Patient Safety Goals

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

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

"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.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

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

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

For the purposes of this paper, the author will only focus on National Patient Safety Goals 01.01.01: Identifying patients correctly and 01.03.01 Eliminate transfusion errors related to patient misidentification.

In 2000, the government released a report, via the AHRQ task force, called Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. This report was released

Following the 1999 IOM report the US government was forced to respond to the reported statistics and the growing demand for political action. This lead to the creation of the Quality Interagency Coordination Task Force (QuIC) on December 7, 2000 directed by President Clinton. The main purpose was to address the concerns of the country with medical errors and patient safety (Wahls et al., 2002). This task force used 12 federal agencies to regulate health services and ensure that bureaus involved in purchasing, providing, researching, or regulating health care service were working in unison to improve the problem of care (Schulman et al., 2000). From this task force came a series of proposed measures that would be the starting point of correcting the growing problem of medical errors. First, the QuIC determined that an error-reporting system should be standard in all 50 states. All members of the QuIC agreed is necessary to improve quality in health care delivery. Second, the QuIC recommended that reporting requirements be expanded to blood banks and other companies that work with blood. Next, they determined that there should be a set of safety measures for patients. This would identify known medical errors and best practice for health care organizations that could help avoid identified and

I have chosen the Hospital National Patient Safety Goals. One goal is improve the accuracy of patient identification. The Joint Commission wants hospitals to use at least two patient identifiers when providing care, treatment, and services. I believe that the person, who is checking in the patient, needs to be made aware of the importance of this process. One way would be to request two pieces of personal identification. Fraud is happening everywhere and requesting two pieces of identification might make this less likely to happen. Every person that comes in contact with the patient needs to check their identification bracelet with the medical record, orders and prescriptions. The HIM professional manages the master patient index and must

The home health agency ordered a registered nurse the admission of a new diabetic patient at home, the process is called Start of Care Assessment (SOC); the doctor ordered the nurse to administer 1000 mcg of Vitamin B12 monthly, intramuscular. The patient has a medical history of cardiovascular disease, obesity, right leg amputation, incontinence and anemia. At the admission, the nurse noted a Stage I pressure ulcer on the sacral area, a Stage I pressure ulcer is a red localized area with the skin intact. The nurse did not documented the ulcer because she thought it would resolve soon. Next month, the nurse did not check the status of the ulcer, and the ulcer progressed to a decubitus ulcer, gangrenous and with cellulitis. The family transported the patient to the hospital, with fever, severe pain, and shortness of breath; the patient died four days later. The family sue the nurse, due to failure to document the pressure ulcer timely and to prevent the progress of the decubitus ulcer, infection, and hospitalization. Most cases of nursing malpractice and negligence are preventable. Several organizations and government agencies develop guidelines, regulations, goals, quality

My organizations’ self-assessment was performed using the SAFER Guidelines for Patient Identification. The organization met 11 of 14 of the Patient Identification Guidelines. There were three areas that we had deficits in which included: #5 Not having “check digit” software incorporated in the medical record, #6 automatic warning for user when first and last name are the same, and #14 –Regular monitoring for patient ID errors.

These encounters make it cumbersome to classify alleviate primary causes of harm. Therefore, it affects the ability of the society to identify and prove the efficacy of patient safety risk management solutions that decrease medical errors and preventable serious safety events.