National Patient Safety Goals Depend on Good Communication

Patient Safety Awareness Week, sponsored by the Institute for Healthcare Improvement, is the perfect time to review the Joint Commission’s National Patient Safety Goals. Each year, the Joint Commission issues a list of top national patient safety goals for healthcare settings, including hospitals, nursing care centers, behavioral health care and human services, ambulatory healthcare, home care, and more.

For 2023, its list of patient safety goals for hospitals includes the following:

1. Identify patients correctly.
2. Improve staff communication.
3. Use medicines safely.
4. Use alarms safely.
5. Prevent infection.
6. Identify patient suicide risks.
7. Prevent mistakes in surgery.

The Joint Commission is an independent, not-for-profit organization that advocates for patient safety issues across the United States. It evaluates and accredits over 22,000 domestic health care organizations and programs.

What do the national patient safety goals have in common?

The national patient safety goals listed by the Joint Commission include some of the biggest preventable risks to patient safety across healthcare systems. Perhaps not surprisingly, they share a common element — they all depend on good communication practices at the organizational, team, and individual levels.

1. Identify patients correctly

The Joint Commission calls for healthcare organizations to always use at least two ways to identify patients — typically the patient’s name and date of birth. While this practice is second nature for most healthcare professionals, errors still happen. It’s important to keep working to reduce any variation in care that might occur.

Whether communicating with care team members or directly with patients, using two ways to confirm a patient’s identity must be embedded in your process. When challenging scenarios occur, be vigilant for potential errors. Patient identification mistakes can easily happen when a patient is seriously ill, unconscious, very young, or given an incorrect ID band. These examples all appeared in a recent study by providers at UC Davis Health.

2. Improve staff communication

The Joint Commission’s second patient safety goal is all about communication. The guidance encourages teams to communicate better with each other when delivering results — specifically, to “get important test results to the right staff person on time.”

Results from tests and diagnostic procedures could potentially have a major impact on a patient’s health outcome if not delivered expediently. Achieving this goal depends not just on individual efforts but your entire communication delivery system. Your organization should have procedures for managing test results that specify acceptable delivery windows for reporting — by whom, to whom, and how and when it should occur.

3. Use medicines safely

The Joint Commission’s third goal has three sub-goals involving the safe use of medications:

• Label un-labeled medicines where medicines and supplies are kept.
• Take extra care with blood thinners.
• Record and pass along correct patient medication information, taking time to find out the patient’s medications, compare their new and prior medications, give the patient written instructions, and tell the patient to always bring their updated medication list to doctor visits.

In another study from UC Davis Health, the authors examined risk factors for medication errors. They examined a case in which a 93-year-old patient received a dose of blood thinner five times greater than the prescribed amount for several day due to confusion by a caregiver about the dosage amounts. When patients are over age 65, take multiple medications, are receiving emergency care, or have risk factors such as complex dosing instructions, the likelihood of errors increases significantly.

As with previous goals, communication is the primary component, both verbal and written.  Communicating clearly about medication requirements during transitions of care — either from one hospital setting to another or during a hospital discharge — helps prevent errors. During these times, it is critical to provide complete medication information and clear instructions to patients or caregivers, paying attention to any cultural differences, allocating sufficient time, following standard procedures, and performing “medication reconciliation” (double-checking the patient’s complete medication list).

4. Use alarms safely

The Joint Commission’s fourth goal specifies that alarms on medical equipment must be heard and responded to on time. Alarms serve a key communication purpose. They convey critical information from monitoring devices about potentially harmful situations that a person might not be able to observe.

However, when alarms malfunction, are not heard, or fail to work as intended, care teams and patients may not receive the intended signals. Leaders must establish alarm system safety as a priority, determine the most important alarms, eliminate unnecessary alarms, and educate all staff on the purpose and proper operation of these systems.

5. Prevent infection

The fifth patient safety goal reinforces hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Millions of people acquire infections when receiving health care. Health care-associated infections (HAIs) are a serious mortality risk for many patient populations. The Joint Commission recommends that healthcare organizations assess their compliance with CDC and/or WHO guidelines, establish a safety program that includes a hand hygiene policy, foster a culture of hand hygiene, monitor compliance, and provide feedback.

The CDC’s guidance on hand hygiene pertains to both healthcare providers and patients. Everyone who enters a healthcare setting should protect themselves and those they encounter by following hand hygiene guidelines. Communication plays a major role in supporting hand cleaning practices. The CDC created a “Clean Hands Count Campaign” with promotional materials that healthcare organizations can use to communicate about good hand hygiene within their facilities.

6. Identify patient suicide risks

The Joint Commission’s sixth goal pertains to reducing the risk of suicide. The tragic frequency of suicides in staffed round-the-clock care settings shows the continued need for better identification of at-risk individuals.

The guidance for this goal lists several ways to mitigate suicide risk for patients, including conducting an environmental risk assessment, monitoring at-risk patients, and using safe transportation procedures when moving patients. Also recommended:

• Screen patients being treated for behavioral health conditions using a validated screening tool.
• Document risk levels and create mitigation plans for each patient.
• Provide training and regular assessment of staff caring for at-risk patients, monitoring patients, or providing counseling and follow-up.
• Evaluate policies regularly to implement improvements.

Communication is an important component of the tactics that the CDC lists to help prevent suicide. The CDC recommends promoting healthy connections, teaching coping and problem-solving, identifying and supporting at-risk individuals, and helping to prevent future risk. Reaching out, engaging, supporting, responding, intervening, and reporting all involve communicating with a population that may have difficulty expressing their need for care. Proactive communication by providers in these cases can save lives.

7. Prevent mistakes in surgery

The Joint Commission’s seventh and final goal is to prevent surgical mistakes. Making sure the correct surgery occurs on the correct patient in the correct place on the body requires not only mindful work but also good communication. Staff must be ready to speak up, confirm information, and ask questions when needed.

The Joint Commission recommends using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The protocol uses multiple complementary strategies to confirm the correct surgical procedure. It also reinforces good communication practices among all members of the team and when possible, the patient and family.

The protocol is most successful in “hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. A hospital should consider its culture when designing processes to meet the Universal Protocol.”

Make good communication part of your culture

All the Joint Commission’s safety goals rely on good communication. Reinforcing excellent communication practices for each of these goals will result in improvement. But creating and sustaining an organizational culture that values and emphasizes teamwork and collaboration will achieve greater success in the long term.

Consider whether your organization has a culture of learning, which emphasizes innovation and improvement as a fundamental value. Such a culture enables staff to seek out new ways to solve problems, strengthen community, and change course quickly to reach goals.

Also consider the leadership style most prevalent in your organization. Do your leaders embody the transformational leadership style? Transformational leaders help elevate patient safety by empowering staff to act independently to make improvements.

Quality care and patient safety have a direct connection to the types of workplaces that we create within our healthcare organizations. Those that foster a culture of learning and whose leaders encourage individuals to take ownership of their work develop teams that perform better. A top-performing organization will achieve greater levels of success and make fewer preventable errors.

• Download our infographic: 5 Things You Can Do This Week To Make Your Patients Safer