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Joint Commission Posts Pre-Release of New 2009 Standards

The Joint Commission has recently posted pre-publication versions of the 2009 National Patient Safety Goals (NPSG) and the 2009 Hospital Accreditation Requirements which includes a new chapter entitled Transplant Safety. The new publications contain a number of new items that may affect a hospital’s current practices regarding tissue and implant handling.

One of the important changes contained in the 2009 NPSG standard is entitled Universal Protocol (UP.01.01.01), and it addresses the pre-procedure verification process commonly referred to as the “Time Out”. The second Element of Performance for UP.01.01.01, found on page 25, reads:

When the patient is in the pre-procedure area, immediately prior to moving the patient to the procedure room, a checklist (for example, paper, electronic, or other medium such as a wall-mounted white-board) is used to review and verify that the following items are available and accurately matched to the patient:

Relevant documentation (for example, history and physical, nursing assessment, and pre-anesthesia assessment).Accurately completed, and signed, procedure consent form.Correct diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly labeled.Any required blood products, implants, devices and /or special equipment for the procedure.”

Tissue TrackCore allows hospitals to easily meet the requirement to review and verify that any needed implants/tissues are available. The holding room or circulating RN can use Tissue TrackCore’s patented Log Activity screen to do a simple search of active inventory for the implants or tissues that are needed for the procedure.

For complete text of the 2009 NPSG standard for hospital programs, see the manual chapter link at

The 2009 Hospital Accreditation Requirements now include a new Transplantation Safety chapter. This chapter contains requirements relating to organ and tissue handling. Formerly part of the Provision of Care, Treatment and Services chapter, these requirements are now contained within a separate chapter. In addition to the numbering changes, there have been some minor changes made to the text. A separate Transplant Safety chapter will result in much greater scrutiny of a hospital’s program, policies, and procedures relating to transplants and implants. For the full text see the Chapter link in the Transplant Safety section at

Medical facility administrators should be sure to review the complete standards in detail, in order to be prepared for when the standards are formally released.

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