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Challenges ahead with new JCAHO Patient Safety Goals

Patient Safety Quality Monthly, May 26, 2004

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JCAHO has recently put out for comment the proposed 2005 National Patient Safety Goals and requirements for hospitals. A number of interesting changes are expected, as well as some minor edits. Until the field has responded to this draft, and JCAHO considers the issues raised, it is not clear which of these proposed requirements will actually become reality.

In the meantime, I would like to comment on JCAHO's new Goal # 8: To "accurately and completely reconcile medications and other treatments across the continuum of care." There are two requirements within this goal:

Every time a patient changes settings, the medications need to be checked and reconciled.

For every patient in every setting, caretakers need to clearly understand who is the licensed independent practitioner in charge and how to contact that person.

These recommendations are based on the need for standardization in the communication and hand-off process. Other high-risk industries have shown that critical communications are often a source of errors that lead to significant adverse events. To eliminate these events, communication in these industries is often highly structured to ensure accuracy and speed.

Who would want to be in an airplane making multiple stops to get to a final destination if the pilot didn't bother going over the critical checklist every time he took off because he had done it 45 minutes previously at the last destination?

Similarly, we would not want our loved ones to be treated in a hospital, knowing that the caregivers are not 100% sure that the right medications are provided each time there is a change to another caregiver or setting.

The second requirement focuses on the physicians' willingness to be responsive and communicative on behalf of the safety of their patients.

In our work with hospitals in this country, this issue is reported at peer review committee meetings because of adverse patient events or through incident reports from frustrated nursing staff who witness near misses. The unwillingness of physicians to identify who is in charge during those adverse events lends to procedural confusion and delays in treatment.

Anyone who has watched a movie involving nuclear submarines has seen the required verbal exchange between officers, which clarifies who is in command. Yet we allow patients to be treated without a clear understanding on who is in charge or how to get a hold of them.

Perhaps it is time that we put into place systems where, every day, and perhaps every shift, nurses can have their queries answered and physicians can confirm who is in charge for the day to properly coordinate their patients' care.

The healthcare field may push back on Goal # 8 as being too big a burden for caregivers. However, it would be well worth it if this goal can help prevent the agony of explaining to patients' families or loved ones why confusion has led to avoidable medical errors.

Best regards,

Bob Marder, MD
Practice Director, Quality and Patient Safety
The Greeley Company

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