MCN Healthcare: Policy Management and Compliance Tools

The Joint Commission (TJC) has released an implementation guide for National Patient Safety Goal 07.05.01 on surgical site infections (SSI).  The guide is based on the results of TJC's SSI Change Project.

NPSG 07.05.01 requires accredited organizations to implement evidence-based practices for preventing surgical site infections.  According to the Institute for Healthcare Improvement SSI's are a significant health concern and represent a large portion of healthcare-associated infections.  Many SSI's are preventable.  TJC's Implementation Guide for NPSG.07.0.01 includes 23 specific, effective practices to help prevent and reduce SSIs.

The information in the Guide is being provided free of charge by TJC to hospitals and is available by following the link below.

Included with today's notice are a selection of example policies and procedures that address SSI prevention strategies.

The Joint Commission (TJC) has published an article about common myths surrounding the sentinel event reporting process.  A sentinel event is "...an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof."  These types of events are called "sentinel" because they signal a need for immediate response and investigation.

Every Joint Commission manual has a section with standards that outline requirements for the management of sentinel events.  For hospitals the requirements are, generally:

• Identify all sentinel events
• Appropriately respond to the event including timely investigation and root cause analysis
• Monitoring any changes put in place in response to the sentinel to ensure they are effective

Key points from TJC's new article include:

• The sentinel event reporting process is voluntary and non-punitive
• Unanticipated deaths are considered reviewable events
• Joint Commission and state reporting requirements are separate
• The need for a "for cause" survey following a sentinel event is determined by the severity if the incident and the systemic risk to patients
• Hospitals should have a sentinel event policy in place

Included with today's notice is an example sentinel event policy and procedure.

Sandoz US is conducting a voluntary nationwide recall to the hospital/user level of two lots of its Methotrexate Sodium, USP, 25 mg/mL, 40 mL vial injectable product in the US, due to the discovery of particulate matter in vials during routine quality examination of retention samples at the manufacturer. Parenteral injection of drug from the affected lots can lead to microembolisation in areas where the particles lodge. Clinical symptoms are not to be expected from these microemboli and Sandoz is not aware of any reports of related adverse events.

Methotrexate is an antimetabolite used in the treatment of neoplastic diseases, severe psoriasis, and rheumatoid arthritis, including polyarticular juvenile rheumatoid arthritis. The lot numbers and expiration dates of the two recalled lots are: CL0996 (expiration date 12/2013) and CJ4948 (expiration date 05/2013). These lots were distributed nationally across the US and to a single foreign country (Poland).

In the event that a patient experiences an adverse reaction or quality problem involving this product, they should immediately contact their healthcare professional as well as Sandoz to report the finding. The Sandoz Drug Information Direct Line is open at 800-525-2492, 24 hours/day, seven days a week, or reports can be made via email at qa.druginfo@sandoz.com.

Read the MedWatch alert, including a link to the Recall Notice, at the link below.