The Joint Commission on Accreditation of Healthcare Organizations has issued its first patient-safety advisory to hospitals based on data collected through the roughly 200 root-cause analyses completed so far.
In a Sentinel Event Alert issued Feb. 27, hospitals were advised not to make concentrated potassium chloride available in nursing units. Out of the 200 sentinel events, 10 were patient deaths attributable to misadministration of potassium chloride. Sometimes caregivers confuse it with another drug or infuse it improperly. To be safe, hospitals should store concentrated potassium chloride in the pharmacy only.
The sentinel event policy is designed to uncover patterns of error from the universe of hospitals that wouldn't be detectable in any individual healthcare organization. Medication errors are the most prevalent kind of sentinel event.
Although hospital associations are advising hospitals against voluntarily reporting sentinel events to the JCAHO, as the agency requested, many hospitals are doing so anyway. The number of self-reports has steadily increased in recent months.
In March, 22 hospitals self-reported sentinel events. Of the 200 sentinel event reports accumulated before March 1, only 24 were self-reported. The JCAHO learned about the rest through media reports, complaints or accreditation surveys.