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

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The Joint Commission patient safety standards

Q What are some of the changes within The Joint Commission's focus on patient safety?

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The patient safety care delivery system encompasses many areas, such as device and medication safety, the electronic health record, strict adherence to patient isolation and hand hygiene, handoff communication, and safe transitions of care, to name a few.


Patient Safety Systems chapter

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, but it does highlight how the existing 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 for leaders implementing a hospital-wide patient safety program.2


Alarm NPSG

On April 18, 2013, The Joint Commission issued a sentinel event alert highlighting the widespread problem of alarm fatigue in hospitals. This led to the implementation of a staggered approach for the alarm National Patient Safety Goal (NPSG 06.01.01) requirements. The two phases of NPSG.06.01.01 include:


* Phase I began in January 2014, during which hospitals had to establish alarms as an organizational priority and identify the most important alarms to manage based on their own internal situation/assessments.


* Phase II begins this month (January 2016), requiring hospitals to develop and implement specific components of policies and procedures that address at a minimum: 1) clinically appropriate settings; 2) when alarm signals can be disabled; 3) when alarm parameters can be changed; 4) who in the organization has the authority to adjust parameters, including turning them off; 5) monitoring and response expectations; and 6) checking individual alarm signals for accurate settings, proper operation, and detectability.3 In addition, education is required for healthcare providers about the alarm system management for which they're responsible.



Diagnostic imaging services

Initially, The Joint Commission announced new and revised diagnostic imaging standards for accredited hospitals, critical access hospitals, and ambulatory healthcare organizations to be effective July 1, 2014, with additional changes to be phased in by 2015. However, it postponed implementation of the revised diagnostic imaging requirements to July 2015. The changes-based on input from imaging experts and key stakeholders-relate to quality and safety issues that pertain specifically to diagnostic imaging services. The proposed standard changes address the following:


* minimum competency for radiology technologists, including registration and certification, by July 1, 2015


* annual performance evaluations of imaging equipment by a medical physicist


* documentation of computed tomography radiation dose in the patient's clinical record


* meeting the needs of the pediatric population through imaging protocols and considering patient size or body habitus when establishing imaging protocols


* management of safety risks in the magnetic resonance imaging environment


* collection of data for incidents in which preidentified radiation dose limits have been exceeded.4



Clearly, as a nurse leader, you'll find that your staff members relate to patient safety as doing the right thing, every time, for the right patient.




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


2. Murray K. Brushing up on patient safety systems. Nurs Manage. 2015;46(7):56. [Context Link]


3. The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. [Context Link]


4. The Joint Commission. Standards changes for organizations providing diagnostic imaging services. [Context Link]