Facts about the 2008 National Patient Safety Goals

On June 1, 2007, The Joint Commission’s Board of Commissioners approved the 2008 National Patient Safety Goals. The Goals and related requirements are below. New Goals and requirements are indicated in bold and accreditation program applicability is indicated in brackets. Gaps in the numbering indicate a Goal has been “retired,” usually because the requirements were integrated into the standards. Program-specific language changes are omitted from this version.

This year’s new requirements (3E and 16A) have a one-year phase-in period that includes defined expectations for planning, development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation by January 2009. See the Implementation Expectations for milestones.

Goal 1	Improve the accuracy of patient identification.
1A	Use at least two patient identifiers when providing care, treatment or services. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
1B	Prior to the start of any invasive procedure, conduct a final verification process, (such as a “time out,”) to confirm the correct patient, procedure and site, using active—not passive—communication techniques. [Assisted Living, Home Care, Lab, Long Term Care]
Goal 2	Improve the effectiveness of communication among caregivers.
2A	For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2B	Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2C	Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. [Ambulatory, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
2E	Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
Goal 3	Improve the safety of using medications.
3C	Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. [Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery]
3D	Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. [Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery]
3E	Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. [Ambulatory, Critical Access Hospital, Home Care, Hospital, Long Term Care, Office-Based Surgery]
Goal 7	Reduce the risk of health care-associated infections.
7A	Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
7B	Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
Goal 8	Accurately and completely reconcile medications across the continuum of care.
8A	There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]
8B	A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care, Office-Based Surgery]
Goal 9	Reduce the risk of patient harm resulting from falls.
9B	Implement a fall reduction program including an evaluation of the effectiveness of the program. [Assisted Living, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Long Term Care]
Goal 10	Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.
10A	Develop and implement a protocol for administration and documentation of the flu vaccine. [Assisted Living, Disease-Specific Care, Long Term Care]
10B	Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. [Assisted Living, Disease-Specific Care, Long Term Care]
10C	Develop and implement a protocol to identify new cases of influenza and to manage an outbreak. [Assisted Living, Disease-Specific Care, Long Term Care]
Goal 11	Reduce the risk of surgical fires.
11A	Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels with enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes. [Ambulatory, Office-Based Surgery]
Goal 12	Implementation of applicable National Patient Safety Goals and associated requirements by components and practitioner sites.
12A	Inform and encourage components and practitioner sites to implement the applicable National Patient Safety Goals and associated requirements. [Networks]
Goal 13	Encourage patients’ active involvement in their own care as a patient safety strategy.
13A	Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery]
Goal 14	Prevent health care-associated pressure ulcers (decubitus ulcers).
14A	Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. [Long Term Care]
Goal 15	The organization identifies safety risks inherent in its patient population.
15A	The organization identifies patients at risk for suicide. [Behavioral Health Care, Hospital (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals)]
15B	The organization identifies risks associated with long-term oxygen therapy such as home fires. [Home Care]

Goal 16	Improve recognition and response to changes in a patient’s condition.
16A	The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

The goals and requirements for each accreditation program are also available on The Joint Commission website.   As of January 1, 2008, all Joint Commission accredited health care organizations and the Disease-Specific Care certified programs will be surveyed for implementation of applicable 2008 goals and requirements—or acceptable alternatives (see below)—as appropriate to the services the organization or program provides. Compliance with applicable requirements or acceptable alternatives will be scored at the associated implementation expectation(s) for that requirement in the NPSGs chapter of each standards manual.

Derivation of the goals

The development and annual updating of the NPSGs and requirements is overseen by an expert panel of widely recognized patient safety experts, as well as nurses, physicians, pharmacists, risk managers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Each year, the Sentinel Event Advisory Group works with Joint Commission staff to undertake a systematic review of the literature and available databases to identify potential new goals and requirements. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other parties of interest, the advisory group determines the highest priority goals and requirements and makes its recommendations to The Joint Commission. In order to maintain the focus of accredited organizations on the most critical patient safety issues, the Sentinel Event Advisory Group may, as part of its annual review, recommend the retirement of selected requirements from the NPSGs. In such cases, they will usually continue as accreditation requirements under the relevant standards.

The Sentinel Event Advisory Group was formed in February 2002 and the Board of Commissioners approved the first NPSGs in July 2002; they became effective in January 2003. Program-specific goals were developed for all accreditation programs in 2004 for implementation in 2005. The Joint Commission established the NPSGs to help accredited organizations address specific areas of concern in regards to patient safety. The Sentinel Event Advisory Group is charged with conducting a thorough review of all Sentinel Event Alert (The Joint Commission’s widely read patient safety advisory) recommendations and other sources of patient safety recommendations, and identifying those that are candidates for the annual NPSGs. The Group also advises The Joint Commission as to the evidence for and face validity of these recommendations, as well as their practicality and cost of implementation. The Advisory Group’s recommendations for annual NPSGs and associated requirements are forwarded to The Joint Commission’s Board of Commissioners for approval prior to the year in which they are to be implemented.

Submitting alternative approaches

An alternative approach to a NPSG requirement must be accepted by The Joint Commission based on the Sentinel Event Advisory Group’s review and recommendation that it is at least as effective as the published requirement in achieving the goal. Organizations that wish to submit alternative approaches to the requirements associated with the NPSGs can do so by filling out a “Request for Review of an Alternative Approach to a NPSG Requirement” form. The form and instructions for submitting it are available on the website.  Members of the Sentinel Event Advisory Group will review each form and advise The Joint Commission on the acceptability of the alternative. If not accepted, the organization will be provided with the rationale and will need either to revise the alternative until it is approved, or to implement the requirement as issued by The Joint Commission. Surveyors will accept organizations’ use of approved alternatives and will evaluate the implementation of those alternatives and other relevant requirements associated with the NPSGs.

For more information, visit contact the Standards Interpretation Group at (630) 792-5900, or complete the Standards Online Question Submission Form.