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© Copyright, The Joint Commission
2014 National Patient
Safety Goals
Background
 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 Patient Safety Advisory Group advises The
Joint Commission on the development and
updating of NPSGs
2014 National Patient Safety Goals - Pg. 2
© Copyright, The Joint Commission
 The first set of NPSGs was effective January 1,
2003
Patient Safety Advisory Group
 Advises The Joint Commission how to address
emerging patient safety issues in NPSGs,
Sentinel Event Alerts, standards and survey
processes, performance measures, educational
materials, and Center for Transforming
Healthcare projects
2014 National Patient Safety Goals - Pg. 3
© Copyright, The Joint Commission
 Comprised of a panel of widely recognized
patient safety experts, including nurses,
physicians, pharmacists, risk managers, clinical
engineers, and other professionals with hands-on
experience in addressing patient safety issues in
a wide variety of healthcare settings
Changes for 2014
A new NPSG focusing on safe clinical
alarm management for hospitals and
critical access hospitals will be introduced
in 2014 with a phased implementation
– Phase two begins January 1, 2016
2014 National Patient Safety Goals - Pg. 4
© Copyright, The Joint Commission
– Phase one begins January 1, 2014
Clinical Alarm Safety: Phase One
Begins January 1, 2014
Hospitals required to:
– identify the most important alarms to
manage based on their own internal
situations
2014 National Patient Safety Goals - Pg. 5
© Copyright, The Joint Commission
– establish alarm safety as organizational
priority
Clinical Alarm Safety: Phase Two
Begins January 1, 2016
Hospitals will be expected to:
– educate staff in the organization about
alarm system management
2014 National Patient Safety Goals - Pg. 6
© Copyright, The Joint Commission
– develop and implement specific
components of policies and procedures
Patient Identification
Goal 1:
2014 National Patient Safety Goals - Pg. 7
© Copyright, The Joint Commission
Improve the accuracy of patient
identification.
Patient Identification
NPSG.01.01.01: Use at least two patient
identifiers when providing care, treatment
and services.
2014 National Patient Safety Goals - Pg. 8
© Copyright, The Joint Commission
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Laboratory, Nursing
Care Center, Office-Based Surgery
Patient Identification
NPSG.01.03.01: Eliminate transfusion
errors related to patient misidentification.
2014 National Patient Safety Goals - Pg. 9
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Improve Communication
Goal 2:
2014 National Patient Safety Goals - Pg. 10
© Copyright, The Joint Commission
Improve the effectiveness of
communication among caregivers.
Improve Communication
NPSG.02.03.01: Report critical results of
tests and diagnostic procedures on a timely
basis.
2014 National Patient Safety Goals - Pg. 11
© Copyright, The Joint Commission
• Applies to: Critical Access Hospital, Hospital, Laboratory
Medication Safety
Goal 3:
2014 National Patient Safety Goals - Pg. 12
© Copyright, The Joint Commission
Improve the safety of using medications.
Medication Safety
NPSG.03.04.01: Label all medications,
medication containers, and other solutions
on and off the sterile field in perioperative
and other procedural settings.
2014 National Patient Safety Goals - Pg. 13
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office Based Surgery
Medication Safety
NPSG.03.05.01: Reduce the likelihood
of patient harm associated with the use
of anticoagulant therapy.
2014 National Patient Safety Goals - Pg. 14
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Nursing Care Center
Medication Safety
NPSG.03.06.01: Maintain and communicate
accurate patient medication information.
2014 National Patient Safety Goals - Pg. 15
© Copyright, The Joint Commission
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Nursing Care
Center, Office-Based Surgery
Clinical Alarm Safety
Goal 6:
2014 National Patient Safety Goals - Pg. 16
© Copyright, The Joint Commission
Reduce the harm associated with clinical
alarm systems.
Clinical Alarm Safety
NPSG.06.01.01: Improve the safety of
clinical alarm systems.
2014 National Patient Safety Goals - Pg. 17
© Copyright, The Joint Commission
• Applies to: Critical Access Hospital, Hospital
Health Care-Associated Infections
Goal 7:
2014 National Patient Safety Goals - Pg. 18
© Copyright, The Joint Commission
Reduce the risk of health care-associated
infections.
Health Care-Associated Infections
• Applies to: Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Laboratory, Nursing
Care Center, Office-Based Surgery
2014 National Patient Safety Goals - Pg. 19
© Copyright, The Joint Commission
NPSG.07.01.01: 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.
Health Care-Associated Infections
NPSG.07.03.01: Implement evidencebased practices to prevent health careassociated infections due to multidrugresistant organisms in acute care hospitals.
2014 National Patient Safety Goals - Pg. 20
© Copyright, The Joint Commission
• Applies to: Critical Access Hospital, Hospital
Health Care-Associated Infections
NPSG.07.04.01: Implement evidencebased practices to prevent central lineassociated bloodstream infections.
2014 National Patient Safety Goals - Pg. 21
© Copyright, The Joint Commission
• Applies to: Critical Access Hospital, Hospital, Nursing
Care Center
Health Care-Associated Infections
NPSG.07.05.01: Implement evidencebased practices for preventing surgical
site infections.
2014 National Patient Safety Goals - Pg. 22
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Health Care-Associated Infections
NPSG.07.06.01: Implement evidencebased practices to prevent indwelling
catheter-associated urinary tract
infections (CAUTI).
(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.)
2014 National Patient Safety Goals - Pg. 23
© Copyright, The Joint Commission
• Applies to: Critical Access Hospital, Hospital
Additional NPSGs for Home
Care, Nursing Care Centers
2014 National Patient Safety Goals - Pg. 24
© Copyright, The Joint Commission
Reducing Falls
Pressure Ulcers
Reduce Falls
Goal 9:
2014 National Patient Safety Goals - Pg. 25
© Copyright, The Joint Commission
Reduce the risk of patient harm resulting
from falls.
Reduce Falls
NPSG.09.02.01: Reduce the risk of falls.
2014 National Patient Safety Goals - Pg. 26
© Copyright, The Joint Commission
• Applies to: Home Care, Nursing Care Center
Pressure Ulcers
Goal 14:
2014 National Patient Safety Goals - Pg. 27
© Copyright, The Joint Commission
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 and take action to address
any identified risks.
Applies to: Nursing Care Center
2014 National Patient Safety Goals - Pg. 28
© Copyright, The Joint Commission
•
Risk Assessment
Goal 15:
2014 National Patient Safety Goals - Pg. 29
© Copyright, The Joint Commission
The organization identifies safety risks
inherent in its patient population.
Risk Assessment
NPSG.15.01.01: Identify patients at risk
for suicide.
• Applies to: Behavioral Health Care, Hospital
2014 National Patient Safety Goals - Pg. 30
© Copyright, The Joint Commission
(Applicable to psychiatric hospitals and patients being
treated for emotional or behavioral disorders in general
hospitals.)
Risk Assessment
NPSG.15.02.01: Identify risks associated
with home oxygen therapy, such as home
fires.
2014 National Patient Safety Goals - Pg. 31
© Copyright, The Joint Commission
• Applies to: Home Care
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery™
UP.01.01.01: Conduct a preprocedure
verification process.
2014 National Patient Safety Goals - Pg. 32
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery™
UP.01.02.01: Mark the procedure site.
2014 National Patient Safety Goals - Pg. 33
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery™
UP.01.03.01: A time-out is performed
before the procedure.
2014 National Patient Safety Goals - Pg. 34
© Copyright, The Joint Commission
• Applies to: Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
For more information…
Questions can be sent to the Standards
Interpretation Group at 630-792-5900 or
via the Standards Online Question Form
2014 National Patient Safety Goals - Pg. 35
© Copyright, The Joint Commission
The National Patient Safety Goals for
each program and more information are
available on The Joint Commission
website at www.jointcommission.org