Patient Safety

NPSG: Identify Client Safety Risks: Reduce the Risk of Suicide

  • Statistics on Suicide

    • Tenth leading cause of death in the U.S. (Heron, 2019; Roeten et al., 2018).

    • Second leading cause of death for ages 10-34 (Suicide Prevention Resource Center [SPRC], 2020).

  • Definition: Suicide defined as death from self-injurious behaviors intended to end one's life (SPRC, 2019).

  • Screening Requirements:

    • All clients (12 years and older) screened for suicidal ideation using validated tools.

    • Detailed assessment for those screening positive, exploring thoughts, plans, and self-injury behaviors (Harmer et al., 2021; Roeten et al., 2018; TJC, 2020b).

  • Safety Measures for At-Risk Clients:

    • Clients identified at risk for suicide placed under continuous surveillance in nonpsychiatric settings.

    • Remove potentially harmful items from the client’s environment using an environmental checklist.

    • Manage items brought into the room and control visitation.

  • Staff Competency:

    • Staff training and competency assessment necessary for proper monitoring and care for at-risk clients.

    • Guidelines for reassessment and written policies required for both inpatient and outpatient therapy (TJC, 2020b).

NPSG: Universal Protocol: Prevention of Adverse Events in Surgery

  • Definition of Adverse Events:

    • Situations that cause unexpected harm to patients (TJC, 2019b).

  • Preoperative Time-Out:

    • A mandated pause before surgery for confirming client, site, and procedure (TJC, 2020b).

  • Safety Protocols:

    1. Use two identifiers to confirm client identity.

    2. Mark the surgical site when applicable.

    3. Perform a time-out (TJC, 2020b).

    • Client identifiers typically include name and date of birth.

    • Clients encouraged to verbally confirm their identity and surgical procedure.

  • Site Marking Procedures:

    • Surgeons must mark correct site for procedures with multiple potential locations.

    • Exclusions apply for bilateral organs or delicate areas; waivers required (National Patient Safety Goals® Effective January 2021 for the Office-Based Surgery Program Goal 1, n.d.; TJC, 2020b).

NPSG: Improve Health Care Equity

  • New Goal for 2024:

    • Focus on reducing disparities in healthcare and social injustice to enhance patient safety.

  • Assessment of Patient Needs:

    • Organizational leaders must identify factors affecting equity; assess social needs (e.g., literacy, housing, transportation, food access) during patient admission.

    • Continuous needs assessment throughout hospitalization including discharge planning enables improved equity (AJN, 2023, Stackpath, n.d.; The Joint Commission, 2024).

  • Standards of Compliance:

    • Facilities must meet and maintain TJC’s standards for compliance to retain accreditation (Mennella & Walsh, 2019a).

    • Over 250 standards, including medical error prevention, infection control, and emergency preparedness considered foundational (Mennella & Walsh, 2019a).

NPSG: Use Alarms Safely

  • Purpose of Clinical Alarm Systems:

    • Audible alerts in medical equipment to warn of serious events or malfunctions.

  • Challenges:

    • Frequent false alarms lead to alarm fatigue, impacting response time to actual emergencies.

    • High noise levels in areas like ICUs complicate care delivery due to desensitization to alarms.

  • Policy Development:

    • Collaborative approach required for creating policies around clinical alarms among nursing staff, leadership, and manufacturers.

    • Nurses should participate in discussing which alarms require immediate attention to ensure client safety.

NPSG: Prevent Hospital-Acquired Infections

  • Definition of HAIs:

    • Infections acquired during hospital stay affecting patients due to different clinical conditions (CDC). Over 500,000 cases reported annually.

  • Types of HAIs:

    1. Central line-associated bloodstream infections (CLABSI)

    2. Catheter-associated urinary tract infections (CAUTI)

    3. Surgical-site infections (SSI)

    4. Ventilator-associated pneumonia (VAP)

  • Focus on MDROs:

    • Multi-drug resistant organisms pose significant risk due to their resistance to standard treatments.

    • TJC mandates hospitals monitor and develop strategies to reduce HAIs, particularly those involving MDROs (Mennella & Walsh, 2019b).

Using Medications Safely: Labeling and Anticoagulant Management

  • Labeling Requirements:

    • All medications used in procedures must be labeled accurately; unlabeled medications must be discarded.

  • Anticoagulant Medications:

    • Critical to manage carefully due to risks of clotting issues; include routine monitoring of patients and awareness of drug interactions.

  • Medication Reconciliation:

    • A crucial process to compare home medications with hospital prescriptions to identify discrepancies; should be routinely performed during admission and discharge for safety.

NPSG: Improve Staff Communication

  • Importance of Reporting Critical Results:

    • Rapid reporting of laboratory results that are potentially life-threatening (e.g., critical sodium levels).

  • Facility Guidelines:

    • Defined elements for critical results reporting including immediate delivery and documentation of notifications to providers.

  • Communication Protocol:

    • Results should not be shared via voicemail but should be communicated directly, enhancing prompt action and complying with HIPAA.

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