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Special Report!
2005 Joint Commission National Patient
Safety Goals: Practical Strategies and
Helpful Solutions for Meeting These Goals
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The Joint Commission’s Sentinel Event Advisory Group has recommended National Patient Safety
Goals and associated requirements for 2005. The topics and corresponding requirements, which
were approved by the Joint Commission’s Board of Commissioners at its July 2004 meeting,
appear below. The 2005 goals are program specific and apply (as indicated) to ambulatory care,
office-based surgery, assisted living, behavioral health care, critical access hospitals, diseasespecific care, home care, hospitals, laboratories, long term care, integrated delivery systems,
managed care organizations, and preferred provider organizations. The Joint Commission made
the National Patient Safety Goals program specific to increase the relevance of the goals and
requirements to the individuals served in each program.
Beginning January 1, 2005, all accredited organizations that provide care relevant to these goals
and requirements will be expected to comply with them. Compliance with all National Patient
Safety Goals and requirements that are relevant to your organization’s services will be evaluated
for continuous compliance throughout the accreditation cycle through on-site surveys, your
Periodic Performance Review (PPR),* and Evidence of Standards Compliance (ESC). Surveyors will
look for evidence of consistent implementation of the requirements. Regardless of when a survey
is conducted during the year, scoring will be based on an expectation of continued compliance
since January 1, 2005. Less than 100% compliance will result in a requirement for improvement.
* For those programs required to complete a PPR.
Organizations do not need to create any extra documentation for the Joint Commission that they
wouldn’t already create while implementing these goals and requirements. The surveyors will look
at whatever documentation an organization has that is relevant and will interview the
organization’s leaders and direct caregivers to determine whether the requirements have been
implemented and how consistently they are being performed. However, if an organization has
created policies and procedures or other documentation that stipulate how the organization is to
comply with a goal and its requirement(s), and a surveyor finds that the organization does not
comply with its policy and procedure, the appropriate recommendation will be written.
TIP It is the actual performance of the goals and their requirements, not the documentation, that
surveyors will be evaluating. Surveyors might ask how you know that you are in compliance on an
ongoing basis throughout the organization. This might involve surveillance or monitoring on your
organization’s part, although this is not required.
Alternative Approaches to the Requirements
If your organization believes it has an alternative approach that meets or exceeds the intent of a
National Patient Safety Goal or its requirement(s) and you wish to implement an alternative
approach in lieu of the published requirement, your organization must submit the alternative to
the Joint Commission for review, using the “Request for Review of an Alternative Approach to a
2005 National Patient Safety Goal Requirement” form that is available on the Joint Commission’s
Web site, at http://www.jcaho.org/accredited+organizations/ patient+safety/05+npsg/
05_npsg_rfr.htm. Your organization must explain its alternative approach and submit the form to
[email protected] for review by the Sentinel Event Advisory Group and Joint Commission staff.
Following review, the Advisory Group will inform your organization and the survey team of its
decision. If your organization’s alternative is not accepted, you will need to revise the proposed
alternative until it is approved or implement the requirement issued by the Joint Commission. The
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Joint Commission provides guidance on how to achieve effective compliance with the goals and
requirements by posting detailed answers to frequently asked questions (FAQs) at the Joint
Commission’s Web site (http://www. jcaho.org), under “National Patient Safety Goals & FAQs.”
TIP During survey, surveyors will only judge whether your organization has implemented a
requirement or an acceptable alternative, not whether an alternative is acceptable. Therefore, you
are encouraged to submit any potential alternative for review at least 60 days before your
scheduled survey to provide adequate time for the alternative to be reviewed.
If the surveyor determines during survey that your organization has not implemented all the
applicable requirements or an acceptable alternative, your organization will receive a score of 0
(for insufficient compliance) and a requirement for improvement. Your organization will have an
opportunity to submit clarification through the ESC process.
Scoring the National Patient Safety Goals
Accredited organizations that provide care relevant to the goals are required to demonstrate
successful implementation of the published requirements or acceptable alternatives to the
requirements, applicable to each goal. Each goal and its requirement(s) will be scored individually,
meaning that scoring will not take an “all or nothing” approach. When an organization does not
fully comply with a requirement, the organization will be assigned a requirement for improvement
at the goal level, in the same way that noncompliance with an element of performance (EP)
generates a requirement for improvement at a standard. All requirements for improvement can
affect the accreditation decision and follow-up requirements, as determined by established
accreditation decision rules. Failure to resolve a requirement for improvement can ultimately lead
to loss of accreditation. (Please see your program’s current accreditation manual for specific
National Patient Safety Goal scoring.) Organizations will need to take the appropriate follow-up
measures to address a requirement for improvement.
The goals and their associated requirements will appear either as requirements in the “National
Patient Safety Goals” chapter in the accreditation and certification manuals for applicable
programs or as EPs in a particular standard. An organization’s performance regarding each goal’s
requirements, whether scored in the “National Patient Safety Goals” chapter or as an EP will be
included in the National Patient Safety Goals section of the 2005 Quality Report.
Three of the requirements associated with the 2004 National Patient Safety Goals that relate to
preventing wrong-site, wrong-procedure, and wrong-person surgery have been incorporated into
the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery (TM)
for ambulatory care, critical access hospitals, hospitals, and office-based surgery. The protocol
became effective July 1, 2004, for ambulatory care, office-based surgery, and hospitals, and will
become effective January 1, 2005, for critical access hospitals. The 2004 goals with requirements
are now replaced by the Universal Protocol for these programs. More information on the Universal
Protocol is included below.
National Patient Safety Goals, Joint Commission Requirements, and Compliance Suggestions
Note: New goals and requirements are indicated in bold.
Goal 1: Improve the accuracy of patient identification.
Requirement 1A: Use at least two patient identifiers (neither to be the patient’s room number* †)
whenever administering medications or blood products,†† taking blood samples and other
specimens for clinical testing, or providing any other treatments or procedures. (Applicable to
ambulatory care, assisted living, behavioral health care, critical access hospitals, disease-specific
care, home care, hospitals, long term care, office-based surgery)
* The room number exclusion does not apply to home care.
† Replace “room number” with “physical location” for ambulatory care and office-based surgery.
†† “Blood products” does not apply to behavioral health care.
NEW! Requirement 1A: Use at least two patient identifiers (neither to be the patient’s location)
whenever collecting laboratory samples or administering medications or blood products, and use
two identifiers to label sample collection containers in the presence of the patient. Processes are
established to maintain samples’ identity throughout the pre-analytical, analytical and postanalytical processes. (Applicable to laboratories)
Joint Commission Requirements
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The intent of this goal and requirement is two-fold: (1) to reliably identify the individual as the
person for whom the care, treatment, or service is intended and (2) to match the care, treatment,
or service to that individual. Therefore, the two patient-specific identifiers must be directly
associated with the individual, and the same two identifiers must be directly associated with the
medication, blood products, or specimen tube (such as on an attached label).
This goal and its requirement do not require that two distinct methods of identification be used or
that the identifiers be physically separate; rather, this goal and its requirement specify that two
pieces of information be used to identify the patient (for example, the patient’s name and date of
birth). It would be acceptable to use a wristband that includes the patient’s name and unique
number to correctly identify the patient (the name and the unique number would be the two
pieces of information).
Compliance Suggestions
Organizations can use information such as the patient’s name, an assigned identification (ID)
number, the patient’s birth date, or bar coding that includes two or more patient-specific
identifiers (not the patient’s room number) as identifiers, but the same two identifiers do not have
to be used throughout the organization. Different identifiers may be used in different settings, as
long as their use is consistent with the intent of this requirement. However, the identifiers should
be consistent within each setting, not just whatever the individual practitioner or staff person
wishes to use.
Requirement 1B: Prior to the start of any invasive procedure, conduct a final verification process§
to confirm the correct patient, procedure, site, and availability of appropriate documents.§§ This
verification process uses active—not passive—communication techniques. (Applicable to assisted
living, disease-specific care, home care, long term care)
§ Add “such as a ‘time out’” for home care and long term care.
§§ Remove “availability of appropriate documents” for home care and long term care.
NEW! Requirement 1B: Immediately prior to the start of any invasive procedure, conduct a final
verification process to confirm the correct patient, procedure, site, and availability of appropriate
documents. This verification process uses active—not passive—communication techniques. The
patient’s identity is re-established if the practitioner leaves the patient’s location prior to initiating
the procedure. Marking the site is required unless the practitioner is in continuous attendance from
the time of the decision to do the procedure and patient consent to the initiation of the procedure
(for example, bone marrow collection, or fine needle aspiration). (Applicable to laboratories)
Joint Commission Requirements
The following three items need to be verified to meet this requirement:
1. The correct patient
2. The correct procedure
3. The correct procedure site
This verification should occur where the procedure is to be performed, immediately before the
procedure is to begin. (In most cases, the patient will already be under anesthesia or sedation.) All
staff involved in the procedure should pause—that is, take a “time out”—to verify that it is the
correct patient, the correct procedure, and the correct site.
For ambulatory care, office-based surgery, and hospital organizations, this requirement is now
addressed under the Universal Protocol, which will also become effective January 1, 2005, for
critical access hospitals. More information on the Universal Protocol is included below.
Compliance Suggestions
The verification process must be interdisciplinary. All members of the team must be involved in
the final verbal verification process. All activity in the room should cease and allow for this
participation. The procedure should be stated aloud, exactly as it appears on the informed consent
form. Remember also to monitor compliance with these procedures.
Goal 2: Improve the effectiveness of communication among caregivers.
Requirement 2A: For verbal or telephone orders or for telephonic reporting of critical test results,
verify the complete order or test result by having the person receiving the order or test result
“read-back” the complete order or test result. (Applicable to ambulatory care, assisted living,
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behavioral health care, critical access hospitals, disease-specific care, home care, hospitals,
laboratories, long term care, office-based surgery)
Joint Commission Requirements
Policy and practice should discourage the use of verbal orders as much as possible. When verbal
orders are unavoidable, an organization should first review its verbal orders policy to ensure
consistency with practice. The process should stipulate that the qualified personnel taking the
order should write down the order and then read it back verbatim to the practitioner who initiated
it. The practitioner should then verbally confirm that the order is correct. This goal and its
requirement apply to all verbal orders, not just verbal orders for medications.
The “read-back” requirement applies to medication orders as well as to all verbal or telephone
orders, including the reporting of critical test results. Critical test results are defined by the
individual health care organization and will typically include stat tests, panic value reports, and
diagnostic tests. (Diagnostic tests can include but are not limited to imaging studies,
electrocardiograms, and laboratory test results requiring urgent response.) For most
organizations, this includes all test results reported verbally or by telephone. If a subset of critical
test results is not defined by the organization, surveyors will consider all verbal or telephone
reports of diagnostic tests to be critical.
In certain situations, such as in the operating room (OR) or the emergency department (ED), this
policy may seem challenging. Your organization can comply by having the circulating nurse or
anesthesia provider write down the order and read it back to the prescriber. The prescriber can
then verbally confirm the order. For further verification, the person who is to administer the order
can say it aloud before administration and again receive verbal confirmation from the prescriber.
The Joint Commission has not established any documentation requirements for this goal. When the
Joint Commission surveys your organization’s compliance with the goal, you will be asked how you
track performance against the goal—that is, how do you know that the process is being done
consistently? Whatever your method is, which may or may not include documentation, the Joint
Commission will evaluate your performance based on your approach to tracking compliance.
Compliance Suggestions
Due to the issues surrounding verbal orders, there is a temptation to eliminate their use. However,
in most health care organizations this is not possible. In emergency situations or during surgery,
verbal orders are a necessary form of communication between nurses and physicians. When verbal
orders are unavoidable, organizations can improve order accuracy and help ensure their safety by
doing the following:
Medication order recipients should repeat the name of the drug and dosage order to the
prescriber and request or provide correct spelling, using aids such as “B as in ball” and “M
as in Mary.” All numbers should also be spelled out; for example, “16” should be stated as
“one six” to avoid confusion with the number 60.
Avoid using abbreviations. For example, “1 tab tid” should be stated as “Take/give one
tablet three times daily.”
Whenever possible, have a second person listen to the verbal telephone order to verify its
accuracy. This is especially important when the person taking the verbal order is
inexperienced with the process.
Record a verbal order directly onto an order sheet in the patient’s chart. Transcribing from
a piece of paper onto the chart introduces another opportunity for error.
Write the medication’s purpose on the order (unless the prescriber considers disclosure
inappropriate). The order should include the drug name, the dosage form, the strength or
concentration, the frequency, the route, the quantity, and the duration. Or use preprinted
order sheets that allow staff to check appropriate boxes describing the desired order.
The person who receives the order should sign, date, and note the time of the order.
Voice mail orders are not acceptable. When an order is not received directly, the nurse or
pharmacist must call the prescriber back to get the order directly, including a “read back.”
When required by organization policy or law, make sure physicians confirm, sign, and date
their verbal orders, especially within the ED. Some tips for gaining physician signatures are
to (1) use flyers posted at the nurses’ station, outlining the verbal order policy, (2) use
clerical staff to remind physicians in person that they need to sign their verbal orders, and
(3) flag verbal orders so they can be checked for the physician’s signature.
Requirement 2B: Standardize a list of abbreviations, acronyms, and symbols that are not to be
used throughout the organization. (Applicable to ambulatory care, assisted living, behavioral
health care, critical access hospitals, disease-specific care, home care, hospitals, laboratories, long
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term care, office-based surgery)
Joint Commission Requirements
An organization should do a thorough review of its list of abbreviations used in the organization,
and develop, with the involvement of physicians, a list of unacceptable abbreviations and symbols
that is shared with all prescribers. Organizations must do the following to meet this goal:
The list of prohibited abbreviations, acronyms, and symbols must be implemented for all
handwritten, patient-specific communications, not just medication orders.
These requirements apply to printed or electronic communications (except for laboratory
programs).
Effective January 1, 2005, the goal requires organizations to achieve 100% compliance with a
reasonably comprehensive list of prohibited “dangerous” abbreviations, acronyms, and symbols.
A minimum list of dangerous abbreviations, acronyms, and symbols was approved by the Joint
Commission and became effective January 1, 2004 (see Table 1). The Joint Commission is working
with other interested organizations to further refine the standardized list of abbreviations,
acronyms, and symbols to be avoided. Once finalized, this information will be conveyed to
organizations through future issues of Joint Commission Perspectives and Perspectives on Patient
Safety.
Compliance Suggestions
Consider implementing the following risk reduction strategies:
Print the list on brightly colored paper/adhesive notes/ posters/stickers/magnets and place
in medical records/ patient charts, near computers, and in patient care areas.
Provide staff with pocket-sized cards with the printed list.
Print the list in the margin or on the bottom of the physician order sheets and/or progress
notes.
Attach laminated copies of the list to the back of the
physician order divider in the patient chart.
Delete prohibited abbreviations from preprinted order sheets and other forms.
Create an educational display for use during Patient Safety Awareness Week.
Convene a regional/community meeting to develop a consistent list for physicians who
maintain privileges at two or more facilities.
Direct the pharmacy not to accept any prohibited abbreviations. Orders with dangerous
abbreviations or illegible handwriting must be corrected before dispensing.
Conduct a mock survey to test staff knowledge.
Work with your software vendor to ensure that changes are made to be consistent with the
list.
Promote a “do not use abbreviation of the month” policy.
Develop and implement a policy to ensure that medical staff refer to the list and take steps
to ensure compliance. Consider including a policy which states that if an unacceptable
abbreviation is used, the prescriber verifies the prescription order before it is filled.
Monitor staff compliance with the list and offer additional education and training, as
appropriate.
NEW! Requirement 2C: Measure, assess and, if appropriate, take action to improve the timeliness
of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test
results and values. (Applicable to ambulatory care, behavioral health care, critical access hospitals,
disease-specific care, home care, hospitals, laboratories, office-based surgery)
Joint Commission Requirements
The Joint Commission requires that critical test results and values be reported and received by the
appropriate caregivers in a timely manner. Organizations are required to measure, assess, and, if
necessary, take action to improve the timely reporting and receipt of critical test results and
values.
Compliance Suggestions
Failure to follow up on critical test results and values in a timely manner represents a significant
patient safety concern in health care organizations. It is important for all licensed caregivers to
manage test results in a reliable, efficient, and evidence-based manner. Timely reporting of critical
test results and values can have a direct impact on quality of care. Organizations should measure
and assess their performance with respect to the timeliness of reporting critical values. By using
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the performance improvement process, organizations can identify current barriers to timely
reporting and focus their efforts on the most significant issues for their unique systems.
Joint Commission List of Dangerous Abbreviations, Acronyms, or Symbols Not
to Be Used (Effective January 1, 2004)
Abbreviation
Potential Problem
Preferred Term
1. U (for unit)
Mistaken as zero, four
or cc
Write “unit”
2. IU (for International
unit)
Mistaken as IV
(intravenous) or 10
(ten)
Write “International unit”
3. Q.D.,
Mistaken for each
other
4. Q.O.D.
(Latin abbreviations for
once daily and every
other day)
The period after the Q
can be mistaken for an
“I” and the “O” can be
mistaken for “I”
5. Trailing Zero (X.0
mg),
Decimal point is missed
Write “daily” and “every
other day”
Never write a zero by
itself after a decimal
point (X mg), and always
use a zero before a
decimal point (0.X mg)
6. Lack of Leading Zero
(.x mg)
7 MS,
8. MSO4,
Confused for one
another
Write “morphine sulfate”
or “magnesium sulfate”
Can mean morphine
sulfate or magnesium
sulfate
9. MgSO4
NEW! Requirement 2D: All values defined as critical by the laboratory are reported directly to a
responsible licensed caregiver within time frames established by the laboratory (defined in
cooperation with nursing and medical staff). When the patient’s responsible licensed caregiver is
not available within the time frames, there is a mechanism to report the critical information to an
alternate responsible caregiver. (Applicable to laboratories)
Joint Commission Requirements
This requirement focuses on the timely reporting of critical values. Delays in reporting critical
laboratory results can produce subsequent delays in patient care, which can negatively impact the
patient’s outcome. Such delays are preventable when a laboratory has a well-defined reporting
system that includes contacting an alternative caregiver when the primary caregiver cannot be
reached.
Compliance Suggestions
This requirement is intended to provide laboratories with guidance on the appropriate elements of
a well-designed critical reporting system, which includes not only defining the critical values but
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also establishing policies for (1) the expected time frames for reporting, (2) who can receive the
critical values, and (3) an alternative reporting mechanism.
Goal 3: Improve the safety of using medications.
Requirement 3A: Remove concentrated electrolytes (including, but not limited to, potassium
chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. * (Applicable to
ambulatory care, critical access hospitals, disease-specific care, home care, hospitals, long term
care, office-based surgery)
Requirement 3B: Standardize and limit the number of drug concentrations available in† the
organization. (Applicable to ambulatory care, behavioral health care, critical access hospitals,
disease-specific care, home care, hospitals, long term care, office-based surgery)
NEW! Requirement 3C: Identify and, at a minimum, annually review a list of look-alike/sound-alike
drugs used in the organization, and take action to prevent errors involving the interchange of these
drugs.†† (Applicable to ambulatory care, behavioral health care, critical access hospitals, home
care, hospitals, long term care, office-based surgery)
* Replace “units” with “areas” for home care.
† Replace “available in” with “used by” for home care.
†† A minimum list will be developed by the Joint Commission and posted on the Joint Commission
Web site (http://www.jcaho.org).
Joint Commission Requirements
Drug concentrations should be limited as much as possible, and all concentrated solutions of highalert drugs should be restricted and kept under the supervision and control of the pharmacy.
These drugs must not be allowed in circulation in undiluted form outside the pharmacy.
Organizations should also annually review a list of look-alike/sound-alike drugs used in the
organization and take action to prevent errors involving the interchange of these drugs.
Compliance Suggestions
Consider the following tips to boost compliance:
When clinically necessary, it is permissible to have undiluted concentrated electrolytes
available on patient care units. Make sure to control access to them and take appropriate
precautions to avoid mistaking undiluted concentrated electrolytes for medications with
similar packages. However, organizations must submit a “Request for Review of an
Alternative Approach to a 2005 NPSG Requirement” when these clinically necessary
situations are identified.
Do not store and dispense concentrated electrolytes using automated dispensing units that
carry their own “failure modes.” Many of the same risks inherent in storing dangerous
drugs in medication closets outside the pharmacy also exist with automated dispensing
units.
When the risk of mistaking a vial of a concentrated electrolyte for something else is high,
medication should be in a ready-to-use form (that is, already diluted) or, if needed in
undiluted form, have special protections against misuse.
When multiple concentrations of a drug are clinically necessary (such as on a pediatric
unit), take special precautions to avoid dosing errors. For example, the order should specify
actual drug dose, not volume, and the dose calculation—including specific data elements,
such as the patient’s weight, dose per unit weight, and rate of administration—should be
written as part of the order. This provides sufficient information for the pharmacist who
reviews the order and prepares the medication and the nurse who administers the
medication to recalculate the dose as a check.
Pediatric and neonatal units should not use the “Rule of 6” to calculate patient-specific drug
concentrations because (1) research shows that standardizing and limiting concentrations in
pediatrics results in fewer errors, (2) pharmacy pre- pared IVs are more accurate and many are
available premixed from the manufacturer, (3) risk of contamination during preparation and
compounding is reduced, and (4) every organization will use the same method, reducing errors
related to orientation and training of new and temporary staff.
For the remainder of 2004, Joint Commission surveyors will accept a transition plan with
demonstrated progress toward full implementation of the plan by January 1, 2005, as evidence of
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compliance with this requirement.
Be sure your staff is well informed to ensure that the correct medication is being
administered, especially because so many drug names sound alike. To reduce lookalike/sound-alike drug misunderstandings, staff should do the following (1):
Write legibly and enunciate when communicating medication information. Make the
listener repeat back the medication to make sure he or she understood correctly.
Remember that brand and generic drug names often sound and look alike.
Consider the potential for dispensing errors when adding medications to your
organization’s formulary.
Group drugs by category rather than by alphabetical order.
Place reminders in computer systems and on labels of medication containers to alert
physicians, nurses, and pharmacists of potential problems.
Include the indication for the medication in the order to help the pharmacist identify
potential errors.
Check the medication package/label against the patient’s chart before giving the
dose to the patient.
See http://www.usp.org/patientsafety/briefsarticlereports/qualityreview/qr762001-03-01b.html
for a list of look-alike/sound-alike drug names from the USP. Refer to the poster included with this
issue for more information.
Note: The Joint Commission is in the process of developing a list of look-alike/sound-alike drug
names. Please refer to upcoming issues of Perspectives on Patient Safety.
Goal 4: Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
Requirement 4A: Create and use a preoperative verification process, such as a checklist, to
confirm that appropriate documents (for example, medical records, imaging studies) are available.
(Applicable to disease-specific care)
Requirement 4B: Implement a process to mark the surgical site and involve the patient in the
marking process. (Applicable to disease-specific care)
Joint Commission Requirements
This goal and its requirements (as well as goal 1, requirement 1B) don’t apply just to operative
procedures; they apply to any invasive procedure exposing patients to more than minimal risk,
including procedures performed in settings other than the OR, such as a special procedures unit,
an endoscopy unit, an interventional radiology suite, and so forth. Certain routine minor
procedures such as venipuncture, peripheral intravenous line placement, insertion of a nasogastric
tube, or insertion of a Foley catheter are not within the scope of this goal.
Organizations are required to mark sites involving right/left distinction, multiple structures, or
multiple levels. However, organizations do not need to mark the site for other types of procedures,
including midline sternotomies, cesarean sections, and interventional procedures for which the
insertion site is not predetermined, such as cardiac catheterizations. Organizations not marking
the site in these cases will not be scored noncompliant for requirement 4B.
Note for cases that would otherwise require site marking: If the practitioner performing the
procedure remains with the patient continuously from the time the decision is made to perform the
procedure and consent is obtained from the patient until the time of the procedure itself, then site
marking is not required. However, if the person performing the procedure leaves the patient’s
presence, then the practitioner should mark the site before leaving the patient.
For more information about wrong-site, wrong-patient, and wrong-procedure surgery, see the
sections on compliance tips and site marking under the Universal Protocol. For ambulatory care,
office-based surgery, and hospitals, goal 4 is now addressed under the Universal Protocol.
Goal 5: Improve the safety of using infusion pumps.
Requirement 5A: Ensure free-flow protection on all general-use and PCA (patient controlled
analgesia*) intravenous infusion pumps used in† the organization. (Applicable to ambulatory care,
assisted living, behavioral health care, critical access hospitals, disease-specific care, home care,
hospitals, long term care, office-based surgery)
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* PCA is not applicable for behavioral heath care.
† Replace “in” with “by” for home care.
Joint Commission Requirements
Inadvertent, unrestricted flow of fluids and/or medications into a patient will frequently result in
death or serious harm. The intent of the goal is to shield the patient from potential adverse
outcomes involving general-use and PCA pumps by requiring intrinsic free-flow protection.
This goal and its requirement apply to all general-purpose and patient-controlled analgesia (PCA)
pumps, including ambulatory pumps. However, this goal and its requirement do not apply to
syringe pumps or enteral pumps.
When an infusion pump is in use, organizations need a system that will never permit fluid to run
into the patient without first going through a free-flow protection device/ mechanism.
Consequently, the device/mechanism needs to be built-in (intrinsic) to one of the two pieces of
equipment that always must be used to get the fluid from the supply reservoir into the patient:
the pump and the administration set that runs from the pump to the patient. If the free-flow
protection device/mechanism is an add-on (that is, not intrinsic to either the pump or the
administration set), it would be possible to use the pump and administration set without the addon protection, thereby creating a risk to the patient of accidental free-flow that could result in
harm or death.
Therefore, it is required that the free-flow protection be intrinsic to either the pump itself or to the
administration set that is always used with the pump. An add-on free-flow protective device that is
not intrinsic to the pump or administration set does not meet the requirement.
Compliance Suggestions
To test whether an infusion pump has free-flow protection, turn off the power but keep the
infusion set primed and loaded in the device. While all the tubing clamps are open and the fluid
container is as high above the device as the tubing allows, verify that no fluid flows out of the set.
Goal 6: Improve the effectiveness of clinical alarm systems.
Requirement 6A: Implement regular preventive maintenance and testing of alarm systems.
(Applicable to disease-specific care)
Requirement 6B: Assure that alarms are activated with appropriate settings and are sufficiently
audible with respect to distances and competing noise within the unit. (Applicable to diseasespecific care)
Joint Commission Requirements
The Sentinel Event Advisory Group considers this goal and its requirements relevant to the entire
array of alarm systems that are triggered by physiologic monitoring of the patient or by variations
in measured parameters of medical equipment directly applied to the patient. Essentially, this goal
applies to alarm systems that are patient specific and are used for the purpose of alerting staff to
a patient emergency (for example, cardiac monitor alarms, apnea alarms, elopement/abduction
alarms, infusion pump alarms). Most commonly, staff is alerted using an audible alarm, but other
signaling methods (for example, visual, pager) are acceptable, as long as they reliably alert staff
to the patient’s need for attention. For alarm systems that meet these criteria, organization policy
may specify when the alarm may be disabled. The Joint Commission doesn’t specify which alarms
should be used or when they can be disabled. However, these judgments should be based on
organization policy, not on individual caregiver preference.
The expectation with this goal is that the organization identifies and manages each clinical alarm
system within some organized program; the organization decides which alarms should be
managed by which programs, be they biomedical equipment programs, facilities management
programs, and so forth. Someone must be aware of and examine these systems.
Activating the alarms and involving clinical staff in the testing process to ensure that each alarm is
audible applies to the testing of the alarm system, not to the preventive maintenance of the alarm
device. The method and intervals for inspecting, testing, and maintaining clinical alarms should be
based on criteria such as manufacturers’ recommendations, risk levels, common industry practice,
and organization experience.
Compliance Suggestions
Some suggestions for meeting this goal and its requirements include the following:
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Review all alarms in use.
Create a list to make sure that all alarms are included in your biomedical preventive
maintenance program.
Evaluate what alarms staff consider to be critical and define the practice concerning these
alarms.
Develop and implement policies that prevent “turn off” capabilities for alarms.
Conduct environmental rounds that focus on the background noises that prevent staff from
hearing the alarms. (This might be related to time of day as well as location within the
facility.)
Review your organization’s policy for alarm response and practice testing the policy. Make
sure that the policy and practice match. Issues such as number and type of staff and time
of day are related to lack of appropriate alarm response.
Goal 7: Reduce the risk of health care–associated infections.
Requirement 7A: Comply with current Centers for Disease Control and Prevention (CDC) hand
hygiene guidelines.*
* Organizations are required to comply with all IA, IB, and IC CDC recommendations.
Requirement 7B: Manage as sentinel events all identified cases of unanticipated death or major
permanent loss of function associated with a health care–associated infection. (Applicable to
ambulatory care, assisted living, behavioral health care, critical access hospitals, disease-specific
care, home care, hospitals, laboratories, long term care, office-based surgery)
Joint Commission Requirements
This goal and its requirements require organizations to comply with all current “Category I”
recommendations (including IA, IB, and IC) in the CDC hand hygiene guidelines and manage as
sentinel events all identified cases of unanticipated death or major permanent loss of function
associated with a health care–associated infection.
Health Care–Associated Infections
Infection control is problematic in most health care settings, and escalating rates of health care–
associated (or nosocomial) infections worry patients and health care professionals. Joint
Commission standards focus on reducing the risks of such infections and, in the case of hospitals,
call for at least one activity in the infection control process to be aimed at preventing the
transmission of infections between patients and staff. Infections common to all settings include
catheter-associated urinary tract infections, bloodstream infections (usually associated with
intravascular devices), and pneumonia. Ambulatory care and acute care providers also battle
surgical-site infections, while home care and long term care professionals often deal with skin and
soft tissue infections. (2–4)
Compliance Suggestions
Because hand hygiene is the most effective way to reduce infection transmission, organizations
should apply the following tips to help improve infection control:
Encourage care recipients and families to speak up and ask health care workers to clean
their hands.
Place posters by sinks and in bathrooms to remind staff to wash their hands. Also, provide
role models to motivate staff to be in compliance with hand hygiene practices.
Monitor hand hygiene adherence and provide feedback to personnel about staff
performance or monitor the volume of alcohol-based hand rub used per 1,000 patient days.
Make improved adherence to hand hygiene practices an institutional priority and provide
appropriate administrative support and financial resources.
Implement a multidisciplinary program designed to improve adherence to recommended
hand hygiene practices.
NEW! Goal 8: Accurately and completely reconcile medications across the continuum of care.
NEW! Requirement 8A: During 2005, for full implementation by January 2006, develop a process
for obtaining and documenting a complete list of the patient’s current medications upon the
patient’s admission* to the organization and with the involvement of the patient. This process
includes a comparison of the medications the organization provides to those on the list. (Applicable
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to ambulatory care, assisted living, behavioral health care, critical access hospitals, diseasespecific care, hospitals, long term care, office-based surgery)
* Replace “admission” with “entry” for ambulatory care, behavioral health care, and office-based
surgery.
NEW! Requirement 8A: Have a process for obtaining and documenting a complete list of the
patient’s current medications upon the patient’s entry to the organization and with the
involvement of the patient. (Applicable to home care)
NEW! Requirement 8B: A complete list of the patient’s medication is communicated to the next
provider of service when it refers or transfers a patient to another setting, service, practitioner, or
level of care within or outside the organization. (Applicable to ambulatory care, assisted living,
behavioral health care, critical access hospitals, disease-specific care, home care, hospitals, long
term care, office-based surgery)
Joint Commission Requirements
Medication management encompasses the system and processes an organization uses to provide
medication to a patient throughout the patient’s continuum of care. There is a high risk for
medication error or adverse drug event (ADE) at hand-offs in the continuum of care. Ensuring
accuracy in the list of the patient’s current medications at each instance of care is essential to
providing safe care.
Few organizations have standard processes in place to reconcile a patient’s medications when he
or she enters the organization or transfers through or out of the organization. A majority of
medication errors occur at the initial points of contact with a patient in which a caregiver is
admitting or transferring the patient to another floor in the hospital or to another health care
organization. (5) For example, a patient’s medication list can change significantly after the patient
is discharged from the organization and reenters the organization. During that time, the patient’s
regular or on-call physician could have changed the medications, or the patient could have
customized the medications because of side effects or cost considerations. Therefore, the historical
record that the organization uses may not always be accurate because the medications can change
at any point in time. As a result, the organization must use many different resources, such as the
historical record, an interview with the patient and family, or a discussion with the patient’s
regular pharmacist or physician, to gain an accurate list of the medications the patient is taking.
CDC Categories Required by the Joint Commission
Hand hygiene guidelines are categorized by the CDC based on the strength of evidence
supporting the recommendation, resulting in
Categories IA, IB, IC, and II. Category IA recommendations are strongly supported by welldesigned experimental, clinical, or epidemiological studies; Category IB recommendations are
supported by certain experimental, clinical, or epidemiological studies and a strong theoretical
rationale; Category IC recommendations are required by regulation; and Category II
recommendations are supported by suggestive clinical or
epidemiological studies or a theoretical rationale. (For more information about the CDC hand
hygiene guidelines, go to http://www.cdc.gov/handhygiene.) The Joint Commission requires all
Category I recommendations, including IA, IB, and IC recommendations to be implemented, but
it does not require Category II recommendations.
Compliance Suggestions
To comply with this goal and its requirements, an organization should develop a standardized
method for creating an accurate list of medications at admission and transfer. Development of a
medication reconciliation form, to be used as a template for gathering information about current
medications, is one method that can be used to standardize care and prevent errors. A specific
staff member should be assigned the responsibility of filling out the medication reconciliation form;
this person should address all discrepancies and issues with the list. In this way, one person
knows everything about a patient’s medication list, rather than several staff members knowing
partial pieces of the patient’s list. The patient’s accurate medication reconciliation form (complete
with medications prescribed by the first provider of service) is communicated to the next provider
of service, whether within or outside the organization. Thereafter, the next provider of service
should check over the medication reconciliation form again to make sure it is accurate.
The following tips will also help boost compliance:
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Although obtaining a copy of a medication profile (from the pharmacy or home health
agency or other organization that the patient was transferred from) is a good initial source
of information, verify it with the patient and/or the patient’s family. Sometimes these
documents are not up to date or accurate, and the patient might have new information.
If the patient was in ambulatory care prior to admission, conduct a “brown bag” review of
the patient’s current medications. Ask the patient’s family to bring in all the patient’s home
medications so that they can be reviewed.
When conducting a patient interview about medications taken, don’t forget over-thecounter drugs, herbals, and dietary supplements. Patients may not view these as
“medications,” but they are.
Develop an internal and external transfer summary and discharge referral form for the
nurse to complete. This form should contain vital information about the patient, including a
complete list of medications the patient is receiving at discharge or transfer. This
information should then be sent to the next level of care or organization.
Eliminate writing discharge prescriptions on blank prescription pads, a copy of which is not
retained in the medical record. Have a form for the physician to complete, which can be
used to document the medications ordered on discharge for the medical record, and
another form to be used as the prescription for an outside pharmacy to fill.
It is particularly important in home care (for example, home infusion) for the home health
agency to share its assessment information with the dispensing pharmacy, and for the
pharmacy to share any medication profile it has on record with the home health agency.
NEW! Goal 9: Reduce the risk of patient harm resulting from falls.
NEW! Requirement 9A: Assess and periodically reassess each patient’s risk for falling, including the
potential risk associated with the patient’s medication regimen, and take action to address any
identified risks. (Applicable to assisted living, critical access hospitals, home care, hospitals, long
term care)
NEW! Requirement 9B: Implement a fall reduction program, including a transfer protocol, and
evaluate the effectiveness of the program (Applicable to long term care)
Joint Commission Requirements
Fatal falls rank high on the list of sentinel events tracked by the Joint Commission. Falls accounted
for approximately 4.6% of the sentinel events reviewed by the Joint Commission through the end
of 2003. An organization should regularly assess each patient’s risk for falling and take action to
prevent the potential falls from happening. This includes risk factors such as previous history of
falls, cognitive impairment, impaired balance or mobility, musculoskeletal problems, chronic
diseases, nutritional problems, and use of multiple medications. A long term care organization
must also implement a fall reduction program, including a transfer protocol, and evaluate the
effectiveness of the program. This program should include risk reduction strategies, in-services,
involvement of patients/families in education, and evaluation of environment of care issues.
Compliance Suggestions
Thorough assessment and reassessment for fall risk is an important part of the interdisciplinary
assessment process. An initial assessment that fails to identify the individual’s overall cognitive
level, muscle strength, pain, and ability to perform activities of daily living can lead to invalid
conclusions about the individual’s status. Thorough assessment enables staff to suggest and
implement a proactive approach to fall prevention as part of the care planning and provision
processes. Some risk reduction strategies include the following: (6)
Install bed alarms or redesign bed alarm checks and tests
Install self-latching locks on utility rooms
Restrict window openings
Install alarms on exits
Add fall prevention to education of patients, residents, or individuals served and their
families
Improve and standardize nurse call systems
Use “low beds” for those at risk for falls
Revise staffing procedures
Counsel individual caregivers
Create a fall prevention committee to assess new individuals or patients for fall potential;
to regularly review falls, evaluate interventions, and look for trends and patterns; and to
communicate their findings to other staff
NEW! Goal 10: Reduce the risk of influenza and pneumococcal disease in* older adults.
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* Add “institutionalized” after “in” for long term care.
NEW! Requirement 10A: Develop and implement a protocol for administration and documentation
of the flu vaccine. (Applicable to assisted living, disease-specific care, long term care)
NEW! Requirement 10B: Develop and implement a protocol for administration and documentation
of the pneumococcus vaccine. (Applicable to assisted living, disease-specific care, long term care)
NEW! Requirement 10C: Develop and implement a protocol to identify new cases of influenza and
to manage an outbreak. (Applicable to assisted living, disease- specific care, long term care)
Joint Commission Requirements
The objective of this new goal is to “reduce the risk of influenza and pneumococcal disease in older
adults.” Pneumococcal disease is responsible for more deaths than any other vaccine-preventable
bacterial disease. In fact, influenza and pneumonia combined represent the fifth leading cause of
death in the elderly. Furthermore, nursing home residents are especially vulnerable to influenza
and pneumococcal disease because of their age, underlying health conditions, and closed
environment. During influenza outbreaks in nursing homes, more than half of the residents may
become ill, and in some outbreaks as many as one-third of infected residents have died.
Influenza and pneumococcal vaccinations are recommended for persons aged 65 years and older
and for persons of any age who have medical conditions that place them at high risk for
complications from influenza. Although influenza vaccinations are administered annually, the
pneumococcal vaccine is generally a once-in-a-lifetime vaccination that can be given at any time.
Both influenza and pneumococcal vaccinations are
covered preventive service benefits under Medicare Part B. Although coverage of immunizations
for adults is an optional service under Medicaid, virtually all states cover immunizations for highrisk groups such as residents of nursing facilities. (7)
Compliance Suggestions
When evaluating interventions that may effectively reduce the risk of influenza and pneumococcal
disease in older adults, one of the first steps is to consider preventive measures. If your health
care organization has ambulatory services such as primary care clinics, consider developing
performance measures to remind health care providers to offer both flu and pneumococcus
vaccines to older adult patients. Have staff and physicians review the medical record in advance or
during the patient’s visit to ensure that the patient had been offered the vaccinations. If the
patient refuses the vaccinations, document that the benefits of the vaccine were discussed and
that the patient refused the vaccinations. If the patient has received the vaccinations, include that
information as part of the admission process.
Organizations can review the number of cases of older adults who contracted influenza and
pneumococcal disease during their stay to identify where they were vaccinated. Results can be
trended for significant patterns such as vaccinations from the clinic, the providers, and so forth.
Feedback can then be provided to the ambulatory sites. For organizations that do not own their
clinics, it is just as important for patients to be assessed for these immunizations on admission.
These data can be shared with providers at the appropriate medical staff meetings. In addition,
organizations need to define the age range of “older adult” to ensure consistency of data collection
and data analysis.
Organizations should consider offering vaccinations for older adults who come through urgent care
facilities and emergency departments because of other health care issues. With the number of
uninsured patients increasing, and as more older adults use urgent care and emergency
departments as a source of primary care, these avenues may be the only way for some adults to
receive the immunizations.
Once a patient is admitted, whether in a hospital or a long term care facility, an organization
needs to be cautious of offering the vaccine if it may do more harm than good.
One of the best prevention techniques is to practice good hand hygiene. Patients and visitors
should also be taught the importance of good hand hygiene. The organization should consider the
visiting policy for visitors who are ill and how this policy will be enforced. The same is true for
human resources policies for employees who arrive at work visibly ill. The organization should
review all potential entry routes that place older patients at risk for influenza and pneumococcal
disease.
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Organizations should continuously monitor the success of their efforts to prevent these diseases by
capturing and analyzing data. The performance measures should be reported to those who
oversee infection control on a regular basis and to the organizations’ performance improvement
infrastructure. The data should also be shared with staff, as appropriate, so they can see the
success rate of reducing the risk of influenza and
pneumococcal disease in older patients.
NEW! Goal 11: Reduce the risk of surgical fires.
NEW! Requirement 11A: Educate staff, including operating licensed independent practitioners and
anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to
minimize oxygen concentration under drapes. (Applicable to ambulatory care, office-based
surgery)
Joint Commission Requirements
Surgical fires were deemed to be a high priority for the ambulatory and office-based surgery
settings by the Sentinel Event advisory group. According to Sentinel Event Alert #29*, more than
27 million outpatient surgeries are performed each year and it is estimated that there are
approximately 100 surgical fires each year.
Three elements are required for a fire to ignite—fuel, oxygen, and heat. Staff education is key to
proper management of these elements, and proper education can help to significantly reduce the
risk for surgical fires. It is important to educate staff, including operating licensed independent
practitioners and anesthesia providers, on how to control heat sources and manage fuels. A wide
range of combustibles and flammables are found in the surgical suite, and education on the use of
alcohol or alcohol-based products can help reduce risk. Proper management of oxygen and
surgical devices is also necessary to prevent fires. Organizations must establish guidelines to
minimize oxygen concentration under drapes, which may be alcohol based.
Compliance Suggestions
The Joint Commission recommends that you help prevent surgical fires through the following
tips†:
Inform staff members, including surgeons and anesthesiologists, about the importance of
controlling heat sources by (1) following laser and electrosurgical unit safety practices, (2)
managing fuels by allowing sufficient time for patient preparation, and (3) establishing
guidelines for minimizing oxygen concentration under the drapes.
Develop implementing and testing procedures to ensure appropriate response by all
members of the surgical team to fires in the operating room.
Use proper procedures to prepare patients.† Any exposed body hair and skin should be
covered with a water-soluble lubricant. The individual’s eyes can be covered with swabs
soaked in sodium chloride.
Make sure equipment is maintained and used properly. All electrosurgical equipment should
be calibrated and inspected frequently.
Make sure staff is trained in preventing and extinguishing fires. Staff should be able to
locate and use the fire extinguishers, as well as be prepared for risks specific to each kind
of surgery they participate in.
* Sentinel Event Alert, Issue 29, Jun. 24, 2003.
† Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Alert, Issue 29,
Jun. 24, 2003.
Organizations are strongly encouraged to report any instances of surgical fires as a means of
raising awareness and ultimately preventing the occurrence of fires in the future. Reports can be
made to the Joint Commission, ECRI, the Food and Drug Administration, and state agencies,
among other organizations.
Creating a fire plan and educating staff is one step organizations can take to reduce the risk of
surgical fires. The facility manager, risk manager, safety director, and operating room manager
can work together to make sure staff is educated on the special fire risks involved in the surgical
suite and how to deal with them.
ECRI offers a free poster titled “Only You Can Prevent Surgical Fires” that lists recommendations
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based on the organization’s more than 25 years of research and publications on surgical fires. The
poster is available at http://www.mdsr.ecri.org/assets/pdf/surgical_fire_poster.pdf. The
recommendations include the following:
Question the need for 100% O2 for open delivery during facial surgery and, as a general
policy, use air or FiO2 at <30% for open delivery (consistent with patient needs).
Do not drape the patient until all flammable preps are dry.
During oropharyngeal surgery, soak gauze or sponges used with uncuffed tracheal tubes to
minimize leakage of O2 into the oropharynx, and keep them wet. Also, moisten sponges,
gauze, and pledgets (and their strings) so they resist igniting.
Also, ECRI recommends that staff participate in special drills and training on the (1) use of firefighting equipment, (2) proper methods for rescue and escape, and (3) identification and location
of medical gas, ventilation, and electrical systems and controls, as well as when, where, and how
to shut off these systems.
New! Goal 12: Implementation of applicable National Patient Safety Goals and associated
requirements by components and practitioner sites.
NEW! Requirement 12A: Inform and encourage components and practitioner sites to implement
the applicable National Patient Safety Goals and associated requirements. (Applicable to integrated
delivery systems, managed care organizations, preferred provider organizations)
Joint Commission Requirements
Integrated delivery systems, managed care organizations, and preferred provider organizations
should assess all the National Patient Safety Goals and requirements to see which are applicable to
the components and practitioner sites that comprise their network. Integrated delivery systems,
managed care organizations, and preferred provider organizations should communicate
information on the National Patient Safety Goals and requirements to their applicable components
(ambulatory care, office-based surgery, assisted living, behavioral health care, critical access
hospitals, disease-specific care, home care, hospitals, laboratories, long term care, and practitioner
sites).
Universal Protocol
UP 1
The organization fulfills the expectations set forth in the Universal Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong Person Surgery and associated implementation guidelines.
Requirement 1A: Conduct a preoperative verification process, as described in the Universal
Protocol.
Requirement 1B: Mark the operative site as described in the Universal Protocol.
Requirement 1C: Conduct a “time out” immediately before starting the procedure as described in
the Universal Protocol.
The Universal Protocol and its requirements are applicable to ambulatory care, critical access
hospitals, hospitals, and office-based surgery.
Wrong site, wrong procedure, and wrong person surgery can be prevented. The Universal Protocol
is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical
specialties and professional disciplines, and it is endorsed by more than 50 professional medical
associations and organizations.
In developing this protocol, consensus was reached on the following principles:
Wrong site, wrong procedure, and wrong person surgery can and must be prevented
A robust approach—using multiple, complementary
strategies—is necessary to achieve the goal of eliminating wrong site, wrong procedure,
wrong person surgery
Active involvement and effective communication among all members of the surgical team
are important for success
To the extent possible, the patient (or legally designated representative) should be involved
in the process
Consistent implementation of a standardized approach using a universal, consensus-based
protocol will be most effective
The protocol should be flexible enough to allow for implementation with appropriate
adaptation when required to meet specific patient needs
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A requirement for site marking should focus on cases involving right/left distinction,
multiple structures (fingers, toes), or multiple levels (spine)
The Universal Protocol should be applicable or adaptable to all operative and other invasive
procedures that expose patients to harm, including procedures done in settings other than
the operating room
In concert with these principles, the following steps, taken together, comprise the Universal
Protocol.
Preoperative Verification Process
Purpose: To ensure that all the relevant documents and studies are available prior to the start of a
procedure and that they have been reviewed and are consistent with each other and with the
patient’s expectations and with the team’s understanding of the intended patient, procedure, site,
and, as applicable, any implants. Missing information or discrepancies must be addressed before
starting the procedure.
Process: An ongoing process of information gathering and verification, beginning with the
determination to do the procedure, continuing through all settings and interventions involved in
the preoperative preparation of the patient, up to and including the “time out” just before the start
of the
procedure.
Marking the Operative Site
Purpose: To identify unambiguously the intended site of incision or insertion.
Process: For procedures involving right/left distinction, multiple structures (such as fingers and
toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the
mark will be visible after the patient has been prepped and draped.
“Time Out” Immediately Before Starting the Procedure
Purpose: To conduct a final verification of the correct patient, procedure, site, and, as applicable,
implants.
Process: Active communication among all surgical/procedure team members, consistently initiated
by a designated team member, conducted in a “fail-safe” mode—that is, the procedure is not
started until any questions or concerns are resolved.
Compliance Suggestions
Consider the following suggestions for ensuring compliance with the preoperative process to verify
the correct patient, the correct site, and the correct procedure:
Develop a checklist of documents that are to be present and procedures that need to be
completed before beginning any procedure.
Have a nurse or another team member place the patient’s chart on a stand in the OR and
open it to the surgeon’s notes describing the planned procedure. This allows the surgeon to
quickly review the record before starting the procedure.
Evaluate staff to make sure they understand the verification policy and process.
Implement an organizationwide process to mark the surgical site, involve the patient in the
marking process, and have the surgical team confirm that the site has been marked.
Rather than tell the patient the specific site, ask the question in a manner that requires the
patient to state the site (for example, “Which hand are we operating on today?”).
Although this is not a Joint Commission requirement, consider implementing a “no mark, no
surgery” policy.
If laterality is an issue, spell out the words in their entirety on the operative schedule and
on the operative consent form.
For spinal surgery, implement a two-stage marking process, as follows: (1) Mark the
general level of the procedure (cervical, thoracic, or lumbar) preoperatively and (2)
intraoperatively, mark the exact interspace(s) to be operated on, using the standard
intraoperative radiographic marking technique.
If the procedure involves x-rays, verify that the films are in the OR, correctly labeled, and
correctly displayed on the view box.
Check that the patient’s name is the same as the name on the film, rather than the same
as the name on the folder.
If there is an obvious wound or lesion that is the site of the intended procedure, site
marking is not required. However, if there are multiple wounds or lesions and only some of
them are to be treated, the wounds to be treated must be marked.
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Site Marking
This goal does not specify the type of mark that must be used in the site-marking process; the
organization should decide what type of mark will be used. Regardless of what mark will be
used, the site-marking process should be consistent throughout the organization. Use of “X” is
discouraged because its meaning may be ambiguous: Does “X” mean operate here or do not
operate here? A line indicating the intended site of incision, the surgeon’s initials, and the word
“yes” are all acceptable ways to mark the site.
For “right/left” cases, it is not acceptable to mark the opposite site with a “NO” rather than
marking the intended operative site; the goal specifies marking the intended site of the
procedure. Several cases of wrong-patient surgery have occurred in organizations that have a
policy for marking only the nonoperative site. Many experts advise that marking the
nonoperative site should not be done even in addition to marking the intended site.
Some organizations identify the operative site or sites by placing a band for each site on the
extremity of the operative side or sides. The belief is that if the proposed surgical procedure is
site-specific (for example, gallbladder, heart, appendix), then the band will be placed on the arm
containing the patient identification armband. The circulating nurse would remove the surgical
site bands only after verification is complete. The Joint Commission does not support this,
however. The point of surgical site marking is not only to identify the intended site but also the
intended patient. Furthermore, it is not intended just to tell the surgeon that he or she is in the
right place, but to tell others they are in the wrong place (“no mark, no surgery”). For some
cases, it is problematic as to how to truly “site mark”—such as when access is through a natural
orifice. The use of the armband—with appropriate identifiers—is an excellent methodology in
such situations. Also, banding can be used in addition to site marking to further reduce the risk
for patients.
For More Information
Your organization might continue to have questions about how to meet specific National Patient
Safety Goals and their requirements. Many of the questions will be answered in upcoming issues of
Perspectives on Patient Safety. In addition, FAQs about these goals and their requirements are
updated regularly on the Joint Commission’s Web site, at http://www.jcaho.org. For more specific
questions that might not be addressed by the FAQs, you can also contact the Standards
Interpretation Group, at 630/792-5000 or via the online question form.
References
1. Joint Commission Resources: “Standards link: Sound-alike medications” Perspectives on Patient
Safety 1(5): 2, 2001.
2. Burke J.P.: Infection control—A problem for patient safety. N Engl J Med 348:651–656, Feb. 13,
2003.
3. Nicolle L.E.: Preventing infections in non-hospital settings: Long-term care. Emerg Infect Dis
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