Compliance with 2003 National Patient Safety Goals

As of January 1, 2003, JCAHO began surveying health care organizations' compliance with the 2003 National Patient Safety Goals (NPSGs). As of February 21, 313 surveys were completed and most health care organizations were found to be in compliance with the Goals. However, some of the recommendations are more challenging than others, including prohibited abbreviations (7 percent non-- compliance), two identifiers (2.6 percent non-compliance) and surgical site marking (2.2 percent non-compliance). As of March 21, JCAHO has received 63 Requests for Review of Alternatives to the NPSGs; 39 were from hospitals. Of the 63 alternatives, 27 were deemed no review necessary (the organization was meeting the Goal or the request was not a true alternative); 10 were not acceptable; six were acceptable with modification; five were acceptable; three requests were withdrawn; and 12 are in the process of review.

Below is a breakdown of the 63 requests by Goal and recommendation:

1.a Two identifiers 1

1.b Time out before surgery 0

2.a Read-back verbal orders 2

2.b Standardize abbreviations 4

3.a Restrict concentrated electrolytes 17

3.b Limit and standardize drug concentrations 4

4.a Preoperative verification process

4.b Mark the surgical site 16

5.a Free-flow protection on infusion pumps 11

6.a Maintenance and testing of alarms 1

6.b Appropriate alarm settings and audibility 1

Examples of JCAHO approved alternative approaches to the recommendations will be provided on the JCAHO website at a future date. (For questions about the National Patient Safety Goals, contact: Standards Interpretation Group, 630-792-5900, or submit your questions with the online form at www.jcaho.org

Sentinel Event Alert Advisory Group To Identify 2004 National Patient Safety Goals

The Sentinel Event Alert Advisory Group met in March to begin identifying the 2004 National Patient Safety Goals (NPSGs). The group:

* Reviewed the existing 2003 Goals for potential continuation in 2004.

* Identified potential new topics for 2004 Goals, including preventing surgical fires, eliminating kernicterus, and reducing the risk of serious nosocomial infections.

* Discussed the linkage between JCAHO's NPSGs and the National Quality Forum's Safe Practices for Better Health Care and Serious Reportable Events.

The Advisory Group will evaluate and consider both the potential new topics and existing Goals in developing its recommendation for 2004 Goals to the Board of Commissioners. The 2004 Goals and Recommendations are expected to be announced in July following approval by the Board. (Contact: Rick Croteau. 630-792-5776)