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Legislation/Regulation > Multi-use Website
Oakbrook Terrace, IL: The Joint Commission; 2018.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, and specific clinical harms such as falls and pressure ulcers. The 2019 NPSGs include two significant revisions. Hospitals and behavioral health facilities now must maintain specific protocols to prevent inpatient suicide, including conducting environmental risk assessments, screening patients admitted for behavioral health reasons for suicide risk, and implementing tailored suicide prevention plans for high-risk patients. The NPSG on ensuring the safety of anticoagulant medications has also been updated to incorporate new evidence in this area.
Journal Article > Study
Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.
This study examined the frequency of medication errors in patients attending an outpatient transplant surgery clinic. Patients in the study were at high risk, taking an average of 11 medications daily. The investigators identified 149 errors in 93 patients, associated with a high risk of clinical adverse events such as hospitalization or rejection of the transplanted organ. Root cause analysis of the errors determined that the health care system was the cause of approximately one-third of the errors, and patient error (failure of the patient to accurately use the prescribed medication) accounted for two-thirds. Errors were identified at every point of the process, from the transplant team to the pharmacy to the patient, and the authors developed a classification system for errors incorporating each of these aspects. A prior study and commentary also discussed the contribution of patient error to the persistent problem of outpatient medication errors.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
Journal Article > Commentary
Pasero C. J Perianesth Nurs. 2013;28:31-37.
Journal Article > Study
Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing.
Meisenberg BR, Grover J, Campbell C, Korpon D. JAMA Network Open. 2018;1:e182908.
Opioid deaths are a major public health and patient safety hazard. This multimodal, health care system-level intervention to reduce opioid overprescribing consisted of changes to the electronic health record, patient education, and provider education and oversight. Opioid prescribing decreased substantially (58%) systemwide with no discernible decrement in patient satisfaction.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.