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The Joint Commission and NAtional Patient Safety Goals

Mikayla Dexter and

Ada Robinson

Today We'll Cover:

The Basics

  • What is The Joint Commission?
  • What are National Patient Safety Goals?
  • Why are these goals important?
  • What are the goals?
  • Mannequin Scenario

Competition!

What is the Joint Commission (TJC)?

The Joint

COmMISSION

  • A not-for-profit organization
  • Aims to ensure quality healthcare, prevent harm, and improve patient advocacy through accreditation of facilities that meet their standards
  • Approx. 80% of US hospitals

  • Set more than 250 hospital accreditation standards
  • Including: Patient rights and education, infection control, medication management, preventing medical errors, staff qualifications, emergency preparedness, data collection and performance improvement

  • Review accredited organizations every 2-3 years

National Patient

Safety Goals

What are National Patient Safety Goals?

  • Goals designed to help organizations address specific areas of concern in regards to patient safety
  • The highest priority patient safety issues are determined from patient outcome statistics, input from practitioners, consumer groups, and other stakeholders

  • Guide healthcare facilities to focus on preventing the major sources of patient harm

Why Should you CARE

About TJC and NSPGs?

The Importance

  • PATIENT SAFETY!

  • YOUR SAFETY!

  • Strengthen community confidence in the quality and safety of care provided at CHS

Did you

KNow?

Maintaining our joint commission certification = our ability to continue to serve our community

Accreditation is needed to treated many of our commercially insured patients

National Patient Safety Goals

The Goals

Note: These are the hospital-based NPSGs. There are many others for other settings (Ex. homecare, skilled nursing facilities)

Goal 1

Goal 1: Improve the accuracy of patient identification

NPSG 01.01.01: Use at least two patient identifiers when providing care, treatment, and services.

GOAL 2: Improve the effectiveness of communication among caregivers.

Goal 2

NPSG 02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.

GOAL 3: Improve the safe use of medications.

GOAL 3

NPSG 03.04.01: Label all medications, medication containers, and other solutions.

NPSG 03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant

therapy.

NPSG 03.06.01: Maintain and communicate accurate patient medication information.

Goal 6

Goal 6: Reduce patient harm associated with clinical alarm systems.

NPSG 06.01.01: Improve the safety of clinical alarm systems.

Goal 7

GOAL 7 Reduce the risk of health care-associated infections.

NPSG 07.01.01: Comply with either current CDC or WHO hand hygiene guidelines.

NPSG 07.04.01: Use evidence-based practices to prevent infection of the blood from central lines.

NPSG 07.06.01: Use evidence-based practices to prevent infections of the urinary tract that are caused by catheters.

Goal 9

GOAL 9: Reduce the risk of patient harm resulting from falls.

NPSG 09.02.01: Reduce the risk of falls.

GOAL 14: Prevent health care-associated pressure ulcers (decubitus ulcers).

GOAL 14

NPSG.14.01.01: Assess and periodically reassess each patient’s and resident’s risk for developing a pressure ulcer and take action to address any identified risks.

GOAL 15: The organization identifies safety risks inherent in its patient population.

GOAL 15

NPSG 15.01.01: Reduce the risk for suicide.

GOAL 16: Improve health care equity

Goal 16

NPSG.16.01.01: Improving health care equity for the organization’s patients is a quality and safety priority.

Universal protocol goals

Universal Protocol

Goals

UP 01.01.01: Conduct a preprocedure verification process.

UP 01.02.01: Mark the procedure site.

UP 01.03.01: A time-out is performed before the procedure.

The MANNEQUIN SCENARIO

The Mannequin Competition

  • Patient Mannequin Scenario:
  • You'll have 5 minutes to examine the patient in the room.
  • You'll then have 5 minutes outside the room to identify as many safety concerns as possible, and match them with a corresponding National Patient Safety Goal (NPSG)

  • You'll get one point for each safety violation you identify, and one point if you match it to the correct National Patient Safety Goal.
  • The person that identifies as many violations as possible wins!

Debrief

NSPG VIOLATED:

Goal 1: Improve the accuracy of patient identification.

Goal 1: Improve the accuracy of patient identification.

Goal 1: Improve the accuracy of patient identification.

Goal 1: Improve the accuracy of patient identification.

Goal 3: Improve the safe use of medications.

Goal 3: Improve the safe use of medications.

Goal 3: Improve the safe use of medications.

Goal 3: Improve the safe use of medications.

Goal 3: Improve the safe use of medications.

Goal 6: Reduce patient harm associated with clinical alarm systems.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 9: Reduce the risk of patient harm resulting from falls.

Goal 9: Reduce the risk of patient harm resulting from falls

Goal 9: Reduce the risk of patient harm resulting from falls.

Universal Protocol Goals

Universal Protocol Goals

Goal 14: Prevent healthcare-associated pressure ulcers.

Goal 14: Prevent healthcare-associated pressure ulcers.

SAFETY CONCERNS:

Two different ID bands

Unlabeled time out sheet

Name on monitor does not match wristband

Unlabeled blood tubes

Unlabeled syringe of medication

Unlabeled saline drip

Saline drip not on an IV pump

Heparin drip not on an IV pump

Home medication bottle on the bedside table

O2 monitor flashing, alarm silenced

Central line without a dressing

IV has no dressing

Foley catheter wrapped around bed rail

Foley catheter still in on day 5 post-op

Foley catheter not secured in the stat lock

Bed not locked

Bed in high position

Call bell on the floor

Time-out sheet incomplete

Wrong limb marked for surgical procedure

Heel resting on hard surface

Sheet bunched under patient

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