2006 National Patient Safety Goals

1. 2006National Patient Safety Goals

2. The purpose of the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety.

3. The Requirements highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. • The Requirements focus on system-wide solutions, wherever possible.

4. Sentinel Event Alerts • Potassium chloride • Wrong site surgery • Suicide • Restraint deaths • Infant abductions • Transfusion errors • High alert medications • Op/post-op complications • Fatal falls • Infusion pumps • Proactive risk reduction • Home fires (O2 therapy) • Kernicterus • Look-alike, sound-alike drugs • Creutzfeldt-Jakob disease • Medical gas mix-ups • Needles & sharps injuries cont’d

5. Sentinel Event Alerts (cont’d) • Dangerous abbreviations • Ventilator-related events • Delays in treatment • Bed rail deaths & injuries • Nosocomial infections • Surgical fires • Perinatal death and injury • Anesthesia awareness • Patient controlled analgesia • Vincristine administration errors

6. Expected Response to Recommendationsin Sentinel Event Alert • All accredited health care organizations are expected to review each issue of Sentinel Event Alert • Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions or reasonable alternatives

7. National Patient Safety Goals • Goals and Requirements are guided by a panel of experts called the Sentinel EventAdvisory Group. • Each year, the Sentinel Event Advisory Group works with the Joint Commission to undertake a systematic review of the literature and available databases to identify potential new Goals and Requirements. • The Goals and their Requirements are published by mid-year.

8. The Sentinel EventAdvisory Group • Nationally recognized experts in patient safety • Systems engineers with practical knowledge of root cause analysis (RCA), failure mode and effects analysis, human factors engineering, etc. • Individuals with hands-on experience in health care organizations, representative of the types and sizes of organizations and the various patient populations • Experts in related fields such as pharmaceuticals, information technology, medical equipment, etc.

9. The Sentinel EventAdvisory Group • Annually recommends core and program-specific NPSGs for adoption by the Board of Commissioners • Reviews draft patient safety recommendations for potential publication in Sentinel Event Alert • Provides advice on the acceptability of alternative practices implemented by accredited organizations in lieu of the specific NPSG Requirements • Recommends topics for future consideration in Sentinel Event Alert

10. Joint Commission 2006 National Patient Safety Goals • Approved by the Joint Commission’s Board of Commissioners on May 20, 2005 • The Goals and Requirements are program-specific

11. Patient Identification Goal: Improve the accuracy of patient identification.

12. Patient Identification • Requirement: Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, Lab, LTC, OBS

13. Patient Identification • Requirement: Prior to the start of any invasive procedure, conduct a final verification process to confirm the correct patient, procedure, site, and availability of appropriate documents. This verification process uses active—not passive—communication techniques. Applies to: AL, DSC, HC, Lab, LTC

14. Improve Communication Goal: Improve the effectiveness of communication among caregivers.

15. Improve Communication • Requirement: For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result. Applies to: AMB, AL, BHC, CAH, DSC, HC Hosp, Lab, LTC, OBS

16. Improve Communication • Requirement: Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, Lab, LTC, OBS

17. Improve Communication • Requirement: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Applies to: AMB, BHC, CAH, DSC, HC, Hosp, Lab, OBS

18. Improve Communication • Requirement: All values defined as critical by the laboratory are reported to a responsible licensed caregiver within time frames established by the laboratory (defined in cooperation with nursing and medical staff). When the patient’s responsible licensed caregiver is not available within the time frames, there is a mechanism to report the critical information to an alternative responsible caregiver. Applies to: Lab

19. Improve Communication • Requirement: Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, Lab, LTC, OBS New for 2006

20. Medication Safety Goal: Improve the safety of using medications.

21. Medication Safety • Requirement: Standardize and limit the number of drug concentrations available in the organization. Applies to: AMB, BHC, CAH, DSC, HC, Hosp, LTC, OBS

22. MedicationSafety • Requirement: Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. Applies to: AMB, BHC, CAH, HC, Hosp, LTC, OBS

23. Medication Safety • Requirement: Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. Applies to: AMB, CAH, Hosp, OBS New for 2006

24. Wrong-Site Surgery Goal: Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

25. Wrong-Site Surgery • Requirement: Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. Applies to: DSC

26. Wrong-Site Surgery • Requirement: Implement a process to mark the surgical site and involve the patient in the marking process. Applies to: DSC

27. Clinical Alarm Systems Goal: Improve the effectiveness of clinical alarm systems.

28. Clinical Alarm Systems • Requirement: Implement regular preventive maintenance and testing of alarm systems. Applies to: DSC

29. Clinical Alarm Systems • Requirement: Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit. Applies to: DSC

30. Health Care-Associated Infections Goal: Reduce the risk of health care-associated infections.

31. Health Care-Associated Infections • Requirement: Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, Lab, LTC, OBS

32. Health Care-Associated Infections • Requirement: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, Lab, LTC, OBS

33. Reconcile Medications Goal: Accurately and completely reconcile medications across the continuum of care.

34. Reconcile Medications • Requirement: Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, LTC, OBS

35. Reconcile Medications • Requirement: A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. Applies to: AMB, AL, BHC, CAH, DSC, HC, Hosp, LTC, OBS

36. Reduce Falls Goal: Reduce the risk of patient harm resulting from falls.

37. Reduce Falls • Requirement: Implement a fall reduction program and evaluate the effectiveness of the program. Applies to: AL, CAH, DSC, HC, Hosp, LTC

38. Influenza and PneumococcalDisease Goal: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.

39. Influenza and Pneumococcal Disease • Requirement: Develop and implement a protocol for administration and documentation of the flu vaccine. Applies to: AL, DSC, LTC

40. Influenza and Pneumococcal Disease • Requirement: Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. Applies to: AL, DSC, LTC

41. Influenza and Pneumococcal Disease • Requirement: Develop and implement a protocol to identify new cases of influenza and to manage an outbreak. Applies to: AL, DSC, LTC

42. Surgical Fires Goal: Reduce the risk of surgical fires.

43. Surgical Fires • Requirement: Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen concentration under drapes. Applies to: AMB, OBS

44. Implementation of NPSGs Goal: Implementation of applicable National Patient Safety Goals and associated Requirements by components and practitioner sites.

45. Implementation of NPSGs • Requirement: Inform and encourage components and practitioner sites to implement the applicable National Patient Safety Goals and associated Requirements. Applies to: Networks

46. Involvement of Patients and Families Goal: Encourage the active involvement of patients and their families in the patient’s care as a patient safety strategy. New for 2006

47. Involvement of Patients and Families • Requirement: Define and communicate the means for patients to report concerns about safety and encourage them to do so. Applies to: AL, DSC, HC, Lab New for 2006

48. Pressure Ulcers Goal: Prevent health care-associated pressure ulcers (decubitus ulcers). New for 2006

49. Pressure Ulcers • Requirement: Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. Applies to: LTC New for 2006

50. Submitting Alternative Approaches • Alternatives much be at least as effective as the published Requirements in achieving the Goals and must be approved by the Sentinel Event Advisory Group. • Submit a “Request for Review of an Alternative Approach to a NPSG Requirement ” form found on www.jcaho.org