Major changes in this sixth annual issuance of National Patient Safety Goals include a new requirement to take specific actions to reduce the risks of patient harm associated with the use of anticoagulant therapy, and a new goal and requirement that address the recognition of and response to unexpected deterioration in a patients condition. These changes were recently approved by the Joint Commissions board of commissioners.
The new anticoagulant therapy requirement addresses a widely-acknowledged patient safety problem and becomes a key element of the goal: Improve the safety of using medications. It is applicable to hospitals, critical access hospitals, ambulatory care and office-based surgery settings, and home care and long-term care organizations. The new goal and requirement respecting the deteriorating patient will ask hospitals and critical access hospitals to select a suitable method for enabling care-givers to directly request and obtain assistance from a specially-trained individual(s) if and when a patients condition worsens. Each of the foregoing new requirements has a one-year phase-in period that includes defined milestones. Full implementation is targeted for January 2009.
Additionally, the requirement related to hand hygiene has been expanded to permit use of the World Health Organization (WHO) Hand Hygiene Guidelines as an alternative to the Centers for Disease Control and Prevention (CDC) guidelines.
Finally, the requirement to limit and standardize drug concentrations that is part of the goal to improve the safety of using medications will be retired as a National Patient Safety Goal, but organization compliance will continue to be evaluated as part of Medication Management standards compliance.
The 2008 National Patient Safety Goals seek to focus the efforts of healthcare organizations on the priority areas where opportunities for improving patient safety are greatest, says Dennis S. OLeary, MD, president of the Joint Commission. Consistently putting these Requirements into action will benefit millions of patients.
The development and annual updating of the National Patient Safety Goals and Requirements continue to be overseen by an expert panel that includes widely recognized patient safety experts, as well as nurses, physicians, pharmacists, risk managers and other professionals who have hands-on experience in addressing patient safety issues in hospitals and other health care settings. Each year, this Sentinel Event Advisory Group works with the Joint Commission to undertake a systematic review of the literature and available databases to identify candidate new goals and requirements. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other parties of interest, the Advisory Group determines the highest priority goals and requirements and makes its recommendations to the Joint Commission.
The 2008 Hospital and Critical Access Hospital National Patient Safety Goals are:
-- Improve the accuracy of patient identification.
· Use at least two patient identifiers when providing care, treatment, or services.
-- Improve the effectiveness of communication among caregivers.
· For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and read-back the complete order or test result.
· Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
· Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
· Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.
-- Improve the safety of using medications.
· Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
· Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
· Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
-- Reduce the risk of health care-associated infections.
· Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
· Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healt care-associated infection
-- Accurately and completely reconcile medications across the continuum of care.
· There is a process for comparing the patients current medications with those ordered for the patient while under the care of the organization.
· A complete list of the patients medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.
-- Reduce the risk of patient harm resulting from falls.
· Implement a fall reduction program including an evaluation of the effectiveness of the program.
-- Encourage patients active involvement in their own care as a patient safety strategy.
· Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
-- The organization identifies safety risks inherent in its patient population.
· The organization identifies patients at risk for suicide. (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.)
-- Improve recognition and response to changes in a patients condition.
· 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 patients condition appears to be worsening.
Source: Joint Commission