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Sentinel event advisory group recommends topics for field review

Patient Safety Monitor Alert, January 7, 2005

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The sentinel event advisory group met in November and December to identify possible National Patient Safety Goals (NPSGs) for 2006, according to JCAHOnline, a monthly newsbrief from the JCAHO.

In addition, the group decided that surveyors should score all organizations for compliance on "free-flow" protection for infusion pumps beginning January 1, 2005. The guidelines on the JCAHO's Web site will state that "pre-assembled" free-flow protective mechanisms are acceptable in relation to IV administrative sets used with infusion pumps.

The group also advised removing the word "directly" from requirement 2d for laboratories on reporting critical test results directly to physicians. The JCAHO will change the guidelines to state that "directly" reporting critical test results can include reporting to an authorized "agent" of the responsible licensed caregiver.

The group recommended these topics for field review:

• culture of safety
• patient involvement in safety
• multi-dose medication vials
• wrong line connections
• healthcare worker fatigue
• delays in treatment
• anticoagulent, insulin, and narcotic use
• decubitus ulcers

To read the news brief, click here.

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