The Joint Commission’s 2011 National Patient Safety Goals

The Joint Commission’s
2011
National Patient Safety Goals
Objectives


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Identify National Patient Safety Goals which
apply to hospital settings.
List two hospital patient safety standards.
Indicate the importance of the National
Patient Safety Goals and The Joint
Commission accreditation.
Background…did you know?

The National Patient Safety Goals
(NPSGs) were established in 2002
(became effective January 1, 2003) to
address specific areas of concern in
regards to patient safety
Background…did you know?

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.
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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.
NPSG Revisions for 2011

The Joint Commission revised four Elements of
Performance (EP’s) within the Goals.

The revised EP’s are effective immediately.

NPSG #8 on medication reconciliation is not
included in the changes; additional work is being
done to evaluate and refine the medication
reconciliation expectations for accredited
organizations.
2011 National Patient Safety Goals
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Now let’s review what the 2011 NPSG’s
are for a hospital setting…
There are six NPSG’s for accredited
hospital organizations and a Universal
Protocol
Revisions are in BOLD
GOAL 1: PATIENT
IDENTIFICATION
Improve the accuracy of patient
identification.

NPSG.01.01.01: Use of two patient identifiers when
providing care, treatment and services.

NPSG.01.03.01: Eliminate transfusion errors related to
patient misidentification.
GOAL 2: IMPROVE
COMMUNICATION
Improve the effectiveness of
communication among caregivers.

NPSG.02.03.01: Report critical results of tests and
diagnostic procedures on a timely basis.
GOAL 3: MEDICATION SAFETY
Improve the safety of using medications.

NPSG.03.04.01: Label all medications, medication
containers, and other solutions on and off the sterile field
in perioperative and other procedural settings.

NPSG.03.05.01: Reduce the likelihood of patient harm
associated with the use of anticoagulant therapy.
Goal 7: Health Care-Associated
Infections
Reduce the risk of health careassociated infections.
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NPSG.07.01.01: Comply with hand hygiene guidelines.
NPSG.07.03.01: Implement evidence-based practices to
prevent multidrug-resistant organism infections in acute
care organizations.
NPSG.07.04.01: Implement evidence-based practices to
prevent central line-associated bloodstream infections.
NPSG.07.05.01: Implement evidence-based practices for
preventing surgical site infections.
Goal 8: Reconcile Medications
Accurately and completely reconcile
medications across the continuum of care.
The implementation date for the revised medication reconciliation requirement
for NPSG 8 will be July 2011.

NPSG.08.01.01: Comparing Current and Newly Ordered Medications.
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NPSG.08.02.01: Communicating Medications to the Next Provider.
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NPSG.08.03.01: Providing a Reconciled Medication List to the Patient
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NPSG.08.04.01: In settings where medications are used minimally, or prescribed for
a short duration, modified medication reconciliation processes are performed.
GOAL 9: Patient Falls
The goal of reducing patient harm resulting
from falls has now become a
STANDARD!!
Goal 14: Pressure Ulcers
The goal of preventing health care-associated
pressure ulcers (decubitus ulcers) has now
become a STANDARD!!
Goal 15: Safety Risk
The organization identifies safety risks inherent in its
patient population.

NPSG.15.01.01: Identifying Individuals at Risk for Suicide
NPSG for Hospitals

All hospitals receiving accreditation from
The Joint Commission must implement the
6 NPSG requirements in an effort to
maintain safe environments and provide
quality care to all patients.
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery
The organization meets the expectations of the Universal
Protocol.
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UP.01.01.01: Conduct a preprocedure verification process.
UP.01.02.01: Mark the procedure site.
UP.01.03.01: A time-out is performed before the procedure.
For more information:
www.jointcommission.org