patient safety. Standards for patient safety serve several purposes. Standards establish consistency and uniformity across multiple individuals and organizations. Standards also set World Health Organization A major international effort to improve patient safety is the High 5s Project. The World Health Organization (WHO) launched the project in 2006 to address continuing major concerns about patient safety around the world. The High 5s name derives from the project’s original intention of significantly reducing the frequency of 5 challenging patient safety problems in 5 countries over 5 years. Seven nations are currently members of the project (High 5s Project, 2013). The Joint Commission Several national organizations have launched safety initiatives. The most widely known is the Joint Commission’s National Patient Safety Goals. The Joint Commission first established the National Patient Safety Goals in 2002 to help accredited organizations target critical areas in which safety could be improved (TJC, 2017b). The goals are a critical method by which the Joint Commission promotes and enforces major changes in patient safety in thousands of participating healthcare Agency for Healthcare Research and Quality Within days of the release of the HMD report To Err Is Human, President Clinton signed into law the Healthcare Research and Quality Act of 1999. The law reauthorized the AHRQ and designated it as the lead agency in supporting federal research in efforts to reduce medical/dental errors (AHRQ, 2003). Ten years later, in summarizing the progress made in patient safety since the enactment of this legislation, AHRQ director Carolyn Clancy cited these efforts: ● Creating a culture of safety: AHRQ’s patient safety culture surveys are designed to help hospitals, nursing homes, and medical offices to assess, improve, and monitor their patient safety performance (AHRQ, 2013). AHRQ’s WebM&M (a peer-reviewed, web-based journal on patient safety) has helped healthcare organizations adopt a blame-free culture and has allowed professionals to learn from one another (AHRQ, 2014). ● Encouraging teamwork: TeamSTEPPS ™ is an evidence- based system to improve teamwork and communication among healthcare professionals, using a comprehensive set of training curricula (AHRQ, 2010b). As of 2009, TeamSTEPPS ™ had been distributed to 14,000 healthcare organizations. ● Reducing healthcare-associated infections: AHRQ supported the development of a patient safety checklist proven to prevent common, costly, and sometimes deadly central-line-associated bloodstream infections by up to 66% (AHRQ, 2009a; Pronovost et al., 2006). ● Preventing medication errors: Blood Thinner Pills: Your Guide to Using Them Safely is designed to enhance care coordination around anticoagulant therapy. Warfarin is the second most common drug, after insulin, implicated in emergency room visits for adverse drug events (AHRQ, 2009b). ● Reducing hospital readmissions: AHRQ supported the development of a toolkit to prevent unnecessary hospital readmissions. By focusing on the discharge process, the traditional weak link in hospital care, the toolkit helped reduce hospital readmission rates by nearly 30% at a Boston teaching hospital (Jack et al., 2009). ● Advances in event reporting: Event reporting and standardized data collection yield critical data. Patient Safety Organizations (PSOs), authorized under the Patient Safety and Quality Improvement Act, are organizations that share the goal of improving the quality and safety of healthcare delivery. Organizations that are eligible to become PSOs include public and private entities, profit and
expectations for the organizations and health professionals, and help to set expectations for consumers and purchasers.
The project’s mission is to facilitate implementation and evaluation of standardized patient safety solutions – called Standard Operating Protocols (SOPs) – to combat patient safety problems. To date, two Standard Operating Protocols have been developed. These protocols address: ● Medication accuracy at transitions of care (medication reconciliation SOP). ● Correct procedures at correct body site (correct-site surgery SOP) (High 5s Project, 2013). organizations in the United States and around the world (TJC, 2017b). All Joint Commission accredited healthcare organizations are surveyed for compliance with the requirements of the Goals. Each year the Goals – for example, the Ambulatory Care Goals shown in Table 4 – are reevaluated. National Patient Safety Goals for various types of healthcare organizations are available on the Joint Commission website at http://www.jointcommission.org/ standards_information/npsgs.aspx not-for-profit entities, and provider entities such as hospital chains. These organizations receive patient safety data while working with providers to improve care without fear of legal repercussions (AHRQ, n.d.b). Table 4: 2017 Ambulatory Care National Patient Safety Goals 2017 Ambulatory Health Care National Patient Safety Goals The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.
Identify patients correctly NPSG.01.01.01
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they get a blood transfusion.
NPSG.01.03.01
Use medicines safely 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. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
NPSG.03.05.01 NPSG.03.06.01
Prevent infection 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. Use proven guidelines to prevent infection after surgery.
NPSG.07.05.01
Prevent mistakes in surgery UP.01.01.01
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. Mark the correct place on the patient’s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made.
UP.01.02.01 UP.01.03.01
This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission.org. Note. © The Joint Commission, 2017. Reprinted with permission. ● Supporting patient safety training: To better prepare physicians and surgeons for high-risk events, AHRQ has supported several projects that assess the use of simulation technology in improving teamwork, communication, diagnostic and technical skills, safety culture, and other hallmarks of safe care. ● Understanding resident fatigue: AHRQ-supported research into medical resident fatigue and its connection to medical/dental errors prompted limits in 2003 on the hours per week that medical residents could work at U.S. hospitals (HMD, 2008) (Clancy, 2009).
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