The Joint Commission emphasizes prevention – identifying problems and correcting them before anything happens. The organization has definitions that you need to know for the following terms:
- Error
- Sentinel Event
- Near Miss
- Hazardous Condition Error
Error
An Error is an unintended act of either omission or commission, or an act that does not achieve its intended outcome. In other words, an Error is:
- Something done by accident
- Something that should have been done but was not
- Something that was done that did not have the expected result.
An example of an Error is a patient’s blood pressure not being measured when it should have been.
Sentinel Event
A Sentinel Event is an unexpected occurrence which actually happened and which either resulted in death or serious physical or psychological injury or carried a significant risk thereof. Serious injury specifically includes loss of limb or function.
An example of a Sentinel Event is the wrong dose of medication being given to an infant, causing death.
Certain types of events are reported to The Joint Commission under their Sentinel Event policy, whether they actually or potentially resulted in death or serious injury. These events are:
- Rape
- Patient suicide
- Infant abduction or discharge to the wrong family
- Hemolytic transfusion reaction involving administration of blood or blood products
- Surgery on the wrong patient or wrong body part.
Near Miss
This term is used to describe any process variation which could have led to a Sentinel Event, but the Sentinel Event did not actually happen because of some kind of intervention. A recurrence of the process variation carries a significant chance of a serious adverse outcome.
Here is an example of a Near Miss. By mistake, a patient is handed a medication to which she is allergic, and which could lead to death or serious illness. Fortunately, she recognizes the medication is different from what she is usually given, questions staff about it, and ultimately receives the correct medication, instead. In this case, the process variation is that the patient is not wearing a wrist band listing her allergies, and that the information about her allergies is not available to staff anywhere else.
Hazardous Condition
This refers to any set of circumstances (other than the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome.
In other words, a Hazardous Condition is:
- Something that could cause the patient harm
- Something other than the patient’s disease or condition.
An example of a Hazardous Condition is a power outage and simultaneous failure of the back-up generator that shuts down life- support systems for some patients, meaning staff must manually ventilate affected patients until power is restored.
All hospitals must have a plan to identify risks to patient safety. They must also have policies for reporting and investigating sentinel events, near misses, and hazardous conditions.
ANNUAL NATIONAL PATIENT SAFETY GOALS
The National Patient Safety Goals are derived primarily from informal recommendations made in the Joint Commission’s safety newsletter, Sentinel Event Alert. The Sentinel Event database, which contains de-identified aggregate information on sentinel events reported to the Joint Commission, is the primary, but not the sole, source of information from which the Alerts, as well as the National Patient Safety Goals, are derived.
- Improve the accuracy of patient identification
Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products; taking blood sample and other specimens for clinical testing, or providing any other treatments or procedures. For example, use the patient’s name and date of birth.
2. Improve the effectiveness of communication among caregivers
For verbal or telephone orders or for reporting critical test results over the telephone, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.
Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
3. Improve the safety of using medications
Have on hand a small supply of the medicines that are used in the hospital
Create a list of medicines with names that look alike or sound alike and update the list every year. This will prevent errors involving the interchange of these drugs.
Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.
Take extra care with patients who take medicines to thin their blood.
4. Prevent infection
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines
Report death or injury to patients from infections that happen in the hospital.
5. Check patient medicines
Find out what medicines each patient is taking. Make sure that it is OK for the patient to take any medicines with their current medicines.
Give a list of the patient’s medicines to the patient’s next caregiver. Give this same list to the patient before they leave the hospital.
6. Prevent patients from falling
Find out which patients are most likely to fall. For example, is the patient taking any medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients.
7. Help patients to be involved in their care
Tell each patient and their family how to report their complaints about safety.
8. Identify patient safety risks
Find out which patients are most likely to try to kill themselves.
9. Watch patients closely for changes in their health and respond quickly if they need help
Create ways to get help from specially trained staff when a patient’s health appears to get worse.
10. Prevent errors in surgery
Create steps for staff to follow so that all documents needed for surgery are on hand before surgery starts.
Mark the part of the body where the surgery will be done. Involve the patient in doing this.
DO NOT USE LIST
Joint Commission has created a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout organization. The Do-Not-Use list applies to all orders and medication-related documentation and information that is handwritten or computer entered as free text
| Do Not Use | Why | Use Instead |
| U (unit) | Mistaken for “0” (zero), the number “4” (four) or “cc” | Write “unit” |
| IU (International Unit) | Mistaken for IV (intravenous) or the number 10 (ten) | Write “International Unit” |
Q.D., QD, q.d., qd (daily) D.O.D., QOD, q.o.d., qod (every other day) | Mistaken for each other. Period after the Q mistaken for “I” and the “O” mistaken for “I” | Write “daily” Write “every other day” |
| Trailing zero (X.0 mg)* Lack of leading zero (.X mg) | Decimal point is missed | Write X mg Write 0.X mg |
| MS MSO4 and MgSO4 | Can mean morphine sulfate or magnesium sulfate. Confused for one another. | Write “morphine sulfate” Write “magnesium sulfate” |
