Print “PDF version

What’s New in the Patient Safety World

December 2020


·       Joint Commission 2021 National Patient Safety Goals

·       Guidelines for Opioid Prescribing in Children and Adolescents After Surgery

·       ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines

·       Do You Have These Infection Control Vulnerabilities?




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:






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





Print “December 2020 Joint Commission 2021 National Patient Safety Goals







Guidelines for Opioid Prescribing in Children and Adolescents After Surgery



The first-ever guidelines for opioid prescribing in children after surgery were just published in JAMA Surgery (Kelley-Quon 2020). The guidelines were developed by expert panel review and opinion. One particular concern was that opioid prescribing in adolescents may lead to opioid misuse and abuse, potentially leading to opioid addiction. They also recognize that many opioid-free analgesic regimens may be used successfully in children.


The guideline emphasizes use of enteral non-opioid regimens as first line therapy for pain post-operatively but also recommends use of perioperative intravenous non-opioids like ketorolac and acetaminophen.


The guidelines also endorse the FDA guidelines regarding limited use of codeine and tramadol for children younger than 18 years. Our extensive columns on the dangers of codeine (and tramadol) use in children are listed below.


The guideline emphasizes that caregivers and children be educated about expectations and methods of pain management both before the day of surgery and again perioperatively. Pain management messaging should be consistent from all members of the perioperative team. Education should be in plain, nonmedical language, regardless of health literacy level, and delivered in the language most familiar to the family.


If opioids are prescribed, perioperative education should include instruction regarding possible adverse drug events, seriousness of adverse drug events, and what to do if they occur.


It is also recommended to educate caregivers and older children to store opioids in a secure location and properly dispose of unused medication. The guideline recommends health care entities caring for pediatric patients should consider providing infrastructure and means for safe opioid disposal. That infrastructure might include a local drug disposal box in the health care facility or home disposal mechanisms, such as drug deactivation compounds.


Disposal of unused opioids is such an important issue, yet options have been poorly understood. The FDA recommends that such unused opioids be returned to the healthcare facility (or other designated site) but, if that is not possible, they be flushed down the toilet. The FDA has a section on disposal of unused medicines (FDA 2020), including a list of medicines recommended for disposal by flushing, which includes opioids. We’ve always been concerned that flushing results in opioids eventually reaching a water supply where animals or humans will become exposed.


A relatively new approach has been to provide bags of activated charcoal to patients at discharge to be used for inactivation and disposal of unused opioids. Brummett et al (Brummett 2019) found that receiving an activated charcoal bag for in-home disposal of unused opioids was associated with a 3.8-fold increase in self-reported disposal among adults who underwent elective surgical procedure, compared with receiving usual care. It resulted in less flushing and less inappropriate garbage disposal. An abstract recently presented at the annual meeting of the American Society of Regional Anesthesia and Pain Medicine by Yi et al (abstract 830) reported on a small prospective study of providing education and a disposal bag to patients at discharge after surgery. Prior to the intervention, 52% did not dispose of their narcotics. After the education and disposal bag were given, this rate increased to 93.5% (Vlessides 2020). The FDA does have an outstanding “Safe Opioid Disposal - Remove the Risk Outreach Toolkit” that includes a host of posters, public service announcements, and videos on the importance of proper disposal of opioids but has not yet added anything regarding the activated charcoal disposal bags as far as we can see.


It’s important to recognize that non-opioid pain regimens can adequately and more safety control pain after surgery in most cases. But sometimes opioids may be needed. Many studies have shown that we tend to prescribe far more opioid pills than needed when patients are discharged post-surgery. Even with efforts to limit such over-prescribing (at the hospital level, specialty society level, or state health department level), it is inevitable that some patients will be left with opioids that are no longer needed. It’s critical that we not only educate patients and caregivers on proper disposal but give them the tools or infrastructure needed to accomplish safe disposal.



Some of our previous columns on opioid safety issues in children:







Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2020; Published online November 11, 2020



FDA (US Food and Drug Administration). Disposal of Unused Medicines: What You Should Know. FDA 2020



FDA (US Food and Drug Administration). List of medicines recommended for disposal by flushing. Updated: April 2018



Brummett CM, Steiger R, Englesbe M, et al. Effect of an Activated Charcoal Bag on Disposal of Unused Opioids After an Outpatient Surgical Procedure: A Randomized Clinical Trial. JAMA Surg 2019; 154(6): 558-561



Vlessides M. Education and Easy Disposal Option Lower Opioid Supply. Anesthesiology News 2020; November 10, 2020



FDA (US Food and Drug Administration). Safe Opioid Disposal - Remove the Risk Outreach Toolkit; Updated 11/1/2020






Print “December 2020 Guidelines for Opioid Prescribing in Children and Adolescents After Surgery








ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines



As the world waits with bated breath for mass vaccinations to protect against the COVID-19 coronavirus, ISMP (Institute for Safe Medication Practices) reminds us of the many types of errors that might occur related to vaccinations (ISMP 2020). We discussed some of these in our November 19, 2019 Patient Safety Tip of the Week “An Astonishing Gap in Medication Safety”. In that column we noted cases where insulin or neuromuscular blocking agents (NMBA’s) were erroneously given instead of intended vaccines, usually with disastrous results. We did discuss some of the root causes and important lessons learned and recommendations for what you should be asking at your organization or facility.


ISMP (ISMP 2020) discusses factors in the following categories related to adverse vaccination-related events:


ISMP then provides solid recommendations on planning vaccination campaigns, safe vaccine storage, staffing and training, safe vaccine dispensing. safe vaccine administration, patient education, and reporting adverse vaccine events.


These recommendations are important regardless of what type of vaccinations you are providing. But they take on even greater significance knowing that several hundred million Americans will soon be getting vaccinated to prevent COVID-19, many requiring more than one dose. Now is a good time to begin preparing your staff and organization for this anticipated surge. This ISMP article is a great place to start.






ISMP (Institute for Safe Medication Practices). Learning from Influenza Vaccine Errors to Prepare for COVID-19 Vaccination Campaigns. ISMP Medication Safety Alert! Acute Care Edition 2020; 25(23): November 19, 2020






Print “December 2020 ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines






Do You Have These Infection Control Vulnerabilities?



A recent article from Health Europa has some valuable lessons in infection control for everyone. Karolinska University Hospital, affiliated with the world-renowned Karolinska Institute in Sweden, agreed to participate in a study to identify its key areas of risk and reduce the spread of infection (Health Europa 2020). Researchers there did bacterial screenings and had 2 individuals (a doctor or nurse plus a second person with another background, such as an industrial designer or psychologist) do direct observation by following a patient through the ward for four hours.


Risk factors identified by the observers could be specific to individual wards or common to all the screened wards:


Results of bacteriologic screenings correlated inversely with the degree of compliance with basic hygiene routines. Wards with the highest levels of compliance had the lowest number of surface bacteria, while the highest number of bacteria were found in the wards with the lowest rates of compliance.


So, what did the hospital do? It switched its cleaning services contract to a new company and mandated that its new cleaning contract staff must be trained in the fundamentals of infection prevention and control, antibacterial measures, and the necessary standards of hygiene within healthcare environments. It updated cleaning routines and established checklists to ensure each cleaning task was documented. Hospital staff were detailed to clean the ‘near-patient environment’ – the equipment used near the patient and while caring for the patient, such as the bed, bedside table, bedside lamp and wheelchair. The hospital’s personnel and the cleaning operatives were trained or retrained in basic infection control cleaning and disinfection processes. The fabric drapes, which had represented a significant vector of infection, were replaced with screens which were less bacteria-retentive and substantially easier to clean.


The hospital continued to take monthly culture samples at the sites in each ward which had initially been identified as having a high bacterial load. A second observational study conducted nine months after the first found that compliance with basic clinical hygiene routines had risen by an average of 16 percentage points. Hospital management found that making staff aware of the initial screening results had rendered them more motivated to improve their compliance with hygiene regulations, leading to positive trends in all the wards which were observed.


Our bet is that Karolinska University Hospital is not alone in having these infection control vulnerabilities. In fact, most of them probably exist at many hospitals. Combining the screening cultures with direct observational methods is likely to help any hospital identify such risk factors. We’d also bet that you’ll find even more if you extend your observation to following patients on intrahospital transports.






Health Europa. Hygiene compliance in preventing healthcare-associated infections. Health Europa 2020; 11th November 2020





Print “December 2020 Do You Have These Infection Control Vulnerabilities?




Print “December 2020 What's New in the Patient Safety World (full column)

Print “December 2020 Joint Commission 2021 National Patient Safety Goals

Print “December 2020 Guidelines for Opioid Prescribing in Children and Adolescents After Surgery

Print “December 2020 ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines

Print “December 2020 Do You Have These Infection Control Vulnerabilities?



Print “PDF version







Tip of the Week Archive


What’s New in the Patient Safety World Archive