Why Do We Have National Patient Safety Goals?

In the Hippocratic Oath, doctors swear to do no harm. But a 2016 study by Johns Hopkins University estimated that more than a quarter-million people died in the US every year as a result of medical error, making it the third leading cause of death in the country, and coming with a cost of $20 billion per year.

In 2018, a study by the Yale School of Medicine investigated further and found that only an estimated 7,150 medical error deaths occurred in otherwise healthy patients. But that’s still far outside the margin of statistical insignificance, and even non-healthy patients are still dying as a result of medical error. Something is clearly wrong.

Death due to medical error can be attributed to inadequately skilled staff, an error in judgment, a system defect, or a preventable adverse event. In a field as complex as medicine, the chance for error can lie practically anywhere: in a hardware breakdown, in a medication mixup, or in a missed test result. Greater safeguards for patients require systemic solutions, like those found in the Joint Commission’s list of National Patient Safety Goals.

The Joint Commission confers with recognized experts and stakeholders in researching their annual patient safety goals. While they’re tailored to particular aspects of healthcare—ambulatory, behavioral health, critical access hospital, home care, hospital, laboratory, nursing care center, and office-based surgery—there’s plenty of overlap between them. These goals are beacons for healthcare administrators looking to tailor their policies towards improved patient safety. But they’re also one of the ways the Joint Commission measures the efficacy, safety, and accountability of accredited healthcare facilities.

To get a brief overview of the National Patient Safety Goals, and why we have them, check out our guide below. But do note that, over time, many goals become national standards of care. When that happens, they are removed from the list of safety goals, and the “number” associated with that particular goal is retired.

Therefore, you will find numbers next to each of the patient safety goals listed below, but you’ll also see some numbers missing. That’s a good thing. The idea is, over time, to have all those numbered goals migrate into standards.

In 2007, the World Health Organization found patient misidentification to result in medication errors, transfusion errors, testing errors, and even the discharge of infants to the wrong families. In 2020, the Agency for Healthcare Research and Quality (AHRQ) published a case study on patient misidentification, finding that it still presents serious challenges to patient safety.

To address this issue, patient safety goals require the use of at least two patient identifiers when providing care, such as patient name and patient date of birth. Furthermore, when working with blood transfusions, a two-person verification step is required (or a one-person verification process accompanied by an automated identification technology, such as barcoding).

Accurate communication among care providers is critical to patient safety. A 2020 study in the Journal of Patient Experience found that communication, or miscommunication, was a common theme found in the majority of medical error cases and close-call situations. Miscommunication can be particularly harmful when it comes in the form of delayed or incorrect test results. This patient safety goal focuses on the reporting of critical test results and diagnostic procedures on a timely basis.

A life-saving medication to one patient can be poison to another, and preventable medication errors have emerged as a prominent cost and quality issue in the US medical system.

To address this, the National Patient Safety Goals prescribe two main steps. First, label all medications, medical containers, and other solutions both on and off the sterile field (this includes syringes, medicine cups, and basins). Second, maintain and communicate accurate patient medicine information by telling the patient clearly about what medications are being prescribed, as well as maintaining an up-to-date list about what other medications the patient might be taking.

Clinical alarm systems present two modes of possible medical error: they go off too often, or they don’t go off enough. A 2021 study from the University of Texas Health Science Center at San Antonio School of Nursing found major inefficiencies and inefficacies in provider-monitor relationships. A 2018 metastudy found similar results across a wide range of settings.

To address these issues, the National Patient Safety Goals have identified reducing the harm associated with clinical alarm systems as a top priority.

Healthcare-associated infections (HAIs) are infections that patients get while receiving care for another condition. The Office of Disease Prevention and Health Promotion estimates that at any given time, one in 25 inpatients have an infection related to their hospital care. The risk factor is raised by the use of catheters, surgery, injections, improper antibiotic use, and improperly disinfected medical sites.

To combat this, the National Patient Safety Goals instruct care providers to comply with guidelines issued by either the Center for Disease Control (CDC) or the World Health Organization (WHO). They further recommend implementing evidence-based practices to prevent HAIs associated with multidrug-resistant organisms, central line-associated bloodstream infections, surgical site infections, and catheter-associated urinary tract infections.

According to AHRQ, up to a million people a year fall while in the hospital, but research shows that up to a third of those falls can be prevented. Small changes such as lowering hospital beds, locking bed wheels, improving lighting, and using non-skid handrails can help reduce the occurrence of such falls. Simple adjustments to policy, such as instituting a fall-prevention kit, can save the increased cost and increased length of a patient’s stay that may result from an in-hospital fall.

They go by a few names: healthcare-associated pressure ulcers, decubitus ulcers, hospital-acquired pressure infections (HAPIs), and bed sores. According to a 2020 study, HAPIs affect up to three million Americans every year.

But it’s not all bad news: a 2021 study found that despite the increase in hospitalizations due to Covid-19, there wasn’t a significant increase in HAPIs, suggesting that healthcare institutions were able to respond quickly to the changing conditions.

The National Patient Safety goals aspire to reduce HAPIs by having care providers assess and periodically reassess each resident patient’s risk for developing a pressure ulcer, as well taking any further action necessary to address any identified risks.

The National Patient Safety Goals point out two critical safety risks for patients and residents: inpatient suicide risk, and risk associated with home oxygen therapy.

Inpatient suicide is a rare but preventable event, especially in psychiatric units: more thorough and holistic screening procedures, combined with care staff understanding the major risk factors, can lower its occurrence.

For home oxygen therapy, there’s an increased risk of an adverse event, such as a fire. A 2020 report found that 311 home oxygen fire incidents over a 20-month period resulted in 164 deaths and 71 serious injuries. Smoking is by far the leading cause of these fires.

To mitigate this, the National Patient Safety Goals recommend a comprehensive risk assessment that investigates home oxygen users and their history of smoking, their living status (alone or with a partner), and any cognitive impairments they may have.

Finally, the Joint Commission outlines the prevention of mistakes in surgery as a universal protocol in its National Patient Safety Goals. In particular, it seeks to avoid what it calls Wrong Site, Wrong Procedure, Wrong Person Surgery. This type of surgery is rare, occurring approximately once in every 112,000 operations. But it’s a unique combination of one of the most egregious medical errors and one of the most preventable.

To combat it, the Joint Commission expects care providers to conduct a pre-procedure verification process, mark the procedure site, and perform a timeout before the procedure. While it may seem like common sense, that’s exactly the point of the universal protocol, as it is with all the National Patient Safety Goals: to put common sense into policy and reduce the chance of a preventable error.

Matt Zbrog

Writer

Matt Zbrog is a writer and freelancer who has been living abroad since 2016. His nonfiction has been published by Euromaidan Press, Cirrus Gallery, and Our Thursday. Both his writing and his experience abroad are shaped by seeking out alternative lifestyles and counterculture movements, especially in developing nations. You can follow his travels through Eastern Europe and Central Asia on Instagram at @weirdviewmirror. He’s recently finished his second novel, and is in no hurry to publish it.