Each year, The Joint Commission (TJC) — formerly known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO — emphasizes a different aspect of safety in health care. In 2006, “communicating” was the theme of new requirements for the hospital-specific National Patient Safety Goals (NPSGs). In 2007, it was “patient involvement.” For 2008, TJC has selected “recognizing changes” is its newest safety focus.

The 2008 goals extend TJC’s expectations that healthcare organizations provide safe, high-quality care. TJC-accredited organizations must show they comply with all requirements of the safety goals or show compliance with “acceptable alternatives” for achieving a goal. (TJC must approve such alternatives.¹) If a hospital fails to demonstrate compliance with any of the requirements during a TJC survey, it will receive a special “requirement for improvement” for that NPSG, which could affect its accreditation.

TJC reviews the patient safety goals and implementation requirements annually; some continue while others are replaced. When TJC is satisfied that the vast majority of hospitals have incorporated practices defined in the NPSGs, it removes them from the annual list. They never actually “go away,” however, but are incorporated into ongoing TJC hospital standards. New patient safety goals are constantly in the pipeline, based on sentinel events reported to TJC and the corrective actions developed in response, from which practice standards are developed for all hospitals to follow.² (A sentinel event is an unexpected event involving death or serious physical or psychological injury, or a risk of them.)

TJC includes required practices in the goals to standardize the risk-reduction strategies that hospitals use.³ By having all hospitals use the same safety strategies, TJC can study whether these strategies actually reduce patient injuries. TJC expects that the number of sentinel events involving the issues addressed in NPSGs will decline. (TJC strongly encourages hospitals to report sentinel events and medical errors.) If the numbers do not decline, the question will arise whether the selected safety strategies are not effective in large-scale implementation, are not actually being practiced, or are being confounded by some factor.⁴

Something for everyone

TJC has patient safety goals for all the different kinds of programs it accredits, such as long-term care, laboratory, and behavioral health.⁵ This module will discuss goals for hospitals. The TJC website is the primary source for information on goals for all programs.

It can be confusing to read the numbered goals and requirements for any one particular program because the numbering is nonconsecutive. A program list shows only the numbers pertaining to that program. So, for example, numbered goals for hospitals move from “3” to “7” because 4, 5 and 6 goals no longer apply. For 2008, there are nine hospital-specific goals with 16 implementation expectations although numbers move from 1A through 16A.

Here are the 2008 hospital NPSGs, with new items in bold. In 2008, TJC will survey hospitals to check for implementation of 2008 goals and requirements (or acceptable alternatives). The two new requirements have milestones for achievement throughout 2008, with full implementation required by January 2009.⁶

Goal: Improve the accuracy of patient identification (continuing goal).

Use at least two patient identifiers when providing care, treatment, or services. Note: TJC expanded this requirement from 2006’s requirement to use two identifiers for specified activities, such as administering medications. The intent is that staff members use two pieces of information to identify patients before providing any medical service to them. TJC has indicated that the two pieces of information do not have to come from different sources; it would be acceptable to use two pieces of identification from an ID wristband. (That is, a nurse could use a patient’s name and birth date from an ID wristband.) All practice areas of a hospital do not have to use the same two identifiers, but all providers within a practice area must use the same two. Staff frequently ask what to do about an unresponsive patient who comes to a facility without identification, as in a trauma situation. The hospital must create for that patient at least two identifiers to use throughout the admission to match specimens and medications. Hospitals may assign the patient a “John Doe” designator and an account number or a medical record number to use throughout an admission. When two people are asked to individually check identifiers before the administration of blood, they should each check the blood against original patient identifiers, not just check that the process was followed by the original nurse. If a hospital allows a patient to state his or her name as a form of identification, the nurse should not ask the patient to simply confirm his or her name, but to actively state it.

A bar coder improves the accuracy of identification as long as it is one of two identifiers. A bar coder can take the trouble out of verifying a series of numbers, such as an account number. Bar coding also removes risks such as transposing numbers in a series or incorrectly copying numbers. Ideally, the bar code on a patient-specific medication is matched to a bar code on a medication record and on a patient wristband using a handheld device. This technology requires coordination of many parts of a healthcare system.

In U.S. hospitals, especially in EDs and critical care settings, blood and other specimen containers sometimes are labeled outside the presence of the patient. But TJC expects that the complete labeling process occur in the presence of the patient.

Goal: Improve effectiveness of communication among caregivers (continuing goal). TJC has identified ineffective communication as the most common type of root cause of sentinel events.

a. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read back” the complete order or test result.

i. This standard applies to all verbal and telephone orders, not just medication orders.

ii. Repeating back an order is not enough. Whenever possible, the person who receives the order should write down the complete order or enter it into a computer, then read it back, and receive confirmation from the person who gave the order.

iii. In emergencies, such as a code or during surgery in the OR, it may not be feasible to do a formal “read back,” so a “repeat back” is acceptable.

iv. TJC clarified that orders left on a phone for a home health nurse, for example, or left with a family member for a nurse’s attention require a call back to the prescriber by the nurse to get the order directly, including a “read-back.”

v. Telephone orders and verbal orders have become part of most nurses’ practices because of the rapid changes in hospital care. Because actions from verbal or telephone orders usually follow quickly after the order is written, the provider usually doesn’t have an opportunity to intervene if a mistake has been made. It becomes crucial that the nurse taking an order has the patient record available to record the order as it is spoken and then reads back the order as it is written. It is not safe for a nurse to verbally restate what the provider has ordered and then later write it down. To do so eliminates the only verifiable information of what was communicated.

b. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

i. TJC requires the following items to be on every organization’s “do not use” list: These required items have not changed since 2005:⁷

             •            “U”: Write “unit.”

             •            “IU”: Write “international unit.”

             •            “QD,” “QOD”: Write “daily” and “every other day.”

             •            Trailing zero (wrong: 1.0) and lack of a leading zero (wrong: .1): Never write a zero by itself after a decimal point, and always use a zero before a decimal point. The one exception is that a trailing zero may be used to demonstrate the level of precision of a value being reported, such as laboratory results.

             •            “MS,” “MSO4,” “MgSO4”: Write “morphine,” “morphine sulfate,” and “magnesium sulfate.”

ii. TJC has clarified when a delay could put a patient at risk, staff are expected to provide care to the patient even if an order contains a dangerous abbreviation if the registered nurse and pharmacists believe the intent of the order is clear and confirmation is obtained later.

iii. Nurses sometimes have been made to feel that they must “interpret” orders that are difficult to read or ambiguous. This dangerous practice has resulted in tragic patient outcomes. Reducing the number of abbreviations, acronyms, and symbols that may result in confusion can help.

c. Measure, assess, and if appropriate take action to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical test results and values.

TJC expects an organization to define for itself the acceptable time between the ordering of critical tests and reporting of results and values, and the time between when results are available and when the responsible licensed caregiver receives them. The organization defines “critical test results,” usually consisting of stat tests or any report requiring an urgent response. If the organization does not define “critical test results,” TJC will consider all verbal or telephone reports of diagnostic test to be critical.

One useful strategy for implementing this goal is to reduce the complexity of communication protocols and increase the specificity. A nurse should not be put in the position of being unsure of what test results fall under the “critical” category. Listing critical test categories and critical result ranges on preprinted forms for immediate reference has proved helpful. 

d. Implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions. 

With today’s time constraints, the time-honored practice of report — when one caregiver hands off responsibility for a patient to another caregiver, including the personal communication of items deemed important for the person “accepting care of the patient” — is in danger of disappearing or being minimized to a degree that its effectiveness is lost. Now, hospitals must identify a consistent report-off process so caregivers are assured that all relevant information moves from one point of care to another with a patient. The opportunity to ask questions and get a response is integral to meaningful handoffs. TJC does not intend that taped reports be eliminated, but it expects that if reports are taped, the overall process still will allow for direct interpersonal communication between the staff.

Numerous occasions for handoffs exist in a hospital besides shift reports. Care is handed off during breaks, diagnostic testing off-unit, unit transfers, as well as when responsibilities are passed on between physicians.

“Standardization” of reporting means that the organization defines essential information to be included in any hand-off. Essential elements include the reason for admission and important historical data, a summary of current condition, important treatments and services provided, and recent changes, expected or unexpected. Many hospitals are adopting the SBAR (situation, background, assessment, and recommendation) method to comply with this NPSG. Caregivers use SBAR during hand-offs to standardize the information provided to the next level of care. Information on SBAR is available at the Institute for Healthcare Improvement website in the patient safety module.

Goal: Improve the safety of using medications (continuing goal, new requirement in 2008, and one requirement dropped. The requirement to standardize and limit the number of drug concentrations used by a hospital has been removed and will now become part of the regular standards surveyed by TJC.)

a. Identify and at a minimum annually review a list of look-alike/sound-alike drugs used in the organization and take action to prevent errors involving the interchange of these drugs.

In 2008, TJC continues the requirement that organizations maintain a list of look-alike/sound-alike drugs selected from tables on the TJC website.⁸ At least 10 drug combinations must be listed. TJC recognizes that with the explosion of new medications with similar names and the inherent dangers of hard-to-read handwriting, organizations must have tools in place to help nurses and others avoid potentially harmful medication errors.

b. Label all medications; medication containers (e.g., syringes, medicine cups, basins); and solutions on and off the sterile field.

This requirement applies anywhere in the facility. This requirement was initially a response to the death of a patient who, while undergoing a procedure, was injected with an unlabeled solution that proved to be an antiseptic solution never intended for injection.⁹ Medications or other solutions in unlabeled containers are unidentifiable. Even if the healthcare team is using only one medication or solution, its container needs to be labeled. Labels should include the drug name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time if expiration occurs in less than 24 hours. All original containers should remain available for reference during a procedure. At shift changes during any procedure, all medications and solutions and their labels are expected to be reviewed by entering and exiting staff.

c. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy (new requirement).

The dosing of anticoagulation agents, such as low-molecular-weight heparin (Dalteparin) and warfarin (Coumadin), is inherently complex. In 2008,TJC expects hospitals to develop safe, comprehensive systems and policies that ensure that only oral-unit-dose products and premixed infusions are used, when available. In addition, a baseline and current International Normalized Ratio (a lab test to monitor the impact of an anticoagulant) should be available for patients receiving warfarin so that therapy can be monitored and adjusted. (A normal INR is about 1.0, and patients on anticoagulant therapy are often maintained at a 2.0-3.0 INR.) Dietary services must ensure that patients on warfarin therapy receive a diet that incorporates an established food/drug interaction program. The TJC also expects programmable infusion pumps to be used to administer heparin IV. Staff, patients, and families must be adequately educated about anticoagulation therapy; teaching should be tailored to the audience and include basic information about anticoagulation drugs, food/drug interactions, and the importance of regular testing of coagulation status.

Goal: Reduce the risk of health care-acquired infections (continuing goal, modified requirement: WHO guidelines added as resource for compliance).

a. Comply with national Centers for Disease Control and Prevention hand hygiene guidelines or the World Health Organization hand hygiene guidelines. (TJC requires implementation of all CDC Category 1A, 1B and 1C guidelines. Information about hand hygiene, referencing the required guidelines, is available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm or at the WHO website: www.who.int/patientsafety/events/05/Summary2ndConsultation.pdf.) The importance of handwashing cannot be overstated. It is the single most effective way to prevent nosocomial infections.

One of the CDC Category 1A guidelines states that healthcare personnel should not wear artificial nails if they care for patients at high risk of acquiring infections (e.g., patients in ICUs or transplant units). TJC requires compliance with this guideline.

b. Manage as sentinel events all cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection. TJC requires a root cause analysis (RCA) of any death or permanent injury in a case that involves infection if at the time of admission the patient had a high likelihood of surviving the episode of care (e.g., the hospitalization). To illustrate, the death of a patient admitted with terminal cancer who later died of an infection would not require an RCA. According to TJC, the traditional rate-based approach to reducing nosocomial infections (such as regular reporting of infection rates at leadership committees) has not been entirely successful and hopes that adding RCA will move the industry further along in improving patient safety.

Goal: Accurately and completely reconcile medications across the continuum of care (continuing goal).

a. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

Patients are at particularly high risk during transitions in care (handoffs).¹⁰ To prevent medication-related adverse events resulting from miscommunication during handoffs, the process of reconciliation must occur. The reconciliation process is the responsibility of the receiving unit. The provider who writes medication orders in the most current setting should conduct the reconciliation although nurses and pharmacists play a role in checking for discrepancies, omissions, duplications, and potential interactions, as well as ensuring that the reconciliation process occurs.

b. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care inside or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

The intent of the goal and requirements is that reconciliation of medications occur as a patient moves throughout an organization and that upon discharge the patient has a written list of medications for home use that takes into consideration preadmission medications and those added or discontinued during hospitalization. 

Goal: Reduce the risk of patient harm from falls (continuing goal).

a. Implement a fall reduction program, including an evaluation of its effectiveness.

This goal should result in changes in patient and staff education, assessment for fall risk, implementation of fall prevention strategies, and continual monitoring of outcomes. Although historically nurses have been taught strategies to prevent falls and have been expected to use them as part of professional practice, hospitals now must have in place systems to ensure that all interventions constituting “best practice” are implemented.

Goal: Encourage patients’ active involvement in their own care as a patient safety strategy (continuing goal).

a. Define and communicate the means for patients and families to report concerns about safety and encourage them to do so.

Since 2002, TJC has encouraged hospitals to establish programs, such as its “Speak Up” campaign, to urge patients to ask questions and report safety concerns.¹¹ Patient safety hotlines, patient advocate staff positions, and safety publicity campaigns satisfy the intent of this new goal. A “culture of safety” requires that patients and families be aware of what is expected and that the healthcare community acknowledge the importance of patients and families as a source of information about potential adverse events and hazardous conditions.

Goal: The organization identifies safety risks inherent in its patient population (continuing goal).

a. The organization identifies patients at risk for suicide. (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.)

The suicide of a patient in a staffed, round-the-clock care setting is one of the most frequent type of sentinel events, according to TJC.¹⁰ To satisfy this goal, hospitals treating patients for emotional and behavioral disorders must assess a patient’s risk of suicide. If this will be a new part of intake assessment, it may be helpful for hospitals to develop specific language for nurses to use when assessing patients for suicide risk. Some patients are admitted for suicidal ideation, but other patients in such settings must be assessed for suicide risk, as well.

Goal (new):  Improve recognition of and response to changes in a patient’s condition.

a. The organization selects a suitable method to enable healthcare staff to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. 

TJC notes that warning signs precede many codes and other critical inpatient events by an average of six to eight hours. Throughout 2008, hospitals are expected to develop processes that empower staff, patients, and families to request additional assistance when they have a concern about a patient’s condition. Many hospitals have begun working on this by introducing “rapid response teams,” frequently comprised of a critical care nurse, a respiratory therapist, and sometimes a pharmacist or physician. Such teams respond to a designated code to come to the patient’s bedside to help with assessment, make determinations on level of care changes (to a critical care bed), or initiate physician-approved protocols. An excellent reference on rapid response teams is the Institute for Healthcare Improvement website, www.IHI.org. 

The goals and requirements listed above are straightforward, and hospitals are expected to take corrective action if they are not in compliance. TJC gives hospitals the option to ask for permission to experiment with unique strategies to reduce risks to patients in the safety areas so that new and better means of improving safety will keep coming into the mix.

The Joint Commission’s patient safety program is in its sixth year, and hospitals and other healthcare organizations will have to comply with an ever-evolving set of core strategies to promote patient safety. These requirements represent an evidence-based national standard of care to increase accountability for patient safety practices.

If you have questions about the NPSGs, speak to the patient safety officer where you work or review the TJC’s “patient safety” web page for hospitals, www.jointcommission.org/PatientSafety.

Connie Kirkpatrick, RN, MS, PhD, director of quality at Franciscan Health System, Tacoma, Wash. The authors have declared no real or perceived conflicts of interest that relate to this educational activity. Nursing Spectrum guarantees that this educational activity is free from bias.