1. Murray, Kathleen DNP, ARNP, NE-BC

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Brushing up on patient safety systems

Q Our hospital is in the window for a visit from The Joint Commission within the next 6 months. Can you highlight the key components of its new 2015 chapter on patient safety systems?

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The Joint Commission journey of patient safety has evolved over time, beginning with Dr. Ernest Codman who has been acknowledged as the founder of patient outcomes and treatment in 1910. Dr. Codman also helped lead the founding of the American College of Surgeons and its hospital standardization program, which eventually became The Joint Commission. Other key patient safety organization milestones include the establishment of the Institute of Medicine in 1970, the Agency for Healthcare Research and Quality in 1989, and the Institute for Healthcare Improvement in 1991.


In 2002, The Joint Commission's focus on the development of national patient safety standards led to the establishment of its National Patient Safety Goals (NPSGs) program, which became effective in 2003. The NPSGs were developed by a patient safety advisory group, which consisted of an interdisciplinary team with in-depth experience and knowledge of patient safety. The first NPSGs included: 1) improve the accuracy of patient identification; 2) improve the effectiveness of communication among caregivers; 3) improve high-alert medication safety; 4) eliminate wrong site, wrong patient, and wrong procedure surgery; 5) improve infusion pump safety; and 6) improve the effectiveness of clinical alarm systems. In 2015, the NPSGs based on patient outcomes data evolved into the following: 1) identify patients correctly, 2) improve staff communication, 3) use medicines correctly, 4) use alarms safely, 5) prevent infections, 6) identify patient safety risks, and 7) prevent mistakes in surgery.


The 2015 patient safety systems chapter provides "guidance for healthcare organizations with a proactive approach to designing or redesigning a patient-centered system that aims to improve quality of care and patient safety."1 The chapter doesn't include new accrediting requirements for The Joint Commission, but it does highlight how existing standard requirements (22 standards) can be applied to positively impact patient safety processes. The leadership standards 03.01.01 (leaders create and maintain a culture of safety and quality throughout the hospital) and 04.04.05 (the hospital has an organization-wide, integrated patient safety program within its performance improvement activities) have a combined total of 24 performance elements ranging from regular evaluation of the culture of safety, processes for managing behaviors that undermine a culture of safety, and education that focuses on safety and quality to leaders implementing a hospital-wide patient safety program.


In addition, the patient safety systems chapter highlights the following:


* fair and just safety culture. The organization has a trusting environment in which staff can report a safety event without fear of retribution. The safety culture does incorporate individual accountability; for example, if there was deviation from established protocols.


* data use and reporting systems. The organization has an infrastructure that supports a transparent and just-in-time reporting process, and collects, analyzes, and utilizes data effectively to drive results. Today, many hospitals have access to a plethora of data but the key is to identify data that align with patient safety strategic priorities; for example, patient falls with injury, medication errors, and adverse drug reactions.


* proactive approach to preventing harm. The organization completes proactive risk assessments to evaluate processes with the potential for failure and understand how the outcomes of the identified failure could cause patient harm. This section also highlights strategies and tools for conducting an effective risk assessment.


* encouraging patient activation. The organization encourages patients and families to actively participate in decisions regarding their healthcare with a focus on patient safety.



This new patient safety systems chapter clearly spotlights the key role of hospital leadership in transitioning the organization to a sustainable infrastructure focused on patient safety through a trusting and transparent patient safety event reporting environment, which results in improvement and a high-reliability organization.




1. The Joint Commission. Patient safety systems chapter for the hospital program. [Context Link]