National Patient Safety Goal (NPSG)

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

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

Identifying patients is key in preventing medication errors and relates to provision 3 in the code of ethics, “The nurse promotes, advocates for, and protects the

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

healthcare organization accrediting bodies, and to maintain credibility with patients and peers alike, must adhere to the National Patient Safety Goals. As stated by Ulrich and Kear (2014), "Not only are nurses responsible for providing safe patient care, we are also responsible for creating an environment in which others can provide safe patient care, and for being the last line of defense when needed between the patient and potential harm. Having a deep understanding of patient safety and patient safety culture allows nurses to be the leaders we need to be in ensuring that our patients are always

The Joint Commission has instituted a number of goals nationally; the aim is to improve patient’s safety. The goals selected look at areas that are of concern in the healthcare industry particularly how it affect patients safety and make recommendations how to reduce if not eradicated these. The Joint Commission is the governing body that accredited hospitals and other health care organizations. The two hospitals that this paper will be comparing, using the goals and criteria recommended by the Joint commission, is Holy Cross Hospital located at 1500 Forest Glen Road, Silver Spring, MD and Shady Grove Hospital situated at, 9901 Medical Center Drive, Rockville, MD.

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

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.

The Joint Commission also addresses safety issues through the publication and distribution of the Sentinel Event which identifies a severe breach in safety and addresses ways on how to improve processes and to prevent harm in the future. It also publishes the National Patient Safety Goals which address healthcare safety and ways to solve problems that focus on issues such as identifying patients correctly, improving communication among staff, and administering medications safely, just to name a few. “A majority of Joint Commission standards are directly related to safety, addressing such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security. The standards also include requirements for preventing accidental harm; responding to patient safety events; and the organization’s responsibility to tell patients about the outcomes of their care” (TJC,

Back in 2003, the Joint Commission created a National Patient Safety Goal due to 23 occurrences of death or injury to a patient where alarms had been applied incorrectly or the alarms had been muted (Sendelbach & Funk, 2013). By 2004, Joint Commission had removed it from their National Patient Safety Goal list and made it a requirement for Joint Commission accreditations (Sendelbach & Funk, 2013). In 2013, it was brought to the attention of the Joint Commission regarding many alarm-related events, including multiple deaths, permanent loss of function, and prolonged hospital stays due to health care worker’s decreased response times to alarms (Horkan, 2014; Joint Commission, 2013). The Joint Commission reinstated a National Patient Safety Goal in 2013 and had requirements for all hospitals that had to be met by July 1, 2014 (Joint Commission, 2013). These goals included being able to make alarm safety a priority and develop a plan to decrease the amount of alarms. This plan could include preventing unnecessary patient monitoring, clarifying who is allowed to monitor and silence alarms, setting the cardiac monitors to have multiple tones, and having a brief delay in the alarm to see if the patient can self-resolve. The second phase of the Joint Commission’s plan was to be implemented by January 2016, to where the hospital must have followed through with their designated plan (Joint Commission, 2013).

Over the last several years, a wide variety of health care organizations have been facing a number of challenges. This is because of pressures associated with: rising costs, increasing demands and larger numbers of patients. For many facilities this has created a situation where patient safety issues are often overlooked. This is because the staff is facing tremendous amounts of pressure, long hours and more patients. The combination of these factors has created a situation where a variety of hospitals need to improve their patient safety procedures. In the case of Sharp Memorial Hospital, they are focused on addressing these issues through different strategies. To fully understand how they are able to achieve these objectives requires looking at: specific ways the organization has responded to the crisis in medical errors, their definition of patient safety, the causes of errors, systematic barriers and transformations that have been adopted. Together, these different elements will provide the greatest insights as to how the facility is coping with the crisis in patient safety.

The Nurses of the Future Nursing Core Competency model is composed of ten competencies. Some of these competencies include patient centered care, collaboration, and teamwork. One particular is safety, which I believe to be one of the most important of the competencies. Safety is minimizing the risk of harm to patients and healthcare providers. This is important to nursing because insuring the safety of a patient is a number one priority, without safety is the care of a patient successful? Nurses are the first line of defense when it comes to safety towards patients and providers. In order to ensure safety there must be a plan of action and then set the plan in motion in order to avoid unsafe outcomes.

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.

2012 Joint Commission Patient Safety Goals. (n.d.). Retrieved January 2014, from Captain James A. Lovell Federal Health Care Center: www.lovell.fhcc.va.gov/about/2012PatientSafetyGoals.pdf