Transcript JOINT COMMISSION’S

JOINT COMMISSION’S
National Patient Safety Goals for 2008
PURPOSE

Promotes specific improvements in
patient safety

Highlights problematic areas in health
care

Describes evidence and expert-based
consensus to solutions to these problems
LIST OF 2008 NPSGs

Goal 1_Improve the accuracy of [patient] identification

Goal 2_Improve the effectiveness of communication among caregivers

Goal 3_Improve the safety of using medications

Goals 4&5&6_NA

Goal 7_Reduce the risk of healthcare-associated infections

Goal 8_Accurately & completely reconcile medications across the continuum of
care

Goal 9_Reduce the risk of [patient] harm resulting from falls

Goals 10&11&12_NA

Goals 13_Define & communicate the means for [patients] and their families to
report concerns about safety and encourage them to do so

Goal 14_NA

Goal 15_The organization identifies safety risks inherent in its [patient] population

Goal 16_Improve recognition & response to changes in a patient’s condition

Universal Protocol_ The organization fulfills the expectation set forth in the
Universal Protocol
GOAL 1: Improve the accuracy of
patient identification
Requirement:
Use at least two patient identifiers when
providing care, treatment or services
Rationale for requirement for Goal 1:
Wrong patient errors occur in virtually all
aspects of diagnosis & treatment
GOAL 1: Improve the accuracy of
patient identification
Implementation Expectations
1.
2.
3.
4.
5.
Two patient identifies are used when
administering medications or blood products;
Two identifiers are used when collecting blood
samples and other specimens for clinical testing;
Two identifiers are used when providing other
treatments or procedures;
The patient’s room number or physical location is
not used as an identifier;
Containers used for blood and other specimens
are labeled in the presence of the patient.
GOAL 2: Improve the effectiveness of
communication among caregivers
Requirement 2A:
For verbal or telephone orders or the
telephonic reporting of critical test
results, verify the complete order or test
result by having a person receiving the
information record and “read-back” the
complete order or test result.
GOAL 2: Improve the effectiveness of
communication among caregivers
Rationale for Requirement 2A:
Ineffective communication is the most
frequently cited category of root causes
of sentinel events.
Effective communication, which is timely,
accurate, complete, unambiguous, and
understood by the recipient, reduces
error and results in improved patient
safety.
GOAL 2: Improve the effectiveness of
communication among caregivers
Implementation Expectation
Requirement 2A:
The receiver of the information writes down
the complete order or test result or enters
it into a computer.
The receiver of the information reads back the
order or test result. The receiver of the
information receives confirmation from the
individual who gave the order or test result.
GOAL 2: Improve the effectiveness of
communication among caregivers
Requirement 2B:
Standardize a list of abbreviations, acronyms,
symbols, and designations that are not to be
used throughout the organization.
Implementation Expectation
The organization implements the list and
applies this list to all orders and medicationrelated documentation when handwritten or
entered as free text into a computer.
GOAL 2: Improve the effectiveness of
communication among caregivers
Implementation Requirement 2B:
The abbreviations not to be used includes:
U,u or IU
Q.D., QD, q.d.
or qd
Trailing zeros
(X.0 mg)
Lack of trailing
zero (.X mg)
Q.O.D., QOD,
q.o.d., or qod
MS, MSO4
,MgSO4
Preprinted forms do not include any
abbreviations identified as not to be used.
GOAL 2: Improve the effectiveness of
communication among caregivers
Implementation Requirement 2C:
Measure, assess, and if appropriate, take
action to improve the timeliness of
reporting, and receipt by the responsible
licensed caregiver, of critical tests and
results and values.
GOAL 2: Improve the effectiveness of
communication among caregivers
Implementation Expectation
Requirement 2C:
The organization defines
1.
Critical tests and critical results and values
2.
Acceptable length of time between the ordering and
reporting of critical tests, results & values
3.
Length of time between availability and receipt of results
The organization
1.
Collects data on the timeliness of reporting of critical
tests, results & values
2.
Assesses data & determines whether there is a need for
improvement
3.
Takes appropriate action to improve & measure the
effectiveness of those actions
GOAL 2: Improve the effectiveness of
communication among caregivers
Requirement 2E:
Implement a standardized approach to
“hand-off” communications, including an
opportunity to ask and respond to
questions.
GOAL 2: Improve the effectiveness of
communication among caregivers
Rationale for Requirement 2E:
The primary objective is to provide accurate
information about care, treatment, and
services, current condition and any recent or
anticipated changes.
The information communicated during a “hand
off” must be accurate in order to meet
patient safety goals.
GOAL 2: Improve the effectiveness of
communication among caregivers
Implementation Expectations for Requirement 2E:
The organization’s process for effective “hand-off’ communication includes:
1.
Interactive communications allowing the opportunity for questioning between the giver and
receiver of information.
2.
Up-to-Date information regarding the care, treatment and services, condition and any recent
or anticipated changes
3.
A process for verification of the received information, including repeating back or read-back
4.
An opportunity for the receiver to review relevant historical data, which may include
previous care, treatment and services
5.
Interruptions during hand-offs are limited to minimize the possibility that information would
fail to be conveyed or would be forgotten
GOAL 3: Improve the Safety of Using
Medications
Requirement 3C:
Identify and, at a minimum, annually review a
list of look-alike/sound-alike drugs used by
the organization,, and take action to
prevent errors involving the interchange of
these drugs.
GOAL 3: Improve the Safety of Using
Medications
Implementation Expectations for Requirements:
3C_Identify & at a minimum, annually review a list of look-alike/soundalike (LASA) drugs;
3D_Label all medications, medication containers
syringes, medicine cups, basins or other solutions on & off the
sterile field;
3E_Reduce the likelihood of patient harm associated with the use of
anticoagulation therapy.
GOAL 7: Reduce the Risk of Healthcare
Associated Infections
Requirement 7:
7A_Comply with current World Health Organization or CDC
Hand Hygiene guidelines;
7B_Manage as sentinel events all identified cases of
unanticipated death or major permanent loss of function
associated with a health care-associated infection.
GOAL 8: Accurately and completely
reconcile medications across the continuum
of care
Requirements :
8A_There is a process for comparing the patient’s current medications with
those ordered for the patient while under the care of the organization;
8B_A complete list of the patient’s medications is communicated to the next
provider of service when a patient is referred or transferred 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. The complete list of medications is also provided to the
patient on discharge from the facility.
GOAL 9: Reduce the risk of patient harm
resulting from falls
9B_Implement a Fall Reduction Program including an evaluation of the
effectiveness of the program
GOAL 13: Encourage patients’ active
involvement in their own care as a patient
safety strategy
13A_Define and communicate the means for
patients and their families to report concerns
about safety and encourage them to do so.
GOAL 15: The Organization identifies safety
risks inherent in its [patient] population
15A_The organization identifies patients at risk for
suicide. [Applicable to psychiatric hospitals and
patients being treated for emotional or behavioral
disorders in general hospitals-(NOT APPLICABLE TO
CRITICAL ACCESS HOSPITALS)]
GOAL 16: Improve recognition and
response to changes in a patient’s condition
16A_The organization selects a suitable method that
enables health care staff members to directly request
additional assistance from a specially trained
individual(s) when the patient’s condition appears to
be worsening.[Critical Access Hospital, Hospital]
UNIVERSAL PROTOCOL
Requirements for UP
1A_Conduct a pre-operative verification process as described in the Universal Protocol;
1B_Make the mark at or near the incision site as described in the Universal Protocol ;
1C_Conduct a “time out” immediately before starting the procedure as described in the Universal
Protocol.
*Universal Protocol Guidelines for Preventing Wrong Site, Wrong Procedure and Wrong
Person Surgery are found on page (17 to 19) of the JC National Patient Safety Goals,
requirements & implementation expectations.
How to access the JC NPSG:
JC Web Address:
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals
At the Joint Commission Web page; click on 2008 National Patient Goals for HOSPITALS.
Click on 2008 National Patient Safety Goal, Manual Chapter
(Includes Rationale & Implementation Expectations)
Test Your Knowledge of the NPSG
Accredited & Certified facilities can chose to implement the NPSG
True or False
Two patient identifiers are used when administering medications or
blood products
True or False
Ineffective communication is cited as the most frequent cause of a
sentinel events
True or False
Q.O.D. & MSO4, are acceptable abbreviations
True or False
A goal for a facility’s ”HAND OFF” Communication Approach is to
allow an opportunity to ask & respond to questions
True or False
One way to prevent an error with look-alike/sound-alike drugs is to
label drugs when transferred from the original packaging to another
container
True or False
A complete list of meds is communicated to the next provider of
service & given to the patient at discharge
True or False
The patient/family is educated on the Fall Reduction” Program
True or False
A “Time Out” before a procedure is used to give staff time to verify that
it is the right patient, procedure, & site.
True or False
Hand Hygiene is the most effective way to prevent the spread of
healthcare acquired infections.
True or False
Please Email or fax the completed test to SNI. The results of your test will be emailed back to you.