© Copyright, The Joint Commission 2009 National Patient Safety Goals

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

2009 National Patient Safety Goals

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

2009 National Patient Safety Goals – Pg. 2

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.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Patient Identification

Goal 1:

Improve the accuracy of patient identification

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.

• Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

New for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Improve Communication

Goal 2:

Improve the effectiveness of communication among caregivers

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


Revised for 2009 – medications added

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Medication Safety

Goal 3:

Improve the safety of using medications

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Health Care Associated Infections

Goal 7:

Reduce the risk of health care associated infections

New for 2009 - Addition of 3 Requirements

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



NPSG.07.05.01: Implement best practices for preventing surgical site infections.


New for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Reconcile Medications

Goal 8:

Accurately and completely reconcile medications across the continuum of care

Completely Revised for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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]


Revised for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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.


New for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.


New for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Reduce Falls

Goal 9:

Reduce the risk of patient harm resulting from falls

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Influenza & Pneumococcal Disease

Goal 10:

Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on



NPSG.10.02.01: The organization develops and implements protocols for administration of the pneumococcus vaccine. [was Goal 10B]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on



NPSG.10.03.01: The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. [was Goal 10C]


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Surgical Fires

Goal 11:

Reduce the risk of surgical fires

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Patient Involvement

Goal 13:

Encourage patients’ active involvement in their own care as a patient safety strategy

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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]


New for 2009 - Addition of 2 elements of performance

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Pressure Ulcers

Goal 14:

Prevent health care associated pressure ulcers (decubitus ulcers)

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Risk Assessment

Goal 15:

The organization identifies safety risks inherent in its patient population

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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)

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Changes in Patient Condition

Goal 16:

Improve recognition and response to changes in a patient’s condition

Clarified for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Universal Protocol

UP.01.01.01: Conduct a pre-procedure verification process.


Revised for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Universal Protocol

UP.01.02.01: Mark the procedure site.


Revised for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


Universal Protocol

UP.01.03.01: A time-out is performed immediately prior to starting procedures.


Revised for 2009

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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).

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


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

© C

opyr

ight

, The

Joi

nt C

omm

issi

on


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


For more informationFor more information::

www.jointcommission.org

Documents

© Copyright, The Joint Commission 2009 National Patient Safety Goals