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2008 Home Care National Patient Safety Goals

2008 National Patient Safety Goals Manual Chapter
(Includes Rationales and Implementation Expectations)

Note: Changes to the Goals and Requirements are indicated in bold. Gaps in the numbering indicate that the Goal is inapplicable to the program or has been “retired,” usually because the requirements were integrated into the standards.

This year’s new requirement (3E) has a one-year phase-in period that includes defined expectations for planning, development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation by January 2009. See the Implementation Expectations for milestones.

Goal 1:Improve the accuracy of patient identification.
1AUse at least two patient identifiers when providing care, treatment or services.
1BPrior to the start of any surgical or invasive procedure, conduct a final verification process, (such as a “time out,”) to confirm the correct patient, procedure and site, using active—not passive—communication techniques.

Goal 2: Improve the effectiveness of communication among caregivers.
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 information record and "read-back" the complete order or test result.
2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
2C Measure and 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.
2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Goal 3: Improve the safety of using medications.
3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.
3EReduce the likelihood of patient harm associated with the use of anticoagulation therapy.


Goal 7: Reduce the risk of health care-associated infections
7A Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

Goal 8: Accurately and completely reconcile medications across the continuum of care.
8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.
8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the organization.

Goal 9: Reduce the risk of patient harm resulting from falls.
9B Implement a fall reduction program including an evaluation of the effectiveness of the program.

Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy.
13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

Goal 15: The organization identifies safety risks inherent in its patient population.
15B The organization identifies risks associated with long-term oxygen therapy such as home fires.


Discussion: 2008 Home Care National Patient Safety Goals