JCAHO 2007 National Patient Safety Goals Hospital Version

  1. 2007 national patient safety goals hospital version manual chapter, including implementation expectations

    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.

    goal 1:improve the accuracy of patient identification.
    1a use at least two patient identifiers when providing care, treatment or services.

    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, 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.
    3b standardize and limit the number of drug concentrations used by the organization.
    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.
    3d label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

    goal 7: reduce the risk of health care-associated infections.
    7acomply with current 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.
    8athere is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.8ba 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 facility.

    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.
    15athe organization identifies patients at risk for suicide. [applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals -- not applicable to critical access hospitals]
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    other areas see:

    ambulatory care and office-based surgery
    assisted living
    behavioral health care
    critical access hospital and hospital
    disease-specific care
    home care
    laboratory
    long term care
    networks
    Last edit by NRSKarenRN on Mar 16, '07
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