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Although many 2009 NPSGs have moved to standards, still important to work toward compliance


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Although many 2009 NPSGs have moved to standards, still important to work toward compliance

Although the 2010 National Patient Safety Goals (NPSG) are a much smaller set than last year’s version, keeping up with those goals that moved to the general standards is important for maintaining best practices as well as receiving fewer requirements for improvement on your next Joint Commission survey, according to Lisa Eddy, RN, CPHQ, CSHA, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Eddy spoke at the 4th Annual Association for Healthcare Accreditation Professionals Conference in May.

“Is there any difference between a standard versus a goal? No, there’s really no difference because a National Patient Safety Goal is really just a standard, and many of the [elements of performance (EP)] continue to be direct impact,” said Eddy. 

However, she did note that the two differ during an actual survey. Joint Commission surveyors are prompted to respond to compliance questions about the NPSGs and the Universal Protocol on their laptops before they can move on with their reports, whereas they have to remember on their own to look for additional issues and know where in the manual they are located. 

Therefore, it’s more likely that surveyors will focus on the current NPSGs, Eddy said.

The following 2009 goals were moved to the standards in 2010:

  • NPSG.02.01.01, verbal/telephone order, critical test result read-back 
  • NPSG.02.02.01, do-not-use entries
  • NPSG.02.05.01, handoff communication
  • NPSG.03.03.01, look-alike/sound-alike medications 
  • NPSG.09.02.01, patient falls 
  • NPSG.13.01.01, patient involvement in care
  • NPSG.16.01.01, rapid response

Of the above standards, Eddy specifically pointed to the standard for do-not-use entries, now located in IM.02.02.01, EPs 2–3, as being an easy standard to clarify if cited. This is because 90% compliance is now good enough, and since there are so many opportunities to measure this, compliance is usually above 90%. 

“If you want to clarify this, the denominator includes every opportunity to use dangerous abbreviations, including every integer or fractional dose,” explained Eddy. 

Also of note is a change with look-alike/sound-alike medications. The Joint Commission no longer requires that its own list be used; hospitals can use lists from other entities. Additionally, precautions must be implemented, but it’s no longer required that they must cross all aspects of the medication management process. However, many facilities get in trouble because they fail to review this list annually, which is still part of the standard.

The 2010 NPSG hot spots include NPSG.03.04.01 (solution labels), the proposed NPSG.03.07.01 (medication reconciliation), NPSG 7 (concerning multidrug-resistant organisms, central line–associated bloodstream infections, and surgical site infections), and the Universal Protocol (UP). 

The NPSG regarding solution labeling contains many areas of confusion, said Eddy. Because of these questions, she recommended holding off on changing any processes concerning labeling until The Joint Commission clarifies them. Questions that are raised by NPSG.03.04.01 as it is currently written include: 

  • Only medication names are mentioned; does The Joint Commission also mean solutions? (Eddy assumed that it does.)
  • What is meant by quantity (in addition to volume and strength)?
  • EP 3 states that date and time are not necessary to be specified for “short procedures.” What is a short procedure?
  • Likewise, what difference would it make whether the procedure is short if the solution is discarded after the procedure?
  • Why date a preparation if it is discarded at the conclusion of the procedure, even a long procedure?

The proposed goal for medication reconciliation follows a more natural process and, therefore, makes compliance more realistic, said Eddy. At the time of publication, the goal had just gone through a field review and The Joint Commission was presenting the proposed goal to its Standards and Survey Procedures Committee. The proposed goal pares down four goals with 13 EPs to one goal with five EPs. Notably missing is the requirement to provide a patient’s medication information to the patient’s physician or next provider of care.

The accreditor is expected to announce the final version in the coming months, with possible inclusion in the 2011 standards. The Joint Commission said it has moved the location of the goal from its original location at Goal 8 to Goal 3, with the rest of the medication safety language.

In 2010, The Joint Commission also greatly reduced the requirements included in the UP. However, it applies to all invasive procedures now, not just “risky” procedures, said Eddy, although that does not include angiocatheter, intravenous IV, Foley catheter, NG tube, ECT, and lithotripsy. Technically, anything that is inserted requires the UP.

Overall, the UP is much simpler, said Eddy. UP.01.01.01, concerning pre-procedure verification, does not require an immediate pre-transfer checklist. Hospitals still must use a standardized list throughout the pre-procedure process, but it does not have to be a separate document in the patient file. 

“It’s difficult to know what ‘standardized throughout the hospital’ is because what happens in the ICU is not what happens in the OR,” said Eddy. She recommended posting the standardized list in the various settings.

UP.01.02.01, concerning site marking, requires among other things that the site marking be performed by either the person performing the procedure or a resident or advanced practice nurse involved with the procedure. It cannot be the preop nurse who does the site marking, said Eddy. 

Additionally, the site must be an unambiguous mark used throughout the hospital, although it no longer has to be the initials of the person performing the procedure. The use of stickers is not mentioned in the standard, and Eddy expected an FAQ about their use.

UP.01.03.01 says the timeout must take place immediately before the procedure. 

“The characteristics are only this: standardized, initiated by a designated team member, meaning the circulator is always going to call it, or the surgeon is always going to call it, and it involves all of the group participating from the beginning,” said Eddy.

The rules for performing a second timeout, part of EP 3, became simpler this year as now it is only necessary when a second procedure is being performed and the person who is performing the procedure changes. Previously, a second timeout had to be performed with any second procedure.

 EP 4 requirements were also simplified, with team members only needing to agree on patient identity, the correct site, and the correct procedure. Previously, the EP required confirmation of any necessary antibiotics, documentation, position, and other aspects of the procedure.

Last, EP 5 requires documentation of the timeout, but the amount and type of documentation is now allowed to be determined by the hospital, said Eddy.