Opportunities & challenges with patient safety goals

2022 Hospital
National Patient Safety Goals

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems
in health care safety and how to solve them.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can
be found at www.jointcommission.org.

Get important test results to the right staff person on time.

Reduce the risk for suicide.

Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the
World Health Organization. Set goals for improving hand cleaning. Use the goals to improve
hand cleaning.

Make sure that the correct surgery is done on the correct patient and at the correct place
on the patient’s body.

Mark the correct place on the patient’s body where the surgery is to be done.

Pause before the surgery to make sure that a mistake is not being made.

Use at least two ways to identify patients. 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.

Identify patients correctly
NPSG.01.01.01

Prevent infection
NPSG.07.01.01

Improve staff communication
NPSG.02.03.01

Identify patient safety risks
NPSG.15.01.01

Prevent mistakes in surgery
UP.01.01.01

UP.01.02.01

UP.01.03.01

Before a procedure, label medicines that are not labeled. For example, medicines in syringes,
cups and basins. Do this in the area where medicines and supplies are set up.

Take extra care with patients who take medicines to thin their blood.

Record and pass along correct information about a patient’s medicines. Find out what
medicines the patient is taking. Compare those medicines to new medicines given to the patient.
Give the patient written information about the medicines they need to take. Tell the patient it is
important to bring their up-to-date list of medicines every time they visit a doctor.

Use medicines safely

NPSG.03.04.01

NPSG.03.05.01

NPSG.03.06.01

Make improvements to ensure that alarms on medical equipment are heard and responded to
on time.

Use alarms safely

NPSG.06.01.01

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 15

A New Mindset for Quality and Safety:
The QSEN Competencies Redefine Nurses’
Roles in Practice

I
mproving the quality and safety of
our healthcare system is the most
pressing issue of our time. Since the
Institute of Medicine (IOM) reveal –

ed the magnitude of quality and safe-
ty outcomes in its report, To Err Is
Human: Building a Safer Health System
(IOM, 2000), there has been a grow-
ing series of efforts for improvements,
including changes to health profes-
sions education. In 2003, the IOM
called for a new framework that would
prepare all health professionals with
six core competencies to be able to
deliver patient-centered care through
teamwork and collaboration, with
evidence-based care from continuous
quality improvement, with a mindset
for safety and employing informatics.
These competencies are the founda-
tion to develop and work in cultures
of quality and safety, and change the
mindset from a focus on individual
provider to a system perspective to
improve outcomes. While the compe-
tencies are familiar terms, they were
redefined for nurses in 2007 by the
Quality and Safety Education for
Nurses (QSEN) project with a new set
of knowledge, skills, and attitudes that
change how nurses work (Cronenwett
et al., 2007).

Gwen Sherwood
Meg Zomorodi

Continuing Nursing
Education

Gwen Sherwood, PhD, RN, FAAN, is Professor
and Associate Dean for Academic Affairs,
University of North Carolina at Chapel Hill,
School of Nursing, Chapel Hill, NC, and Co-
Investigator, Quality and Safety Education for
Nursing (QSEN). She may be contacted directly
via email at [email protected]

Meg Zomorodi, PhD, RN, CNL, is a Clinical
Associate Professor, University of North Carolina at
Chapel Hill, School of Nursing, Chapel Hill, NC.

Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-
tion to this continuing nursing education activity.

Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 23.

This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).

American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.

This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.

Copyright 2014 American Nephrology Nurses’ Association

Sherwood, G., & Zomorodi, M. (2014). A new minds

Goal 1
Improve the accuracy of patient identification.

NPSG.01.01.01

Use at least two patient identifiers when providing care, treatment, and services.

–Rationale for NPSG.01.01.01–

Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-
fold: first, to reliably identify the individual as the person for whom the service or treatment is intended;
second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s
name, an assigned identification number, telephone number, or other person-specific identifier.

Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable
features. In addition to well-known misidentification errors such as wrong patient/wrong procedure,
misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which
poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system
among all providers is necessary to prevent errors.

Element(s) of Performance for NPSG.01.01.01

1. Use at least two patient identifiers when administering medications, blood, or blood components; when
collecting blood samples and other specimens for clinical testing; and when providing treatments or
procedures. The patient’s room number or physical location is not used as an identifier.
(See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)

2. Label containers used for blood and other specimens in the presence of the patient.
(See also PC.02.01.01, EP 10)

3. Use distinct methods of identification for newborn patients.
Note: Examples of methods to prevent misidentification may include the following:
– Distinct naming systems could include using the mother’s first and last names and the newborn’s
gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
– Standardized practices for identification banding (for example, using two body sites and/or bar coding
for identification).
– Establish communication tools among staff (for example, visually alerting staff with signage noting
newborns with similar names).

© 2020 The Joint Commission
Page 1 of 14

Report Generated by DSSM
Wednesday, Oct 28 2020

National Patient Safety Goals Effective
January 2021 for the Hospital Program

Goal 2
Improve the effectiveness of communication among caregivers.

NPSG.02.03.01

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

–Rationale for NPSG.02.03.01–

Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate
a life-threatening situation. The objective is to provide the responsible licensed caregiver thes

# 1

Opportunities & Challenges with Patient Safety Goals

Annerys Velazco

St. Thomas University

NUR 415 AP 1

Dr. Rosa Rousseau

08/04/22

 

The Joint Commission established the National Patient Safety Goals in 2003 as a program to promote quality and patient safety. The NPSGs were developed to assist accredited organizations in addressing specific patient safety concerns. The selected 2022 NPSG for this study is Goal 3: improving the safety of using medications (NPSG.03.04.01). In perioperative and other procedural settings, all drugs should be labeled, including medication containers, and other solutions on and off the sterile field. In this case, medication containers include syringes, medicine cups, and basins. In the clinical settings, the unlabeled medications and other solutions are usually unidentifiable. As a result, errors, sometimes fatal, have occurred as a result of drugs and other solutions being removed from their original containers and placed in unlabeled containers (Larmené-Beld et al., 2018). This dangerous practice is a direct violation of the basic principles of safe medication administration, and yet, it is common practice in many workplaces. Therefore, this NPSG goal ensures that there is labeling of all pills, medication containers, and other solutions in a process that is risk-reducing and is much compatible with good medication management practices. Further, the goal addresses a known danger point in the delivery and administration of drugs in perioperative and other procedural settings.

To fully achieve this goal there are various elements of performance that need to be achieved. First, the healthcare provider has to label drugs and solutions that are not immediately provided in the perioperative and other procedural settings. This is true even if only one medicine is utilized. According to Bowdle et al. (2018), in the sterile field today, the labelling errors usually involve the mixing of two liquids in labelled containers. As such, the approach that is necessary to prevent these errors, supported by 2022 NPSG goal 3, is straightforward and very simple and that is; correct and full labeling of all solution and drug containers on the sterile field in every procedural area, every time. The second element of performance is that labeling occurs in perioperative and other procedural settings on and off the sterile field when any medical solution is transferred from the original packing to another container. The basic function of a label in this case is to guarantee that healthcare provider and the patient can readily identify the medicine even if it has been placed in a new container. It is essential to note that, there may arise confusion between medications with similar names, labels, or packaging. This has been recognized as a major source of error among healthcare providers who administer medication to patients.<

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