© Copyright, The Joint Commission 2015 National Patient Safety Goals

2015 National Patient Safety Goals - Pg. 2 © Copyright, The Joint Commission  The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety  The first set of NPSGs was effective January 1, 2003  The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs Background

2015 National Patient Safety Goals - Pg. 3 © Copyright, The Joint Commission Patient Safety Advisory Group  Panel of widely recognized patient safety experts –Nurses, physicians, pharmacists, risk managers, clinical engineers, other professionals  Hands-on experience in addressing patient safety issues in wide variety of health care settings  Advises The Joint Commission how to address emerging patient safety issues –NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, Center for Transforming Healthcare projects

2015 National Patient Safety Goals - Pg. 4 © Copyright, The Joint Commission 2015 NPSGs  No new Goals for 2015  NPSG on home oxygen safety modified for home care  Minor language changes for NPSG (AHC, HAP, CAH, OBS)

2015 National Patient Safety Goals - Pg. 5 © Copyright, The Joint Commission Patient Identification Goal 1: Improve the accuracy of patient identification.

2015 National Patient Safety Goals - Pg. 6 © Copyright, The Joint Commission Patient Identification  NPSG : Use at least two patient identifiers when providing care, treatment and services. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 7 © Copyright, The Joint Commission Patient Identification  NPSG : Eliminate transfusion errors related to patient misidentification. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

LHS Compliance To Goal 2 patient identifiers used for in house patients. (Name and medical record number) Patients specimens labeled at the bedside using the Lattice system. 2 person verification process before performing blood transfusions, and administration of insulin, heparin, also any medication given on the PCA or CADD pump.

2015 National Patient Safety Goals - Pg. 9 © Copyright, The Joint Commission Improve Communication Goal 2: Improve the effectiveness of communication among caregivers.

2015 National Patient Safety Goals - Pg. 10 © Copyright, The Joint Commission Improve Communication  NPSG : Report critical results of tests and diagnostic procedures on a timely basis. Applies to: Critical Access Hospital, Hospital, Laboratory

LHS Compliance To Goal SBAR report form will be initiated. VBR- Verification by read back process in use for verbal orders and test results. Standard list of unapproved abbreviations. Critical Test and Critical Results reporting done by using the verify system.

2015 National Patient Safety Goals - Pg. 12 © Copyright, The Joint Commission Medication Safety Goal 3: Improve the safety of using medications.

2015 National Patient Safety Goals - Pg. 13 © Copyright, The Joint Commission Medication Safety  NPSG : Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office Based Surgery

2015 National Patient Safety Goals - Pg. 14 © Copyright, The Joint Commission Medication Safety  NPSG : Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Applies to: Ambulatory, Critical Access Hospital, Hospital, Nursing Care Center

2015 National Patient Safety Goals - Pg. 15 © Copyright, The Joint Commission Medication Safety  NPSG : Maintain and communicate accurate patient medication information. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Nursing Care Center, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 16 © Copyright, The Joint Commission Clinical Alarm Safety Goal 6: Reduce the harm associated with clinical alarm systems.

2015 National Patient Safety Goals - Pg. 17 © Copyright, The Joint Commission Clinical Alarm Safety  NPSG : Improve the safety of clinical alarm systems. Applies to: Critical Access Hospital, Hospital

2013 National Patient Safety Goals - Pg. 18 © Copyright, The Joint Commission Clinical Alarm Safety: Phase One  Begins January 1, 2014  Hospitals required to: –establish alarm safety as organizational priority –identify the most important alarms to manage based on their own internal situations

2013 National Patient Safety Goals - Pg. 19 © Copyright, The Joint Commission Clinical Alarm Safety: Phase Two  Begins January 1, 2016  Hospitals will be expected to: –develop and implement specific components of policies and procedures –educate staff in the organization about alarm system management

2015 National Patient Safety Goals - Pg. 20 © Copyright, The Joint Commission Health Care-Associated Infections Goal 7: Reduce the risk of health care-associated infections.

2015 National Patient Safety Goals - Pg. 21 © Copyright, The Joint Commission Health Care-Associated Infections  NPSG : Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 22 © Copyright, The Joint Commission Health Care-Associated Infections  NPSG : Implement evidence- based practices to prevent health care- associated infections due to multidrug- resistant organisms in acute care hospitals. Applies to: Critical Access Hospital, Hospital

2015 National Patient Safety Goals - Pg. 23 © Copyright, The Joint Commission Health Care-Associated Infections  NPSG : Implement evidence- based practices to prevent central line- associated bloodstream infections. Applies to: Critical Access Hospital, Hospital, Nursing Care Center

2015 National Patient Safety Goals - Pg. 24 © Copyright, The Joint Commission Health Care-Associated Infections  NPSG : Implement evidence- based practices for preventing surgical site infections. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 25 © Copyright, The Joint Commission Health Care-Associated Infections  NPSG : Implement evidence- based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Applies to: Critical Access Hospital, Hospital (Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children.)

LHS Compliance To Goal Hand Hygiene Cover your cough IV Therapy Class Scrub the IV Hub

2015 National Patient Safety Goals - Pg. 27 © Copyright, The Joint Commission Reduce Falls Goal 9: Reduce the risk of patient harm resulting from falls.

2015 National Patient Safety Goals - Pg. 28 © Copyright, The Joint Commission Reduce Falls  NPSG : Reduce the risk of falls. Applies to: Home Care, Nursing Care Center

LHS Compliance To Goal Falls risk program. Nursing policy #F-2-1 You will be required to read this policy, then take and receive a passing grade on the falls risk test in your LMS.

2015 National Patient Safety Goals - Pg. 30 © Copyright, The Joint Commission Pressure Ulcers Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers).

2015 National Patient Safety Goals - Pg. 31 © Copyright, The Joint Commission Pressure Ulcers  NPSG : Assess and periodically reassess each resident’s risk for developing a pressure ulcer and take action to address any identified risks. Applies to: Nursing Care Center

LHS Compliance To Goal Thorough assessment and documentation of skin assessment. Nurses have the option of consulting the skin care specialist. (Kim Kovarik) Sorian will also auto refer based upon the nursing assessment.

2015 National Patient Safety Goals - Pg. 33 © Copyright, The Joint Commission Risk Assessment Goal 15: The organization identifies safety risks inherent in its patient population.

2015 National Patient Safety Goals - Pg. 34 © Copyright, The Joint Commission Risk Assessment  NPSG : Identify patients at risk for suicide. Applies to: Behavioral Health Care, Hospital (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.)

2015 National Patient Safety Goals - Pg. 35 © Copyright, The Joint Commission Risk Assessment  NPSG : Identify risks associated with home oxygen therapy, such as home fires. Applies to: Home Care

LHS Compliance To Goal Screening for suicide risk Behavioral health program in the ED.

2015 National Patient Safety Goals - Pg. 37 © Copyright, The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™  UP : Conduct a preprocedure verification process. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 38 © Copyright, The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™  UP : Mark the procedure site. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

2015 National Patient Safety Goals - Pg. 39 © Copyright, The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™  UP : A time-out is performed before the procedure. Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

LHS Compliance To Goals Verification takes place when the procedure is scheduled, in preadmission testing, at the time of admission, before entering the procedure room, and when caregivers are changed with the patient actively involved. Procedure site is marked. Time out is done prior to starting the procedure to include correct patient, correct procedure, and correct site. Complete the checklist prior to start of procedure and all team members of the team must be in agreement.

2015 National Patient Safety Goals - Pg. 41 © Copyright, The Joint Commission  The National Patient Safety Goals for each program and more information are available on The Joint Commission website at  Questions can be sent to the Standards Interpretation Group at or via the Standards Online Question FormStandards Online Question Form For more information…