Dear KMRRRG Insured:
This issue highlights the Joint Commission's 2014 National Patient Safety Goals. KMRRRG physicians and providers play an integral role in patient safety. As University Medical Center works hard to implement, meet and surpass these initiatives, it is important for everyone to become familiar with the process improvement efforts that support positive patient experiences and exemplary care.

2014 National Patients Safety Goals
January 2, 2014
The Joint Commission
http://www.jointcommission.org

In 2002 The Joint Commission partnered with The Patient Safety Advisory Group to establish The National Patient Safety Goals (NPSGs) to help accredited organizations address specific areas of concern in regards to patient safety.  Together, they have recently released the 2014 NPSGs:
 
Changes for 2014:
A new NPSG focusing on safe clinical alarm management for hospitals and critical access hospitals will be introduced in 2014 with a phased implementation

• Phase one begins January 1, 2014
• Phase two begins January 1, 2016

Clinical Alarm Safety: Phase One

• Begins Januaey 1, 2014
• Hospitals are required to:
  • establish alarm safety as organizational priority
  • identify the most important alarms to manage based on their own internal situations

Clinical Alarm Safety: Phase Two

• Begins January 1, 2016
• Hospitals will be expected to:
  • develop and implement specific components of policies and procedures
  • educate staff in the organization about alarm system management

Goals:

• Patient Identification
  • Goal 1: Improve the accuracy of patient identification
    • NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services.
      • Applies to:  Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery
    • NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.
      • Applies to:  Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery
• Improve Communication
  • Goal 2: Improve the effectiveness of communication among caregivers.
    • NPSG.02.03.01:  Report critical results of tests and diagnostic procedures on a timely basis.
      • Applies to:  Critical Access Hospital, Hospital, Laboratory
• Medication Safety
  • Goal 3: Improve the safety of using medications NPSG.03.04.01:  Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Applies to:  Ambulatory, Critical Access Hospital, Hospital, Office Based Surgery
    • NPSG.03.05.01:  Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
      • Applies to:  Ambulatory, Critical Access Hospital, Hospital, Nursing Care Center
    • NPSG.03.06.01:  Maintain and communicate accurate patient medication information.
      • Applies to:  Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Nursing Care Center, Office-Based Surgery
• Clinical Alarm Safety
  • Goal 6: Reduce the harm associated with clinical alarm systems.
    • NPSG.06.01.01: Improve the safety of clinical alarm systems.
      • Applies to: Critical Access Hospital, Hospital
• Health Care-Associated Infections
  • Reduce the risk of health care-associated infections.
    • NPSG.07.01.01:  Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
      • Applies to:  Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Nursing Care Center, Office-Based Surgery
    • NPSG.07.03.01:  Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.
      • Applies to:  Critical Access Hospital, Hospital
    • NPSG.07.04.01:  Implement evidence-based practices to prevent central line-associated bloodstream infections.
      • Applies to:  Critical Access Hospital, Hospital, Nursing Care Center
    • NPSG.07.05.01:  Implement evidence-based practices for preventing surgical site infections.
      • Applies to:  Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery
    • NPSG.07.06.01:  Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).
      • Applies to:  Critical Access Hospital, Hospital
      • (Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is not consensus that these practices apply to children.)
• Reduce Falls
  • Goal 9: Reduce the risk of patient harm resulting from falls
    • NPSG.09.02.01:  Reduce the risk of falls.
      • Applies to:  Home Care, Nursing Care Center
• Pressure Ulcers
  • Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers).
    • NPSG.14.01.01:  Assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks.
      • Applies to:  Nursing Care Center
• Risk Assessment
  • Goal 15: The organization identifies safety risks inherent in its patient population
    • NPSG.15.01.01:  Identify patients at risk for suicide.
      • Applies to:  Behavioral Health Care, Hospital
      • (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.)
    • NPSG.15.02.01:  Identify risks associated with home oxygen therapy, such as home fires.
      • Applies to:  Home Care
• Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™
  • UP.01.01.01:  Conduct a preprocedure verification process.
    • Applies to:  Ambulatory, Critical Access Hospital, Hospital,  Office-Based Surgery
  • UP.01.02.01:  Mark the procedure site.    
    • Applies to:  Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery
  • UP.01.03.01:  A time-out is performed before the procedure.

Applies to:  Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

For more information:

• The National Patient Safety Goals for each program and more information are available on The Joint Commission website at www.jointcommission.org
• Questions can be sent to the Standards Interpretation Group at 630-792-5900 or via the Standards Online Question Form