National Patient Safety Goals (NPSGs) and Universal Protocol 2011 Update

National Patient Safety Goals (NPSGs) and Universal Protocol

2011 Update

The Joint Commission

2011 Goals1. Improve the accuracy of patient

identification

2. Improve the effectiveness of communication among caregivers

3. Improve the safety of using medications

7. Reduce the risk of healthcare-associated infections

15. Identify safety risks inherent in patient populations

NPSG 1: Improve the Accuracy of Patient Identification NPSG.01.01.01

Use at least two patient identifiers when providing care, treatment or services administering medications, blood, or blood components collecting blood samples and other specimens for clinical testing providing treatments or procedures.

The patient’s room number or physical location is not used as an identifier.

Label containers for blood and other specimens in the presence of the patient.

Policy # PC124MV

NPSG.01.01.03 Eliminate transfusion errors related to patient misidentification

Before initiating a blood or blood component transfusion:

Match the blood or blood component to the order Match the patient to the blood or blood component Use a 2-person verification process, or a one-person

verification process accompanied by automated identification technology, such as bar coding.

When using a two-person verification process one individual conducting the identification verification is

the qualified transfusionist who will administer the blood or blood component to the patient

the second individual is qualified to participate in the process, as determined by the hospital.

Policy # PC071MV

NPSG 2 Improve the effectiveness of communication among caregivers

02.03.01 Develop and implement written procedures for managing the critical results of tests and diagnostic procedures that address :

The definition of critical results By whom and to whom critical results are reported The acceptable length of time between availability

and reporting of critical results Readback to confirm correct information understood

Evaluate the timeliness of reporting the critical results

Policy # PC050MV

Critical Results ReportingPercent Called Within 60 Minutes

60%

80%

100%Goal

NPSG 3: Improve the safety of

using medications 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.

Elements of Performance NPSG 03.04.01

In peri-operative and other procedural settings:Label medications and solutions that are not immediately administered. (This applies even if there is only one medication being used.)

Labeling occurs when any medication or solution is transferred from the original packaging to another container.

Labels include the following: Medication name Strength Quantity Diluent and volume (if not apparent from the container) Expiration date when not used within 24 hours Expiration time when expiration occurs in less than 24 hours

Elements of Performance for NPSG 03.04.01

Verify all medication or solution labels both verbally and visually. Verification is done by two individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it.

Label each medication or solution as soon as it is prepared, unless it is immediately administered.

Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process.


Immediately discard any medication or solution found unlabeled

Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.Note: This does not apply to multi-use vials that are handled according to infection control practices.

All medications and solutions, both on and off the sterile field, and their labels, are reviewed by entering and exiting staff responsible for the management of medications.

NPSG 3: Improve the safety of

using medications 03.05.01 Reduce the likelihood of patient harm associated with anticoagulant therapy

Policy # MM004MV


Use only oral unit-dose products, pre-filled syringes, or premixed infusion bags when these types of products are available.

Use approved protocols for the initiation and maintenance of anticoagulant therapy. The written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants.

Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current INR to adjust this therapy. The baseline status and current INR are documented in the medical record.

Use a clinical dietician to manage potential food and drug interactions for patients receiving warfarin.

When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing.


Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families.

Patient/family education includes the following: The importance of follow-up monitoring Compliance Drug-food interactions The potential for adverse drug reactions and interactions

Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization.

Reconciling Medication Information

NPSG 03.06.01Maintain and communicate accurate patient medication information


Obtain information on the medications the patient is currently taking when admitted to the hospital or seen in an outpatient setting

Define the types of medication information to be collected in non-24 hour settings (such as outpatient radiology) and different patient circumstances.

Compare the medication information the patient brought to the hospital with the medications ordered for the patient in the hospital to identify and resolve discrepancies.


Provide the patient/family with written information on the medications the patient should be taking when they are discharged from the hospital, or at the end of an outpatient encounter.

Explain the importance of managing medication information to the patient when discharged from the hospital, or at the end of an outpatient encounter

NPSG 7: Reduce the Risk of Health Care-Associated Infections

07.01.01 Implement a program that follows either the current CDC or WHO hand hygiene guidelines

Set goals for improving compliance with hand hygiene guidelines

Improve compliance based on established goals

Policy # IP054MV


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

Note: Applies to, but is not limited to, epidemiologically important organisms such as MRSA, clostridium dificile, VRE, and multi-drug-resistant gram negative bacteria.


Risk Assessment

Policies and best practices

Education for staff and physicians

Education for patients & families

Surveillance program

Measure outcomes

Provide data to leaders, physicians, nursing & clinical staff

Alert system for patients with known colonization or infection


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

Note: This requirement covers short-term and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.


Central venous catheter insertion checklist & standardized protocol

Femoral veins not used for adults when possible

Standardized supplies

Protocol for barrier precautions during insertion

Skin antiseptic per literature

Protocol to disinfect hubs/ports

Education for staff & physicians

Educate patients/families

Policies/practices

Risk assessments

Data provided to leaders, physicians, nursing and clinical staff

Evaluate all central venous catheters routinely, & remove when no longer needed


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


Risk assessments

Select best practice measures/monitor compliance

Antimicrobial prophylaxis Hair removal

Policies/practices

Educate staff and physicians

Educate patients/families

Measure infection rates 30 days post procedure or for 1 year if implantable device

Evaluate effectiveness of prevention efforts

Data to leaders, physicians, nursing & clinical staff

Goal 15: The Organization Identifies Safety Risks Inherent In Its Patient Population

NPSG 15.01.01Identify patients at risk for suicide.

Elements of PerformanceRisk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.

Address the patient’s immediate safety needs and most appropriate setting for treatment

When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information to the patient and their family.

Policy # PE024MV

Universal ProtocolPrevention of Wrong Person, Wrong Procedure,

Wrong Site Surgery

UP.01.01.01 Conduct a pre-procedure verification process, involving the patient if possible - verify correct patient, correct procedure, correct site

Identify the items that must be available for the procedure, and use a standardized list to verify their availability. At a minimum, these items include:

Relevant documentation (H&P, signed consent form, nursing assessment, pre-anesthesia assessment)

Any required blood products, implants, devices, and/or special equipment for the procedure

Labeled diagnostic and radiology test results that are properly displayed

Match the items that are to be available in the procedure area to the patient

UP 01.02.01 Mark The Procedure Site

Identify those procedures that require marking of the incision or insertion site (more than one possible location for the procedure, and performing the procedure in a different location would negatively affect quality or safety)

Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure, and will be present when the procedure is performed.

The method of marking the site and the type of mark is unambiguous, and is used consistently throughout the hospital.

A written alternative process is in place for patients who refuse site marking, or when it is technically or anatomically impossible or impractical to mark the site. (e.g. mucosal surfaces or perineum, teeth, premature infants for whom the mark may cause a permanent tattoo)

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

Conduct a time-out immediately before starting the invasive procedure or making the incision.

The time-out has the following characteristics: Standardized Initiated by a designated member of the team Involves immediate members of the procedure team

(Individual performing the procedure, anesthesia provider, circulating RN, OR tech, and other active participants)

When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated

Team members agree, at a minimum on correct patient ID, correct site, correct procedure to be done

Document the completion of the time-out

Policy # PC274MV

Where to find the NPSG’s?

Inside St. Luke’s

Quality and Patient Safety

Patient Safety

National Patient Safety Goals 2011

Documents

National Patient Safety Goals (NPSGs) and Universal Protocol 2011 Update