|
Joint Commission Online
 |
|
February 2008 |
|
|
|
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)
-Top-
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)
-Top-
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)
-Top-
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 |
(Contact: Standards Interpretation Group, (630) 792-5900 or submitt an online question.
-Top-
The Joint Commission seeks comment on proposed revisions to the Medication Management (MM) standards MM4.10, MM.8.10 and new standard MM.4.15, which relates to pharmacist review of medication orders in the Emergency Department. The proposed revised standards and new standard will affect the hospital and critical access hospital programs. Comments will be solicited through April 1. View Field Reviews.
(Contact: Joyce Marshall, jmarshall@jointcommission.org)
-Top-
The Joint Commission is engaged in the following activities as part of its Standards Improvement Initiative:
- Posted the following website surveys to gather feedback on proposed changes to:
- Waived Testing requirements for the ambulatory care, home care, hospital and office-based surgery program manuals. The survey will be available through March 13.
- Transplantation Safety requirements (previously called Tissue Storage and Issuance) for the ambulatory care, critical access hospital, hospital and office-based surgery program manuals. The survey will be available through March 21.
- Documentation of Care requirements for the ambulatory care, critical access hospital, home care, hospital and office-based surgery program manuals. The survey will be available through March 26.
- The Nursing chapter for the critical access hospital and hospital program manuals. The survey will be available through March 28.
- The second half of the Provision of Care, Treatment, and Services chapter for the ambulatory care, critical access hospital, home care, hospital and office-based surgery program manuals. The survey will be available through April 2.
View the surveys.
- The Standards and Survey Procedures (SSP) Committee reviewed the first part of the Provision of Care chapter and the Ethics, Rights, and Responsibilities chapter that have been modified based on field input. They also reviewed a proposed new chapter on Life Safety (LS). This new chapter does not include any new requirements. The Joint Commission’s current Life Safety Code® requirement consists of a single element of performance (EC.5.20 EP 1) that refers organizations to the National Fire Protection Association (NFPA) for the specific expectations of the EP. The new chapter includes applicable requirements from the NFPA document. SSP members reviewed the chapters to ensure that: language is clear; the sequence of the standards and elements of performance is logical; each EP addresses only one item that can be surveyed and scored; and deletions to the standards are in fact redundant or non-essential. The SSP Committee approved these chapters, with recommended changes that will be reviewed by them during a conference call in early April. At a meeting in late April, the SSP Committee will review the field review results for the remaining parts of the Provision of Care chapter and the chapters on Nursing, Emergency Management, and Equipment.
- Staff conducted meetings with focus groups from the ambulatory care, critical access hospital, home care, hospital, and office-based surgery programs to garner their advice regarding needed changes and clarifications of existing standards. The focus groups included representatives from accredited organizations, unaccredited groups, medication management program experts, payers and the Joint Commission’s Small and Rural Advisory Group. The Accredited Customer Group will meet again via conference call in March to review open issues from all chapters.
- Analyzed the results of the first pilot tests of the revised standards for the Infection Control, Performance Improvement, and Information Management chapters of the manuals. The first pilot tests were conducted with Joint Commission surveyors.
- Started testing the database conversion of the standards. The conversion takes the standards from print to an electronic format.
- Created a communications plan for informing the field about the upcoming changes emanating from SII, including: re-numbering of the standards; a new scoring and decision process; deletion of standards deemed redundant or non-essential; re-organization of the manuals; posting standards on the website with tracking history; availability of Standards Interpretation Group staff to answer questions; and language changes for various health care settings. The communication vehicles will include: articles in Joint Commission publications, Q&As, Power Point presentations, streaming videos, audio conferences, webcasts and/or podcasts, education briefings, conferences, seminars, speaking engagements, and accreditation program manuals (electronic and hard copy).
SII is part of a continuous effort to eliminate non-essential standards and to ensure that the remaining standards are understandable and relevant to the care setting to which they apply. The initiative is limited to changes of current standards; it is not designed to introduce new requirements. Click here for more information. Click here to submit questions and suggestions.
SII Timeline
October 2006: The Standards Improvement Initiative was launched. The Joint Commission began seeking feedback through an on-line opinion survey and public comment on standards for the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.
June 2007: “Virtual” pilot testing was conducted with selected surveyors and Central Office staff.
August and October 2007: The Surveillance, Prevention and Control of Infection, Improving Organization Performance, and Management of Information chapters were approved by the Standards and Survey Procedures Committee.
November 2007 and January 2008: The Management of Human Resources, Management of the Environment of Care, and Medication Management chapters were approved by the Standards and Survey Procedures Committee.
Early 2008: The Joint Commission will begin conducting mock surveys using the improved standards and manuals.
June 2008: Target date for completing improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals. Final revised standards will be provided to accredited organizations in the affected programs.
January 2009: Improvements to the standards are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs.
(Contact: Carol Gilhooley, cgilhooley@jointcommission.org)
-Top-
Beginning January 2008, The Joint Commission’s Quality Report for hospitals will reflect measure results for Surgical Care Improvement Project (SCIP) measures for the prevention of Venous Thromboembolism (VTE) in surgical patients. The data is available for those organizations that have selected VTE-1 and VTE-2 measures for reporting purposes. The full name of the VTE-1 measure is: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered. The full name of the VTE-2 measure is: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours after Surgery. Affected hospitals began reporting data on these measures with discharges as of October 2006. In addition to the posting of VTE-1 and VTE-2 data, Quality Check includes a placeholder for the reporting of Children’s Asthma Care (CAC) measure data. The actual data will be available next quarter for those organizations that have selected CAC measures for reporting purposes.
(Contact: Dawn Allbee, dallbee@jointcommission.org)
-Top-
As of December 31, 2007, The Joint Commission’s sentinel event statistics have been updated on the Joint Commission website. Since the sentinel event database was implemented in January 1995, the Joint Commission has received 4,817 reports of sentinel events. A total of 4,945 patients were affected by these events, with 3,478, or 70 percent, resulting in patient death. The 10 most frequently reported sentinel events are:
- Wrong-site surgery - 625
- Suicide - 596
- Operative/post-operative complication - 568
- Medication error - 446
- Delay in treatment - 360
- Patient fall - 281
- Assault, rape or homicide - 177
- Patient death or injury in restraints - 176
- Perinatal death or loss of function - 143
- Unintended retention of foreign body* - 141
* Added to reviewable events in June 2005; data represents events reviewed since June 2005.
(Contact: Anita Giuntoli, agiuntoli@jointcommission.org)
-Top-
The Joint Commission and the National Quality Forum are accepting applications for the 2008 John M. Eisenberg Patient Safety and Quality Awards, which recognize individuals and health care organizations that are making significant contributions in improving the safety and quality of patient care. The awards honor the memory of Dr. Eisenberg, a nationally recognized leader in health care quality improvement who advocated for health care—based on a strong foundation of research—that meets the needs and perspectives of patients. The deadline for nominations is April 14, 2008. Nomination forms are available online at The Joint Commission website and http://www.qualityforum.org/.
(Contact: Linda Hanold, lhanold@jointcommission.org)
-Top-
-Top- |
|
|