National Patient Safety Goals Effective January 2021 for the Hospital Program

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National Patient Safety Goals Effective January 2021 for the Hospital Program

National Patient Safety Goals Effective January 2021 for the Hospital Program
National Patient Safety Goals Effective January 2021 for the Hospital Program

The hospital identifies safety risks inherent in its patient population.

Goal 15

Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure.

The Universal Protocol is based on the following principles: – Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented. – A robust approach using multiple, complementary strategies is necessary to achieve the goal of always conducting the correct procedure on the correct person, at the correct site. – Active involvement and use of effective methods to improve communication among all members of the procedure team are important for success. – To the extent possible, the patient and, as needed, the family are involved in the process. – Consistent implementation of a standardized protocol is most effective in achieving safety.

The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. A hospital should consider its culture when designing processes to meet the Universal Protocol. In some hospitals, it may be necessary to be more prescriptive on certain elements of the Universal Protocol or to create processes that are not specifically addressed within these requirements.

Hospitals should identify the timing and location of the preprocedure verification and site marking based on what works best for their own unique circumstances. The frequency and scope of the preprocedure verification will depend on the type and complexity of the procedure. The three components of the Universal Protocol are not necessarily presented in chronological order (although the preprocedure verification and site marking precede the final verification in the time-out). Preprocedure verification, site marking, and the time- out procedures should be as consistent as possible throughout the hospital.

Note: Site marking is not required when the individual doing the procedure is continuously with the patient from the time of the decision to do the procedure through to the performance of the procedure.

© 2020 The Joint Commission Page 10 of 14

Report Generated by DSSM Wednesday, Oct 28 2020

National Patient Safety Goals Effective January 2021 for the Hospital Program

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