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Goals evaluated during unannounced visits
Since January 2003, the Joint Commission on Accreditation of Healthcare Organizations requires that all accredited home care organizations implement recommendations associated with National Patient Safety Goals that are relevant to the services the agency provides. Compliance with the goals will be evaluated during all unannounced and regularly scheduled surveys.
The 2004 National Patient Safety Goals are:
1. Improve the accuracy of patient identification.
A. Use a least two patient identifiers whenever taking blood samples or administering medications or blood products.
B. Prior to the start of any surgical or invasive procedure, conduct a final verification process to confirm the correct patient, procedure, and site, using active communication techniques.
2. Improve the effectiveness of communication among caregivers.
A. Implement a process for taking verbal or telephone orders or critical test results that require a verification read back of the complete order or test result by the person receiving the order or test result.
B. Standardize the abbreviations, acronyms, and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use.
3. Improve the safety of using high-alert medications.
A. Remove concentrated electrolytes from patient care units.
B. Standardize and limit the number of drug concentrations available in the organization.
4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
A. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
B. Implement a process to mark the surgical site and involve the patient in the marking process.
5. Improve the safety of using infusion pumps.
A. Ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in the organization.
6. Improve the effectiveness of clinical alarm systems.
A. Implement regular preventive maintenance and testing of alarm systems.
B. Ensure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
7. Reduce the risk of health care-acquired infections.
A. Comply with current Centers for Disease Control and Prevention hand hygiene guidelines.
B. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.
(For more information about the National Patient Safety Goals, including frequently asked questions as well as acceptable alternatives to compliance with the goals, go to www.jcaho.org/accredited+organizations/patient+safety/index.htm.)