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El Paso’s City Wide Orientation

Overview of

The Joint Commission’s 2010 National Patient

Safety Goals (NPSG’s)

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A Bit of history The Joint Commission (TJC) approved the

first set of National Patient Safety Goals (NPSG) for healthcare organizations to be effective January 1, 2003.

The purpose of NPSG’s is to promote specific improvements in patient safety

The requirements focus on system-wide problematic areas in health care and describe evidence and expert-based solutions to these problems

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You are the key to the You are the key to the Patient Safety GoalsPatient Safety Goals

The Joint Commission’s (TJC) mission is to “continuously improve the safety and quality of care delivered to the public through the provision of health care accreditation.”

The NPSG’s have related specific requirements for improving the safety of patient care in healthcare organizations.

TJC requires accredited health care organizations implement NPSG’s as appropriate to the services provided by the organization. All accredited health care organizations such as Hospitals, Assisted Living, Home Care, Behavioral Health Care, Disease-Specific Care, Ambulatory, Laboratory, etc., are surveyed to evaluate the implementation of these goals as they relate to the services of the organization.

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How do NPSG’s get selected/ decided upon?

Each year, The Joint Commission (TJC) staff in collaboration with the Patient Safety Advisory Group, comprised of a panel of patient safety experts, nurses, physicians, pharmacists, risk managers, and other professionals with hands-on experience in addressing patient safety issues, are charged with identifying goals to be retired and/or revised and recommendations for new NPSG’s based on the highest patient safety issues.

This is done through review of medical literature and available healthcare databases. TJC’s Board of Commissioners have final approval of annual NPSGs and associated requirements that are to be implemented.

www.jointcommission.org/

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2010 NPSG’s The following is a list of the six NPSG’s and the Universal Protocol for

Hospital Settings followed by specific evidence-or expert-based recommendations as required by TJC to be implemented:

Goal # 1 Improve the accuracy of patient identification.

A) Use at least two patient identifiers when giving medications or blood products, when obtaining a blood sample and other specimens for clinical testing, or performing any other treatments or procedures. Labeling of containers used for blood and other specimens is to be done in the presence of the patient.

Simply put, it means you have the right patient for the right treatment. Pretty basic stuff, but you’ve heard stories of “mixing up” patients duringprocedures or delivering medications to the wrong patient. Never, ever usethe patient’s room number or physical location as a patient identifier!

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2010 NPSG’s

Goal # 1 Improve the accuracy of patient identification.

B) Make sure that the correct patient gets the correct blood type when they get a blood transfusion.

Remember, ALWAYS verify blood products at the bedside of the patient (not at the nurses’ station or wherever!)

Did you know that the majority (over 95%) of blood transfusion reactions occur due to an administrative error resulting in the wrong blood getting to the wrong patient?

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2010 NPSG’s

Goal # 2 Improve the effectiveness of communication among caregivers.

A) Report critical results of tests and diagnostic procedures on a timely basis

This certainly seems reasonable…Quickly get report results to the right staff person!The reporting of this information to the right staff person must be clearly documented and must reflect what was done with the information (the action taken).

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2010 NPSG’s

Goal # 3 Improve the safety of using medications

A) Label all medications and containers, or other solutions on and off the sterile field.

And this is not just the operating room, this covers all treatment areas! You cannot rely on knowing what “the brown liquid stuff is” in the container. Label, label, and communicate!

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2010 NPSG’s

Goal # 3 Improve the safety of using

medications. (cont)

B) Reduce the likelihood of patient harm associated with the use of anticoagulation therapy

Imagine the consequences of poorly delivered anticoagulation therapy. Know the methodology and the step-by-step requirements for documentation/ checks for providing our patients with this care. This requirement applies to organizations that provide anti-coagulation therapy and/or long term anticoagulation prophylaxis where the clinical expectation is that the lab values will remain outside normal values.

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2010 NPSG’s

Goal # 7 Reduce the risk of health care-associated infections.

A) Comply with current World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines (also refer to the Infection Control module of this program).

The hand hygiene guidelines (CDC) address important issues healthcare personnel need to comply with such as: 1) hand washing, 2) no wearing of artificial nails, and 3) keeping natural nails less than one quarter inch long for staff caring for patients at high risk of acquiring infections (e.g. transplant units and intensive care units). Each accredited organization has developed internal policies to comply with the CDC guidelines to meet TJC requirements.

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2010 NPSG’s

Goal # 7 Reduce the risk of health care-associated infections (cont)

B) Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

C) Implement evidence-based practices to prevent central-line associated blood stream infections

D) Implementing evidence-based practices for preventing surgical site infections

Meaning we don’t do what we want to do when we want to do it! There are proven ways to reduce human error, reduce infections

and the hospital should implement those methods and monitor their personnel for compliance!

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2010 NPSG’s

Goal # 8 Accurately and completely reconcile medications across the continuum of care.

A) Have a process for comparing patient’s current meds with those ordered while under the organization’s care.

B) Communicate the list of patient’s meds to the next provider of service when transferring, referring or discharging (within or outside the organization). If the patient is going home, be sure they get a complete list too along with an explanation.

This just makes sense… know what medications the patient is on andpass on that information across the care continuum. A process must be in place for comparing patient’s current meds with those ordered while under an organization’s care and when that care is continued. This can include herbals, supplements, and other non-traditional things, that the patient might be taking, not just the current prescriptions on record.

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2010 NPSG’s

Goal # 15

The organization identifies safety risks inherent in its patient population

By providing regular screening, organizations will be able to identify patients at risk for suicide, depression, emotional disorders or behavioral disorders; the goal would then be to provide the appropriate treatment paths to include ensuring their safety while in their care.

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2010 NPSG’sAlso on the list of goals:The organization meets the expectations of the

Universal Protocol

Pre-Procedure verification of the correct person, correct site, and correct procedure

The procedure site is marked before the patient is moved to the OR suite, by a licensed independent practitioner. This individual will be involved directly in the procedure and will be present at the time the procedure is performed. Insertion procedures for which the site is unknown (cardiac cath and PICC lines) do not require marking

A time-out is performed immediately prior to starting procedures. During the “time out”, all other activities are suspended, to the extent possible without compromising patient safety

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Why do we have the NPSG’s?

To avoid error, to avoid sentinel events!To make healthcare a safer environment!

Each of these NPSG’s stemmed from errors that have been made in the past!

Did you notice?

For those of you clever enough to notice…

Our list of 2010 NPSG’s does not have # 4, # 5, or # 6 safety

goals anymore, why? They have since become standards!

The NPSG’s do include other items such as:

Goal # 9: Reduce risk of patient harm resulting from falls

Goal # 14: Prevent health care-associated pressure ulcers (decubitus ulcers).

But these goals, and others, are applicable as goals in other healthcare organization settings to include long-term health and home care.

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Sentinel Events

Sentinel Event

NPSG requirements include the organization’s response to adverse events. TJC designed a policy to help health care organizations identify “sentinel events” and take appropriate action to prevent their recurrence.

A sentinel event is an unexpected occurrence involving death or serious physical injury including loss of limb or function or psychological injury or the “risk thereof” (see TJC website at www.jointcommission.org).

A “risk thereof” refers to an occurrence that although no harm has taken place at this time, any recurrence would potentially have a serious adverse outcome to a patient.

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TJC Sentinel Events lead to a Root Cause Analysis

Another term you should know: Root Cause Analysis

Whenever a sentinel event occurs, the health care organization is expected to complete a “root cause analysis” (investigation) to review the systems and processes that can be changed to prevent a failure in the future and protect patients from harm.

At its core, TJC accreditation is intended to reduce the risk of adverse patient outcomes. Currently, TJC surveys are unannounced with the intention of being a risk reduction activity.

During the on-site survey, if any NPSG is found to be less than 100% compliance the organization will receive a requirement for improvement (RFI).

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Summary of TJC NPSG's

In summary, The Joint Commission is committed to improving the safety and quality of care for patients in accredited health care organizations.

Healthcare workers and healthcare students should know their role in patient safety!

The NPSG requirements mandated by TJC are in place to reduce the risk of adverse outcomes to patients receiving services in the various health care organizations. All health care organizations receiving accreditation from TJC must implement the NPSG requirements in an effort to maintain safe environments and provide quality care to all patients.

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For more information:

www.jointcommission.org