New JCAHO Safety Goals as Standard of Care

Jennifer Kemmet Jordan, J.D., LL.M. Candidate

Most of us are familiar with the power and influence wielded by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) within the healthcare field today.   Now, in an effort to further protect patient safety, the JCAHO has approved and implemented its 2003 National Patient Safety Goals.  These goals are derived directly from a pool of past sentinel events issued in Sentinel Event Alert recommendations, but unlike the recommendations, these new Safety Goals are not just recommendations, and compliance is mandatory as of January 1, 2003.  Failure to comply with the goals via direct implementation of the applicable recommendations (or via submission, acceptance, and implementation of an acceptable alternative) will result in a special Type I recommendation which, if not corrected within a maximum of two months, will result in a decision of Conditional Accreditation.  The following is a summary of the list of National Patient Safety Goals for 2003 which are described in more depth and with the complete recommendations on the JCAHO website at

1. Accurate patient identification improvement by using two patient identifiers when taking blood or administering medication or blood products, and a final verification process using active communication techniques prior to any surgical or invasive procedure.

2. Effective communication improvement among caregivers, including verification of verbal orders and standardized use of abbreviations, acronyms, and symbols used throughout the organization.

3. Improvement in the safety of using high-alert medications including the removal of concentrated electrolytes from patient care units and standardization and limitation of drug concentrations available in the organization.

4. Elimination of wrong-site, wrong-patient, wrong-procedure surgery by creation of a preoperative verification process and actual marking of the surgical site involving the patient.

5. Improved safety in the use of infusion pumps ensuring free-flow protection on all general use and patient controlled pumps in the organization.

6. Improved effectiveness of clinical alarm systems by implementing regular testing of the alarms to ensure they work and can actually be heard at the distance needed to alert a caregiver in the unit.

In order to ensure effective focus on the priority of patient safety, the JCAHO will establish no more than six new goals for any given year, and each goal will include no more than two “succinct, evidence- or expert-based recommendations” in the words of the JCAHO.  Each year new goals will be announced in July and implementation will be mandatory beginning January 1, of the following year.  The Safety Goals along with their recommendations, any acceptable alternatives, and cumulative compliance rates are published on the JCAHO website to maintain the highest level of accessibility to health care organizations, ensuring compliance and overall patient safety.

Keeping all of this in mind, by publishing these mandatory Safety Goals for all to see it is not difficult to envision how these Safety Goals could quickly become nice, succinct examples of standards of care to be used in medical malpractice lawsuits.   In a recent Audio Conference offered by the American Society for Healthcare Risk Management (ASHRM), presenters Ronni P. Solomon, Esq. and Richard J. Crouteau, M.D., discuss how plaintiffs will attempt to use these New Safety Goals to inculpate a healthcare organization or provider as failing to meet the standard of care if the exact recommendations and safety procedures listed on the JCAHO website were not followed; and how defendants will attempt to exculpate the healthcare organization or provider by showing that the exact recommendations have been implemented by the organization or provider and were followed.

These new Safety Goals differ from other JCAHO recommendations or survey standards in their public accessibility and  wide online publication and the fact that they are mandatory in nature as opposed to simply being recommendations.  For these reasons, the new Safety Goals can easily be shown as demonstrating an effective national standard of care.  On the other hand, by labeling what are essentially “Safety Mandates” as “Safety Goals” the JCAHO has skirted the issue as to whether or not these goals actually represent a “National Standard of Care,” leaving the issue open to debate in our courts of law.  Therefore, regardless of which side you represent in the legal community, if you practice in the medical malpractice arena, it will be very important for you to familiarize yourself with the JCAHO National Patient Safety Goals each year.