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The national patient safety goals and their implications for perioperative nurses
The Joint Commission on Accreditation of Healthcare Organization's (JCAHO's) national patient safety goals became effective Jan 1, 2003.1 These goals apply to all JCAHO accredited facilities and those seeking accreditation. The six goals were developed from a thorough review of all Sentinel Event Alerts published by JCAHO. From these alerts, an expert panel identified evidence-based or consensus-based, cost-effective, feasible recommendations to promote patient safety. The Joint Commission plans to add six to 12 goals annually and reevaluate, modify, or delete previously identified goals.
Perioperative nurses should be aware of each of these goals and remain alert for opportunities to improve existing clinical practice. Each goal provides opportunities to work with team members to address common risks in perioperative settings. The unique environment of the OR requires clinicians to consider creative solutions specific to this setting. To meet these goals, perioperative team members must address and identify system problems and solutions to ensure patient safety during all phases of surgical care.
THE GOALS
The first goal calls for organizations to improve the accuracy of patient identification by using two patient identifiers when taking blood or administering blood or medications. A recommendation related to this goal is that before any invasive procedure, team members conduct a final verification or take a “time out.” This goal, though fairly straightforward, presents some challenges in the OR. For example, a patient may have received anesthesia or medications, making it impossible for the patient to identify himself or herself by name. Another challenge exists if the patient's identification bracelet has been removed or is under surgical drapes. Obviously, there must be a clear policy and procedure for ascertaining identity by having the information readily available to all clinicians in the room and any staff member who provides relief coverage.
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the importance of implementing a process for taking verbal or telephone orders that require verification or “read back” of the complete order by the person taking it and
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standardizing abbreviations, acronyms, and symbols throughout an organization, including identifying which ones should not be used.
Again, these recommendations could be challenging to implement in the OR. For example, verbal orders typically are given through a mask. Time pressures during emergency situations also may serve as a barrier to following the read-back recommendation. All team members must be involved in developing and instituting changes in practice to ensure that caregivers achieve this goal.
The third goal relates to improving safety when using high-alert medications. Removing concentrated electrolytes, such as potassium chloride, potassium phosphate, and sodium chloride (ie, concentrations greater than 0.9%), from patient care areas and standardizing and limiting the number of medication concentrations used in an organization are examples of efforts to improve patient safety in the clinical setting. This goal may present particular challenges in the OR and other perioperative settings where surgeons and anesthesia care providers expect to have ready access to these concentrated electrolyte solutions or to particular medication concentrations. Clinicians need to understand that this recommendation can reduce the risk of errors. Members of the pharmacy team should be included when addressing concerns and potential issues.
Eliminating wrong site, wrong patient, and wrong procedure surgery is the fourth goal. Despite two different Sentinel Event Alerts that address this very specific problem, sentinel events related to wrong site surgery still occur. This patient safety goal includes recommendations to create and use a preoperative verification process to confirm that all appropriate documents are available and to implement a process to mark the surgical site that includes the patient in the marking process. The risk of wrong site surgery exists in any OR or during any invasive procedure. Nurses involved in caring for patients undergoing surgery or other invasive procedures need to work with other team members to establish and implement a policy and procedure that is followed in a consistent manner. Every patient has the right to expect that the correct procedure will be performed on the correct site.
The fifth goal addresses improving the safety of using infusion pumps by ensuring freeflow protection on all general-use and patient-controlled analgesia IV pumps used in an organization. Numerous adverse events have occurred nationwide related to free-flowing IV pumps. Peri-operative nurses need to determine whether pumps used in their facilities have free-flow protection. If not, nurses and other clinicians must be particularly vigilant when handling such devices. Furthermore, in situations in which IV pumps are not in use, IV tubing clamps never should be placed or left in the wide open position. One simple distraction when a clamp is wide open could lead to the too rapid infusion of IV fluid or medication.
The sixth and final goal for 2003 relates to improving the effectiveness of clinical alarm systems. The recommendations for this goal include implementing regular preventive maintenance and testing of alarm systems and assuring that alarms are activated appropriately and are sufficiently audible with respect to distances and competing noises. Clinicians in perioperative settings need to address this potential problem. Are alarms tested and checked on a regular basis? Are all alarms turned on and audible? Are there providers who do not like alarms and routinely turn them off? Adverse events have occurred when changes in a patient's condition were not detected because critical alarms were in the off position. Every clinician must accept that there are reasons alarms were designed and included in critical medical equipment.
IMPLEMENTING THE GOALS
These goals may appear simple and straightforward. The reality of implementing them in clinical practice, however, presents many challenges. First and foremost, health care occurs within complex systems that have their own inherent cultures. Additionally, clinicians receive very little interdisciplinary education and training, but they are expected to perform as members of highly functioning teams to save lives. These factors, along with the complexity of human communication and the demands of the current health care system, have the potential to make what should be a simple task much more difficult.
For perioperative clinicians to be successful in implementing these goals, each member of the health care team must agree that taking definitive action will promote patient safety. Next, team members must work together to develop strategies to implement these recommendations and involve every team member in the process. For example, policies and procedures to prevent wrong site surgery are only as effective as the most reticent staff member. If one member of the team refuses to participate in the process, it is difficult, if not impossible, to fully achieve these goals. Perioperative nurses play key roles in the success of implementing these safety goals. By alerting other members of the team to these goals and working toward effective strategies, nurses can help decrease variability in practice and improve processes and clinical outcomes.
CONCLUSION
These six patient safety goals provide organizations with a focus for their safety efforts. Every professional nurse should determine what his or her organization is doing to address these goals and participate in related projects. Nurses play critical roles in identifying and addressing patient safety needs and should serve as active participants with other members of the health care team. Only collaborative teamwork will lead to creative strategies that are congruent with these goals and address practice issues unique to perioperative settings. Patient safety must remain the first priority. Together, members of the health care team can achieve these important and attainable goals.
Biography
SUZANNE C. BEYEA, RN, PhD, FAAN,is director of nursing research, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
