JCAHO
Joint Commission Issues Alert on
Dangers of Family Members,
Caregivers Delivering
Patient-Controlled Analgesia

Well-intentioned family members and caregivers who want to keep patients from suffering may actually be putting them at risk by becoming involved in administering patient-controlled analgesia, according to a warning issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in December.

Patient-controlled analgesia (PCA) is a pain-control system that allows patients to treat their own pain rather than wait for a nurse or other healthcare professional to give more medication. PCA uses a computerized pump that is hooked up to the patient's IV. The patient can receive the pain medication by pressing a button, allowing that individual greater control in managing the pain he or she is experiencing. The patient provides a built-in safety check in this system because an over-sedated patient is not able to push the button to cause a harmful or even fatal overdose. Problems can arise, however, when a family member or healthcare professional administers PCA. This is called "PCA by proxy."

This issue of the Joint Commission's Sentinel Event Alert was distributed to more than 8,500 accredited hospitals, critical access hospitals, and homecare organizations across the country to provide practical advice to healthcare organization leaders and healthcare professionals to help prevent PCA by proxy errors.

"PCA-by-proxy errors are readily preventable and can be virtually eliminated through timely and appropriate education and training of staff and family members," said Dennis S. O'Leary, M.D., president of the Joint Commission.

The Alert offers a series of specific recommendations — developed in consultation with the United States Pharmacopia (USP) and the Institute for Safe Medication Practices (ISMP) — to prevent these errors.

These include:

• Ensure that the right patients receive PCA — Some patients may not be appropriate candidates because of their age, mental state, level of consciousness, intellectual capacity, or other factors that require close monitoring of the delivery of pain medications.
  
  
• Carefully monitor patients — Opiates can lower heart rates and blood pressure and suppress breathing, making patient observation an important component of a safe PCA program.
  
  
• Teach patients, family members, and other caregivers about the proper use of PCA — The dangers of having others press the medication button need to be understood by all involved in the care of the patient. Written instructions should be provided to family members that emphasize that PCA doses by proxy are NOT to be given.

"PCA-by-proxy errors are usually the direct result of family members or healthcare professionals administering doses for the patient, with the intent of keeping them comfortable," said Michael Cohen, R.Ph., M.S., Sc.D., president, ISMP. "This well-intentioned effort can result in over-sedation, respiratory depression, and even death."

The USP medication errors database lists 460 fatalities or instances of harm to patients as a consequence of errors related to PCA; 15 cases were the direct result of PCA error by proxy. Most of the errors by proxy were attributed to family members.

Source: www.jcaho.org

Malcolm Baldrige National Quality Award
Robert Wood Johnson
University Hospital Hamilton
Wins Baldridge Award

Robert Wood Johnson University Hospital Hamilton (RWJ Hamilton) has joined an elite community of businesses recognized for performance excellence and quality achievement. Secretary of Commerce Donald Evans notified RWJ Hamilton on November 22, 2004, that the hospital had been selected as a recipient of the prestigious Malcolm Baldrige National Quality Award in the category of healthcare.

RWJ Hamilton is the only healthcare recipient for 2004. The organization joins a group of only three other healthcare organizations who have ever received the award.

"We are deeply honored to be recognized for our performance excellence," said Christy Stephenson, president and CEO. "We attribute our success to the employees and physicians who provide outstanding healthcare every day. The people of RWJ Hamilton live our mission by providing 'Excellence through Service.'"

Robert Wood Johnson University Hospital Hamilton is a not-for-profit healthcare provider dedicated to offering the highest quality of hospital, emergency, and outpatient services to the Greater Mercer County community. Located in Hamilton Township, New Jersey, the hospital has over 1,734 employees and over 650 physicians on the medical staff, representing over 30 medical specialties. The hospital is part of the Robert Wood Johnson Health System and Network and is affiliated with the University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School.

The Baldrige Award is the top honor a U.S. organization can receive for quality management and quality achievement and raises awareness about the importance of performance excellence as a competitive edge. Criteria for the award include leadership, strategic planning, customer and market focus, information and analysis, human resource focus, process management, and business results.

For more information on the Malcolm Baldrige National Quality Award, please visit the National Institute of Standards and Technology Web site, www.baldrige.nist.gov.

Source: Robert Wood Johnson University Hospital Hamilton Web site, www.rwjhamilton.org.

AHRQ
New Survey Helps Hospitals
Measure and Improve Patient
Safety Culture

HHS' Agency for Healthcare Research and Quality (AHRQ) has announced a new tool to help hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units. The Hospital Survey on Patient Safety Culture, being released in partnership with Premier, Inc., the Department of Defense (DoD), and the American Hospital Association (AHA), addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm.

"Improving patient safety is not just a function of having the best research findings available," said AHRQ Director Carolyn M. Clancy, M.D. "There has to be an environment or culture that encourages health professionals to share information about patient safety problems and actions that can be taken to make care safer, and that also supports making any changes needed in how care is delivered."

Assessments of patient safety culture typically include an evaluation of a variety of organizational factors that have an impact on patient safety, including awareness about safety issues, evaluating specific patient safety interventions, tracking changes in patient safety over time, setting internal and external benchmarks, and fulfilling regulatory requirements or other directives.

The Hospital Survey on Patient Safety Culture includes the survey guide, the survey, as well as a feedback report template in which hospitals can enter their data to produce customized feedback reports for hospital management and staff. These items provide hospitals with the basic knowledge and tools needed to conduct a safety culture assessment and suggestions about how to use the data.

The survey was pilot tested with over 1,400 hospital employees from 21 hospitals in the United States to ensure that the items were easily understood and relevant to patient safety in a hospital.

The survey can be found online at www.ahrq.gov/qual/hospculture/. Printed copies may be ordered by calling 1-800-358-9295 or by sending an e-mail to ahrqpubs@ahrq.gov.

Source: www.ahrq.gov

World Alliance for Patient Safety
Global Patient Safety
Challenge 2005/2006:
"Clean Care is Safer Care"

The following information provided background for an international consultation that was held in Geneva, Switzerland, on December 3, 2004. —Ed.

WHO launched a World Alliance for Patient Safety on October 27, 2004. The fundamental purpose of the Alliance will be to facilitate the development of patient safety policy and practice in all WHO member states. Each year the Alliance will deliver a number of work programs covering systemic and technical aspects of patient safety. A key program for the Alliance is the delivery of a "Global Patient Safety Challenge." The topic chosen for the first challenge is healthcare-associated infections, and the title of the challenge is "Clean Care is Safer Care." The intention will be to examine a number of existing WHO strategies and guidelines in the areas of infection prevention, blood safety, procedure-related safety, equipment safety, and others, in order to develop a comprehensive and integrated WHO strategy for hand hygiene. Initially, closely monitored implementation of the integrated strategy will take place in six geographical districts, one in each WHO region, to assess its impact.

Objectives for 2005

• Designate hand hygiene in healthcare settings as a patient safety priority worldwide.
  
  
• Initiate clinical governance for hand hygiene promotion at all levels of healthcare settings.
  
  
• Develop comprehensive hand hygiene in healthcare settings promotion guidelines that include staff education and motivation to promote behavioral modification facilitation of system changes, use of performance indicators, and engagement of stakeholder support.
  
  
• Issue recommendations and develop instruments for continuous, long-term monitoring and feedback mechanisms, as well as outcome measures, to monitor progress.

The objective of the consultation is to review available evidence on hand hygiene and to reach consensus on the outline of the WHO Guidelines on Hand Hygiene. The consultation will also designate working groups to research specific topics in hand hygiene within the next six months.

Outcome of the Consultation
The consultation will result in an agreed outline of the draft guidelines and a work program for the participants involved in developing the guidelines. It is intended that the final guidelines be published by May 2005.

Source: www.who.int/patientsafety/en/

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