Complying with the 2008 national patient safety goals

AORN Journal,  March, 2008  by Kathleen Catalano,  Kevin Fickenscher

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Nearly $1.9 trillion is spent on medical care each year in the United States. (1) In spite of this, medical errors occur frequently, and Americans suffer from injuries caused by these errors. Some of these errors result in patient death.

In an effort to reduce errors, the Joint Commission publishes National Patient Safety Goals (NPSGs) and requires accredited organizations and those pursuing accreditation to comply with these goals. (2) The NPSGs are part of the patient safety trilogy espoused by the Joint Commission, which includes the Sentinel Event Standards and Guidelines, Patient Safety Standards, and the NPSGs. A full understanding of the Joint Commission's requirements and, when appropriate, the incorporation of technologic solutions can automate and streamline the process of compliance with the NPSGs.

PATIENT SAFETY

The focus on patient safety has long been a part of the the Joint Commission's mission, which is

   To continuously improve the safety
   and quality of care provided to the
   public through the provision of health
   care accreditation and related services
   that support performance improvement
   in health care organizations. (3)

Beginning in 1995, the Joint Commission began reviewing certain sentinel events (ie, unexpected occurrences involving death or serious physical injury, including the loss of limb or function, or psychological injury, or the risk thereof (2)) and requiring health care organizations to perform root-cause analyses of those events. The Sentinel Event Alerts (4) are a by-product of these reviews. These alerts are published in an effort to capture the attention of health care organizations for the purpose of helping them recognize, explore, and correct potential problems, thereby preventing similar sentinel events in the future.

The Institute of Medicine (IOM) increased the national focus on patient safety with its three publications, To Err Is Human: Building a Safer Health System, (5) Crossing the Quality Chasm: A New Health System for the 21st Century, (6) and Patient Safety: Achieving a New Standard for Care, (7) published in 2000, 2001, and 2004, respectively. It is noteworthy that the IOM publications not only highlighted the number of medical errors that have resulted in death in health care organizations annually (ie, between 44,000 and 98,000 (5)), but they also called for a national health information infrastructure designed to foster the sharing of patient safety information and the design of safer delivery systems.

THE DEVELOPMENT OF THE NPSGs

The Joint Commission responded to the subsequent public outcry over medical errors by formulating specific patient safety standards for accredited organizations. These standards became part of the accreditation survey process in January 2001 (8) and were followed by the NPSGs in January 2003. (9)

The Joint Commission's Sentinel Event Advisory Group is responsible for drafting the NPSGs, which subsequently are reviewed and adopted by the Joint Commission Board of Commissioners. The Joint Commission has chosen to maintain the sequential numbering methodology of the original NPSGs; meaning that an existing or retired number will never be reused for any other NPSG. The Joint Commission believes that this will allow better and more efficient tracking of NPSG progress and also will cause less confusion.

As anticipated, the NPSGs have evolved over time. The Joint Commission has added implementation expectations and rationales for each goal. (10) During the Joint Commission's survey of a health care organization, it will evaluate the organization's actual performance with respect to each NPSG, not just the intent of the organization to comply "sometime in the future."

Organizations have tried many methods to increase their compliance with the NPSGs. Many of these methods have worked for a limited period of time; however, the results are not always sustainable. Information technology (IT) solutions may help to minimize lapses in some areas of compliance with the NPSGs. This article reviews the 2008 hospital program NPSGs and, when applicable, focuses on ways in which IT solutions (eg, clinical information systems, applications, processes) might be used to address them.

GOAL 1--IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION

Requirement 1A of NPSG 1, "Improve the accuracy of patient identification," (11) is that health care organizations use two patient identifiers when providing care, treatment, or services. The intent of this goal is the identification of the correct patient and the ability to match the service and/or treatment (ie, administering medication, collecting blood samples and other specimens for clinical testing, providing treatments or procedures, administering blood products) with the correct patient.

The patient identifiers may vary depending on the area in which the patient is treated (eg, hospital, ambulatory surgery center [ASC]), but neither identifier should be the patient's room number. In hospitals, the patient's armband is the vehicle of choice from which identification is made. Traditionally, two patient identifiers are needed only for patient treatment, but administrators may want to consider using two patient identifiers when passing out food trays or picking up patients for procedures.