The National 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

Over time the health care industry has become more complex. Health care is rapidly evolving and continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care, with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN focuses on the following competencies: patient-centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems (Qsen.org, 2014).

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

When the Institute of Medicine came out with a report called To Err Is Human it drew a lot of attention to the media on patient safety because of the statistics that the report found. One of the big things that this report found was that "between 44,000 and 98,000 people died each year in the United States hospitals due to medical errors and adverse events" (Bonacum, 2017, p. 3). This was also one of the reasons why the Healthcare Research and Quality Act of 1999 passed. This act allowed research to be done using scientific evidence and report things such as effectiveness, outcomes, costs, quality, etc. in the health care field ("Healthcare Research and Quality Act of 1999," 2014). It is a good thing that the Institute of Medicine came out with this report because it made patient safety a very important issue that needed to be resolved, it was definitely an eye opener. The above number of people dying because of medical errors is surprisingly high, if I did my math correctly that’s about 122-272 people dying each day. Wow! There are other factors that

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).

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

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.

It is evident that patient safety is one of the most important principal in place as a nurse. To insure this there are many standards that are set in place that as a registered nurse need to be met, some including, professional responsibility and accountability, having knowledge based practice, ethical practice, service to the public and self-regulation (SRNA, 2014). “These standards and foundation competencies serve as the criteria against which all registered nurses, practising in all domains of nursing practice (direct care, education, administration, and research, and the evolving domain of policy) will be measured by clients, employers, colleagues and themselves”(SRNA, 2014). Having these standards allows register nurses and the public to have a clear understanding of what needs to be met in order to insure that there is proper patient safety. However there are still many issues that contribute to unacceptable patient safety, including medication administration errors, post operative care, and patients mental health. However, “medication errors are one of the most common types of medical errors that occur in healthcare institutions” (J.Choo, 2010). A medication error, according to The National Coordinating Council for Medication Error Reporting and Prevention “is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or

Patient safety is an essential component of hospital environments that has generated international debates and received many interpretations. It involves practices that seek to reduce risks and unnecessary health-related medication errors to an acceptable minimum (Silva & Camerini, 2012). Nurses’ role in the medication process includes administering drugs. This role exposes them to the possibility of making errors that can potentially harm the patient, or even result in death. The research articles authored by Westbrook et al. (2011) entitled “Errors in the Administration of Intravenous Medications in Hospital and the Role of Correct Procedures and Nurse Experience” and Ding et al. (2015) titled “Incidence of Intravenous Medication Errors

A risk management plan is created so as to support Little Falls Hospitals mission and vision statements as it pertains to the clinical risk of the hospital, patients, visitors, volunteers, and employee safety, and any possible operational, business, and property risks.

The origins of the statement “time is of the essence” are unknown, however this term is widely used in business transactions with the implication that the task at hand will be completed within the time parameters specified, and if no speciation is provided than as expediently as possible (West’s Encyclopedia of American Law, edition 2, 2008). Never was this statement more true than when used in regards to responding to critical lab values or adverse findings in diagnostic studies, which, in this instance, could literally mean the difference between life and death. Effective and timely communication between the departments that identify critical lab value or adverse diagnostic finding, the nursing staff, and the attending or consulting physicians is essential in consistently achieving this goal in acute care hospitals as outlined by The Joint Commission.