Complying with the 2008 national patient safety goals

AORN Journal,  March, 2008  by Kathleen Catalano,  Kevin Fickenscher

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These systems, however, are not without problems. In an article published in the Joint Commission Journal on Quality and Patient Safety in September 2007, researchers noted that errors from handwritten prescriptions required clarification and correction by a pharmacist; however, errors also occurred when the technologic application, using a databank library, automatically inserted incorrect abbreviations. (14) This functionality certainly must be monitored carefully.

The danger of being unable to read an individual's handwriting or to understand an abbreviation, acronym, symbol, or dosage designation is greatly reduced when efforts are made to comply with this requirement. Opposition to these efforts, however, is present in some organizations. Physicians may be of the belief that the abbreviations, acronyms, symbols, and dosage designations they learned in medical school are "sacred" and that their use should not be questioned, regardless of substantiated arguments to the contrary.

REQUIREMENT 2C. Requirement 2C instructs health care organizations to measure, assess, and, if appropriate, take action to improve the timeliness of reporting and the timeliness of receipt of critical test results and values by the responsible licensed caregiver. With clinical information systems, documentation of these exchanges becomes easier, and measurement can be done electronically.

REQUIREMENT 2E. Hand-off communication was first adopted as NPSG requirement 2E in 2006. It requires that the health care organization establish a standardized approach to hand-off communications. This communication must be interactive between staff members, allowing them the opportunity to ask and respond to questions whenever a patient is transferred between caregivers, for example, when the postanesthesia care unit nurse receives a patient from the anesthesia care provider after surgery. Whatever the hospital's policy, it should be followed by all staff members, and hand-off communications should cover up-to-date information about the patient's care, treatment, service, current condition, and any anticipated changes to that condition. Verification, including repeat-back or read-back of patient information, also should become part of this process. Interruptions during hand offs should be minimized, if at all possible.

GOAL 3--IMPROVE THE SAFETY OF USING MEDICATIONS

National Patient Safety Goal 3 is to "Improve the safety of using medications." (11) There are three requirements of this NPSG, and two have IT implications.

REQUIREMENT 3C. Requirement 3C refers to look-alike/sound-alike medications. Health care organizations are to review their list of look-alike/sound-alike medications and take action to prevent errors involving their interchange. Although the Joint Commission has established tables of look-alike and sound-alike medications and suggests safety strategies for avoiding errors related to these products, they have not recommended a specific method for managing these medications. Developments in pharmacy robotics, automated cabinets, and bar code medication administration should help health care providers' comply with this directive.