The Joint Commission National Patient Safety Goals

Patient Care

Critical Alarm Management

  • Critical alarms require a fast response.
  • Identify alarm signals that can be minimized to decrease alarm fatigue.
  • Check individual alarm signals for accurate settings, proper operation and detectability.

Suicide Risk

Identify patients at risk for suicide:

  • Screen/assess patients with emotional/behavioral disorders to determine risk for suicide.
  • Patients at risk are managed for safety.

Critical Test Results

All critical laboratory, electrocardiogram and diagnostic radiology results are to be:

  • Reported to nursing unit or directly to the treating physician
  • Documented on the Critical/Result Reporting form and read back
  • Confirmed critical lab results in Centricity
  • Communicated to the licensed caregiver (nurse/physician) who will act on the results
  • Measured related to timeliness of reporting and improved as necessary

Physicians are to be notified of critical test results as soon as results are received.

Patient Identification – Use of Two Identifiers

Name and date of birth (DOB) must be used for:

  • Medication administration
  • Blood administration
  • Treatments/procedures
  • Blood draws
  • Collecting specimens for clinical testing

Specimen container must be labeled in presence of patient.

Do not use patient room number as an identifier.

Transfusions

  • Two-person verification of patient identification
  • One person is nurse of patient

Universal Protocol

Pre-Procedure Verification Process

All surgical and invasive procedures, including those at the bedside, must have a pre-procedure verification process (i.e., ticket to OR).

Procedure Site Marking

All surgical and invasive/bedside procedures involving laterality, levels (spine), multiple structures (digits) or laparoscopic procedures involving laterality must have the site confirmed by the patient and marked by the physician, utilizing initials, prior to taking patient to the OR/procedure area. Site marking must be completed by the physician/proceduralist.

‘Time-Out’ – Final Verification Process

A time-out is performed immediately prior to starting any procedure in any setting. During the time-out, the entire team openly verifies and documents at a minimum the following:

  • Patient name
  • Procedure
  • Surgical/procedure site

All team members must be present and fully engaged in time-out procedure.

Infections

 Prevention of Infections

  • Reduce infections due to multiple drug-resistant organisms
  • Reduce central line infections by adhering to protocol
  • Reduce surgical site infections by using clippers to remove hair and administer prophylactic antibiotics
  • Reduce catheter-associated urinary tract infections

Hand-Hygiene Guidelines

Gel in–Gel out when entering and leaving patient room. Use five Moments for Hand Hygiene. Wash hands:

  • When entering the room and/or before patient contact
  • Before clean/aseptic procedures
  • After body fluid exposure risk
  • After patient contact and/or when leaving the room
  • After contact with the patient’s surroundings

Wash with soap and water for diagnosis of Clostridium difficile. No artificial nails for health care workers providing direct patient care.

Medication

 Anticoagulation Therapy

  • Utilize protocols for anticoagulation
  • Baseline INR obtained before administration
  • Dietary notified when warfarin initiated
  • Educate patient about risks and side effects

Labeling Medications/Solutions/Containers

Label all medications/solutions/containers on and off the sterile field in perioperative and other procedural settings. Labeling includes:

  • Drug/solution name
  • Drug strength/amount
  • Expiration date when not used within 24 hours
  • Expiration time when expiration occurs in less than 24 hours
  • Diluents for intravenous ad mixtures
  • Medication verified by two staff when not drawn up by person administering

Medication Reconciliation

  • Obtain patient’s current medication list at point of entry.
  • Enter/write medication orders.
  • Identify and reconcile discrepancies. Check for omissions, duplicates and correct medication/dose/frequency/route/time.
  • Instruct patient to give list of medications to provider.
  • Provide patient with complete list of medications upon discharge or transfer.

 

Applicable policies addressing these goals can be found on the LVHN intranet by clicking on Resources-General-TJC-TJC Accreditation-NPSGs.