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    JCAHO's Patient Safety Goals, Part 1: A practical guide

    CE Center

    RN/AHC Media Home Study Program

    CE credit is no longer available for this article. (Expired December 2008)


    Originally posted December 2006


    TERRI METULES is clinical editor and JEFF BAUER is managing editor at RN. The authors have no financial relationships to disclose.

    Everyone's heard of JCAHO's National Patient Safety Goals. But how familiar are you (really) with what they say? And did you know that a new goal has been added for 2007? Read on to learn how to use these goals to keep patients safe.

    What you don't know about the most recent addition to JCAHO's National Patient Safety Goals (NPSGs) might literally cost your patient his life. JCAHO's new goal for 2007, Goal 15, calls for your hospital to identify safety risks inherent in its patient population.1 Among other things, it requires that you assess the risk for suicide in any patient admitted for an emotional or behavioral disorder.1

    The addition of Goal 15 is the "news" when it comes to the 2007 NPSGs. In fact, much of the rest of the goals remain largely unchanged from 2006. The problem, though, is that many nurses are unfamiliar with the details of these goals, which are developed to ensure more accurate patient identification, better communication among clinicians, and quicker reporting of tests results.

    So to catch you up on what these goals are all about, and the latest addition to them, we've put together a two-article package that covers a number of the 2007 NPSGs. This month we'll detail Goal 15 and examine JCAHO's goals related to improved communications. Next month, we'll look at JCAHO's medication-related goals. (For a list of the goals, see the box below.)

    A snapshot of the Safety Goals

    An ongoing process creates a new goal

    JCAHO introduced its NPSGs in 2003 and updates them annually. The Goals are the result of a collective effort by JCAHO's advisors, a group that includes experts in patient safety, medicine, nursing, and pharmacy. These experts review all of the sentinel event data, define problem areas, and advise JCAHO on how it can help hospitals remedy these problems on their patients' behalf.

    Goal 15 is the latest addition. It calls for assessing for risks inherent in your patient population.1 This simply means your hospital should be scrutinizing its own sentinel events or occurrence data to identify potential risks to patient safety. It should be looking for trouble spots in the care environment, such as a lack of proper equipment or inadequate security, and checking for staff-related factors, such as not enough staff, incomplete assessments, or inadequate training. Your hospital should also be looking for patient-related factors, such as frailty, dementia, or emotional problems.

    As part of this goal, JCAHO also requires a complete assessment and follow-up on every patient admitted for behavioral or emotional problems. That's critical when you consider that suicide has been the most frequently reported sentinel event in staffed, round-the-clock facilities since JCAHO began its reporting policy in 1996.1

    According to JCAHO Associate Director of Standards Interpretation Gigi Acevedo, RN, MSN, "Hospitals can either use a standard tool or develop their own, but in any case, a suicide risk assessment must be documented on the patient's chart." (To find out how to assess for suicide, see the box titled "Could your patient be at risk for suicide?" in the article, "But I'm not a psych nurse!").

    This requirement doesn't, however, apply to a patient who has a history of behavioral or emotional problems who is admitted for a physical condition such as an appendectomy. Acevedo is quick to clarify, though, that for these patients, "JCAHO encourages you to assess for the risk of suicide, but you won't be scored on it."

    Focus remains on communication

    In addition to knowing what's required by the new goal, you also need to be familiar with the rest of JCAHO's NPSGs, including those that dictate improved communication. One of JCAHO's communication goals targets patient identification. "Wrong patient" errors have been widely publicized, can occur in virtually any setting, and can be fatal. Therefore, Goal 1 is to improve the accuracy of patient identification.1

    JCAHO requires that you use at least two "patient identifiers" whenever you provide a patient with care, treatment, or services.1 A patient identifier is a piece of person-specific information you can use to reliably identify someone as the right person for the drug, blood product, or treatment you're about to administer or the specimen you're going to collect.2 Examples include an individual's name, assigned identification number, social security number, and telephone number.2 A patient's room number or physical location is not an acceptable identifier.1

    Both identifiers may be in the same location, such as on a wristband or armband, although ID bands are not required. Bar coding that includes at least two identifiers will comply with this goal.2

    Because the two identifiers are used to match the right patient to the right treatment, they need to appear in both places—that is, for instance, on a wristband and the medication itself.2 For specimens, you're required to label the container with the two identifiers, in the patient's presence, at the time of collection.2

    Establishing two identifiers for a patient who's unresponsive when he arrives in your ED can be challenging. In such cases, JCAHO suggests that you assign the patient an identification number and a "temporary" name, such as John Doe, that can be used to match the patient to specimens, drugs, and blood products.2

    Good communication can prevent errors

    Because poor communication is so often the cause of errors, Goal 2 requires hospitals to improve the effectiveness of communication among caregivers.1 As part of this goal, JCAHO established four requirements that apply to nurses working in hospitals.

    The first is called the "read back" requirement. Whenever you receive a verbal or telephone order or are notified of critical test results, you must take three steps to verify the information.1 First, write it down on the order form or enter it into a computer. Next, read the information back to the clinician with whom you're speaking. Finally, have her confirm that what you read back was correct.1 Simply repeating a verbal order or test result is not acceptable.2

    This read back requirement applies to all caregivers. When, for example, you call a physician with a test result, she needs to write it down, read it back to you, and have you confirm it.

    Read back is not required when verbal communication doesn't include orders or test results, as might be the case during a physician-to-physician consultation or similar dialogue between clinicians.2 But it is required for orders left on voice mail.2 If a physician or other prescriber leaves an order on your voice mail, write it down and then call her and read back the information.2

    In emergency situations, such as a code, it may not be feasible for you to write down information and then read it back. In such cases, simply repeating the order is acceptable.2

    Nurses appear to be quickly adapting to the read back requirement. "As a result of this goal, nurses at the hospitals we evaluate are less willing to take casual verbal orders given by a practitioner as she is standing in the patient's room or walking down the hall," said Anne Huben-Kearney, RN, MPA, CPHQ, a clinical manager in risk management for ProMutal Group, a Boston-based medical malpractice insurer. "They're enforcing the requirement that verbal orders are for emergencies only."

    Goal 2 also requires that hospitals develop a list of abbreviations, acronyms, symbols, and dose designations that are not to be used in the organization.2 Although hospitals have been focusing on prohibiting potentially confusing abbreviations since JCAHO issued a sentinel event alert on the subject in 2001, this is an issue many facilities still need to address.

    During JCAHO's 2005 surveys, 23% of healthcare organizations failed to comply with this requirement.3 JCAHO's official "do not use" list and a few abbreviations that may someday be included on this list appearing in the box below.

    JCAHO's "do not use" list

    The third requirement for Goal 2 deals with the communication of test results. It calls for hospitals to assess and, if necessary, make changes so that critical test results are reported quickly to the appropriate clinicians.2

    Critical tests are those tests whose results should always be reported right away, even if the result is normal.2 Such tests are sometimes called Stat exams. Critical results, which some clinicians call "panic values" or "red-line values," are specific findings, even from routine tests, that always require rapid communication.2

    Hospitals get to decide how abnormal a finding must be in order to be considered critical. Critical results can come from any type of diagnostic test, including imaging studies, electrocardiograms, and lab tests.

    Hospitals also get to determine how long it should take for results to be reported. Your role is to know which tests your facility defines as critical, how long the lab has to report the results, and what steps to take if results aren't received within that time.

    Better "hand-off" communication

    The fourth requirement for Goal 2 involves "hand-off" communication, the passing of patient-specific information, such as the patient's current condition, recent changes in condition, or ongoing treatment, from one clinician to another. Because no one nurse or physician can be with a patient 24 hours a day, this type of communication is a necessity to ensure patient safety.

    To help ensure that every clinician who cares for a patient gets an accurate picture of the patient's status, JCAHO requires that a facility devise a standardized, consistent approach to "hand-off" communication.1 To standardize "hand-off" communication, a hospital needs to identify which situations constitute "hand-off" communication, who's involved, what information should be communicated, and what print or electronic information should be available.2 A tool some facilities use to standardize hand-off communication is the Situation-Background-Assessment-Recommendation (SBAR) technique, which JCAHO describes at www.jcipatientsafety.org/show/asp?durki=11794.

    During hand-off communication, clinicians need an opportunity to ask and answer questions. This part of the requirement may affect the way nurses provide their change-of-shift reports. Audiotaping these reports isn't acceptable unless the process includes a way for the nurse who is receiving the report to ask clarifying questions—which seems unlikely.2 A system where the receiving nurse listens to an audio report and then calls the nurse from the previous shift at home if she has any questions is not acceptable. That's because nurses may be less likely to ask questions than if the report were given face-to-face.2 The bottom line is that in-person change-of-shift report may be the best way to comply with this requirement.

    That's how they do it at Inova Fairfax Hospital in Falls Church, VA. "At each shift change at our facility, the incoming and outgoing nurses together check each patient's chart," said Clifford Bray, RN, who works in Inova's neuroscience ICU. "Together they also do in-room rounds to assess the patient."

    Some nurses are finding that having to do change-of-shift reports in person has certain advantages. "RNs in our department give nurse-to-nurse reports at the nursing station using the chart and our patient tracking system," said Becky Siirola, RN, Infection Control/Quality Coordinator at Primary Children's Medical Center in Salt Lake City. "But lately some nurses have begun to give their report outside the patient's room, and then they enter the room and introduce the incoming nurse. This is a great practice because it gives patients and their parents another opportunity to ask questions and get updates." At some facilities, nurses do their change-of-shift reports in the patient's presence.

    In addition, JCAHO offers some other practical suggestions for improving hand-off communication. Always use clear language. Define the terms you use, and avoid jargon, abbreviations, and unclear, potentially confusing, or vague expressions like "He's doing fine" or "She's a little unstable."4

    Give yourself enough time to complete hand-off communication. Limit interruptions, and focus on the information you're exchanging.4 Keep the information patient-centered, and avoid irrelevant details.4

    Get patients involved in their own safety

    Effective communication involves patients, too. When patients know what to expect, they're more likely to notice a potential error in their care. That's the reasoning behind Goal 13: Encourage patients' active involvement in their own care.1 Previously, this goal applied to only a few of the programs JCAHO accredits, such as home care and assisted living. But as of January 1, 2007 it will apply to hospitals.1 To meet this goal, hospitals must encourage patients and their families to report concerns about safety, and they must develop ways for them to do so.

    Regardless of what type of system your hospital uses to accomplish this, there are steps you can take to encourage patients to help ensure their own safety. First, teach your patient that he plays an important role in his care.5 Make sure he understands that he has both the right and responsibility to be aware of and understand any treatment he receives, and to take part in decisions about his care. Strongly encourage him to ask questions.

    Let him know that his healthcare providers are open to hearing his safety concerns. Your patient may fear that voicing his concerns will anger his nurse or physician and result in poor care.5 Assure him that this will not be the case, and that the healthcare team values his input.

    Teach your patient to do his part to help prevent infection. Explain that his nurses and physicians should always wash their hands or use an alcohol-based hand rub before caring for him, and let him know it's all right to ask them if they've washed their hands.5

    Patients can also help follow up on diagnostic testing. Instruct them to ask about test results and not to assume that no news is good news.5 Make sure they have the proper contact information for follow-up.

    Encouraging patients to be more involved in their own care can be time-consuming, but according to Scott Poston, Director, Emergency Services at Clear Lake Regional Medical Center in Webster, TX, the payoff can be substantial. "We realized that spending a few extra minutes teaching our patients to care for themselves can prevent or reduce return visits for repeat problems," he said.

    Of course, meeting JCAHO's goal is not the only reason to encourage patients to have a voice in their care. Those who are actively involved in their care often have better outcomes.5 To help hospitals educate patients about their role in healthcare, JCAHO created the Speak Up program (877-223-6866; www.jointcommission.org/PatientSafety/SpeakUp). Speak Up can provide facilities with posters, brochures, and other materials to teach patients about wrong-site surgery, organ donation, infection control, medication errors, and medical errors in general.

    Obviously, in order for your hospital to remain accredited, it's important for you to do your part to help it meet JCAHO's NPSGs. But in addition to demonstrating compliance, achieving these goals ensures that you're providing your patients with the care they need in the safest possible manner.


    1. Joint Commission on Accreditation of Healthcare Organizations. "2007 national patient safety goals, critical access hospital version, manual chapter, including implementation expectations." 2006. www.jointcommission.org/NR/rdonlyres/1AD5F8C0CB2D46F08052C2AD126C1377/0/07_CAH_NPSGs.pdf (12 Sept. 2006).

    2. Joint Commission on Accreditation of Healthcare Organizations. "FAQs for the 2006 national patient safety goals." 2006. www.jointcommission.org/NR/rdonlyres/7C116D6D-AE82-449E-BA45-1DE49D2A0A34/0/06_npsg_faq.pdf (12 Sept. 2006).

    3. Joint Commission on Accreditation of Healthcare Organizations. "Facts about the official "do not use" list." 2006. www.jointcommission.org/PatientSafety/DoNotUseList/facts_dnu.htm (12 Sept. 2006).

    4. Joint Commission International Center for Patient Safety. (2005). Strategies to improve hand-off communication: Implementing a process to resolve questions. Joint Commission Perspectives on Patient Safety, 5(7), 11.

    5. Joint Commission International Center for Patient Safety. (2006). Patient-inclusive care: Encouraging patients to be active participants in their care. Patient Safety Link, 2(2), 1.

    Participate in RN's December 2006 Web Poll!

    Has JCAHO's requirement for hand-off communication changed how you give change-of-shift reports?