Author: C. Jason Rawlings (CRCST) | Director of Clinical Services
October 4, the Joint Commission released its new National Patient Safety Goals (NPSGs), effective January 2020. Now part of the commission’s accreditation standards, the goals aim to improve patient safety in hospitals and behavioral health care organizations by addressing issues related to procedural accuracy, infection prevention, and surgical mistakes, among others. Here’s a quick run-down of the goals:
Improve the Accuracy of Patient Identification
Making sure you have the right patient is crucial no matter what procedure or treatment is being administered. This overarching goal encompasses two NPSGs, one focused on best practices for accurately identifying patients and the other dealing with blood transfusions, where giving the transfusion to the wrong patient could cause further health problems.
To correctly identify patients, the Joint Commission calls for two means of identification, such as the patient’s name, date of birth, an assigned identification number, or a telephone number. Special care should be taken with newborns, whom the commission says “are at a higher risk of misidentification due to their inability to speak and lack of distinguishable features.” Signage and ID bands can fill the gaps in identifying infants.
When it comes to blood transfusions, medical personnel should match the blood or blood component to the appropriate order and then match the patient to the transfusion, using either a two-person verification process or a one-person verification with help from automated identification technology.
Improve the Effectiveness of Communication Among Caregivers
This goal relates mostly to test results or diagnostic procedures of a critical nature. Too often, poor communication systems delay the relaying of test results that uncover critical, sometimes life-threatening conditions. To improve patient care and intervention, clear procedures should be established and laid out that define what should be considered “critical”, clearly assign who is responsible for reporting that information, as well as to whom they should address their reports, and what amount of time is acceptable to pass between the availability of critical information and the transmission of that information to the appropriate personnel.
Improve the Safety of Using Medications
This goal seeks to ensure that the correct medication is administered without causing adverse results due to blood thinners (anticoagulants) or interactions with other medications that the patient is taking.
First, personnel should make sure to label all medications anytime they are transferred from their original container. This includes medications in syringes, cups, and basins. Labels should include:
- Name of medication or solution
- Diluent name and volume
- Expiration date when not used in 24 hours or expiration time if the expiration occurs within 24 hours (expiration date and/or time aren’t necessary for shorter procedures)
All labels should be verified both verbally and visually by two individuals. Any unlabeled medications or solutions should be discarded immediately. All labeled containers and their contents should be removed and discarded at the end of the procedure.
Special care should be taken when treating patients undergoing anticoagulant therapy. Blood thinners are often used to prevent unwanted blood clotting, but because of this, they can cause problems when a patient starts bleeding. According to the Joint Commission, “anticoagulant medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance.” All of this means that hospitals must maintain and follow strict, careful procedures to maintain patient safety and prevent complications connected to anticoagulants.
Finally, it’s crucial that hospitals and medical personnel maintain and communicate accurate patient medication information. In order to make sure additional prescriptions don’t cause new or exacerbate existing health issues, personnel must make sure they have an accurate understanding of what patients are currently taking. It’s highly encouraged to have patients bring up-to-date lists of their current medicines every time they visit the doctor, so that clinicians can compare patients’ current prescriptions to any new medications, and successfully avoid harmful reactions between medications or the prescription of redundant medications. The information needed to do this includes:
- Name of medication
Reduce the Harm Associated with Clinical Alarm Systems
Alarm systems aren’t effective if they aren’t managed properly. This goal seeks to address that by providing some guidance in how to assess the current alarm system and the needs of hospital personnel in order to make sure the alarm system meets the hospital’s needs. Efforts aim to ensure alarms are heard and responded to in a timely manner.
Reduce the Risk of Health Care-Associated Infections
Health care-associated infections can come from a variety of sources, whether the simple lack of hand hygiene or unsanitary catheters. This goal calls for healthcare organizations to follow the hand-cleaning guidelines provided by the Centers for Disease Control and Prevention or the World Health Organization, and also identifies the need for institutional education, assessments, policies, and practices aimed at preventing drug-resistant infections (such as Staph infections), bloodstream and urinary tract infections, and surgical site infections.
The Hospital Identifies Safety Risks Inherent in Its Patient Population
This goal is primarily aimed at preventing patient suicide in behavioral health facilities by identifying individuals who are at risk of suicide, and removing objects or environmental elements that could be used to self-harm.
Prevent Wrong Site, Wrong Procedure, Wrong Person Surgery Mistakes
No one wants to wake up from surgery and find the wrong side of their body bandaged up after a procedure. This goal aims to ensure that the right surgeries are conducted on the correct patients, on the correct parts of their bodies. Medical personnel should start by conducting a pre-procedure verification where they gather information from the patient and confirm the patient’s identity and procedural need. Then, personnel should mark the place on the patient’s body where the surgery will be done. Before starting surgery, medical personnel should pause and again ensure that everything (and everyone) is correct.
Each of these goals serves a specific purpose in improving and ensuring patient safety (not to mention, satisfaction). You can read the full descriptions from the Joint Commission here. What opportunities do you see for the SPD to aid in fulfilling these goals?
ANSI/AAMI ST79:2017. Association for the Advancement of Medical Instrumentation (AAMI)
Performance Management & Quality Improvement. CDC. https://www.cdc.gov/publichealthgateway/performance/index.html
Performance Management: Turning Point. Public Health Foundation. http://www.phf.org/programs/turningpoint/Pages/Turning_Point_Performance_Management_Refresh.aspx
Process. A Publication of the International Association of Healthcare Central Service Material Management. May/June 2020. www.iahcsmm,org
Quality Audit – A Tool for Continuous Improvement and Compliance. https://www.mastercontrol.com/gxp-lifeline/quality_audit_tool_compliance_0810/
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