National Patient Safety Goals and Recommendations

Improve the accuracy of patient identification.
Recommendations:

• Use at least two patient identifiers (not the patient’s room number) whenever taking blood samples or administering medications or blood products.
• Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "timeout," to confirm the correct patient, procedure, and site, using active — not passive — communication techniques.

Improve the effectiveness of communication among caregivers.
Recommendations:

• Implement a process for taking verbal or phone orders that requires a verification "read-back" of the complete order by the person receiving the order.
• Standardize the abbreviations, acronyms, and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use.

Improve the safety of using high-alert medications.
Recommendations:

• Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.
• Standardize and limit the number of drug concentrations available in the organization.

Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
Recommendations:

• Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
• Implement a process to mark the surgical site and involve the patient in the marking process.

Improve the safety of using infusion pumps.
Recommendation:

• Ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in the organization.

Improve the effectiveness of clinical alarm systems.
Recommendations:

• Implement regular preventive maintenance and testing of alarm systems.
• Ensure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

Source: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.