Most of the 2007 National Patient Safety Goals (NPSG) approved by The Joint Commission are general in nature and are not specific to wound care. Since its inception, the NPSG program has promulgated 15 goals. Some goals carry over from year to year, but The Joint Commission removes or "retires" goals from the list once they are formally incorporated in specific accreditation standards.
Their purpose is to reduce or eliminate human and system-based errors in the practice of health care. Systems-based errors or the potential for them can be thought of as stress points, or potential areas where problems can, and do, occur in complex patient care interactions and systems. Although medical and surgical interventions that fall within the accepted standards of practice are aimed at treatment or palliation, the potential for complication or for a human or system error still exists. Errors are most likely to occur when administering a given treatment modality; thus the patient's safety may be put at risk. In The Joint Commission's stated patient safety goals, if any of the 15 stated goals or areas along the continuum of care are overlooked, it could potentially lead to increasing the patient's risk for "near miss" or a "sentinel event." A sentinel event essentially means that the patient is placed in a situation that could potentially bring harm to their well being, or a threat to life and limb.
The NPSGs list 15 Joint Commission patient safety goals. And although these do not specifically relate to the practice of Wound Care, I have taken the liberty to list some specific goals and considerations that do relate to the practice of acute and chronic wound care.
* Goal 1: This is related to the accuracy of patient information. Proper patient identification is a critical element in laboratory, pharmacy, and surgical procedures. This includes verifying the patient's identity and the specific anatomical site for a given procedure. Meeting or exceeding this goal ensures that the right surgical procedure is performed at the right site and on the right patient. In other words, adherence to this goal eliminates the chances of wrong limb or wrong site of surgery.
* Goal 2: This goal simply emphasizes effective communication. It is the verification of critical verbal orders, the receipt of laboratory results, and the appropriate timely dissemination of critical patient laboratory data. This goal has the principle aim to ensure that entries in the electronic or written medical record are clearly legible to avoid misinterpretation. Essential elements of effective communication include timeliness of critical information and the establishment of a chain of dissemination of critical information from one caregiver to the other. When transmitting or relaying patient information, the data transmission must be impeccable, and the system must follow a zero tolerance for miscommunications to ensure the patient's safety. For example, when a wound is debrided, the dressing is changed, the patient's nutritional parameters trend downward, or a white count is elevated. The communication chain must proceed and all parties, including the patient, must be informed with appropriate documentation.
* Goal 3. The safety of administering medications and ensuring the precise labeling of drug doses, concentrations, and formulations is addressed by this goal. A poignant example to consider here is the potential to have a basin of clear fluid (normal saline) at the bedside while irrigating a wound. Although the practitioners intention is to cleanse the wound with normal saline (a colorless, clear, odorless liquid), a tragedy could happen. In some cases, the intended substance was inadvertently replaced or the operator failed to check or verify the labels. These are examples of human and system errors. The human eye cannot discern the difference between lidocaine with epinephrine and normal saline in an irrigation basin. In fact, this confusion has happened. The bottom-line with this initiative is to check any given drug or solution 3 times, preferably with another person to ensure the patient does not receive the wrong dose or concentration. In addition, any vessel used to store an irrigation solution must be labeled.
* Goal Number 7. This is designed to reduce the risk of health care related infections. The low-effort, high-impact behavior for wound practitioners is to comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines-simply put, hand washing before and after each patient encounter. This goal requires that health care providers manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. This particular goal is especially applicable to wound care.
* Goal number 13. This has the most applicability to wound care but is the most vague and terse; it basically states that we must prevent health care-associated pressure ulcers (decubitus ulcers). It requires the health care giver to assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks. This goal is obviously very important to us and to our patients. Moreover, given the complexity inherent to accomplishing this goal I feel the statement from the NPSGs requires more thought, content, and input from wound care practitioners.
The Anatomy and Physiology of the Goals
The development and updating of the NPSGs is overseen by a panel of widely recognized patient safety experts, including nurses, physicians, pharmacists, risk managers, and other professionals who have experience in addressing patient safety issues in a wide variety of health care settings. Annually, the Sentinel Event Advisory Group (SEAG) and The Joint Commission conduct a systematic review of the literature and available databases to identify potential new goals and requirements. Following a solicitation of input from the field (you and your organization), the SEAG determines the highest priority goals, which are recommended to The Joint Commission. To maintain the focus of accredited organizations on the most critical patient safety issues, the SEAG may, as part of its annual review, recommend the retirement of selected requirements from the NPSGs. In such cases, they will usually continue as accreditation requirements under the relevant standards.
The Joint Commission established the NPSGs to help accredited organizations address specific areas of concern in regards to patient safety. The SEAG is charged with conducting a thorough review of all Sentinel Event Alert recommendations and other sources of patient safety recommendations, and identifying those that are candidates for the annual NPSGs.
How Do We Become Involved?
Submitting alternative approaches is one way to get involved. Organizations that wish to submit alternative approaches to the NPSG requirements can complete and submit a "Request for Review of an Alternative Approach to a NPSG Requirement" form http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_). Members of the SEAG will review each form and advise The Joint Commission on the acceptability of the alternative. If not accepted, the organization will be provided with the rationale and will need to revise the alternative until it is approved, or to implement the requirement as issued by The Joint Commission. Surveyors will accept organizations' use of approved alternatives and will evaluate the implementation of those alternatives and other relevant requirements associated with the NPSGs.
For more information, contact the Standards Interpretation Group at (630) 792-5900, or complete the Standards Online Question Submission Form (http://www.jointcommission.org/Standards/OnlineQuestionForm/).
Creative Initiatives
One group in New Jersey has made significant strides in its efforts to help prevent and reduce the incidence of pressure ulcers in its care facilities. In July 2007, the New Jersey Hospital Association's (NJHA) Pressure Ulcer Collaborative reported a 70% reduction in the incidence of pressure ulcers after nearly 2 years of applying shared best practices and preventive techniques. The NJHA Collaborative, which is comprised of 150 acute care and specialty hospitals, nursing homes, and home care agencies, first met in 2005 to develop and share standardized assessment and preventive strategies. Their efforts reflect the objective of patient safety goals.
At the Hospital of the University of Pennsylvania in Philadelphia, PA, an initiative is under way to improve both patient and staff safety. Units that are fully equipped with ceiling mounted lifts in the patient rooms are being monitored for nosocomial pressure ulcer rates, as well as fall rates. The goals of the lifts are to: prevent injury to nursing staff, decreasing nursing lost time in days, decrease financial impact of lost time, improve patient outcomes, improve staff satisfaction, and recruit and retain bedside nurses. As a collateral benefit of this multifaceted safety initiative, preliminary data is trending toward a significant reduction in the incidence of pressure ulcers in the first quarter of 2008.
Conclusions
Following the recommended NPSGs set forth by The Joint Commission is one strategy that will help wound care practitioners in their mission to provide the best care possible, while ensuring each patient's safety. In addition, I propose we all need to continue to look for new ways to improve patient safety practices and enhance our wound care efforts. Within each of our facilities, we can further improve upon the national and organizational standards already in practice.
Richard "Sal" Salcido, MD
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