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JCAHO also will be looking for a hard copy of verbal orders for laboratory test- ing, per state and federal guidelines. to be written in its entirety and then read back verbatim. Consideration should be given to not accepting chemotherapy medications as a verbal order. It may be pmdent to have a second person listen GOAL 3 Improve the safety of using high-alert medications Since the first Sentinel Event Alert, one death resulting from accidental GOAL I Improve the accuracy of iden- tification: This patient safety goal is imponant in the proper identification of patients receiving blood or blood products. Here are suggestions for proper identification of patients receiving blood producl" Do's and Don'ts for Patient- Blood Product Identification: • Do match the patient's name and account/medical record number (0 the blood product documentation. • Do consider using a blood bank- specific identification system that assigns unique identification num- bers to patients, requisitions, speci- mens, and blood products. This will help ensure that the compatibility specimen is tmceable to the blood product being administered. • Do have at least two individuals check the information on the blood product against the documentation to ensure accurdCY. • Don't use the patient'S room number or bed number as an identifier. • Don't ask a colleague to verify that it is Patient Z's blood. • Do ask the colleague to match the blood with Patient Z's name and unique identifier. What to Do Write the purpose of the medication (that is the diag- nosis or the indication for use) on the prescription on the same patient Develop a policy for taking verbal or telephone orders Provide generic and brand name on all medication labels Provide patients with written information about their drugs, including the brand and generic names when accepting telephone orders for medications. JCAHO makes the follow- ing suggestions to lower the risk of errors resulting from misinterpreted ver- bal orders for medication: Rationale • Minimizes the risk of confusion resulting from look alike medications e.g., Losec and Lasix • Pharmacist can screen the medication for the proper dose. duration. and appropriateness to diagnosis and will minimize duplicate orders • Allows for safe and appropriate labeling of all medications, and minimizes opportUnity for error • Ensures consistency between the documents and helps to prevent misinterpretation of orders. • Providing written information allows the indi- vidual printed material for other healthcare providers to check and verify. • Always discuss the medication and use with the individual. injection of Potassium Chloride (KCL) has been reponed. Medications are included in a High-Alen Medication List with risk factors and planning dis- cussed, Common Risk Factors and Proaetive Planning Tips for High-Alert Medications GOAL 2 Effective communication and the importance of a "read back" of telephone or verbal orders for medications: In facilities ulat allow verbal orders or telephone orders, although discoumged as much as possible, there should be a system of checks and balances to ensure ulat verbal orders for medications are confirmed and correct. JCAHO states that consistency of practice should be ensured through policy and procedure. TI,e process should allow for the order I. Insulin Common Risk Factors • No dose-check systems • Mix.ups due to insulin and heparin vials being kept in close proximity to each other on nursing units • "U" used as an abbreviation for "units" in orders (can be confused with "0," leading to a IQ-fold overdose) • Incorrect rates programmed into an infusion pump Proactive Planning • Establish a check system in which one nurse prepares the dose and another nurse reviews it • Do not store insulin and hep- arin near each other. • Spell out "units" rather than abbreviate it. • Establish an independent check system for infusion pump rates and concentration settings. .' Spr ng 2003 .JVAD 47
