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Introduction - -In view of recent studies never an acceptable patient identifier.
that have shown an alarming number of medical The Patient Safety Goals identify that newborn
errors in the United States, causing thousands of patients are at greater risk of misidentification.
unnecessary injuries and deaths, the Joint Examples of methods to prevent misidentification
Commission has developed an evolving set of of newborn patients can include:
patient safety initiatives to address some of these Using distinct naming systems to include the
problems. mother's first and last names with the newborn's
The Joint Commission's National Patient Safety gender (for example: Wilson, Cathy Girl or
Goals (NPSG) consists of specific patient safety Wilson, Cathy Girl A and Wilson, Cathy Girl B for
goals and descriptive measures to meet these multiples)
goals. These goals apply to all Joint Standardized practices for identification banding
Commission-accredited institutions. Working with staff to communicate when
This program will discuss the Joint Commission's newborns have similar names, etc.
current patient safety goals, the requirements In addition, all specimen containers should be
that are mandated to meet those goals and the labeled in the presence of the patient.
Elements of Performance that have been
identified as methods to meet each requirement.
In addition to these goals, we will also describe Improve the Effectiveness of Communication
the Joint Commission's Universal Protocol for Among Caregivers - -Timeliness of critical
preventing wrong-site surgery tests and results
The second goal is to improve the effectiveness
of communication among caregivers, specifically
Safety Goals - -Before discussing the the timely report of critical results of tests and
patient safety goals and elements of diagnostic procedures. This includes the
performance to meet those goals, it is important acceptable length of time between availability of
to note that the Joint Commission has developed results and their report, and developing
goals for the variety of patient care settings and procedures for managing critical results.
programs it accredits—including home care Critical values are far outside normal levels and
agencies, laboratories, and ambulatory surgi- can be life-threatening. The hospital needs to
centers—not just acute care hospitals. Therefore, define the level at which results of diagnostic
it is important to be aware of the specific goals tests are critical, and then set an acceptable
that apply to your facility. length of time between ordering the test and
receiving the results.
The hospital will collect data on the timeliness of
Improve the Accuracy of Patient Identification - receipt of test results by the responsible licensed
-Use two forms of identification caregivers, assess this data and decide whether
The first goal is to improve the accuracy of corrective action needs to be taken. Finally, the
patient identification. You should use at least two hospital must take any action necessary to
forms of patient identification every time you improve timeliness and follow up to make sure
administer medications or blood products, take the measures are working.
blood samples, or perform treatments and The next goal is to improve the safety of using
procedures. If the patient has a wristband, medications.
acceptable identifiers include name, ID number, The first measure to improve the safety of using
or barcode if the barcode itself includes two medication calls for the labeling of all
patient-specific identifiers. The room number is medications, medication containers or other
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solutions, when they are taken out of their Then, facilities must have developed alarm
original container. This applies on and off the management policies and procedures for the
sterile field, in perioperative and other procedural alarms identified that address, at a minimum:
settings. Clinically appropriate settings;
The Joint Commission uses "medications" as a When alarms can be disabled or parameters can
broad term to mean any agent used to treat or be changed;
diagnose a patient, including over the counter Who in the facility can set and change the
drugs and herbal remedies as well as settings and parameters;
intravenous solutions and radiopaque dyes. What staff is responsible for monitoring and
Labeling must be done when any medication or responding to alarms;
solution is transferred from the original packaging How individual alarm settings, proper operation,
to another container, such as a syringe. and detectability will be checked.
The label must include the name and strength of In addition, staff and licensed independent
the medication, and the date, the amount (if not contractors must be educated about the purpose
obvious from the container), diluent name and and proper operation of the alarm systems for
volume, date and time prepared and the which they are responsible.
expiration time, if exp
Reduce the Risk of Healthcare-Associated
Improve the Safety of Clinical Alarms - - Infections - -The next safety goal is aimed
The next safety measures are directed at at reducing the risk of healthcare-associated
improving the safety of clinical alarms. A variety infections (HAIs). The first measure to achieve
of alarm systems are used to identify potential this goal calls for compliance with current CDC
patient problems, but if they are not managed hand hygiene guidelines or the WHO hand
properly, patient care can be compromised. hygiene guidelines.
Some of the difficulties that can occur include: Comply with current CDC hand hygiene
Alarms that are hard to detect; guidelines
Numerous pieces of equipment with alarms, and The most recent CDC guideline on hand hygiene
areas of the hospital which have multiple alarm recommends hand decontamination before and
signals. This can desensitize staff and lead to after direct contact with a patient, after wearing
missed, ignored, or the disarming or silencing of gloves, after touching patient care equipment or
alarms; environmental surfaces, and before performing
Alarms sounding at default settings that are not invasive procedures.
appropriate for the patient. In all these situations, the preferred hand hygiene
Hospitals must have identified the most important technique is now decontamination with an
alarm signals to manage by: alcohol-based hand rub. This has been shown to
Obtaining input from staff; be more effective against microbes and quicker
Identifying risks to patients if the alarms are not and easier to perform than washing with soap
answered; and water, thus encouraging greater adherence
Deciding if specific alarms are needed, or are to hand hygiene.
unnecessary and contribute to noise or alarm The manufacturer's recommended amount of the
fatigue; agent should be applied to the palm of one hand,
Evaluating for potential patient harm by reviewing then the hands should be rubbed together so the
variance reports and history of internal incidents; agent covers all surfaces of the hands and
Researching published best practice guidelines. fingers. Rub until the hands are dry, and do not
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