In plain language with little room for discussion, the Joint Commission on Accreditation of Healthcare Organizations has taken a stand on nearly a dozen specific directives for preventing harm to patients in hospitals.
But safety experts and even JCAHO officials said the measures announced last week are a first step, and most hospitals are already in compliance with the new directives.
Beginning Jan. 1, 2003, the Oakbrook Terrace, Ill.-based agency will require proof that an accredited provider is adhering to a handful of safety measures advocated for years by medical experts and professional groups but not uniformly adopted in the field.
The 11 recommended measures serve as the means to achieve six patient-safety goals adopted by the JCAHO and announced last week (See chart). They "specifically address errors that are happening all too frequently," said JCAHO President Dennis O'Leary, M.D.
Failure to demonstrate compliance will result in a Type I recommendation, the most serious finding of noncompliance with accreditation standards, he said, adding that continued lack of compliance could risk accreditation.
The measures deal with elements of care that are basic to any facility's operational goals: giving the right medication to the right patient, operating on the correct part of the body, or preventing life-threatening doses of drugs or chemicals from getting into an intravenous line.
The new initiative prescribes ways to implement practices shown to prevent mistakes rather than leaving hospitals to adopt their own methods. "The know-how to prevent these errors exists," O'Leary said. "We now need to focus on making sure that healthcare organizations are actually taking these preventive steps."
Surveyors will interview nurses and other personnel for evidence the practices are followed, not just put in writing, O'Leary said. "There's a difference between having a policy and having it happen," he said.
The timeline gives some hospitals less than six months to make it happen. But experts at the forefront of error prevention said healthcare facilities already have had enough time.
"We've been telling hospitals to take concentrated potassium chloride off the nursing floor for years," said Michael Cohen, president of the Institute for Safe Medication Practices, citing one example. "It really has no place on patient-care units, but it's kept there for convenience."
Warnings of another JCAHO-targeted safety threat, malfunctioning infusion pumps, began in earnest in 1994 with an advisory from the Food and Drug Administration. A JCAHO alert in 2000 called for replacing pumps that can allow unmetered drug dosages to spill into a patient's vein.
But only one-half of 1% of operating pumps in hospitals have this free-flow problem, according to estimates from Novation, the group purchasing organization for hospital alliances VHA and University Healthsystem Consortium. No manufacturer continues to make the pumps, and the product life of the units is six to seven years. Replacements cost $1,900 for a single-channel pump, according to Novation.
The errors targeted in the first set of safety standards generally are rare events that if eliminated would not make much of a dent in the annual total of incidents causing patient harm, said Carol Haraden, vice president of patient-safety issues at the Institute for Healthcare Improvement, Boston. "We don't see many events, but when we do see them it's catastrophic," she said.
Potassium can be urgently needed in some cases to head off cardiac arrest, and some nurses aren't comfortable relying on delivery from a pharmacy, said David Gaugh, Novation's senior director of pharmacy contracting. But caregivers in a hurry might mix dilutions improperly or mistake a vial of concentrate for something else-with harmful or fatal results, Gaugh said.
Though rare, errors that occur from failure to follow the new measures-such as surgery on the wrong body part or accidental death by lethal injection-are the ones that make headlines. "Fatal events happen rarely, but you don't want to be the one it happens to," Cohen said.
"It's fair to say most healthcare organizations are in compliance with most of these recommendations-the point being that all are not in compliance with all of them," said Richard Croteau, M.D., the JCAHO's executive director of strategic initiatives.
A panel of 22 physicians, nurses, pharmacists and other patient-safety experts settled on the six JCAHO accreditation goals and 11 concrete actions after considering a total of 72 preventive recommendations included in a series of 25 alerts issued since 1998, Croteau said.
The short list of prescriptive actions detailed last week replaces an aborted attempt last year to make hospitals responsible for responding to a rising backlog of alerts published in the JCAHO's Perspectives magazine. The large quantity of alerts created "confusion about priorities," leading the commission to define a handful of "unambiguous" expectations, O'Leary said. "The need to focus is the overriding issue. If we ask people to do too many things, they will do none of them well," he said.
The inaugural safety goals are significant, not so much for the immediate benefit they yield, but for the framework established for additional requirements, Haraden said. "They had to set this up to get the ball rolling," she said. "It's a marvelous floor, a good place to start because it directs action. But we have a long way to go."
Even O'Leary described the actions as symbolic, putting healthcare managers and physicians on notice that specific patient-safety norms are part of the accreditation process.
"This gives the managers of the hospitals much more clout," said Cohen, who also is a member of the expert panel.
But hospital managers will face a challenge in changing the primary focus of medical practice to safety rather than the autonomy of individual practitioners, Haraden said. "Nothing changes the culture until you change the way you do work," she said. "Removing potassium from the floors won't change the culture."
Progress on compliance with current JCAHO safety standards as well as future additions will require hospitals to change physician and staff attitudes and lobby medical manufacturers for changes in their products, as well as changing healthcare processes, said Rhonda Anderson, chief operating officer of Desert Samaritan Medical Center, Mesa, Ariz., and a member of the JCAHO board representing the American Hospital Association. For example, only 40% of 3,000 orthopedic surgeons surveyed in 1998 said they marked the site of surgery in accordance with a campaign to prevent wrong-site surgery by the American Academy of Orthopaedic Surgeons. That error-prevention measure is among the first set of JCAHO safety prescriptions.
Though many minds may have been changed in orthopedics and other specialties since 1998 about taking such measures to prevent mix-ups, Croteau said, hospital managers are charged with forging the sense of responsibility needed to convert stragglers and diehards who enjoy medical privileges.
"With privileges come some responsibilities, and it all has to do with teamwork," he said. "That may seem like tough love, but we're trying to protect the patients."
Hospitals hosting surveyors in 2003 also will have to show evidence of compliance for their own protection, Haraden said. "If you don't have this (evidence) to hand to them the minute they walk in the door, you're going to be dodging that bullet for the length of the entire visit."