The Joint Commission on Accreditation of Healthcare Organizations has garnered a reputation for following up on negative media reports about providers. Critics say the harsh glare of the media spotlight often gives way to a team of commission surveyors.
But when the agency recently issued a warning on drug infusion pumps just weeks after a newspaper series highlighted pump malfunctions as the cause of 39 deaths, no one accused the accrediting agency of media grandstanding.
"This is a sincere effort on their part," said Don Nielsen, M.D., senior vice president of quality leadership at the American Hospital Association.
The commission issued a sentinel event alert on Nov. 30 regarding infusion pumps that lack devices to cut off the flow of drugs when the pumps malfunction.
The alert, sent to 19,000 hospitals, nursing homes, home health agencies and other providers accredited by the Joint Commission, cited research dating back to 1991 about drug-overdose deaths blamed on pump problems.
Russell Massaro, M.D., executive vice president of accreditation operations at the Oakbrook Terrace, Ill.-based JCAHO, said the research and the expert advice on how to combat the errors both reached the critical mass necessary to trigger an alert.
The alert calls for providers to replace infusion pumps lacking fail-safe devices with pumps that have the devices built in, as opposed to adding the restrictive devices after the pumps are manufactured.
The agency has come under fire from providers for picking up on issues after incidents are highlighted in the media.
Most recently, the commission conducted an announced survey of Tulane University Hospital and Clinic in New Orleans shortly after the Wall Street Journal reported that eight patients were exposed to Creutzfeldt-Jakob disease, a fatal condition related to mad cow disease. The exposure came when surgical instruments used on a patient with the condition were not sterilized by the more-intensive methods necessitated by CJD before they were used on the eight other patients.
A Joint Commission spokeswoman said surveyors found the hospital to be in compliance during the Nov. 9 inspection. The hospital maintained its status of accredited with recommendations for improvement, which was granted after the hospital's triannual survey on Sept. 20.