• Section 6. National Patient Safety Goals

    National Patient Safety Goals

    The Joint Commission’s National Patient Safety Goals were developed to promote specific improvements in patient safety. The goals highlight problematic areas in healthcare and describe evidence and expert-based consensus to solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality healthcare, the goals generally focus on system-wide solutions.21

    No adverse event should ever occur anywhere in the world if the knowledge exists to prevent it from happening. However, such knowledge is of little use if it is not put into practice. Translating knowledge into practical solutions is the ultimate foundation of the safety solutions.

    The basic purpose of the solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients.  An individual solution will present the problem, the strength of evidence supporting the solution, potential barriers to adoption, risks’ of unintended consequences created by the solution, patient and family roles in the solution, and references and other resources.

    Patient Safety Solutions are defined as: "Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of healthcare." 

    Four Leaps in Hospital Quality, Safety, and Affordability

    Through the annual Leapfrog Hospital Survey, Leapfrog rates hospitals across the country on a range of safety and quality standards. 

    Endorsed by the National Quality Forum (NQF), the four original “leaps” are:22

    Computerized Physician Order Entry (CPOE). With CPOE systems, hospital staff enter medication orders via computers linked to software designed to prevent prescribing errors. CPOE has been shown to reduce serious prescribing errors by more than 50%.

    Evidence-Based Hospital Referral (EBHR). Consumers and healthcare purchasers should choose hospitals with the best track records. By referring patients needing certain complex medical procedures to hospitals offering the best survival odds based on scientifically valid criteria—such as the number of times a hospital performs a procedure each year or other process or outcomes data—studies indicate that a patient’s risk of dying could be significantly reduced. 

    ICU Physician Staffing (IPS). Staffing ICUs with intensivists – doctors who have special training in critical care medicine – has been shown to reduce the risk of patients dying in the ICU by 40%.

    NQF Safe Practices. The National Quality Forum-endorsed Safe Practices cover a range of practices that, if utilized, would reduce the risk of harm in certain processes, systems, or environments of care.

    Electronic Health Records

    When the Health Information Technology for Economic and Digital Health (HITECH) Act was passed in 2009 as part of the American Recovery and Reinvestment Act, hopes were high that widespread use of electronic health records (EHRs) would reduce the rate of adverse drug events in hospitals.  Advocates believed incentives that encouraged hospitals and physicians to adopt EHRs would not only encourage faster adoption, but help to improve patient health.

    Hospital Acquired Conditions Reduction Program

    There are financial penalties if hospitals do not reduce the rate of “hospital-acquired conditions.” The Hospital Acquired Conditions Reduction Program, which is mandated under the Affordable Care Act, is a means to reduce patient injuries and hold hospitals accountable for the quality of care they deliver.

    The health law mandates payment reductions for the quarter of hospitals that Medicare assessed as having the highest rates of “hospital-acquired conditions”, including bloodstream infections from catheters, blood clots, bed sores and other complications that are considered avoidable.


    Case Example: Florida Hospitals Reduce Medicare Payments

    These are examples of facilities fined for making medical errors that endangered the patients health.

    Seven South Florida hospitals will have their Medicare payments reduced by one percent next year due to high rates of potentially avoidable infections and other injuries to patients, federal health officials reported this week.

    Among the seven hospitals from Monroe to Palm Beach counties to have their payments reduced, two are being penalized for a second consecutive year: Jackson Health System in Miami-Dade, and Broward Health Coral Springs. Both are tax-payer supported hospital systems.

    Section 5. Sentinel Events and Patient SafetySection 7. Building a Safety Culture