Download Get ready for the new patient safety and medication

Vol. 14 No. 3
March 2003
—INSIDE—
Medication
Check out these resources to
obtain lists of dangerous
abbreviations, ways to
prevent errors linked to
name confusion, and more
on p. 4.
See a sample chart of
unacceptable abbreviations
on p. 4.
Check out how one
hospital charts standard
administration times on p. 5.
Life Safety Code
CMS adopts the 2000 version
of the Code on p. 5.
Range orders
See a sample range order
policy on pp. 6–7.
Survey process change
Read how a Virginia
psychiatric hospital survived
the new patient safety and
medication interview on
p. 8.
Congratulations to Ronda
Hajduk of IHS Hospital at San
Antonio, Gaylene Robinson of
Newman Regional Health in
Emporia, KS, and Cynthia
Rawlinson, of Winchester
(VA) Medical Center who each
won $100 for filling out the
BOJ reader survey! We encourage you to fill out our surveys
to be eligible to win, too.
FOR PERMISSION TO REPRODUCE
PART OR ALL OF THIS NEWSLETTER FOR
EXTERNAL DISTRIBUTION OR USE IN
Med use
series
Revised medication
standard tackles legibility,
abbreviations, and more
Think about clarifying drug administration times and range orders in
your medication policies.
chapter, thus making them “MM”
standards rather than TX. The JCAHO’s
Standards and Survey Process Committee was due to approve the stanThe draft medication standard TX.3.6 dards this month.
gives direction on the systems to
look at, such as not using unaccept- In addition, the JCAHO pulled the
able abbreviations and symbols, re- draft standards from its Web site due
ducing the use of verbal medication to additional revisions. The JCAHO
orders, and standardizing the times will not likely repost the draft medof dose administration, to name a
ication standards since they are due
few. See a synopsis of the draft
for publication in an upcoming isstandard—due to take effect in
sue of Joint Commission Perspectives.
2004—on p. 2.
In this issue, BOJ takes a look at
Note: The overhaul of the JCAHO’s the following elements in TX.3.6:
hospital accreditation manual en• Legibility of medication orders
tails placing all medication stan• Abbreviations and look-alike,
> p. 2
dards in a Medication Management
sound-alike drugs
Get ready for the new patient
safety and medication interview
It’s more important than ever to understand and discuss your patient
safety initiatives and medication
safety since the JCAHO replaced
the patient care interview with a
patient safety and medication interview—effective in January.
disappear in 2004 with the advent
of the new Shared Pathways–New
Visions survey process where surveyors track actual patients through
chart reviews and random staff
questions rather than conducting
formal interviews.
The JCAHO will hold the 45-minute
patient safety and medication interview—applicable to hospitals only—
during the beginning of the triennial survey, prior to unit visits. Note:
This new interview will probably
TIP: Gather a few “knowledgeable
individuals with direct, hands-on
responsibilities” to attend the interview instead of a larger group or
manager/director-level people, says
Mark Forstneger, a
> p. 8
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Revised medication standard
< p. 1
• Standardizing times of dose administrations
• Range orders
Writing orders clearly
Staff at Provena St. Joseph Medical Center in Joliet,
IL, discuss how to enforce legible physician handwriting during the pharmacy and therapeutics (P&T)
committee meetings. Everyone approved of posting
notes in the nursing units to advise physicians to
write legibly because bad handwriting can result in
medication errors, says Ben Muoghalu, PharmD,
the hospital’s pharmacy director.
While posting reminder notes helped some physicians, the hospital took improving legibility one step
further by investing in technology. The Pyxis Corporation has an upgrade option to their automated dis-
pensing system, the Pyxis Connect, where nursing
staff scan physician orders and the digital image appears in the pharmacy on a monitor. “If you have a
question about the order, such as a decimal point or
period, you zoom into that part of the screen,” explains Muoghalu.
Staff note when they have to repeatedly scrutinize
orders and take this information to the P&T committee, and then the medical executive committee, which
follows up with physicians who have reported bad
handwriting. “The idea is to not point fingers, but to
send out a general message that there’s a problem
and let’s fix it,” Muoghalu says.
Physician leaders explain that it’s possible to improve
handwriting, and it just takes a few more minutes to
The draft TX.3.6
Hospitals create policies and procedures that support safe medication, prescribing, ordering, and
transcribing.
Intent of TX.3.6
Policies and procedures that support safe medication
handling should specifically address the following:
• Clear, accurate, complete, and legible medical
orders to prevent confusion, including defining
the following elements:
- Unacceptable abbreviations, symbols,
acronyms, and codes
- Special precautions or procedures for ordering
drugs with look-alike or sound-alike names
- Suggested actions when medication orders are
not clear, complete, or legible
• Minimizing the use of verbally transmitted medication orders and defining how to validate the
accuracy of verbally transmitted medication
orders
• A process for using, reviewing, and updating of
preprinted order sheets
• Defining situations in which staff permanently or
temporarily cancel all or some of patients’ med-
ication orders, including automatic stop orders,
and ways to reinstate them
• Specifying the unacceptability of blanket orders
(i.e., “resume all home meds,” etc.)
• “As needed” (or PRN) v. scheduled prescriptions
or orders
• Standardizing the times of dose administration,
concentration of IV medications and dose scales
• Specifying the acceptability, appropriate use,
required elements, and approval process for the
following:
- Standing orders
- Medication protocols
- Titrating orders
- Taper orders
- Dose scales
- Range orders
- Drug compounds not commercially available
- Orders for medication-related devices
- Orders for investigational medications, home
remedies, and herbal products
- Discharge orders
Source: Adapted from www.jcaho.org.
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write slower and, thus, clearer.
for “twice a day” used by caregivers. For some, BID
means 9 a.m. and 3 p.m., but for others it means 9
a.m. and 9 p.m.
Abbreviations to avoid
A lot of information exists on dangerous medication
abbreviations (see “Links to suggested Web sites for
medication safety” on p. 4). Pharmacy staff at Provena
St. Joseph Medical Center looked at the Institute for
Safe Medication Practices’ (ISMP) list of dangerous
abbreviations to avoid and picked the most common
ones, Muoghalu says.
The pharmacy staff at Lutheran
and Fairview Hospitals in Cleveland also simplified the abbreviations to avoid and picked seven
from the ISMP list, says Michael
Hoying, the pharmacy director
for both hospitals. (See “Unacceptable abbreviation” on p. 4.)
Therefore, it’s crucial to classify BID to avoid patients
receiving duplicate medications, a potentially fatal error. At Provena St. Joseph Medical Center, nursing and
pharmacy staff meet to discuss an agreed-upon standard administration time. “You need to have both parties get together instead of going back and forth,” says
Muoghalu.
“If range orders aren’t
discussed ahead of time,
there’s a huge range of
interpretation.”
—Benjamin Muoghalu, PharmD
If a practitioner writes a drug
order with one of the unacceptable abbreviations, the nurse or pharmacist must request that he or she rewrite the order, Hoying says.
The pharmacist enters these clarifications as interventions into the pharmacy computer order entry system.
Pharmacists also regularly audit charts to identify
practitioners who frequently use unacceptable abbreviations so they can follow up with them, Hoying says.
Consider look-alike/sound-alike drugs
Provena St. Joseph Medical Center staff researched
look-alike and sound-alike drugs and compiled a list.
They took the list one step further by inserting a popup option in the order entry screen for the most common drugs that sound and look alike.
When pharmacists enter orders for drugs associated
with look- and sound-alikes, a question on the screen
pops up, asking, “Are you sure this is what the physician ordered?” “This stops them and makes them
double check,” Muoghalu says.
Standardizing dose administrations
Establishing standard times of giving doses helps
prevent medication errors. But you must first define
what you mean by “bis in die” (BID), the Latin term
Staff at Lutheran and Fairview
Hospitals also eliminated confusion with standard dosing times
by creating a policy that lists dosing times, including daily (“quaque die” or QD) at 10 a.m., BID
times at 8 a.m. and 8 p.m., and so
on, Hoying says (see “Sample standard administration times” on p. 5).
Handling range orders
Range orders are nonspecific orders that leave a lot of
room for interpretation. For example, “A 50- to 100milligram (mg) dose every four to six hours.” One measure to handle range orders is to start a patient on a
low dose and then increase the dose, if needed, says
Muoghalu.
“It’s an order that’s not very specific, so it must be hospital-specific,” he says. “Meaning, write down the parameters in your policy. If range orders aren’t discussed
ahead of time, there’s a huge range of interpretation.”
For example, if two pharmacists differ on the highest
v. lowest doses, caregivers giving differing doses can
hurt patients. “We took this to the P&T and agreed we
would handle as an institution to start at the lowest
dose (50 mg) and that every six hours is the longest
interval,” Muoghalu says. “We work our way up
based on the patient’s response.”
The goal at Lutheran and Fairview Hospitals is to
make certain that staff have the same approach to
start patients on a low dose and then justify why a
patient needs a higher dose, Hoying says. Caregivers
> p. 4
must consider the same patient parameters
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Revised medication standard
< p. 3
for the intensity and orientation of pain, according to
the hospitals’ pain scales. “But we sometimes struggle with this because pain is not an exact science,”
Hoying says. “Patients who come out of surgery may
say their pain is a 10 (on the 1–10 Wong Baker pain
scale) and that they need the highest dose.”
Physicians must figure out which dose should cover
each particular patient and consider the patient’s
pain history, whether he or she takes pain medications at home, and so on.
A consultant told Lutheran and Fairview staff to let
the pain scale dictate the drug dose, so the hospital
for now changes orders according to the patient’s
mild, moderate, or severe pain.
(Note: Consider age specifics, however, since it
could be dangerous to give a 92-year-old complaining of pain at a “10” a high dose of morphine, for
example.) Staff change dose ranges according to
nurse assessments. See “Sample range orders policy” on pp. 6– 7.
Links to suggested Web sites for medication safety
• The Institute for Safe Medication Practices
(www.ismp.org), a list of dangerous abbreviations—www.ismp.org/msaarticles/dangerous%
20abbrev.doc.htm.
• Ways to prevent dispensing errors linked to
name confusion—www.ismp.org/msaarticles/
name.htm.
• The U.S. Pharmacopeia lists look-alike/soundalike drugs at www.usp.org. Type in “look alikes”
in the search option to call up the database.
Unacceptable abbreviations
INTENDED
MEANING
0.5 mg
U or u
ABBREVIATION/
DOSE EXPRESSION
No zero before
decimal dose (.5 mg)
Zero after decimal
point (1.0)
U or u
µg
q.d.
µg
q.d.
Microgram
Every day
X3d
X3d
Grains
Apothecary symbols
Times three
days
Dram grain
minim
AVOID
.5 mg
1.0 mg
1 mg
Unit
MISINTERPRETATION
CORRECTION
Misread as 5 mg
Use “0.5 mg”
Misread as 10 mg if the decimal
point is not seen
Read as a zero (0) or as four (4),
causing a tenfold overdose or
greater (4U seen as “40” or
4u seen as “44”)
Mistaken for “mg” when handwritten
Mistaken as q.i.d., especially if the
period after the “q” or the tail of the
“q” is misunderstood as an “i”
Mistaken for “three doses”
Use “1 mg”
Misunderstood or misread (symbol
for dram misread for “3” and minim
misread as “mL”)
Use “unit”
Use “mcg”
Use “daily” or
“every day”
Use “for three days”
Use the metric
system
Source: Lutheran and Fairview Hospitals, Cleveland. Reprinted with permission.
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Sample standard administration times
All nursing personnel will follow standard administration times for general units. The organization approved the following standard administration times (Note: Times below are according to military time.):
QD
BID
TID
QID
Q4H
Q6H
Q8H
Q12H
AC
PC
QHS
QSHIFT
QPM
Q2H
Q3H
1000
1000 2200
0800 1400
0800 1200
0400 0800
0600 1200
0800 1600
1000 2200
0730 1130
0900 1300
2200
0800 1600
2200
Even hours
0300 0600
2000
1600
1200
1800
2400
2000
1600
2400
2000
2400
1200
1500
1800
1630
1800
2400
0900
2100
2400
Note: The day shift should give morning insulin (except in acute rehab where the night shift give insulin)
Note: Staff administer Coumadin at 1400 QD
Note: Staff administer Dioxin at 1400 QD
Source: An excerpt from Cleveland’s Lutheran and Fairview Hospitals’ medication administration record
policy. Reprinted with permission.
Gear up for the 2000 version of the Life Safety Code
The changeover means high costs to hospitals
The Centers for Medicare & Medicaid Services (CMS)
in January adopted the 2000 edition of the Life Safety Code (LSC), which its surveyors will begin to enforce on September 11.
The next few months allow CMS to train surveyors on
the nuances of the newer Code, says James Lathrop,
vice president of Koffel Associates, Inc., in Niantic,
CT.
This adoption applies to hospitals, long-term care
facilities, ambulatory surgery centers, and hospices that
receive Medicare funding. However, many JCAHOaccredited hospitals have long complied with the 1997
LSC, so the change won’t be as drastic as it will for
other health care facilities, Lathrop says.
The JCAHO began enforcing the 2000 version on
> p.
March 1.
11
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Sample range orders policy
Policy
This institution allows staff to write medications in dose and frequency range, provided the administration of the
medication follows the procedure outlined below. A range order is expressed (for example) as: “Tylenol 325mg
tablets one to two every four to six hours, PRN pain.”
Procedure
When staff write an order that includes a range of dose and frequency, include in the physician’s order the instructions on how the nurse determines what dose or time frame in which to administer the dose. In the absence of such
instructions, the nurse has the authority to adjust medication levels within the dosage and frequency ranges stipulated by the prescriber and according to the following established protocol.
In instances where staff order ranges for symptoms, such as nausea, without an established scale the nurse’s subjective and objective assessment of the patient will determine the medication range to be used. For example, if the
patient is vomiting, staff will use a stronger dose of the medication than if the patient complains of mild nausea. In
all circumstances, the medication ranges for nausea/vomiting are within the usual range of prescribing.
PAIN SCALE
1.
2.
3.
MILD
MODERATE
SEVERE
VERBAL SCORE GIVEN BY PATIENT
0–3
4–7
8–10
Determining dose/route to administer with a range order:
If conditions for administration of medication are not written in the physician orders, staff will follow these guidelines:
1. For mild pain, nausea, agitation, or other symptoms, the nurse will administer the lowest dose of the drug
ordered for the symptom.
2. For moderate pain, nausea, agitation, or other symptoms, the nurse will administer the middle dose (if applicable) of the drug ordered for the symptom.
3. For severe pain, nausea, agitation, or other symptoms, the nurse will administer the highest dose of the drug
ordered for the symptom.
4. For orders written as IM or IV, IV is the preferred route of administration.
Monitoring of sedative agents in the critical care units (except for ventilated patients):
When sedatives (without paralytic agents) are ordered in the critical care areas, the sedative will be titrated within
the dose and frequency of the physician order to maintain the Ramsay sedation level 3 (patient responds to commands only) or less.
• If staff order more than one sedative, the physician will be contacted for clarification.
Determining frequency of PRN medications:
To determine frequency of PRN medications, staff will follow these guidelines.
1. The nurse will administer the PRN medication initially using the longest time frame range ordered by the
physician.
2. If symptoms appear before the next dose, the dosing interval can be decreased to the lower end of the range.
(For example, an order for q4–6h prn should start out as being given every six hours. If no relief, then the dosing interval may be decreased to every four hours).
NOTE: If supplemental symptom relief (pain, agitation, etc.) is needed prior to the next approved frequency (i.e.,
before three hours in the q3–4h prn frequency) staff may give additional incremental doses prior to the next dosing
interval time provided that the total dose during the interval does not exceed the maximum prescribed dose. If the
maximum prescribed dose has been administered and additional doses are needed before the next dosing interval
time, a new order is required.
Determining which medication to give when staff order both an oral and IV/IM medication:
1. PRN medications will be given IV/IM until the patient takes fluids by mouth without complications.
2. If the patient takes POs without complications, the nurse will give PO PRN medications unless the medication is
only dispensed in IV form.
3. EXCEPTION: Nurse’s assessment of the patient. Factors such as number of days postop, the level of functioning
of the GI tract, allergies, or the patient’s preference of PRN ordered may influence the route of administration.
Example: Order written for Morphine 2–6mg IV q3–4h prn for abdominal pain. Patient rates pain as a “5.”
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8 a.m.:
8:30a.m.:
10:30a.m.:
Total dose:
Give Morphine 4mg IV.
Give an additional 1mg IV for unrelieved pain.
Give an additional 1mg IV for breakthrough pain.
4mg+1mg+1mg does not exceed dose limit for shortest interval–3 hours!
Dose of medication less than the range prescribed
Doses for a medication less than the range (i.e., administering 25mg when the order was written for 50–75mg) cannot be given based on the higher dose order.
• Contact the prescriber for authorization to administer a dose lower than the range specified.
Determining which medication to choose when more than one is ordered for the symptom:
When choices of medications are given without a specific condition indicated in the order, these guidelines will be
followed in the order listed.
PAIN/SYMPTOM
MILD
Analgesics
MODERATE
Tylenol 650mg
Vioxx
Tylenol #3
Darvocet N–100
Darvon
Vicodin 5/500
Percocet 5/325
Percodan 5/325
Vicodin ES 7.5/750
Nubain (nalbuphine)
OxyIR 5mg
Talwin Nx
Dilaudid (PO)
If oral route not available: Use
Morphine Note: Use Demerol in
situations where the patient is
unable to tolerate other medications
Marinol
Compazine
Vistaril
Ativan
Phenergan
Tigan
Scopalamine patch
Imodium
Anti-emetics
Benadryl
Reglan
Anti-diarrheals
Anti-spasmodics
Kaopectate
Pepto-Bismol
Donnatal 1 tab
Levsin 0.125 mg
Bentyl 20mg
Anxiolytics/
Sedatives
Benadryl
Hydroxyzine
Antihistamines
Benadryl
Muscle relaxants
Flexeril 10mg
Paragon Forte DSC 250mg (1/2 tab)
Dantrium 25mg
Robaxin 500mg
Lioresal 5mg
Decongestants
Antitussives
Sudafed 30mg
Robitussin DM
Benadryl
Tessalon 100mg
Donnatal 2 caps
Levsin 0.25mg
Bentyl 20mg–40mg
Librax
Xanax
Ativan
Librium
Klonopin
Valium
(Seconal 100mg in pregnancy)
–Not available
Vistaril
Claritin
Flexeril 20mg
Parafon Forte DSC 500mg
Dantrium 50mg
Robaxin 750mg
Soma
Soma Compound
Robaxisol
Norflex 100mg
Norflex 60mg IV
Lioresal 10mg
Sudafed 30mg
Robitussin DM
Robitussin AC
Hycodan 5mg
Tessalon 100–200mg
SEVERE
Percocet 5/325 (2 tabs)
Percodan 5/325 (2 tabs)
OxyContin
Fentanyl
Sufentanil
Morphine
Dilaudid
MS Contin
Stadol
Methadone
Decadron
Thorazine
Zofran
Anzemet
Kytril
Lomitil
Levsin 0.375mg
Bentyl 40mg
Seconal 200mg- not available
Chloral Hydrate
Haloperidol
Phenergan
Flexeril 40mg
Paragon Forte DSC 750mg (1 and
_ tab)
Dantrium 100mg
Norflex 60mg IV
Robaxin 1500mg
Soma
Lioresal 20mg
Sudafed 60mg
Hycotuss
Hycodan 10mg
Source: Lutheran and Fairview Hospitals, Cleveland, OH. Reprinted with permission.
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Patient safety interview
< p. 1
spokesperson for the JCAHO.
Potential candidates could include direct caregivers,
such as nurses, doctors, respiratory therapists, pharmacists, or social workers—medication, pharmacy
and therapeutics (P&T), and pain control committee
members, says a source close to the JCAHO. Also
include performance improvement (PI) staff and
someone who can talk about your Failure Modes
and Effects Analysis (FMEA).
Surveyors might also ask what you have reported to
the board regarding your patient safety program. “And I
think the expectation among surveyors—although the
standards don’t really say it—is that the FMEA gets to
[the board],” says the observer.
Show how you use data
Get ready to talk about what kind of error data (on
issues such as medication errors, adverse drug events,
or patient falls) you collect, what you’ve learned, and
what you’re doing about it.
Policies must match practice
Part of the new interview’s purpose is to educate surveyors about your policies so that they can see whether the policies meet actual practices in the units. For
instance, staff may tell a surveyor in the interview that
they couldn’t hear some intravenous (IV) clinical alarms
at the end of the hall, so they moved the pumps closer to the nursing station. “When I [give] a unit tour and
see someone with an IV pump at the end of the hall, I
say ‘Gee, are you supposed to be doing that?’ ” says
the JCAHO source.
In general, surveyors will look into a number of safety and medication issues. For instance, they’ll want to
know how you’ve adopted the 2003 National Patient
Safety Goals and how you’ve measured your success
(through measures such as random audits).
Expect questions about how you chose your FMEA
topic, what you learned, and what you’re measuring.
Surveyors may walk staff through how they select,
prescribe, prepare, administer, and monitor a real or
hypothetical drug. For instance, they will want to know
how the P&T committee handles the sound-alike drugs
Celexa and Celebrex if adding them to the drug formulary. The JCAHO wants to know how pharmacy staff
alert people to sound-alike drug names and how they
separate drugs. Expect other questions about medication safety, such as how you control drugs if you don’t
have a 24-hour pharmacy, or how anesthesiologists
reduce medication risks. “There’s been a big deal on
paralytic drugs, and how they look like other drugs
that aren’t paralytics,” says the JCAHO observer.
Check out “How a Virginia psych hospital fared during the new patient safety and medication use interview” below. Prepare yourself for the interview with
the tips listed on p. 9 and sample surveyor questions
on p. 10.
Survey monitor
How a Virginia psych hospital fared during the new
patient safety and medication use interview
Larry Simmons, NHA, dealt with questions about
after-hours pharmacy access, handling verbal orders,
and more during the new patient safety and medication use interview when State Hospital was surveyed
in January.
psychiatric hospital in Williamsburg, VA, one surveyor
requested that nursing staff from the wards attend the
afternoon’s patient safety and medication interview.
The surveyors asked the nurses how they handle
verbal orders.
At the end of the opening conference at the 500-bed
“What they wanted to hear was, ‘I write down the
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order and I read it back to the physician,’ ” says
Simmons, the facility’s director of quality management.
any infusion pumps, they scrutinized other devices
the hospital uses—such as drip bottles and peg tubes.
Surveyors also asked, “What is the hospital’s patient
safety program?”
“They gave us a supplemental recommendation because even though the patient safety goal mentions infusion pumps, we should look at all devices to ensure
that we have free-flow protection,” says Simmons.
TIP: Train all staff, from nurses to housekeepers, on
your patient safety policies, says Simmons. “They’re
spending more and more time on the units,” he says.
After-hours pharmacy access
Surveyors grilled staff on how the pharmacy processes new orders, including staff handling medications after hours since the hospital doesn’t have a
pharmacist on duty 24 hours a day.
State Hospital uses a DocuMed system after hours
and has a pharmacist on call 24 hours a day, seven
days a week. “They were satisfied with the answer
but emphasized that a pharmacist needs to review
all new orders,” Simmons notes.
Surveyors also talked about the process of dispensing
medications. “We walked through our process, but
they didn’t look at a specific drug or patient,” says
Simmons.
Surveying goals compliance
Regarding checking into patient safety goals compliance, when surveyors learned the hospital didn’t have
Surveyors also looked into the facility’s patient identification policies—to ensure that it includes two identifiers and that staff knew the policies. One of the
hospital’s methods is to ask the patient his or her
name. A surveyor asked, “What do you do when a
patient doesn’t or can’t respond?” Interviewees said
they ask the accompanying attendant the patient’s
name.
Looking at the FMEA
Surveyors perhaps didn’t grill staff on the hospital’s
FMEA because Simmons gave them a notebook covering the project, as well as the hospital’s staffing
standards plans and performance improvement
projects.
However, the organization did receive a supplemental recommendation because the definitions in one
of its staffing and clinical indicators (the hospital
compared staff vacancies to incidence and prevalence of skin ulcers and staff injuries to patient
aggression) weren’t clear.
Patient safety and medication use interview tips
Consider the following advice from the JCAHO when
discussing your patient safety and medication systems
if your survey takes place this year: Note: This interview
will likely go away in 2004 (see “Get ready for the new
patient safety and medication interview” on p. 1).
✓ The new interview is an ideal time to discuss
your Failure Modes and Effects Analysis results,
says JCAHO spokesperson Mark Forstneger.
✓ Share a flow chart of your medication management process and a completed “medication systems analysis,” says Forstneger.
✓ Create a patient safety notebook containing all
your initiatives—including patient safety goals
compliance—to stay organized. “It’s great to have
a little notebook on patient safety so you can go
through it and show surveyors what you have
done,” says a source close to the JCAHO.
✓ Don’t forget to include in your patient safety notebook what you’ve done in response to the Sentinel
Event Alerts. Although you are no longer required to
comply with them—the patient safety goals replaced
them—you still must read and consider the Alerts,
> p. 10
and discuss them, says the observer.
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Page 9
www.accreditinfo.com
Interview tips
< p. 9
✓ Continually evaluate your organizations’ weak
points to prioritize projects. Many people refer to
the Institute for Safe Medication Practice’s selfassessment test on medications at www.ismp.org/
vhasurvey/survey_instructions.html.
✓ Consider—and show how you did so—patient
safety during new construction or remodeling
projects. Infection control—a hot area for 2003
surveys—also falls under patient safety.
✓ Expect lots of questions about wrong-site surgeries. The JCAHO receives five to seven reports
of wrong-site surgeries each month, the JCAHO
observer says. Surveyors will want to see a checklist—with every stage in the patient’s care cycle
signed off by caregivers—that starts from the
time a patient walks in the door.
Sample patient safety and medication interview questions
Your recently surveyed “BOJ Talk” colleagues saved
some surveyor questions from the new patient safety and medication interview to share with their
colleagues.
The following questions will help you prepare for
the new interview session:
• How did staff present the patient safety program
during orientation?
• When did you begin your patient safety initiative?
• How do you handle verbal orders?
• Are there any medications that the pharmacist
must review prior to administration?
• How do you address medication
misadministration?
• How do you deal with possible problems with
the physician orders?
• What are you doing about legibility?
• How do you handle blanket orders, such as,
“Take medications at home”?
• How do you handle dangerous abbreviations?
• What do you tell patients about their role in
preventing errors?
• How do you know about side effects of medications, and when should you call the physician
about them?
• Tell me about what you report as an error. Do
you report near-misses?
• What do you discuss about safety during unit
meetings?
• How do you educate patients about their perceived risks to safety?
• On what kinds of events do you perform rootcause analyses?
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Briefings on JCAHO—March 2003
www.accreditinfo.com
Life Safety Code
< p. 5
CMS will not exempt any existing facility from the
2000 LSC, though the agency adds that states may
seek approval from CMS to enforce their own fire
safety requirements, and CMS itself can issue caseby-case waivers of particular requirements.
A better understanding
The fact that CMS and the JCAHO will use the same
edition of the LSC will eliminate confusing and sometimes aggravating cases where facilities find themselves
trying to comply with two sets of requirements from
different editions of the Code.
• Requiring emergency lighting—Paragraph
19.2.9 requires existing health care facilities to install
emergency lights that will illuminate means of egress
for at least 90 minutes if the power goes out.
Approximately 640 facilities don’t have emergency
lighting, CMS estimates. It will cost each site an average of $9,000 to upgrade this equipment. Because of
the associated financial cost, CMS extended the deadline for complying with this provision until March
11, 2006.
Additional financial concerns
For example, the 1997 and 2000 versions require
automatic sprinklers to protect all new health care facilities. The 1985 edition didn’t mandate this, instead
relying only on building compartments to protect life
safety. The following are changes of note between
the 1997 and 2000 versions, many of which carry
financial implications:
Existing health care facilities not compliant with the
2000 LSC may also face considerable costs in the
near future due to the following requirements:
• The use of roller latches—CMS now prohibits
the use of roller latches, which means many facilities will retroactively be out of compliance. A
roller latch is a device to keep the door closed.
CMS claims that improperly maintained roller
latches are dangerous. Also, roller latch problems
are among the top life safety violations it finds
during Medicare surveys.
• 19.3.4.3.2 mandates that the fire alarm system
automatically notifies the fire department or monitoring station during an alarm—Medicare officials
predict that more than 2,300 buildings will need
to install this type of system at an average cost of
$1,707, in addition to monthly service fees
The agency estimates there are more than 190,000
latches that will need to be replaced, leading to a
total cost of $47.6 million. Recognizing the financial
burden of this provision, CMS extended the deadline
to comply until March 11, 2006.
• More room for creativity in building—Chapter
5 of the 2000 LSC contains a new section on performance-based design, which allows organizations
to use unique engineering solutions to address unusual building characteristics that the LSC might
otherwise not permit. CMS included the performance option just in case some health care facilities
think it will help in developing distinctive architectural designs.
• 19.3.1 requires protection of vertical openings—CMS
estimates that 1,100 facilities will spend an average
of $19,095 to install necessary protection features
• 19.3.6.1 requires corridor separations with fire-resistant barriers with various exceptions, including
for buildings protected by sprinklers—The agency
says about 1,640 sites must upgrade their corridor
protection at a cost of $7,455 to $9,260 per facility
Visit www.access.gpo.gov/su_docs/fedreg/a030110c.
html to read the final rule. Note: Look for the CMS
heading.
Questions? Comments?
Contact Senior Managing Editor Julia Fairclough
Telephone:
781/639-1872,
Ext. 3273
E-mail:
jfairclough@
hcpro.com
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please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on JCAHO—March 2003
© 2003 HCPro, Inc.
Page 11
Quick tip: Brush up on management
of information details at your facility
➤
Your list of who is qualified to accept and transcribe
verbal orders must be part of your medical staff’s
rules and regulations, according to IM.7.7.
However, many hospitals create a list that’s far too
exhaustive, says Steve Bryant, practice director of
accreditation and regulatory compliance services at
The Greeley Company, a division of HCPro, in Marblehead, MA. Therefore, include on your list only
those staff members who know enough about
medicine to question whether a medication, dose,
or procedure is appropriate for a particular patient.
On the other hand, Bryant sees some lists that are
too short, allowing only a specific nurse or case manager to accept verbal orders. That can cause problems
if staff must track down these people before the patient can receive care because no one else can take
the order.
“There’s no right or wrong answer here,” Bryant
says. “You just want to do what makes sense and
follow your own policy.”
Briefings on JCAHO
Editorial Advisory Board
Timely data
Here’s a quick pointer on IM.7.6
compliance—managing medical record data in a
timely manner. You cannot have more than one quarter in the year prior to your survey in which the number of delinquent records was equal to or exceeds twice
the average monthly discharges, says Jean Clark, RHIA,
director of health information services for CareAlliance
Health Services in Charleston, SC.
The JCAHO considers incomplete records delinquent
30 days after discharge. Ensure that your physicians
don’t misinterpret 30 days after discharge to mean 30
days from when the record hits the physician’s files,
Clark says.
Some state laws say incomplete records are delinquent after 14 or 21 days.
“If your state laws aren’t tighter than JCAHO, don’t
shoot yourself in the foot. Give yourself the full 30 days,”
Clark says. Include the rules on when delinquency starts
in your medical staff’s rules and regulations.
Suzanne Perney, Publisher/Vice President
Matt Cann, Executive Editor
Julia Fairclough, Senior Managing Editor
[email protected]
Hugh P. Greeley, Contributing Editor,
Chair, The Greeley Company,
Marblehead, MA
Deb Ankowicz, RN, BSN, CPHQ
Risk Management Consultant
Physician’s Insurance Company of Wisconsin
Madison, WI
George Fredericks, RPh, MBA
Director of Pharmacy Services
Northeast Health Systems
Albany, NY
Diane Rogier
Former President
National Association for Healthcare Quality
Glenview, IL
James G. Billingsley, MD
Vice President for Medical Services
Franciscan Health Services Northwest
Tacoma, WA
Joan Iacono, MSN, MBA
Consultant
Kennett Square, PA
Angelo Sparagna III, MD
Vice President of Medical Affairs
Shore Memorial Hospital
Somers Point, NJ
Steven W. Bryant
Practice Director
Accreditation Services
The Greeley Company
Marblehead, MA
Jodi Eisenberg, CMSC, CPHQ
Coordinator of Accreditation and Licensure
Northwestern Memorial Hospital
Chicago, IL
Peter J. Leeson, DO
Chief Executive Officer
Leeson Consulting Group
San Luis Obispo, CA
David P. Meyer, JD
Partner, Meyer, Kreuzer, and Esp
Wheaton, IL
Paula S. Swain, MSN, CPHQ, FNAHQ
Swain & Associates
Healthcare Improvement and
Compliance Consulting
Charlotte, NC
Briefings on JCAHO (ISSN 1054-6995) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $349/year or $628/two years. Back
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Briefings on JCAHO—March 2003