2015 – Patient Safety Goal Review

The goals listed below are the items identified by the Joint Commission for Health Care Accreditation for 2015. Each year the JC identifies the goals that it feels will help improve the levels of patient care and safety in health care organizations around the world.

These goals were developed by a panel of patient safety experts made up of nurses, physicians, risk managers, and others who have experience with patient safety issues.

To improve the accuracy of patient identification:

1. Two identifiers should be used to confirm a patient receiving treatment or medication. All specimens and blood samples should be labeled at the bedside in order to minimize confusion. Possible identifiers could include: name, medical record, birth date, telephone number, etc.

2. In an effort to prevent transfusion errors – two identifiers should be used to match blood products and a two person verification process is used. One person must be the person who will administer the blood product, and the other must be qualified to verify blood (per hospital policy). One person verification processes are possible whenever bar coding or other forms of automated identification technology exists.

To improve the effectiveness of communication among caregivers:

3. The Joint Commission recommends creating policies to define critical test results and timeframes for reporting these to the correct personnel.

Improving the safety of using medications:

4. All medications and diluents in any syringe or container are to be labeled with the name of the substance, the strength, the volume and the respective expiration date.

5. Face-to-face anticoagulant therapy risks should be reduced through patient-provider education and face-to-face teaching including the precautions they need to take and the need for regular INR monitoring.

6. Comparing the medications a patient is taking with newly ordered medications to address duplications, omissions, and interactions should be regular practice.

To reduce the harm associated with clinical alarm systems:

7. Recognizing the point at which alarms contribute to noise pollution is crucial. Alarms of all types must be identified, prioritized, and responded to on time.

Reducing the risk of healthcare-associated infections:

8. Standard hand cleaning guidelines from the CDC and WHO are to be employed. Organizations should set goals and assess their compliance with the CDC and / or WHO guidelines and foster a culture of hand hygiene.

9. Hospitals should use proven guidelines such as hand hygiene, contact precautions, and cleaning and disinfecting patient care equipment to prevent the spread of organisms such as methicillin resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE ), and multidrug-resistant gram-negative bacteria.

10. Evidence based guidelines to prevent bloodstream infections from short and long term central venous catheters and peripherally inserted central catheters is crucial.

11. Prevent infection after surgery using best practices and monitor compliance.

12. Implement policies to prevent indwelling catheter-associated urinary tract infections (CAUTI). The usage and total amount of days needed for indwelling catheters should be kept to the absolute minimum.

Identify safety risks inherent in the patient population:

13. Examine psychiatric patients for suicide inclinations. Examine the surrounding environment for features that may or may not increase the risk of suicide. Provide suicide prevention information such as a crisis hotline upon discharge to patients.

Reducing the Amount of Mistakes in Surgery:

14. Pre-procedure verification processes should be conducted – make sure all relevant documents are available and have been reviewed. Ensure preadmission testing and assessment is completed and that missing information or discrepancies are addressed.

15. Mark the correct site on the patient's body where a procedure is to be done. This is especially important for situations in which there is more than one possible location.

16. Employ time-outs prior to surgery. A time-out is a final check that the correct patient, site, and procedure have been identified. Questions or concerns are to be resolved prior to the procedure taking place.