The 2005 National Patient Safety Goals

AORN Journal,  Jan, 2005  by Suzanne C. Beyea

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In July 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced its 2005 National Patient Safety Goals. These goals and associated requirements are developed by JCAHO's Sentinel Event Advisory Group. The Joint Commission specified that starting Jan 1, 2005, all accredited organizations that provide care that is relevant to these goals and standards must comply with these specifications and will be evaluated for continuous compliance during their on-site accreditation reviews.

The 2005 goals reflect the fact that three of the requirements related to preventing wrong site, wrong procedure, and wrong person surgery that were included in the 2004 National Patient Safety Goals have been incorporated into JCAHO's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. This protocol applies to ambulatory settings, critical access hospitals, hospitals, and office-based surgery facilities and becomes effective for all of these facilities on July 1, 2005. (1,2)

The 2005 National Patient Safety Goals include both previously identified goals and new goals. Furthermore, some previously established goals now include new requirements to help organizations direct activities that promote patient safety. Overall, the intent of the goals and requirements is to decrease the incidence and severity of adverse events, including sentinel events. Information JCAHO has been collecting about sentinel events provides helpful insights into high-priority risk situations for health care organizations. This column specifically addresses the 2005 National Patient Safety Goals for hospitals, critical access hospitals, and ambulatory settings. (1)

The 2005 National Patient Safety Goals

The first patient safety goal relates to improving the accuracy of patient identification. It states that two patient identifiers must be used when a clinician is

* administering blood or medications,

* taking blood or other laboratory specimens, or

* providing treatments or procedures.

The Joint Commission specifies that under no circumstances should a patient's room number serve as patient identification. This goal requires that health care organizations establish and follow a policy in which two pieces of information are used to identify a patient and match him or her to the procedure to be performed or the care to be provided. (1)

The second patient safety goal addresses the need to improve the effectiveness of communication among caregivers. The Joint Commission specifies that for oral or telephone orders or for critical test results reported via the telephone, the person receiving the order or laboratory result should read back the complete order or study result. The goal also addresses two additional requirements. The first is that each health care organization establish a list of prohibited abbreviations. The other requires health care organizations to measure, assess, and if indicated, take action to ensure that reporting of critical tests and values to the responsible licensed caregiver is timely. (1)

The third patient safety goal addresses the need to improve medication safety. This goal addresses two previously established initiatives. The first requires removing concentrated electrolytes from patient care units and standardizing and limiting the number of medication concentrations available in a health care facility. Within this goal, a new requirement addresses annually identifying and reviewing a list of look-alike/sound-alike medications used in a health care facility. Additionally, this goal requires organizations to take specific actions to prevent errors related to the accidental interchange of look-alike/ sound-alike medications. (1)

The fourth National Patient Safety Goal relates to safe infusion pump use. It requires ensuring that all general-use IV pumps and infusion pumps used for patient-controlled analgesia have free-flow protection.

The fifth goal remains unchanged from 2004 and relates to reducing the risks of iatrogenic infections. Specifically, JCAHO asks that organizations comply with the Centers for Disease Control and Prevention's hand hygiene guidelines. This goal also requires health care organizations to manage as sentinel events all iatrogenic infections that result in a patient's death or permanent major loss of function. (1)

The sixth goal addresses the need to accurately and completely reconcile medications across the continuum of care. This goal and its requirements specify that health care organizations must develop a process to ensure that when patients are admitted to the facility, a complete and accurate list of medications the patient currently is taking is obtained and on discharge or transfer, an updated and accurate list is provided to the next care provider. This goal specifies that the patient should be involved in the process to ensure both completeness and accuracy of the medication list. (1)

The last patient safety goal relates to the need to reduce the risk of patient harm resulting from patient falls in hospitals and critical access hospitals. This goal addresses the need to assess and periodically reassess circumstances surrounding each patient fall, including the patient's medication regimen, and taking action to address any identified risks. Although perioperative nurses rarely encounter patient falls, they do occur; thus, perioperative nurses must identify and address the factors that contribute to falls and develop strategies to prevent their occurrence. (1)