The joint commission s 2011 national patient safety goals
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The Joint Commission’s 2011 National Patient Safety Goals. Objectives. Identify National Patient Safety Goals which apply to hospital settings. List two hospital patient safety standards. Indicate the importance of the National Patient Safety Goals and The Joint Commission accreditation.

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The Joint Commission’s 2011 National Patient Safety Goals

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The Joint Commission’s2011 National Patient Safety Goals


  • Identify National Patient Safety Goals which apply to hospital settings.

  • List two hospital patient safety standards.

  • Indicate the importance of the National Patient Safety Goals and The Joint Commission accreditation.

Background…did you know?

  • The National Patient Safety Goals (NPSGs) were established in 2002 (became effective January 1, 2003) to address specific areas of concern in regards to patient safety

Background…did you know?

  • The Joint Commission’s (TJC) mission is to “continuously improve the safety and quality of care delivered to the public through the provision of health care accreditation.”

  • The NPSG’s have related specific requirements for improving the safety of patient care in healthcare organizations.

  • TJC requires accredited health care organizations implement NPSG’s as appropriate to the services provided by the organization. All accredited health care organizations such as Hospitals, Assisted Living, Home Care, Behavioral Health Care, Disease-Specific Care, Ambulatory, Laboratory, etc., are surveyed to evaluate the implementation of these goals as they relate to the services of the organization.

NPSG Revisions for 2011

  • The Joint Commission revised four Elements of Performance (EP’s) within the Goals.

  • The revised EP’s are effective immediately.

  • NPSG #8 on medication reconciliation is not included in the changes; additional work is being done to evaluate and refine the medication reconciliation expectations for accredited organizations.

2011 National Patient Safety Goals

  • Now let’s review what the 2011 NPSG’s are for a hospital setting…

  • There are six NPSG’s for accredited hospital organizations and a Universal Protocol

    Revisions are in BOLD


Improve the accuracy of patient identification.

  • NPSG.01.01.01: Use of two patient identifiers when providing care, treatment and services.

  • NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.


Improve the effectiveness of communication among caregivers.

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


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.

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

Goal 7: Health Care-Associated Infections

Reduce the risk of health care-associated infections.

  • NPSG.07.01.01: Comply with hand hygiene guidelines.

  • NPSG.07.03.01: Implement evidence-based practices to prevent multidrug-resistant organism infections in acute care organizations.

  • NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated bloodstream infections.

  • NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections.

Goal 8: Reconcile Medications

Accurately and completely reconcile medications across the continuum of care.

The implementation date for the revised medication reconciliation requirement for NPSG 8 will be July 2011.

  • NPSG.08.01.01: Comparing Current and Newly Ordered Medications.

  • NPSG.08.02.01: Communicating Medications to the Next Provider.

  • NPSG.08.03.01: Providing a Reconciled Medication List to the Patient

  • NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.

GOAL 9: Patient Falls

The goal of reducing patient harm resulting from falls has now become a STANDARD!!

Goal 14: Pressure Ulcers

The goal of preventing health care-associated pressure ulcers (decubitus ulcers) has now become a STANDARD!!

Goal 15: Safety Risk

The organization identifies safety risks inherent in its patient population.

  • NPSG.15.01.01: Identifying Individuals at Risk for Suicide

NPSG for Hospitals

  • All hospitals receiving accreditation from The Joint Commission must implement the 6 NPSG requirements in an effort to maintain safe environments and provide quality care to all patients.

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

The organization meets the expectations of the Universal Protocol.

  • 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.

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