February, 2008

• Patient Safety
  • Joint Commission Alert shines light on preventing MRI accidents, injuries
  • Updated Speak Up materials on infection control
• Accreditation
• CDC/WHO Hand Hygiene Guidelines Crosswalk now available
• Most challenging standards and requirements for first half of 2007
• Field review of proposed Medication Management standards
• Public Information
  • New on Quality Check—SCIP Venous Thromboembolism measure rates
  • Updated sentinel event statistics
• Communication
  • Call for 2008 Eisenberg Awards application

Patient Safety

Joint Commission Alert shines light on preventing MRI accidents, injuries

The Joint Commission issued a Sentinel Event Alert that urges hospitals and ambulatory care centers to pay special attention to preventing accidents and injuries that can occur during MRI scans. More than 10 million MRI scans are performed each year in the United States and while most cause no harm, the inherent dangers of the process are not well known. The most common types of injuries are burns, while some of the more devastating accidents are caused by common objects that become missiles when brought into the MRI scanner’s magnetic field. The Sentinel Event Alert brings the reality of risks associated with MRIs to the attention of the nation’s accredited health care organizations, and offers practical solutions to avoiding injuries or deaths. “The MRI environment can be dangerous and this Alert provides insight into the range of accidents and injuries that could occur and actions that can be taken to avoid them,” says Peter B. Angood, M.D., vice president and chief patient safety officer, The Joint Commission. “The time is ripe for this information since the increasing use of MRI presents more opportunities for error to occur.”  View the entire news release and the Alert. 
(Contact:  Peter Angood, pangood@jointcommission.org)

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Updated Speak Up materials on infection control

The Joint Commission recently updated its Speak Up materials on infection control to include vaccinations. Now titled “Five Things You Can Do To Prevent Infection,” the brochure and poster are available for free download from The Joint Commission website.
(Contact:  Cathy Barry-Ipema, cbarry-ipema@jointcommission.org) 

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Accreditation

CDC/WHO Hand Hygiene Guidelines Crosswalk now available

As of January 1, 2008, the Joint Commission’s National Patient Safety Goal Requirement 7A gives organizations the option of complying with current World Health Organization Hand Hygiene Guidelines or the Centers for Disease Control and Prevention Hand Hygiene Guidelines. Before 2008, the requirement included only the CDC guidelines. Joint Commission Resources and the Joint Commission International Center for Patient Safety have created a crosswalk to help organizations compare the two sets of guidelines. The crosswalk is available in the February 2008 issue of The Joint Commission Perspectives or online.  Note:  A correction published in the March 2008 issue of Perspectives on Patient Safety indicated that the laboratory services and health care staffing services programs had been omitted from the program applicability list.
(Contact:  Peter Angood, pangood@jointcommission.org)

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Most challenging standards and requirements for first half of 2007

Each year, The Joint Commission collects data on organizations’ compliance with its standards, National Patient Safety Goals, Universal Protocol and Accreditation Participation Requirements to identify trends and focus education on challenging requirements. The table below identifies the standards and requirements that were most frequently identified as “not compliant” from January 1, 2007 through June 30, 2007 for hospitals and critical access hospitals. Hospitals can use this information to benchmark their performance against all accredited hospitals and to investigate their performance to determine if their processes meet requirements. For more information, see the Standards Frequently Asked Questions.

Standard or Goal	Summary of requirement	Hospital	CAH
PC.2.120	The CAH defines in writing the time frame(s) for conducting the initial assessment(s).	--	11 percent
PC.2.130	Initial assessments are performed as defined by the CAH.	--	8 percent
PC.8.10	Pain is assessed in all patients.	--	8 percent
MM.2.20	Medications are properly and safely stored.	43 percent	16 percent
MM.3.20	Medication orders are written clearly and transcribed accurately.	20 percent	--
IC.3.10	Based on risks, the CAH establishes priorities and sets goals for preventing the development of health care-associated infections within the CAH.	--	11 percent
EC.5.20	Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®.	27 percent	18 percent
HR.1.20	Staff qualifications are consistent with his or her job responsibilities.	--	8 percent
IM.6.10	The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served.	24 percent	--
IM.6.50	Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals.	20 percent	--
MS.4.10	The CAH collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.	--	8 percent
MS.4.15	The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.	--	11 percent
Goal 2B	Standardize a list of abbreviations, acronyms, symbols and dose designations that are not to be used throughout the organization.	29 percent	8 percent
Goal 2C	Measure, 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.	36 percent	24 percent
Goal 3C	Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.	--	8 percent
Goal 3D	Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.	17 percent	--
Goal 8A	There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.	20 percent	8 percent
UP 1C	Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol.	23 percent	16 percent