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Beware of these four JCAHO survey hot spots

Nurse Leader Weekly, September 3, 2004

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Let these recent survey examples help you identify focus areas for your mock tracer surveys in preparation for your next Joint Commission for Accreditation of Healthcare Organizations' visit:

1. High-alert medications: Surveyors were impressed with how Renaissance Behavioral Health System ensures the safety of high-alert medications (National Patient Safety Goal #3).

Facilities in the Jacksonville, FL-based system store medications in a locked room that is well-lit, quiet, and organized to make sure that nurses can concentrate when working with the high risk medications, says Leah Guthrie, BA, RN, LHCRM, director of quality improvement/risk management at Renaissance.

Staff label high-risk medications appropriately and are careful to store look-alike/sound-alike drugs apart from one another. Only one staff person per shift holds keys to the room for security reasons.

Prior to administering drugs, a nurse asks patients their names and verifies the information against their identification bands.

Head's up: The 2005 National Patient Safety Goals will require you to take proactive measures to prevent look-alike/sound-alike drug errors.

2. Emergency drills: Surveyors studied how Renaissance staff prepare and assist patients during emergency situations. Staff at the beginning of each shift are assigned sole responsibility for one disabled or restrained patient in the event of an emergency. Managers check regularly to ensure that staff comply with this policy and further monitor their compliance during monthly fire drills.

3. Patient ID: Tulare (CA) District Healthcare Systems received a recommendation for improvement for using room numbers and 911 as identifiers for critical patients who have not been officially registered into the hospital system, such as those brought in by ambulance.

Solution: The ED now uses a special green-colored band that displays a temporary number that nursing staff can use until the patient is registered, says Julie Gresham, RN, JCAHO coordinator. Staff identify all other patients by their names and dates of birth.

4. Biohazard safety: Tulare also received a recommendation for improvement for not using a biohazard bag to transport blood from the lab to a nursing unit. The blood was kept in a blood-unit bag when carried between the two buildings, says Gresham.

Solution: The hospital now requires staff to place the blood-unit bag in a biohazard bag during transportation.

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