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Course Contents

	Purpose/Goals    Objectives    Overview    Competency    Performance Improvement (PI)    Risk Management    Sentinel Events    Root Cause Analysis    Medication Errors        Prescription errors, Written or spoken        Handwritten orders are also a dangerous          source of errors.        High-alert Drugs        Infusion Pump Errors        Computerization of the Medication          Administration Process    Wrong Site Surgery    Deaths of Restrained Patients    Blood Transfusion Errors    Operative and Post-operative Complications    Deaths from Falls        JCAHO Patient Safety Goals    Conclusion    References      Click any section in the index above to browse to the corresponding course section

Purpose/Goals

The purpose of this course is to familiarize healthcare professionals on the performance improvement process and educate healthcare professionals to identify situations where errors commonly occur and apply strategies for prevention.

Objectives

After reading the material, the student will be able to:

1. identify programs to reduce medical errors,

2. define Sentinel Event,

3. define Root Cause Analysis,

4. identify the top 5 medications associated with serious medication errors, and

5. identify the most common root causes associated with frequently occurring medical errors.

Overview

Preventable events resulting from medical errors are a factor in approximately 98,000 deaths in hospitals annually (Pape, 2001). Recent studies found that serious adverse events occurred in up to 12% of hospital admissions (Rex, et al., 2000). Serious medical errors are devastating to the patient, family and staff. Medical errors increase expenses in additional patient care, and in litigation.

The severe consequences of medical errors are one reason that healthcare is a highly regulated business. All healthcare organizations have to be licensed. They also have to meet industry standards, building and safety codes, Federal Statutes and State Statutes.

Healthcare organizations are subject to inspection for compliance with statutes, regulations and industry standards. Inspections can be scheduled or unscheduled. Scheduled inspections are conducted periodically. Unscheduled inspections can be conducted randomly, or they can be conducted for cause, like a patient complaint. One of the most well know inspection agencies for hospitals, is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). It is an independent organization, meaning that JCAHO is neither a government agency, nor does it have a financial interested in any healthcare organization. If a healthcare organization meets industry standards, JCAHO accreditates that organization.

Competency

Healthcare organizations must determine an individual's qualifications and ability to do the job. This involves checking education, license, experience, and credentials before an employee is hired. At least annually, staff performance should be evaluated. Competency, continued licensure and continuing education should also be checked at least annually. For licensed independent practitioners, like physicians and nurse practitioners, that process is called credentialing and privileging.

Licensure agencies maintain databases on license and issues that may inhibit practice. This is usually done on a statewide basis. There is a national database for licensed independent practitioners that include additional information, like malpractice court settlements.

Performance Improvement (PI)

Healthcare organizations have ongoing programs to identify, correct and prevent medical errors. These programs were previously known as Quality Assurance. It focused on analyzing outcomes and processes within a department to improve outcomes. PI evolved out of this approach. PI has a more global focus of the organization’s processes, instead of being focused on a singular department. JCAHO requires and closely monitors each organization’s PI programs.

PI is a way to systematically monitor, analyze, and improve an organization’s performance and outcomes. PI methods state that most defects in quality are due not to individual factors, but rather to failure of support systems or to poor design of work processes (Rex, et al., 2000). The basic principles are that customers come first; every employee should be involved; teamwork is essential; and PI efforts are ongoing.
PI should improve an organization’s performance. This is done by reducing factors that contribute to unanticipated adverse events and outcomes. Unanticipated adverse events and outcomes can be caused by poorly designed systems, system failures, or errors. Decreasing unanticipated adverse events and outcomes requires an environment where patients, families, staff, and leaders can identify and manage risks to safety. Such an environment encourages the following (JCAHO, 2004, PI Overview):

	Recognizing and acknowledging risks and unanticipated adverse events
	Initiating actions to reduce these risks and unanticipated adverse events
	Reporting internally on risk reduction initiatives and their effectiveness
	Focusing on processes and systems
	Minimizing individual blame or retribution for involvement in an unanticipated adverse event
	Investigating factors that contribute to unanticipated adverse events and sharing that acquired knowledge both internally and with other hospitals

The following are other related concepts that you may be familiar with. Continuous Quality Improvement (CQI) is an approach that ensures that organizations always look for ways to improve processes and practices. Total Quality Management (TQM) is a management system that encompasses quality planning, quality control, and quality improvement. These programs are slightly different from PI, but in the real world, you may hear the terms used interchangeably.

Quality Control (QC) is an ongoing, systematic measurement to determine compliance and accuracy. It is required for some equipment or measurement tests. Examples are checking the high and low control limits on a glucometer or the temperature of the medication refrigerator. QC is often a component of, or is mentioned in relationship to PI.

Risk Management

Risk Management (RM) is a program that is focused on eliminating or minimizing the effects of accidental losses to an organization. RM works closely with and sometimes overlaps functions with PI. The Risk Managers are involved with risk financing, through insurance companies to minimize financial losses. They usually investigate serious medical errors, institute damage control and consult with legal council as needed.

Incident reports are an important source of information for a Risk Manager. Aggregate data from incident reports is statistically analyzed to identify areas of risk and exposure. Risk control techniques are then applied to those areas of focus. The usual techniques are avoidance, transfer, prevention, reduction, segregation and duplication.

Avoidance is a technique that eliminates the possibility of a loss. This is also known as a forcing function. This technique involves designing equipment or processes to make it impossible to use it incorrectly (Leape, et al., 2000). Examples are stocking only one concentration of a medication or removing concentrated Potassium Chloride from floor stock. These functions are effective, but can be inconvenient and time consuming for personnel.

Transfer is the process of negotiating with insurance companies to transfer the financial burden of a loss. This technique assumes that the loss cannot be prevented so we must be insured against those times when it happens.

Loss prevention reduces the probability or frequency of a loss but does not eliminate the chance of loss, nor does it reduce the severity of that loss. This is also known as a constraint function. This means that equipment or a process is designed to make it difficult to use it incorrectly (Leape, et al., 2000). Examples are limiting floor stock or a policy limiting verbal orders. Constraints can help prevent errors that might be made by less experienced or distracted personnel.

Loss reduction focuses on reducing the severity of damage. For example, frequent monitoring instituted for conscious sedation procedures does not reduce the risk of the sedation being too deep. However, it allows early intervention to reverse the sedation and provide adequate oxygenation.

Segregation means that a process is totally separated from the rest of a clinical setting to reduce or eliminate errors. For example, changing the medication administration system so the pharmacist fills the order and administers the medication to a patient. This eliminates the potential error at the point the pharmacy usually hands off the medication to nursing. However, as with most segregation techniques, it is too expensive and impractical.

Duplication means that there is a backup. For instance, having employees cross-trained. That way, someone is available to perform a job when the person who normally performs that job is unexpectedly unavailable.

Sentinel Events

JCAHO (2004) defines a sentinel event as:
“an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.”

This type of occurrence is called "sentinel" because it indicates the need for immediate investigation and response. The following events are considered a sentinel event, even if the outcome is not death or major permanent loss of function: suicide; unanticipated death of a full term infant; infant abduction or discharge to the wrong family; rape; hemolytic transfusion reaction; and surgery on the wrong patient or wrong body part (JCAHO, 2004). A near miss is a potential error that fails to cause injury by chance or because it is stopped before it occurs. The natural course of the patient's illness or underlying condition is not considered a sentinel event (JCAHO, 2004).

JCAHO requires accredited organizations to identify and respond appropriately to sentinel events. Appropriate response includes conducting a timely and thorough investigation, implementing improvements to reduce risk, and monitoring the effectiveness of the improvements (JCAHO, 2004).

Healthcare organizations have always been concerned with medical errors. However, attempts to prevent and minimize errors have been somewhat isolated. This is due to the confidential nature of the information and the negative impact that information can have on a healthcare organization if it leaks. Sentinel events sometimes hit the news, causing a public uproar, but the majority of errors remain knowledge that is confined to a few people. Healthcare organizations are encouraged to report sentinel events to JCAHO. The information from these reports is evaluated and published in the Sentinel Event Alert. It includes aggregate data, specific examples, and strategies for prevention. The Sentinel Event Alert is available on the Internet at http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea.htm.

Root Cause Analysis

JCAHO requires use of root cause analysis (RCA) to investigate the processes and systems that contribute to a sentinel event. RCA is a tool that helps identify and clarify the bottom line factors that precipitate an error or near miss. RCA focuses on systems and processes, not on individual performance (JCAHO, 2004).

The RCA process repeatedly digs deeper into an issue by asking “Why” questions until no additional logical answers can be identified (Rex, et al., 2000). A team of people representing the areas that are involved in an event is brought together to do this analysis. The team begins with a standardized template called an Ishikawa diagram. (Figure 1) This template is also known as a fish bone diagram or cause and effect diagram.

Figure 1, Ishikawa Diagram. The major headings are suggested and can be changed.

The team selects major headings for the diagram that will include categories of possible causes. The headings should be as independent from each other as possible to avoid confusion. The team identifies the potential factors that would cause the problem. These are written along the major branches of the diagram. For each cause listed, the team asks “why?” Those reasons are written down as smaller branches on the diagram. The rule of thumb is to ask “why” five times. When you reach a point where there is no additional logical answer to the question “why,” you have reached what is called a root cause (Gaucher, 1993).

Once the Ishikawa diagram is complete, the underlying causes of the event are summarized. Changes that could be made in systems and processes that would reduce the risk of similar adverse events are suggested (Rex, et al., 2000).

One type of cause is special cause found in clinical processes. Special cause is a factor that is intermittently and unpredictably. This causes a variation that is not inherent in the system. An example is a patient has an allergic reaction to a medication that they have successfully taken in the past. The other type of cause is common cause in organization’s process. Common cause is a factor that results from variation that is inherent in the process or system. RCA seeks to identify potential areas for improvement in a process or system that might help reduce the risk of occurrence of an event. An example is allowing only premixed Potassium Chloride solutions on the nursing unit will prevent the possibility of making an error in the dilution (JCAHO, 2004).

RCA has a limitation, which is known as the blinder effect. That is the tendency for the team to look only at one part of the process that led to the event, instead of the entire process (JCAHO, 2001, Feb).

Medication Errors

“Medication errors are one of the most common causes of avoidable harm to patients in health care organizations”(JCAHO, 1999). One study found that medication errors occur in 6%-10% of hospitalized patients. Most of these errors are harmless. 1%-2% cause injury and an additional 5% are near-misses (Leape, et al., 2000). Another study found that 1% of medication errors were fatal (Rex, et al., 2000). The MEDMARX 2002 database found that 1.7% of the total number of medication errors resulted in patient injury (USP, 2003).

The types of medication errors include: prescribing, omission, wrong time, unauthorized drug, improper dose, wrong drug preparation, wrong administration techniques, deteriorated drugs, improper monitoring and compliance, product errors, process errors and human errors. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer (USP, 2001).

Administering medication is a crucial nursing responsibility. To ensure safe and effective drug therapy, the nurse must to be familiar with indications, usual dosages, and intended effects of drugs. Remember the 5 rights: right patient, right drug, right dose, right route, and right time. Each patient must be assessed before administration and medication should be delayed or withheld if indicated.

Nurses are most likely to be blamed for medication errors because they are involved at the administration point. However, medication errors are complex and are rarely the result of one person’s actions (Pape, 2001). The medication system in hospitals is complicated. There are multiple steps and many individuals involved. Every time a document or medication changes hands, there is an increased potential for error.

In a study of serious medication errors that caused injuries or had the potential to cause injuries, 30% occurred in the prescribing phase, 38% in the nurse administration phase and 12% during pharmacy dispensing (Leape, et al., 2000). The 2002 MEDMARX data report found that incorrect administration technique is responsible for the largest number of harmful medication errors, 6.2%. Incorrect administration is related to either preparation or administration, or both. Examples are not diluting concentrated medications, crushing sustained-released medications, wrong eye application of eye drops, and using incorrect IV tubes for medicine administration (USP, 2003).

In general, hospitals lack effective programs for monitoring medication errors. Most rely on spontaneous reporting. Since medical personnel are often punished when they make an error, most errors are not reported (Rex, et al., 2000) (Leape, et al., 2000). Medication Errors are usually reported on an incident report form or a report form specifically for medication errors. Adverse Drug Events (ADEs) is a common term used to describe medication errors in healthcare settings. These forms are forwarded to Risk Managers who evaluate the incident and keep statistics on the ADEs.

Prescription errors, Written or spoken

Verbal orders are a dangerous source of errors. Certain numbers and drug names sound alike (Pape, 2001). Confusion over the similarity of drug names, either written or spoken, accounts for about 15% of all reports to the United States Pharmacopeial, Medication Errors Reporting Program between 1/1/96 to 12/31/00 (USP, 2001). Comprehensive recommendations to reduce medication errors associated with verbal orders are published by the National Coordinating Council for Medication Error Reporting and Prevention at www.nccmerp.org.

Handwritten orders are also a dangerous source of errors.

One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions. Underlying factors contributing to many of these errors are illegible or confusing handwriting by clinicians and the failure of health care providers to communicate clearly with one another. Examples of especially problematic abbreviations include "U" for "units" and "µg" for "micrograms." When "U" is handwritten, it can often look like a zero. There are numerous case reports where the root cause of sentinel events related to insulin dosage has been the interpretation of a "U" as a zero. Using the abbreviation "µg" instead of "mcg" has also been the source of errors because when handwritten, the symbol "µ" can look like an "m". The use of trailing zeros (e.g., 2.0 vs. 2) or use of a leading decimal point without a leading zero (e.g. .2 instead of 0.2) are other dangerous order writing practices. The decimal point is sometimes not seen when orders are handwritten using trailing zeros or no leading zeros. Misinterpretation of such orders could lead to a 10-fold dosing error (JCAHO, 2001, Sept.).

Another source of medication errors is confusion between similar drug names including brand names and generic names. Confusion is compounded by illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labeling, and incorrect selection of a similar name from a computerized product list (USP, 2001). Suggestions for minimizing the risk of errors include (JCAHO, 2001, May):

	Do not store problem medications alphabetically by name. Store such identified medications out of order, or in an alternate location.
	Provide or ask for both the generic and brand names of drugs for medication orders in order to provide patients and staff with information to avoid unintentional duplication.
	Write the purpose of the medication on the prescription. This inexpensive and efficient method to minimize errors helps the pharmacist in screening the medication order for proper dose, duration, and appropriateness, and it may also enable the pharmacist to intervene when multiple prescribers unknowingly order duplicative therapy for the same patient. It also minimizes the risk of confusion due to look-alike names of medications as well as the risk of misinterpretation due to poorly handwritten orders.
	Develop a policy for taking verbal or telephone orders. For example, when taking verbal drug orders, clearly repeat the name of the drug, the dosage ordered, and request or provide correct spelling. This is particularly important for sound-alike drugs.

High-alert Drugs

One study found that the majority of medication errors resulting in death or serious injury were caused by a list of specific medications. These were labeled high-alert medications. The top 5 high–alert medications were: insulin; opiates and narcotics; injectable potassium chloride (or phosphate); intravenous anticoagulants, and sodium chloride solutions above 0.9% (JCAHO, 1999, Nov).

The following are drug specific strategies for prevention of medication errors. These are recommended by JCAHO, in the publication Sentinel Event Alert (JCAHO, 1999, Nov).

Insulin:

	Establish a check system where one nurse prepares the dose and another nurse reviews it.
	Do not store insulin and heparin near each other.
	Spell out the word unit instead of using the abbreviation U.
	Build in an independent check system for infusion pump rates and concentration settings.

Opiates and Narcotics:

	Limit the opiates and narcotics available in floor stock.
	Educate staff about hydromorphone and morphine.
	Implement PCA protocols that include double checks of the drug, pump settings, and dosage.

Injectable Potassium Chloride (KCL) (or Phosphate):

	Remove concentrated KCL from floor stock.
	Move the drug preparation off the units and use commercially available premixed IV solutions.
	Standardize and limit drug concentrations.

Intravenous Anticoagulants:

	Standardize concentrations and use premixed solutions.
	Use only single-dose containers.
	Separate heparin and insulin.
	Remove heparin from the top of medication carts.

Sodium Chloride Solutions Concentration above 9%:

	Remove sodium Chloride concentration solutions above 9% from nursing units.
	Standardize and limit drug concentrations.
	Double check pump rate, drug concentration and line attachments.

Infusion Pump Errors

The types of infusion pump errors seen are the use of pumps that do not protect from free–flow of fluids to the patient; the wrong drug concentration; or the wrong rate is set (JCAHO, 2000, Nov). The underlying causes are human error, staffing patterns, work pressure, varied concentrations of critical drugs, and lack of standards.

Free-flow of fluids occurs when the infusate flows freely, under the force of gravity, without being controlled by the infusion pump. Infusion pump tubing needs a built in, anti-free-flow mechanism. This prevents gravity free-flow by closing off the tubing to prohibit flow when the administration set is removed from the pump.

If an infusion pump does not have free-flow protection, devices that attach to the administration set are available. However, they are not recommended, because the mechanisms are packaged separately and must be manually attached to a set. Clinicians may forget to use the mechanism or may accidentally remove them (JCAHO, 2000, Nov).

Training and education are important in the prevention of infusion pump administration errors. Be sure to inservice staff who may not be administering medication, but may be handling the infusion pumps, such as aides, radiology technicians and transporters. Another concern is that patients, family members or visitors may mishandle pumps.

Having a second nurse check calculations and settings for infusion pumps, when high-alert drugs are used, is recommended (JCAHO, 1999, Nov).

Computerization of the Medication Administration Process

Automation in pharmacy and nursing unit medication dispensing has not yet proven an impact on error prevention. However, computerize physician order entry has been shown to decrease serious errors in medication systems by 55%-80% (Leape, et al., 2000).

Most physicians’ orders are still handwritten and then manually transcribed to a medication administration record. This leaves a lot of opportunity for errors. A computerized physician order entry, in which the physician must enter all orders by computer, eliminates handwriting and transcription errors. It also makes it possible to automatically check doses, drug-drug interactions, allergies and significant patient characteristics, like impaired renal function.

A computerized order entry system presents it’s own set of problems. There is a significant expense that smaller facilities may not be able to afford. Cost prohibitions or lack of space may limit the number of PCs to the point that practitioners have long wait times for computer access. It seems slow and inconvenient at times. In addition, physicians who are less computer savvy may be resistant to change.

Wrong Site Surgery

The root causes of wrong site surgery were identified as a breakdown in communication between surgical team members and the patient and family; policy issues such as marking of the surgical site was not required; verification in the operating room and a verification checklist were not required; and patient assessment was incomplete, including an incomplete pre-operative assessment; staffing issues; distraction factors; availability of pertinent information in the operating room; and organizational cultural (JCAHO, 2001, Dec.).The following are strategies to prevent wrong site surgery (JCAHO, 2001, Dec.).

	Implement a process for clearly marking the operative site and involving the patient in the marking process is needed
	Create and use a verification checklist including appropriate documents, for example, medical records, X-rays and/or imaging studies
	Each member of the surgical team should do an oral verification of the correct site in the operating room
	The surgical team should take a time out in the operating room to verify the correct patient, procedure and site
	Use active, not passive communication techniques
	Monitor compliance with procedures

Deaths of Restrained Patients

In two years, the JCAHO reviewed 20 cases of deaths of patients who were physically restrained. Twelve deaths occurred in psychiatric hospitals, six in general hospitals, and two in long term care facilities (JCAHO, 1998). In 40%, the cause of death was asphyxiation. Asphyxiation was related to three situations. In come cases, excessive weight was put on the back of the patient in a prone position. Some patients had a towel or sheet placed over their head to protect staff from spitting or biting. And finally, some patients had an obstructed airway from pulling the patient's arms across the neck area. The remaining cases were caused by strangulation, cardiac arrest, or fire. All of the strangulation deaths were geriatric patients who were placed in vest restraints. Half of the strangulated patients died when they slipped between unprotected split side rails. All deaths by fire were of male patients who were trying to smoke or were using a cigarette lighter to burn off the restraints (JCAHO, 1998).

The following factors may contribute to an increased risk of death while restrained (JCAHO, 1998):

	Patients who smoke.
	Patients with deformities that preclude the proper application of the restraining device, especially with vest restraints.
	The supine position may predispose the patient to aspiration.
	The prone position may predispose the patient to suffocation.
	Patients restrained in a room that is not under continuous observation.

JCAHO and the organizations that experienced restraint deaths offered the following suggestions for preventing restraint deaths (JCAHO, 1998).

	Revise procedures for assessing the medical condition of psychiatric patients.
	Increase efforts to reduce the use of physical restraint and therapeutic hold by using risk assessment and early intervention with less restrictive measures.
	Increase staff education regarding alternatives to physical restraints and proper application of restraints or therapeutic holding.
	Consider age, sex and gender of patients when developing therapeutic hold policies.
	Revise staffing models.
	Develop procedures for consistent application of restraints.
	Continuously observe any patient in restraints.
	If restrained in the supine position, ensure that the head is free to rotate to the side and elevate the head of the bed.
	If restrained in the prone position, ensure that the airway is unobstructed at all times and that expansion of the patient's lungs is not restricted by excessive pressure on the patient's back.
	Never place a towel, bag or other cover over a patient's face when initiating a therapeutic hold.
	Do not use restrains in a bed with unprotected split side rails.
	Discontinue use of high vests and waist restraints.
	Ensure that smoking materials are removed from patient's access, including access from family and friends.

Blood Transfusion Errors

The processes involved in blood transfusion are complex. The potential for error is compounded when there are time constraints, like in an acute hemorrhage. Of 12 cases of blood transfusion errors reviewed by JCAHO, 11 were hemolytic reactions and one was an infectious reaction.

Incomplete patient/blood verification was a factor in 66% of the cases. 25% of the cases involved the handling or processing of blood samples or blood units for more than one patient, at the same time, in the same location. In all but one case, there were multiple failures to follow established procedures. The failures usually involved the verification of patient identity and correct blood unit for that patient. JCAHO found that the root causes fell into six general areas:(JCAHO, 1999, Aug).

	Incomplete patient/blood verification.
	The signs and symptoms of a transfusion reaction were not recognized.
	No informed consent for a transfusion.
	Multiple samples were being crossmatched at the same time or a crossmatch being started before the order was received.
	Insufficient orientation and training or insufficient staffing levels.
	Blood for multiple operating room patients being stored together in the same refrigerator.
	Incomplete communication among caregivers or errors on patient identification band, specimen label, or blood labels.

The following risk reduction strategies were recommended: (JCAHO, 1999, Aug).

	In-service training on transfusion-related procedures and revising the staffing model.
	Processes were changed, like revising the patient identification band procedures; revising patient/blood verification procedures; revising and implementing new informed consent procedures; discontinuing processing of multiple samples; or discontinuing the use of the room number as the patient identifier.
	Technical system redesign, like enhanced computer support or new patient identification band system.
	Environmental redesign, like discontinuing use of an operating room refrigerator for multiple blood units or adding laboratory workstations.
	Prohibiting simultaneous crossmatching of multiple patients by the same technologist.
	Introducing a computerized verification step into the process, like a bar code reader.
	Use "unique" identification bands for patients receiving blood transfusions.

Operative and Post-operative Complications

JCAHO has reviewed 64 cases related to operative and post-operative complications. 90% of the complications occurred in non-emergent procedures. The most frequent complications were (JCAHO, 2000, Feb):

	Nasogastric or feeding tube insertion into the trachea or a bronchus, usually involving a failure to confirm placement, interpretation of radiological placement by a non-Radiologist, or failure to communicate results of confirmation tests.
	Massive fluid overload from absorption of irrigation fluid
	Open orthopedic procedures associated with acute respiratory failure and cardiac arrest in the operating room.
	Endoscopic procedures with perforation of adjacent organs.
	Central venous catheter insertion into an artery.
	Imaging-directed percutaneous biopsy or tube placement, resulting in liver laceration, peritonitis, or respiratory arrest.
	Burns from electrocautery used with a flammable preparation solution.

66% of the errors involved incomplete communication among caregivers. 50% identified a failure to follow established procedures. Other failures were necessary personnel not being available; pre-operative assessment being incomplete; deficiencies in credentialing and privileging; Inadequate supervision of house staff; inconsistent post-operative monitoring procedures; and failure to question inappropriate orders. Organizations that experienced complications identified the following risk reduction strategies: (JCAHO, 2000, Feb).

	Staff orientation and training.
	Education and counseling of physicians.
	Expand on-call coverage, especially in radiology.
	Standardize procedures across settings of care.
	Revise credentialing and privileging procedures.
	Clearly define expected channels of communication.
	Revise the competency evaluation process.
	Monitor consistency of compliance with procedures.
	Implement a teleradiology program.

Deaths from Falls

JCAHO has reviewed 22 cases related to fatal falls. 50% of the deaths were the result of head trauma, usually a subdural hematoma. Most of the patients were elderly, with 50% older than 80. (JCAHO, 2000, Jul). 77% individuals had an altered mental status due to chronic mental illness or acute intoxication. A history of prior falls, use of sedation and anticoagulation were frequently associated risk factors. Other risk factors were a recent environmental change and urinary urgency. A disproportionate number of falls occurred on nights, weekends and holidays (JCAHO, 2000, Jul).

More than half of the organizations identified communication issues among caregivers as a root cause. These included failure to communicate information during nursing report, shift changes or a transfer from a hospital to a nursing home; caregivers not documenting changes in conditions in the medical record; and families’ inadequate communication about conditions and history of falling. Root causes included the following (JCAHO, 2000, Jul):

	Incomplete patient assessment and reassessment.
	Incomplete plan of care or lack of protocol.
	Environment of care issues like design of windows, door locks and nursing stations.
	Malfunction or misuse of equipment like bed alarms.
	Incomplete orientation of staff.
	Unavailable or delayed medical care.
	Insufficient education of patients.
	Inadequate staffing.
	Reduced use of restraints without alternatives.
	Inadequate supervision of orientees.

The following risk reduction strategies that were identified (JCAHO, 2000, Jul):

	Improve staff orientation and training.
	Implement or revise a fall risk assessment process.
	Implement a falls prevention protocol.
	Install bed alarms or redesign bed alarm checks and tests.
	Install self-latching locks on utility rooms.
	Restrict window openings.
	Install alarms on exits.
	Add fall prevention to education of patients and families.
	Improve and standardize nurse call systems.
	Use low beds for those at risk for falls.
	Revise staffing procedures.
	Counsel individual caregivers.
	Revise the competency evaluation process.

JCAHO Patient Safety Goals

JCAHO has made patient safety a priority. During JCAHO inspections, the following 2004 Patient Safety Goals will be a major focus (JCAHO, 2004).
 

Conclusion

Healthcare professionals have a responsibility to be knowledgeable about the PI process and to participate as opportunity presents. Healthcare professionals also have a responsibility to be aware of clinical situation that are prone to error, and to participate in procedures to prevent those errors.

References

Gaucher, R., et al. (1993). Total quality in healthcare: From theory to practice. San Francisco, CA, Jossey-Bass Inc.

Leape, L., et al. (2000). Reducing adverse drug events: Lessons from a breakthrough series collaborative. The Joint Commission Journal on Quality Improvement. 26(6) 321-331.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1998, Nov). Preventing restraint deaths. Sentinel Event Alert. Issue 8. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_6.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999, August). Blood transfusion errors: Preventing future occurrences. Sentinel Event Alert. Issue 10. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_10.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999, November). High-alert medications and patient safety, Sentinel Event Alert. Issue 11. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_11.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2000, February). Operative and post-operative complications: Lessons for the future. Sentinel Event Alert. Issue 12. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_12.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2000, July). Fatal falls: Lessons for the future. Sentinel Event Alert. Issue 14. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_14.htm

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2000, November). Infusion pumps: Preventing future adverse events, Sentinel Event Alert. Issue 15. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_15.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2001, May). Look-alike, sound alike drug names. Sentinel Event Alert. Issue 19. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_19.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2001, September). Medication errors related to potentially dangerous abbreviations. Sentinel Event Alert. Issue 23. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_23.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2001, December). A follow-up of review of wrong site surgery. Sentinel Event Alert. Issue 24. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_24.htm.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2001, February). Mix –up leads to a medication error, Sentinel Event Alert. Issue 16. Retrieved 12/21/03 from http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_16.htm.

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