National Patient
Safety Goals
2011

Medical errors are one of the nation’s leading cause of
death and injury.

The Institute of Medicine estimates as many as 44,000 to
98,000 people die each year as a result of medical errors.

Beginning in 2003, The Joint Commission has enforced
national patient safety goals for healthcare organizations
to strive for in order to increase patient safety.
The Joint Commission has identified five Patient Safety
Goals & 1 Universal Protocol to improve patient safety:
1.
2.
Improve the Accuracy of Patient Identification
Improve the Effectiveness of Communication among
Caregivers
3. Improve the Safety of Using Medications
4. Reduce the Risk of Healthcare-Associated Infections
5. The Organization Identifies Safety Risks Inherent in its
Patient Population
U.P. Prevent wrong-site, wrong-procedure and wrong
patient procedures
1. Improve the Accuracy of Patient Identification
Standard:
 Use at least two (2) patient identifiers.

Patient Identifiers must be used….


When administering blood products


When administering medications
When taking blood samples & other specimens
When providing any other treatments or procedures
At SLRHC……..

To confirm a
patient’s identity
Ask the patient’s
name
 Ask for the patient’s
date of birth

Can you tell me your name
and date of birth?

For a patient who cannot
respond:

Check patient’s ID band

Compare ID band to PRISM
record or requisition slip

In an emergency situation - patient may receive treatment
prior to identification if the treatment is deemed necessary to
stabilize the patient’s condition.
1. Improve the Accuracy of Patient Identification
(cont’d)
Standard:


Eliminate transfusion errors related to patient
misidentification.
Before initiating a transfusion, the patient is matched to
the blood / blood component during a two-person
verification process.
2. Improve the Effectiveness of Communication
among Caregivers
Standard:
 Report critical results of tests and diagnostic procedures
on a timely basis.



Lab or diagnostic department personnel will notify appropriate
staff (MD/PA/NP or RN) as soon as possible, but no longer than
30 minutes after the result is available.
STAT requests are treated as alert requests and will be reported
within 1 hour of receipt.
The nurse is responsible to notify the provider within 1 hour of
the time the result is received.
3. Improve the Safety of Using Medications
Standards:

Label all medications, medication containers (i.e.
syringes, medicine cups, basins) or other solutions
on or off the sterile field.

Reduce the likelihood of harm associated with the
use of anticoagulation therapy.
3. Improve the Safety of Using Medications
(cont’d)
Standards:

Maintain and communicate accurate patient
medication information.

Reconcile all medications the patient is currently taking
and document this information in the medical record.

Provide written information on the medications the patient
should be taking upon discharge from the hospital.
4. Reduce the Risk of Healthcare-Associated
Infections
Standards:

Comply with CDC hand hygiene guidelines.

Our Hand Hygiene Team monitors staff compliance with hand
hygiene.
At SLRHC……..

Signs are posted as a reminder to wash hands before
and after patient contact.

Alcohol-based hand cleansers are placed in designated
patient care areas.
4. Reduce the Risk of Healthcare-Associated
Infections (cont’d)
Standards:



Implement evidence-based practices to prevent health
care-associated infections due to multidrug-resistant
organisms.
Implement evidence-based practices to prevent central
line-associated bloodstream infections.
Implement evidence-based practices for preventing
surgical site infections.
5. The organization identifies safety risks inherent in
its patient population
Standard:
 Identify patients at risk for suicide.
At SLRHC….
 All patients admitted for emotional or behavioral
disorders are assessed throughout their stay for
suicide risk.
 Patients on the general inpatient unit are
assessed on admission for suicidal history or
ideation.
Universal Protocol: Prevent Wrong-Site, WrongProcedure and Wrong Patient Procedures



Conduct a pre-procedure verification process.
Mark the procedure site.
Implement a TIME OUT immediately before
starting the procedure to confirm:







Correct patient
Correct procedure
Correct site/location
Correct side
Correct position
Correct implant (when applicable)
Correct supplies/equipment available
At SLRHC……

Verification is conducted by all of the team
members

Site is marked with the proceduralist’s initials
for all procedures involving laterality

“TIME OUT” is used prior to the start of the
procedure and involves ALL team members