Download NPSG - El Paso Community College

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
Patient 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 during
procedures or delivering medications to the wrong patient. Never, ever use
the 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 careassociated 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 and
pass 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’s
Also 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!
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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.
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
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