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Joint Commission International: An Overview
Karen H. TimmonsPresident and Chief Executive Officer
Joint Commission International
Association of Companies Health Insurance Funds 13 March 2009
Prague, Czech Republic
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– To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services
Mission of Joint Commission International
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Ernest A. Codman: End Result Theory
– “So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement,
– Must find out what their results are.– Must analyze their results, to find their
strong and weak points.– Must compare their results with those of
other hospitals.– Must welcome publicity not only for their
successes, but for their errors.”[1]
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The American College of Surgeons described the need for
standardization of hospitals through accreditation as the need to:
– “Encourage those which are doing the best work, and to stimulate those of inferior
standard to do better.”
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The Joint Commission
– An independent, non-profit, non-governmental agency
– Accredits over 15,000 health care organizations in the United States
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Why International Standards?
The Joint Commission standards:– Are filled with U.S. and state laws and regulations – Include many “political” considerations such as
requirements for an organized medical staff– Use American jargon such as “advanced directives”– Rely on National Fire Protection Association
requirements for facility review–no international version of these requirements
– Have a U.S. cultural overlay for patient rights
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Standards Subcommittee: How We Get Stakeholder Input
– Brazil– Czech Republic– Germany– Italy– Poland– Portugal– P.R. of China– Republic of South Africa– Saudi Arabia– U.S.A.
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JCI Hospital Standards Translations
–Arabic–Brazilian Portuguese –Chinese–Czech–Danish–European Portuguese
–German–Greek/Cyprus–Italian–Korean–Japanese–Spanish–Turkish
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International Structure
– International Board of Directors– International Accreditation Committee– International Standards Committee– Regional Advisory Councils – Four International Offices– International translations of many products
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Offices
– Headquarters– Oak Brook, IL, USA
– International– Europe
– Ferney-Voltaire, France (edge of Geneva)– Milan, Italy (Project Office)
– Middle East– Dubai Health Care City
– Asia Pacific– Singapore
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Regional Advisory Councils
– Asia-Pacific– Europe– Middle East
– Provide advice and counsel to JCI management about standards and patient safety initiatives
– Guidance on regional or cultural adaptations
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European Regional Advisory Council
– BQS – Danish Institute for Patient Safety – Danish Institute for Quality and
Accreditation in Healthcare (IKAS)
– European Parliament – European Society for Quality in
Healthcare (ESQH) – Fundación Acreditación
Desarrollo Asistencial– Georgian Alliance for Patient
Safety – Haute Autorité de Santé (HAS)
– Health Care Quality Indicator Project
– HOPE (European Hospital Federation)
– International Hospital Federation – International Pharmaceutical
Federation (FIP)– The Karolinska Institute– Ministry of Health, State of Israel– Ministry of Health, Turkey – National Patient Safety Agency – Socialstyrelsen – Swedish Medical Injury Insurance– WHO
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JCI Today
– Global knowledge disseminator of quality improvement and patient safety
– Non-profit affiliate of the Joint Commission– 236 accredited organizations in 35 countries– Commitment to partnering with NGOs, HCOs,
etc.– ISQua-accredited– WHO Collaborating Centre for Patient Safety
Solutions
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International Accreditation Programs
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Accredited Hospitals in Czech Republic
• Central Military Hospital• Institute of Hematology and Blood
Transfusion• Na Homolce Hospital
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• A government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes
• Usually a voluntary process
Accreditation – A Definition
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Accreditation: A World Trend
– The U.S., Canada, and Australia have the oldest accreditation systems
– In Europe, Germany, France, Ireland, and Spain have new accreditation systems
– In Asia, China, Thailand, and Malaysia are developing national accreditation programs
– The WHO, World Bank, and development banks recognize and endorse the accreditation model
– The International Society for Quality in Health Care (ISQua) accredits accrediting bodies
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Common Core of Health Care Accreditation Around the World
Administered by a recognized body• Establishes and publishes standards• Conducts objective on-site evaluations• Publishes accreditation decision
Professional involvement• Consensus on standards of quality and safety• Professionals serve as the external evaluators
Focus is on continuous improvement
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What is Accreditation Intended to Accomplish?
• Maximize quality/minimize safety risk• Improve patient care processes and outcomes• Enhance patient safety
• Strengthen the confidence of patients, professionals, and payors about the organization
• Improve the management of health services• Enhance staff recruitment, retention, and
satisfaction• Provide education on better/best practices
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Increasing Requests for Ensuring Quality and Safety for Medical Travel• International Medical Travel Association issued position paper
advocating that international health care organizations be held to high standards set by recognized accreditation authorities1
• American Medical Association adopted guiding principles on medical tourism2
– Outline steps for care abroad for consideration by patients, employers, insurers, and third parties
– Require patients to be made aware of their legal rights and have access to physician licensing and facility accreditation
• Increasing exposure in international trade journals highlighting the need to research quality when considering medical travel3
• Deloitte study mentions JCI in particular in reference to patients’ increasing concerns about quality in international hospitals4
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Accreditation
– Assesses the capability of an organization to provide good results
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Joint Commission International Accreditation
International Accreditation Philosophy– Maximum achievable standards– Patient-centered– Culturally adaptable– Process stimulates continuous improvement
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The Accreditor’s Tools
Standards Evaluation Methodology Patient Safety Goals and Tools Data on Performance and Benchmarks Education
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Standards
– A system framework– Address all the important managerial and
clinical functions of a health care organization– Focus on patients in context of their family– A balance of structure, process, and
outcomes standards– Set optimal, achievable expectations– Set measurable expectations
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Standards are Continually a “Work in Progress”
– The heart of any accreditation program is the standards upon which all else is based – the evaluation methodology, decision process, evaluator training, and other operational elements
– Thus, a standard must be “good”, not just on the day the standard is written, but on a continuing basis
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Evidence of Performance is Available
– Standards have multiple dimensions and thus have multiple sources of evidence– Policy – document review– Knowledge – staff training logs, interviews with
staff– Practice – clinical observation, patient interviews– Documentation of practice – open and closed
record review– A good standard permits a convergent validity scoring
process – all surveyors evaluating all types of evidence and reaching one score
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Joint Commission International Standards
– Organized Around Important Functions– Patient-Centered Standards
– Access to Care and Continuity of Care– Patient and Family Rights– Assessment of Patients– Care of Patients– Anesthesia and Surgical Care– Medication Management and Use– Patient and Family Education
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JCI Standards, continued
– Organized Around Important Functions– Organization Management Standards
– Quality Improvement and Patient Safety– Prevention and Control of Infections– Governance, Leadership, and Direction– Facility Management and Safety– Staff Qualifications and Education– Management of Communication and
Information
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Patient Tracer: Systems Analysis
– Set of components that work together toward common goal
– Evaluation of how - and how well - the organization’s systems function
– Addresses interrelationships of elements– Translates standards compliance issues into
potential vulnerabilities as far as patient quality and safety
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International Patient Safety Goals and Tools
– Represent proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts
– Incorporating these new tools into our accreditation requirements is a significant step
– Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important
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JCI International Patient Safety Goals
1. Identify patients correctly
2. Improve effective communication
3. Improve the safety of high-alert medications
4. Ensure right-site, right-patient, right-procedure surgery
5. Reduce the risk of health care-associated infections
6. Reduce the risk of patient harm from falls
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JCI’s Measurement Strategy
– Accreditation is continuous– Accreditation status publicly disclosed– Complements existing standards requirements– International comparisons– Meets needs of multiple stakeholders– Develop and identify measures that address clinical
and managerial dimensions– Need for and rigor of data validation– Measurement system supported by IT platform– JCI currently has 20 performance measurement
requirements
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International Cardiac Surgery Benchmarking (ICSB) Project
• Pilot program addressing international clinical cardiac indicators
• Enables hospitals to evaluate the current status of their coronary artery bypass graft (CABG) and valve-related surgery risk-adjusted mortality rates
• Encourages hospitals to implement and measure rates of improvement using the New York State Department of Health (NYSDOH) Cardiac Surgery Reporting System (CSRS) as a model
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ICSB Project Objectives
• Participating hospitals will get information to help them improve quality of care and assess a patient’s risk factors before cardiac surgery
• Multi-site and multi-country use of the ICSB assessment and reporting tool to guide organized quality improvement and benchmarking efforts
• Long-term goal–to improve the outcomes of cardiac surgical procedures in participating organizations
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Speak Up™
– Help Prevent Errors in Your Care – Help Avoid Mistakes in Your Surgery – Information for Living Organ Donors – Five Things You Can Do to Prevent Infection – Help Avoid Mistakes With Your Medicines – What You Should Know About Research Studies – Planning Your Follow-up Care – Help Prevent Medical Test Mistakes – Know Your Rights – Understanding Your Doctors and Other Caregivers – What You Should Know About Pain Management
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Sentinel Event Database
– Sentinel Event database collects data from accredited organizations on errors that have occurred
– Information in database led to the publication of Sentinel Event Alert, published by The Joint Commission
– Sentinel Event Alerts highlight significant risk areas in care
– Offer suggestions and recommendations for mitigating risk
– Latest Alert focuses on information technology
Client name/ Presentation Name/ 12pt - 38
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Sentinel Event Experience to Date
741 Events of wrong site surgery 698 Inpatient suicides631 Operative/post op complications492 Events relating to medication errors442 Deaths related to delay in treatment341 Patient falls218 Assault/rape/homicide 212 Retained foreign objects189 Deaths of patients in restraints175 Perinatal death/injury132 Transfusion-related events113 Infection-related events 86 Deaths following elopement 85 Anesthesia-related events 85 Fires992 “Other”
Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008:
= 5632 RCAs
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Accreditation Represents a Risk Reduction Strategy
– That an organization is doing the right things and doing them well;
– Thereby significantly reducing the risk of harm in the delivery of care; and
– Optimizing the likelihood of good outcomes.
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The Value and Impact of Accreditation
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Impact of Accreditation
– What is the evidence that– Accreditation improves quality and safety
of care?– High quality lowers cost of health care?– The cost of implementing accreditation
standards is worth the achievable benefit?
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Impact of Accreditation (cont’d)
– The process of Joint Commission International accreditation has set many of the fundamental principles that guide health care organizations today
– Many of these principles are routine in health care today but were revolutionary in their time
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Impact of Accreditation: Some Examples
Medical Records• First required in 1917, many considered
the medical record unnecessary• Today the medical record is inarguably
the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing
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Impact of Accreditation:Some Examples
Infection Control Programs– In the mid-1950s, patients, especially surgery
patients and newborns, acquired infections in epidemic proportions
– In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections
– Infection control programs were created that reduced the spread of devastating infectious agents
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Impact of Accreditation:Some Examples
Fire Safety– Non-smoking standards for hospitals were developed due to the
adverse effects of passive non-smokers and significant fire hazards
Advance Directives– Protects patients from a life or death they would not have wished – Requires organizations to establish Do-Not-Resuscitate (DNR)
standards and request an advance directive from each patient so the individual’s wishes can be documented in the patient chart
– In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard
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Accreditation: The Value Equation – JCI has conducted descriptive research with a sample
of accredited hospitals to determine the value of accreditation
– Accredited hospitals report significant improvements in:– Leadership– Medical records management– Infection control– Reduction in medication errors – Staff training and professional credentialing– Improved quality monitoring
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Recent Studies Support the Value of Joint Commission Accreditation
– Longo study showed that accreditation is a significant factor in whether facilities engaged in actions widely recognized to improve patient safety; advocates accreditation as a means for improving health care5
– Health Affairs report indicated that Joint Commission accreditation requirements influenced hospitals’ efforts toward implementing patient safety initiatives6
– Study in Hospital Topics found accreditation to be effective in driving efforts to reduce errors7
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WHO WHO World Alliance World Alliance
for Patient for Patient SafetySafety
to address the problem of to address the problem of patient safety worldwidepatient safety worldwide
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World Alliance for Patient Safety: Ten Action Areas
Catalyse countries’ action to achieve safety of care
Global Patient Safety Challenges : 1. Clean Care is Safer Care2. Safe Surgery Saves Lives
Patients for Patient Safety
Reporting & Learning
Solutions to improve patient safety
Research for Patient Safety
International Classification for Patient Safety (ICPS)
High 5s
Technology for Patient Safety
Knowledge Management
Special projects: - Education- Radiotherapy- Rewarding excellence- When things go wrong- Vincristine sulphate
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Solutions for Patient Safety
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Clean Care is Safer Care
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Patients for Patient Safety
• A patient engagement initiative• Focus on individuals (“champions”), not
organizations• Links to other World Alliance strands• Creation of regional groups
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Taxonomy for Patient Safety
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International Patient Safety Events Taxonomy
• Cornerstone of patient safety communications
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Reporting and Learning
Available on www.who.int/patientsafety
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Harvard Practice
Medical Study
1984
Utah Colorado
Study 1992
Australian Quality in Healthcare Study 1992
Adverse events in British Hospitals
1999-2001
Danish Adverse Event Study
2001
Adverse Events in New Zealand Study 2002
Canadian Adverse Event Study
2004
French Adverse Event Study
2004
The Commonwealth Fund Survey
2005
Research for Patient Safety
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Technology for Patient Safety
– “To identify and clarify the role and objectives of technology in improving patient safety both in the developed and developing world, and future directions (research, education, implementation) for the alliance regarding technology for patient safety.”
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High 5s Project Objective
– To achieve significant, sustained, and measurable reduction in the occurrence of patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning community that fosters the sharing of knowledge and experience in implementing innovative standardized operating protocols and evaluating their impact.
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High 5s Standardized Operating Protocols
– Managing Concentrated Injectable Medicines (U.K.)
– Assuring Medication Accuracy at Transitions in Care (Canada)
– Performance of Correct Procedure at Correct Body Sites (U.S.)
– Improved Hand Hygiene to Prevent Health Care-Associated Infections (New Zealand) (deferred)
– Communication During Patient Care Handovers (Australia) (deferred)
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WHO Collaborating Centrefor Patient Safety Solutions
– Identify Current Regional Safety Problems and Solutions Available
– Understand Regional Barriers to Solutions– Assess Risk of Solutions– Adapt Solutions to Local/Regional Needs– Develop/Disseminate Solutions
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Definition
A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.
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Topic Selection Process
– Sentinel Event Topic Areas– Expert Panels– National Agencies and Governments– Professional societies and organizations– Patient and family advocacy organizations– Field reviews– Open solicitations
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Confusing drug names is one of the most common causes of Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of medication errors and is a worldwide concern. With tens of
thousands of drugs currently on the market, the potential for error thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and created by confusing brand or generic drug names and
packaging is significant. The recommendations focus on using packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the protocols to reduce risks and ensuring prescription legibility or the
use of preprinted orders or electronic prescribing.use of preprinted orders or electronic prescribing.
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The widespread and continuing failures to correctly identify patients The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person often leads to medication, transfusion and testing errors; wrong person
procedures; and the discharge of infants to the wrong families. The procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient recommendations place emphasis on methods for verifying patient
identity, including patient involvement in this process; standardization of identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and identification methods across hospitals in a health care system; and
patient participation in this confirmation; and use of protocols for patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name.distinguishing the identity of patients with the same name.
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Gaps in hand-over (or hand-off) communication between patient care Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious units, and between and among care teams, can cause serious
breakdowns in the continuity of care, inappropriate treatment, and breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving potential harm for the patient. The recommendations for improving
patient hand-overs include using protocols for communicating critical patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve information; providing opportunities for practitioners to ask and resolve
questions during the hand-over; and involving patients and families in the questions during the hand-over; and involving patients and families in the hand-over process. hand-over process.
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Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or
incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. The
recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in
the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site.
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While all drugs, biologics, vaccines and contrast media have a While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used defined risk profile, concentrated electrolyte solutions that are used
for injection are especially dangerous. The recommendations for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and address standardization of the dosing, units of measure and
terminology; and prevention of mix-ups of specific concentrated terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. electrolyte solutions.
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Medication errors occur most commonly at transitions. Medication Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient reconciliation is a process designed to prevent medication errors at patient
transition points. The recommendations address creation of the most transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking—complete and accurate list of all medications the patient is currently taking—
also called the “home” medication list; comparison of the list against the also called the “home” medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; admission, transfer and/or discharge orders when writing medication orders;
and communication of the list to the next provider of care whenever the and communication of the list to the next provider of care whenever the patient is transferred or discharged.patient is transferred or discharged.
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The design of tubing, catheters, and syringes currently in use is The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through such that it is possible to inadvertently cause patient harm through
connecting the wrong syringes and tubing and then delivering connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The medication or fluids through an unintended wrong route. The
recommendations address the need for meticulous attention to recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients route of administration), and when connecting devices to patients
(i.e., using the right connection/tubing). (i.e., using the right connection/tubing).
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nalOne of the biggest global concerns is the spread of Human
Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles.
The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and
other health care workers regarding infection control principles; education of patients and families regarding transmission of blood
borne pathogens; and safe needle disposal practices.
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opyr
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, Joi
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omm
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on In
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atio
nalOne of the biggest global concerns is the spread of Human
Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles.
The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and
other health care workers regarding infection control principles; education of patients and families regarding transmission of blood
borne pathogens; and safe needle disposal practices.
72
© C
opyr
ight
, Joi
nt C
omm
issi
on In
tern
atio
nal
Next Set of Solutions
Preventing Central Line Infections Communicating Critical Test Results Recognizing and Responding to
Deteriorating Patients Preventing Pressure Ulcers Preventing Harm from Patient Falls
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Next Set of Solutions (cont’d) Prototype will target four audiences: 1. Government policy at ministry of health level2. Health care organization at the CEO level3. Clinician/provider levels
4. Patient and family level
