The Joint Commission’s 2018 National Patient Safety Goals (NPSGs) are in effect and available on The Joint Commission’s website. These standards are simple, actionable, and applicable to the work that surgeons perform, especially the Universal Protocol (UP) for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The NPSGs were established in 2002 to help accredited organizations address specific areas of concern with respect to patient safety issues. The first set of NPSGs took effect in January 2003. They were developed and have been updated with input from the Patient Safety Advisory Group, which is composed of nurses, physicians, pharmacists, risk managers, clinical engineers, and other health care professionals.
The 2018 NPSGs outlines goals for the following programs: ambulatory health care, behavioral health care, critical access hospital, home care, hospital, laboratory services, nursing care center, and office-based surgery.
NPSGs for hospital and office-based surgery
The 2018 NPSGs applicable to The Joint Commission’s Hospital and Office-Based Surgery (OBS) Accreditation programs are listed below and feature language from the simplified versions of the NPSGs. It is important to note that some NPSGs are applicable only to the hospital program, not to the OBS program.
UP for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
- UP.01.01.01: Make sure that the correct operation is done on the correct patient and at the correct place on the patient’s body.
- UP.01.02.01: Mark the correct place on the patient’s body where the operation is to be done.
- UP.01.03.01: Pause before the operation to make sure that a mistake is not being made.
NPSG 1: Improve the accuracy of patient identification
- NPSG.01.01.01: Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This step is done to ensure that each patient gets the correct medicine and treatment.
- NPSG.01.03.01: Make sure that the correct patient gets the correct blood when a blood transfusion is performed.
NPSG 2: Improve the effectiveness of communication among caregivers
- NPSG.02.03.01: Get important test results to the right staff person on time (hospital program only).
NPSG 3: Improve the safety of using medications
- NPSG.03.04.01: Before a procedure, label medicines that are not labeled (for example, medicines in syringes, cups, and basins). Do this in the area where medicines and supplies are set up.
- NPSG.03.05.01: Take extra care with patients who take blood thinners (hospital program only).
- NPSG.03.06.01: Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines with new medicines given to the patient. Make sure the patient knows which medicines to take at home. Tell the patient it is important to bring an up-to-date list of medicines every time they visit a doctor.
NPSG 6: Reduce the harm associated with clinical alarm systems
- NPSG.06.01.01: Make improvements to ensure that alarms on medical equipment are heard and responded to on time (hospital program only).
NPSG 7: Reduce the risk of health care-associated infections
- NPSG.07.01.01: Use the hand-cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
- NPSG.07.03.01: Use proven guidelines to prevent infections that are difficult to treat (hospital program only).
- NPSG.07.04.01: Use proven guidelines to prevent infection of the blood from central lines (hospital program only).
- NPSG.07.05.01: Use proven guidelines to prevent infection after the operation.
- NPSG.07.06.01: Use proven guidelines to prevent infections of the urinary tract that are caused by catheters (hospital program only).
NPSG 15: The organization identifies safety risks inherent in its patient population
- NPSG.15.01.01: Find out which patients are most likely to try to commit suicide (hospital program only).
For more information
Questions about the 2018 NPSGs should be directed to The Joint Commission’s Standards Interpretation Group at 630-792-5900 or by using the Standards Online Question Form.
The full chapter of 2018 NPSGs for the Hospital Accreditation program is available on The Joint Commission’s website.
To view the NPSGs for all programs online.
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.