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JCAHO to lead worldwide effort to cut medical errors

Nurse Leader Weekly, November 8, 2005

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will coordinate an international effort to reduce medical errors, the World Health Organization (WHO) announced in August, 2005.

The accreditor and its affiliate, Joint Commission International (JCI), will head up a four-year effort to analyze errors and best practices to improve patient safety and spread solutions worldwide, officials said. The aim of the effort is to reduce harm that impacts nearly one out of every 10 hospitalized patients.

"That's really the task that the Joint Commission-with all of its expertise-is taking on for us," said Liam Donaldson, MD, chair of the WHO's World Health Alliance for Patient Safety. "This is not some remote problem in some far-flung corner of the world. Patient safety can affect every mother, every father, every child."

Tailored solutions

The JCAHO hopes to conduct a gap analysis and offer two solutions in the next two years, said Karen Timmons, president and chief executive officer of JCI.

A network of organizations, including the National Patient Safety Foundation and Britain's National Patient Safety Agency, will work with the commission to identify existing solutions, needs, and priorities, Timmons said. Officials could then tailor solutions to individual problems in different areas of the world.

Safety data and solutions could come from a range of sources, including the JCAHO's sentinel-event database, National Patient Safety Goals best practices, and the International Patient Safety Goals, which the commission will field-test in 2006, said Peter Angood, MD, chief patient safety officer at the JCI Center for Patient Safety.

Error reporting a problem

One of the major hindrances to patient-safety improvement is error reporting, Donaldson said. People often blame individual staff members instead of looking at how the system may have contributed to harm, he said.

"The likelihood of mistakes happening is greater because of faults in the system," Donaldson said. "Human error is inevitable, but we can eliminate system weaknesses that exacerbate human errors."

Donaldson pointed to an error that killed a child in Nottingham, England, in 2001. The child was receiving treatment for leukemia at a hospital when staff accidentally injected the cancer drug vincristine intrathecally-into his spine-instead of intravenously, as it should have been. Staff mistook the vincristine for a different drug, he said.

The mix-up occurred because certain protocols were not followed, Donaldson said. Staff should have administered the vincristine at a different time to avoid confusion with the other drug, the pharmacy should have sent the two drugs to the floor in different bags instead of in the same one, and nurses should have notified a senior physician to come supervise the treatment.

The JCAHO issued a Sentinel Event Alert about vincristine errors on July 14, noting that 37 errors have occurred with the cancer drug since 1968.

Tip: Take immediate action to identify any weaknesses in policy and procedure when a patient-safety alert becomes public, Donaldson said.

Source: This article is adapted from Briefings on JCAHO, October 2005, HCPro, Inc.

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