Patient Safety Goals
JCAHO National Patient Safety Goals
All JCAHO-accredited healthcare organizations are surveyed for
implementation of the following safety requirements or acceptable
alternatives as appropriate to the services the organization
- Improve the accuracy of patient identification.
- Use at least two patient identifiers (neither to be the
patient's room number) whenever taking blood samples or
administering medications or blood products.
- Improve the effectiveness of communication among
- For verbal or telephone orders or for telephonic
reporting of critical test results, verify the complete
order or test result by having that person receiving the
information record and "read-back" the complete order or
- Standardize the abbreviations, acronyms, symbols, and
dose designations that are not to be used throughout the
- 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.
- Implement a standardized approach to "handoff"
communication, including an opportunity to ask and respond
- Improve the safety of using high-alert medications.
- Identify and, at a minimum, annually review a list of
look-alike/sound-alike drugs used in the hospital, and take
action to prevent errors involving the interchange of these
- Label all medications, medication containers (e.g.,
syringes, medicine cups, basins) or other solutions on and
off the sterile field
- Reduce the likelihood of patient harm associated with
the use of anticoagulation therapy
- Reduce the risk of health care-acquired infections.
- Comply with current CDC guidelines for hand hygiene.
- Manage as sentinel events all identified cases of
unanticipated death or major permanent loss of function
associated with a healthcare-acquired infection.
- Accurately and completely reconcile medications
across the continuum of care.
- There is a process for comparing the patient's current
medications with those ordered for the patient while under
the care of the organization.
- A complete list of the patient's medications is
communicated to the next provider of service when the
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.
- Reduce the risk of patient harm resulting from
- Implement a fall prevention program and evaluate the
effectiveness of the program.
- Encourage patients' active involvement in their own
care as a patient safety strategy.
- Define and communicate the means for patients and their
families to report concerns about safety and encourage them
to do so.
- The organization identifies safety risks inherent in
its patient population.
- IThe organization identifies individuals at risk for
- Improve recognition and response to changes in a
- The organization selects a suitable method that enables
healthcare staff members to directly request additional
assistance from a specially trained individual(s) when the
patient's condition appears to be worsening.
The first National Patient Safety Goals were approved by the
Joint Commission's Board of Commissioners in July 2002. JCAHO
established these goals to help accredited organizations address
specific areas of concern in regards to patient safety. Each goal
includes no more than two succinct, evidence- or expert-based
recommendations. Each year, the goals and associated recommendations
are reevaluated; some may continue while others will be replaced
because of emerging new priorities. New goals and recommendations
are announced in July and become effective on January 1 of the
For more information, contact Linda Kissik, Director of IOP &
Risk Management, at (401) 769-4100, Ext. 2046.