The purpose of the National Patient Safety Goals is to improve patient safety. The Joint Commission established its National Patient Safety Goals (NPSGs) in order to help accredited organizations address specific areas of concern in regard to health care safety, and to focus on how to solve them.  

The Joint Commission determines the highest priority patient safety issues and also whether a goal is applicable to a specific accreditation program and subsequently tailors the goal to be program-specific.

The following define and explain the 2018 National Patient Safety Goals and corresponding Elements of Performance (EPs) that apply particularly to…

Identify patients correctly

NPSG.01.01.01: Use at least two identifiers when providing care, treatment, or services. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

Rationale: Wrong-patient errors occur in virtually all stages of diagnosis and treatment. It is important to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual.

  • Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital

NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification

  • Applies to hospital, ambulatory health care, critical access hospital

Improve the effectiveness of communication among caregivers

NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis

Rationale: Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. Providing the responsible licensed caregiver these results within an established timeframe will allow the patient to be promptly treated.

  • Applies to hospital, critical access hospital

Improve the effectiveness of communication among caregivers.

NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.

Rationale: Develop written procedures for managing the critical results of tests and diagnostic procedures.

  • Applies to hospital

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.

Note: Medication containers include syringes, medicine cups, and basins

Rationale: Medications or other solutions in unlabeled containers are unidentifiable. The labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safe medication management.

  • Applies to hospital, ambulatory health care, critical access hospital

NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Rationale: Anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance. The use of standardized practices for anticoagulation therapy that include patient involvement can reduce the risk of adverse drug events.

  • Applies to hospital, ambulatory health care, critical access hospital

NPSG.03.06.01 Maintain and communicate accurate patient medication information

Rationale: There is evidence that medication discrepancies can affect patient outcomes. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.

  • Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital

Reduce the harm associated with clinical alarm systems

NPSG.06.01.01: Improve the safety of clinical alarm systems

Rationale: Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety.

  • Applies to hospital, critical access hospital

Reduce the risk of health care-associated infections

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.

Rationale: According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations.

  • Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital

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

Rationale: Patients continue to acquire health care–associated infections at an alarming rate. Risks and patient populations, however, differ between hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment.

  • Applies to hospital, critical access hospital

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

  • Applies to hospital, critical access hospital

NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections

  • Applies to hospital, ambulatory health care

NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

Prevent patients from falling

NPSG.09.02.01: Reduce the risk of falls.

Rationale: Falls account for a significant portion of injuries in hospitalized patients, long term care residents, and home care.

The evaluation could include a patient’s fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments recipients.
  • Applies to home care, critical access hospital

The hospital identifies safety risks inherent in its patient population

NPSG.15.01.01: Identify patients at risk for suicide.

Rationale: Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event.

  • Applies to hospital, behavioral health

NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires.

Rationale: A critical aspect of safe patient care at home relates to the use of oxygen. Oxygen administration presents a high risk for fire due to the acceleration of flame that oxygen causes in the presence of flammable substances (such as upholstery and clothing) and open flames (such as candles, gas appliances, and smoking materials).

  • Applies to home care

The hospital identifies safety risks inherent in its patient population

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

Rationale: Hospitals should always make sure that any procedure is what the patient needs and is performed on the right person. The frequency and scope of the verification process will depend on the type and complexity of the procedure.

  • Applies to hospital, ambulatory health care, critical access hospital

UP.01.02.01: Mark the procedure site.

  • Applies to hospital, ambulatory health care, critical access hospital

UP.01.03.01: A time-out is performed before the procedure.

Rationale: The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are identified.

  • Applies to hospital, ambulatory health care, critical access hospital

If you would like to read more about the new National Patient Safety Goals for 2018 or download the entire chapter, or find out which other types of hospitals or health centers these goals apply to, visit the National Patient Safety Goals website.

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