National Patient Safety Goals Performance Detail

National Patient Safety Goal 1: Improve the accuracy of patient identification.

Requirement 1A: Use at least two patient identifiers when providing care, treatment or services.

What this information tells us
These data report the percentage of hospitals using at least two patient identifiers when providing care, treatment or services.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 97.2 percent in using at least two patient identifiers.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 2: Improve the effectiveness of communication among caregivers.

Requirement 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.

What this information tells us
These data report the percentage of hospitals that verified complete orders or test results of verbal or telephone orders or for telephone reporting of critical test results by having the person receiving the information record and “read-back” the complete order or test result.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 96.3 percent in verifying complete orders or test results by recording and reading back the complete order or test result.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 2: Improve the effectiveness of communication among caregivers.

Requirement 2B:  Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

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What this information tells us
These data report the percentage of hospitals that standardized a list of abbreviations, acronyms, symbols, and dose designations not to be used throughout the organization.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 76.4 percent in standardizing a list of “do not use” abbreviations, acronyms, symbols, and dose designations.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 2: Improve the effectiveness of communication among caregivers.

Requirement 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

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What this information tells us
These data report the percentage of hospitals that measured and assessed, and if needed, took action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 64.9 percent in improving the timely reporting of critical test results and values.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 2: Improve the effectiveness of communication among caregivers.

Requirement 2E: Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

What this information tells us
These data report the percentage of hospitals that implemented a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 98.2 percent in implementing a standardized approach to “hand off” communications.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 3: Improve the safety of using medications.

Requirement 3B: Standardize and limit the number of drug concentrations used by the organization.

What this information tells us
These data report the percentage of hospitals that standardized and limited the number of drug concentrations used by the organization.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 99.3 percent in standardizing and limiting drug concentrations.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 3: Improve the safety of using medications.

Requirement 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.

What this information tells us
These data report the percentage of hospitals that identified and, at a minimum, annually reviewed a list of look-alike/sound-alike drugs used by the organization, and took action to prevent errors involving the interchange of these drugs.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 94.6 percent in identifying and reviewing a list of look-alike/sound-alike drugs and taking action to prevent errors involving these drugs.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 3: Improve the safety of using medications.

Requirement 3D: Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

What this information tells us
These data report the percentage of hospitals that labeled all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 82.0 percent in labeling all medications, medication containers and other solutions on and off the sterile field.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 7: Reduce the risk of health care-associated infections.

Requirement 7A: Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

What this information tells us
These data report the percentage of hospitals that complied with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 91.2 percent in complying with current CDC hand hygiene guidelines.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 7: Reduce the risk of health care-associated infections.

Requirement 7B:  Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

What this information tells us
These data report the percentage of hospitals that managed as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 100 percent in managing as sentinel events all cases of unanticipated death or permanent function loss associated with health care-associated infection.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 8: Accurately and completely reconcile medications across the continuum of care.

Requirement 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.

What this information tells us
These data report the percentage of hospitals having a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 82.1 percent in having a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 8: Accurately and completely reconcile medications across the continuum of care.

Requirement 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 facility.

What this information tells us
These data report the percentage of hospitals that communicated a complete list of the patient’s medications to the next provider of service when it referred or transferred a patient to another setting, service, practitioner or level of care. Also, discharged patients were provided with a complete list of their medications.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 88.1 percent in communicating a complete list of patient medications to the next service provider and providing the list of medications to discharged patients.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 9: Reduce the risk of patient harm resulting from falls.

Requirement 9B:  Implement a fall reduction program including an evaluation of the effectiveness of the program.

What this information tells us
These data report the percentage of hospitals that implemented a fall reduction program and evaluated its effectiveness.

Result

• In 2007, Joint Commission-accredited hospital achieved national average performance of 94.9 percent in implementing and assessing a fall reduction program.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy.

Requirement 13A:  Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

What this information tells us
These data report the percentage of hospitals that defined and communicated the means for patients and their families to report concerns about safety and encouraged them to do so.

Result

• In 2007, Joint Commission-accredited hospital achieved national average performance of 99.5 percent of defining and communicating the means for patients and their families to report concerns about safety and encouraged them to do so.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

National Patient Safety Goal 15: The organization identifies safety risks inherent in its patient population.

Requirement 15A: The organization identifies patients at risk for suicide.

What this information tells us
These data report the percentage of hospitals that identified patients at risk for suicide.

Result

• In 2007, Joint Commission-accredited hospital achieved national average performance of 97.8 percent in identifying patients at risk for suicide.

What one should know about the data

• These data were reported only by psychiatric hospitals and those general hospitals that had patients being treated for emotional or behavioral disorders.
• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

Universal Protocol: The organization fulfills the expectations set forth in the Universal Protocol.

Requirement UP 1A:  Conduct a preoperative verification process as described in the Universal Protocol.

What this information tells us
These data report the percentage of hospitals that conducted a preoperative verification process as described in The Joint Commission’s Universal Protocol.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 99.0 percent in conducting a preoperative verification process as described in the Universal Protocol.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

Universal Protocol: The organization fulfills the expectations set forth in the Universal Protocol.

Requirement UP 1B: Mark the operative site as described in the Universal Protocol.

What this information tells us
These data report the percentage of hospitals that marked the operative site as described in The Joint Commission’s Universal Protocol.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 93.5 percent in marking the operative site as described in the Universal Protocol.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

Universal Protocol: The organization fulfills the expectations set forth in the Universal Protocol.

Requirement UP 1C:  Conduct a "time out" immediately before starting the procedure as described in the Universal Protocol.

What this information tells us
These data report the percentage of hospitals that conducted a “time out” immediately before starting the procedure as described in The Joint Commission’s Universal Protocol.

Result

• In 2007, Joint Commission-accredited hospitals achieved national average performance of 78.8 percent in conducting a “time out” immediately before starting the procedure as described in the Universal Protocol.

What one should know about the data

• 1,466 hospitals underwent onsite surveys during 2007.
• Delaware, Montana and Vermont did not have enough surveys in 2007 to make state comparisons useful.

 

Number of surveys for National Patient Safety Goals in 2007