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Joint Commission 2009 National Patient Safety Standards: Reality compared with Expectations.

Posted Dec 23 2008 9:14pm
National patient safety goals (NPSG) have been established to raise the bar not only on safe delivery of patient care but also to improve the quality of that care that is delivered. Millions of dollars each year are needlessly spent because of errors in patient identification, not using established procedures like "time outs" prior to surgery, and mishandling medications. There are many errors in documentation that take place such as writing the wrong information in a patient's chart. This type of error can be very common with electronic documentation platforms. The following is a review of just one of the Joint Commission's (JCAHO) safety goals.

Goal 1: Improve the accuracy of patient identification.

A simple task one would think. Using two patient identifiers such a the patient's name and date of birth. Matching up lab specimen labels with the patient while in the patient's room. With the advent of paperless documentation systems lab specimen labels can often be misplaced especially in busy emergency department settings. Quite often a patient's room may have the labels of the previous patient still in the room or on the chart after they have been discharged and a new patient is placed in the room and the chart has more labels in it. This time the labels have two different names. When providers are rushed they don't always look at the labels. Nursing staff don't always obtain the two patient identifiers either - even though they document that they do. Reality versus expectations.

Physician providers rifling through a patient's chart may inadvertently mix documentation from one person's chart with that of another. I have personally seen this happen several times with paper documentation systems. With electronic paperless systems you can't get the charts mixed up. However, providers will often start documenting on a patient using a computer and only realized sometime later that they documented on the wrong patient. This I have seen many times when nursing and MD providers are switching over to paperless systems or they are in a rush.

In busy emergency departments (ED) patients are continually being put in rooms and taken out depending on the needs of the hour. Critical patients come to an ED by ambulance and the rooms are all filled. A patient must be moved to the hallway quickly and the new critical patient is moved into their room. With all the providers and technicians in an ED setting it is easy to see why patient identifiers are not permitted to be room numbers - the guy in room 4, or the one in the hall under the picture, for example. Reality however shows us that even though providers are not allowed to use locations as a means of identifying patients, it does happen.

Taking a phrase from Niki the average lay person or healthcare administrator would say "just do it". How hard is it to ask a person their name and date of birth? How hard is to obtain proper identification when a person is unable to speak for themselves? When patients arrive unconscious it is a bit harder to identify them, but not impossible.

In today's healthcare environment which is overly burdened and everyone is operating at over capacity, leaders must ensure compliance with safety standards and procedures, through on gong training, involving staff in departmental performance measures, and improving efficiency within the work environment so that providers feel less rushed.
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