Just had JCAHO survey 2 weeks ago. That is part of their national safety agenda BECAUSE too many orders are being written incorrectly and docs denying that order read back to them.
Improve the accuracy of patient identification.
use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products.
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.
Improve the effectiveness of communication among caregivers.
Implement a process for taking verbal or telephone orders that require a verification "read-back" of the complete order by the person receiving the order.
Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
Improve the safety of using high-alert medications.
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.
Standardize and limit the number of drug concentrations available in the organization.
Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
Implement a process to mark the surgical site and involve the patient in the marking process.
Improve the safety of using infusion pumps.
Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.
Improve the effectiveness of clinical alarm systems.
Implement regular preventive maintenance and testing of alarm systems.
Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit