What is the purpose of the National Patient Safety Goals?
The primary objective of the National Patient Safety Goals is to enhance the safety and quality of patient care within healthcare settings. Drafted and maintained by The Joint Commission, these goals aim to address specific areas of concern in patient safety. They gather data each year on emerging safety issues and then customize the goals to specific care settings. They highlight critical priorities, direct attention to areas prone to avoidable harm, and ensure healthcare organizations adopt best practices to reduce medical errors.
By focusing on tangible, evidence-based strategies, the aim is not only to minimize patient harm but to build a culture of safety throughout healthcare systems.
What are the strategies to improve the quality of care and patient safety?
The quality of patient care is of paramount importance in the healthcare sector. As our understanding of patient care deepens, healthcare organizations globally are focusing on enhancing safety measures. The National Patient Safety Goals (NPSG) serve as a roadmap for these endeavors, illuminating the path forward. Let’s delve into the key strategies underlined by the NPSG to uplift the standard of care and ensure patient safety:
Accurate Patient Identification
In Theory: Implementing a dual system of identification, like using a patient’s name combined with their date of birth, is essential. This minimizes the risk of errors, ensuring that each patient receives the appropriate medication and treatment. (NPSG.01.01.01)
In Practice: The University of Texas Medical Branch at Galveston (UTMB) has advocated a straightforward yet effective approach termed “Do-the-2,” which emphasizes verifying two patient identifiers every time, for every patient, to ensure accurate patient identification. This principle is aimed at reducing medical errors that stem from incorrect patient identification, which is regarded as one of the most preventable types of medical errors (e.g. incorrect order entry, specimen collection/labeling errors, medication errors, wrong site surgeries, etc.). The UTMB’s advice underscores the importance of having robust patient identification processes in place when providing care, treatments, and services.
Enhancing Staff Communication
In Theory: Prioritizing efficient communication within the medical team is crucial. This involves promptly conveying vital test results to the right personnel, thereby facilitating timely intervention and reducing delays in treatment. (NPSG.02.03.01)
In Practice: Numerous frameworks such as SBAR or I-PASS have emerged in recent years to address the challenge of clinical communication breakdowns, which can carry serious consequences. One study of the I-PASS communication framework in 32 diverse hospitals — adult, pediatric, academic, and community — found striking results. At each hospital, supervising doctors monitored and gathered data on more than 3,000 patient handoffs before, during, and after program execution. Separately, the I-PASS team examined 1,620 written handoff documents. Upon evaluating error surveillance reports, the researchers observed a remarkable 47 percent decline in adverse events, major and minor, following I-PASS deployment.
Notable enhancements in handoff communication quality and completeness were also recorded:
Post-implementation, verbal handoffs were 66 percent complete (up from 20 percent), and written handoffs climbed to 74 percent (up from 10 percent).
Outgoing providers delivered high-caliber verbal and written patient summaries 81 and 78 percent of the time, respectively — a leap from 39 and 21 percent.
Incoming providers offered a quality synthesis of the received information 83 percent of the time, compared to 31 percent before I-PASS.
Safe Medication Practices
Labeling all medicines, especially those outside their original containers like those in syringes or basins, becomes imperative to avoid mix-ups. (NPSG.03.04.01)
For patients on blood thinners, additional precautions are needed given the potential risks associated with these medications. (NPSG.03.05.01)
Establish a rigorous system for recording and communicating the medications a patient is on. When introducing new medications, a comparative analysis with the current medications is essential. Educating the patient is equally important. Providing them with written information about their medication and emphasizing the importance of maintaining an up-to-date list of their medicines can mitigate risks. (NPSG.03.06.01)
In Practice: Implementing safe medication practices is crucial to ensuring patient safety and reducing the likelihood of medication errors in healthcare facilities. Evolve best practices over time based on experience and evidence. For instance, the 2022-2023 Targeted Medication Safety Best Practices from the Institute for Safe Medication Practices (ISMP) focused on improving the safety of oxytocin use, enhancing vaccine administration through barcoding, and implementing multifocal efforts to reduce high-alert medication errors.
Effective Alarm Systems
In Theory: Regular audits and updates to medical equipment alarm systems can ensure they function optimally. Healthcare staff should be trained to promptly respond and avoid becoming desensitized to these alarms to avert potential crises. (NPSG.06.01.01)
In Practice: Effective Alarm Systems in healthcare settings are pivotal for patient safety. Alarm Fatigue Mitigation, Technology Utilization, and Alarm Management Strategies need constant evaluation and updates. The American Association of Critical-Care Nurses provides practice alerts to outline Alarm Management Strategies.
In Theory: Adopting hand cleaning guidelines from recognized organizations like the CDC or WHO is a foundational step. Setting tangible goals around hand hygiene and continuously working towards them can significantly reduce infection rates. (NPSG.07.01.01)
In Practice: Hand Hygiene is not a new concept in patient safety, but a challenging one nonetheless. A group of study authors set out to compile a list of successful hand hygiene interventions. The study was structured in four stages. Initially, data from a prior systematic literature review was utilized to pinpoint distinct elements of existing interventions aimed at enhancing Hand Hygiene in Intensive Care Units. Subsequently, a workshop involving a 10-member expert panel was convened to identify more intervention components. In the third phase, the 91 intervention components unearthed from both the literature review and workshop were condensed into a final roster of 21 hand hygiene interventions. In the concluding phase, a total of 39 stakeholders, including health services researchers, ICU personnel, and the general public, assessed the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention.
Identifying Patient Safety Risks
In Theory: Recognizing the mental health aspect of patient care is pivotal. By providing the necessary resources and support, healthcare institutions can play a role in mitigating risks, particularly those associated with self-harm or suicide. (NPSG.15.01.01)
In Practice: In 2001, Henry Ford Behavioral Health emerged as a trailblazer by introducing the ambitious objective of “zero suicides,” and crafting a care pathway to evaluate and adjust suicide risk among patients suffering from depression. This pioneering initiative yielded remarkable outcomes, achieving zero suicides over a span of 18 months during 2009-2010, and a statistically significant reduction in suicide rates within Henry Ford since the program’s outset. Henry Ford Health System has continued to improve on this strategy and makes its Zero Suicide Prevention Guidelines free and available for public use. The Joint Commission also provides a number of resources on suicide prevention, including a free toolkit.
Improving Health Care Equity – NEW in 2024
In Theory: Enhancing healthcare equity is a chief priority for both quality and patient safety. For instance, it’s crucial for organizations to identify healthcare disparities within their patient population and develop a documented plan to address and improve healthcare equity. (NPSG.16.01.01)
In Practice: Many organizations are finding that to address equity in healthcare, entire operations with varying perspectives are required. For example, organizations like Boston Medical Center have founded work groups called The BMC Equity Accelerator and The BMC Social Needs Screening Program. The BMC Equity Accelerator provides funding and support to BMC clinicians and researchers who are working to develop and implement interventions to reduce healthcare disparities. The BMC Social Needs Screening Program screens all BMC patients for social needs, such as food insecurity and housing instability. Patients who are identified as having social needs are then connected with resources to address those needs.
During a study conducted as part of the BMC Social Needs Screening Program, clinics performed screenings on 70% of all new patients (1,696) using the THRIVE framework. Out of these, 26% of patients indicated facing one or more social challenges. The most common issues identified were employment (12%), food insecurity (11%), and difficulties affording medications (11%). Moreover, each positive screening outcome was associated with a specific ICD-10 visit diagnosis code, enhancing the precision of data reporting and providing a clearer understanding of the major concerns affecting patients.
“The ability to successfully incorporate this critical information into the electronic medical record is a true game changer when it comes to addressing the whole patient,” said Pablo Buitron de la Vega, MD, MSc, the study’s lead author and a physician in general internal medicine. “As a physician, this information is vital to the health and well-being of my patients and their families. Now that I am aware of these issues, I can better treat them by connecting them with resources that will help them thrive.”
“This data-driven approach is a novel way to address health care inequity while also addressing the rising costs of health care, including Medicaid,” said Nancy Kressin, PhD, a professor of medicine at BU School of Medicine and the study’s senior author. “We believe that THRIVE can help change the delivery of care at BMC, within our ACO, and that its scalability can have positive impacts on health care delivery at the national level.”
Avoiding Surgical Errors
In Theory: Implementing rigorous checks to ensure the right surgical procedure is conducted on the right patient and at the correct site is non-negotiable. (UP.01.01.01) This includes clearly marking the surgical site (UP.01.02.01) and having a standardized ‘time-out’ procedure before initiating the surgery to confirm details and prevent mishaps. (UP.01.03.01)
In Practice: In the pursuit of enhanced patient safety within surgical settings, ensuring accurate patient identification and correct surgical site marking are paramount. This National Patient Safety Goal underscores the necessity of rigorous checks to prevent wrong-site, wrong-patient surgeries—a critical step towards minimizing surgical errors and promoting superior patient care. Various strategies and technological innovations have been proposed and evaluated to address this significant concern.
Universal Protocol: Early efforts to prevent wrong-site, wrong-procedure, and wrong-patient errors (WSPE or WSS) focused on redundant mechanisms for identifying the correct site, procedure, and patient. One such mechanism is the “sign your site” initiative instructing surgeons to mark the operative site unambiguously. The Universal Protocol from The Joint Commission is a standard approach to prevent WSPEs. It includes site marking and a “time out” before the procedure to review critical aspects of the operation with all involved personnel.
Surgical Timeouts: A surgical timeout is a planned pause before the procedure begins to review important aspects with all involved personnel. This step is to ensure that everyone is on the same page regarding the patient’s identity, the surgical site, and the procedure to be performed.
Surgical Safety Checklists: Incorporating timeout principles into surgical safety checklists has been proven to improve surgical and postoperative safety, although the low baseline incidence of WSPEs makes it difficult to establish that a single intervention can reduce or eliminate WSPEs.
Technology-Assisted Process Innovations: The StartBox Patient Safety System is a technology developed to prevent wrong-site, wrong-patient surgeries. A 2020 study involving 11 surgeons at six sites evaluated the system’s efficacy across a total of 487 procedures. The StartBox System consists of a mobile software application, a safety-engineered blade delivery kit, and a data reporting tool. The StartBox System begins with an audio recording of the surgeon describing the planned procedure to the patient, including site and laterality. Upon hospital check-in, the StartBox patient record is checked to confirm the correct procedure. Then, the patient’s hospital wristband is scanned and associated with a StartBox Blade Delivery Kit (BDK) labeled with a QR code that references the patient’s unique procedure, site, and laterality. The packaging of the BDK is also color-coded for easy identification of laterality: Lavender, for Left; Rose, for Right; Neutral Gray, for No Laterality. The saved audio recording of the decision for surgery is also replayed in the preoperative holding area, as well as in the operating room where surgical personnel listen to the agreed-to procedure discussion just prior to the surgical time-out. Any member of the medical staff can flag errors with the use of a “No Go” function in the StartBox application, which triggers a real-time alert in the system, and all “No Gos” must be resolved before the surgery can be initiated. Immediately prior to surgery, the time-out is conducted as prescribed by the Universal Protocol. This time-out is recorded by the application as an additional audio file that is saved to the cloud system to document this confirmation. Upon successful completion of time-out requirements, the BDK is placed on the sterile field. The BDK contains four sterile scalpel blades and safely delivers each blade, minimizing the potential for sharps injury. With the StartBox System, the BDK serves as a key constraint: the blade for the first incision is not delivered to the surgeon until the patient’s identity, correct procedure, correct site, and correct laterality have been confirmed and documented by the surgical team during the time-out.
What are 5 steps to improving patient safety?
Risk Assessments and Gap Analyses: Health systems should conduct regular evaluations of their processes and environments. By identifying potential patient safety issues, proactive measures can be adopted to prevent errors and mishaps. In addition to identifying risks, processes, and tools should be regularly evaluated for gaps. For example, many hospitals fail to conduct a periodic gap analysis on critical aspects of their operations such as their patient safety event reporting process. Get access to ADN’s free Patient Safety Event Reporting Gap Analysis Template.
Education and Training: Keeping health care staff updated with the latest evidence-based practices ensures they are equipped with the knowledge to provide optimal care. Regular training can significantly reduce the occurrence of medical errors.
Verification Processes: Implementing strict verification processes, especially in medication administration and surgical procedures, ensures that every step is double-checked, drastically cutting down on preventable mistakes.
Monitoring and Reporting: Encouraging a culture where medical errors, no matter how minor, are reported helps in the identification of patterns. Recognizing these patterns is the first step toward implementing corrective measures. Read more here about the biggest barriers to event reporting.
Focus on High-Risk Areas: Certain areas, like patient falls or healthcare-associated infections, are notoriously high-risk. Special attention and strategies tailored for these areas can significantly improve patient safety.
The National Patient Safety Goals provide a robust framework guiding healthcare organizations towards enhanced patient safety. However, achieving these goals necessitates a holistic approach, intertwining evidence-based practices, technology, communication, and continuous learning. As health care professionals, the responsibility to minimize patient harm and elevate the standards of patient care is immense.
By heeding the strategies outlined by The Joint Commission and being vigilant in our quest to prevent errors, we can ensure that our health systems become paragons of safety and quality in patient care.