The Joint Commission
Improving America's Hospitals - A Report on Quality and Safety


Introduction from The Joint Commission President
Executive Summary
Background Information
Quality and Safety Key Performance Results
Quality and Safety Performance Detail
Glossary and References
2007 Report (PDF)
2006 Report (PDF)
Quality and Safety Performance Detail  
Home > > National Patient Safety Goals Performance Detail

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 (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing or providing any other treatments or procedures.
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of using at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing or providing any other treatments or procedures.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 91.9 percent in using at least two patient identifiers.

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  •  North Dakota did not have any surveys in 2006.

 



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

 
Requirement 1B:  Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active—not passive—communication techniques.
 
  

What this information tells us

These data report the percentage of hospitals complying with the requirement of, prior to the start of any surgical or invasive procedure, conducting a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active—not passive—communication techniques.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 74.2 percent in conducting a final verification or “time-out” process prior to surgery. 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
 


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 order or test result “read-back” the complete order or test result.
 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of, for verbal or telephone orders or for telephonic reporting of critical test results, verifying the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 84.3 percent in verifying by reading back the complete order or test result. 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006 


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

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

What this information tells us

These data report the percentage of hospitals complying with the requirement of standardizing the abbreviations, acronyms and symbols not to be used throughout the organization.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 63.1 percent in standardizing “do not use” abbreviations, acronyms and symbols.

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 

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

 
Requirement 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.
 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of measuring, assessing and, if appropriate, taking 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 2006, Joint Commission-accredited hospitals achieved national average performance of 73.1 percent in improving the timely reporting of critical test results and values.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
  

 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 complying with the requirement to implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 93.9 percent in improving the timely reporting of critical test results and values.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
  


National Patient Safety Goal 3:  Improve the safety of using medications.
 
Requirement 3B:  Standardize and limit the number of drug concentrations available in the organization. 
 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of standardizing and limiting the number of drug concentrations available in the organization.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 98.3 percent in standardizing and limiting drug concentrations.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 

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 in 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 complying with the requirement of identifying and, at a minimum, annually reviewing a list of look-alike/sound-alike drugs used in the organization, and taking action to prevent errors involving the interchange of these drugs.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 92.6 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

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
  

National Patient Safety Goal 3: Improve the safety of using medications.
 
Requirement 3D: Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.
 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement to label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 91.1 percent in labeling all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings.

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.



National Patient Safety Goal 4:  Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

 
Requirement 4A: Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
 

 

What this information tells us

These data report the percentage of hospitals complying with the requirement of creating and using a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 97.1 percent in creating and using a preoperative verification process to confirm the availability of appropriate documents.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
 



National Patient Safety Goal 4:  Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

 
Requirement 4B:  Implement a process to mark the surgical site and involve the patient in the marking process. 
 

 
  

What this information tells us

These data report the percentage of hospitals complying with the requirement of implementing a process to mark the surgical site and involving the patient in the marking process.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 93.4 percent in implementing a process of surgical site marking and involving the patient in this process.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 
Note: This requirement is surveyed under The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
 



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 complying with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
 

Result

  • In 2006, 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

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 

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 complying with the requirement of managing as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 99.9 percent in managing as sentinel events all cases of unanticipated death or permanent function loss associated with health care-acquired function. 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 



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

 
Requirement 8A: Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 
 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of implementing a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 66.1 percent in developing a process for obtaining and documenting a complete list of a patient’s medications with the involvement of the patient.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006 
 

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 it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization. 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement of communicating a complete list of the patient’s medications 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.
 

Result

  • In 2006, Joint Commission-accredited hospitals achieved national average performance of 72.5 percent in communicating a complete list of patient medications to the next provider of service.
 

What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 

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

 
Requirement 9B: Implement a fall reduction program and evaluate the effectiveness of the program. 
 
 

What this information tells us

These data report the percentage of hospitals complying with the requirement to implement a fall reduction program and evaluate the effectiveness of the program.
 

Result

  • In 2006, Joint Commission-accredited hospital achieved national average performance of 93.5 percent of assessing and periodically reassessing each patient’s risk for falling.

 What one should know about the data

  • 1,429 hospitals underwent on-site surveys during 2006.
  • North Dakota did not have any surveys in 2006.
 




 
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Copyright 2007 Joint Commission
© 2007 The Joint Commission
To obtain a hard copy of this report, contact Caron Wong at (630) 792-5178.