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What’s New in the
Patient Safety World
December 2020
Joint Commission
2021 National Patient Safety Goals
The Joint Commission
has announced its 2021 National Patient Safety Goals (TJC
2020). The NPSG’s for hospitals
are:
Goal 1. Improve the
accuracy of patient identification.
· NPSG.01.01.01 Use at least two ways to
identify patients. For example, use the patient’s name and date of birth. This
is done to make sure that each patient gets the correct medicine and treatment
Goal 2. Improve the effectiveness of communication among caregivers.
· NPSG.02.03.01 Get important test results to
the right staff person on time
Goal 3. Improve the
safety of using medications.
· NPSG.03.04.01 Before a procedure, label
medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and
supplies are set up.
· NPSG.03.05.01 Take extra care with patients
who take medicines to thin their blood.
· NPSG.03.06.01 Record and pass along correct
information about a patient’s medicines. Find out what medicines the patient is
taking. Compare those medicines to new medicines given to the patient. Give the
patient written information about the medicines they need to take. Tell the
patient it is important to bring their up-to-date list of medicines every time
they visit a doctor.
Goal 6. Reduce patient harm associated with clinical alarm systems.
· NPSG.06.01.01 Make improvements to ensure
that alarms on medical equipment are heard and responded to on time.
Goal 7. Reduce the risk of healthcare–associated infections.
· NPSG.07.01.01 Use the hand cleaning
guidelines from the Centers for Disease Control and Prevention or the World
Health Organization. Set goals for improving hand cleaning. Use the goals to
improve hand cleaning.
Goal 15. The hospital identifies safety risks inherent in its
patient population.
· NPSG.15.01.01 Reduce the risk for suicide.
Universal Protocol. Introduction to the Universal Protocol for Preventing Wrong
Site, Wrong Procedure, and Wrong Person Surgery™
· UP.01.01.01 Make sure that the correct
surgery is done on the correct patient and at the correct place on the
patient’s body.
· UP.01.02.01 Mark the correct place on the
patient’s body where the surgery is to be done.
·
UP.01.03.01
Pause before the surgery to make sure that a mistake is not being made
You can access the NPSG’s for other venues at the Joint
Commission’s NPSG
website.
We’ll comment on the Elements of
Performance for just a few of these NPSG’s.
Element(s) of Performance for NPSG.07.01.011 really focus on
hand hygiene They require you implement a program following either the current
CDC or WHO hand hygiene guidelines, that you set goals for compliance, and you
actually improve compliance based on those goals.
Element(s) of Performance for NPSG.02.03.01
1. Develop written procedures for managing the critical
results of tests and diagnostic procedures that address the following:
- The definition of critical results of tests and diagnostiic procedures
- By whom and to whom critical results of tests and diagnosstic procedures are
reported
- The acceptable length of time between the availability annd reporting of
critical results of tests and diagnostic procedures
2. Implement the procedures for managing the critical
results of tests and diagnostic procedures.
3. Evaluate the timeliness of reporting the critical results
of tests and diagnostic procedures.
We refer you to our many columns on “communicating
significant results” listed below.
See also our other
columns on communicating significant results:
- May 1,
2007 “The
Missed Cancer”
- February
12, 2008 “More
on Tracking Test Results”
- October
13, 2009 “Slipping
Through the Cracks”
- July
2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- March
9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- March 1, 2011 “Tests Pending at Discharge”
- August 21, 2012 “More on Missed Followup
of Tests in Hospital”
- October
2, 2012 “Test
Results: Everyone’s Worst Nightmare”
- March
12, 2013 “More
on Communicating Test Results”
- October 2013 “New AHRQ Toolkit: Improving Your Office
Testing Process”
- January 2014 “Email Alerts for Pending Test Results”
- July 2015 “Technology to Avoid Delays in Follow-up
of Significant Results”
- November 17, 2015 “Patient
Perspectives on Communication of Test Results”
- December 20, 2016 “End-of-Rotation
Transitions and Mortality”
- September 2018 “ECRI
Institute Partnership: Closing the Loop”
- September 24, 2019 “EHR-related Malpractice
Claims”
- November 26, 2019 “Pennsylvania Law on
Notifying Patients of Test Results”
- January 2020 “The Joint Commission on
Closing the Loop”
- September 8, 2020 “Follow Up on Tests
Pending at Discharge”
References:
The Joint Commission. National Patient Safety Goals
Effective January 2021 for the Hospital Program. The Joint Commission 2020
The Joint Commission. 2021 National Patient Safety Goals.
The Joint Commission 2020
https://www.jointcommission.org/standards/national-patient-safety-goals/
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