In June 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued National Patient Safety Goals (NPSG) that became effective January 1, 2007. The NPSG and the requirements are selected by a Sentinel Advisory Group, a panel of national patient-safety experts. The panelists base the recommendations on a comprehensive evaluation of reported sentinel-event data, professional literature, and patient-safety information. They also consider recommendations from various multidisciplinary professional resources, including pharmacy experts working in a wide range of health care settings.1
The 2007 NPSG is JCAHO's fifth NPSG issuance. Since its inception, the NPSG program has promulgated 15 goals. Some goals carry over from year to year, but JCAHO removes or "retires" goals from the list once they are formally incorporated in specific accreditation standards.
Table 1 contains an abridged version of the 2007 NPSG and the requirements. Specific and detailed NPSG descriptions are available on JCAHO's Web site, www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accredited programs requiring NPSG compliance include the following2,3:
Medication safety continues its priority placement in 2 explicit NPSG (Goals 3 and 8). Despite progress toward improvement, look-alike/sound-alike drugs remain serious issues, as does pharmacy continuity of care. To help staff members identify potentially problematic drug names, JCAHO provides a list of confusing names on its Web site. Samples include the following:
Implementation expectations require organizations to select a minimum of 10 look-alike/sound-alike drug combinations and to develop error-prevention strategies proactively.2 One recommended intervention, for example, is text or format highlighting on computer screens (eg, hydrOXYzine and hydrALAzine).4
Goal 8 focuses on pharmacy continuum of care and includes a new requirement: clinicians must provide a complete list of patients' current medications to them at discharge. Experience and research confirm increased medicationerror risk at patient-transition points. Medication reconciliation between internal and external providers minimizes errors. Medication reconciliation evaluates patients' admission and discharge medications and identifies and resolves omissions, duplications, discrepancies, and potential drug interactions. Active health care providers then communicate the reconciled list with posttransition providers, including those external to the organization.2
Goal 2, improving communication, calls for standardizing abbreviations and setting requirements for verbal and telephone orders. The continued use of "do not use" abbreviations is one of the most frequent noncompliance accreditation findings: 23% of organizations continue to use abbreviations now considered dangerous (Table 2).5,6
Many issues potentially affect health care and patient safety, including the following:
The authors of one study, however, report that JCAHO regulatory initiatives have been among the most significant change-producing forces.7
Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Va.
1. The Joint Commission on Accreditation of Healthcare Organizations. Facts about the 2007 National Patient Safety Goals. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_facts.htm. Accessed November 21, 2006.
2. The Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission Announces the 2007 National Patient Safety Goals and Requirements. Jt Comm Perspect. 2006;26:1-31.
3. The Joint Commission on Accreditation of Healthcare Organizations. 2007 National Patient Safety Goals. Available at: www.jointcommission.org/NR/rdonlyres/0F26F75F-B4B4-463F-B9CC-6B4723BFF9F0/0/2007_NPSG_presentation.ppt. Accessed November 28, 2006.
4. The Joint Commission on Accreditation of Healthcare Organizations. Facts about the 2007 NPSG's look-alike/sound-alike drug list. Available at: www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf. Accessed November 28, 2006.
5. The Joint Commission on Accreditation of Healthcare Organizations. Official "do not use" list." Available at: www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/0/06_dnu_list.pdf. Accessed November 28, 2006.
6. The Joint Commission on Accreditation of Healthcare Organizations. Facts about the official "do not use" list. Available at: www.jointcommission.org/PatientSafety/DoNotUseList/facts_dnu.htm. Accessed November 28, 2006.
7. Devers K, Hoangmai H, Liu G. What is Driving Hospitals' Patient-Safety Efforts? Health Aff. 2004;23:103-115. Available at: www.medscape.com/viewarticle/470061. Accessed November 21, 2006.