Below is an update on National Patient Safety Goals (NPSGs) that ‘Hospitals” and “Critical Access Hospitals” (CAH) are having trouble meeting—the % indicates the % failing to meet reqt. Nursing (says Shirley D) will use this info as we design MNA CE programs. It may also be of general interest in terms of where quality problems are happening in hospitals.
Most challenging standards for first half of 2008
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The Joint Commission collects data on accredited organizations’ compliance with standards and National Patient Safety Goals (including the Universal Protocol) to identify trends and focus education on challenging requirements. The table below identifies the Joint Commission standards and NPSGs that were most frequently identified as “not compliant” from January 1, 2008 through June 20, 2008 for hospitals and critical access hospitals. Hospitals can use this information to benchmark their performance against all accredited hospitals. For more information, see the Frequently Asked Questions at http://www.jointcommission.org/Standards/FAQs. Standards and NPSGs with Highest Non-Compliance Rates
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Standard |
Summary of requirement |
Hospital |
CAH |
|
NPSG 2B |
Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. |
18 percent |
— |
|
NPSG 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 tests and critical results and values. |
41 percent |
41 percent |
|
NPSG 3D |
Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. |
18 percent |
12 percent |
|
NPSG 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. |
22 percent |
— |
|
UP 1C |
Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol. |
20 percent |
— |
|
PC.2.120 |
The critical access hospital defines (in writing) the time frame(s) for conducting the initial patient assessment(s). |
— |
10 percent |
|
PC.13.20 |
Operative or other procedures and/or the administration of moderate or deep sedation or anesthesia are planned. |
17 percent |
— |
|
MM.2.20 |
Medications are properly and safely stored. |
34 percent |
29 percent |
|
EC.4.11 |
The critical access hospital plans for managing the consequences of emergencies. |
— |
7 percent |
|
EC.5.20 |
Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®. |
46 percent |
49 percent |
|
EC.5.40 |
The hospital maintains fire-safety equipment and building features. |
28 percent |
34 percent |
|
EC.7.40 |
The critical access hospital maintains, tests, and inspects its emergency power systems. |
— |
12 percent |
|
EC.7.50 |
The critical access hospital maintains, tests, and inspects its medical gas and vacuum systems. |
— |
17 percent |
|
HR.1.20 |
Staff qualifications are consistent with his or her job responsibilities. |
20 percent |
10 percent |
|
IM.6.10 |
The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served. |
30 percent |
12 percent |
|
IM.6.50 |
Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals. |
40 percent |
12 percent |
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MS.4.110 |
The organization may grant disaster privileges to volunteers eligible to be licensed independent practitioners. |
— |
10 percent |
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