JCAHO’s first of seven national patient safety goals is: “to improve the accuracy of patient identification.” JCAHO has mandated that hospitals use at least two (2) patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products, taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. 

Harborview policy states that name and date of birth are to be used as the primary patient identifiers. Other acceptable identifiers are the patient’s medical record number (MRN), or social security number (you must match two). Example: MRN is the second identifier used for blood transfusion specimens and blood transfusion. Patients who cannot be positively identified by name are given a “DOE” full name and MRN. 

Birth dates as second identifiers might pose special issues with our immigrant populations. Names may seem similar and countries that do not recognize birth dates are all given a common birth date of January 1, and the year of their immigration to the United State. Using a third identifier in these cases will ensure the right patient.

In compliance with JCAHO’s second safety goal, “improve the effectiveness of communication among caregivers,” the DO NOT USE ABBREVIATIONS list was implemented at Harborview in January 2004. The following abbreviations have been commonly associated with misinterpretation and are unacceptable for use in orders and other forms of patient-specific clinical documentation.

Any documentation involving medications or ANY order containing an abbreviation with which the reader is unfamiliar must be clarified with the author of the order.

Dangerous Abbreviations – Avoid Using

 Harborview implemented a “hard stop” where orders will not be accepted if prohibited abbreviations are used, except in a life threatening situation. The ordering provider will need to rewrite the order.

A JCAHO safety goal is to eliminate wrong-site, wrong-patient, wrong-procedure surgery. Harborview has developed a “Universal Surgery/Procedure Protocol” (verification of patient, procedure, site, and team accountability). It is an administrative policy and procedure that:

Addresses any surgical or invasive procedure in the outpatient and inpatient setting.

Covers the OR, procedural, and bedside settings.

Requires verification of the patient’s identity, consent, and site marking. This includes a final “TIME OUT” check we call a “PPV” (pre-procedure verification), which includes:

• Correct patient
• Correct side and site (with marking of site)
• Agreement of procedure to be done
• Availability of implants, special equipment or other special requirements
• Correct positioning

The Operating Room has additional requirements to the "Time Out."

It exempts the site marking requirement in crash/emergent cases where the delay could cause potential harm to the patient.

It also exempts minor procedures, such as N/G placement and venipuncture.

Requires documentation that the PPV has been completed.

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