Ntl Pt Sfty Goals & Lasa

Front 1

What is the purpose of the The Joint Commission’s National Patient Safety Goals (NPSGs)?

Back 1

to promote specific improvements in patient safety

Front 2

What do the NPSGs highlight or focus on?

Back 2

Focus on system-wide solutions, wherever possible.

Highlight problematic areas in health care and describe evidence and expert-based solutions to these problems.

Front 3

The goals and requirements are guided and prioritized by who?

Back 3

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.

Front 4

The Joint Commission 2009 National Patient Safety Goals

Back 4

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

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Goal 1
Patient Identification

Back 5

Improve the accuracy of patient identification
NPSG.01.01.01: Use at least two patient identifiers
when providing care, treatment and services. [was
Goal 1A]

Front 6

Goal 2
Improve Communication

Back 6

Improve the effectiveness of communication among caregivers

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]

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]

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]

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]

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Goal 3
Medication Safety

Back 7

Improve the safety of using medications

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]

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]

NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. [was Goal 3E]

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Goal 7
Health Care Associated Infections

Back 8

Reduce the risk of health care associated infections

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]

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]

NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections.

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

Front 9

Goal 8
Reconcile Medications

Back 9

Accurately and completely reconcile medications across the continuum of care

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]

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]

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.

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

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Goal 9
Reduce Falls

Back 10

Reduce the risk of patient harm resulting from 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]

Front 11

Goal 10
Influenza & Pneumococcal Disease

Back 11

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

NPSG.10.01.01: The organization develops and implements protocols for administration of the flu vaccine. [was Goal 10A]

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

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

Front 12

Goal 13
Patient Involvement

Back 12

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

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]

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Goal 15
Risk Assessment

Back 13

The organization identifies safety risks inherent in its patient population

NPSG.15.01.01: The organization identifies patients at risk for suicide. [was Goal 15A]

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Goal 16
Changes in Patient Condition

Back 14

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

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The organization meets the Universal Protocol.

Back 15

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

UP.01.02.01: Mark the procedure site.

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

Front 16

Please count and confirm there are only three F’s in the following sentence:

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.

Back 16

There are 6 F's! Conformational Bias - This concept is generally defined as when you see what you think or expect you should see, rather than what is actually present.

Front 17

In response to a medication event in which a wrong concentration of Heparin was given, a proposed action might be “double check all Heparins prior to administration.” In this scenario, a caregiver double-checking Heparins could assume that the previous co-worker, likely known by the caregiver, is competent and selected the correct concentration.

Back 17

Example of clinical-based example of confirmation bias. This confirmation bias might lead to an incorrectly selected concentration of Heparin because the first caregiver might not have recognized a problem for a number of reasons that have nothing to do with skill level — such as fatigue, workload, or distraction.

Front 18

What could a Root Cause Analysis (RCA) team recommend on reviewing this situation?

Back 18

Though this is required by NPSG 3b, “Standardize and limit the number of drug concentrations used by the Organization,” a team might find a new and better systems-based way to do this, perhaps a stronger action that might have been previously overlooked. How well have the number of concentrations of Heparin have been minimized within the facility?

Front 19

What could a Root Cause Analysis (RCA) team recommend on reviewing a closed drug delivery system that uses “Cubie Drawers™” (lidded bins)?

Back 19

In such a system, only active drugs on the patient profile may be accessed from that system’s dispensing machine. An action of this type is more likely to eliminate or greatly reduce the likelihood of an adverse event. Correct refilling of the drug can be assured by bar coding the replacement prior to replenishing the dispensing unit.

Mixing drug delivery product lines is another example of a stronger action. Using a combination of amps, vials, and syringe delivery systems helps to differentiate products, thus applying human factors principles. Implementing a mixture of delivery systems can also help to minimize drug mix-ups. Most VA medical centers use the Carpuject™ syringe system for delivery of injectable drugs. Medication events have been reported because of the similarity of drugs stocked within this system. Using a mixture of delivery systems can help to minimize or eliminate drug mix-ups.

As a final example of a stronger, systemic action, RCA teams could consider the feasibility of using different companies or package sizes to differentiate products. Manufacturers often design a similar look and size for packaging to enhance brand recognition, not to promote patient safety. By mixing manufacturers’ products, packaging is easier to distinguish. Further, using different sized packages for different forms of creams, ointments, and gels can also help to differentiate products.

Over seventy different medications are available in the Carpuject™ system. Problems have occurred because of the similarity in shape and size of the system.