Patient safety goals are essential to the well-being of patients and the success of hospitals and other healthcare establishments. In 2002, The Joint Commission, an organization that accredits healthcare organizations and programs, established the National Patient Safety Goals program to assist accredited organizations in addressing areas of concern.
The Joint Commission gathers input from practitioners, consumer groups and other stakeholders annually to determine the highest priority issues affecting safety in hospitals and other healthcare institutions. The seven 2019 National Patient Safety Goals for hospitals provide a guideline to combat those issues that stood out most recently.
2019 Patient Safety Goals
National patient safety goals for hospitals that became effective in January of 2019 include:
- Improving patient identification
- Cultivating communication among caregivers
- Ensuring the safety of medication use
- Reducing harm caused by the use of alarm systems
- Avoiding healthcare-induced infections
- Identifying safety risks in patients
- Preventing mistakes in surgery
The goals are lofty but necessary. Healthcare professionals’ understanding of new requirements and how to put them into action is the key to success. Let’s look at each of these goals in more detail.
Improve the Accuracy of Patient Identification
The Joint Commission points out that errors involving treating the wrong patient occur at all stages of the healthcare process, from diagnosis to treatment. Newborns are at a higher risk of misidentification due to their inability to identify themselves and lack of recognizable differentiating features.
A review of studies by the ERCI Institute found that 97 percent of clinicians at one hospital reported charting or entering orders on the wrong patient within the prior three months. While many of these errors are caught, others are not. From incorrect wrist band information to surgery on the wrong patient, the consequences can be dire.
To improve the accuracy of identifying patients, The Joint Commission requires:
- Using at least two patient identifiers when administering medications, providing other treatment or procedures and collecting blood or other bodily fluids
- Labeling containers for blood and other specimens with the patient present
- Using distinct methods of identifying newborn patients, including clear naming systems, standardized practices for identification banding and communication tools among staff to identify things such as newborns with similar names
Improve the Effectiveness of Communication Among Caregivers
This goal is meant to ensure the results of critical tests and diagnostic procedures are communicated to other caregivers in a timely manner. Critical results are abnormal results that are life threatening and require a rapid response from caregivers.
The American Association for Clinical Chemistry (AACC) stated, “In a rapidly changing information technology environment, lab results now compete with a swelling, cacophonous chorus of alerts and alarms that follow physicians throughout their day, often from the very electronic health records designed to streamline communications.” It’s clear that guidelines need to be in place for health information that is essential to the care providers.
Licensed caregivers should receive critical results within an established timeframe, so patients are treated promptly and correctly. To make this happen, The Joint Commission recommends:
- Developing written procedures for managing critical results, including defining what critical results are, who needs to report the results and who needs to receive the results
- Evaluating the timeliness of reporting critical results of tests
Improve the Safety of Using Medications
This goal addresses unlabeled medications. According to The Joint Commission, unlabeled medication has resulted in errors with tragic results. Unfortunately, the Commission found that moving medications and solutions from their original bottles into unmarked containers is common in many organizations.
A mix-up in medications can have lasting effects on a patient, even leading to death in some cases. Labeling can reduce this pressing risk. To ensure that harm is not brought to patients because of mislabeled or unlabeled medications, guidelines include:
- Labeling all medications that as they’re prepared, when they’re not immediately administered and when they’re transferred from original packaging into another container. Any unlabeled medication or solution should be discarded
- Labels should include the medication or solution name, the strength, the amount of medication or solution contained, the name and volume of any diluent and the expiration date and time
- Verifying all medication or solution labels verbally and visually by two individuals when the person preparing the medication is not the person administering it
Reduce Harm Associated with Clinical Alarm Systems
The clinical alarm systems meant to help keep patients safe can sometimes do more harm than good if they’re not used correctly. Numerous alarm systems can desensitize or overwhelm healthcare professionals and cause them to miss alerts, or worse, disable the alarm systems.
The AAMI Foundation stated, “When alarms don’t work well, they pull caregivers away from other duties and other patients — or worse, train caregivers to ignore the alarm sounds altogether. Alarms that are ignored can and have resulted in patient deaths.”
The Joint Commission recommends that each hospital or unit develop a systematic alarm system that works for them. In addition, it recommends:
- Establishing alarm system safety as a hospital priority and educating staff and independent practitioners about the purpose and operation of their alarm systems
- Identifying the most important alarm systems to manage based on input from medical staff, the risk to patients and published best practices
- Creating policies and procedures for how to deal with alarms, including when alarm systems can be disabled, who can set alarm parameters and how to monitor and respond to alarm signals
Reduce the Risk of Healthcare-Associated Infections
According to the Centers for Disease Control and Prevention (CDC), on average, healthcare providers clean their hands half as often as they should. Furthermore, one in 25 hospital patients suffers from at least one healthcare-associated infection each day. That means millions of people acquire an infection while receiving care each year, including infections resistant to antibiotics.
Thus, hospitals must focus on hand washing hygiene guidelines to protect their patients. A few of these guidelines include:
- Implementing a program that complies with either the CDC or the World Health Organization’s (WHO) hand hygiene guidelines
- Setting goals and improving compliance with hand hygiene guidelines
- Educating staff and patients about multidrug-resistant infections and prevention strategies
Identify Safety Risks Inherent in the Patient Population
Healthcare professionals are often in a unique position to identify patients at risk for suicide. While it’s most important and only required in psychiatric hospitals or in patients being treated for emotional and behavioral disorders in general hospitals, all healthcare professionals can use these guidelines to help patients.
According to the CDC, in 2017, suicide was the tenth leading cause of death in the overall patient population. Suicide while in a staffed care setting is frequently reported.
Here are some steps from The Joint Commission to reduce the number of suicides in patients:
- Conducting risk assessments to identify patient characteristics and environmental features that affect the risk for suicide
- Addressing patients’ immediate safety needs
- Providing suicide prevention information to a patient or family member when they leave a healthcare facility
Prevent Mistakes in Surgery
Mistakes in surgery do happen, leading to clear steps being put in place to reduce the incidence of surgery mishaps. While research shows surgical errors are relatively rare, occurring in one in 112,000 procedures, the number could be higher since only surgeries performed in operating rooms are recorded.
The Joint Commission stated that evidence indicates the procedures where patients are most at risk are those where general anesthesia or deep sedation is used. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM includes:
- Conducting a pre-procedure verification process which consists of an ongoing method of gathering information and confirming that everything aligns with the patient’s needs and expectations
- Marking the procedure site when there is more than one possible location for the procedure, such as different limbs or lesions, with patient involvement if possible
- Identifying all the items that must be available for the procedure with a standardized list, including relevant documentation, labeled diagnostic test results and any blood products, implants, devices and special equipment needed for the procedure
- Performing a standardized time-out before the procedure with the members of the procedure team to conduct a final assessment that the correct patient, site and procedure are clear
Make a Difference in Patient Safety
Ensuring patient safety in hospitals is a huge task and an important one. The guidelines and requirements provided offer a fantastic roadmap, but implementing them is a unique challenge. It requires skill, training and a clear understanding of all patient safety goals.
Every healthcare professional on staff must take responsibility to make sure all patients in hospitals are free from harm due to error or deviance from protocol. Any improvements made over time indicate a true win for the healthcare professionals who worked hard to make them happen. Most importantly, advances in patient safety lead to better outcomes for the patient population.
If you’re interested in making a difference in patient safety, consider earning your health services management degree from Jefferson Online. A bachelor’s degree in health services management gives you a unique understanding of the needs of the changing healthcare industry. Our program is fully online, and we offer rolling admissions. Staffed with a faculty with years of real-world experience, Jefferson ensures you’ll be prepared to make a true impact in several healthcare settings upon graduation.