PATIENT SAFETY GOALS
FOR LABORATORIES.
DRAFT COPY ONLY.
(Procedure 254).
http://www.netautopsy.org/axsop/axsop254.htm


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United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose, and noninfringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document..



PRINCIPLE OF THE TEST.

      National Patient Safety Goals For Laboratories.



STEP-BY-STEP DESCRIPTION.


1. National Patient Safety Goals For Laboratories.

2. Media contact:
Ms. Charlene D. Hill
Media Relations Manager
630.792.5175
email: chill@jcaho.org
3. (OAKBROOK TERRACE, Ill. May 31, 2005). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) today announced the 2006 National Patient Safety Goals and related Requirements that will apply specifically to its accredited laboratories.

4. Major additions to this fourth annual issuance of National Patient Safety Goals, which were approved by the Joint Commission's Board of Commissioners, include a new Requirement that "hands-off" of patients between caregivers be standardized, with particular attention to assuring the opportunity for asking and responding to questions. This Requirement is part of the Goal: "Improve the effectiveness of communication among caregivers." In addition, a new Goal encourages the active involvement of patients and their families in the patient's care as a patient safety strategy, and includes a specific Requirement that the laboratory define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

5. "The 2006 National Patient Safety Goals extend the Joint Commission's commitment to focusing attention on the greatest opportunities for improving patient safety," says Dennis S. O'Leary, M.D., president, Joint Commission. "We are confident that accredited organizations will integrate these requirements into their efforts to redesign internal systems to avoid unnecessary patient disabilities and loss of life."

6. The development and annual updating of the National Patient Safety Goals and Requirements continues to be overseen by an expert panel that includes widely-recognized patient safety experts, as well as nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Each year, the Sentinel Event Advisory Group works with the Joint Commission to undertake a systematic review of the literature and available databases to identify candidate new Goals and Requirements. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other parties of interest, the Advisory Group determines the highest priority Goals and Requirements and makes its recommendations to the Joint Commission.

7. The Board of Commissioners also affirmed the six existing "do not use" abbreviations that constitute a single Requirement under the Goal: "Improve the effectiveness of communications among caregivers," but acted to delete a related stipulation that each organization also identify an additional three organization-specific "do not use" abbreviations that have been integral to this Requirement as well. Failure to substantially eliminate the utilization of "do not use" abbreviations in medication orders remains one of the most frequent non-compliance findings during Joint Commission surveys.

8. The 2006 Laboratory National Patient Safety Goals are: Improve the accuracy of patient identification. Use at least two patient identifiers (neither to be the patient's location) whenever collecting laboratory samples or administering medications or blood products, and use two identifiers to label sample collection containers in the presence of the patient. Processes are established to maintain samples' identity throughout the pre-analytical, analytical and post-analytical processes.

9. Immediately prior to the start of any invasive procedure, conduct a final verification process to confirm the correct patient, procedure, site and availability of appropriate documents. This verification process uses active – not passive – communication techniques. The patient's identity is re-established if the practitioner leaves the patient's location prior to initiating the procedure. Marking the site is required unless the practitioner is in continuous attendance from the time of the decision to do the procedure and patient consent to the initiation of the procedure (for example, bone marrow collection, or fine needle aspiration).

10. Improve the effectiveness of communication among caregivers. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.

11. Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.

Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

All values defined as critical by the laboratory are reported directly to a responsible licensed caregiver within time frames established by the laboratory (defined in cooperation with nursing and medical staff). When the patient's responsible licensed caregiver is not available within the time frames, there is a mechanism to report the critical information to an alternative responsible caregiver.

Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.

Reduce the risk of health care-associated infections.

Comply with current U.S. Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health-care associated infection.

Encourage the active involvement of patients and their families in the patient's care as a patient safety strategy.

12. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. The full text of the 2006 Goals and Requirements is posted on the Joint Commission website. Compliance with the Requirements or alternatives judged to be acceptable is a condition of continuing accreditation for Joint Commission-accredited laboratories.

13. To view this news release online visit: http://www.jcaho.org/news+room/news+release+archives/06_npsg_lab.htm

To view the 2006 Laboratory National Patient Safety Goals visit: http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm