2009 National Patient Safety Goals

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

National Patient Safety Goals Goals and Requirements are guided and prioritized by the Sentinel Event Advisory Group. Each year, the Sentinel Event Advisory Group works with The Joint Commission to undertake a systematic review of the medical literature and available health care databases to identify potential new Goals and Requirements. The updated Goals and their Requirements are published annually by mid-year after extensive vetting, public commentary and approval phases.

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

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

The Joint Commission 2009 National Patient Safety Goals Approved by The Joint Commission’s Board of Commissioners in May 2008 The Goals and Requirements are program-specific Include improvements emanating from the Standards Improvement Initiative, including: New numbering system for sorting in new electronic manuals Minor language changes for consistency

Patient Identification Goal 1: Improve the accuracy of patient identification

Patient Identification NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services. [was Goal 1A] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office- Based Surgery Revised for 2009

Patient Identification NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct patient, procedure and site using active, not passive, communication techniques. [was Goal 1B] ~ EPs Mirror the Universal Protocol ~ Applies to Home Care, Lab, Long Term Care Revised for 2009

Patient Identification NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery New for 2009

Improve Communication Goal 2: Improve the effectiveness of communication among caregivers

Improve Communication NPSG.02.01.01: For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. [was Goal 2A] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

Improve Communication NPSG.02.02.01: There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. [was Goal 2B] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

Improve Communication NPSG.02.03.01: The organization measures, assesses and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, and critical results and values by the responsible licensed caregiver. [was Goal 2C] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

Improve Communication NPSG.02.05.01: The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. [was Goal 2E] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery Revised for 2009 – medications added

Medication Safety Goal 3: Improve the safety of using medications

Medication Safety NPSG.03.03.01: The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications. [was Goal 3C] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery

Medication Safety NPSG.03.04.01: Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. [was Goal 3D] Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

Clarified and Revised for 2009 Medication Safety NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. [was Goal 3E] Applies to: Ambulatory, Critical Access Hospital, Home Care, Hospital, Long Term Care Clarified and Revised for 2009

Health Care Associated Infections Goal 7: Reduce the risk of health care associated infections New for 2009 - Addition of 3 Requirements

Health Care Associated Infections NPSG.07.01.01: Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. [was Goal 7A] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

Health Care Associated Infections NPSG.07.02.01: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care associated infection. [was Goal 7B] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery

Health Care Associated Infections NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals. Applies to: Critical Access Hospital, Hospital New for 2009

Health Care Associated Infections NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. Applies to: Ambulatory, Critical Access Hospital, Home Care, Hospital, Long Term Care New for 2009

Health Care Associated Infections NPSG.07.05.01: Implement best practices for preventing surgical site infections. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery New for 2009

Reconcile Medications Goal 8: Accurately and completely reconcile medications across the continuum of care Completely Revised for 2009

Reconcile Medications NPSG.08.01.01: A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. [was Goal 8A] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery Revised for 2009

Reconcile Medications NPSG.08.02.01: When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the organization’s care directly to his or her home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, or the original referring provider, or a known next provider of service. [was Goal 8B] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery Revised for 2009

Reconcile Medications NPSG.08.03.01: When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery New for 2009

Reconcile Medications NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery New for 2009

Reduce Falls Reduce the risk of patient harm resulting from falls Goal 9: Reduce the risk of patient harm resulting from falls

Reduce Falls NPSG.09.02.01: The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program. [was Goal 9B] Applies to: Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care

Influenza & Pneumococcal Disease Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

Influenza & Pneumococcal Disease NPSG.10.01.01: The organization develops and implements protocols for administration of the flu vaccine. [was Goal 10A] Applies to: Disease-Specific Care, Long Term Care

Influenza & Pneumococcal Disease NPSG.10.02.01: The organization develops and implements protocols for administration of the pneumococcus vaccine. [was Goal 10B] Applies to: Disease-Specific Care, Long Term Care

Influenza & Pneumococcal Disease NPSG.10.03.01: The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. [was Goal 10C] Applies to: Disease-Specific Care, Long Term Care

Surgical Fires Goal 11: Reduce the risk of surgical fires

Surgical Fires NPSG.11.01.01: The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. [was Goal 11A] Applies to: Ambulatory Care, Office-Based Surgery

Patient Involvement Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy

New for 2009 - Addition of 2 elements of performance Patient Involvement NPSG.13.01.01: Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so. [was Goal 13A] Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery New for 2009 - Addition of 2 elements of performance

Pressure Ulcers Goal 14: Prevent health care associated pressure ulcers (decubitus ulcers)

Pressure Ulcers NPSG.14.01.01: Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. [was Goal 14A] Applies to: Long Term Care

Risk Assessment Goal 15: The organization identifies safety risks inherent in its patient population

Risk Assessment NPSG.15.01.01: The organization identifies patients at risk for suicide. [was Goal 15A] Applies to: Behavioral Health Care, Hospital (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals)

Risk Assessment NPSG.15.02.01: The organization identifies risks associated with home oxygen therapy such as home fires. [was Goal 15B] Applies to: Home Care

Changes in Patient Condition Goal 16: Improve recognition and response to changes in a patient’s condition Clarified for 2009

Changes in Patient Condition NPSG.16.01.01: 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. [was Goal 16A] Applies to: Critical Access Hospital, Hospital

Universal Protocol The organization meets the expectations of the Universal Protocol. Applies to: Ambulatory, Critical Access Hospital, Disease-Specific Care, Hospital, and Office-Based Surgery Revised for 2009

Universal Protocol UP.01.01.01: Conduct a pre-procedure verification process. Applies to: Ambulatory, Critical Access Hospital, Disease-Specific Care, Hospital, and Office-Based Surgery Revised for 2009

Universal Protocol UP.01.02.01: Mark the procedure site. Applies to: Ambulatory, Critical Access Hospital, Disease-Specific Care, Hospital, and Office-Based Surgery Revised for 2009

Universal Protocol UP.01.03.01: A time-out is performed immediately prior to starting procedures. Applies to: Ambulatory, Critical Access Hospital, Disease-Specific Care, Hospital, and Office-Based Surgery Revised for 2009

Submitting Alternative Approaches Proposed alternatives must be at least as effective as the published Requirements in achieving the Goals. Proposed alternatives must be formally approved by The Joint Commission based on the Sentinel Event Advisory Group’s review. Forms to submit a “Request for Review of an Alternative Approach to a NPSG Requirement ” are found at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/npsg_rfr.htm

Submitting Alternative Approaches If an alternative approach is not formally accepted by The Joint Commission, the organization will need to further revise the alternative approach until it is approved… And continue to implement the original Goal Requirements as issued by The Joint Commission until the alternative approach approval is achieved.

Surveying and Scoring the National Patient Safety Goals All applicable Goals & Requirements, or acceptable alternative approaches, must be implemented. Surveyors evaluate the actual performance, not just the intent of meeting the Goals and Requirements. NPSG Requirements are scored as either Compliant or Not Compliant. Failure to comply with a NPSG Requirement will result in a “Requirement for Improvement” (RFI).

Public Disclosure of Compliance with the National Patient Safety Goals Aggregate data: Data from 2003 - 2007 surveys are posted on The Joint Commission website Individual health care organizations: Compliance with specific Requirements Revised “Quality Reports” on website since mid-year 2004

For more information: www.jointcommission.org