Folks,
My wife just received this as part of the communciations she is privy to in
the American Dietetic Association. This contains good news and bad news!
It's quite long, so I'm forwarding only a portion of the message --- the
salient portions. No need to ask for the complete message from me.
I have not yet investigated the links. Please be assured that I plan to submit
some formal correspondance on this matter. I invite you folks to do the same,
as always keeping the comments temperate in tone and professional in
approach.
Jim
[begin quoted and abridged material]
....
Subject: JCAHO "Do Not Use" List: Abbreviations, Acronyms and Symbols
Date: Fri, 21 Nov 2003 14:11:58 -0700
....
November 21, 2003
TO: ADA Members
FROM: ....
RE: JCAHO "Do Not Use" List: Abbreviations, Acronyms and Symbols
Medical errors have been identified as the fourth most common cause of
patient deaths in the United States. To help reduce the numbers of
errors related to incorrect use of terminology, the Joint Commission on
Accreditation of Healthcare Organizations recently issued a list of
abbreviations, acronyms and symbols that should no longer be used. The
action supports one of JCAHO's national patient safety goals: to improve
the effectiveness of communications among caregivers.
Between 44,000 and 96,000 deaths each year may be attributed to medical
errors, spawning efforts throughout the healthcare system to
systematically address the issues and better protect patient safety.
JCAHO's national patient safety goals are one example. This
communication shares the information with you as dietetics professionals
to take action to help reduce medical errors.
National Patient Safety Goals
JCAHO's effort to further protect patient safety and address this health
care issue is embodied in the approval and implementation of seven
National Patient Safety Goals (NPSGs). These goals are not accreditation
standards -- they are prescriptive accreditation requirements. In
summary, they are:
1. Improve the accuracy of patient identification.
2. Improve the effectiveness of communication among caregivers.
3. Improve the safety of using high-alert medications.
4. Eliminate wrong-site, wrong-patient and wrong-procedure surgery.
5. Improve the safety of using infusion pumps.
6. Improve the effectiveness of clinical alarm systems.
7. Reduce the risk of health care-acquired infections.
The National Patient Safety Goals along with their recommendations are
published on the JCAHO Web site to maintain the highest level of
accessibility to health care organizations, ensuring compliance and
overall patient safety. The complete recommendations also can be found
on the JCAHO Web site at
www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_npsg.htm
<http://www.jcaho.org/accredited%2Borganizations/patient%2Bsafety/04%2Bnpsg/0
4_npsg.htm>.
....
In January 2004, as JCAHO conducts its facility surveys, it will check
to see that any terms on the "list of dangerous abbreviations are not
found in handwritten clinical documentation." Organizations found not to
be in compliance will be required to submit a plan for continued
improvement.
By April 1, 2004, additional terms will be identified and eliminated
from use. By the end of 2004, JCAHO expects full compliance in all
handwritten, print and electronic media documents related to these
dangerous abbreviations.
A "minimum list" of dangerous abbreviations, acronyms and symbols
Beginning January 1, 2004, the following items must be included on
each accredited organization's "Do not use" list:
[to be read in five columns, I think --- Jim F.]
Set
Item
Abbreviation
Potential Problem
Preferred Term
....
6.
Trailing zero
(X.0 mg),
Lack of leading zero (.X mg)
Decimal point is missed
Never write a zero by itself after a decimal point (X mg), and always
use a zero before a decimal point (0.X mg)
....
[end columnar material --- Jim F.]
In addition to the "minimum required list"
The following items should also be considered when expanding the "Do not
use" list to include the additional three or more items referenced in
the [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]>
Abbreviation Potential Problem Preferred Term
�g
(for microgram) Mistaken for mg (milligrams) resulting in one
thousand-fold dosing overdose Write "mcg"
....
c.c.
(for cubic centimeter) Mistaken for U (units) when poorly written. Write
"ml" for milliliters
....
JCAHO has created a set of Frequently Asked Questions (FAQs) that
explain the new requirements in greater detail. Visit
www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm
<http://www.jcaho.org/accredited%2Borganizations/patient%2Bsafety/04%2Bnpsg/0
4_faqs.htm>.
In addition, the Institute for Safe Medication Practices (ISMP) has
published a list of dangerous abbreviations relating to medication use
that it recommends should be explicitly prohibited. It is available on
the ISMP Web site: www.ismp.org <http://www.ismp.org>.
Additional background information on medical errors:
The problem of medical errors has been highlighted over the years,
including by Dr. Lucian Leape and most recently in a report from the
U.S. Institute of Medicine. In its 2000 report "To Err is Human," IOM
defined an error as the failure of a planned action to be completed as
intended -- that is, an error of execution; or the use of a wrong plan
to achieve an aim -- that is, an error of planning.
IOM found that latent errors or system failures pose the greatest threat
to safety in a complex system because they lead to operator errors.
These failures are built into the system and present long before an
error occurs. They may be difficult for the people working in the system
to identify since they often are hidden in computers or layers of
management and because people become accustomed to working around the
problem.
Discovering and fixing latent failures and decreasing their duration are
likely to have a greater effect on building safer systems than efforts
to minimize errors at the point at which they occur.
[end quoted and abridged material]
--
James R. Frysinger
Lifetime Certified Advanced Metrication Specialist
Senior Member, IEEE
http://www.cofc.edu/~frysingj
[EMAIL PROTECTED]
[EMAIL PROTECTED]
Office:
Physics Lab Manager, Lecturer
Dept. of Physics and Astronomy
University/College of Charleston
66 George Street
Charleston, SC 29424
843.953.7644 (phone)
843.953.4824 (FAX)
Home:
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Charleston, SC 29407
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