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2
2004 National Patient
Safety Goals
1. Improve the accuracy of patient identification.
a. Use at least two patient identifiers (neither
to be the patient’s room number) whenever
taking blood samples or administering medications
or blood products.
[Scored at Standard PC.5.10, EP #4]
b. Prior to the start of any surgical or invasive
procedure, conduct a final verification process,
such as a “time out,” to confirm
the correct patient, procedure and site, using
active—not passive—communication
techniques.
[Scored at Standard PC.13.20, EP #9]
2. Improve the effectiveness of communication
among caregivers.
a. Implement a process for taking verbal or
telephone orders or critical test results that
require a verification “read-back”
of the complete order or test result by the
person receiving the order or test result. [Scored
at Standard IM.6.50, EP #4]
b. Standardize the abbreviations, acronyms and
symbols used throughout the organization, including
a list of abbreviations, acronyms and symbols
not to use.
[Scored at Standard IM.3.10, EP #2]
3. Improve the safety of using high-alert
medications.
a. Remove concentrated electrolytes (including,
but not limited to, potassium chloride, potassium
phosphate, sodium chloride >0.9%) from patient
care units.
[Scored at Standard MM.2.20, EP #9]
b. Standardize and limit the number of drug
concentrations available in the organization.
[Scored at Standard MM.2.20, EP #8]
4. Eliminate wrong-site, wrong-patient,
wrong-procedure surgery.
a. Create and use a preoperative verification
process, such as a checklist, to confirm that
appropriate documents (e.g., medical records,
imaging studies) are available.
b. Implement a process to mark the surgical
site and involve the patient in the marking
process.
5. Improve the safety of using infusion
pumps.
a. Ensure free-flow protection on all general-use
and PCA (patient controlled analgesia) intravenous
infusion pumps used in the organization.
6. Improve the effectiveness of clinical
alarm systems.
a. Implement regular preventive maintenance
and testing of alarm systems.
b. Assure that alarms are activated with appropriate
settings and are sufficiently audible with respect
to distances and competing noise within the
unit.
7. Reduce the risk of health care-acquired
infections.
a. Comply with current CDC hygiene guidelines.*
b. Manage as sentinel events all identified
cases of unanticipated death or major permanent
loss of function associated with a health care-acquired
infection.
Source: www.jcaho.org
*
www.cdc.gov/handhygiene/
To
comment on this story, send e-mail to editorca@nurseweek.com.
> The Seventh Annual National Patient Safety
Foundation Congress in Orlando, Fla., May 5-9,
2005. See www.npsf.org
for details.
> AORN has produced tool kits for the implementation
of JCAHO’s Universal Protocol for Preventing
Wrong Site, Wrong Procedure, Wrong Person Surgery.
See www.aorn.org
for more information.
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