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Washington, DC, Oct. 16, 2006 — Adverse healthcare events are a leading cause of death and injury in the United States, even though well-documented methods are available that could prevent the occurrence of such events. In 2003, the National Quality Forum (NQF) endorsed 30 "safe practices" that should be universally utilized in applicable healthcare settings to reduce the risk of harm resulting from processes, systems, or environments of care.

To ensure the practices reflected new evidence and innovation, NQF undertook an effort to update the list of practices, and today announces endorsement of 3 new practices and 23 practices from the initial list that have materially changed; 4 practices remain unchanged.

The 26 materially changed or new practices, in brief, are:

• Create and sustain a healthcare culture of safety.
  
  
• Ask each patient or legal surrogate to "teach back" key information about proposed treatments or procedures for which he or she is asked to provided informed consent.
  
  
• Following serious, unanticipated outcomes, the patient and, as appropriate, family should receive communication about the event.
  
  
• Implement critical components of a well designed nursing workforce.
  
  
• Ensure that non-nursing direct care staffing levels are adequate, staff is competent and have had orientation, training, and education to perform assigned direct care duties.
  
  
• Ensure that care information is transmitted and documented in a timely and clearly understandable form to patients and patient's healthcare providers within and between care settings.
  
  
• For verbal or telephone orders or for telephonic reporting of critical test results, verify complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.
  
  
• Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, laboratory specimens or other diagnostic studies.
  
  
• A "Discharge Plan" must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to caregivers with confirmation of receipt.
  
  
• Implement a computerized prescriber order entry system built upon foundation of re-engineered evidence-based care, practitioner readiness and integrated information technology infrastructure.
  
  
• Standardize a list of "Do Not Use" abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization.
  
  
• The healthcare facility must develop, reconcile, and communicate an accurate medication list throughout the continuum of care.
  
  
• Pharmacists should actively participate in medication management systems.
  
  
• Standardize methods for labeling and packaging of medications.
  
  
• Identify all "high alert" drugs and establish policies and processes to minimize risks associated with the use of these drugs.
  
  
• Healthcare organizations should dispense medications, including parenterals, in unit-dose, or when appropriate unit-of-use form, whenever possible.
  
  
• Action should be taken to prevent ventilator-associated pneumonia by implementing ventilator bundle intervention practices.
  
  
• Adhere to effective methods of preventing central venous catheter-associated blood stream infections and specify the requirements in explicit policies and procedures.
  
  
• Prevent surgical site infections by implementing four components of care.
  
  
• Comply with current Centers for Disease Control and Prevention Hand Hygiene Guidelines.
  
  
• Immunize healthcare workers and patients who should be immunized against influenza annually.
  
  
• For high-risk elective cardiac procedures or other specified care, patients should be clearly informed of likely reduced risk of adverse outcome at treatment facilities that participate in clinical outcomes registries and minimize the number of surgeons performing procedures with strongest volume-outcomes relationship.
  
  
• Implement the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person SurgeryTM for all invasive procedures.
  
  
• Evaluate each patient undergoing elective surgery for risk of an acute ischemic perioperative cardiac event and consider prophylactic treatment with beta-blockers.
  
  
• Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers.
  
  
• Every patient on long-term oral anticoagulants should be monitored by a qualified health professional using a careful strategy to ensure an appropriate intensity of supervision.

Also endorsed were recommendations related to disseminating, implementing, and updating the list of practices, as well as several areas where additional research should be undertaken.

Detailed specifications and information on the recommendations may be found at www.qualityforum.org.

Source: The National Quality Forum