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NATIONAL PATIENT SAFETY GOALS (NPSGs) {DIRECT IMPACT} - page 1 / 1

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HEALTH CENTERS’ MOST CHALLENGING STANDARDS/NPSGs in 2010 Joint Commission Ambulatory Care Standards Generating FINDINGS in 20%+ CHCs Surveyed

ENVIRONMENT OF CARE

  • Security and safety risks are managed.

    • EC.02.01.01/EP #1 & #3 (identify & minimize risk)

  • Manage hazardous materials and waste.

    • EC.02.02.01/EPs #7 (energy sources), #11 (MSDS, permits), #12 (labels) {DIRECT IMPACT}

  • Fire safety equipment is maintained.

    • EC.02.03.05/EP #15 (inspect fire extinguishers monthly)

  • Collect information to monitor conditions in the environment.

  • EC.04.01.01/EP#15 (Evaluate each environment of care plan annually) {DIRECT IMPACT}

Medical equipment is maintained, tested, and inspected.

{DIRECT IMPACT}

  • EC.02.04.03/EPs #3 (test & maintain medical equipment on inventory) & #4 (document

testing/maintenance of sterilizers)

HUMAN RESOURCES

  • Verify staff qualifications.

    • HR.01.02.05/EP #1 (primary source verify all staff who are licensed/certified/registered)

  • Clinical privileges are granted to licensed independent practitioners.

    • HR.02.01.03/EPs #3 (primary source verify training), #5 (licensure), #16 (query NPDB), #23 (site specific privileges)

INFECTION CONTROL

  • Identify risks for acquiring/transmitting infection. IC.01.02.01/EP#1&2 (Identify & prioritize risks based on location, community, and services provided)

  • Reduce the risk of infections associated with medical equipment, devices, supplies.

    • IC.02.02.01/EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}

MEDICATION MANAGEMENT

  • Safely manage high-alert and hazardous medications.

    • MM.01.01.03/EPs#1&2 (identify in writing and have process to manage)

  • Address safe use of look-alike/sound-alike medications.

    • MM.01.02.01/EPs #1 & #2 (develop list & take action to prevent interchange)

  • Medications are stored safely.

    • MM.03.01.01/EPs #2 (store meds per mfgrs' recs), #6 (prevent unauthorized people from obtaining),#7 (label with exp date),#8 (remove expired/contaminated meds & store separately)

NATIONAL PATIENT SAFETY GOALS (NPSGs) {DIRECT IMPACT}

  • Use at least 2 patient identifiers when providing care, treatment, or services.

  • NPSG.01.01.01/EP#1 (2 pt identifiers) &#2 (label specimen containers in patient’s presence)

UNIVERSAL PROTOCOL A timeout is performed before the procedure.

  • UP.01.03.01 (conduct & document time-out before starting procedure)

{DIRECT IMPACT}

PROVISION OF CARE

  • When warranted by the patient’s condition, either conduct or refer patient for a comprehensive pain assessment. [PC:01.02.07/EP# ] {DIRECT IMPACT} WAIVED TESTING

  • Staff/LIPs performing waived testing are competent.

    • WT.03.01.01/EP#5 (at least 2 of 4 assessment methods used/person/test/yr) {DIRECT IMPACT}

  • Perform quality control checks for waived testing on each procedure.

    • WT.04.01.01/EPs#2 (expired reagent); #4 (check daily); #5 (2 control levels)

  • Maintain records for waived testing.

    • WT.05.01.01/EP#3 (quantitative test results have reference intervals in record)

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