1. JCAHO Patient Safety Requirements Background & Summary

2. Background 1999 Institute of Medicine report: “To Err is Human: Building a Safer Health System” • Estimated 44,000 – 98,000 medical error deaths annually • More than from highway accidents, breast cancer, or AIDS

3. Additional IOM Activity • Quality of Healthcare in America Project • Crossing the Quality Chasm -report recommends total redesign of health care delivery system

4. JCAHO Patient Safety Requirements • In response to IOM reports and public outcry • Intermeshed throughout the standards • >50% of standards now relate to patient safety

5. What Must We Do? • Create Culture of Safety • Program development and oversight • Encourage error reporting • Non-punitive system • Don’t tolerate cover-ups • Support employees involved in serious errors

6. Culture of Safety (continued) • Root Cause Analysis • Intensely analyze the error • Redesign system • Test new design • Educate staff on changes • Follow-up on the new design

7. Ask Questions • Safety Survey: ask for suggestions on improving safety • Employees • Medical staff • Patients

8. Technology Promotes Safety • Assess needs • Accessibility • Timeliness • Links to internal equipment • Links to external resources

9. Patient Centered Care • Assess for safety risk factors like falls • Incorporate assessment into care plan • Provide safety education for patients and families

10. Prevent Errors (continued) • Analyze & redesign high risk areas including: • Medication (from ordering to administration) • Errors reported by other facilities • Those identified in risk management

11. Prevent Errors • Adequate allocation of resources • Human • Information • Physical • Financial

12. Disclose Unanticipated Outcomes • The attending physician must tell the patient and family if the outcome is significantly different from that anticipated • This includes surgical complications

13. Disclose Errors • Tell the patient and/or family when an error has occurred