JCAHO Says So, Part Two

by Joan Bristow, Vice President, Risk Management

In the last issue of The Doctor’s Advocate, we began a series of articles to promote the 2004 Joint Commission on Accreditation for Healthcare Organizations (JCAHO) National Patient Safety Goals. We continue our series with the next two goals, which are presented here with an eye toward their relevance to our insured physicians, rather than in the order promulgated by JCAHO.

JCAHO Goal No. 1: Improve the accuracy of patient identification.

JCAHO offers two requirements for the patient identification process:

1. Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
2. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as “time out,” to confirm the correct patient, procedure and site, using active—not passive—communication techniques.

Historically, patient misidentification has been and will continue to be the one avoidable adverse eventin risk management. Bad outcomes are sometimes unavoidable, but incorrectly identifying a patient is an inexcusable and totally unacceptable error.

Focusing your undivided attention on the patient as the identification process takes place goes a long way toward avoiding misidentification. Do you recall our previous article on improving communication skills? Correct patient identification depends largely on applying those skills.

Case example:Susan was a float nurse, assigned to cover the dinner hour on a busy med/surg floor at Community Hospital. The nurse on her way to dinner asked if Susan would mind administering a pain injection to Mrs. Abigail in Room 223. Getting a positive nod from Susan, she went off the unit.

Susan checked Mrs. Abigail’s medical record for correct medication and dose, drew up the medication, gathered her supplies for administration and headed into Room 223, where there were two elderly ladies lying in their beds. Going to the first bed, Susan asked, “Are you Mrs. Abigail?” When the patient moved her head, Susan gave the injection and left the room, intent on documenting that she had indeed administered a pain medication. Imagine Susan’s alarm when she discovered that she had given the pain injection to Mrs. Jones in Bed A, instead of Mrs. Abigail in Bed B.

Outcome—the “wrong” patient received a STAT remedy without adverse outcome, and she even enjoyed the brief respite she had from her own discomfort. The “right” patient was then properly medicated for her pain.

Loss prevention measures:

• Always ask the patient to identify him/herself.
• Never reverse the question by asking, “Are you...?”
• Refrain from using room numbers or even bed numbers to identify patients.
• Practice respect when addressing patients—use first names or familiar nicknames only when given the authority to do so.
• Use the five Rs for all medication administrations:
• • Right patient
  • Right medication
  • Right dosage
  • Right route
  • Right interval/frequen

Loss prevention tips:

Develop written guidelines for the two-step patient identification process (PIP). This will facilitate the learning curve and ensure consistent application. Test-try the guidelines by asking the patient and his or her family members to participate in the process. When they make suggestions, accept their ideas graciously, and then test-try the enhanced process for its efficiency and reasonableness. Encourage good communication skills, and provide education for the patient as well as for health care workers. Document the PIP in the medical record.

JCAHO Goal No. 4 (which is very similar to Goal No. 1): Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

The two requirements are to:

1. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
2. Implement a process to mark the surgical site, and involve the patient in the marking process.

Although most operating rooms and surgicenters have already begun to implement procedures to achieve this goal, one of the difficulties of compliance arises from the inconsistent application or interpretation of the procedures. An example might be that Orthopedic Surgeon A marks the incorrectknee, while Orthopedic Surgeon B decorates the correctknee. You can see how easy it is to err with this type of inconsistency. The two examples below—with very different outcomes—illustrate this point.

Case examples:A 32-year-old female was scheduled for carpal tunnel surgery. In the surgicenter, preoperative preparation took place according to written procedures within the operating room, including verification that the consent document was present in the medical record.

After induction, a skin incision was made on the right wrist, as per the consent document. Immediately, the circulating nurse called, “Hold it! I have two consents, one for right and one for left.” The surgeon broke scrub to review the medical record and refresh his memory. He then recalled that both wrists were in need of reparative surgery but that the left was more severe and was to be done first. He closed the skin incision on the right wrist and performed surgery on the left.

See how easy it is to err? It’s not enough to validate the presence of the medical record and imaging studies, etc.; there is also a responsibility to verify correct information within these documents.

The ultimate outcome of this case example is rather interesting. Along with a sincere apology, the patient was given a full and complete explanation of why she came from surgery with two incisions. Unfortunately, she developed an infection in the incision on the incorrect wrist and, when chastised by the surgeon, went immediately to an attorney. It seems that there is another lesson to be learned from this case—appropriate postoperative care includes using good communication skills to speak to patients in a caring and compassionate manner.

A second case of misidentification: A middle-aged male had two fingers that were curled and in need of tendon release. He had no medical or surgical insurance and only had sufficient funds for one finger repair. The procedure went smoothly. When he awoke in the recovery room, the patient looked at his bandaged finger and said, “Wrong one.” The surgeon was summoned, came quickly to recovery, looked at the medical record, and agreed that he had erred. He calmly spoke with the patient, apologized, and suggested that he return the patient to surgery for the correct digit repair at no extra charge to the patient.

Outcome —no litigation. Lesson learned—good postoperative manners, care, and communication will help you avoid claims.

Loss prevention tips:

• Insist on a consistently applied written policy: all surgeons will mark the same site—whether the correct site or incorrect site—with appropriate markings.
• Involve patients in the marking process a minimum of three times: in the doctor’s office, on arrival in the facility, and prior to any induction of anesthesia.
• Ensure that documentation within the medical record is made and validated by a second health care worker.

Conclusion