In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program; the first set of NPSGs was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety. ¹

A panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. ¹

Below are the National Patient Safety Goals and rational issued by the Joint Commission effective for 2014-2015. ²

Goal 1: Improve the accuracy of patient identification.

NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, or services.

Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.

Element 1: Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient's room number or physical location is not used as an identifier.

Element 2: Label containers used for blood and other specimens in the presence of the patient.

NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification.

Element 1: Before initiating a blood or blood component transfusion:

• Match the blood or blood component to the order.

• Match the patient to the blood or blood component.

• Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding.

Element 2: When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient.

Element 3: When using a two-person verification process, the second individual conducting the identification verification is qualified to participate in the process, as determined by the organization.

Goal 2: Improve the effectiveness of communication among caregivers.

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

Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a lifethreatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.

Element 1: Develop written procedures for managing the critical results of tests and diagnostic procedures that address the following:

• The definition of critical results of tests and diagnostic procedures

• By whom and to whom critical results of tests and diagnostic procedures are reported

• The acceptable length of time between the availability and reporting of critical results of tests

• and diagnostic procedures

Element 2: Implement the procedures for managing the critical results of tests and diagnostic procedures.

Element 3: Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

Goal 3: Improve the effectiveness of communication among caregivers.

NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. This unsafe practice neglects basic principles of safe medication management, yet it is routine in many organizations.

Element 1: In perioperative and other procedural settings both on and off the sterile field, label medications and solutions that are not immediately administered. This applies even if there is only one medication being used.

Element 2: In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container.

Element 3: In perioperative and other procedural settings both on and off the sterile field, medication or solution labels include the following:

• Medication name

• Strength

• Quantity

• Diluent and volume (if not apparent from the container)

• Expiration date when not used within 24 hours

• Expiration time when expiration occurs in less than 24 hours

Element 4: Verify all medication or solution labels both verbally and visually. Verification is done by two individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it.

Element 5: Label each medication or solution as soon as it is prepared, unless it is immediately administered.

Element 6: Immediately discard any medication or solution found unlabeled.

Element 7: Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.

Element 8: All medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting staff responsible for the management of medications.

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

Anticoagulation therapy can be used as therapeutic treatment for a number of conditions, the most common of which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant. However, it is important to note that anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety Goal has great potential to positively impact the safety of patients on this class of medications and result in better outcomes.

To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy program. Effective anticoagulation patient education includes face-to-face interaction with a trained professional who works closely with patients to be sure that they understand the risks involved with anticoagulation therapy, the precautions they need to take, and the need for regular International Normalized Ratio (INR) monitoring. The use of standardized practices for anticoagulation therapy that include patient involvement can reduce the risk of adverse drug events associated with heparin (unfractionated), low molecular weight heparin, and warfarin.

Element 2: Use approved protocols for the initiation and maintenance of anticoagulant therapy.

Element 3: Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the clinical record.

Element 7: Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. Patient/family education includes the following:

• The importance of follow-up monitoring

• Compliance

• Drug-food interactions

• The potential for adverse drug reactions and interactions

Element 8: Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization.

NPSG.03.06.01 Maintain and communicate accurate patient medication information.

The large number of people receiving health care who take multiple medications and the complexity of managing those medications make medication reconciliation an important safety issue. In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies.

There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.

Element 1: Obtain and/or update information on the medications the patient is currently taking. This information is documented in a list or other format that is useful to those who manage medications.

Element 2: Define the types of medication information to be collected in different settings and patient circumstances.

Element 3: For organizations that prescribe medications: Compare the medication information the patient brought to the organization with the medications ordered for the patient by the organization in order to identify and resolve discrepancies.

Element 4: For organizations that prescribe medications: Provide the patient (or family as needed) with written information on the medications the patient should be taking at the end of the episode of care (for example, name, dose, route, frequency, purpose).

Element 5: For organizations that prescribe medications: Explain the importance of managing medication information to the patient at the end of the episode of care.

Goal 6: Reduce the harm associated with clinical alarm systems.

NPSG.06.01.01 Improve the safety of clinical alarm systems

Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within different units in a single hospital.

Element 1: As of July 1, 2014, leaders establish alarm system safety 1. as a hospital priority. A During 2014, identify the most important alarm signals to manage based on the following:

- Input from the medical staff and clinical departments

- Risk to patients if the alarm signal is not attended to or if it malfunctions

- Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue

- Potential for patient harm based on internal incident history

- Published best practices and guidelines EC.02.04.01.)

Element 2: As of January 1, 2016, establish policies and procedures for managing the alarms identified in EP 2 above that, at a minimum, address the following:

- Clinically appropriate settings for alarm signals

- When alarm signals can be disabled

- When alarm parameters can be changed

- Who in the organization has the authority to set alarm parameters

- Who in the organization has the authority to change alarm parameters

- Who in the organization has the authority to set alarm parameters to “off”

- Monitoring and responding to alarm signals

- Checking individual alarm signals for accurate settings, proper operation, and detectability (For more information, refer to Standard EC.02.04.03)

Element 3: As of January 1, 2016, educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

Goal 7: Reduce the risk of health care–associated infections.

NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, or services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback.

Element 1: Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines.

Element 2: Set goals for improving compliance with hand hygiene guidelines

Element 3: Improve compliance with hand hygiene guidelines based on established goals.

NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in critical access hospitals.

Patients continue to acquire health care–associated infections at an alarming rate. Risks and patient populations, however, differ between critical access hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each critical access hospital based on its risk assessment. The elements of performance for this requirement are designed to help reduce or prevent health care–associated infections from epidemiologically important multidrug-resistant organisms (MDROs).

Element 1: Conduct periodic risk assessments (in time frames defined by the critical access hospital) for multidrug-resistant organism acquisition and transmission.

Element 2: Based on the results of the risk assessment, educate staff and licensed independent practitioners about health care–associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter.

Element 3: Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care–associated infection prevention strategies.

Element 4: Implement a surveillance program for multidrug-resistant organisms based on the risk assessment.

Element 5: Measure and monitor multidrug-resistant organism prevention processes and outcomes, including the following:

• Multidrug-resistant organism infection rates using evidence-based metrics

• Compliance with evidence-based guidelines or best practices

• Evaluation of the education program provided to staff and licensed independent practitioners

Element 6: Provide multidrug-resistant organism process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

Element 7: Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

Element 8: When indicated by the risk assessment, implement a laboratory-based alert system that identifies new patients with multidrug-resistant organisms.

Element 9: When indicated by the risk assessment, implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms.

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

Element 1: Educate staff and licensed independent practitioners who are involved in managing central lines about central line–associated bloodstream infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities. Element 2: Prior to insertion of a central venous catheter, educate patients and, as needed, their families about central line–associated bloodstream infection prevention.

Element 3: Implement policies and practices aimed at reducing the risk of central line–associated bloodstream infections. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

Element 4: Conduct periodic risk assessments for central line–associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the critical access hospital, and this infection surveillance activity is critical access hospital-wide, not targeted.

Element 5: Provide central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

Element 6: Use a catheter checklist and a standardized protocol for central venous catheter insertion.

Element 7: Perform hand hygiene prior to catheter insertion or manipulation.

Element 8: For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.

Element 9: Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters.

Element 10: Use a standardized protocol for sterile barrier precautions during central venous catheter insertion.

Element 11: Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations.

Element 12: Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.

Element 13: Evaluate all central venous catheters routinely and remove nonessential catheters.

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

Element 1: Educate staff and licensed independent practitioners involved in surgical procedures about surgical site infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities.

Element 2: Educate patients and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention.

Element 3: Implement policies and practices aimed at reducing the risk of surgical site infections. These policies and practices meet regulatory requirements and are aligned with evidence based guidelines (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

Element 4: As part of the effort to reduce surgical site infections:

• Conduct periodic risk assessments for surgical site infections in a time frame determined by the organization.

• Select surgical site infection measures using best practices or evidence-based guidelines.

• Monitor compliance with best practices or evidence-based guidelines.

• Evaluate the effectiveness of prevention efforts.

Element 5: Measure surgical site infection rates for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices. The organization’s measurement strategies follow evidence-based guidelines.

Element 6: Provide process and outcome (for example, surgical site infection rate) measure results to key stakeholders.

Element 7: Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations.

Element 8: When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations.

NPSG.07.06.01 (NEW) Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

Element 1: During 2012, plan for the full implementation of this NPSG by January 1, 2013. Note: Planning may include a number of different activities, such as assigning responsibility for implementation activities, creating time lines, identifying resources, and pilot testing.

Element 2: Insert indwelling urinary catheters according to established evidence-based guidelines that address the following:

• Limiting use and duration to situations necessary for patient care

• Using aseptic techniques for site preparation, equipment, and supplies

Element 3: Manage indwelling urinary catheters according to established evidence-based guidelines that address the following:

• Securing catheters for unobstructed urine flow and drainage

• Maintaining the sterility of the urine collection system

• Replacing the urine collection system when required

• Collecting urine samples

Element 4: Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following:

• Selecting measures using evidence-based guidelines or best practices

• Monitoring compliance with evidence-based guidelines or best practices

• Evaluating the effectiveness of prevention efforts

Goal 9: Reduce the risk of patient harm resulting from falls.

NPSG.09.02.01 Reduce the risk of falls.

Falls account for a significant portion of injuries in hospitalized patients, long term care residents, and home care recipients. In the context of the population it serves, the services it provides, and its environment of care, the organization should evaluate the patient’s risk for falls and take action to reduce the risk of falling as well as the risk of injury, should a fall occur. The evaluation could include a patient’s fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments.

Element 1: Assess the patient’s risk for falls.

Element 2: Implement interventions to reduce falls based on the patient’s assessed risk.

Element 3: Educate staff on the fall reduction program in time frames determined by the organization.

Element 4: Educate the patient and, as needed, the family on any individualized fall reduction strategies. Evaluate the effectiveness of all fall reduction activities including assessment, interventions and education.

Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers).

NPSG.14.01.01 Assess and periodically reassess each resident’s risk for developing a pressure ulcer and take action to address any identified risks.

Pressure ulcers (decubiti) continue to be problematic in all heath care settings. Most pressure ulcers can be prevented, and deterioration at Stage I can be halted. The use of clinical practice guidelines can effectively identify residents and define early intervention for prevention of pressure ulcers.

Element 1: Create a written plan for the identification of risk for and prevention of pressure ulcers.

Element 2: Perform an initial assessment at admission to identify residents at risk for pressure ulcers.

Element 3: Conduct a systematic risk assessment for pressure ulcers using a validated risk assessment tool such as the Braden Scale or Norton Scale.

Element 4: Reassess pressure ulcer risk at intervals defined by the organization.

Element 5: Take action to address any identified risks to the resident for pressure ulcers, including the following:

• Preventing injury to residents by maintaining and improving tissue tolerance to pressure in

• order to prevent injury

• Protecting against the adverse effects of external mechanical forces

Element 6: Educate staff on how to identify risk for and prevent pressure ulcers.

Goal 15: The organization identifies safety risks inherent in its patient population.

NPSG.15.01.01 Identify individuals at risk for suicide.

Suicide of an individual served while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals.

Element 1: Conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide.

Element 2: Address the immediate safety needs and most appropriate setting for treatment of the individual served.

Element 3: When an individual at risk for suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family.

NPSG.15.02.01 Identify risks associated with home oxygen therapy such as home fires.

Many sentinel events reported by home care programs to The Joint Commission were due to a fire in the patient’s home. In each case, when patients were injured or killed as a result of a home fire, home oxygen was in use.

Element 1: Conduct a home oxygen safety risk assessment that addresses at least the following:

• Whether there are smoking materials in the home

• Whether there are other fire safety risks in the home, such as the potential for open flames

• Whether or not the home has functioning smoke detectors

Element 2: Inform the patient and family/caregiver of the findings of the safety risk assessment and educate the patient and family/caregiver about the causes of fire, precautions that can prevent fire-related injuries, and recommendations to address the specific identified risk.

Element 3: Assess the patient’s level of comprehension of and compliance with identified risks and suggested interventions.

The National Patient Safety Goals for each program and more information are available on The Joint Commission website at www.jointcommission.org or contact your facility patient safety officer. Patient safety is an ongoing battle. Keeping tuned in to the National Patient Safety Goals and recommendations is the responsibility of all health care professionals to help maintain a safe environment for patients in all areas of health care.

1. Facts About the National Patient Safety Goals. The Joint Commission Web site. http://www.jointcommission.org/standards_information/npsgs.aspx.

2. 2011 National Patient Safety Goals Now Available. The Joint Commission Web site. http://www.jointcommission.org/standards_information/npsgs.aspx.