THE THEME of National Nurses Week in 2016 is “A Culture of Safety,” so now's the perfect time to review the 2016 Joint Commission National Patient Safety Goals (NPSGs) for hospitals, which were to be fully implemented by January 1, 2016.1,2 The purpose of the NPSGs is to improve patient safety by applying evidence- and expert-based solutions to high-risk, problem-prone areas with a significant risk to patient safety and the potential for patient harm. In the Institute for Healthcare Improvement Global Trigger Tool, harm is defined as “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.”3
Reducing preventable patient harm through the implementation of safe practices continues to be a focus for healthcare organizations. The NPSGs provide the framework for how organizations can best address these high-risk areas. This article explains new requirements for clinical equipment alarms and reviews existing NPSGs that are still in effect.4
Alarm safety: A new focus for 2016
Clinical alarms on equipment such as cardiac monitors, infusion pumps, and mechanical ventilators are designed to improve safety for patients. The risk of patient harm increases when alarms aren't managed properly. According to The Joint Commission sentinel event database, 98 alarm-related events were reported between January 2009 and June 2012. Of those, 80 resulted in a patient's death, 13 in permanent loss of function, and 5 in additional care needed.5
The NPSG on alarm safety has been in effect since July 2014. Initially, it required hospitals to make alarm safety an organizational priority by focusing on the risks associated with clinical alarms. The new 2016 requirements aim to mitigate the risk of the improper use and management of clinical alarms. The requirements focus on proper alarm management and staff education on the appropriate use and purpose of the alarms. Although not all clinical alarms require nurses to intervene for the patient, they do require nurses to respond. Managing the high volume of clinical alarms, particularly in areas such as the ED and ICU, can be challenging.
Research has demonstrated that from 72% to 99% of clinical alarms are false, which can contribute to alarm fatigue.6Alarm fatigue, sensory overload caused by exposure to an excessive number of alarms, can result in either desensitization or missed alarms.
The Boston Globe reported an example of this that occurred in 2010 when a patient, age 60, died as a result of a delayed response to alarms signaling a change in the patient's condition.5 The 2016 requirements for alarm management address the issue of alarm fatigue.
Hospitals need to establish policies and procedures for safely managing alarms. The new 2016 requirements for hospitals include addressing the following:7
- What are the clinically appropriate settings for alarm signals?
- When can alarm signals be disabled?
- When can alarm parameters be changed?
- Who has the authority to set or change alarm parameters?
- Who has the authority to set alarm parameters to “off”?
- How are alarm signals monitored and responded to?
- How are individual alarm systems checked to ensure accurate settings, proper operation, and detectability?
- How should staff and licensed independent practitioners be educated about the purpose and proper operation of alarm systems for which they're responsible?
Several requirements for preexisting NPSGs haven't changed for 2016. While many of these NPSGs have been in effect for years, they continue to be areas of concern for patient safety where related harm events continue to occur.1
• Improve the accuracy of patient identification. Patient identification, which is fundamental to patient-centered care, should include the patient's active participation in all stages of the process whenever possible. The patient identification NPSG addresses errors that have resulted in the failure to correctly identify patients.
In 2011, the Pennsylvania Patient Safety Authority analyzed 813 wrong-patient medication errors and found that clinicians don't always use two patient identifiers to verify patient identification. This was one of the top three contributors to these errors.8
Before providing care, patients must be correctly identified with two distinct identifiers, such as name and date of birth. The patient's physical location such as room number isn't an acceptable identifier. These identifiers must then be matched with the care, treatment, or services to be provided. Matching the correct patient to the correct care is a critical step in verifying the accuracy of patient identification.
• Improve the effectiveness of communication among caregivers. Critical test and diagnostic procedure results can indicate that a patient's clinical status is potentially life-threatening. In 2014, the ECRI Institute developed a list of the top patient safety concerns by analyzing over 300,000 patient events. The third most common errors were those related to reporting critical test results.9 Failing to communicate critical results in a timely manner or making an error in communicating critical results can undermine patient safety and quality of care. This NPSG requires organizations to implement procedures for the effective and timely communication of critical results. For example, if the lab reports a critical low potassium level for a patient, the result should be called to the provider immediately upon receipt of the report and a prescription obtained for a potassium replacement.
• Improve the safety of using medications. This multifaceted NPSG includes improving medication labeling, reducing patient harm associated with use of anticoagulants, and performing medication reconciliation.
All medications, medication containers, and other solutions not immediately administered to the patient must be labeled at the time of preparation. When unlabeled medications or solutions are found, they should be immediately discarded to eliminate the risk of administering the incorrect medication to the patient.
Anticoagulation therapy requires close patient monitoring, accurate dosing, and patient adherence. Educating staff, patients, and prescribers is an essential component of this NPSG. Reducing harm associated with anticoagulant therapy also involves using unit-dose medications, prefilled syringes, or premixed infusions and protocols to manage anticoagulation therapy safely and effectively.
Medication reconciliation is intended to identify and resolve medication discrepancies. The process of reconciling medications involves comparing medications a patient is currently using (or should be using) with newly prescribed medications. Patients transitioning to and from different sites and levels of care are at increased risk for medication discrepancies: A recent study of medication reconciliation at admission and discharge demonstrated that at least one reconciliation error was detected in 64.5% of patients at admission and in 32.4% of patients at discharge.10
Patients need be educated about the importance of managing information about their medications. They should be encouraged to keep a list of all medications, doses, and frequency, and they should know the reason they're taking the medication.
• Reduce the risk of healthcare-associated infections. Patients are at risk for acquiring an infection when they receive care or treatment while in the hospital. Healthcare-associated infections (HAIs), often preventable, are a threat to patient safety. Adhering to hand hygiene guidelines, using evidence-based practices to prevent HAIs, and properly cleaning and disinfecting the patient's environment and patient care equipment are key components in prevention.
This NPSG also requires organizations to implement strategies to monitor and prevent infections related to multidrug-resistant organisms, central line-associated bloodstream infections, surgical site infections, and catheter-associated urinary tract infections. Progress in reducing HAIs has been slow despite evidence of interventions to reduce the incidence.11
Identifying safety risks
Patients at risk for suicide who are being treated for emotional or behavioral disorders must be identified to address their immediate safety needs and to provide treatment in the most appropriate setting. A Joint Commission Sentinel Event Alert published in February 2016 on detecting and treating suicide ideation in all settings noted that suicide is the 10th leading cause of death in America.12 This NPSG requires organizations to assess the suicide risk of patients being treated for emotional or behavioral disorders, address their needs, and provide suicide prevention information upon discharge.
This NPSG has three distinct safe practices to prevent wrong-site, wrong-procedure, and wrong-person surgery. Wrong-patient, wrong-site, or wrong-procedure surgeries have accounted for the most frequently reviewed sentinel event category for the past 3 years by The Joint Commission.7
These are the three components of the universal protocol:
- Before the procedure, verify that information gathered about the patient and procedures is correct.
- Confirm the patient's identification, correct procedure, correct site, and items needed for the procedure.
- The organization determines which procedures require site marking. The licensed independent practitioner who's accountable for the procedure marks the site before the procedure begins. Ideally, the patient should be actively involved in the site marking.
- Organizations must establish an alternative process for patients who refuse site marking and for situations in which it's technically or anatomically impossible or impractical to mark the site.
- A time-out is conducted immediately before starting the procedure for a final verification of the correct patient, site, and procedure.
Achieving the goals
Improving patient safety continues to be a high priority for organizations. Patient safety can be improved by adhering to the NPSGs, engaging patients in their own care, and creating a culture where all members of the healthcare team are accountable for safe practices.
1. American Nurses Association. Nursing World. National Nurses Week 2016. www.nursingworld.org/NationalNursesWeek
2. The Joint Commission. National Patient Safety Goals effective January 1, 2016. Hospital Accreditation Program. 2016. www.jointcommission.org/assets/1/6/2016_NPSG_HAP.pdf
3. Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events
. 2nd ed. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009.
4. The Joint Commission. Facts about the National Patient Safety Goals. 2016. www.jointcommission.org/facts_about_the_national_patient_safety_goals/
5. The Joint Commission. Sentinel Event Alert. Issue 50. Medical device alarm safety in hospitals. 2013. www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF
6. Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care
7. The Joint Commission. 2016 National Patient Safety Goals, Hospital Accreditation Standards. www.jointcommission.org/standards_information/npsgs.aspx
8. Yang A, Grissinger M. Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention. Pa Patient Saf Advis
. 2013;10(2):41–49. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Jun;10(2)/Pages/41.aspx
9. ECRI Institute. Risk Management Reporter. Top 10 patient safety concerns for healthcare organizations: 2015. 2015;34(2).
10. Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, González-García L, Cabeza-Barrera J, Galvez J. Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. Int J Clin Pract
11. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med
12. The Joint Commission: Sentinel Event Alert Issue 56: Detecting and treating suicide ideation in all settings. 2016. www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf