00033255-0001

Reducing the Risk of Errors Associatedwith Concentrated Electrolyte SolutionsHigh-Risk, High-Alert Drugs and Complying with

Standard MM.7.10

Undiluted potassium chloride (KCL) is used to execute death row prisoners.1 Inthe United States, 5 to 10 patients die every year when they are accidentally

injected with KCL.1 Although KCL is the most common electrolyte associated withmedication errors, potassium phosphateconcentrate and hypertonic (> 0.9%)saline can also be lethal if not adminis-tered appropriately.2 Reversing theeffects of improperly administered con-centrated electrolytes is frequently chal-lenging, and death is the typical patientoutcome.2 Fortunately, most catastroph-ic errors can be eliminated by adoptingsome simple precautionary measures.2

Standard MM.7.10* requires thatorganizations develop processes formanaging high-risk or high-alert med-ications. Elements of performance forMM.7.10 include the following:1. The organization identifies the high-

risk or high-alert medications usedwithin the organization, if any.

2. Based on the services provided, theorganization develops processes forprocuring, storing, ordering, transcribing, preparing, dispensing, administering,and/or monitoring high-risk or high-alert medications (see Sidebar 1, page 3, for adetailed description of these processes).

3. The processes for managing high-risk or high-alert medications are implemented.

http://www.jcrinc.com

The Joint Commission:

The SourceFor Joint Commission Compliance Strategies

TM

1. Reducing the Risk of Errors

Associated with Concentrated

Electrolyte SolutionsLearn about methods to comply withStandard MM.7.10 and risk-reductionstrategies for your medication management system.

4. ACCREDITATION ESSENTIALS:Medical Staff Communication:

Cornerstone of Care Coordination—

Standard MS.2.20Read about methods for complying withStandard MS.2.20 and the importance ofstructured communication techniques toconvey the proper information at the correct time to the correct people.

6. ACCREDITATION ESSENTIALS LINK:Maintaining Existing Privileges—

Standard MS.4.40Read about the importance of conductingobjective and fact-based evaluations foryour medical staff.

9. SPOTLIGHT ON SUCCESS:Seton Family of Hospitals Improves

Perinatal Care: Complying with the

Improving Organization Performance

Standards PI.3.10 and PI.3.20 in 20082007 Ernest A. Codman Award winnerSeton Family of Hospitals illustrate meth-ods and processes used to improve peri-natal care at their organization.

March 2008Volume 6 Issue 3

CONTENTS

High-alert drugs include investigational drugs,

controlled medications, drugs not approved by

the Food and Drug Administration, medications

with a narrow therapeutic range, psychothera-

peutic medications, and look-alike/sound-alike

medications. Organizations should make the

determination as to whether new medications to

the organization are high risk.

(Continued on page 2)

* Standard MM.7.10 applies to the following programs: ambulatory care, behavioral health

care, critical access hospitals, home care, hospitals, and long term care.

http://www.jcrinc.com2 The Joint Commission: The Source March 2008

High-risk or high-alert drugs, suchas concentrated electrolyte solutions,are those medications that have thehighest risk of causing injury whenmisused, or that carry a higher risk forabuse, errors, or other adverse out-comes. Lists of high-risk or high-alertdrugs are available from such organiza-tions as the Institute for SafeMedication Practices, and the UnitedStates Pharmacopeia, based on nationaldata about medication use. However,organizations need to develop theirown list of high-risk or high-alert drugsbased on their unique utilization pat-terns or drugs, and their own internaldata about medication errors and sen-tinel events. Examples of high-alertdrugs include investigational drugs,controlled medications, medicationsnot on the approved Food and DrugAdministration list, medications with anarrow therapeutic range, psychothera-peutic medications, and look-alike/sound-alike medications. Organizationsdetermine whether medications that arenew to the market or new to the organ-ization are high risk.

Risk-Reduction Strategies

The risk for error can occur during anyof the components of the medicationmanagement system. Potential risksand strategies to mitigate these risks arediscussed in detail on the followingpages.

Selection and ProcurementRisk Factors1,5:• Improperly adding KCL to intra-

venous (IV) solutions• Mistaking KCL for other medica-

tions such as saline, heparin, orfurosemide

Strategies for Risk Reduction3,5,6:• Use premixed solutions or commer-

cially outsourced admixtures, whenpossible.

• Standardize and limit the range ofKCL dilutions available.

• Purchase concentrated electrolyte solu-tions from different vendors, if possi-ble, to avoid packaging similarities.

• Inventory all concentrated elec-trolytes in the organization and per-form a failure mode and effectsanalysis. Evaluate the look-alikepotential of product containers.

StorageRisk Factors5:• Storing KCL on patient care units• Storing concentrated electrolytes in

close proximity to other drugs withsimilar packaging in the pharmacy

• Not having a pharmacy that operates24/7

Strategies for Risk Reduction2,3,5,6:• Ideally, remove concentrated elec-

trolyte solutions from all nursingunits; store in specialized pharmacypreparation areas.

• Label with a visible florescent warn-ing label that states MUST BEDILUTED.

• In the pharmacy, store bulk suppliesand immediate inventory of concen-trated electrolytes in an area segregat-

ed from other drugs, and distinctlyseparate by product type.

• Do not allow nurses to enter thepharmacy when it is closed. Keep astock of carefully selected after-hoursmedications, including premixedsmall- and large-volume KCL in asecured area, such as a controlled-access cabinet.

Ordering and TranscribingRisk Factors5:• Availability of multiple concentra-

tions of the same drug• Illegible handwriting• Incomplete orders• Use of the term bolus, which is mistak-

en to mean that the dose should begiven by IV push, using a syringe

Strategies for Risk Reduction2,5,6:• Prescribe potassium solutions for

intravenous administration in thoseconcentrations that are available ascommercially prepared ready-to-usediluted solutions.

• Include the rate of infusion in allorders.

• Use preprinted order forms.• Standardize terminology for prescrib-

ing; the term bolus should not beused in reference to KCL.

• Program alerts into computer sys-tems to warn of excessive doses or ofthe need for dose adjustment as indi-cated by laboratory results.

Preparation and DispensingRisk Factors5:• Solutions being prepared by

untrained staff• Human error• Vials being dispensed to hospital units

The Joint Commission: The SourceTM

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Contributing Writers: Ruth Carol, Julie Henry,Kathleen Vega

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Reducing the Risk of Errors Associated

with Concentrated Electrolyte Solutions

Continued from page 1


Strategies for Risk Reduction2,3,5,6:• If there is a need for a potassium

solution in a dilution that is notcommercially prepared in ready-to-use diluted form, prepare the solu-tion in the pharmacy.

• Label the prepared solution with aHIGH-RISK WARNING label priorto administration.

• Require a pharmacist to perform afinal, independent check of all prod-ucts used for IV admixtures of elec-trolyte solutions.

• Vials should not be dispensed forindividual patients. The pharmacyshould dispense premixed solutionsor prepare patient-specific admix-tures as needed. Although some hos-pitals may make an exception for thecardiac bypass surgical suite, manyhospitals have been able to eliminatevials in all areas by providing phar-macy-prepared mini-bags of selectedconcentrations.

AdministrationRisk Factors5:• Diluted KCL being infused too

rapidly• Undiluted KCL being administered

intravenously• Concentrated electrolyte solutions

administered to the wrong patientStrategies for Risk Reduction2,6:• Use an infusion pump to administer

potassium riders.• Require an independent double

check for correct product, dosage,method of delivery, dilution, andpatient prior to IV administration ofconcentrated electrolyte solutions.

MonitoringRisk Factors:• No adjustment in orders based on

new laboratory results• No policy for repeat laboratory stud-

ies and electrolyte monitoringStrategies for Risk Reduction5:• Monitor patients’ electrolytes before,

during, and after replacement thera-

py; perform electrocardiograph asindicated.

• Establish a standard protocol for fre-quency of laboratory studies and mon-itoring of electrolyte levels. The Source

References1. American Health Consultants: Medication

errors: Keep close tabs on your KCL (potassi-um chloride). Hosp Peer Rev 23:101–102,Jun. 1998.

2. Joint Commission International Center forPatient Safety: Control of ConcentratedElectrolyte Solutions. WHO CollaboratingCentre for Patient Safety Solutions.http://www.jcipatientsafety.org/24725/(accessed Dec. 20, 2007).

3. Institute for Safe Medication Practices:Potassium May No Longer Be Stocked onPatient Care Units, but Serious Threats StillExist! http://www.ismp.org/newsletters/acutecare/articles/20071004.asp?ptr=y(accessed Dec. 30, 2007).

4. Joint Commission Resources: UnderstandingMedication Management in Your Health CareOrganization. Joint Commission onAccreditation of Healthcare Organizations,Oakbrook Terrace, IL, 2006.

5. American Pharmacists Association (AphA):Medication Errors. Washington DC: APhA2007.

6. National Patient Safety Agency: Patient safe-ty alert on the prevention of accidental over-dose with intravenous potassium, Jul. 2002.

The Joint Commission: The Source March 2008 3

• Selection: Safe and appropriate selection of medica-

tions available for use in the organization

• Procurement: The task of obtaining selected medica-

tions that are not available from the organization’s own

pharmacy from a source outside the organization

• Storage: Maintaining a supply of medications on the

organization’s premises. Storage includes medications

stored in the pharmacy, as well as all other locations on

the premises, and addresses safety, stability, availability,

and security of medications.

• Ordering/Prescribing: Synonymous terms for when an

authorized person transmits a legal order or prescription

that directs the preparing, dispensing, and/or administer-

ing of a specific medication to a specific patient.

Ordering and prescribing do not include requisitions to

order stock supplies.

• Transcribing: A process in which a person other than

the prescriber may rewrite or retype the order

• Distribution: Providing, furnishing, or otherwise making

available a supply of medications to the health care

provider

• Preparation: The compounding, manipulation, or other

activity needed to get a medication ready for administra-

tion as ordered

• Dispensing: Providing, furnishing, or otherwise making

available a supply of medication to the patient for whom

it is ordered according to a prescription or medication

order. Dispensing does not include providing an individ-

ual with a dose of medication previously dispensed by a

pharmacy.

• Administration: The provision of a prescribed and pre-

pared dose of an identified medication to the individual

for whom it was ordered. This includes directly introduc-

ing the medication into or onto the individual’s body or

providing the medication to the individual, who intro-

duces the medication into or onto his or her own body.

• Monitoring: The evaluation of a patient throughout the

continuum of care, to ascertain the effectiveness and

efficacy of the medication and to prevent the occurrence

of any serious adverse outcomes. The perceptions of the

patient should be considered during monitoring.

Sidebar 1. Components of the Medication Management SystemUniversal processes essential to the medication management system include the following:


The management and coordinationof patient care, treatment, and

services calls for practitioners with theappropriate privileges to collaborate.Effective communication is an under-pinning of their coordination effortsthat are essential to the safe manage-ment of patient care, treatment, andservices.

Health care organizations that usestructured communication techniquesto address the content, timing, andpurpose of communication can assistpractitioners in conveying the properinformation at the correct time to thecorrect people.

Many of these techniques can beused in clinical arenas throughout theorganization or health care setting.

SBAR

The Situation–Background–Assessment–Recommendation (SBAR) technique isuseful for framing a brief and conciseconversation, particularly one that isemergent in nature. SBAR sets expecta-tions for what will be communicatedamong team members and how. Thisapproach also promotes critical thinkingbecause the clinician initiating the com-munication knows to provide the physi-cian not only with an assessment of thepatient’s situation, but a recommenda-tion for how to handle it.

SBAR stands for the following1:1. Situation—What is going on with

the patient?2. Background—What is the clinical

background or context?3. Assessment—What do I think the

problem is? 4. Recommendation—What would I

do to correct it?

Situational Awareness

Situational awareness involves an ongo-ing dialogue between team members tomaintain awareness of the current situ-ation, typically a procedure or processthat is under way. This strategy keepsall the practitioners in agreement withregard to recognizing potential problemareas and planning how to addressthem, should they occur. This tech-nique also helps clinicians act in aneffective manner by thinking ahead todiscuss and plan contingencies.

Red flags that signal a loss of situa-tional awareness are as follows2:• Ambiguity• Reduced/poor communication• Confusion• Trying something new under pressure• Deviating from established norms• Verbal violence• Doesn’t feel right• Fixation• Boredom• Task saturation• Being rushed/behind schedule

Call Out

Using this technique, practitioners “callout” each phase of a process as theybegin it, letting other team membersknow that it is okay to proceed. Thephases are called aloud, particularly dur-ing rapidly-changing situations. In theoperating room (OR), for example, thisstrategy is typically used at two points:the start of a procedure, and the closing.But it can also be used at other pivotalmoments, such as acknowledging thecorrect sponge count, or in anticipationof the next step in the process, such asthe patient is coming off bypass. Whenusing this technique, clinicians shouldspeak clearly and loudly.

Briefings

These short discussions between teammembers get all the practitioners at thesame starting point, thus promoting asense of collaboration among thehealth care team and helping avoid sur-prises. During briefings, clinicianscompare notes, identify what they wantto accomplish, identify resources to doso, and anticipate obstacles. It could bedone at the beginning of the shift or atany point in any clinical care situation,such as the beginning of a surgery.

When conducting briefings, practi-tioners should include the followingsteps2:• Get the person’s attention.• Make eye contact, face the person.• Introduce yourself.• Use the individual’s name.• Ask knowable information.• Explicitly ask for input.• Provide information.• Talk about next steps.• Encourage ongoing monitoring and

cross-checking.Similarly, the Neonatal Intensive

Care Quality Improvement Collabora-tive 2002—a collaborative of five terti-ary perinatal centers designed toimprove collaboration, communica-tion, and coordination between mater-nal and neonatal caregivers—developedthe following steps to improve commu-nication during delivery room crises3:• Get the person’s attention.• Express your concern.• State the problem.• Recommend action.• Achieve a decision.• Make eye contact.• Listen to understand.• Repeat back what the person says.• Call people by their first name.

ACCREDITATION ESSENTIALS

Medical Staff Communication: Cornerstone of Care Coordination—Standard MS.2.20


In the Institute for HealthcareImprovement’s version of briefings,known as huddles, the care team assem-bles at a predetermined time each day toexamine the schedule and anticipate theneeds of the patients coming in thatday.4 Team members can discuss whichpatients on the schedule are unlikely toshow up for their appointments, eitherbecause they’ve been hospitalized, can-celled their appointments, or were in theprevious week; what equipment will benecessary; and what additional servicescan be provided at the appointment tominimize a recurring visit. Lessonslearned from huddles are recorded andreviewed at weekly team meetings.

After implementing a briefingsproject in the OR at Orange CountyKaiser, wrong-site surgeries, which hasbeen a problem, became nonexistent.1

The OR was perceived as having anoutstanding environment with regardto safety and teamwork. Nursingturnover was reduced by 16%, with80% of the OR nurses indicating thatthey were comfortable speaking up andfelt that their input was valued.

Debriefing

This technique allows a team to betterprepare for the next encounter andavoid repeating the same mistakes.After a procedure is completed or atthe end of the day, practitioners assessprocesses the team did well, challengesthey faced, lessons learned, and whatwould be done differently the nexttime the opportunity presented itself.The more specific the debriefing, themore beneficial it could be.

MDRs

A multidisciplinary round (MDR) is apatient-focused communication systemintegrating care delivered by multipleproviders using concurrent feedback,redundancy, and rapid cycle improve-ment. The fundamental goal of MDRis to enhance communication and

coordination among providers at thebedside. The Berkshire Medical Centerused MDR to coordinate care andensure adherence to evidence-basedguidelines, specifically the AmericanHeart Association’s Get with theGuidelines Program, for all of itsnon–intensive care unit medicalpatients. Use of the MDR rapidlyimproved adherence to the guidelines,resulting in a 44.4% decrease in acutemyocardial infarction (AMI) mortality,a 34.5% decrease in stroke mortality,and a 33.9% decrease in heart failuremortality.5

Moreover, this MDR model hasbeen replicated in several other organi-zations through the Northeast. Whilelarge organizations can apply MDR onindividual units to groups of 30 to 60patients, smaller ones can apply it totheir entire inpatient population.5

Similarly, implementation of a resi-dent-centered MDR at the NorwalkHospital was associated with a signifi-cant improvement in quality coremeasure performance in targeted areasof congestive heart failure from 65% to76%, AMI from 89% to 96%, pneu-monia from 27% to 70%, and all com-bined from 59% to 78%.6 Residentsreported substantial improvement incore measure knowledge, systems-basedcare, and communication.

Multidisciplinary Team Meetings

Multidisciplinary teams benefit fromconcentrated time together to plan theirroles and responsibilities, as well as todiscuss opportunities for improvementin their work. Planned team meetings,scheduled weekly or monthly, are themost effective tool for accomplishing


Standard MS.2.20The management and coordination of each patient’s care, treatment, and servic-

es is the responsibility of a practitioner with appropriate privileges.

Rationale

Quality of care, treatment, and services is dependent upon coordination and

communication of the plan of care and is given to all relevant health care

providers to optimize resources and provide for patient safety. Practitioners have

privileges that correspond to the care, treatment, and services needed by individ-

ual patients. Communication and coordination are keys to the safe management

of patient care, treatment, and services. Communication among all practitioners

and staff involved in a patient’s care, treatment, and services is vital to ensuring

coordinated, high-quality care.

Elements of Performance

1. Licensed independent practitioners with appropriate privileges manage and

coordinate a patient’s care, treatment, and services.

2. A patient’s general medical condition is managed and coordinated by a

physician.

3. The organized medical staff, through its designated mechanism, determines

the circumstances under which consultation or management by a physician

or other licensed independent practitioner is required.

4. Consultation is obtained for the circumstances defined by the organized

medical staff.

5. There is coordination of the care, treatment, and services among the

practitioners involved in a patient’s care, treatment, and services.



The ongoing professional evaluationof physicians and licensed inde-

pendent practitioners is the primarymethod hospitals use to ensure thattheir clinicians have the necessary skills,knowledge, and attitudes to providequality patient care.

To that end, organizations shouldhave in place clearly defined processesto facilitate such evaluations. Theseprocesses are important, as ongoingprofessional practice evaluation is fac-tored into the decision to maintain,revise, or revoke a clinician’s existingprivileges (see Figure 1, page 8).

In the past, practitioner assess-ments were conducted every two yearsas part of the reprivileging process.However, many organizations havenow adopted a more proactive and sys-tematic approach by scheduling quar-terly departmental reviews.1

Who Performs the Evaluation?

In some hospitals, each department hasits own quality or peer review commit-tee. At Tulsa, Oklahoma–based SaintFrancis Hospital, each of the 17 depart-ments has its own Peer Evaluation andPatient Safety Committee, which per-forms its own evaluations.2 For thesmaller departments, chart reviews areconducted after department meetings.Consequently, the whole department is,in essence, the review committee. Largerdepartments appoint from 5 to 10physicians to serve on the committee.

Individuals involved in this processshould be trained in how to conductobjective and fact-based evaluations, aswell as in using the appropriate scoringmethodologies and other reporting tools.

Other organizations choose to haveone medical staff oversight committee,which is chaired by the medical directoror another medical staff leader. Leadersfrom each major department comprisethe oversight committee that mayinclude nonphysician members such asthe vice president of operations or thenursing services director. In this scenario,if the committee finds practice trendsthat require further review, it typicallyrefers them to the appropriate depart-ment for a more in-depth investigation.

If conflicts of interest exist or theorganization lacks staff members withsufficient subject-matter expertise, anexternal peer-review organization can behired, or the organization can develop acollaborative arrangement with anotherlocal hospital to perform evaluations.

Criteria for Evaluation

The medical staff must choose andclearly define the information neededto make the determination that a prac-titioner does indeed provide safe, effec-tive, and appropriate patient care.

Criteria used in the ongoing pro-fessional practice evaluation mayinclude the following:• Review of operative and other clini-

cal procedure(s)* performed andtheir outcomes

• Pattern of blood and pharmaceuticalusage

• Requests for tests and procedures• Length-of-stay patterns• Morbidity and mortality data• Practitioner’s use of consultants

At the Emory Clinic, part ofEmory Healthcare System in Atlanta,physicians use a performance assess-

ment form to evaluate their peers on anongoing basis. The form covers the fol-lowing performance elements2:• Medical record keeping• Outpatient care• Inpatient care• Clinical safety• Support of the organization• Resource management• Performance improvement• Interpersonal skills• Communication skills• Abusive behavior

Case ReviewsThe medical staff should establish cri-teria for selecting case reviews, whichare commonly used in evaluations. Forexample, case reviews can look at singleincidents, evidence of a clinical practicetrend, or both. This process should beused consistently across disciplines. Inaddition, a minimum case reviewrequirement, such as 10%, should beestablished and applied uniformlyacross all departments.

At Saint Francis Hospital, criteriafor case reviews include clinical perti-nence, medical record timeliness, andlegibility.2 Although indicators used forreview are determined by each depart-ment, they all measure return to theemergency room within 72 hours,return to the intensive care unit, orlength of stay greater than three daysfollowing a vaginal delivery.

It is imperative that the medical staffdetermine red flags to indicate when fur-ther investigation is necessary. Withoutthese, the committee lacks direction onthe appropriate action to take. If the cri-terion is an unexpected death, the redflag may be the lack of documentationof the patient’s deterioration during 48hours preceding death, or the event maybe related to a surgical procedure.

ACCREDITATION ESSENTIALS LINK

Maintaining Existing Privileges—Standard MS.4.40

* These include operative and other invasive and noninvasive procedures that place the patient

at risk.


Aggregated DataAggregated performance measurementdata, such as those set forth by The JointCommission and the Centers forMedicare & Medicaid Services, areanother source commonly used in theseevaluations. These include adverseevents, sentinel events, significant depar-tures from generally accepted standardsof practice, significant complicationsresulting either from a treatment or pro-cedure, or procedures performed on thewrong patient or body site.

The medical staff may opt to usecompliance with the safe practices rec-ommended by the Joint Commission’sNational Patient Safety Goals. It mayconsider looking at how well the prac-titioner complies with the currentCenters for Disease Control andPrevention or World HealthOrganization hand hygiene guidelines;whether he or she accurately and com-pletely reconciles medications acrossthe continuum of care; or if the clini-cian uses the list of approved abbrevia-tions, acronyms, symbols, and dosedesignations for medications.

Other relevant performance mea-surement data may be derived fromactivities that address infection control,risk management, and utilization review.Many associations, such as the Societyfor Thoracic Surgery, maintain registrieswith large databases of performancemeasurement projects that can begleaned for data.

Discipline-Specific DataKeep in mind that some of these datamay not be applicable to each andevery clinician because they may coverspecific conditions that not all physi-cians treat. Consequently, additionaldiscipline-specific performance datamay have to be incorporated into thecriteria. The rate of physician compli-ance with surgical care improvementproject criteria, surgical injuries,unplanned procedures not noted in the patient’s consent, wrong-site surgeries, and the incidence of postop-erative deep vein thrombosis, are someexamples of criteria that can be used inthe surgery department. The medicalstaff may focus on events that are

unique to particular patient popula-tions or interventions.

Even if each department identifiesdiscipline-specific criteria, it can look tothe same measures being used through-out the organization. These may includemortality rates, complication rates, med-ication errors, health care–associatedinfection rates, and readmission rates.

Other CriteriaIn addition to case reviews and aggregat-ed performance measurement data, themedical staff often use peer recommen-dations that come about through directobservation or discussions with otherindividuals involved in patient care,including consulting physicians, nurses,physician assistants, and administrativepersonnel.

Additional information may bederived from the assessment of a practitioner’s interpersonal skills or professional behavior. In this case,patient/family complaints may be con-sidered. Employing a tool such as the


Standard MS.4.40Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise

existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

Elements of Performance

The process for the ongoing professional practice evaluation includes the following:

1. There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice

2. The type of data to be collected is determined by individual departments and approved by the organized medical staff

3. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or

revoke any existing privilege(s)


The intent of Standard MS.4.40 is for organizations to look at data on performance of practitioners with privileges in

an ongoing manner rather than at the two year appointment process. This allows the practitioner to take the necessary

steps to improve performance on a timely basis. The frequency of the evaluation can be defined by the organized

medical staff, for example, every three months, six months, or nine months. Note: Every twelve months would be periodic rather than ongoing.

It is important to remember that zero data is in fact data. Zero data can be measured as evidence-based good

performance and is acceptable, for example, no infections, no complications, or no complaints. It is not acceptable to

find that a practitioner has not performed a privilege for two years at the two year appointment process.


Communication Assessment Tool, a 15-item instrument thathas proven to be reliable and valid for measuring patient per-ceptions of a physician’s interpersonal and communicationskills,3 can help keep the assessment objective.

Many medical specialty societies offer guidance on appro-priate discipline-specific knowledge and skill levels for clini-cians. For example, the American College of Surgeons defined afive-level model for verifying and documenting surgeons’ partic-ipation in educational programs and the surgeon’s knowledgeand skills, including demonstration of satisfactory patient out-comes.4 The American College of Cardiology Foundation, theAmerican Heart Association, and the American College ofPhysicians Task Force on Clinical Competence and Trainingdeveloped recommendations intended to assist in assessing thecompetence of cardiovascular health care providers in practiceand undergoing periodic review.5 The recommendations suggestthat physicians perform a minimum of 50 examinations a yearto maintain their expertise, plus 30 hours of continuing medicaleducation over three years.

InterventionThe medical staff should delineate the course of action to betaken when an evaluation reveals a question about the practi-

tioner’s professional performance. The medical staff shouldfollow that course of action, which should be defined in thebylaws. The clinician whose performance is being reviewedshould be allowed to participate in the process as deemedappropriate by the medical staff.

When the review committee at Saint Francis Hospitalfinds a deviation from the acceptable standard of care, thephysician is contacted for input before it makes a final deter-mination. The Source

References1. Understanding Focused and Ongoing Professional Practice Evaluations.

AllMed Healthcare Management. http://www.allmedmed.com/resources/articles/practice_evaluations.html. (accessed Dec. 14, 2007).

2. Joint Commission Resources: Credentialing and Privileging Your MedicalStaff: Examples for Improving Compliance. Oakbrook Terrace, IL: JointCommission on Accreditation of Healthcare Organizations, 2007.

3. Makoul G., Krupat E., Change C.H.: Measuring patient view of physi-cian communication skills: Development and testing of the communica-tion assessment tool. Patient Education and Counseling 67:333–342,2007.

4. Sachdeva A.K., Russell T.R.: Safe introduction of new procedures andemerging technologies in surgery: Education, credentialing, and privileg-ing. Surg Clin N Am 87:853–866, 2007.

5. American College of Cardiology Foundation/American HeartAssociation: 2007 Clinical Competence Statement on Vascular Imagingwith Computed Tomography and Magnetic Resonance. Circulation116:1318–1335, 2007. http://circ.ahajournals.org (accessed Dec. 14,2007).

Accreditation Essential Link: Maintaining Existing Privileges—Standard MS.4.40


Figure 1. Other Factors to Consider—Ongoing Professional Practice EvaluationDoes the organization have or plan to have the resources necessary to support the privilege?

(Standard MS.4.00 Prior to granting of a privilege, the resources necessary to support the requested privilege are

determined to be currently available, or available within a specified time frame.)

Has the credential verification process established that the applicant has the licensure, training, education, and abili-

ty to perform the privilege?

(Standard MS.4.20 The organized medical staff reviews and analyzes all relevant information regarding each

requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the

requested privilege.)

Does focused professional practice evaluation validate competence?

(Standard MS.4.30 The organized medical staff defines the circumstances requiring monitoring and evaluation of a

practitioner’s professional performance.)

Does data collected through the ongoing professional practice evaluation validate competency?

(Standard MS.4.40)


For nearly 10 years, organizationsacross the country have been work-

ing diligently to reduce preventablemedical errors and improve the safetyand quality of care they provide. Onesuch organization is AscensionHealth—a large, Catholic, nonprofithealth system with a network of morethan 75 acute care, long term care, andother health care facilities in 20 statesand the District of Columbia. In 2003Ascension set a goal for its entire sys-tem to eliminate preventable patientdeaths by 2008 across all populations.To achieve this goal, the organizationneeded to implement a culture shiftand transform the care provided in itsfacilities.

A first step to achieving this goalwas to identify seven high-risk, high-vol-ume diagnostic categories and patientcare areas in which preventable patient

deaths were more likely to occur. Byeliminating preventable deaths in theseareas, Ascension believed it could achievesignificant progress in meeting its ulti-mate goal. Ascension charged several ofits organizations to serve as alpha sitesfor improvement, encouraging them todevelop transformational practices thatcould eliminate patient harm and pre-vent death within one or more of theseven areas. The Seton Family ofHospitals, a health care network in theAscension system, was asked to serve(along with two other Ascension min-istries) as an alpha site for the high-riskarea of perinatal safety.

As a first step to improving perina-tal safety and eliminating preventablebirth trauma, Seton formed an interdis-ciplinary work team, called thePerinatal Safety (PNS) team. Thisgroup had representation from all four

of Seton’s hospitals that providedobstetrical services. Made up of a vari-ety of disciplines, including medicalstaff, nursing staff, and organizationleadership, the goal of this team was tospearhead the perinatal safety initiativeand champion change efforts.

Focusing on Evidence-Based

Practices

With the help of the Institute forHealthcare Improvement (IHI), the PNSteam researched and investigated evi-dence-based practices regarding perinatalsafety and preventable birth trauma.“Unfortunately, when we started, wecould not find any preexisting changepackage of best practices in the obstetri-cal area for us to work from,” says FrankMazza, M.D., vice president of medicalaffairs at Seton Medical Center, thelargest of Seton Family of Hospitals. “Insome cases, when established best prac-tices didn’t exist, the PNS team neededto develop best practices via consensuswith all relevant stakeholders, test thebest practices on a small scale, and thenimplement the ones that were effectivein driving improvement on a broaderbasis.” Seton used the Plan-Do-Study-Act model of rapid cycle change to testand implement both evidence-based andconsensus-based practices.

To focus its efforts, Seton reviewedliterature and determined the five areas


SPOTLIGHT ON SUCCESS

Seton Family of Hospitals Improves Perinatal CareComplying with the Improving Organization Performance Standards PI.3.10 and

PI.3.20 in 2008

(Reducing the possibility of a bad outcome is important to improving safety and performance. One important factor in improvingperformance requires effective reduction of components that could contribute to adverse events and/or outcomes. Unanticipated adverseevents and/or outcomes are sometimes experienced through poorly designed systems, system failures, or errors. Through organizationalleadership implementation and collaborative plan efforts, complying with The Joint Commission’s Improving OrganizationPerformance standards (PI.3.10 and PI.3.20) can prove to be effective in achieving your organization’s goals and initiatives. Here’show Seton Family of Hospitals became a 2007 Ernest Amory Codman Award winner by using performance improvement methods.)

Organization Facts: Seton Family of Hospitals is a nine-hospital health sys-

tem headquartered in Austin, Texas. As part of the Ascension Health system,

Seton Family of Hospitals has more than 10,000 employees, and services 11

counties with a population of 1.7 million people throughout central Texas.

Program Description: Seton Family of Hospitals engaged in an initiative to

improve perinatal safety and eliminate preventable birth trauma within its facil-

ities. The organization implemented evidence-based and consensus-based

practices, and used small tests of change to improve performance and elimi-

nate preventable errors.

Outcomes: As of 2006, the organization reduced the rate of preventable birth

trauma by 93%. As a result of the initiative, the organization also reduced the

number of admissions to the neonatal intensive care unit and patient length of

stay. (Continued on page 10)


of highest risk for obstetrical harm. “Wezeroed in on these areas, feeling that ifwe could eliminate preventable trauma,we would be well on our way to achiev-ing our ultimate goal,” says Mazza.Following are the five critical areas:• Failure to recognize fetal

distress/nonreassuring fetal status• Failure to effect a timely caesarean

(C-section) birth• Failure to properly resuscitate a

depressed baby• Inappropriate use of oxytocin/

misoprostol• Inappropriate use of vacuum/forceps

“For each of these five areas, weapplied evidence-based practice where itexisted, and developed consensus-basedapproaches where evidence-based prac-tices were not available,” says Mazza. “Indesigning new processes, we followed theprinciples of standardization, simplifica-tion, and built-in redundancy.”Following are some of the many inter-ventions the organization implemented: • Adopted the National Institute of

Child Health and HumanDevelopment’s common language fornurses and physicians to use in thelabor and delivery setting when dis-cussing fetal heart rate monitoring.

• Conducted interdisciplinary confer-ences in which nurses and physiciansanalyzed fetal heart rate strips. “Inthe context of the labor and deliveryunit, where the frequency of seriousadverse events is low but risk tomother and infant is high, we foundthat interdisciplinary fetal heartmonitor strip review sessions offeredrealistic, risk-free environments toexamine practices and reinforce skillsthat develop and promote teamworkand communication,” says Mazza.

• Created a customized Situation–Background–Assessment–Recommen-dation communication tool to help

nurses and physicians communicate inthe labor and delivery unit. This toolhelps structure communication andensures that the appropriate informa-tion is consistently and accuratelyshared every time communicationtakes place.

• Developed, in conjunction with theother Ascension alpha sites and theIHI, a consensus-based practiceregarding the use of the high-risk drugoxytocin, which is used to induce oraugment labor. The elements of thispractice included performing and doc-umenting the following:– Reassuring fetal status– Examination of the cervix within

one hour before or after start ofoxytocin

– Absence or active management ofuterine hyperstimulation withincreases in oxytocin

– Documentation of gestational age >39 weeks, or estimated fetal weight,depending on whether oxytocin wasused to electively induce a patient oraugment contractions

• Eliminated the practice of electivelyinducing labor prior to 39 weeks ges-tation. “Oftentimes a patient is elec-tively induced early because it is moreconvenient for the physician or themother. The physician may be leavingtown, or the mother may want tocoordinate the delivery with plans thather family has made to help supportthe new baby,” says Mazza. “However,based on our literature review, as wellas our own internal data, we believedthat electively inducing a patient priorto 39 weeks could lead to an increasedrisk of birth trauma and injury. Byeliminating this practice, we hoped toeffect a reduction in our birth traumarate.”

• Implemented evidence-based prac-tices regarding the use of vacuum

devices and forceps during the sec-ond stage of labor. These practicesrestricted when vacuum tools andforceps could be used and requiredphysicians to document the follow-ing in the medical record:– The indications for instrumental

delivery– The estimated fetal weight relative

to the size of the maternal pelvis– The presentation and station of

the fetal head• Empowered bedside and scheduling

staff to “stop the line” when deviationsfrom best practice were encountered.“For example, if a physician calls toschedule an induction, and the patientis only 38½ weeks along, the sched-uler is empowered to say ‘no’ to thephysician. The physician can feel freeto move up the chain of command,but the answer will still be no,” saysMazza.

Measuring Success

As Seton developed and implementedits transformational practices, theorganization created both process andoutcome measures to monitor changeand measure success. Process measuresdetermine whether processes and pro-cedures are being followed, such aswhether physicians are refraining fromelective inductions prior to 39 weeks,or whether instrumented delivery-associated best practices are followed.

Spotlight on Success: Seton Family of Hospitals Improves Perinatal Care



these types of activities that are essential to quality patient care.4

One hospital found that the implementation of multidis-ciplinary team meetings yielded improved communicationand enhanced quality of care. For starters, it allowed for prac-titioners from various disciplines to develop a common lan-guage used verbally and in written reports. When a mutuallyagreed upon terminology was used, it enhanced communica-tion between the disciplines.7 In addition, as medical technol-ogy continues to advance, the choice of investigation and theinterpretation of results are more complex. Thus, the meet-ings served as a venue for practitioners to update each otherregarding technology and continuing professional develop-ment. Such interactions added quality to the diagnosis, dis-ease staging, and patient management decisions.

Medical Emergency Teams

This multidisciplinary team is designed to respond to staffconcerns about a patient’s health. When a patient experiencesa change in status, staff calls the medical emergency team(MET) to check the patient and take the necessary action.

Typically the MET is activated if the patient experiencesan acute change in heart rate, blood pressure, respiratory rate,pulse oximetry saturation despite oxygen administration,conscious state, or urine output.

Structured communication techniques have been provento promote effective communication, which enhances patient

safety by preventing the loss of crucial medical informationand promoting the sharing of relevant information at the cor-rect time in the most efficient manner. Best of all, these tech-niques work in all types of health care organizations, particu-larly those that have embraced a multidisciplinary approachto patient care. The Source

References1. Leonard M., Graham S., Bonacum D.: The human factor: The critical

importance of effective teamwork and communication in providing safecare. Qual Saf Health Care 13 (Suppl 1):185–90, 2004.

2. Leonard, M.: The Human Factor: Teamwork and Communication inPatient Safety. http://www.mihealthandsafety.org/2004_conference/Leonardslides.ppt (accessed Jan. 4, 2008).

3. Ohlinger J., et al.: Evaluation and development of potentially betterpractices for perinatal and neonatal communication and collaboration.Pediatrics 118:S147–S152, 2006. http://www.pediatrics.org/cgi/content/full/118/Supplement_2/S147 (accessed Jan. 1, 2008).

4. Institute for Healthcare Improvement: Use Regular Huddles and StaffMeetings to Plan Production and to Optimize Team Communication.http://www.ihi.org/IHI/Topics/OfficePractices/Access/Changes/IndividualChanges/UseR GET REST (accessed Dec. 19, 2007).

5. Ellrodt G., et al.: Multidisciplinary Rounds (MDR): An implementationsystem for sustained improvement in the American Heart Association’sGet with the Guidelines Program. Critical Pathways in Cardiology6(3):106–116, 2007.

6. O’Mahony S., et al.: Use of multidisciplinary rounds to simultaneouslyimprove quality outcomes, enhance resident education, and shortenlength of stay. J Gen Intern Med 22(8):1073–1079, 2007.

7. Kane B., et al.: Multidisciplinary team meetings and their impact onworkflow in radiology and pathology departments. BMC Medicine.5:15, 2007. http://www.biomedcentral.com/1741-7015/5/15 (accessedJan. 4, 2008).


Accreditation Essentials: Medical Staff Communication: Cornerstone of Care Coordination—Standard MS.2.20


Outcome measures examine the actualoutcomes of processes, such as the inci-dence of premature births associatedwith electively induced labor and theincidence of birth trauma associatedwith the use of vacuum/forceps. Theultimate outcome measure that Setonexamined was the number of birthtraumas that occurred per 1,000 births.

Lessons Learned

In implementing this initiative, Setonlearned that effective performanceimprovement results from interdiscipli-nary collaboration. “Because multiplespecialties—nurses, doctors, adminis-trators, and so forth—work in thesame space, any performance improve-

ment must involve input and commit-ment from all these areas,” says Mazza.

The organization also realized thevalue of using data to drive perfor-mance improvement. “Like any organi-zation, we received some push backfrom staff and physicians about imple-menting many of our new processes.By sharing improvement data with staffand physicians, it helped show thevalue of the improvements, and gotmore people on board,” says Mazza.

Achieving Success

Seton Family of Hospitals has achieveddramatic improvements in perinatalcare. Over the course of the program,Seton reduced its birth trauma rate by

93%, from 0.3% in 2001 (a numberthat already represented half the nation-al average) to 0.02% in 2006. Over thepast four quarters, the birth trauma ratehas dropped to zero. The organizationhas also reduced its use of vacuum andforceps, reducing its instrumental delivery rate from 7.4% to 4.7%, andeliminated elective inductions prior to39 weeks. Seton also decreased prema-turity rates from 0.25% to 0.16%. Theorganization achieved this transforma-tion in care as a result of continualenhancements to care managementaccomplished through repeated smalltests of change, and the use of evidence-based and consensus-driven obstetricalpractices. The Source


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Volume 6, Issue 3, March 2008

Send address corrections to:The Joint Commission: The Source™Superior Fulfillment131 W. First St.Duluth, MN 55802-2065800/746-6578

Call for ApplicantsJohn M. Eisenberg Patient Safety and Quality Awards

through a specific initiative or project,have made an important contribution topatient safety and health care quality.The awards program provides an oppor-tunity for individuals and/or organiza-tions to receive national recognition fortheir ongoing contributions to patientsafety and quality of care.

This memorial awards program was cre-ated jointly by NQF and The JointCommission and named for John M.Eisenberg, director of the Agency forHealthcare Research and Quality and amember of the founding Board ofDirectors of NQF. It honors the endur-ing contributions of this impassionedadvocate of health care quality improve-ment, who passed away in March 2002.

Awards are available annually in thefollowing categories:• Individual Achievement• Innovation in Patient Safety and

Quality—National• Innovation in Patient Safety and

Quality—Local• Research

The awards will be presented in con-junction with NQF’s Annual Nat-ional Policy Conference on Qualityin Washington, D.C., on October15–16, 2008. Additional informa-tion about the award and the awardapplication form are available onThe Joint Commission Web site(http://www.jointcommission.org)and the NQF Web site (http://www.qualityforum.org).

On February 1, 2008, The JointCommission and The NationalQuality Forum (NQF) beganaccepting applications for the JohnM. Eisenberg Patient Safety andQuality Awards for 2008.

The John M. Eisenberg PatientSafety and Quality Awards recognizethe achievements of individuals whohave made significant and lastingcontributions to improving patientsafety and health care quality andindividuals and organizations who,

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