I’ve Been Thinking about the Joint Commission’s 2008 National Patient Safety Goals (NPSGs). Along with some favorite swear words.

April 12, 2007 | In: I've Been Thinking

I’ve been thinking . . . about the Joint Commission’s 2008 National Patient Safety Goals (NPSGs). Along with some favorite swear words.

Last year at The unSUMMIT on Bedside Barcode Technology in Practice, the esteemed Kenneth Barker received the Way-Paver Award—”honoring the exceptional contributions of individuals and institutions that have helped clear a path and pave the way for bar-code point of care (BPOC) in America’s hospitals.” After graciously accepting the award, the world-renowned pharmacy-practice sage got to the point with a handful of words. He simply noted that over his long career, he has always argued that you start with a study. “Well,” he added, “we have done enough study on bar-coding. It’s time to get ‘er done.”

The next morning I interviewed Dr. Barker at a packed breakfast meeting. I concluded the quick hour by borrowing the questions James Lipton asks at the end of each episode of Inside the Actors Studio. When I asked, “What is your favorite swear word?” Ken paused and said, “When I get mad, I whistle.”

This morning I learned how the Joint Commission’s coming 2008 NPSGs are shaping up. And I’m whistling.

I’ve learned that, once again, their first goal will be, “Improve the accuracy of patient identification.” No problem with what’s there. It’s what’s not there that’s causing me to purse my lips and exhale.

The Potential 2008 NPSGs had given me hope, as they added language that called for hospitals to investigate and initiate planning for the use of positive-ID technology. Adopting the potential goal would have, de facto, pressed hospitals to incorporate bar-code and/or RFID technology at the point of administering medications and blood products as well as collecting blood and specimen samples.

I’m upset because the technology language did not make the pass en route to the final goals.

I’m experiencing a touch of deja vu. Back in 2005, JCAHO proposed a goal that would have expressly required hospitals to implement BPOC by 2007. I registered my protest at the time—not over the initiative but over the timing. It seemed like too much too soon to me and I suggested 2010. Truth is, I may have been too cautious, as a follow-up HIMSS survey showed that 68 percent of the respondents thought that most hospitals could implement by the end of 2008!

Anyway, here’s what upsets me. For several years now, “improving patient identification” has been number one (not two or five) on JCAHO’s list. They say their safety goals “highlight problematic areas in health care and describe evidence and expert-based consensus to solutions to these problems.” Yet, for all their repeating of the number one goal, it seems to me that positive-patient identification is as problematic as ever.

If we have evidence that BPOC makes a dramatic improvement, then why is JCAHO pulling back a second time?

Nearly 15 percent of our nation’s hospitals have implemented BPOC and are experiencing dramatic reduction in medication errors. Hospital Corporation of America facilities across the country as well as Brigham and Women’s Hospital in Boston, have gathered strong evidence. Their research shows that BPOC improves the accuracy of patient identification. By the way, professionals from these organizations will present their findings at The unSUMMIT, May 9-11 in San Diego CA. You can be sure that I will forward these presentations on to the commission.

Meanwhile, I say we can’t wait for JCAHO to rule on the subject. It’s time to get ‘er done!

OK, I’m done whistling for a while.

Mark Neuenschwander


Copyright 2007 The Neuenschwander Company

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