Joint Commission : A National Patient Safety Goal

Patient Safety and Quality Improvement Act (PSQIA) was signed into law on July 29, 2005, published on November 21, 2008 and became effective on January 19, 2009 (U.S. Department of Health & Human Services, n.d). PSQIA catalyzes sharing of healthcare data, information and patient safety practices between health care organizations by creating Patient Safety Organizations (PSO). Providers can report or share information related to patient safety events with PSO without the fears of liability, because “ PSQIA provides federal privilege and confidentiality protections for patient safety information, called patient safety work product” (USDHMS, n.d ). This means protected information cannot be introduced in any federal, state, local, or tribal civil,

The National Patient Safety Goal (NPSG) program was created in 2002 by the Joint Commission to help organizations identify and address issues with patient safety. The people who determine what the safety goals are and how they should be addressed is called the Patient Safety Advisory Group. This group is composed of medical professionals who have “hands-on experience in addressing patient safety issues in a wide variety of health care settings.”(The Joint Commission, 2015) The first group of goals set by the advisory group were published Jan. 1, 2003. Currently, there are 6 hospital patient safety goals:

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

The Six Aims for Improvement and the 2016 National Patient Safety Goals (NPSG) are both guidelines for bettering and protecting the patient and their experience while being cared for in the hospital. In the book, Contemporary Nursing: Issues, Trends, & Management, it states that the six guiding aims should be accepted by every individual and group involved in the provision of healthcare, including health care professionals, public and private health care organizations, purchasers of health care, regulatory agencies and organizations, and state and federal policymakers (Cherry, Jacob, 2017, p.381). The NPSG clearly states its mission on its page. It says, “The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them” (2016 Hospital National Patient Safety Goals, 2015). Through this reflection of the guidelines, I will group them into categories and reflect on their meanings and how to implement them in nursing.

378). Hospitals have an array of medical devices at the bedside that have alarms, which have grown significantly within recent years. Nurses may be exposed to over 350 physiologic alarm monitors per day, resulting in sensory overload thus leading to desensitization. When the alarm sounds it should be corrected immediately, even though it may be a false alarm or no issues with the patient. The Joint Commission has identified alarm fatigue as a 2014 National Patient Safety Goal, requiring hospitals “to establish improvement of alarm system safety as an organization priority” (as cited in Horkan, 2014, p. 83). Alarms are deliberately designed for high sensitivity so that nurses do not miss a true event. Firing alarms are usually muted, disabled or ignored by nurses altogether because alarms are viewed as a nuisance. Alarm hazards have generated national attention, in one highly publicized case an alarm sounded for 75 minutes before a nurse responded to a patient’s heart monitor that needed a battery replaced. When the nurse finally went to change the battery the patient was found unresponsive and could not be resuscitated because he had gone into cardiac arrest (Sendelbach & Funk, 2013). The patient’s heart monitor battery eventually died and did not issue the critical alarm alert. In another event, a patient fell getting out of bed and bleed to death because the nurse

National Patient Safety Goals (NPSGs), established in 2002 by the Joint Commission, is to help accredited organizations address specific areas of concern in regard to patient safety ("Catheter-Associated," 2015). NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) is a 2015 NPSG ("The Joint Commission," 2015). Our facility has 1.32 CAUTIs per 1000 device days (Carson, 2015). Decreasing CAUTIs can be achieved with a strict goal, addressing the financial implications, interdisciplinary collaboration, nursing leadership, a measurement tool, and discussing the future healthcare delivery methods.

The following are the National Patient Safety Goals for 2016: improve the accuracy of patient identification, improve the effectiveness of communication of caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections, and for the hospital to identify safety risks inherent in its patient population (Hudson 2016 page 2). Under each category there are specific goals, such

The Joint Commission Accreditation Body assesses health care organization’s compliance with National Patient Safety Goals. The goal of the Joint Commission Body is to focus on critical aspects and patient safety issues in health care organizations, which can vary according to the setting of the health care being performed (Chassin, 2008). Infections occurring in surgical sites of patients account for 15% of all infections that transpire in a hospital setting, and the risk of death doubles in patients who develop infections. The dangers of surgical site infections include superficial, deep, and organ or space infections. The different infections include cellulitis, gangrene, MRSA, and wound sinus, which can lead to amputation, organ

National Patient Safety Goals (NPSGs) were established in 2002 by the Joint Commission to help accredited organizations address specific areas of concern in regard to patient safety ("Catheter-Associated," 2015). NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) is a 2015 NPSG ("The Joint Commission," 2015). Our facility has 1.32 CAUTIs per 1000 device days (Carson, 2015). Decreasing our CAUTIs can be achieved with a strict goal, addressing the financial implications, interdisciplinary collaboration, nursing leadership, a measurement tool, and discussing the future healthcare delivery methods.

Goal 6: Know Your Alarms. Alarms familiarity on your unit is integral to the best patient safety. Take faulty

Clinical alarm systems in acute and critical care health care settings are an assistive way to maintain communication between the client and the nurse. Awareness and comprehension of health devices is crucial to provide nurses with appropriate strategies for critical or non critical interventions that can lead to sentinel events. The ECRI, a nonprofit institute, has identified alarm hazards as the “Top Ten Health Technology Hazards” for 2014. (cite) In 2013 The Joint Commission published a Sentinel Event Alert proposing a National Safety Goal to focus on alarm safety (cite). This topic is pertinent information to be recognized and set as an achievable action in improving patient safety.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

With the proliferation of technology in the today’s healthcare environment, the healthcare community is increasingly concerned about the patient safety risks associated to clinical alarm hazards. In 2012, 2013, and 2014, the Emergency Care Research Institute (ECRI) identified clinical alarm hazards as a high priority potential danger area in hospitals and health systems (ECRI, 2014). The Joint Commission, the American Association of Critical-Care Nurses (AACN), the Food and Drug Administration (FDA), ECRI, and the Association for the Advancement of Medical Instrumentation (AAMI) have all identified the need to address alarm management and alarm fatigue as a priority patient safety concern (Horkan, 2014). In response to these concerns, federal regulatory mandates are increasingly coupled with recommended alarm management practices and protocols. Despite these focused efforts, alarm fatigue and alarm management continue to be priority national patient safety concerns.

A sentinel alarm event occurred at several hospitals within the AW Network, which prompted the Pennsylvania Department of Health to conduct a Center for Medicare Services level investigation. This type of investigation requires an action plan with a measure of correction. Parallel with the alarm events, the Joint Commission had created the National Patient Safety Goal 06.01.01, also known as goal six, to reduce harm associated with clinical alarms (The Joint Commission, 2014). The potential patient risks for an adverse event from alarm mismanagement are experienced around the world, and while the particulars of each event varies; research suggests that by reducing nuisance alarms, the chance for an adverse event diminishes (Gorges,

Issues related to a lack of patient safety have been going on for a lot of years now. Throughout the first decade of the 21st century, there has been a national emphasis on cultivating patient safety. Patient safety is a global issue, that touches countries at all levels of expansion and is one of the nation's most determined health care tests. According to the Institute of Medicine (1999), they have measured that as many as 48,000 to 88,000 people are dying in U.S. hospitals each year as the result of lapses in patient safety. Estimates of the size of the problem on this are scarce particularly in developing countries; it is likely that millions of patients worldwide could suffer disabling injuries or death every year due to unsafe medical care. Risk and safety have always been uninterruptedly been significant concerns in the hospital industry. Patient safety is a very much important part of our health care system and it really