# NCPS TIPS -- Dec 2003/Jan 2004

### Contents: 1. Update on JCAHO Patient Safety Goals for 2004

> 2\. New Patient Safety Goal 7
>
> 3\. Modified Patient Safety Goal 2

### 1. Update on JCAHO Patient Safety Goals for 2004

By Noel Eldridge, MS, NCPS Executive Officer and Gary Roselle, MD, VHA
Program Chief for Infectious Diseases

In 2002, JCAHO established six Patient Safety Goals for 2003. These were
detailed in the December 2002 issue of TIPS
(<http://www.patientsafety.gov/TIPSDec02.pdf>). For 2004, JCAHO has
reaffirmed the six Goals for 2003, expanding one (2a), clarifying one
(2b), and adding a new two-part Goal 7. The Goals for 2004 are listed
below.

JCAHO has a web page where frequently asked questions and answers
regarding the Patient Safety Goals are listed. It is presently available
at:
<http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm>.

#### JCAHO Patient Safety Goals for 2004

1)  Improve the accuracy of patient identification.

    a.  Use at least two patient identifiers (neither to be the
        patient's room number) 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, such as a "time out," to
        confirm the correct patient, procedure and site, using
        active---not passive---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 (including, but not limited to,
        potassium chloride, potassium phosphate, sodium chloride \>0.9%)
        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 are available,
        e.g., medical records, imaging studies.

    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.  Assure 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 CDC 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.

**2. New Patient Safety Goal 7**

#### Goal 7a: Complying with CDC Hand Hygiene Guidelines

The Centers for Disease Control and Prevention issued

Hand Hygiene Guidelines on October 25, 2002
(<http://www.cdc.gov/handhygiene/>). The Guidelines provide a review of
scientific data and contain recommendations "designed to improve hand
hygiene practices of healthcare workers and to reduce the transmission
of pathogenic organisms."

The Guidelines were developed by a committee convened by CDC, in
collaboration with the Society for Healthcare Epidemiology of America,
the Association of Professionals in Infection Control and Epidemiology,
the Infectious Disease Society of America.

The Guidelines contain "Category IA, IB, and IC" recommendations that
are required by JCAHO Goal 7a, and have been summarized in the four
boxes on page 2. Appropriate personnel are to review the CDC Guidelines
in their original form. "Category II" recommendations are suggested by
CDC and JCAHO, but not required. Category II items may be considered by
VA facilities and adopted as locally determined. Some are already common
practice, such as removing rings before surgical scrub.

Healthcare-associated infections account for 50% of all major hospital
complications and have occurred in approximately 1-in-20 patients
admitted to US hospitals according to Priority Areas for National
Action, IOM 2003 (<http://www.nap.edu/catalog/10593.html>), which
selected nosocomial infections as 1 of 20 priority healthcare quality
improvements. The CDC has identified healthcare workers' hands as one of
the major vectors for these infections.

Perhaps the most important point in the Guidelines is that alcohol
hand-rubs have been shown to be extremely effective in killing
microorganisms -- often better than antibacterial soaps -- while also
being associated with a low incidence of dermatitis in healthcare
workers.

Previous studies indicate that the adherence to recommended hand-hygiene
practices averages 40%, with mean baseline rates as low as 5%. One
reason for low compliance has been the inconvenience of repeatedly using
soap and water. Alcohol hand-rubs are easier to use: when an alcohol
hand-rub is used as directed, neither water nor hand-drying with towels
is required or suggested.

Newer hand-rubs, although they contain 60% alcohol, are much easier on
the skin than earlier versions of these products due to the
incorporation of ingredients such as emollients. There is reason to
believe that the increased use of alcohol hand-rubs can simultaneously
reduce the incidence of infections in patients and of hand dermatitis in
healthcare workers.

#### Using Hand Hygiene Products In the VA

The VA presently has a Blanket Purchase Agreement (BPA) with only two
approved alcohol hand-rub suppliers: Coloplast (Sween Isagel) and Ecolab
(Huntington Quik-Care). The 21-ounce Coloplast gel can be wall-mounted
or dispensed from a tabletop. This product is also available in a
4-ounce pocket-sized product. The Ecolab product is an aerosol foam,
designed for wall-mount, that comes in two sizes, 7 and 15 ounces.

Many antimicrobial soaps are approved for purchase in the VA. At this
time, the two BPA-approved suppliers for these are Gojo-Purell and
Steris. A BPA has also been established for gloves, and the sole
supplier at this time is Bosma Industries for the Blind.

The intranet URL for all soaps, hand-rubs, and gloves for which VHA has
established a BPA is
<http://vhacoweb1/logistics/standards/Logistics.htm>. Searching by
manufacturer is the easiest way to bring up the applicable choices. When
a product is needed in an area for which no BPA has been established,
then VA facilities are free to purchase supplies as necessary.
Currently, this includes items such as hand lotions and alcohol-based
surgical scrub products.

Using an alcohol hand-rub is easy: apply the product to the palm of one
hand and rub hands together, covering all surfaces of hands and fingers,
until hands are dry. Some special-use products, including many developed
for surgical-scrub, require special guidance. In these cases, the
manufacturers' instructions should be followed. When using soap, one
should: cover all surfaces of the hands and fingers with soap and water;
wash for at least 15 seconds; dry with a disposable towel; and use the
towel to turn off the faucet. Avoid using hot water with soap because it
increases the risk of dermatitis. As with alcohol hand-rubs,
requirements differ for surgical scrub.

Additional information on ways to implement successful hand hygiene
programs is being studied by NCPS. New information will be provided as
it becomes available.

Goal 7b. Managing as sentinel events all identified cases of
unanticipated death or major permanent loss of function associated with
a healthcare-acquired infection.

This is not a new requirement. It is consistent with the guidance
provided in Appendices A and D in the VHA Patient Safety Improvement
Handbook, 1050.1, available at
<http://vaww.va.gov/publ/direc/health/handbook/1051-1hk1-30-02.pdf>, as
well as in other literature. As noted, RCAs are required in cases where
a "catastrophic" event has occurred, or in other cases where the
incident is scored as a 3 on the Safety Assessment Code. Catastrophic is
defined as "Death or major permanent loss of function (sensory, motor,
physiologic, or intellectual) not related to the natural course of the
patient's illness or underlying condition (i.e., acts of commission or
omission)."

JCAHO has provided the following clarification of this goal:

"Many patients who die with nosocomial infections are very sick and may
have multiple other problems. How do we determine whether the patient's
death was "unanticipated?"

This determination is based on the condition of the patient at the time
of admission to the organization. A death or major permanent loss of
function should be considered a sentinel event if the outcome was not
the result of the natural course of the patient's illness or underlying
condition(s) that existed at the time of admission. For example, an
otherwise healthy patient who is admitted for an elective procedure,
develops a wound infection, becomes septic, and dies, should be
considered a sentinel event. However, cases in which the patient is
immunocompromised or elderly with multiple co-morbidities are more
difficult to classify. The knowledge that a certain percentage of
patients with a given condition will die does not mean that the death of
any one of these patients is "anticipated." If, at the time of
admission, the patient's condition is such that he or she has a high
likelihood of not surviving the episode of care (e.g., the
hospitalization), then that patient's death would not be considered a
sentinel event. Otherwise, it should be managed as a sentinel event,
that is, a root cause analysis should be conducted."

Questions on this topic should be directed to your facility Patient
Safety Manager, who is responsible for understanding and using the
methods identified in 1050.1 to establish whether there is a requirement
to perform an RCA.

#### [Summary of CDC Recommendations for Hand Hygiene for the New JCAHO Patient Safety Goal 7a]{.underline}

Appropriate personnel are to review the CDC Guidelines in their original
form.

*I. All Health Care Workers With Direct Patient Contact*

1)  Use an alcohol hand-rub or antimicrobial soap to routinely
    decontaminate your hands before and after you touch a patient.\
    *Note: A single act of hand "washing" (with an alcohol hand-rub or
    an antimicrobial soap) after one patient and before the next patient
    suffices to decontaminate your hands if you are not recontaminating
    your hands in-between patients (as in talking on the telephone,
    handling objects, etc.). A good rule of thumb is that if you apply
    an alcohol hand-rub as you leave one patient and are still rubbing
    your hands together as you arrive at the next patient then there is
    no need to repeat hand antisepsis.*

2)  Put gloves on before you touch non-intact skin, blood, mucous
    membranes, or potentially infectious materials such as soiled
    linens.

3)  Use an alcohol hand-rub or antimicrobial soap before donning sterile
    gloves when inserting a central venous catheter, an indwelling
    urinary catheter, a peripheral vascular catheter, or performing
    other similar invasive procedures.

4)  Remove gloves after caring for a patient or touching potentially
    infectious materials, and use an alcohol hand-rub or antimicrobial
    soap to decontaminate your hands after removing gloves.

5)  Healthcare workers that may have direct contact with patients at
    high risk for infection must not wear artificial fingernails.

6)  Wash your hands with soap and water if they are visibly soiled or
    contaminated with body fluids.

7)  Wash hands with soap and water after using a restroom.

8)  Wash hands with soap and water before eating.

*II. Surgical Hand Hygiene*

1)  Before donning sterile gloves for surgical procedures use either an
    antimicrobial soap or an alcohol-based hand-rub with persistent
    activity.

2)  When using an alcohol-based surgical hand-scrub product with
    persistent activity, follow the manufacturer's instructions. Usage
    protocols may vary by manufacturer. For example, some products
    recommend that health care workers dip each fingernail in the
    antimicrobial solution prior to applying the product to their hands
    and forearms.\
    *Note: Most alcohol hand-rub products designed for non-surgical
    applications do not have persistent activity. "Persistent activity"
    is not a characteristic of alcohol, but is a characteristic of most
    other antimicrobial agents such as Chlorhexidine Gluconate, which
    are added to the alcohol-based products and soaps designed for use
    by surgeons. Consult infection control staff if you have questions
    on the appropriate use of alcohol-based surgical scrub products.*

3)  When performing surgical hand antisepsis using an antimicrobial
    soap, long scrub times (e.g., 10 minutes) are not necessary. Scrub
    hands and forearms for the length of time recommended by the
    manufacturer, usually 2 to 6 minutes.

III\. Facility Management (Supplies)

1)  Provide an alcohol-based hand-rub at the entrance to the patient's
    room and/or at the bedside, as well as other convenient locations.
    To provide an alternative to alcohol-based hand-rubs for
    decontaminating hands, provide antimicrobial soap in all patient
    care areas where soap is provided (i.e., at all sinks with a soap
    dispenser).

2)  Make pocket-sized containers of alcohol hand-rub available to HCWs.
    Note: This does not imply a requirement for HCWs to carry
    pocket-sized alcohol hand-rubs.

3)  Provide healthcare workers with hand lotions or creams to minimize
    irritant contact dermatitis.\
    *Note: Be sure to provide products designed for healthcare
    applications that do not reduce the effectiveness of other hand
    hygiene products, such as gloves and antimicrobial compounds, e.g.,
    Chlorhexidine Gluconate (CHG). Some lotions are specifically
    advertised as "CHG compliant." Providing lotion should not be seen
    as a frill.*

4)  Do not add soap to partially empty dispensers. "Topping off" soap
    dispensers can lead to bacterial contamination.\
    *Note: This means that in patient care settings soap should be
    provided in disposable bladders or other products that prevent old
    and new soap from mixing.*

5)  Store supplies of alcohol-based hand-rubs in cabinets or areas
    approved for flammable materials.

IV\. Facility Management (Administrative Action)

1)  Make improved hand-hygiene an institutional priority and provide
    administrative and financial support. *Note: Financial support
    includes providing adequate supplies of alcohol hand-rubs (wall
    mounted and pocket-sized), antimicrobial soaps, gloves (regular and
    sterile), and lotion.*

2)  Solicit input from employees regarding the feel, fragrance, and skin
    tolerance of products, such as soap, alcohol hand-rub and gloves.

3)  Monitor health care workers' adherence to hand-hygiene practices and
    provide information regarding the workers' performance.

**3. Modified Patient Safety Goal 2**

**Goal #2 Improve the effectiveness of communication among caregivers.**

**Goal 2a: 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.**

JCAHO has expanded Goal 2(a) to help prevent the occurrence of
miscommunication when reporting "critical test results." In 2004, JCAHO
will require that the "read back" process apply to "critical test
results" reported verbally or by telephone. Critical test results are
defined by the individual healthcare organization and will typically
include "stat" tests, "panic value" reports and other diagnostic test
results that require urgent response (i.e., imaging studies,
electrocardiograms and laboratory). Though JCAHO has not established any
documentation requirements for this goal, JCAHO will survey this
read-back activity. Expect JCAHO to focus on how performance is tracked
against the goal, i.e., how the organization knows that the process is
being done in a consistent manner, which may or may not include
documentation. Each facility should establish with its medical staff an
expectation for "read-back" whenever receiving critical test results
verbally, including over the telephone.

Note: Your facility must define which test results are considered
"critical test results," otherwise surveyors will consider all verbal or
telephone reports of diagnostic tests to be "critical."

**Goal 2b: Standardize the abbreviations, acronyms and symbols used
throughout the organization, including a list of abbreviations, acronyms
and symbols not to use**

On November 3, 2003, JCAHO clarified Goal 2b. This goal had required a
100 % compliance, in all forms of clinical documentation, with a
reasonably comprehensive, facility-defined list of prohibited
"dangerous" abbreviations, acronyms and symbols. Though 100 % compliance
continues to be the long-term objective of this requirement, recognizing
that this type of change will take time, JCAHO has instructed its
surveyors to score a facility "In Compliance" if:

-   Use of any item on the list below is "sporadic" (less than 10 % of
    the instances of the intended term are abbreviated or symbolized);
    AND

-   Whenever any prohibited item has been used in an order, there is
    written evidence of confirmation of the intended meaning before the
    order is carried out; AND

-   The organization has implemented a plan for continued improvement to
    achieve 100 percent compliance by the end of 2004.

Additionally, JCAHO has approved a "minimum list" of dangerous
abbreviations, acronyms and symbols. Beginning January 1, 2004, the
following items must be included on each accredited organization's "do
not use" list:

  ------------------- ------------------------- --------------------------
  **Abbreviation**    **Potential Problem**     **Preferred Term**

  U (for unit)        Mistaken as zero, four or Write "unit"
                      cc                        

  IU (for             Mistaken as IV            Write "international unit"
  international unit) (intravenous) or 10 (ten) 

  Q.D., Q.O.D.,       Mistaken for each other.  Write "daily" and "every
  (Latin abbreviation The period after the Q    other day"
  for once daily and  can be mistaken for an    
  every other day)    "I" and the "O" can be    
                      mistaken for "I".         

  Trailing zero (X.0) Decimal point is missed.  Never write a zero by
  mg), lack of                                  itself after a decimal
  leading zero (.X                              point (X mg), and always
  mg)                                           use a zero before a
                                                decimal point (0.X mg)

  MS, MSO4, MgSO4     Confused for one another. Write "morphine sulfate"
                      Can mean morphine sulfate or"magnesium sulfate"
                      or magnesium sulfate.     
  ------------------- ------------------------- --------------------------

Note: An abbreviation on the "do not use" list should not be used in any
of its forms---upper or lower case; with or without periods. For
example, if "Q.D." is on your "do not use" list, "QD" or "qd" should not
be used for any other purpose.

Effective April 1, 2004 (if you do not already have an additional
facility-defined "do not use" list in place), you must identify and
apply at least an additional three "do not use" abbreviations, acronyms
or symbols of your own choosing. Below are examples provided by JCAHO:

  ------------------- --------------------------------- --------------------
  **Abbreviation**    **Potential Problem**             **Preferred Term**

  µg(for microgram)   Mistaken for mg (milligrams)      Write \"mcg\"
                      resulting in one thousand-fold    
                      dosing overdose.                  

  H.S.(for            Mistaken for either half-strength Write out
  half-strength or    or hour of sleep (at bedtime).    \"half-strength\" or
  Latin abbreviation  q.H.S. mistaken for every hour.   \"at bedtime\"
  for bedtime)        All can result in a dosing error. 

  T.I.W.(for three    Mistaken for three times a day or Write \"3 times
  times a week)       twice weekly resulting in an      weekly\" or \"three
                      overdose.                         times weekly\"

  S.C. or S.Q.(for    Mistaken as SL for sublingual, or Write \"Sub-Q\",
  subcutaneous)       \"5 every\".                      \"subQ\", or
                                                        \"subcutaneously\"

  D/C (for discharge) Interpreted as discontinue        Write \"discharge\"
                      whatever medications follow       
                      (typically discharge meds).       

  c.c.(for cubic      Mistaken for U (units) when       Write \"ml\" for
  centimeter)         poorly written.                   milliliters
  ------------------- --------------------------------- --------------------

Note: the Institute for Safe Medication Practices (ISMP) has published
an updated list of dangerous abbreviations relating to medication use
that it recommends should be explicitly prohibited. This list is
available on the ISMP website: <http://www.ismp.org/>.