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Safety First The Joint Commission’s National Patient Safety Goals for 2013-2014 CE694 :: 1.00 Hours

Authors:

Connie Kirkpatrick, RN, MS, PhD Connie Kirkpatrick, RN, MS, PhD, is administrator for quality and patient safety at Good Samaritan Hospital in Puyallup, Wash. The author has declared no real or perceived conflicts of interest that relate to this educational activity.

Charles F. Bombard, RN, MHA, CPHQ, FACHE Charles F. Bombard, RN, MHA, CPHQ, FACHE, is director of quality improvement at Tampa General Hospital in Florida.

Doris Schmidt, RN, BSN, MS, LRM Doris Schmidt, RN, BSN, MS, LRM, is the manager of regulatory compliance at Tampa General Hospital in Florida.

Objectives The purpose of this National Patient Safety Goal program is to inform nurses about The Joint Commission’s current NPSGs that apply to hospitals. After studying the information presented here, you will be able to:

Name the current goals and elements of performance (requirements) Explain the new goal effective January 1, 2014 Describe the intent of the patient safety goals

Consider this patient scenario. Amberly was scheduled for an arthroscopy on her right knee. Her orthopedic surgeon wrote instructions to his administrative assistant that he would be operating on Amberly’s left knee. She called the OR scheduling office and gave them Amberly’s name and the physician’s request to schedule her for a left knee arthroscopy. Amberly was put on the OR schedule as a left knee arthroscopy. Upon admission to the hospital, Amberly was prepared for surgery. When consenting for surgery, she stated that her right knee was to have the operation. In the OR, the nurse checked Amberly in to the preop holding area and verified her name and date of birth with her ID wristband. The nurse asked Amberly what surgery she was scheduled for and found that the OR schedule and consent form, along with the patient, did not agree on the site of the surgery. The OR nurse stopped all activity associated with her surgery until the discrepancy was resolved. This stoppage by the nurse is part of the universal protocol, one of the original (and continuing) National Patient Safety Goals, or NPSGs, that contains three requirements: verification of correct procedure, patient and site against all relevant documentation; marking of the surgical site by the proceduralist; and conducting a timeout just before the start of the procedure, when the

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physician, nurse and anesthesia provider agree that they have the right patient and are doing the right procedure at the right site. For Amberly, there would have been two other stops along the way that would have prevented this error: site marking and the timeout before surgery. This is why the universal protocol is so valuable. It really does make a difference in preventing wrong patient, wrong procedure and wrong site surgeries. Since 2002, The Joint Commission has evaluated patterns of clinical outcomes involving injury or potential risk to patients in accredited hospitals across the U.S. Based on an annual evaluation of these safety issues, TJC establishes goals to guide hospitals to avoid potential unnecessary patient outcomes, thus serving as an ongoing safety net for care delivery.1 All 2013 NPSGs will remain in effect during 2014, and only one new goal will be established in 2014; it is discussed below as NPSG.06.01.01.2 TJC-accredited organizations must show they comply with all requirements of the safety goals or show compliance with “acceptable alternatives” for achieving a goal. (TJC must approve such alternatives.) If a hospital fails to demonstrate compliance with any of the requirements during a TJC survey, it will receive a “requirement for improvement” for that NPSG, which could affect its accreditation. TJC reviews the patient safety goals and implementation requirements annually; some continue while others may be replaced. When TJC is satisfied that the vast majority of hospitals have incorporated practices defined in a safety goal, it retires the goal from the annual list. However, goals never actually go away; they are incorporated into TJC hospital standards. For example, handoff communication among caregivers was once a NPSG, but when it was retired from the safety goal list, it moved into the Provision of Care chapter (PC.02.02.01, EP 2) of the hospital manual. TJC is constantly considering new patient safety goals, based on sentinel events and the corrective actions, from which practice standards are developed for all hospitals to follow.3 TJC includes required practices in the goals to standardize the risk-reduction strategies that hospitals use.2 By having all hospitals use the same safety strategies, TJC can study whether these strategies actually reduce patient injuries. Something for Everyone TJC has patient safety goals for all the programs it accredits, such as long-term care, laboratory services and behavioral health. This module will discuss goals for hospitals. TJC's website is the primary source of information on goals for all programs. It can be confusing to read the numbered goals and requirements for any one program because the numbering is not consecutive. A program list shows only the numbers pertaining to that program. For example, numbered goals for hospitals move from 3 to 7 because goals 4, 5 and 6 no longer apply. For 2013 and now 2014, there are seven hospital-specific goals with 85 implementation requirements (elements of performance, or EPs). This module uses TJC’s numbering system and shows only items active for 2013 and 2014. Here are the 2013 hospital NPSGs that remain in effect in 2014. In 2013, TJC surveyed hospitals to check for implementation of 2013 goals and requirements (or acceptable alternatives) and will continue to do so in 2014. EPs are listed for each NPSG. Information related to the NPSGs and EPs discussed below can be accessed at The Joint Commission's primary website.

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Goal – Improve the accuracy of patient identification. Requirements: NPSG.01.01.01 (two EPs): Use at least two patient identifiers when providing care, treatment or services. EP 1. Use at least two patient identifiers when administering medications, blood or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient’s room number or physical location is not used as an identifier. (See also MM.05.01.09, EPs 8 & 11andNPSG.01.03.01, EP 1.) EP 2. Label containers used for blood and other specimens in the presence of the patients. (See also NPSG.01.03.01, EP 1.) The intent is that staff members use two pieces of information to identify patients before providing any medical service to them. TJC has indicated that the two pieces of information do not have to come from different sources; it is acceptable to use two pieces of identification from an ID wristband. (That is, a nurse could use a patient’s name and birth date from an ID wristband.) All practice areas of a hospital do not have to use the same two identifiers. But all providers in a practice area must use the same two. Staff members often ask what to do about an unresponsive patient who comes to a facility without identification, as in a trauma situation. The hospital must create for that patient at least two identifiers to use throughout the admission to match specimens and medications. Hospitals may assign the patient a “John Doe” designator and an account number or a medical record number to use during an admission. A bar coder improves the accuracy of identification as long as it is one of two identifiers. A bar code can take the trouble out of verifying a series of numbers, such as an account number. Bar coding also removes risks such as transposing numbers in a series or incorrectly copying numbers. The bar code on a patient-specific medication is matched to a bar code on a medication record and on a patient wristband using a handheld device. This technology requires coordination of many parts of a healthcare system. In U.S. hospitals, especially in EDs and critical care settings, blood and other specimen containers sometimes are labeled outside the presence of the patient. But TJC expects that the complete labeling process occur in the presence of the patient. NPSG.01.03.01 (three EPs): Eliminate transfusion errors related to patient misidentification. EP 1. Before initiating a blood or blood component transfusion:

Match the blood or blood component to the order Match the patient to the blood or blood component Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding

(See also NPSG.01.01.01, EPs 1 & 2) When two people are asked to individually check identifiers before the administration of blood, they each should check the blood against original patient identifiers, not just check that the original nurse followed the process. If a hospital allows a patient to state his or her name as a form of identification, the nurse should not ask the patient to simply confirm his or her name, but to state it actively.

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EP 2. When using a two-person verification process, one person conducting the identification verification is the qualified transfusionist (e.g.,aregistered nurse) who will administer the blood or blood component to the patient. EP 3. When using a two-person verification process, the second person conducting the identification verification must be qualified to participate in the process as determined by the hospital (e.g.,a second RN is generally considered to be an appropriate verifying person). Goal – Improve the effectiveness of communication among caregivers. Requirements: NPSG.02.03.01 (three EPs): Report critical results of tests and diagnostic procedures on a timely basis. EP 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 diagnostic procedures By whom and to whom critical results of tests and diagnostic procedures are reported The acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures. (If left undefined, all results are considered critical to relay to decision makers [e.g.,physicians] who make treatment decisions based on diagnostic results.)

EP 2. Implement the procedures for managing the critical results of tests and diagnostic procedures. EP 3. Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures. Goal – Improve the safety of using medications. Requirements: NPSG.03.04.01 (eight EPs): Label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings. (Medication containers include syringes, medicine cups and basins.) This NPSG applies to all medications and “other” solutions, such as skin prep or specimen preservative. EP 1. Label medications and solutions that are not immediately administered. This applies even if there is only one medication being used. Note: “Immediately” means directly administered after preparation, without any break in the process. EP 2. Labeling occurs when any medication or solution is transferred from the original packaging to another container. (Do not prelabel the container.) EP 3. Medication or solution labels include the following: name, strength, quantity, diluent and volume (if not apparent from the container), and expiration date when not used in 24 hours. Note: Date and time are not required on labels for short durations, as defined by the hospital. EP 4. Verify all medication or solution labels both verbally and visually. Verification is done by two people qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will administer it.

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EP 5. Label each medication or solution as soon as it is prepared unless it is immediately administered. (Therefore, dispense and label the product before dispensing and labeling the next product. Do not fill two basins, then label.) EP 6. Immediately discard any medication or solution found unlabeled. EP 7. Remove all labeled single-use containers on the sterile field and discard their contents at the conclusion of the procedure. Note: This does not apply to multiuse vials that are handled according to infection control practices. EP 8. Review all medications and solutions both on and off the sterile field; their labels are reviewed by entering and exiting staff responsible for the management of medications. NPSG.03.05.01 (eight EPs): Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Note: This requirement does not apply to routine short-term prophylactic anticoagulation for venous thromboembolism prevention or routine situations in which laboratory values are expected to remain essentially normal. EP 1. Use only oral unit-dose products, prefilled syringes or premixed infusion bags when these types of products are available. Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children. EP 2. Use approved protocols for the initiation and maintenance of anticoagulant therapy. EP 3. Before starting a patient on warfarin (Coumadin), assess the patient’s baseline coagulation status. For all patients receiving warfarin therapy, use a current international normalized ratio (INR, a laboratory test to monitor the effect of an anticoagulant) to adjust therapy. Baseline and current INR are documented in the medical record. EP 4. Use authoritative resources to manage potential food and drug interactions for patients on warfarin. EP 5. When heparin is administered IV and continuously, use programmable pumps to provide consistent and accurate dosing. EP 6. A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants. EP 7. Provide education about anticoagulant therapy to staff, patients and families. Patient/family education includes the importance of follow-up monitoring, adherence, drug-food interactions and the potential for adverse drug reactions and interactions. EP 8. Evaluate anticoagulation safety practices, take action to improve practices and measure the effectiveness of those actions in a timeframe determined by the organization. NPSG.03.06.01 (five EPs): Maintain and communicate accurate patient medication information (medication reconciliation). EP 1. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. Current medications include those taken at scheduled times and those taken on an as-needed basis. It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain

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this information from the patient and other sources will be considered as meeting the intent of the EP. EP 2. Define the types of medication information to be collected in non-24-hour settings and different patient circumstances. Examples of non-24-hour settings include the ED, primary care, outpatient radiology, ambulatory surgery and diagnostic settings. EP 3. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital to identify and resolve discrepancies. Discrepancies include omissions, duplications, contraindications, unclear information and changes. EP 4. Provide the patient (or family as needed) with written information on the medications the patient should take when he or she is discharged from the hospital or at the end of an outpatient encounter (e.g., name, dose, route, frequency, purpose). EP 5. Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter. Patients and/or family should be encouraged to carry medication information at all times in the event of emergency situations. Goal – Improve clinical alarm safety. (New in 2014)3 This goal will be implemented in two phases. The first begins January 1, 2014, when hospitals will be required to establish alarm safety as a priority and identify the most important alarms to manage. The second phase begins January 1, 2016, when hospitals will be expected to develop and implement specific components of policies and procedures and to educate staff about safe alarm system management. Requirements: NPSG.06.01.01 (4 EPs): Improve the safety of clinical alarm systems. This NPSG focuses on managing clinical alarm systems that have the most direct relationship to patient safety. EP 1. As of July 1, 2014, leaders establish alarm system safety as a hospital priority. EP 2. During 2014, identify the most important alarm signals to manage based on input from the medical staff and clinical departments, risk to patients if the alarm signal is not attended to or if it malfunctions, whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue, potential for patient harm based on internal incident history and published best practices and guidelines. EP 3. As of January 1, 2016, establish policies and procedures for managing the alarms identified in EP 2 above that, at a minimum:

Address clinically appropriate settings for alarm signals When alarm signals can be disabled When alarm parameters can be changed Who in the organization has the authority to set alarm parameters Who in the organization has the authority to change alarm parameters Who in the organization has the authority to set alarm parameters to “off” Monitoring and responding to alarm signals Checking individual alarm signals for accurate settings, proper operation and detectability

EP 4. As of January 1, 2016, educate staff and licensed independent practitioners about the

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purpose and proper operation of alarm systems for which they are responsible.

Goal – Reduce the risk of healthcare-associated infections. Requirements: NPSG.07.01.01 (three EPs): Comply with the current Centers for Disease Control and Prevention hand hygiene guidelines or World Health Organization hand hygiene guidelines. EP 1. Establish a program that follows categories 1A, 1B and 1C of either the current CDC or the current WHO hand hygiene guidelines. (See also IC.01.04.01, EP 5) EP 2. Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 3) EP 3. Improve compliance with hand hygiene guidelines based on established goals. The importance of hand washing cannot be overstated. It’s the single most effective way to prevent healthcare-acquired infections. One of the CDC’s Category 1A guidelines states that healthcare personnel should not wear artificial nails if they care for patients at high risk of acquiring infections (e.g., patients in ICUs or transplant units). TJC requires compliance with this guideline. NPSG.07.03.01 (nine EPs): Establish evidence-based practices to prevent healthcare-associated infections because of multiple drug-resistant organisms in acute care hospitals. (This applies to methicillin-resistant Staphylococcus aureus, Clostridium difficile, vancomycin-resistant enterococci and multidrug-resistant gram-negative bacteria.) EP 1-9. Hospitals are required to perform periodic organizational risk assessments and education of licensed independent practitioners, staff and patients and their families as needed and to maintain surveillance systems for multiple drug-resistant organisms. Patients and their families, as needed, who are infected or colonized with multidrug-resistant organisms must be educated about strategies to prevent healthcare-associated infections. Measurements are required, including rate- based metrics (that allow for differing patient at-risk population volumes between units or hospitals), with data shared widely with hospital staff. TJC expects compliance with evidence- based guidelines aimed at reducing the risk of transmitting multiple drug-resistant organisms. An alert system to identify new, readmitted and transferred patients with multiple drug-resistant organisms must be in place. These EPs are within the purview of infection control and prevention committees and are generally managed by a professional RN infection preventionist. NPSG.07.04.01 (13 EPs): Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. This goal covers short- and long-term central venous catheters and peripherally inserted central catheter lines. Hospitals must have comprehensive protocols or guidelines in place that address insertion, maintenance and timely removal of central lines. EP 1-13. In 2011, the specific use of chlorhexidine was removed as part of a standardized protocol for skin preparation using an antiseptic for central venous catheter insertion. This change reflected a requirement to use an antiseptic that is cited in scientific literature or endorsed by professional organizations. Education of staff, licensed independent practitioners, patients and families as needed is expected for management of central lines and associated infections and their prevention. TJC expects organizations to conduct risk assessments, monitoring and surveillance

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hospitalwide (not targeted) and to share rate-based data widely with staff. The use of a checklist and standardized protocol for central venous catheter insertion is required, with details on steps required as part of the insertion process. NPSG.07.05.01 (8 EPs): Implement best practices for preventing surgical site infections. EP 1-8. The specific timeframes for administration of prophylactic antimicrobials and their discontinuation have been removed. The new language requires prophylaxis according to “methods cited in scientific literature or endorsed by professional organizations.” The use of clippers or depilatories specifically has been removed, with the requirement that when hair removal is necessary, staff use “a method that is cited in scientific literature or endorsed by professional organizations.” Education about the prevention of surgical site infections is expected for staff, licensed independent practitioners and patients and their families as needed when involved in surgical procedures. Staff involved in surgical procedures must be educated about surgical site infections and their prevention upon hire or if surgical procedures are added to their job responsibilities and annually thereafter. Organizations must implement evidence-based guidelines, risk assessment programs, monitoring systems and surveillance programs that extend for specified time intervals after discharge. Data must be shared with key people, such as members of the infection control committee, including nurses, physicians and other clinical staff. If hair removal is necessary, staff must use a method that is cited in scientific literature or endorsed by professional organizations. The Centers for Medicare and Medicaid Services uses the Surgical Care Improvement Project to delineate multiple evidence-based interventions to reduce the risk of surgical infections. The project is a national partnership of organizations interested in improving surgical care by reducing surgical complications.4 NPSG.07.06.01 (three EPs) Implement evidence-based practices to prevent indwelling catheter- associated urinary tract infections. This NPSG is not applicable to pediatric patients.1 EP 1. Insert indwelling urinary catheters according to established evidence-based guidelines that address the following: limiting the use and duration to situations necessary for patient care and using aseptic techniques for site preparation, equipment and supplies. EP 2. Manage indwelling urinary catheters according to established evidence-based guidelines that address the following: securing catheters for unobstructed urine flow and drainage, maintaining the sterility of the urine collection system, replacing the urine collection system when required and collecting urine samples. EP 3. 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, monitoring compliance with evidence-based guidelines or best practices and evaluating the effectiveness of prevention efforts. Note: Surveillance may be targeted to areas with a high volume of patients using indwelling catheters. Goal – The hospital identifies safety risks inherent in its patient population. Requirements: NPSG.15.01.01 (three EPs): Identify patients at risk for suicide.This NPSG applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.

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EP 1. Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. EP 2. Address the patient’s immediate safety needs and most appropriate setting for treatment. EP 3. When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family. Goal – Prevent wrong site, wrong procedure and wrong person surgery. Requirements: UP.01.01.01 (three EPs): Conduct a preprocedure verification process. (Note the use of “UP” [universal protocol] to identify this and the two following requirements.) EP 1-3. A preprocedure verification is an ongoing process of information gathering and confirmation. It verifies the correct procedure for the correct patient at the correct site (involving the patient when possible). Items that must be available for the procedure are identified and the use of a standardized list to verify their availability is required. They include relevant documentation, diagnostic and radiology test results, special equipment, blood products or devices. All items must be matched to the patient. UP.01.02.01 (five EPs): Mark the procedure site. EP 1-5. At a minimum, sites are required to be marked when there is more than one possible location for the procedure and when proceeding in the incorrect location would jeopardize patient safety. Patients should be involved in site marking when possible. The licensed independent practitioner who is ultimately accountable for the procedure and who will be present during the procedure marks the site. Limited delegation of site marking is allowed to medical residents, advanced registered nurse practitioners and physician assistants if they will be present during the procedure. No ambiguity should exist about the method of marking a site and type of mark used in the hospital. For patients who refuse site marking or for situations in which site marking is technically impractical, a written process must be in effect. UP.01.03.01 (five EPs): A timeout is performed immediately before starting procedures. EP 1-5. Timeouts are conducted immediately before starting an invasive procedure or making an incision. They are required to be standardized, initiated by a designated team member and involve all immediate members of the procedure team. Documents of timeout completion are required per hospital policy. The goals and requirements listed earlier are straightforward, and hospitals will be expected to take corrective action if they are not in compliance. TJC gives hospitals the option to ask for permission to experiment with unique strategies to reduce risks to patients in the safety areas so that new and better means of improving safety will keep coming into the mix. TJC’s patient safety program is in its 11th year; hospitals and other healthcare organizations will have to comply with an ever-evolving set of core strategies to promote patient safety. These requirements represent an evidence-based national standard of care to increase accountability for patient safety practices. If you have questions about the NPSGs, speak to the patient safety officer or accreditation specialistwhere you work or review TJC’s Patient Safety Web page for hospitals.

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References

1. 2013 Hospital National Patient Safety Goals. The Joint Commission Web site. http://www.jointcommission.org/assets/1/6/2013_HAP_NPSG_final_10-23.pdf. Accessed September 9, 2013. 2. The Joint Commission Announces 2014 National Patient Safety Goal. The Joint Commission Web site. http://www.jointcommission.org/joint_commission_announces_2014_npsg/. Published July 19, 2013. Accessed September 9, 2013. 3. Sentinel event. The Joint Commission Web site. http://www.jointcommission.org/sentinel_event.aspx. Accessed September 9, 2013. 4. Surgical Care Improvement Project. Joint Commission Web Site. http://www.jointcommission.org/surgical_care_improvement_project/. August 15, 2012. Accessed September 9, 2013.