Joint Commission Perspectives on Patient Safety™ gives readers “how to” information on analyzing and preventing errors, emphasizing a proactive approach to prevention, in addition to providing strategies for reacting to adverse events.

To access your current online Patient Safety subscription, click here.

Current Issue
Volume 8, Issue 12 | December 2008

The Physicians Role in Medication Reconciliation
Medication reconciliation is a key component of patient safety. Equally important is winning physician involvement in the process. To help prevent medication errors associated with inadequate medication reconciliation, National Patient Safety Goal 8 requires health care organizations to accurately and completely reconcile medications across the continuum of care. Physicians play a key role in medication reconciliation and it is the prescriber’s ultimate responsibility to know what medication the patient is taking when writing new medication orders

Patient Safety Pulse
Your Patient Safety News

Part I. Providing Safe and Beneficial Enteral Feeding:
Correctly confirming placement of the feeding tube
For patients who cannot eat normally (usually due to swallowing issues or artificial airways), there is an option to provide enteral feedings via a tube inserted through their nose or mouth which descends to their stomach or small intestine. Enteral feedings provide vital nutrition in a way that preserves the integrity of the gastrointestinal (GI) system and has fewer infectious complications than parental nutrition through an intravenous line. However, there are risks involved with enteral feedings and health care providers need to ensure that this method of feeding is safe and beneficial to patients.

Learning From Never Events
One hospital’s reaction to a wrong-site surgery
Transparency. It’s a word that’s being used more and more by health care providers and administrators. Beth Israel Deaconess Medical Center (BIDMC) in Boston set a standard of transparency in the health care field when it openly discussed a wrong-site surgery that took place at the hospital both internally and externally. This article provides an in-depth look at the ways in which one organization responded to a wrong-site surgery event and took action to prevent recurrence of such events.

Joint Commission Perspectives on Patient Safety gives readers “how to” information on analyzing and preventing errors in patient care. While this newsletter emphasizes prevention (a proactive approach), it also addresses the real-world issues of reacting to adverse events.

In addition, Patient Safety:

• Teaches health care organizations how to analyze and prevent errors; provides the tools and information necessary to help organizations create and implement a culture of safety
• Links standards compliance and the survey process to establishing proactive risk reduction and error prevention activities
• Explains how organizations can use the root cause analysis process and failure mode and effects analysis to improve their processes and prevent errors and
• Presents case studies, examples, forms, and tools for organizations to adapt for their own risk reduction and error prevention activities. New features address the medication process, FMEA, and discipline-specific information about patient safety. Perspectives on Patient Safety is also available online! Receive each issue right on your computer with a few clicks of your mouse. By signing up for online access, you get
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Senior Editor: Jim Parker
Project Manager: Bridget Chambers
Manager, Publications: Paul Reis
Executive Director, Publications: Catherine Chopp Hinckley, Ph.D.
Vice President, Learning: Charles Macfarlane, F.A.C.H.E.
Joint Commission Perspectives on Patient Safety Editorial Advisory Board is listed here [need link].

Editorial Policy
Reference to a name, organization, product, or service in Joint Commission Perspectives on Patient Safety should not be construed as an endorsement by the Joint Commission nor is failure to include a name, organization, product, or service to be construed as disapproval.

Subscription Information
Joint Commission Perspectives on Patient Safety™ (ISSN 1534-5181) is published monthly (12 issues per year) by Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.

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©2009 by Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Resources, Inc (JCR), a not-for-profit affiliate of the Joint Commission, has been designated by the Joint Commission to publish publications and multimedia products. JCR reproduces and distributes the materials under license from the Joint Commission.

No part of this publication may be reproduced or transmitted in any form or by any reasons without written permission.

FAQs
How can I order Perspectives on Patient Safety?
To order Perspectives on Patient Safety, call Superior Fulfillment at 800/746-6578, or click here to order online.

Can I place my order through a subscription agent?
Yes, we welcome orders through agencies. Agents, click here for pricing and other information.

Who within my organization should subscribe to Perspectives on Patient Safety?
This newsletter is intended for performance improvement and risk management professionals in all accredited health care settings, as well as nurse managers, medical staff leaders, pharmacy leaders, and consultants for all accredited health care settings.

What topics does Perspectives on Patient Safety cover?
Please read About Patient Safety above

How often does Perspectives on Patient Safety publish?
Perspectives on Patient Safety is published 12 times a year by Joint Commission Resources.

How much content is archived online?
Archives date to the first published issue in May 2001. You can access the archives here.

Who has access to the online newsletter?
Only paid subscribers have access to the archives.

How can I get a sample issue?
Call Superior Fulfillment at 800/746-6578 to request a free sample of the latest issue of Perspectives on Patient Safety. Or view a free sample issue online here.

How can I purchase a past issue?
Call Superior Fulfillment at 800/746-6578 to order a past issue of Perspectives on Patient Safety or click here to purchase past issues or articles via IngentaConnect.

Can I make copies of an issue or an article?
Yes, with permission. Please be aware that a fee might apply under certain circumstances.

Can I submit articles?
Yes. The Author Guidelines are as follows:

Contact the Perspectives on Patient Safety editor (630/792-5459 or patientsafety@jcrinc.com) ahead of time about your article and to get specific directions, if needed.

Please submit articles that describe your own organization’s noteworthy performance measurement activities. Your experiences can be a significant resource to other Perspectives on Patient Safety readers. A panel of Joint Commission experts on standards and accreditation issues will review each article that is considered suitable for publication. Notification of the editorial decision usually will be provided within one month. Authors should be available to answer the editor’s questions and approve edited copy.

Write your article in an informal, first-person style directly addressing our readers (I-we/you-your). Briefly describe your organization (location, number of beds, types of patients, etc.), note any specific Joint Commission requirements this project or experience addresses, and let us know about any graphics (figures, tables) you could provide. Tips and "lessons learned" summaries make effective, helpful conclusions. Articles should be between 650 and 1,200 words, including any accompanying tables or charts. Please submit your article in a file format compatible with Word 6.0 to patientsafety@jcrinc.com or on CD-ROM (please fax any graphics that cannot be transmitted to us electronically and provide camera-ready copy, if available).

Send all articles to
Jim Parker, Senior Editor
Department of Publications
Joint Commission Resources
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
patientsafety@jcrinc.com

How can I find past articles on a specific topic?
Click here to view past issues and topics.

Can my organization be featured as a case study in Perspectives on Patient Safety?
Yes; if your organization has done an exemplary job in promoting safety and preventing errors, and you’d like to share your story with other organizations, please contact Perspectives on Patient Safety at patientsafety@jcrinc.com.

Editorial Advisory Board
Joint Commission Perspectives on Patient Safety Editorial Advisory Board (in alphabetical order)

Peter B. Angood, M.D., F.R.C.S.(C.), F.A.C.S., F.C.C.M
Vice President and Chief Patient Safety Officer, The Joint Commission

Bonnie M. Barnard, M.P.H., C.I.C.
Quality Specialist, St. Peter’s Hospital, Helena, Montana

Diane D. Cousins, R.Ph.
Vice President, Center for the Advancement of Patient
Safety, United States Pharmacopeia

Laura Botwinick
Vice President for Innovation and New Product Development, Joint Commission Resources

Hedy Cohen, R.N., M.S.
Vice President, Institute for Safe Medication Practices

Kathy Connolly, R.N., M.S.Ed., C.P.H.R.M.
Assistant Vice President
Risk Management, Premier Insurance Management Services, Inc.
Nilda Conrad, M.B.A., C.P.M.S.M., C.P.C.S.
Asst. Vice President, Med-Surg & Prof. Affrs., North General Hospital, New York, and President, National Association of Medical Staff Services

David Fuller
Senior Space Systems and Operations Engineer and Associate Fellow of the American Institute of Aeronautics and Astronautics

Suzanne Graham, R.N., Ph.D.
Director of Patient Safety, California Regions, Kaiser Permanente

Robert S. Lagasse, M.D.
Diplomate, American Board of Anesthesiologists, Professor and Vice Chairman, Department of Anesthesiology, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, New York, and Member, American Society of Anesthesiologists

Jeannell M. Mansur, R.Ph., Pharm.D., F.A.S.H.P.
Practice Leader, Medication Safety Joint Commission Resources

David Marx
Senior Registrar in Pediatrics, Head of Paediatric Gastroenterology Team, Dept. of Pediatrics and Adolescent Medicine University Hospital, Czech Republic

Deborah Nadzam, Ph.D., R.N., F.A.A.N.
Practice Leader, Patient Safety, Joint Commission Resources

Rita Shane, Pharm.D., F.A.S.H.P.
Director, Pharmacy Services and Assistant Dean, Clinical Pharmacy, UCSF School of Pharmacy, Cedars-Sinai Medical Center, Los Angeles

Paula Spears, D.N.Sc., R.N.
Corporate Director, Professional Practice and Advancement, Methodist Le Bonheur Healthcare, Memphis, Tennessee

Sherry Umhoefer, R.Ph., M.B.A.
Vice President, Quality and Compliance, McKesson Medication Management

Contact the editor

About Content
For questions regarding the content of Perspectives on Patient Safety, please contact:

Jim Parker, Senior Editor
Joint Commission Resources
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
630/792-5459
630/792-4459 (fax)
patientsafety@jcrinc.com

About Standards Interpretation
If you have questions regarding interpretation or clarification of The Joint Commission standards, please contact The Joint Commission's Standards Interpretation Group (SIG) by calling 630/792-5900.

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