Joint Commission- National Patient Safety Goals

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient identification use at least two patient identifiers. Joint Commission is also focusing on ways to make sure patient gets the correct blood for blood transfusions.

Medication safety is focusing on communication, recording and passing along correct information about the patient’s medication before, during and after the hospital admission. (“The joint commission,” 2014) Joint Commission made patient identification number one on patient safety goals for 2014 because of how important it is to have the correct identity of every patient. Over the years there have been many areas of patient misidentification. Some near misses and some fatal. Misidentification can happen anywhere in a hospital setting and can include wrong drug administration, misidentification of blood or blood transfusion and wrong patients for surgical interventions. This is way it is so important that all departments in an organization use the same method for patient identification. Patient identification has been a problem for several reasons.

One is communication, we assume way too much as a whole. Instead of communicating with the patient we assume it’s the right patient and continue with treatment, only later to find it was the wrong person. Another reason is time. As nurses we are always rushing around and short of time. With so many task to do in such as short amount of time the pressure is on. We rush and can cause some serious, possibly fatal errors. Joint Commission made patient identification number one on the National Patient Safety Goals by having at least two patient identifiers for every intervention done to a patient decreasing the likelihood of having an error (World Health Organization, 2007). There are still some barriers or obstacles to overcome on getting everyone on board with using two identifiers for patient identification. Change is difficult for some people and getting them to realize that the way they used to do things may not be the best and safest practice anymore.

So, behavioral change can be difficult but with good strong positive leadership even the most stubborn person eventually will comply with change. At the hospital I work at we have been using two patient identifiers, name and date of birth, for at least four years. I think it has helped saved many near misses that I have personally been involved with and I am an advocate for making sure patients have ID bands on. I also try to educate patients and families on the reasons why staff are always asking for their name and date of birth. Another system that has been implemented is computerized charting system. This is becoming more prevalent in hospital around the United States. This system helps ensure patient identification as well.

For example, the patients information is inputted into the computer with all their information, such as name, date of birth, lab values, allergies, medications, x-rays and many other items as well. All this information is linked to their medical record number and stays in the database and any time the patient returns you have their medical record right in front of you. As long as all the information is put in correctly at time of admission all the information on the patient is provided. There is also a system which we use where I work called Admin RX. This system allows you to scan the patient and then the medication, which is another way of making sure you have the right patient with the right medication. However, there are issues with this system as well because the computer is only as smart as we allow it to be.

If pharmacy puts in the computer the wrong medication or dose, or information is incorrect, the computer will still allow you to administer. It goes back to communication, knowing your patient and how important it is to still ask questions and have conversation with your patient about the medication you are about to give them. Read their history and physical to get a better idea of everything going on with your patient so we can continue to provide safe quality care. Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”.

Ensuring medication reconciliation to the patient, health providers and any new consults that are seeing the patient as well, are essential for patient safety. Comparing patient’s current medications to newly ordered medications is vital to patient safety so that multiple medications of the same actions or non-compatible medications are not being given, which could have the potential of a fatal outcome. Communication is a must. Being computerized is one step closer to becoming safer when it comes to medication safety. Where I work we have an admit nurse seven days a week that addresses all Emergency room patients and admitted patients medications. Her role is to talk to the patient or family if needed and get an up to date list of dose and frequency of all medication being taken at home and update this in their medical records.

During their admission the doctors will use this as a reference as to what to continue or change during their admission and will revise again at discharge. The discharge nurse will go over every medication new and old so the patient is aware of any changes. Since the implementation of CPOE there have been studies that show substantial reduction in medication errors. One study in 2008 by JAMIA showed that “34% of US acute-care hospitals had adopted CPOE and since this adoption and implementation they estimate 17.4 million medication errors per avoided due to CPOE- a 12.5% reduction nationally (Radley, Wasserman, Olsho, Shoemaker, Spranca & Bradshaw, 2013)”.

I think this system has been very helpful for all interdisciplinary departments involved because by being all computerized everyone can access the records from anywhere in the hospital and they can actual read it legibly which has been a great safety measure. Lastly, inadequate education to patients, on how to read, understand and the importance of their discharge medication can cause confusion and accidents. It is vital that the discharge nurse educates and the patient feels confident about their discharge medications and instructions.

In conclusion, Joint Commission’s mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (“The joint commission,” 2014). Everyone always gets so nervous when it’s time for the Joint Commission survey but if we continue to do the right thing, for the right patient, at the right time and follow the policies and procedures that are put in place for us, the safety and quality of care for the patient will not be jeopardized. Having the gold seal of approval from Joint Commission shows patients, families and staff that your facility is committed to providing the safest, high quality, evidence-based practice, patient-centered healthcare possible. As a nurse, practicing the habits that Joint Commission has outlined will help improve patient safety and outcome.

References

The joint commission. (2014, January 03). Retrieved from http://www.jointcommission.org/2014_national_patient_safety_goals_slide_presentation/ World Health Organization. (2007). Patient identification. Patient Safety Solutions, 1(2), Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf Radley, D., Wasserman, M., Olsho, L., Shoemaker, S., Spranca, M., & Bradshaw, B. (2013). Reduction in medications errors in hospitals due to adoption of computerized provider order entry systems. 10(1136), Retrieved from http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full Finkelman, A., & Kenner, C. (2013). Professional nursing concepts: competencies for quality leadership. (2nd ed.). Burlington, MA: Jones & Bart Learning.