JCAHO also will be looking for a hard copy of verbal orders for laboratory test­ing, per state and federal guidelines.

to be written in its entirety and then readback verbatim. Consideration should begiven to not accepting chemotherapymedications as a verbal order. It may bepmdent to have a second person listen

GOAL 3Improve the safety of usinghigh-alert medications

Since the first Sentinel Event Alert,one death resulting from accidental

GOAL IImprove the accuracy of iden­tification:

This patient safety goal is imponantin the proper identification of patientsreceiving blood or blood products. Hereare suggestions for proper identificationof patients receiving blood producl"

Do's and Don'ts for Patient­Blood Product Identification:

• Do match the patient's name andaccount/medical record number (0

the blood product documentation.• Do consider using a blood bank­

specific identification system thatassigns unique identification num­bers to patients, requisitions, speci­mens, and blood products. This willhelp ensure that the compatibilityspecimen is tmceable to the bloodproduct being administered.

• Do have at least two individualscheck the information on the bloodproduct against the documentationto ensure accurdCY.

• Don't use the patient'S room numberor bed number as an identifier.

• Don't ask a colleague to verify thatit is Patient Z's blood.

• Do ask the colleague to match theblood with Patient Z's name andunique identifier.

What to DoWrite the purpose of themedication (that is the diag­nosis or the indication foruse) on the prescription onthe same patientDevelop a policy for takingverbal or telephone orders

Provide generic and brandname on all medication labels

Provide patients with writteninformation about theirdrugs, including the brandand generic names

when accepting telephone orders formedications. JCAHO makes the follow­ing suggestions to lower the risk oferrors resulting from misinterpreted ver­bal orders for medication:

Rationale• Minimizes the risk of confusion resulting fromlook alike medications e.g., Losec and Lasix• Pharmacist can screen the medication for theproper dose. duration. and appropriateness todiagnosis and will minimize duplicate orders

• Allows for safe and appropriate labeling of allmedications, and minimizes opportUnity for error• Ensures consistency between the documentsand helps to prevent misinterpretation of orders.• Providing written information allows the indi­vidual printed material for other healthcareproviders to check and verify.• Always discuss the medication and use withthe individual.

injection of Potassium Chloride (KCL)has been reponed. Medications areincluded in a High-Alen MedicationList with risk factors and planning dis­cussed,

Common Risk Factors and Proaetive Planning Tipsfor High-Alert Medications

GOAL 2Effective communication andthe importance of a "readback" of telephone or verbalorders for medications:

In facilities ulat allow verbal orders ortelephone orders, although discoumgedas much as possible, there should be asystem of checks and balances to ensureulat verbal orders for medications areconfirmed and correct. JCAHO statesthat consistency of practice should beensured 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 andheparin vials being kept inclose proximity to each otheron nursing units• "U" used as an abbreviationfor "units" in orders (can beconfused with "0," leading to aIQ-fold overdose)• Incorrect rates programmedinto an infusion pump

Proactive Planning• Establish a check system inwhich one nurse prepares thedose and another nurse reviewsit• Do not store insulin and hep­arin near each other.• Spell out "units" rather thanabbreviate it.• Establish an independentcheck system for infusion pumprates and concentration settings.

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Spr ng 2003 .JVAD 47