JCAHO Issues National Alert About Infection-Related Deaths; Encourages Greater Reporting

OAKBROOK TERRACE, Ill. -- The nation's leading advocate for healthcare quality and safety today called for greater reporting of the deaths of patients who contract fatal infections while being treated for other illnesses or injuries.

The bulletin issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) advises that the deaths of patients from hospital-acquired infections are being seriously underreported across America. The Sentinel Event Alert, sent to nearly 17,000 JCAHO-accredited healthcare facilities, also urges compliance with new guidelines from the Centers for Disease Control and Prevention that advise health care professionals to use alcohol-based handrubs--in conjunction with traditional soap and water and sterile gloves -- to prevent these acquired infections.

The CDC estimates that more than 2 million patients annually develop infections while hospitalized for other health problems and that nearly 90,000 die as a result of these infections. Despite these high figures, the Joint Commission's 7-year-old patient safety reporting database includes only 10 such reports that cover 53 patients.

"We are receiving a disproportionately low volume of reports on the number of patient deaths from infections acquired in the healthcare setting, possibly because many health care organizations do not view these events as `errors' under the definition of a sentinel event," says Dennis S. O'Leary, M.D., president of JCAHO. "However, in view of the importance and high visibility of such occurrences, we are urging healthcare organizations to share this information with the Joint Commission, just as they might share information about other types of sentinel events with us."

Because of the nature of these events, the Joint Commission believes it is likely that healthcare facilities will have already conducted the related in-depth analyses required as part of the accreditation standards. Increased reporting will lead to greater understanding of the factors that lead to their occurrence and effective strategies for prevention, according to the JCAHO alert.

Meanwhile, the Joint Commission is intensifying its attention to infection control practices as part of its continuing on-site surveillance of accredited organizations. The Joint Commission is also convening a new infection control expert panel to suggest ways in which current JCAHO standards can be strengthened.

The new warning about infections acquired in healthcare settings is the latest in a series of patient safety alerts issued by the Joint Commission. Previous alerts have focused on wrong-site surgery, deadly medication mix-ups, patient suicides, infant abductions and fatal falls among the elderly, among others.

Making patient safety its top priority, JCAHO maintains one of the nation's most comprehensive voluntary reporting systems for healthcare errors. The current database includes detailed information about the causes of serious adverse events, and has enabled the Joint Commission both to warn health care facilities about potential risks and to identify strategies for preventing these tragedies. The complete list and text of

past issues of Sentinel Event Alert can be found on JCAHO's Web site at www.jcaho.org.

Source: JCAHO