The News Room

The Joint Commission has announced its 2009 National Patient Safety Goals and related requirements for accredited hospitals and critical access hospitals. These Goals apply to the more than 15,000 Joint Commission-accredited and -certified healthcare organizations and programs.  

Major changes include three new requirements related to preventing deadly healthcare-associated infections due to multiple drug-resistant organisms (MDROs), central line-associated bloodstream infections and surgical site infections. These additions build on an existing Goal to reduce the risk of healthcare-associated infections, and recognize that patients continue to acquire preventable infections at an alarming rate within hospitals. These new infection-related requirements have a one-year phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.

“The 2009 National Patient Safety Goals represent ongoing opportunities for improvement that can immediately benefit patients,” says Mark R. Chassin, MD, president, The Joint Commission. “By taking action to consistently meet the Goals, healthcare organizations can substantially improve patient safety in America.”

A revision of the requirements for the existing medication reconciliation Goal is based on feedback obtained from a Medication Reconciliation Summit convened in late 2007 and is included in the 2009 update. Other changes to the National Patient Safety Goals include a requirement to eliminate transfusion errors related to patient misidentification in hospitals, critical access hospitals, ambulatory care facilities and office-based surgery practices. New requirements for several programs focus on engaging patients in their care regarding infection control, prevention of surgical adverse events, and the patient identification process.

The requirements associated with the existing Universal Protocol, initiated to prevent errors in surgical and non-invasive surgical procedures, were also improved for 2009. These changes, which address the topics of procedure verification, marking the procedure site, and conducting a “time out” immediately prior to starting procedures, were based on feedback received at the Wrong Site Surgery Summit in 2007.

The 2009 Hospital and Critical Access Hospital National Patient Safety Goals (with changes underlined and in bold type) are:

Improve the accuracy of patient identification.

• Use at least two patient identifiers when providing care, treatment, and services.  
• Eliminate transfusion errors related to patient misidentification.

Improve the effectiveness of communication among caregivers.

• For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result.
• There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
• The organization measures, assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.
• The organization implements a standardized approach to hand off communications, including an opportunity to ask and respond to questions.

Improve the safety of using medications.

• The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications.
• Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
• Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. (Note: This requirement applies only to organizations that provide anticoagulation therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the patient’s laboratory values for coagulation will remain outside normal values. This requirement does not apply to routine situations where short-term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the patient’s laboratory values for coagulation will remain within, or close to, normal values.)

Reduce the risk of healthcare associated infections.

• Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
• Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a healthcare associated infection.
• Implement evidence-based practices to prevent healthcare-associated infections due to multiple drug-resistant organisms in acute care hospitals. (Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant Enterococci (VRE), and multiple drug-resistant gram negative bacteria.)
• Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. (Note: This requirement covers short and long term central venous catheters and PICC lines.)
• Implement best practices for preventing surgical site infections.

Accurately and completely reconcile medications across the continuum of care.

• A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.
• When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the organization’s care directly to his or her home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, or the original referring provider, or a known next provider of service. (Note: When the next provider of service is unknown or when no known formal relationship is planned with a next provider, giving the patient, and family as needed, the list of reconciled medications is sufficient.)
• When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family.
• In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. (Note: This requirement does not apply to organizations that do not administer medications. However, it is important for healthcare organizations to know what types of medications their patients are taking because these medications could affect the care, treatment, and services provided.)

Reduce the risk of patient harm resulting from falls.

• The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

Encourage patients’ active involvement in their own care as a patient safety strategy.

• Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

The organization identifies safety risks inherent in its patient population.

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

Improve recognition and response to changes in a patient’s condition.

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

The development, annual review and modification of the National Patient Safety Goals, first introduced in 2003, is overseen by the Sentinel Event Advisory Group, a panel that includes widely recognized patient safety experts, nurses, physicians, pharmacists, risk managers and other professionals who have hands-on experience in addressing patient safety issues in hospitals and other healthcare settings. Each year, this panel works with The Joint Commission to undertake a systematic review of the literature and available databases to identify potential new Goals and requirements. The Joint Commission also conducts an extensive field review of candidate new Goals and seeks input from practitioners, provider organizations, purchasers, and consumer groups among others. The Joint Commission’s Board of Commissioners approves the Goals and requirements each year. Compliance with the requirements is a condition of continuing accreditation or certification for Joint Commission-accredited and -certified organizations.

The full text of the updated Universal Protocol and 2009 National Patient Safety Goals and requirements for all accreditation programs, along with the elements of performance, can be found along on The Joint Commission’s website. Compliance with the Goals is a condition of continuing accreditation or certification for Joint Commission-accredited and -certified organizations.