The National Patient Safety Goals are set by the Joint Commission (TJC), an independent nonprofit organization that accredits healthcare organizations in the United States. The Joint Commission NPSG’s goals are designed to address specific areas of concern within healthcare and improve patient safety. The NPSG’s are developed using information about emerging patient safety issues from widely recognized experts and stakeholders and is updated yearly (TJC, 2023). It is important to understand and adhere to these goals in your nursing practice.
In this Assignment, you will review the NPSG’s and identify 3 goals relevant to your nursing practice, choose one goal as a priority for your institution, reflect on the role of nursing and how adherence to the national patient safety goals contributes to a culture of safety in the healthcare setting. In addition, you will find and analyze a real-world example where the failure to meet one of the current NPSG’s resulted in an adverse event. You will also identify a Leapfrog Group Safety Grade and consider potential evidence-based interventions that might be implemented based on your local hospital safety grade.
Reference
The Joint Commission. (2023). 2023 national patient safety goals. https://www.jointcommission.org/standards/national…
To prepare:
Download the National Patient Safety Goals template download National Patient Safety Goals template Navigate to the Joint Commission websiteinks to an external site. and choose one of the following areas that closest matches your area of practice:
Hospital, Ambulatory Health, Assisted Living, Behavioral health, Critical Access Hospital, Home care, Nursing care. Choose the “Easy to Read” Version of the NPSG. Please note: Retired NPSG’s should not be used.
Review the Required Learning Resources
Consider how current NPSG guidelines are used in your clinical practice Navigate to the Leapfrog Groups webpageinks to an external site.. Enter your zip code and choose a facility in your city. Identify the safety grade assigned to your local facility and consider potential safety improvements that might be implemented based on a local hospital safety grade
The Assignment
Complete the National Patient Safety Goals template.
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The National Patient Safety Goals Template
Please choose three current national patient safety goals. Navigate to the Joint Commission website and choose one of the following areas that closest matches your area of practice:
• Hospital
• Ambulatory Health
• Assisted Living
• Behavioral Health
• Critical Access Hospital
• Home Care
• Nursing Care Center (LTC, Nursing Home)
Please be sure to choose the “Simplified” version of the NPSG; retired NPSG’s should not be used.
After selecting one of the areas, that closest matches your area of practice, please complete the following table:
Nursing Specialty
State your nursing specialty and the type of facility where you practice. For example, a Med/Surg RN practicing in an acute care facility.
Chapter
Identify the appropriate NPSG Chapter for your current area of practice.
NPSG 1
For the first selected NPSG, provide the year, name, and number of each goal and in your own words provide a brief description of the NPSG.
NPSG 2
For the second selected NPSG, provide the year, name, and number of each goal and in your own words provide a brief description of the NPSG.
NPSG 3
For the third selected NPSG, provide the year, name, and number of each goal and in your own words provide a brief description of the NPSG.
NPSG Priority
Choose one NPSG that you believe is a priority for your facility. Support your experiences, thoughts, and ideas with evidence from the literature.
Reflection
Reflect on the role of nurses and ensuring patient safety. How does adherence to the National Patient Safety Goals contribute to a culture of safety in the healthcare setting?
Real-World Example
Find and analyze a real-world example where the failure to meet one of the current NPSG’s resulted in an adverse event. Discuss the consequences and lessons learned. You may choose an incident in your facility (Remember your HIPAA responsibility and be sure to remove any identifying patient information). You may also choose an example from the media or professional literature.
Safety Grade
The Leapfrog Hospital safety grade is a public service provided by the Leapfrog Group, a nonprofit organization focused on healthcare quality and safety. The safety grade is designed to assess in grade hospitals in the United States based on their performance in preventing medical errors, injuries, infections and other aspects of patient safety. Nearly 3,000 hospitals are issued a Safety Grade twice per year. Navigate to the Leapfrog Group’s webpage. Enter your zip code and choose a facility in your city to complete the following:
Name of facility:
Overall facility safety grade?
What areas have been identified as needing improvement? Please list the top three areas.
1.
2. 3.
Evidence-Based Interventions
Consider three potential evidence-based interventions that might be implemented based on your local hospital safety grade. Please cite your sources.
1.
2. 3.
References
(Please cite all references used below)
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National Patient Safety Goals in Acute Care Nursing
The Joint Commission’s National Patient Safety Goals (NPSGs) play a crucial role in improving patient safety and quality of care across healthcare settings. This paper examines three key NPSGs relevant to acute care nursing practice, analyzes their importance, and explores their implementation to foster a culture of safety.
Nursing Specialty: Medical-Surgical Registered Nurse in an Acute Care Hospital
Chapter: Hospital National Patient Safety Goals
NPSG 1: NPSG.01.01.01 (2023) – Improve the accuracy of patient identification
This goal requires using at least two patient identifiers when providing care, treatment, or services. Healthcare providers must use two identifiers (e.g., name and date of birth) to ensure the correct patient receives the intended care. This helps prevent errors related to medication administration, specimen collection, and procedures (The Joint Commission, 2023).
NPSG 2: NPSG.03.05.01 (2023) – Reduce the risk of central line-associated bloodstream infections
This goal focuses on implementing evidence-based practices to prevent central line-associated bloodstream infections (CLABSIs). It includes proper hand hygiene, using maximum sterile barrier precautions during central line insertion, and regularly assessing the need for continued central line use (The Joint Commission, 2023).
NPSG 3: NPSG.06.01.01 (2023) – Reduce the harm associated with clinical alarm systems
This goal addresses the potential patient safety risks associated with clinical alarm systems. It requires hospitals to establish policies for managing alarms, educate staff about the purpose and proper operation of alarm systems, and regularly inspect, test, and maintain alarm systems (The Joint Commission, 2023).
NPSG Priority: NPSG.03.05.01 – Reduce the risk of central line-associated bloodstream infections
Central line-associated bloodstream infections (CLABSIs) remain a significant concern in acute care settings, with substantial morbidity, mortality, and healthcare costs (Haddadin et al., 2022). Implementing evidence-based practices to prevent CLABSIs is crucial for improving patient outcomes and reducing healthcare-associated infections.
In our facility, we have observed an increased incidence of CLABSIs over the past year, particularly in intensive care units. This trend aligns with recent literature suggesting that the COVID-19 pandemic has led to an increase in healthcare-associated infections, including CLABSIs, due to factors such as increased central line use, staffing challenges, and supply chain disruptions (Fakih et al., 2022).
Prioritizing NPSG.03.05.01 would involve reinforcing evidence-based practices for central line insertion and maintenance, enhancing staff education, and implementing rigorous monitoring and feedback systems. Recent studies have shown that multifaceted interventions, including the use of chlorhexidine-impregnated dressings, daily chlorhexidine bathing, and adherence to central line bundles, can significantly reduce CLABSI rates (Blot et al., 2021).
Reflection on the Role of Nurses in Ensuring Patient Safety
Nurses play a pivotal role in ensuring patient safety and adhering to National Patient Safety Goals. As frontline healthcare providers, nurses are uniquely positioned to implement safety measures, identify potential risks, and intervene to prevent adverse events. Adherence to NPSGs contributes to a culture of safety by:
Standardizing practices: NPSGs provide clear, evidence-based guidelines that help standardize care processes across healthcare settings. This standardization reduces variability and the potential for errors.
Promoting accountability: By clearly defining safety expectations, NPSGs foster a sense of accountability among healthcare providers. Nurses are empowered to speak up when they observe deviations from safety protocols.
Encouraging continuous improvement: The regular updates to NPSGs reflect evolving best practices and emerging safety concerns. This encourages healthcare organizations to continuously evaluate and improve their safety measures.
Enhancing communication: Many NPSGs focus on improving communication among healthcare providers and between providers and patients. Effective communication is essential for preventing errors and ensuring high-quality care.
Raising awareness: NPSGs help raise awareness about critical patient safety issues, ensuring that all healthcare team members are cognizant of potential risks and mitigation strategies.
By consistently adhering to NPSGs, nurses contribute to creating a healthcare environment where safety is prioritized, errors are minimized, and patients receive the highest quality of care. This commitment to safety extends beyond individual actions, fostering a collective responsibility for patient well-being throughout the healthcare system.
Real-World Example: Failure to Meet NPSG Resulting in Adverse Event
In 2019, a highly publicized case at Vanderbilt University Medical Center highlighted the critical importance of adhering to NPSG.01.01.01 – Improve the accuracy of patient identification. A nurse administered vecuronium, a powerful paralytic, instead of Versed (midazolam), a sedative, to a patient awaiting a PET scan. This medication error resulted in the patient’s death (Kelman, 2019).
The error occurred due to multiple breakdowns in the medication administration process, including:
Failure to use two patient identifiers: The nurse did not verify the patient’s identity using two identifiers before administering the medication.
Overriding automated dispensing cabinet warnings: The nurse overrode safeguards in the medication dispensing system without proper verification.
Inadequate medication reconciliation: The nurse failed to recognize that vecuronium, not Versed, had been retrieved from the cabinet.
This tragic incident underscores the critical importance of adhering to patient identification protocols and medication safety practices. It also highlights the need for a systems approach to patient safety, addressing factors such as work environment, technology use, and organizational culture that can contribute to errors.
Lessons learned from this incident include:
The importance of consistent adherence to patient identification protocols, even in seemingly routine situations.
The need for robust medication safety systems that are not easily overridden.
The critical role of a safety culture that encourages questioning and speaking up when potential risks are identified.
The importance of ongoing education and training for healthcare providers on patient safety practices and potential risks.
This case serves as a stark reminder of the potential consequences of failing to adhere to National Patient Safety Goals and the critical importance of maintaining vigilance in all aspects of patient care.
Safety Grade
Name of facility: Memorial Hospital
Overall facility safety grade: B
Areas identified as needing improvement:
Handwashing
Communication about medicines
Communication about discharge
Evidence-Based Interventions:
Implement a multimodal hand hygiene improvement strategy: This approach, recommended by the World Health Organization, includes system change, training and education, evaluation and feedback, reminders in the workplace, and institutional safety climate. A systematic review by Gould et al. (2017) found that multimodal interventions are more effective in improving hand hygiene compliance compared to single interventions.
Enhance medication communication through standardized processes: Implement the use of structured communication tools, such as medication cards or electronic applications, to improve patient understanding of their medications. A study by Daliri et al. (2019) demonstrated that the use of a medication card significantly improved patients’ knowledge about their medications and adherence to treatment.
Improve discharge communication using the teach-back method: This evidence-based approach involves asking patients to explain in their own words what they need to know or do regarding their health. A systematic review by Talevski et al. (2020) found that the teach-back method effectively improves patient comprehension and reduces hospital readmissions.
In conclusion, the National Patient Safety Goals provide a crucial framework for improving patient safety in healthcare settings. By prioritizing these goals, particularly in areas such as preventing central line-associated bloodstream infections, healthcare organizations can significantly enhance patient outcomes and foster a culture of safety. Nurses play a pivotal role in implementing these safety measures and contributing to continuous quality improvement in healthcare delivery.
References
Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2021). Prevention of central line-associated bloodstream infections through quality improvement interventions: A systematic review and meta-analysis. Clinical Infectious Diseases, 72(1), 34-42. https://doi.org/10.1093/cid/ciaa239
Daliri, S., Hugtenburg, J. G., Ter Riet, G., van den Bemt, B. J., Buurman, B. M., Scholte op Reimer, W. J., … & Karapinar-Çarkit, F. (2019). The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study. PLOS ONE, 14(3), e0213593. https://doi.org/10.1371/journal.pone.0213593
Fakih, M. G., Bufalino, A., Sturm, L., Huang, R. H., Ottenbacher, A., Saake, K., … & Cacchione, J. (2022). Coronavirus disease 2019 (COVID-19) pandemic, central-line–associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): The urgent need to refocus on hardwiring prevention efforts. Infection Control & Hospital Epidemiology, 43(1), 26-31. https://doi.org/10.1017/ice.2021.70
Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews, (9). https://doi.org/10.1002/14651858.CD005186.pub4
Haddadin, Y., Annamaraju, P., & Regunath, H. (2022). Central line associated blood stream infections. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430891/
Kelman, B. (2019, March 27). Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap. The Tennessean. https://www.tennessean.com/story/news/health/2019/02/04/vanderbilt-nurse-reckless-homicide-charge-vecuronium-versed-drug-error/2769589002/
Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4), e0231350. https://doi.org/10.1371/journal.pone.0231350
The Joint Commission. (2023). Hospital National Patient Safety Goals. https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals/
