From Surgeries on Incorrect Body Parts to Misidentified Newborns, New Goals Shed Light on Common Preventable Failures
The Joint Commission is a non-profit accrediting organization with a mission to help healthcare providers improve patient care and safety. The organization recently published its 2022 National Patient Safety Goals (NPSGs) to address patient safety concerns studied by the Patient Safety Advisory Group (PSAG) of healthcare experts that advises the Commission. The NPSGs target core safety issues and what must occur to prevent problems in proper delivery of medical care.
How does the Joint Commission Evaluate Medical Facilities?
In addition to developing and releasing National Patient Safety Goals, the Joint Commission accredits healthcare facilities that comply with its standards. After an on-site evaluation, the Commission may certify a facility with its Golden Seal of Approval after an on-site review and compliance with its suggested improvements. In deriving the standards, the Commission takes advisement from the PSAG, a body of medical professionals, such as nurses, physicians, pharmacists, hospital directors, and other experienced medical practitioners who know the problems in healthcare firsthand. They help develop the standards, goals, and improvements the Commission uses to evaluate, accredit, and certify medical providers across the spectrum of healthcare delivery.
Goals for Patient Safety in 2022 Reflect Critical Failures
After reviewing the most pressing patient safety problems in healthcare in 2022, the PSAG recommended practices to improve healthcare performance in six problem areas that often lead to patient injury. These include:
- Patient identification
- Staff communication
- Medication dispensing
- Medical device maintenance
- Suicide prevention
Failures to properly perform all of the above activities may also amount to medical malpractice when the patient is injured, experiences complications, or dies as a result.
Goal 1: Address Patient Misidentification
The first goal the panel identified in NPSG.01.01.01 is patient identity error improvement. The PSAG recommends a dual identification system, at minimum, to ensure the correct patient receives the appropriate care and treatment. For example, a facility may use a patient’s name, telephone number, assigned number, and birth date to verify identification. The goal is to reduce errors in misidentified patients during diagnosis and treatment. Such errors occur system-wide in hospitals, clinics, urgent care centers, and other provider facilities, especially with newborns. The multiple identifiers reduce the chances that a patient does not receive medication for another patient, nor a newborn receive breast milk from another mother, nor a child be overdosed with the wrong amount of medication for their age and size, exposing all of these patients to injury and complications.
Another error targeted by a multiple identification system is wrong test results. Blood and other patient samples produce lab results that aid diagnosis and treatment. When the lab returns results to the wrong patient, the treating physician does not get the vital information they need to assess the patient’s health problem. The delay in connecting the lab results to the correct patient may cause further injury, even fatal injuries when conditions like cancer require quick treatment to keep the disease from spreading and lowering the treatment success rate. Additionally, in the case of neonatal care, the recommendation is to identify patients, not by room numbers, but by more descriptive identifiers, such as the full name of the mother and the newborn’s gender.
Goal 2: Reduce Communication Errors Among Staff Members
Another problem area for many medical institutions is staff communication. NPSG.02.0.01 recommends reporting diagnostic test results promptly to avoid endangering patients who need timely treatment. Healthcare facilities must establish written protocols that mandate timeframes for test result returns to patients and staff responsibilities in getting those results to the proper parties. Procedures for defining critical test results and diagnostics must also include who reports results to the appropriate parties. Thus, even if misidentification is not the cause for patient care delays, poorly defined lines of communication between medical professionals, test results, and patients can lead to unintended injuries.
Goal 3: Improve Safe Practices with Medications
Another recurring problem, medication errors, is the primary concern of the third goal, NPSG.03.04.01. All medications need labels, and all patients require the correct medicines and instructions for taking drugs. Thus, when hospital staff prepares for surgery, they may bring medications, syringes, medicine cups, and other medication dispensing tools in anticipation of the patient’s needs. In addition, all items taken from containers with labels must also contain labels to avoid administering the wrong medication or wrong dose. By labeling medicines and their containers with names, dosages, expiration dates, and the like, medical staff reduces medication errors, especially if protocols of duplicate verification are in place. In addition, two-person medication identification verification ensures errors are less likely when different people handle patient medication administration.
Moreover, specific medications require much more precise management by those dispensing them and the patients receiving them. For example, anticoagulants or blood thinners address various conditions, including bypass surgery. Patients undergoing heart surgery may require warfarin or another anticoagulant for the rest of their life to avoid blood clots. Anticoagulation therapy departments keep patients taking their medication correctly and adjusting the doses as the patient’s medications, diet, and age change. The results of improper blood thinner dosing can be fatal. Patients can bleed out or suffer fatal embolisms from clots if their blood gets too thin or too thick. Patient education is crucial, as is careful patient monitoring by medical staff. Protocols must be in place to address patient education and medication tracking, especially as a patient changes medical providers.
Also, medication reconciliation, ensuring all medications interact well with one another, is another crucial system check that needs improvement in most medical facilities. All providers must have procedures to track a patient’s medication changes and compare new and existing medications for compatibility. In addition, providers need systems to verify medication names, dose, purpose, and administration methods. Hospital settings are especially vulnerable to medication reconciliation errors since patients may not know all their medications. The Commission recommends reasonable efforts to acquire medication information from the patient and others who know, like relatives and primary care physicians, and impress the importance of patients updating their medication at each visit.
Goal 4: Properly Use and Respond to Alarms
NPSG.06.01.01 addresses clinical alarm systems improvement. Alarms on medical devices keep staff aware of patient emergencies or device failures. However, if the alarm systems do not work correctly or too many devices have alarms, patient injury is more likely to occur when medical staff does not hear an alarm go off or hear too many alarms go off. Other issues are improper settings for alarms that cause alarms to go off too often or not often enough. Therefore, each medical facility must create alarm system management protocols and dedicate personnel to maintaining effective alarm systems critical to patient safety, including when to turn them on and off and who responds to them.
Goal 5: Implement Infection-Prevention Strategies
The fifth goal aims to reduce the prevalent problem of infection spread by adhering to strict hand washing guidelines from leading disease prevention organizations like the CDC and WHO. All organizations suffer from patients contracting infections at hospitals, clinics, and other medical settings. Recommended handwashing compliance develops a culture and consciousness of appropriate hygiene when handling patients to reduce infection risks that could lead to severe complications that jeopardize patient health.
Goal 6: Better Prevent Patient Suicide
The final goal pertains to suicide prevention by risk identification in psychiatric hospitals or outpatient settings. To reduce risk, an institution should evaluate avenues for potentially suicidal patients to commit suicide, like door hinges and hooks. The Commission recommends that all facilities treating psychiatric patients remove objects that a patient could use to cause self-harm. They also recommend carefully screening and documenting potentially suicidal patients and training staff to recognize signs of possible suicide attempts and actions to respond to such attempts.
When You or a Loved one has been Injured in New Jersey
Given the newly established goals for patient safety, medical professionals who do not follow Commission recommendations risk injuring the patients who count on them, not to mention exposure to medical malpractice lawsuits. Malpractice often involves negligent practitioners or facilities who fail to follow the medical and safety standards established by medical boards and accrediting organizations. Despite the guidelines, training, education, and resources available, preventable medical mistakes happen virtually every day across the nation.
If you or a loved one received substandard medical care in a hospital, doctor’s office, stroke center, clinic, same-day surgical center, or birthing center that led to injury, you should consult with a medical malpractice attorney to learn the rights and legal paths that you may have grounds to take. With help from a seasoned legal professional in the medical malpractice field, you can have your case fully investigated for potential failures that may entitle you to a compensatory settlement or jury award.
With decades of experience focusing exclusively on medical malpractice litigation in New Jersey, the lawyers at Fronzuto Law Group are uniquely equipped to advise you on how you can recoup your economic and non-economic losses and recover the resources you need to improve your health condition. Medical negligence may have robbed you of so much, but a successful claim against those liable may at the very least, begin to set things right.