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Ultimate Guide to the National Patient Safety Goals 2025 (NPSGs)

An authoritative guide designed for healthcare leaders detailing evidence-based tactics for successfully implementing each of The Joint Commission’s 2025 National Patient Safety Goals.

Table of Contents

Hospital leaders – especially Directors or VPs of Quality and Patient Safety – can drive safer care by systematically implementing each National Patient Safety Goal. Below is an authoritative guide to the eight NPSGs for 2025, detailing each goal and element of performance, followed by actionable tactics supported by recent research, best-practice guidelines, and real-world implementation examples.

View the full list of 2025 National Patient Safety Goals and associated Elements of Performance.

National Patient Safety Goals 2025

National Patient Safety Goals 2025: #1 Identify Patients Correctly

 

2025 National Patient Safety Goal: NPSG 01.01.01:
Use at least two patient identifiers when providing care, treatment, and services.
Element(s) of performance for NPSG 01.01.01
EP 1Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient’s room number or physical location is not used as an identifier. (See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)
EP 2Label containers used for blood and other specimens in the presence of the patient. (See also PC.02.01.01, EP 10)
EP 3

Use distinct methods of identification for newborn patients.

Note: Examples of methods to prevent misidentification may include the following:

  • Distinct naming systems could include using the mother’s first and last names and the newborn’s gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
  • Standardized practices for identification banding (for example, using two body sites and/or bar coding for identification).
  • Establish communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names).

Accurately identifying patients is foundational to preventing wrong-patient errors. This goal emphasizes using multiple patient identifiers and standardized processes so every test, medication, or procedure is matched to the correct person. Hospitals must eliminate identification mistakes by hardwiring verification steps into care workflows.

Use at Least Two Identifiers for Every Patient Encounter

Ensure staff always verify at least two distinct identifiers (for example, name and date of birth) before providing any care, administering medications, drawing labs, or performing procedures​ (Source: ​jointcommission.org). This practice is required by NPSG standards and has been effective in avoiding misidentifications. Electronic health records (EHRs) and wristband systems should make it easy to check identifiers, and never allow room numbers or physical location to be used as an identifier (to avoid mix-ups if patients move rooms) ​(Source: psnet.ahrq.gov).

Implement Barcode Scanning and Other Technology Aids

Use bar-code medication administration (BCMA) and patient wristband scanning systems to verify patient identity at the point of care. Scanning the patient’s ID band provides an electronic double-check before medications, blood products, or tests are given. A meta-analysis found that wristband barcode scanning reduced medical errors by 57.5% ​​(Source: psnet.ahrq.gov). Many hospitals have reported sharp drops in wrong-patient errors after deploying barcode systems that prompt staff if the patient’s ID does not match the order.

Label Specimens and Diagnostics at the Bedside

Require that blood tubes, specimen containers, imaging requisitions, and other labeled materials be labeled in the presence of the patient immediately after collection. This ensures the label is attached to the correct patient’s sample. Incorporate two-identifier verification into the labeling process (e.g., patient states name/DOB while the phlebotomist labels the tube) to catch errors on the spot.

Related Reading: Specimen Study Helps 15 Hospitals Make Critical Process Changes to Prevent Errors

Address Look-Alike/Sound-Alike Names and Engage Patients in ID Checks

Flag patients with similar names in the EHR (e.g. alert banners for “J. Smith” vs “John Smith Jr.”) to prompt extra caution. For high-risk procedures (such as blood transfusions or surgeries), use an independent double-check – two clinicians should separately confirm the patient’s identity and agreement of identifiers. Encourage patients to participate by stating their name and DOB and speak up if an ID check does not occur. This patient engagement adds another layer of safety ​​​(Source: psnet.ahrq.gov). The Joint Commission’s Speak Up Patient Safety Program is another tactic that can help encourage patient engagement in their own care.

Audit and Train for Compliance

Continuously monitor compliance with patient ID protocols (e.g. random audits of whether two identifiers are used). Provide refresher training and share incident learnings. If near-misses occur (like a wrong patient near-miss caught by scanning), treat them as teaching opportunities. A culture of “zero tolerance” for skipping ID checks reinforces that every staff member is accountable for patient identification safety.

Leverage Patient Photos in EHRs to Prevent Misidentification

Integrating patient photographs into electronic health records provides an additional visual identifier to help staff quickly verify patient identity, especially in busy clinical settings. Recent studies have demonstrated that displaying patient photos in EHRs can significantly reduce wrong-patient order entry (WPOE) errors.

A notable study conducted at Brigham and Women’s Hospital found that the inclusion of patient photographs in EHRs led to a 35% reduction in wrong-patient order entry errors. Similarly, research published in JAMA Network Open reported that displaying patient photographs prominently in the EHR banner was associated with a significant decrease in the rate of wrong-patient orders.

Further, an evaluation from the Agency for Healthcare Research and Quality (AHRQ) highlighted patient photos as a noninterruptive decision-support tool, effectively improving patient identification without causing alert fatigue among healthcare providers (AHRQ Digital Healthcare Research).

Implementing patient photos can therefore serve as a practical, cost-effective approach to reinforcing patient identification accuracy, directly contributing to safer clinical care processes.

National Patient Safety Goals 2025: #2 Improve Staff Communication

2025 National Patient Safety Goal: NPSG 02.03.01:
Report critical results of tests and diagnostic procedures on a timely basis.
Element(s) of performance for NPSG 02.03.01
EP 1

Develop and implement written procedures for managing the critical results of tests and diagnostic procedures that address the following:

  • The definition of critical results of tests and diagnostic procedures
  • By whom and to whom critical results of tests and diagnostic procedures are reported
  • The acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures

Ⓓ Documentation is required.

EP 2Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

Effective communication among caregivers is critical for timely, safe care. This goal focuses on standardized communication of critical information – whether during handoffs, when conveying critical test results, or in daily interactions. Hospitals should implement structured communication tools and “closed-loop” confirmation practices to ensure information is reliably exchanged and understood.

Use Structured Hand-off Protocols Like I-PASS

Implement standardized patient handoff protocols for shift-to-shift handoffs and inter-departmental transfers. Tools like the I-PASS handoff bundle ensure that critical patient information is not omitted. A 2025 systematic review published in BMJ Quality & Safety evaluated structured handoff protocols. This review found moderate-certainty evidence that the I-PASS tool reduces medical errors and adverse events ​​(Source: ​qualitysafety.bmj.com). Make these formats mandatory for both verbal handoffs and written handoff summaries in the EHR.

Report Critical Test Results in a Timely, “Closed-Loop” Manner

Establish a policy that critical lab values and diagnostic findings (e.g. dangerously high potassium or a radiology finding of a pneumothorax) are reported to the responsible provider within a set time frame. Use a reliable communication method that ensures receipt – for instance, a dedicated call center or an automated alert system that continuously tries providers until results are acknowledged ​​​(Source: cdc.gov). Many hospitals are adopting secure texting for critical results: one study demonstrated a reduction in average notification time from 11.3 minutes to 3.0 minutes by sending critical lab results directly to physicians’ smartphones, with 95% of providers preferring this over pager call-backs ​​​(Source: pmc.ncbi.nlm.nih.gov)​. Whatever the method, require that the receiving clinician confirms the result (closed-loop), and document the communication time.

Implement Read-Back Verification for Verbal Orders and Results

For any critical value relayed by phone or any telephone order, staff must perform a read-back – repeating the information received – to verify accuracy (Source: ​jointcommission.org). For example, if a lab calls a critical result, the nurse should write it down and read it back (“…confirming, potassium 2.8 for John Doe”). This practice, mandated by Joint Commission standards, has prevented innumerable errors caused by misheard information. Train all clinicians on read-back and enforce it as a standard operating procedure, especially in high-risk situations (critical lab values, verbal medication orders, etc.).

Leverage Team Training and Communication Coaching

Invest in programs like TeamSTEPPS, which is an evidence-based teamwork system aimed at improving communication and safety culture ​​(Source: ​ahrq.gov). Conduct simulation exercises for high-risk scenarios (e.g. emergency response, OR to ICU handoff) to practice clear communication and teamwork. A formal TeamSTEPPS training or similar communication workshops can improve staff assertiveness to speak up about concerns and foster habits like checking back and clarifying questions​. In a high-reliability organization, every team member should feel responsible for sharing critical information and confirming it was received – e.g., a nurse should feel empowered to call a physician if a critical report was not acknowledged within the policy timeframe.

Use Communication Tools for Special Situations

Implement condition-specific communication protocols, such as rapid response team alerts, critical lab result escalation trees, or patient deterioration watchlists. For example, an SBAR can be required when a nurse calls a physician about a patient’s urgent issue, to organize the information. Similarly, use pre-surgery briefings and post-op debriefings to make sure key information is transferred between teams. By institutionalizing these communication practices, staff know what to communicate, when, and how – reducing errors caused by miscommunication.

Enhance Critical Result Management with AI-Driven Alerts

Artificial intelligence (AI) tools are increasingly being utilized to prioritize and escalate critical test results automatically, ensuring timely provider acknowledgment. AI-driven communication systems can identify delays, trigger escalation protocols, and enhance the overall reliability of critical result reporting, thereby closing communication gaps.

Recent studies have demonstrated the effectiveness of AI in this domain. For instance, a study published in JAMA Internal Medicine found that implementing an AI-enabled early warning system was associated with a significant reduction in the risk of clinical deterioration and subsequent care escalation in hospitalized patients. The study concluded that such AI interventions could enhance patient safety by facilitating timely clinical responses. (Source: jamanetwork.com)

Another study at Mount Sinai Health System reported that hospitalized patients were 43% more likely to have their care escalated and significantly less likely to die if their care team received AI-generated alerts signaling adverse changes in their health. This underscores the potential of AI-driven alerts in improving patient outcomes. (Source: news-medical.net)

By integrating AI-driven alert systems into clinical workflows, healthcare providers can enhance the timeliness and effectiveness of their responses to critical patient data, ultimately improving patient outcomes and safety.

National Patient Safety Goals 2025: #3 Use Medicines Safely

2025 National Patient Safety Goal: NPSG 03.04.01:

Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Note: Medication containers include syringes, medicine cups, and basins.

Element(s) of performance for NPSG 03.04.01
EP 1

In perioperative and other procedural settings both on and off the sterile field, label medications and solutions that are not immediately administered. This applies even if there is only one medication being used.

Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process.

EP 2In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container.
EP 3

In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the following:

  • Medication or solution name
  • Strength
  • Amount of medication or solution containing medication (if not apparent from the container)
  • Diluent name and volume (if not apparent from the container)
  • Expiration date and time

Note: The date and time are not necessary for short procedures, as defined by the hospital.

EP 4Verify all medication or solution labels both verbally and visually. Verification is done by two individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it.
EP 5

Label each medication or solution as soon as it is prepared, unless it is immediately administered.

Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process.

2025 National Patient Safety Goal: NPSG 03.05.01:

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Note: This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for preventing venous thromboembolism (for example, related to procedures or hospitalization).

Element(s) of performance for NPSG 03.05.01
EP 2The hospital uses approved protocols and evidence-based practice guidelines for reversal of anticoagulation and management of bleeding events related to each anticoagulant medication.
EP 3

The hospital uses approved protocols and evidence-based practice guidelines for perioperative management of all patients on oral anticoagulants.

Note: Perioperative management may address the use of bridging medications, timing for stopping an anticoagulant, and timing and dosing for restarting an anticoagulant.

EP 7

The hospital uses only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available.

Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children.

2025 National Patient Safety Goal: NPSG 03.06.01:
Maintain and communicate accurate patient medication information.
Element(s) of performance for NPSG 03.06.01
EP 1

Obtain information on the medications the patient is currently taking when they are admitted to the hospital or seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.

Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.

Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.

Ⓓ Documentation is required.

EP 2

Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in non-24-hour settings.

Note: Examples of non-24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings.

EP 3

Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies.

Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the hospital, does the comparison.

EP 4

Provide the patient (or family, caregiver, or support person as needed) with written information on the medications the patient should be taking when they are discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose).

Ⓓ Documentation is required.

EP 3

Explain the importance of managing medication information to the patient when they are discharged from the hospital or at the end of an outpatient encounter.

Note: Examples include instructing the patient to give a list to their primary care provider; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For patient education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

Medication safety efforts aim to prevent errors at all stages – ordering, dispensing, administering, and monitoring. The 2025 NPSG priorities for medication safety include proper labeling of medications, safe management of high-risk drugs (like anticoagulants), and thorough medication reconciliation during care transitions. Hospitals should adopt best practices and technology to minimize medication errors that could harm patients.

Label All Medications and Solutions, Especially in Procedural Settings

Unlabeled syringes, cups, or basins can lead to dangerous mix-ups. Require that every medication or solution is labeled with name, concentration, and expiration immediately after it is prepared or placed into a container, unless it’s going to be used instantly (Source: ​jointcommission.org). This is particularly vital in the operating room or other procedural areas where multiple drugs (saline, anesthetics, etc.) might be on a table – for example, a syringe on the sterile field must have a label if it’s not administered right away. The Joint Commission highlights medication labeling as a simple but critical step to avoid inadvertent drug swaps. Conduct regular audits in areas like ORs, cath labs, and EDs to ensure labeling compliance.

Implement Safeguards for High-Risk Medications (Especially Anticoagulants)

Anticoagulant therapy (like heparin or warfarin) is a common source of serious adverse drug events, so specific protocols are needed. Use standardized, evidence-based protocols for initiating and managing anticoagulation (Source: ​jointcommission.org) – for instance, weight-based heparin dosing with checks, warfarin nomograms, and specified INR monitoring frequency. Also put in place protocols for reversal of anticoagulation and management of bleeding complications (e.g., ready availability of vitamin K, protamine, or reversal agents for DOACs, guided by current guidelines). Many hospitals have created multidisciplinary anticoagulation stewardship programs that review all hospital anticoagulation orders, ensure dosing is appropriate, and follow up on lab results. Such programs have been shown to reduce anticoagulation errors and bleeding events. Additionally, provide patient-specific education on anticoagulants – patients should be counseled on dose timing, dietary interactions (for warfarin), signs of bleeding, and the importance of follow-up lab tests.

Ensure Medication Reconciliation at Every Transition of Care

Create a robust process to maintain and communicate accurate medication information for each patient​ (Source: ​jointcommission.org). On admission, collect a “best possible” medication history (consider using pharmacy staff or medication history technicians to improve accuracy). Compare that list to admission orders and resolve discrepancies. Similarly, at discharge, reconcile the hospital medications with pre-admission meds and produce an updated, clear medication list for the patient (and their next providers). This prevents inadvertent omissions or duplications (for example, continuing a home blood pressure medication that was held in hospital, or inadvertently prescribing two drugs in the same class). A pharmacy-led medication reconciliation program at one hospital reduced drug discrepancies significantly. Analysis of the discharge reconciliation process revealed that medication errors were reduced from 90% to 47% on the surgical unit and from 57% to 33% on the medicine unit (Source: ​academic.oup.com). Best practices include using EHR tools to flag changes, involving patients in verifying their med lists, and educating them on any new medications added or stopped. Monitor reconciliation completion rates and intervene if compliance falters.

Leverage Technology for Medication Safety

Utilize available technology to minimize human error. For instance, Barcode Medication Administration (BCMA), which involves scanning the patient and medication barcode before giving doses, ensures the “five rights” – right patient, drug, dose, time, route. Hospitals using BCMA have reported significant reductions in wrong-medication and wrong-patient errors ​(Source: psnet.ahrq.gov). Smart infusion pumps with dose-error reduction software should be used for continuous IV infusions (such as heparin drips) – the Joint Commission now requires programmable pumps for heparin to prevent infusion rate errors ​(Source: jointcommission.org). In the pharmacy, use automated dispensing cabinets with safety features (like alerts for look-alike/sound-alike drugs) and limit access to high-alert meds. Technology is not foolproof, so also address any workarounds (e.g., if nurses bypass scanning due to equipment issues, fix those issues and retrain staff rather than allowing workarounds to persist​ (Source: pmc.ncbi.nlm.nih.gov).

Educate Patients and Staff on Medication Safety

Ensure that patients are counseled about their medications – especially high-risk ones – in plain language. For example, a heart failure patient on a new anticoagulant should know why it’s needed and the bleeding precautions to take. Engage patients to be a final check (e.g., encourage them to speak up if a pill looks different than before). For staff, provide periodic training on medication safety, such as safe anticoagulation practices, opioid monitoring, or insulin management. Use real case studies of errors (anonymized) to reinforce lessons. A culture of safety encourages staff to report “near-miss” medication errors without fear – each near-miss is a chance to identify system weaknesses (like confusing labeling or pharmacy dispensing errors) and address them before harm occurs.

National Patient Safety Goals 2025: #4 Use Alarms Safely

2025 National Patient Safety Goal: NPSG 06.01.01:
Improve the safety of clinical alarm systems.
Element(s) of performance for NPSG 06.01.01
EP 1Leaders establish alarm system safety as a hospital priority.
EP 2

Identify the most important alarm signals to manage based on the following:

  • Input from the medical staff and clinical departments
  • Risk to patients if the alarm signal is not attended to or if it malfunctions
  • Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
  • Potential for patient harm based on internal incident history
  • Published best practices and guidelines

(For more information on managing medical equipment risks, refer to Standard EC.02.04.01)

EP 3

Establish policies and procedures for managing the alarms identified above that, at a minimum, address the following:

  • Clinically appropriate settings for alarm signals
  • When alarm signals can be disabled
  • When alarm parameters can be changed
  • Who in the organization has the authority to set alarm parameters
  • Who in the organization has the authority to change alarm parameters
  • Who in the organization has the authority to set alarm parameters to “off”
  • Monitoring and responding to alarm signals
  • Checking individual alarm signals for accurate settings, proper operation, and detectability

(For more information, refer to Standard EC.02.04.03)

Ⓓ Documentation is required.

Clinical alarm systems – cardiac monitors, pulse oximeters, IV pumps, ventilators, etc. – are crucial for patient monitoring, but alarm fatigue from excessive or non-actionable alarms is a well-documented safety hazard. This NPSG calls for hospitals to better manage alarm policies, ensuring that critical alarms are responded to while unnecessary alarms are reduced. The goal is a safer, quieter environment where clinicians do not become desensitized to important alarms.

Establish Alarm Safety as a Leadership Priority and Inventory Alarms

Hospital leadership should convene a multidisciplinary alarm management committee (including clinical engineers, nurses, physicians) to review all alarm-equipped devices in the hospital. Identify which alarm signals are most important for patient safety – for example, asystole or apnea alarms are life-critical, whereas an IV pump “infusion complete” alarm might be less urgent. By cataloguing alarm types and default settings, the team can prioritize which alarms require immediate response and which can be adjusted. The Joint Commission expects hospitals to designate the “most important alarms to manage” based on their own environment (Source: ​jointcommission.org)​. Focus on areas like intensive care, telemetry units, and OR/PACU where alarm overload is common.

Develop Policies to Reduce Non-Actionable Alarms and Prevent Alarm Fatigue

Create evidence-based policies for alarm parameters and default settings. This can include widening default alarm limits (within safe ranges) to reduce false alarms, tailoring alarm thresholds to the individual patient’s condition, and establishing delays or tiered escalation for certain alarms. For example, in some units pulse oximeter alarms for brief desaturations (a few seconds) can be delayed to alarm only if sustained, preventing constant chimes for self-correcting dips. Johns Hopkins Hospital and others have reported success by daily customization of cardiac monitor alarms (adjusting heart rate thresholds per patient) and eliminating duplicate alarms, resulting in a dramatic drop in alarm rate​ (Source: pmc.ncbi.nlm.nih.gov). All alarm settings changes should be done according to policy and tracked. The policy should also address who can modify alarm parameters (ensuring only competent staff do so, and critical alarms are not disabled). Regular maintenance of equipment to prevent nuisance alarms (e.g., ECG electrodes changed daily to reduce false leads-off alarms) is another tactic. A 2023 quality improvement study at Mayo Clinic implemented such interventions – stopping continuous monitoring on patients who didn’t need it and educating staff – and saw a ~17% reduction in total alarm load in just two months (Source: ​pmc.ncbi.nlm.nih.gov).

Train and Educate Staff about Proper Alarm Management

All clinical staff should be educated on the new alarm policies, the rationale behind them (reducing noise and improving safety), and their responsibility to respond promptly to alarms. Emphasize the dangers of alarm fatigue, where caregivers become desensitized – multiple studies link alarm overload to missed alarms and patient harm​ (Sources: sciencedirect.com​, psnet.ahrq.gov). Training should cover how to properly set alarm parameters for each patient, how to distinguish alarm priority levels (if the system has escalating tones or visual cues), and the protocol for responding (e.g., what to do if an alarm is sounding and it’s not your patient). Simulation drills can help – for instance, on a telemetry unit, a drill where an alarm is ignored can be used to discuss how to ensure someone always “owns” responding. Importantly, foster a culture where silencing or pausing alarms inappropriately is unacceptable; staff should never permanently silence an alarm without addressing the patient condition or fixing the cause.

Improve Alarm Notification and Response Workflows

Consider technologies that route critical alarms directly to the responsible nurse or a central monitor watcher to ensure alarms are not missed. Some hospitals use middleware to send alarm alerts to a nurse’s smartphone or pager, reducing reliance on hearing the alarm sound. Assign accountability – e.g., a unit might have a dedicated monitor technician who notifies nurses of lethal arrhythmias immediately. Audit response times to critical alarms and adjust staffing or roles if needed (for example, if nurses are tied up and can’t respond, a “backup responder” should be alerted). Ensure that for every alarm that triggers, there is a clear action – even if it’s assessing the patient – so that alarms are never ignored. The Joint Commission in 2021 set national targets to eliminate alarm-related fatalities by improving these alarm response systems, underscoring how crucial this issue is. (Source: pmc.ncbi.nlm.nih.gov).

Deploy Alarm Analytics Dashboards and Predictive AI Tools

Advanced hospitals are enhancing patient safety by integrating real-time alarm data into clinical analytics dashboards. These dashboards consolidate alerts from various monitoring devices, enabling clinicians to quickly identify critical alarms and respond promptly. For instance, GE Healthcare’s alarm management solutions incorporate centralized monitoring units that streamline alarm notifications, reducing response times and improving patient outcomes. (Source: gehealthcare.com)

In addition to dashboards, predictive AI algorithms are being utilized to anticipate patient deterioration events. Nationwide Children’s Hospital implemented a machine learning tool known as the Deterioration Risk Index (DRI), which analyzes electronic medical records to identify patients at risk of clinical deterioration. Over an 18-month period, the use of DRI led to a more than two-thirds reduction in deterioration events among inpatients. ​(Source: childrenshospitals.org)

Similarly, Stanford Health Care employed an AI model to predict clinical deterioration events, such as unplanned ICU transfers, within a 6- to 18-hour window. This proactive approach resulted in a 20% reduction in such events, demonstrating the efficacy of predictive analytics in improving patient care. (Source: healthcareitnews.com)

By leveraging alarm analytics dashboards and predictive AI tools, healthcare providers can not only reduce alarm fatigue but also intervene earlier in patient care, thereby enhancing overall safety and outcomes.

Continuous Evaluation of Alarm Data

Monitor alarm metrics regularly – how many alarms per bed per day? What percentage are true vs false? Use this data to fine-tune your approaches. Success can be seen in places like UCSF, which reduced audible monitor alarms in ICUs by more than 60% through interdisciplinary alarm management and saw no adverse events as a result (Source: jointcommissionjournal.com). If alarm-related incidents or near misses occur, perform a root cause analysis: Was the alarm volume too low? Did staff assume “false alarm” incorrectly? Use these learnings to further adjust policies or retrain staff. Alarm safety improvement is an ongoing process, but it pays off in better patient outcomes and a calmer healing environment.

Related Reading: Improving Clinical Alarm Management: Guidance and Strategies

National Patient Safety Goals 2025: #5 Prevent Infection

2025 National Patient Safety Goal: NPSG 07.01.01:
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.
Element(s) of performance for NPSG 07.01.01
EP 1Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) and/or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.06.01.01, EP 3)
EP 2Set goals for improving compliance with hand hygiene guidelines.
EP 3Improve compliance with hand hygiene guidelines based on established goals.

Healthcare-associated infections (HAIs) are a major patient safety risk, but they are often preventable through diligent infection prevention and control practices. This goal highlights adherence to proven guidelines (like hand hygiene compliance) and the use of evidence-based bundles to prevent device-related and surgical infections. Hospitals should treat infection prevention as a top priority, with the aim of zero preventable infections.

Enforce Rigorous Hand Hygiene Practices Hospital-Wide

  • Adhere to CDC and WHO Guidelines: Implement and enforce a hand hygiene program following CDC or WHO guidelines, emphasizing the “5 Moments for Hand Hygiene”—before touching a patient, before clean/aseptic procedures, after body fluid exposure, after touching a patient, and after touching patient surroundings (CDC, 2023; WHO, 2023).
  • Enhance Accessibility to Hand Hygiene Products: Ensure alcohol-based hand sanitizers and handwashing facilities are readily accessible at patient care points and high-traffic areas throughout the hospital to facilitate compliance.
  • Compliance Monitoring and Feedback: Employ electronic monitoring systems or regular observational audits to track compliance rates. Provide staff with immediate, specific feedback to encourage continuous improvement in hand hygiene adherence.

Leadership Engagement and Staff Training on Hand Hygiene

  • Leadership Accountability: Hospital leadership should visibly support and prioritize hand hygiene compliance, incorporating it into institutional safety culture.
  • Ongoing Education: Offer regular, evidence-based educational programs to reinforce correct hand hygiene practices among all healthcare staff. Training should address common compliance barriers and emphasize the critical role of hand hygiene in infection prevention.

Patient and Visitor Engagement in Hand Hygiene

  • Involve Patients in Hand Hygiene: Encourage patients to participate actively in infection prevention by asking healthcare providers if they’ve cleaned their hands before care. Provide visible reminders in patient rooms and waiting areas.
  • Visitor Hand Hygiene: Ensure visitors understand the importance of hand hygiene through clear signage and readily accessible hand hygiene stations at hospital entrances, patient rooms, and communal areas.

Set Clear, Measurable Hand Hygiene Goals

  • Establish and Track Compliance Targets: Define clear compliance goals (e.g., greater than 90% adherence hospital-wide) and publicly display unit-level performance. Regularly celebrate improvements to sustain momentum and demonstrate the importance of hand hygiene to staff.
  • Continuous Improvement Initiatives: Use hand hygiene compliance data to inform ongoing quality improvement efforts. Address gaps promptly by identifying and mitigating barriers to compliance, such as workload pressures or inadequate product availability.

By focusing specifically on these rigorous hand hygiene practices, hospitals can significantly reduce the incidence of healthcare-associated infections, protect patients, and enhance overall safety outcomes.

National Patient Safety Goals 2025: #6 Reduce the Risk for Suicide

2025 National Patient Safety Goal: NPSG 15.01.01:

Reduce the risk for suicide.

Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation during the course of care.

Element(s) of performance for NPSG 15.01.01
EP 1

For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).

For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.

Note: Nonpsychiatric units in general hospitals do not need to be ligature resistant. Nevertheless, these facilities should routinely assess clinical areas to identify objects that could be used for self-harm and remove those objects, when possible, from the area around a patient who has been identified as high risk for suicide. This information can be used for training staff who monitor high-risk patients (for example, developing checklists to help staff remember which equipment should be removed when possible).

Ⓓ Documentation is required.

EP 2

Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool.

Note: The Joint Commission requires screening for suicidal ideation using a validated tool starting at age 12 and above.

EP 3

Use an evidence-based process to conduct a suicide assessment of patients who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens patients for suicidal ideation and assesses the severity of suicidal ideation.

EP 4Document patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide.
EP 5

Follow written policies and procedures addressing the care of patients identified as at risk for suicide. At a minimum, these should include the following:

  • Training and competence assessment of staff who care for patients at risk for suicide
  • Guidelines for reassessment
  • Monitoring patients who are at high risk for suicide

Ⓓ Documentation is required.

EP 6Follow written policies and procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide.
EP 7Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of patients at risk for suicide and take action as needed to improve compliance.

Hospitals must proactively identify patients at risk for harm – particularly those at risk of suicide or self-harm. This goal involves systematic screening for risk factors (like suicidal ideation) and taking action to mitigate those risks in the hospital environment and beyond. By recognizing at-risk individuals early, hospitals can prevent tragic events and ensure patients get the help they need.

Screen All Patients for Suicide Risk when Indicated Using Validated Tools

For hospitals that treat behavioral health conditions or emergency patients with psychiatric complaints, implement a suicide risk screening on admission (or initial evaluation) for those populations (Source: jointcommission.org). The Joint Commission requires that all patients being treated for emotional or behavioral disorders be screened for suicidal ideation. Many hospitals have expanded this to universal screening in emergency departments and inpatient units – using tools like the Columbia-Suicide Severity Rating Scale (C-SSRS) or the PHQ-9 depression questionnaire (which has suicide ideation questions). The screening should be done by trained staff in a sensitive manner, and positive screens should trigger an immediate, more thorough risk assessment by a qualified professional. In one landmark study (ED-SAFE), implementing suicide screening in the ER and follow-up care led to a 30% reduction in suicide attempts among those patients in the following year – demonstrating the life-saving potential of systematic screening and intervention (Source: jamanetwork.com).

Conduct a Thorough Risk Assessment and Level-of-Risk Stratification

If a patient screens positive or otherwise is suspected to be at risk (e.g., expresses suicidal thoughts, has recent suicide attempt, or shows self-harm behavior), perform a formal suicide risk assessment using a standardized approach. This includes evaluating the patient’s suicidal ideation frequency and intensity, intentions or plan, past attempts, mental health and substance use history, and access to means (like firearms or medications) (Source: jointcommission.org). Document the findings and an immediate safety plan/mitigation strategy. For example, a high-risk patient might be placed on one-to-one observation, in a ligature-resistant room, with removal of any personal belongings that could be used for self-harm. Moderate risk might warrant 15 minute checks and secured unit placement. The assessment should also consider other safety risks inherent in the population – for instance, in older adults, risk of falls; in those on opioids, risk of overdose. Addressing patient safety risks means looking at each individual’s context.

Create a Safe Environment for At-Risk Patients

For patients identified as high risk for suicide, take immediate actions to minimize environmental hazards. This includes using ligature-resistant rooms or safe rooms whenever possible (rooms with no anchor points for hanging, tamper-proof fixtures, etc.), removing unnecessary medical equipment, cords, or objects that could be used for self-harm, and ensuring supervision. Train staff to perform a safety sweep of the room and patient’s belongings. Many hospitals have a checklist for making a room “suicide safe.” In psychiatric units, maintaining a ligature-resistant environment is mandatory under Joint Commission standards. Additionally, adjust care processes: e.g., no unsupervised passes, monitored bathrooms, plastic utensils for meals, etc., as needed for safety. Assign sitters or 1:1 observers for patients who require continuous observation (per your risk protocol)​. All staff (nurses, techs, sitters) should be briefed on the patient’s risk and what to monitor (e.g., patient trying to obtain sharp objects).

Engage Mental Health Expertise and Initiate Treatment

Identifying the risk is only the first step; ensure that at-risk patients get expert evaluation and intervention promptly. This might mean psychiatry consults for patients on medical units who voice suicidal ideation, or evaluation by a licensed mental health professional in the ED. Start interventions such as safety planning (a brief intervention where the provider works with the patient on coping strategies and sources of support) and, when appropriate, begin or adjust medications for underlying conditions (e.g., antidepressants, anti-anxiety meds). Sometimes just the act of a compassionate suicide risk assessment and engagement in care can reduce a patient’s immediate sense of crisis. For patients with substance use contributing to self-harm risk, involve addiction medicine as well. Train staff on de-escalation and empathetic communication, so that at-risk patients feel heard and safe, not judged – this can diffuse potential violence or agitation, which is also a safety risk.

Provide Continuous Observation and Frequent Re-assessment

Suicide risk can fluctuate, so re-assess patients periodically (for instance, each shift or each day) and adjust the precautions accordingly (Source: jointcommission.org). If a patient’s mood improves or they contract for safety, you might be able to step down from 1:1 observation to frequent checks, but do so cautiously and with team consensus. Conversely, if a patient becomes more agitated or hopeless, intensify precautions. Always communicate risk status at handoffs (e.g., a banner in the chart “Suicide Risk – high” and verbal sign-out highlighting it). Maintain observation until the patient is formally cleared by mental health professionals.

Ensure Safe Discharge and Follow-up for Patients At Risk

A very vulnerable time is when a patient leaves the hospital. Before discharge, create a personalized safety plan: this includes recognizing warning signs, listing coping strategies, people or agencies to contact in a crisis, and removing access to lethal means (for example, involving family to temporarily lock up firearms or unused medications at home). Provide the patient and family with emergency contact information such as the 988 Suicide & Crisis Lifeline, local crisis center numbers, and arrange prompt follow-up appointments with outpatient behavioral health providers. If possible, make a connection while still inpatient – some hospitals do a warm handoff by having a case manager or peer support specialist schedule the first therapy session or ensure the patient has a follow-up within days of discharge. Research shows post-discharge follow-up (calls or visits) significantly reduces suicide rates ​(Source: psychiatryonline.org). Therefore, consider programs where staff reach out within 24-48 hours post-discharge to check on the patient’s well-being and remind them of their support. Document the discharge plan and educate the patient’s family on what to do if risk escalates again. By taking these steps, hospitals can extend the safety net beyond their walls, during the critical transition period.

National Patient Safety Goals 2025: #7 Improve Health Care Equity

2025 National Patient Safety Goal: NPSG 16.01.01:
Improving health care equity for the hospital’s patients is a quality and safety priority.
Element(s) of performance for NPSG 16.01.01
EP 1

The hospital designates an individual(s) to lead activities to improve health care equity for the hospital’s patients.

Note: Leading the hospital’s activities to improve health care equity may be an individual’s primary role or part of a broader set of responsibilities.

EP 2

The hospital assesses the patient’s health-related social needs (HRSNs) and provides information about community resources and support services.

Note 1: Hospitals determine which HRSNs to include in the patient assessment. Examples of a patient’s HRSNs may include the following:

  • Access to transportation
  • Difficulty paying for prescriptions or medical bills
  • Education and literacy
  • Food insecurity
  • Housing insecurity

Note 2: HRSNs may be identified for a representative sample of the hospital’s patients or for all the hospital’s patients.

Ⓓ Documentation is required.

EP 3

The hospital identifies health care disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the hospital’s patients.

Note 1: Hospitals may focus on areas with known health care disparities identified in the scientific literature (for example, organ transplantation, maternal care, diabetes management) or select measures that affect all patients (for example, experience of care and communication).

Note 2: Hospitals determine which sociodemographic characteristics to use for stratification analyses. Examples of sociodemographic characteristics may include the following:

  • Age
  • Gender
  • Preferred language
  • Race and ethnicity

Ⓓ Documentation is required.

EP 4

The hospital develops a written action plan that describes how it will improve health care equity by addressing at least one of the health care disparities identified in its patient population.

Ⓓ Documentation is required.

EP 5

The hospital acts when it does not achieve or sustain the goal(s) in its action plan to improve health care equity.

Ⓓ Documentation is required.

EP 6At least annually, the hospital informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to improve health care equity.

Achieving equity in healthcare is now recognized as a patient safety imperative – meaning that every patient should receive high-quality, safe care regardless of their race, ethnicity, language, or socioeconomic status. This new NPSG (effective 2023) requires hospitals to identify disparities in their outcomes and take action to improve equity. In practice, this involves analyzing data to find care gaps, engaging leadership in an equity strategy, addressing patients’ social needs, and implementing targeted improvements for underserved groups.

National data show, for example, Black patients received worse care than White patients on 36% of patient safety metrics, and low-income households fared worse than higher-income households on 33% of safety metrics​ (Source: psnet.ahrq.gov). These inequities highlight the need for focused equity interventions.

Use Data to Identify Care Disparities in Your Hospital

Start by stratifying key quality and safety data by patients’ sociodemographic characteristics to uncover any inequities. For example, analyze infection rates, readmissions, surgical complications, or patient experience scores by race, ethnicity, primary language, gender, insurance type, etc. This analysis may reveal gaps – perhaps surgical infection rates are higher in patients with limited English proficiency, or pain control is worse in minority patients. Your hospital’s own data will pinpoint where to focus. Use a robust data approach (your quality analytics team can use EHR data, safety event reports, patient surveys, etc.). Importantly, involve frontline staff and community representatives in discussing the data – they can provide context for why a disparity might exist and ideas for addressing it.

Designate an Equity Leader and Develop a Strategic Plan

Improving equity must be an organizational priority. Appoint a dedicated leader or team responsible for health equity initiatives (Source: ​ihs.gov). Many hospitals now have a Chief Equity Officer or an interdisciplinary health equity committee. This leader/coordinator will drive efforts such as staff education, data monitoring, and improvement projects. Next, develop a written action plan to address at least one identified disparity, as per Joint Commission requirements. The plan should clearly state: the specific disparity you’re targeting (e.g., higher 30-day readmission rates in Medicaid patients), the population of focus, a measurable goal, strategies or interventions to achieve improvement, and how progress will be monitored. For instance, if data show that non-English speaking patients have lower medication understanding and higher readmissions, your plan might involve providing multilingual pharmacist counseling and follow-up calls to those patients, aiming to cut readmissions by X%. Make sure leadership allocates resources for these efforts – improvement won’t happen without buy-in from the top. Some hospitals have incorporated equity metrics into their quality dashboards and executive performance goals, underscoring that equitable care is as important as any clinical target.

Address Patients’ Health-Related Social Needs as Part of Care

Recognize that social determinants of health (SDOH) – like lack of transportation, food insecurity, or unstable housing – can directly impact patient safety and outcomes. Integrate a process to assess patients’ social needs and connect them with resources (Source: ​ihs.gov). For example, upon admission or in the ED, patients could be screened with a brief SDOH questionnaire (many validated tools exist) to identify needs such as difficulty affording medications or unsafe living conditions. If needs are identified, have a system to provide information or referrals to community resources (food banks, housing assistance, free transportation services, etc.). Under NPSG 16, hospitals are required to at least assess some patient population for health-related social needs and provide resource information​. By systematically addressing social needs, you not only demonstrate respect and caring, but you may prevent safety issues (e.g., a patient won’t skip follow-up because they lacked a ride, or won’t split pills due to cost – factors that disproportionately affect vulnerable groups). Ensure staff (nurses, case managers, social workers) are trained and empowered to act on these screenings.

Implement Targeted Interventions to Reduce Identified Disparities

Based on the disparities you find, launch quality improvement projects just as you would for any clinical issue – but tailor them to the affected population. If data show fewer minorities receive core measures in cardiac care, initiate an equity-focused review of those cases to identify gaps (maybe implicit bias or communication barriers) and intervene (through training or process changes). Set specific goals (e.g., eliminate the gap in blood pressure control between Black and White patients within 1 year) and measure outcomes continuously (Source: ​ihs.gov). Use the Plan-Do-Study-Act (PDSA) cycle or other QI frameworks for these projects. Celebrate improvements and communicate them hospital-wide to show that equity efforts yield results.

Educate and Equip the Workforce to Provide Equitable Care

Improving equity also means tackling issues like implicit bias and cultural competency among staff. Conduct training sessions on recognizing implicit biases in healthcare – for example, how pain might be underestimated in certain racial groups due to stereotypes (Source: ​psnet.ahrq.gov). Training should provide clinicians with tools to ensure all patients are heard and respected (use of interpreter services for language needs, understanding cultural health beliefs, etc.). Encourage diverse hiring and include patient representatives from the community in advisory councils to bring forward issues minority patients face. Another strategy is standardizing care protocols to minimize biased decisions – if everyone gets the same fall assessment or the same discharge checklist, there’s less room for subjective differences in care. The Joint Commission’s new standards also require that leaders periodically inform key stakeholders (like the Board, community groups) about the progress in improving health equity. Transparency and accountability go a long way. Some hospitals publish an annual equity report with performance data stratified by race/ethnicity, along with actions taken – this level of openness can motivate continued improvement and trust with the community.

Sustain and Spread Successful Equity Initiatives

Once you’ve demonstrated improvement in one disparity, integrate those practices into standard operations and then tackle the next disparity. For instance, if you successfully improved diabetes control in one clinic for a vulnerable population by using patient navigators, consider spreading that model to other clinics or for other chronic diseases. Hardwire equity by adding equity considerations into all safety and quality committees (e.g., if a new sepsis protocol is developed, ensure it works for non-English speakers, etc.). The goal is to embed an equity lens so thoroughly that it becomes part of everyone’s daily work – analogous to infection control or medication safety. By systematically reducing disparities, hospitals will not only meet the NPSG requirements but will truly ensure all patients are safer.

National Patient Safety Goals 2025: #8 Prevent Mistakes in Surgery

2025 National Patient Safety Goal: UP 01.01.01:
Conduct a preprocedure verification process.
Element(s) of performance for UP 01.01.01
EP 1

Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.

Note: The patient is involved in the verification process when possible.

EP 2

Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:

  • Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and preanesthesia assessment)
  • Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed
  • Any required blood products, implants, devices, and/or special equipment for the procedure

Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the preprocedure verification. It is not necessary to document that the standardized list was used for each patient.

Ⓓ Documentation is required.

2025 National Patient Safety Goal: UP 01.02.01:
Mark the procedure site.
Element(s) of performance for UP 01.02.01
EP 1

Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.

Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intraoperative imaging techniques may be used for locating and marking the exact vertebral level.

EP 2Mark the procedure site before the procedure is performed and, if possible, with the patient involved.
EP 3

The procedure site is marked by a licensed practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, the licensed practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:

  • An individual in a medical postgraduate education program who is being supervised by the licensed practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed
  • A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed practitioner performing the procedure (that is, an advanced practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who will be present when the procedure is performed.

Note: The hospital’s leaders define the limited circumstances (if any) in which site marking may be delegated to an individual meeting these qualifications.

EP 4

The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital.

Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site.

EP 5

A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).

Note: Examples of other situations that involve alternative processes include:

  • Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
  • Teeth
  • Premature infants, for whom the mark may cause a permanent tattoo

Ⓓ Documentation is required.

2025 National Patient Safety Goal: UP 01.03.01:
A time-out is performed before the procedure.
Element(s) of performance for UP 01.03.01
EP 1Conduct a time-out immediately before starting the invasive procedure or making the incision.
EP 2

The time-out has the following characteristics:

  • It is standardized, as defined by the hospital.
  • It is initiated by a designated member of the team.
  • It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.
EP 3When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.
EP 4

During the time-out, the team members agree, at a minimum, on the following:

  • Correct patient identity
  • The correct site
  • The procedure to be done
EP 5

Document the completion of the time-out.

Note: The hospital determines the amount and type of documentation.

Ⓓ Documentation is required.

Wrong-site, wrong-procedure, or wrong-patient surgeries are catastrophic events that are fully preventable with rigorous protocols. The Universal Protocol and the WHO Surgical Safety Checklist provide a framework to eliminate surgical mistakes. This goal entails a series of pre-operative and intra-operative checks – from verifying the patient and procedure, to marking the surgical site, to taking a final “time-out” pause – as well as fostering teamwork in the OR. When reliably implemented, these practices have proven to significantly reduce surgical errors and complications.

Conduct a Pre-Procedure Verification (“Surgical Checklist”) for Every Case

Well before the patient enters the operating room (for example, in the pre-op holding area), have a standardized verification process to confirm all the relevant documents and studies are available and correct (Source: jointcommission.org). This includes verifying the patient’s identity with two identifiers, the procedure planned, the site/side of the procedure, and that consent forms have been signed and match the intended surgery. Also verify that any required implants, special equipment, or imaging results are ready. Many hospitals use a checklist for this phase – often a nurse, with the patient involved, will review each item (e.g., “Mrs. Jones, we have you scheduled for a left knee arthroscopy, is that correct?”). Resolving discrepancies at this stage (such as discovering a consent form is missing or the x-ray isn’t in the room) prevents downstream errors. As part of the Universal Protocol, this pre-procedure verification is a mandatory step and should involve all relevant team members (pre-op nurse, anesthesiologist, surgeon) as appropriate.

Mark the Surgical Site Unambiguously

For procedures involving laterality (left vs right), multiple structures (e.g., fingers, limbs), or levels (spinal surgery), the correct site must be marked on the patient’s body before the surgery. The Joint Commission requires that the mark be made by a licensed provider who will be involved in the procedure (often the surgeon) and that it should be sufficiently permanent to be visible after skin prep (usually marking with a surgical marker “YES” or surgeon’s initials on the correct site). For example, if operating on the left eye, the surgeon should mark “left eye” or initials above that eye. Do not mark non-operative sites (to avoid confusion) except in cases like a possible level spine surgery (then initial the level that was verified by x-ray). Have a policy on acceptable site marking – some use an “X” not to operate on or a line pointing to the correct vertebral level after radiographic confirmation, etc. The patient (if awake and able) should be involved: “We are marking the left knee you’re having surgery on, correct?” Marking has prevented many a near-miss – if a clinician is about to prep the right side and sees no mark (because the left was the correct side and is marked), they know to stop. Special cases: for teeth, a dental diagram is used; for some minimal access procedures (endoscopy), site marking might not apply – have those exceptions defined. Overall, site marking is a simple but powerful visual communication that everyone in the OR can see, serving as a final check against wrong-site errors.

Perform a “Time-Out” in the OR Immediately Before Incision

The surgical time-out is a final pause performed in the OR with the entire surgical team immediately before the procedure begins (for example, after anesthesia induction and patient positioning, but before the incision). During the time-out, all activity should pause and the team verbally confirms critical information: correct patient identity, correct site and side (pointing to the mark), correct procedure to be done, and as applicable any special considerations (having the correct implants, antibiotics given, patient positioning, etc.)​(Source: jointcommission.org). The surgeon, anesthesiologist, circulating nurse, scrub tech – everyone participates and must be in agreement. This active communication time-out is required by the Universal Protocol and is extremely effective in catching any last-minute discrepancies. For instance, if the consent said left hip but the OR schedule said right hip, this is the moment someone might speak up. It is important that the time-out is done consistently for every case – even minor procedures – and that it is not pro forma. Encourage a culture where anyone in the OR can halt the start of surgery if something doesn’t sound right. Document the time-out in the record (many ORs have a checklist sheet or an EHR flow sheet to tick off that the time-out was completed and what was verified).

Adopt the WHO Surgical Safety Checklist for Comprehensive Safety

The WHO 19-item Surgical Safety Checklist (which includes steps for sign-in, time-out, and sign-out) covers not only patient/procedure verification but also other safety measures (like ensuring prophylactic antibiotics are given, counting instruments and sponges, and discussing post-op plans). Many hospitals worldwide have implemented it and seen significant drops in post-op complication rates and mortality – studies showed a 30%+ reduction in surgical complications and deaths after checklist adoption (Source: ​who.int). Incorporate the checklist into your workflow: for example, a “sign-in” phase in the anesthetic room (checking allergies, airway risk, etc.), the “time-out” in OR (patient, site, procedure, etc.), and a “sign-out” before the team leaves the OR (discussing specimen labeling, instrument counts correct, any equipment problems, and post-op management plans). This creates multiple layers of verification and promotes teamwork.

If your hospital already uses a checklist, periodically audit its completion and quality – ensure it’s done with meaning, not just ticking boxes. Engage surgeons by sharing data or stories of checklist catches (near-misses averted), so they champion its use rather than see it as bureaucratic.

Foster a Culture of Speaking Up in the OR

Even with protocols, human factors matter. Encourage surgeons and OR staff to adopt a team mentality – where any team member can question a discrepancy (like “Is this definitely the correct implant size?” or “Did we confirm the spinal level with x-ray?”) without hesitation. Research shows communication issues are a root cause of many surgical errors. Techniques from crew resource management (CRM) can be applied: having briefings and debriefings, flattening hierarchy so that even a junior nurse feels comfortable stopping the line if something is amiss. Some hospitals conduct after-action reviews for near-misses (like catching a wrong-level spine case before cutting) to learn how to improve processes and to positively reinforce the individuals who spoke up. Over time, as these practices become ingrained, wrong-site surgeries and other “never events” can truly become relics of the past. In fact, many organizations have gone years without a wrong-site surgery due to rigorous adherence to these protocols. Consistency is key – every patient, every time – no shortcuts, even when the schedule is running behind or for “quick cases.”

Your Roadmap to Safer Care: Implementing the National Patient Safety Goals 2025

By diligently implementing each of these 2025 National Patient Safety Goals with leadership support, staff training, patient engagement, and continuous improvement, hospitals can measurably enhance patient safety. Each goal’s tactics – from the basics of patient identification and hand hygiene to the newer focus on health equity – are backed by evidence and real-world success stories. As healthcare leaders, insisting on these best practices and providing the resources and accountability to carry them out will drive your organization toward zero harm. Remember, achieving excellence in patient safety is an ongoing journey of learning and improving – but with these targeted efforts in 2025, you will be closer to the ultimate goal of zero preventable patient harm.

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Health care with stethoscope and pills glass tube

How to Improve Medication Errors in Hospitals

Medication errors remain a critical patient safety issue. Learn actionable strategies for quality improvement in medication errors, from reporting enhancements to tech solutions like CPOE and BCMA.

Table of Contents

Hospital administrators often express concerns about patient safety and seek effective strategies for how to improve medication errors. These types of errors cause harm to about 1.3 million people annually on a global scale and are responsible for one death daily in the United States, according to the World Health Organization. The worldwide impact of medication errors totals about $42 billion per year, the organization reports.

How to improve medication errors

Understanding the Scope for Improving Medication Errors

“The downstream effects include physical and emotional harm of patients and family members, losing trust in the healthcare system, and increased healthcare costs,” says Farzana Samad, a pharmacist who is the health scientist administrator at the Agency for Healthcare Research and Quality. (Statistics source: WHO).

In healthcare settings, improving medication errors requires addressing various causes such as wrong administration, incorrect orders, improper holds, wrong doses, improper storage, omissions, duplicates, and lack of monitoring, Samad explains. In hospitals, factors such as culture, technology, processes, and available resources influence medication error rates.

Why Underreporting Impacts a Quality Improvement Project for Medication Errors

Knowing how to improve medication errors begins with measuring their occurrence nationally. However, underreporting remains a significant barrier. In addition, reporting requirements vary between states, and a centralized database doesn’t exist, says Christina Michalek, a pharmacist and director of Membership and Patient Safety Organization (PSO) at the Institute for Safe Medication Practices (ISMP) and administrative coordinator for the Medication Safety Officers Society.

Reporting errors is vital for designing a quality improvement project for medication errors. Understanding systemic gaps allows hospitals to implement best practices that prevent harm, Samad notes. Lower reported rates might reflect not only ineffective strategies but also fear of reporting or cumbersome reporting systems.

Even errors that don’t reach patients offer lessons for a safety improvement plan for medication errors. “Severity bias might cause underreporting,” Samad explains, underscoring the need for a cultural shift toward learning and transparency.

Why Benchmarking Fails in Quality Improvement for Medication Errors

Although progress exists, quantifying medication error improvements remains challenging. Many healthcare systems mistakenly rely on benchmarking comparisons to gauge safety improvements.

Michalek cautions: “There is no acceptable incident rate for medication errors.” Instead of focusing on how many errors are reported, organizations should prioritize the quality improvement initiative for medication errors — analyzing error types and improving systemic weaknesses.

Significant variability exists across institutions in definitions, thresholds, and reporting habits. “The easiest way to improve your error rate is to stop reporting—and that’s certainly no way for organizations to learn and improve,” Michalek adds.

Best Practices for a Safety Improvement Plan for Medication Errors

Instead of benchmarking, ISMP recommends a proactive safety improvement plan for medication errors that focuses on actionable steps:

  • Boost reporting of close calls (good catches).
  • Educate leadership and the board about the importance of reporting.
  • Focus on system improvements based on real-world events.

Increasing the number of safety interventions demonstrates a quality improvement initiative for medication errors that fosters a true culture of learning and safety.

Technology’s Role in Decreased Medication Administration Errors and Quality Improvement

Hospitals can strengthen their quality improvement for medication errors by implementing critical technology tools. Katie Stewart of The Leapfrog Group emphasizes the importance of:

  • Computerized Provider Order Entry (CPOE): Used to catch common prescribing errors. Studies show CPOE reduces harm from prescriber errors by up to 55%.
  • Bar Code Medication Administration (BCMA): Scanning medications at the bedside ensures the right drug is administered at the correct time and dose.

Two measures in the Leapfrog Hospital Safety Grade reveal progress. In 2018, only 65.6% of hospitals met CPOE standards, but by 2024, that number rose to 88.1%. Similarly, BCMA adoption jumped from 47.3% in 2018 to 86.9% in 2024.

These systems are essential components of any quality improvement project for medication errors.

Staffing Solutions to Support Quality Improvement Medication Errors Initiatives

Beyond technology, staffing innovations help with decreased medication administration errors quality improvement. A study in the Journal of Nursing Management highlights the role of pharmaceutical technical assistants on nursing wards.

Their support freed up nurses for direct patient care, which nurses perceived as contributing to fewer errors. “Clear communication procedures and continuity were vital for success,” researchers concluded.

This staffing model provides a strong, people-centered strategy for hospitals aiming for sustained quality improvement medication errors outcomes.

How AI Technology Boosts a Quality Improvement Initiative for Medication Errors

Emerging tech, such as AI-enabled wearable cameras, offers another layer of protection. At the University of Washington, Dr. Kelly Michaelsen explored using wearable cameras to detect medication errors during administration.

Serving as a “second set of eyes,” the AI system could identify the contents of a syringe before injection, reducing errors caused by distraction or time pressure. Michaelsen stresses the importance of coupling technology with a culture of safety — minimizing interruptions and ensuring providers have sufficient time for checks. (Source: https://www.nature.com/articles/s41746-024-01295-2)

AI applications could become a powerful part of future safety improvement plans for medication errors.

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Clinical Decision Support in AI

How Clinical Decision Support AI Can Dramatically Improve Patient Safety

Clinical decision support AI is poised to radically improve patient safety. But that potential hinges on the use of high-quality data. This article explores the key data challenges that must be addressed to fully leverage AI in clinical decision support and minimize harm.

Table of Contents

Artificial intelligence (AI) holds plenty of promise for patient safety. But there’s a catch: To successfully improve patient safety, clinical decision support AI needs to be developed with high-quality, reliable data. If subpar data is used, AI models will not result in the desired patient safety improvements – and, worse yet, could cause significant harm.

Indeed, clinical decision support AI and other AI applications developed with unreliable data could lead to large numbers of patient injuries, according to a study published in Nature Medicine. Conversely, if an individual provider makes a decision based on poor data, the harm is likely to be much more contained. To make matters worse, when using clinical decision support AI, clinicians do not necessarily have the training to identify underlying glitches such as data bias, overfitting, or other software errors that might lead to less-than-optimal patient care. For example, such flaws in AI could result in incorrect medication dosage.

Clinical Decision Support AI

How Clinical Decision Support AI Can Impact Patient Safety

Clinical decision support AI and other AI models are poised to have a significant positive impact on patient safety. According to a literature review published in JMIR Medical Informatics and a study published in the American Journal of Infection Control, when developed and implemented correctly, AI in clinical decision support can enhance patient safety by improving:

Such improvements can elevate patient safety efforts in a variety of domains such as:

  • Healthcare-associated infections
  • Adverse drug events
  • Venous thromboembolism
  • Surgical complications
  • Pressure ulcers
  • Falls
  • Decompensation
  • Diagnostic errors

What’s more, AI can play a role in improving adherence to existing safety protocols. Consider the following: When a machine learning (ML) algorithm was developed to provide real-time hand hygiene alerts based on data from multiple types of sensors, compliance to best practices rose from 54% to 100%, according to a study in the Journal of Hospital Infection Control.

Exploring Data Challenges with Clinical Decision Support AI

While the possibilities are promising, the application of AI and ML to improve patient safety is an emerging field and many algorithms have not yet been externally validated or tested prospectively. Indeed, algorithms may be limited in generalizability, and performance could potentially be affected by the clinical context where the solution is implemented, according to an article in Digital Medicine.

Perhaps most importantly, to achieve optimal results, AI and ML algorithms designed to reduce medical errors and improve patient safety should be developed by accessing intelligence from large databases that contain accurate information on errors.

While access to voluminous data is key, the potential of AI for clinical decision support also hinges on data quality, bias mitigation, and data privacy and security. For example, if an AI model is developed with data that does not represent certain groups, the results of care delivered with the assistance of clinical decision support AI will not be equitable, according to an original research article in Health Policy and Technology. In fact, a systematic review by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center found that algorithms developed on subpar data can exacerbate racial and ethnic disparities, while those developed on high-quality, inclusive data can potentially reduce disparities.

Data privacy and ethical use is another challenge associated with the development and implementation of clinical decision support system AI, according to the World Economic Forum.

How to Ensure Data Quality for Clinical Decision Support AI

To achieve the best clinical care and patient safety results, the quality of data needs to be a top concern as AI is developed and implemented.

To address quality concerns, Oliver Haase, a professor at the University of Applied Sciences in Konstanz, German, recommends the use of a data quality plan that includes the following components:

  1. Key quality metrics for the data
  2. A standard procedure for adding new data
  3. The process for future, consistent data cleaning
  4. A process for continuous data quality monitoring

Likewise, a data manipulation plan that describes the data processing steps should be leveraged. This plan should be implemented as reusable code.

In addition, it is important to ensure that clinical decision support AI model goals are in alignment with specific patient safety goals, such as identifying patient decompensation or improving infection control, according to a perspective article published by AHRQ. If the AI model is not precisely aligned with such patient safety goals, it might either miss critical signs of risk or generate false alarms.

Addressing Common Data Concerns

Researchers and developers also need to mitigate the effects of data bias. To do this, they should routinely analyze model metrics to detect bias, edit input variables, and explore the use of synthetic data, which involves creating artificial data that mimic real patient data but without the inherent biases, according to a review published by AHRQ.

Moreover, data-sharing practices for training and deploying clinical decision support AI must prioritize HIPAA compliance, encryption, and transparency to maintain patient trust and safety.

Because healthcare data contains personal and private patient information, sharing such data for AI model training and research purposes must be carried out with utmost caution and adherence to strict privacy and security measures, according to AHRQ.

Why New Data Could Make Clinical Decision Support AI Even Better

With data available today—especially laboratory information, imaging, and continuous vital sign data—it should be possible to reduce the frequency of many types of harm. However, when the data are available, they are often unstructured, undocumented, or disputed.

High-quality, large, annotated databases will prove quite fruitful in minimizing patient harm in the future. New types of data, especially from the huge array of sensing technologies becoming available, but also including data from various other sources like information supplied directly by patients, genomic sequencing, and social media, offer new opportunities to improve predictions as the first step toward development of preventive interventions to improve safety.

These types of data are becoming more accessible over time for research and to drive innovation in clinical decision support AI.

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5 Leaders Share Patient Safety Strategy and Objectives for 2025

As hospitals refine their patient safety strategy for 2025, leaders share proven approaches to reducing readmissions, improving CMS Star Ratings, and optimizing care for high-cost patients. Discover how data-driven strategies and quality improvement initiatives are shaping safer, more efficient hospital care.

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As hospitals continue to face quality and cost pressures in 2025, hospital leaders are prioritizing patient safety objectives to enhance care quality and reduce risks. From readmissions management and CMS Star Ratings to addressing high-cost diagnoses and new structural measures, healthcare quality leaders are striving for a comprehensive patient safety strategy to drive improvements.

That’s what five hospital leaders in quality, compliance, and patient safety shared in recent interviews with American Data Network. While challenges remain, these professionals are moving forward with tools and strategies for quality improvement and patient safety, leveraging multidisciplinary collaboration to achieve results in 2025 and beyond.

Patient Safety Strategy

Patient Safety Strategy #1: Reducing Readmissions Through Proactive Care

Many quality, safety, and compliance leaders continue to focus on reducing hospital readmissions as a core patient safety objective.

“For us, readmissions is one of the big things we’re focusing on, as well as patient satisfaction,” shares Cara Cruz, BA, RN, CIC, CPHQ, Director of Risk and Quality, Patient Safety Officer, and Infection Control Officer at Carson Valley Health. Cruz calls readmission prevention “a real challenge” requiring a multifaceted patient safety strategy.

At Carson Valley, a comprehensive discharge planning process ensures patients have their medications and post-discharge care within two business days. Monthly focus groups analyze readmitted patients, using risk stratification models to guide outreach:

  • Care managers engage low-risk patients.
  • Provider clinics focus on high-risk patients based on diagnosis criteria.

This approach has been “hugely, widely successful,” Cruz says.

However, data access remains a barrier. While internal readmissions are trackable, external readmissions—those occurring at unaffiliated hospitals—are often invisible in the system.

At Unity Health in Arkansas, Timothy Copeland, MT (ASCP), MHA, Director of Quality/Risk Management, emphasizes that optimizing discharge efficiency and reducing readmissions are key priorities for their patient safety strategy in 2025.

Patient Safety Strategy #2: Strengthening Quality and Safety Measures

Facilities are also making a push to meet CMS’ expanding group of structural measures surrounding patient safety. That is going to be a major focus at San Luis Valley Health Regional Medical Center in Alamosa, Colorado, says Margaret White, CPHQ, Director of Quality and Safety at the facility.

White notes new structural measures that CMS finalized in the 2025 Hospital Inpatient Prospective Payment System (IPPS) final rule that begin during the 2025 reporting year, including the Patient Safety Structural Measure (PSSM) and the Age Friendly Structural Measure. Both of the new measures are linked to 2027 payment determinations.

“CMS is finalizing several new hospital quality initiatives, including digital measures for patient harm events, expansion of healthcare-associated infection measures to oncology wards, and structural measures to support safety and age-friendly care,” the agency said. “The new attestation-based structural measures assess whether hospitals demonstrate a structure, culture, and leadership commitment that prioritizes and implements best practices for patient safety and age-friendly care.”

Each of the new measures has five attestation domains. PSSM domains include:

  • Domain 1: Leadership Commitment to Eliminating Preventable Harm
  • Domain 2: Strategic Planning and Organizational Policy
  • Domain 3: Culture of Safety and Learning Health System
  • Domain 4: Accountability and Transparency
  • Domain 5: Patient and Family Engagement

The Age Friendly Hospital Measure attestation domains cover:

  • Domain 1: Eliciting Patient Healthcare Goals
  • Domain 2: Responsible Medication Management
  • Domain 3: Frailty Screening and Intervention
  • Domain 4: Social Vulnerability
  • Domain 5: Age-Friendly Care Leadership

In the 2025 IPPS rule, CMS also said it would modify two current measures, with one revision affecting facilities in 2025: The agency is changing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure beginning in the 2025 reporting year (payment determinations in 2027). The revisions to the HCAHPS Survey add three new survey sub-measures, remove one existing survey sub-measure and revise one existing survey sub-measure, according to CMS.

According to White of San Luis Valley Health, while a lot of national groups are providing education about the new measures, finding an organization or third-party that can help hospitals navigate both of the new measures can be a challenge. “I haven’t found a group that’s focusing on both,” White says.

What’s more, the measures – and the work they entail – can further pinch scarce hospital resources. “It’s hard to find the funds to meet the measures,” White adds.

At Cheyenne Regional Medical Center, hospital leaders are taking a proactive approach to navigating the new measures. “We’re meeting monthly to go over every measure,” says Brianna Best Lima, BA, MA, CPHQ, Manager, Data Management at Cheyenne Regional. That focus aligns with Cheyenne’s “ramping up efforts around value-based care and patient safety,” Lima says.

For hospitals looking to assess and improve their patient safety culture, resources such as the Hospital Survey on Patient Safety Culture provide valuable insights into safety perceptions, reporting behaviors, and areas needing attention.

Patient Safety Strategy #3: Achieving Higher CMS Star Ratings

Publicly reported CMS Star Ratings continue to influence hospital performance initiatives, shaping strategic priorities for 2025 and beyond.

Hospitals with a well-established culture of safety in healthcare tend to excel in CMS safety metrics, as they proactively address risks, implement best practices, and engage staff in continuous quality improvement.

“Our focus is related to publicly reported data and patient experience feedback that doesn’t always make it into reports,” says Copeland of Unity Health.

The CMS Star Ratings system evaluates hospitals across five key domains:

  • Mortality
  • Safety of care
  • Readmission rates
  • Patient experience
  • Timely and effective care

According to CMS data, most hospitals are in the three-star (17.8%) and four-star (16.4%) range, while fewer than 10% achieve five-star status.

For Carson Valley Health, improving their Star Rating is a top priority. “A primary goal in 2025 will be to move into the five-star category,” Cruz.

By refining quality improvement strategies and leveraging proactive patient engagement initiatives, hospitals can improve CMS ratings while also advancing their overall patient safety strategy.

Patient Safety Strategy #4: Managing High-Cost Patient Populations to Improve Outcomes and Reduce Costs

Cheyenne Regional is also working to address the “high-dollar, high-cost patients,” Lima says. That includes focusing on high-cost diagnostic groups, such as those with heart failure and those undergoing chemotherapy.

Hospitals that prioritize high-cost patient populations can see multiple benefits, both in cost containment and patient outcomes. These patients often require frequent hospital visits, specialized treatments, and complex care coordination, which can strain hospital resources if not managed effectively. By identifying and addressing these groups proactively, hospitals can reduce avoidable hospitalizations, optimize resource allocation, and improve overall efficiency.

At Northwell Health in New York, the 21-hospital system has taken steps to stem costs by proactively addressing the “mental health crisis” that has been on the uptick since the COVID-19 pandemic, says Peter Silver, M.D., MBA, Senior Vice President and Chief Quality Officer with Northwell Health. “Hospitals are under increasing financial pressure,” Silver says. Northwell embarked on a multiyear initiative to reduce unnecessary hospitalizations and attendant costs by screening all ambulatory patients for depression.

To date, the health system has successfully screened some 2 million patients, Silver says. Northwell also places a heavy emphasis on disease management for highly prevalent conditions like hypertension and steers patients toward preventive services, such as colonography and mammography, that can identify diseases early and reduce downstream spending.

Focusing on high-cost patient management aligns with value-based care initiatives, which emphasize preventing complications and unnecessary admissions rather than just treating acute episodes. This approach can also enhance patient experience and satisfaction, as better coordination and targeted interventions often lead to fewer disruptions in care and improved quality of life.

By refining strategies for high-cost, high-risk patients, hospitals can balance financial sustainability with improved patient outcomes, reinforcing their overall patient safety strategy while maintaining compliance with performance-based reimbursement models.

Conclusion

In 2025, hospital leaders are embracing a dynamic, multifaceted patient safety strategy to navigate the evolving challenges of healthcare quality. From reducing readmissions and improving CMS Star Ratings to adopting new quality measures and managing high-cost patient populations, hospitals are refining their approaches to drive better outcomes and financial sustainability.

Yet, as Silver at Northwell Health emphasizes, there is no singular focus when it comes to quality and safety efforts. Instead, organizations must continuously adapt, minimize errors, and—most importantly—learn from them. By leveraging proactive strategies, data-driven insights, and collaborative leadership, hospitals can build a stronger, safer healthcare system that prioritizes both patient well-being and long-term success.

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Ambulatory Surgery Center

The Ultimate Ambulatory Surgery Center Survey on Patient Safety Culture Guide

A strong safety culture is critical for ambulatory surgery centers. The Ambulatory Surgery Center Survey on Patient Safety Culture provides leaders with insights to assess risks, improve communication, and enhance compliance. Learn how to implement this evidence-based tool for better patient outcomes.

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For ambulatory surgery centers, delivering high-quality, safe, and efficient care is a top priority. Unlike hospital settings, ASCs operate on a scheduled basis, allowing for streamlined workflows and predictable patient volumes. However, maintaining a robust safety culture requires proactive leadership, data-driven decision-making, and continuous improvement.

The Ambulatory Surgery Center Survey on Patient Safety Culture, developed by the Agency for Healthcare Research and Quality (AHRQ), is designed to help ASCs measure staff perceptions of safety, teamwork, error prevention, and leadership effectiveness. By leveraging this tool, ASC executives can identify strengths, uncover vulnerabilities, and drive measurable improvements in safety and patient outcomes.

Ambulatory Surgery Center Survey on Patient Safety Culture

What Is the Ambulatory Surgery Center Survey on Patient Safety Culture?

The Ambulatory Surgery Center Survey on Patient Safety Culture, also known as the ASC SOPS, is a validated assessment tool designed to evaluate safety culture in outpatient surgical facilities. Unlike hospital-based patient safety culture surveys, this tool is tailored specifically for ASCs, where efficient workflows, clear communication, and leadership engagement are essential for optimal patient outcomes.

Key Focus Areas of the Survey:

  • Teamwork and communication across roles and departments
  • Staff perceptions of patient safety and willingness to report concerns
  • Leadership effectiveness in fostering a culture of safety
  • Incident reporting processes and follow-through on safety concerns
  • Staffing levels and their impact on patient care
  • Adherence to safety protocols and compliance with best practices

By analyzing survey results, ASC leaders gain valuable insights into their facility’s safety strengths and weaknesses, allowing them to implement targeted interventions for improvement.

Why Safety Culture Matters: The Evidence

A growing body of research highlights the direct link between a strong patient safety culture and improved healthcare outcomes. A December 2023 study, “Enhancing Patient Safety Culture in Hospitals,” published in Cureus, reviewed 47 separate articles—including systematic reviews and cross-sectional, qualitative, and descriptive studies—and found that hospitals with a well-established patient safety culture experience fewer medical errors and adverse events. The study concluded that prioritizing patient safety through structured programs and training can dramatically enhance healthcare quality, performance, and productivity.

Why the Ambulatory Surgery Center Survey on Patient Safety Culture Matters to Executive Leaders

1. Strengthening Patient Safety & Reducing Surgical Complications

A strong safety culture is directly linked to lower rates of surgical site infections (SSIs), procedural errors, and unplanned hospital transfers. By assessing safety culture, ASC leaders can:

  • Identify and address communication breakdowns.
  • Reduce preventable complications through evidence-based interventions.
  • Foster a proactive safety mindset among staff.

2. Meeting Regulatory & Accreditation Standards

ASCs must adhere to rigorous CMS, The Joint Commission (TJC), and Accreditation Association for Ambulatory Health Care (AAAHC) patient safety requirements. The AHRQ ASC Survey supports compliance with:

  • CMS Quality Reporting Program
  • ASC Accreditation Requirements (AAAHC, TJC, DNV)
  • State & Federal Patient Safety Regulations

By proactively addressing safety concerns identified in the survey, ASCs can avoid regulatory penalties and demonstrate their commitment to high-quality care.

3. Improving Staff Engagement & Retention

Turnover and staffing shortages remain challenges for ASCs. Employees who feel valued, heard, and supported in their safety efforts are more likely to stay engaged. A well-executed safety culture survey helps leaders:

  • Increase staff trust in leadership.
  • Improve reporting transparency and error prevention.
  • Reduce burnout by addressing workload concerns.

4. Benchmarking Against National Standards

By leveraging the AHRQ SOPS® Database, ASCs can compare their safety culture scores against national benchmarks. Understanding how your facility stacks up against industry peers provides clear direction for improvement and helps identify best practices from top-performing ASCs.

A Practical Roadmap for Leaders: How to Implement the Ambulatory Surgery Center Survey on Patient Safety Culture Survey

Step 1: Secure Leadership Buy-In & Define Objectives

Senior leadership support is crucial. Executives should articulate how the survey results will be used to drive real safety improvements, not just as a compliance checkbox.

Step 2: Encourage Broad Participation

To ensure an accurate assessment, encourage participation from all roles, including:

  • Surgeons
  • Anesthesia providers
  • Nurses
  • Technicians
  • Administrative staff

Step 3: Analyze the Data & Identify Trends

Avoid getting lost in data overload—focus on key insights:

  • Are certain departments reporting lower safety perceptions?
  • Do staff feel comfortable reporting errors?
  • Are there gaps in handoff communication?

Step 4: Develop & Implement Targeted Solutions

  • If communication is a challenge, implement structured handoff protocols. (See our guide Patient Handoff Templates: An Executive Guide to Safer Transitions.)
  • If error reporting is low, introduce a Just Culture framework to reduce fear of punitive actions.
  • If staffing concerns emerge, assess workload distribution and scheduling flexibility.

Step 5: Reassess Regularly & Track Progress

Safety culture improvement is an ongoing process. Re-administer the survey annually or biannually to measure progress and refine safety strategies.

Why Partnering with an Experienced SOPS Survey Provider Maximizes Your Results

Administering and analyzing the ASC Survey on Patient Safety Culture requires expertise. Partnering with a trusted external provider ensures:

1. Higher Response Rates & Data Accuracy

Experienced providers optimize survey distribution, anonymity, and participation, leading to more reliable insights.

2. Expert Data Interpretation & Benchmarking

Rather than just receiving raw data, ASC leaders get deep-dive analytics comparing their facility to national benchmarks.

3. Actionable Insights for Leadership Decision-Making

Survey partners provide customized reports, executive summaries, and can even present findings to senior leadership, making it easier for leaders to act on the data.

4. Faster Implementation & Continuous Improvement

By outsourcing survey administration, ASC leaders can focus on implementing improvements rather than managing data collection logistics.

Leveraging the ASC Survey on Patient Safety Culture for Long-Term Success

A data-driven approach to patient safety culture not only reduces errors but also strengthens your facility’s reputation and competitive positioning.

By implementing the Ambulatory Surgery Center Survey on Patient Safety Culture, your ASC can:

  • Improve patient outcomes and safety scores.
  • Enhance regulatory compliance & accreditation readiness.
  • Boost staff retention and workplace satisfaction.
  • Build a high-performance, safety-focused environment.

Get Expert Support for Your ASC’s Safety Culture

Take a proactive approach to ASC safety. Contact American Data Network today for a free consultation and discover how our SOPS® Survey services can streamline your assessment, provide critical benchmarks, and drive measurable improvements in patient care.

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a doctor and nurse discussing a culture of safety in healthcare

Culture of Safety in Healthcare: Elevating Patient Outcomes and Trust

Cultivating a culture of safety in healthcare isn’t just about compliance—it’s about enhancing patient outcomes, building trust, and driving operational excellence. Learn how strategic leadership, open communication, and continuous improvement are revolutionizing the patient experience and solidifying trust in healthcare organizations. Ready to elevate your facility’s safety culture? Read on to learn the key strategies that make a difference.

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A culture of safety in healthcare is more than just a strategic priority on a roadmap; it’s a foundational element of high-quality patient care. When healthcare organizations prioritize safety, they see improvements not only in clinical outcomes but also in patient satisfaction, operational efficiency, and staff morale.

Yet, creating a culture of safety in healthcare requires more than policies and protocols—it demands a leadership-driven commitment to fostering an environment where safety is at the forefront of every decision, action, and communication.

Culture of Safety in Healthcare

Culture of Safety in Healthcare: Impact on Clinical Indicators and Reducing Adverse Events

One of the most significant benefits of a culture of safety in healthcare is its ability to reduce adverse events. By creating an environment that encourages transparent communication, continuous learning, and a proactive approach to risk management, healthcare organizations can achieve substantial improvements in clinical outcomes.

1. Reduction in Surgical Site Infections (SSIs)

A robust safety culture healthcare can significantly lower the incidence of SSIs. One recent study assessing the surgical outcomes at a group of community hospitals in Minnesota found a significant link between aspects of safety culture and decreased rates of surgical site infections (SSI) following colon surgery. In this study, researchers tracked the Hospital Survey on Patient Safety Culture and National Healthcare Safety Network definitions and colon SSI rates. Ultimately, nine out of 12 dimensions of a patient safety culture “were significantly associated with lower colon SSI rates,” according to the study. (Fan et al., J Am Coll Surg, Feb. 2016)

Key safety culture dimensions linked to lower SSIs include:

  • Teamwork across and within units,
  • Organizational Learning,
  • Communication about Error,
  • Management Support for Patient Safety, and
  • Supervisor/Manager Expectations and Actions Promoting Safety, among others.

2. Reduction in Patient Falls

Patient falls are a common adverse event in healthcare settings, leading to increased morbidity, longer hospital stays, and higher costs. However, facilities that cultivate a culture of safety in healthcare see substantial reductions in fall rates. According to a 2023 study in the Journal of Clinical Nursing, units with a strong safety climate and collaborative teamwork—particularly between nurses, physicians, and pharmacists—reported fewer patient falls. (Alanzi et al., J Clin Nurse, Oct. 2023)

3. Decrease in Hospital-Acquired Infections (HAIs)

Additional research has added to the body of evidence tying a positive culture of safety to health outcomes:

Using Surveys to Strengthen a Culture of Safety in Healthcare

An effective way to measure and enhance a culture of safety in healthcare is through a Survey on Patient Safety Culture (SOPS). These surveys provide valuable insights into staff perceptions of safety practices, communication openness, and leadership support. Conducting regular SOPS assessments allows healthcare organizations to:

  • Identify strengths and areas for improvement in safety culture.
  • Measure the impact of safety initiatives on staff perceptions.
  • Benchmark performance against national standards for patient safety.

American Data Network offers an SOPS Service designed to help healthcare organizations administer, analyze, and act on the results of these surveys. By leveraging ADN’s expertise, hospitals can gain comprehensive analytics reports that drive targeted safety interventions and foster a culture of continuous improvement.

Enhancing Patient Experience with a Culture of Safety in Healthcare

A high-quality culture of safety in healthcare not only prevents adverse events but also enhances the overall patient experience. Patients who feel safe and secure are more likely to report positive experiences, leading to higher satisfaction scores and improved hospital reputations.

A study published in the Journal of Patient Safety explored the relationship between patient safety culture and patient experiences. Researchers found a significant positive correlation between high staff safety culture scores (using the Hospital SOPS tool) and high patient satisfaction scores (using the CAHPS Hospital Survey).

  • Facilities with a strong culture of safety received better ratings for communication, staff responsiveness, and overall patient care experience.
  • Twelve out of fifteen safety culture dimensions were positively linked to improved patient satisfaction scores, demonstrating that safety culture impacts every aspect of patient interactions.

These findings underscore the strategic advantage of prioritizing a culture of safety healthcare not only to improve clinical outcomes but also to foster positive patient relationships and enhance overall experiences.

Leadership’s Role in Building a Culture of Safety in Healthcare

Successful implementation of a culture of safety in healthcare hinges on leadership’s commitment to safety as a core organizational value. Leaders play a pivotal role by:

  • Setting Clear Expectations: Establishing safety as a non-negotiable priority for all staff levels.
  • Modeling Safety-First Behavior: Demonstrating accountability and transparency when addressing safety concerns.
  • Encouraging Open Communication: Creating a non-punitive environment where staff feel safe to report errors and near-misses without fear of retribution.
  • Investing in Continuous Learning: Supporting ongoing education and training initiatives to keep staff updated on best practices and emerging safety trends.

An annual perspective by the Patient Safety Network (PSNet) emphasized that leadership’s support and involvement are crucial for embedding a healthcare culture of safety across all organizational layers. (PSNet Annual Perspective, March 2024)

Conclusion: Why a Culture of Safety in Healthcare is a Strategic Imperative

A culture of safety in healthcare is not just about compliance or reducing adverse events; it is about creating an environment where patients feel secure, staff feel supported, and clinical outcomes are optimized. Healthcare leaders who prioritize safety culture healthcare:

  • Build Trust: Patients are more likely to trust and recommend facilities known for their safety commitment.
  • Boost Financial Performance: By reducing adverse events and hospital-acquired infections, facilities save on costs associated with readmissions, extended stays, and legal claims.
  • Enhance Organizational Reputation: A strong safety culture reinforces a facility’s reputation as a leader in patient-centered care.

As healthcare organizations navigate an increasingly complex landscape, investing in a culture of safety in healthcare is a strategic imperative for sustainable success. Facilities that champion safety as a core value will not only improve patient outcomes but also achieve long-term operational excellence.

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nursing home survey on patient safety culture

Nursing Home Survey on Patient Safety Culture: Elevating Resident Care and Outcomes

Discover how the Nursing Home Survey on Patient Safety Culture can revolutionize your approach to resident safety and quality improvement. Learn why forward-thinking leaders are embracing this tool to benchmark performance, strengthen teamwork, and proactively address challenges unique to long-term care environments. Don’t miss the strategic insights and actionable guidance that can help your organization stand out as a patient safety leader.

7 min read

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As a leader tasked with ensuring resident safety in a nursing home setting, your responsibilities extend beyond meeting regulatory requirements. You must cultivate a proactive, resident-centered environment where continuous quality improvement is woven into daily operations. One powerful yet often underutilized resource available to you is the Nursing Home Survey on Patient Safety Culture, developed by the Agency for Healthcare Research and Quality (AHRQ). 

Focusing on patient safety culture (PSC) isn’t just a best practice—it’s a proven catalyst for better outcomes. A March 2023 scoping review, “The association between patient safety culture and adverse events,” found that in more than three-quarters (76%) of the studies evaluated, higher PSC scores were linked to lower rates of adverse events. In other words, strengthening your internal safety climate can directly correlate with preventing harm and improving the quality of resident care.

By harnessing insights from the Nursing Home Survey on Patient Safety Culture, you can align leadership strategies with frontline realities, boost staff engagement, and craft targeted interventions that reduce errors and enhance care delivery. Whether it’s refining your strategic planning, optimizing staff training, reallocating resources, or adjusting policies, this evidence-based tool provides the data-driven guidance you need to transform intention into meaningful action.

In this comprehensive guide, we’ll explore how the Nursing Home Survey on Patient Safety Culture works, why it matters to executive-level decision-makers, and how to integrate its findings seamlessly into your strategic initiatives and quality improvement efforts.

Nursing Home Survey on Patient Safety Culture

What Is the Nursing Home Survey on Patient Safety Culture?

The Nursing Home Survey on Patient Safety Culture offers a structured way to understand the human factors affecting resident safety in long-term care settings. Unlike generic surveys, it zeroes in on the unique environment of nursing homes, addressing challenges such as staff turnover, communication during shift changes, adherence to care plans, and management of chronic conditions.

Key Focus Areas of the Survey Include:

  • Teamwork and staff collaboration
  • Communication openness and information exchange
  • Response to mistakes and non-punitive error reporting
  • Staffing levels, training, and workload management
  • Leadership support and organizational learning

By examining these areas, you gain data-driven insights into how your frontline teams perceive safety and identify where to implement targeted improvements for better resident outcomes.

Access the Full Survey Here: AHRQ Nursing Home Survey on Patient Safety Culture (PDF)

Why the Nursing Home Survey on Patient Safety Culture Matters to Executive Leaders

1. Aligning Strategic Goals With Day-to-Day Reality

Broad metrics like regulatory compliance reports and satisfaction scores provide a snapshot of performance but don’t fully illuminate why certain issues persist. This survey allows you to identify underlying cultural barriers—such as fear of speaking up or inconsistent handoff communication—that influence safety and quality. Understanding these dynamics helps align your strategic initiatives with the frontline experiences that shape resident outcomes.

2. Supporting Value-Based Care in Long-Term Settings

As reimbursement models evolve, demonstrating a strong safety culture is critical. Insights from the survey can inform resource allocation, training programs, and policy changes that address root causes of adverse events. By tackling these issues proactively, you enhance resident care quality and position your nursing home favorably within value-based payment frameworks.

3. Enhancing Staff Engagement, Retention, and Morale

Turnover and staffing challenges are persistent concerns in nursing homes. Using this survey to highlight and improve workplace conditions, teamwork, and communication can help staff feel valued, heard, and empowered. This leads to higher retention rates, a more stable workforce, and ultimately, more consistent, compassionate care for residents.

4. Benchmarking Against National Standards

Because AHRQ’s survey is widely recognized, you can benchmark your results against national averages. Knowing where your nursing home stands relative to peers helps you measure the effectiveness of your initiatives and identify best practices from top-performing institutions.

Implementing the Survey: A Practical Roadmap for Leaders

Step 1: Secure Leadership Buy-In and Define Objectives

Your endorsement is vital. Communicate the survey’s value to your executive team and department heads. Clarify how the results will guide policy updates, training investments, and quality improvement efforts. Establish concrete goals, such as improving staff perceptions of communication clarity or reducing misunderstandings during shift changes.

Step 2: Encourage Broad Participation

For an accurate picture, invite input from all roles—nurses, aides, therapists, housekeeping, and administrative staff. Emphasize confidentiality and fairness, ensuring staff understand that honest feedback leads to improvement, not punitive measures.

Step 3: Analyze and Interpret Results in Context

Go beyond raw scores. Look for patterns that reveal root causes. For example, if certain shifts report lower trust in management support, investigate communication methods, staffing levels, or training gaps that may be influencing perceptions.

Step 4: Engage Interdisciplinary Teams in Improvement

Once key areas for improvement emerge, assemble a diverse team to propose solutions. Including representatives from various roles ensures that recommended changes are practical, feasible, and more likely to gain acceptance at all levels.

Step 5: Tailor Training, Policies, and Systems

If the survey highlights inconsistent adherence to care plans, consider implementing more robust staff education or digital tools for care coordination. If staff fear reporting mistakes, invest in training on just culture principles, making it clear that learning from errors, not assigning blame, is your organizational standard.

Step 6: Communicate Progress and Reassess Regularly

Transparency is key. Share improvement milestones with all staff, celebrating wins and acknowledging challenges. Periodically re-administer the survey (annually or biannually) to track your progress, keep the momentum going, and continuously refine your patient safety culture strategy.

How Partnering with an Experienced SOPS Survey Provider Maximizes Your Results

Administering the Nursing Home Survey on Patient Safety Culture on your own can be time-consuming and complex. Partnering with an experienced external provider can simplify the process, ensure high-quality data, and offer expert insights that drive meaningful changes.

1. Smooth SOPS Survey Administration

A seasoned partner handles logistics—distributing surveys, ensuring anonymity, and providing engagement resources—so your staff can focus on care. This typically increases response rates and data reliability.

2. Expert Analysis and Benchmarking

Experienced providers bring domain expertise and comparative data sets. They help interpret results, highlight what’s significant, and pinpoint where your nursing home stands relative to similar facilities nationwide.

3. Clear Reporting and Actionable Guidance

Turning data into strategy can be daunting. A partner transforms survey results into comprehensible reports and dashboards, helping you quickly identify priorities. They’ll also provide best-practice recommendations for improvement, accelerating your ability to implement effective interventions.

4. Sustained Focus on Strategic Decision-Making

By outsourcing survey administration and analysis, you free up leadership time. Instead of wrestling with data logistics, you can devote energy to setting strategic goals, making informed decisions, and overseeing long-term improvements in resident safety.

Leveraging the Survey Data for Long-Term Organizational Growth

A robust patient safety culture is the foundation for delivering exceptional, person-centered care in a nursing home setting. By using the Nursing Home Survey on Patient Safety Culture as a strategic tool, you:

  • Build a High-Performing, Resident-Centered Environment: Engaged staff and proactive leadership jointly create safer, more responsive care delivery.
  • Improve Regulatory Compliance and Accreditation: A strong safety culture supports meeting standards set by The Joint Commission, CMS, and other regulatory bodies.
  • Enhance Reputation and Competitive Edge: Nursing homes known for their safety culture and compassionate care attract both residents and high-quality staff, strengthening your market position.

Final Thoughts

As a senior leader committed to advancing resident safety and quality in a nursing home environment, the Nursing Home Survey on Patient Safety Culture provides a clear, data-driven path. When leveraged thoughtfully, it becomes an essential catalyst for continuous improvement—illuminating frontline realities, guiding strategic investments, and fostering a culture of trust, collaboration, and ongoing learning.

Ready to Get Started?

Don’t wait for regulatory pressures or adverse events to prompt action. Take a proactive step in enhancing your safety culture today. Contact American Data Network to learn how our SOPS Survey services can streamline your assessment process, provide valuable benchmarks, and guide you toward sustainable, lasting improvements that truly elevate the quality of care in your nursing home.

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