Washington state hospital keeps survey 'uneventful'

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Color coding cuts down unapproved abbreviations

Often, simple steps help hospitals perform better on Joint Commission surveys. For Valley General Hospital in Monroe, WA, it was a matter of color coding pharmacy medications, eliminating unapproved abbreviations at the source, and distributing educational newsletters to staff members.

In October 2007, the then 72-bed hospital underwent its Joint Commission (formerly JCAHO) survey. The survey lasted the usual four days and involved two surveyors (an RN and a social worker) for Valley General's chemical dependency unit. According to Quinn Hatala, RN, BSN, manager of clinical quality and patient safety at Valley General, the survey was "uneventful."

Valley General's Joint Commission surveyors focused on the National Patient Safety Goals (NPSG) and used patient tracers as a main tool to assess compliance, common practice for the accrediting body. They found a few habits that could be refined, but in general, found many of Valley General's practices and policies in compliance.

Hatala says the surveyors could find no unapproved abbreviations in her entire facility. Valley General's policy requires any unapproved abbreviations to be addressed at the pharmacy. If one is found-usually written by a physician new to the hospital-the pharmacy calls the physician to discuss and correct the order, says Hatala.

"[The pharmacy] calls the doctors specifically to talk to them about the order, and right then and there get a patient order . . . If [unapproved abbreviations] come up, they're immediately corrected, and the physician gets immediate education on the abbreviation," says Hatala. "That is our policy, and it's quite effective."


Another pharmacy practice, created after the Joint Commission surveyor alerted the hospital to a possible look-alike/soundalike danger, also helps the hospital crack down on medication compliance. Although frontline staff members use a laminated sheet that lists both unapproved abbreviations and look-alike/soundalike drugs on the front of every chart, possible problems elsewhere in the hospital concerned the surveyor.

"Where we fell down was in our pharmacy," says Brenda Rogers, RN, BS, associate administrator of clinical services and chief nursing executive of Valley General. "We did not have a really clear visual definition [of the medications], so we changed the way we labeled the medication in the pharmacy and did some color coding to correct that."

Now, Valley General's pharmacy labels look-alike/soundalike medications with bright yellow labels and larger fonts and high-alert medications with red labels to ensure that pharmacists are especially careful when reading these medications.

Like at many other hospitals, time-outs were also a concern. Although Valley General documented and performed time-outs methodically, its documentation didn't indicate when the time-outs occurred.

"[The surveyor] said some hospitals conduct multiple time-outs and she doesn't care if you're doing one or three," says Hatala. "[The Joint Commission] wants to see that one is done immediately prior to the first incision."

Valley General staff members are now aware that they need to write the time on surgery documentation.

Changes in policies and procedures are only part of a survey process, says Hatala. Staff education can be just as important, especially when surveyors perform patient tracers.

"The staff received a weekly newsletter throughout what we anticipated to be our survey year, and that raised the level of awareness and reinforced their existing knowledge," says Hatala. "It really paid off well because during the survey, staff knew what to expect from the surveyor and could articulate our processes very well to the surveyors."