Table 12. 2009 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals

Goal 1:  Improve the accuracy of patient identification

NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment and services.

NPSG.01.02.01: Prior to the start of any surgical or invasive procedure, individuals involved in the       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.

NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.

Goal 2:  Improve the effectiveness of communication among caregivers

NPSG.02.01.01: For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.

NPSG.02.02.01: There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

NPSG.02.03.01: The organization measures, assesses and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, and critical results and values by the responsible licensed caregiver.

NPSG.02.05.01: The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.

Goal 3: Improve the safety of using medications

NPSG.03.03.01: The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used by the organization and takes action to prevent errors involving the interchange of these medications.

NPSG.03.04.01: Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Goal 7:  Reduce the risk of health care associated infections

NPSG.07.01.01: Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

NPSG.07.02.01: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a health care-associated infection.

NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections.

NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Goal 8:  Accurately and completely reconcile medications across the continuum of care

NPSG.08.01.01: A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

NPSG.08.02.01: When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the organization’s care directly to his or her home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, or the original referring provider, or a known next provider of service.

NPSG.08.03.01: When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family.

NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.  

Goal 9:  Reduce the risk of patient harm resulting from falls

NPSG.09.02.01: The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

NPSG.10.01.01: The organization develops and implements protocols for administration of the flu vaccine.

NPSG.10.02.01: The organization develops and implements protocols for administration of the pneumococcus vaccine.

NPSG.10.03.01: The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks.

Goal 11: Reduce the risk of surgical fires

NPSG.11.01.01: The organization educates staff, including licensed independent practitioners who are involved with surgical procedures and anesthesia providers, on how to control heat sources, how to manage fuels while maintaining enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.    

Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy

NPSG.13.01.01: Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

Goal 14: Prevent health care associated pressure ulcers (decubitus ulcers)

NPSG.14.01.01: Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.

Goal 15: The organization identifies safety risks inherent in its patient population

NPSG.15.01.01: The organization identifies patients at risk for suicide.

NPSG.15.02.01: The organization identifies risks associated with home oxygen therapy such as home fires.

Goal 16: Improve recognition and response to changes in a patient’s condition

NPSG.16.01.01: 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.

Adapted from Joint Commission on the Accreditation of Healthcare Organizations [129-131].