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According to Rick Croteau, MD, executive director for strategic initiatives at JCAHO, the response thus far to the commission's patient safety guidelines has been good, but not great. "We're seeing in general fairly good compliance," Croteau said, "but a number of places are still struggling with some of the recommendations."

One of the recommendations that health care professionals still grapple to implement, Croteau said, is moving away from writing the more common but potentially dangerous abbreviations, acronyms and symbols on medications and orders.

He points to the example of the symbol "u" to represent "units." When written in a rushed manner, Croteau said, the letter can be mistaken for a zero-and thus cause a patient to receive 10 times the appropriate dosage. He adds that too many facilities also do not place zeroes in front of decimal points (e.g., 0.5 instead of .5), which again can lead to delivery of a disastrously high dosage.

"It requires a true behavior change," Croteau said in explaining the difficulty with this particular compliance. "People have gotten into the habit of using certain abbreviations in their professional career and to change now is difficult."

As tough as some of the recommendations may be to implement, health care facilities must comply with them or face an eventual loss of accreditation, Croteau said. He added that JCAHO continues to communicate its safety objectives to its member organizations and provide them with whatever guidance they need to meet them.

Behavior change, nurses and other health care professionals say, is at the heart of not only many of JCAHO's recommendations, but the overall effort to enhance patient safety, and such change starts with moving toward a process that seeks solutions rather than punishment.

"The key is to move away from a culture of blame to one that focuses on fixing the system," Smith said, adding that if workers aren't comfortable talking publicly about their near misses, the larger problems behind them won't be addressed.

She points to her own experience as an example. Her near miss many years ago, she said, made her much more careful and aware-but no official avenue was available to discuss the incident or determine whether it was part of a bigger problem.

Today, nurses and other employees at her Delaware hospital report potential mistakes and openly discuss them in order to look for larger trends or difficulties within the system. "It's important to know about near misses, so we can look at how they happened and come up with ways of correcting them. You can't fix what you don't know."

The Safety Tracking Tool, as officials at Beebe Medical Center call their reporting system, entails filling out a report card about a mistake or near miss and sending it to the appropriate department for review. For example, Smith said, a nurse who discovers that the pharmacy has provided the wrong medication for a patient will produce a detailed description of the incident, from the time and date it occurred to the name and even a photograph of the wrong medication.

"It could be that two similar-sounding medications were stacked next to each other in the pharmacy when they probably shouldn't have been," Smith said. "But you need to fully and openly examine the situation in order to find out what may have happened."

In another sign that points to a growing openness about medical errors and greater efforts to address their possible root causes, a number of private companies have developed patient safety training programs designed to prompt health care professionals to think about, discuss and, ultimately, eradicate on-the-job mistakes.

One such program is SafeStart, a five-week session that focuses on what its developers consider to be the main factors behind most medical mistakes-rushing, frustration, fatigue and complacency. The program, its developers say, helps nurses to work around possible staffing shortages by showing them how to feel less rushed or complacent-thus making them more thorough and cautious in their work.

"We address the human side of mistakes," said Michelle Teeters, product manager for the Texas-based program. "It's largely a commonsense approach that tries to make nurses and others more aware of problematic situations and empower them to change it."

Such empowerment, however, doesn't come cheap. The SafeStart program costs $10,000, and many hospitals have decided on a more inhouse approach. A handful of hospitals have used SafeStart, however, including Athens-Limestone Hospital in Athens, Ala.

"It worked well for us," said Patricia Moss, RN, risk manager for the hospital. "It makes you more aware of why you feel rushed or frustrated and thus helps you gain more control over it."