What’s New in the Patient Safety World

December 2016

The Joint Commission NPSG for CAUTI’s



The Joint Commission has revised for 2017 NPSG.07.06.01, its national patient safety goal for prevention of CAUTI’s (catheter-associated urinary tract infections).


The elements of performance for NPSG.07.06.01 are:

  1. Educate staff and licensed independent practitioners involved in the use of indwelling urinary catheters about CAUTI and the importance of infection prevention. Education occurs upon hire or granting of initial privileges and when involvement in indwelling catheter care is added to an individual’s job responsibilities. Ongoing education and competence assessment occur at intervals established by the organization.
  2. Educate patients who will have an indwelling catheter, and their families as needed, on CAUTI prevention and the symptoms of a urinary tract infection.
  3. Develop written criteria, using established evidence-based guidelines, for placement of an indwelling urinary catheter. Written criteria are revised as scientific evidence changes. (Examples are provided in the document and we’ve provided them in our many columns on CAUTI prevention listed below).
  4. Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter. The procedures address the following:

-          Limiting use and duration

-          Performing hand hygiene prior to catheter insertion or maintenance care

-          Using aseptic techniques for site preparation, equipment, and supplies

-          Securing catheters for unobstructed urine flow and drainage

-          Maintaining the sterility of the urine collection system

-          Replacing the urine collection system when required

-          Collecting urine samples
(The NPSG acknowledges that there are certain medical conditions, predominantly neurological ones, that require a prolonged use of an indwelling urinary catheter in order to avoid adverse events and promote patient safety.)

  1. Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following:

-          Selecting measures using evidence-based guidelines or best practices

-          Having a consistent method for medical record documentation of indwelling urinary catheter use, insertion, and maintenance.

-          Monitoring compliance with evidence-based guidelines or best practices

-          Evaluating the effectiveness of prevention efforts
(The NPSG notes that surveillance may be targeted to areas with a high volume of patients using in-dwelling catheters, as identified through the hospital’s risk assessment.)


Of course, we are advocates of incorporating your evidence-based criteria into your CPOE system. That can help ensure appropriate use of catheters and may help you meet some of the documentation requirements. Innovative hospitals will also use barcoding to help create documentation for things like time of insertion, review for continuation, etc.


This NPSG and all the other 2017 National Patient Safety Goals are now available on The Joint Commission website (TJC 2016).




Our other columns on urinary catheter-associated UTI’s:








The Joint Commission. Hospital Accreditation Program. National Patient Safety Goals Effective January 2017. Accessed November 18, 2016







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