates the use of verification, site-marking and "time-out" procedures to be applied as consistently as possible everywhere in the organization that invasive procedures are performed. The clinician performing the procedure should do the site marking or provide confirmation of the resident's marking. A pause, or "time-out," is required before any invasive procedure; all staff must agree on the procedure and its location.
5. Improve infusion pump safety. All pumps, including those used for patient controlled analgesia (PCA) will be set with free-flow protection to prevent the patient from receiving large amounts of medication unexpectedly.
6. Improve clinical alarm system safety. Our clinical engineering department will maintain an inventory of high and medium risk patient care equipment requiring preventive maintenance and alarm system testing. Staff members are to respond quickly and appropriately to all clinical alarms, which must be sufficiently audible or visible to the appropriate staff members.
7. Reduce the risk of health care associated infections. One example is a recently approved policy eliminating the use of artificial fingernails by all staff and employees who come into contact with patients. Artificial nails have been found to harbor bacteria that are hard to remove with our usual methods of hand hygiene.
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Many of these goals may seem obvious or inherent in our processes. However, they have been identified because all of these in fact have led to past errors at our institution and others. At all times, please report any unsafe practices you are aware of at SHC through the patient safety net system available on all clinical workstations throughout the institution. The program is found under the "patient care" class of programs and it is labeled UHC PSN. It's important to note that all safety reports are assessed and reports may be made anonymously if desired.
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If all of us learn, consistently implement, and articulate these seven goals to the surveyors, we will have achieved the dual medical staff goals of practicing safe medicine while helping the hospital succeed - for the benefit or our patients, our community and ourselves. Stanford is committed to developing a culture of safety in the hospital and clinics.
- - - And finally. . .
As we enter this time of year I want to wish each and every one of you a safe and happy Holiday Season and may you have a healthy New Year!
