National Patient Safety Goals (NPSGs)
The NPSG that requires using at least two identifiers when providing care, treatment, and services.
What is "Improve the accuracy of patient identification"?
The EOC management plan that deals with fire prevention, detection, and suppression systems.
What is the "Fire Safety Management Plan"?
This required process ensures that a patient's home medications are accurately compared to new medication orders.
What is "Medication Reconciliation"?
The single most important measure for preventing the spread of infection.
What is "Hand Hygiene"?
The type of survey where the Joint Commission follows a patient's experience through the organization.
What is a "Patient Tracer"?
The NPSG focused on reducing infections by emphasizing hand hygiene and preventing healthcare-associated infections.
What is "Prevent infection"?
This EOC management plan ensures the safe handling, storage, and disposal of materials like chemotherapy agents or radioactive waste.
What is the "Hazardous Materials and Waste Management Plan"?
Medications, solutions, and containers must be fully labeled, even on the sterile field, with at least these three pieces of information.
What are "drug/solution name, strength/amount, and expiration date/time"?
This type of precaution is required for patients with infections transmitted by airborne droplets smaller than 5 microns, like tuberculosis.
What are "Airborne Precautions"?
The ideal way for staff to respond to surveyor questions: truthfully, professionally, and by only answering what is directly asked, without doing this.
What is "volunteering information" (or "offering unnecessary details")?
This NPSG involves effectively communicating critical test results and urgent diagnostic information.
What is "Improve staff communication"?
The maximum allowable length of an uncoiled medical gas hose or tubing in a patient care area.
What is 20 feet?
The Joint Commission requires a process to manage these types of medications, often involving a specific list and precautions due to their heightened risk of harm.
What are "High-Alert Medications"?
The required frequency for assessing and documenting staff competency in infection control practices.
What is "annually" (or "upon hire and annually thereafter")?
This crucial preparation activity involves simulating a survey to identify gaps and areas for improvement.
What is a "mock survey"?
The NPSG that addresses medication reconciliation, look-alike/sound-alike drugs, and accurate labeling of medications.
What is "Use medicines safely"?
This is the required frequency for fire drills in each shift and in each occupancy type (e.g., healthcare, business) per year.
What is "four times per year"? (or "quarterly")
All drug orders must include the medication name, dose, frequency, route, and this fifth critical component.
What is the "signature of the prescriber"?
This term describes infections patients acquire while receiving medical care, often a focus of Joint Commission scrutiny.
What are "Healthcare-Associated Infections (HAIs)"?
This document is the ultimate source of truth for Joint Commission standards and elements of performance.
What is the "E-dition" (or "Joint Commission Standards Manual")?
This NPSG requires implementing a Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery.
What is "Prevent mistakes in surgery"?
The document that outlines the hospital's strategies for preparing for, responding to, and recovering from emergencies.
What is the "Emergency Management Plan" (or "Emergency Operations Plan")?
This list, often maintained by the pharmacy, helps prevent errors by identifying drugs that look or sound similar.
What is the "Look-Alike/Sound-Alike Drug List"?
When a surveyor observes a lapse in hand hygiene, the staff member should be prepared to state the "Five Moments" for this practice.
What are the "Five Moments for Hand Hygiene"?
If a surveyor observes a non-compliance, the organization may be required to submit this detailing corrective actions and timelines.
What is a "Plan of Correction (POC)"?