Opportunities & challenges with patient safety goals

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 For this week, you will download the Joint Commission’s 2022 Patient Safety Goals and select one safety goal. 

After studying Module 6: Lecture Materials & Resources, discuss the following:

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.


Read and watch the lecture resources & materials below early in the week to help you respond to the discussion questions and to complete your assignment(s).

(Note: The citations below are provided for your research convenience. You should always cross reference the current APA guide for correct styling of citations and references in your academic work.)


  • Mason, D. J., Gardner, D. B., Outlaw, F. H. & O’Grady, E. T. (2020).
    • Chapters 56, 58-60, 62-63, 66, & 70-71



Online Materials & Resources

  • Visit the CINAHL Complete under the A-to-Z Databases on the University Library’s website, locate and read the article(s) below:
    • Dyal, B., Whyte, M., Blankenship, S. M., & Ford, L. G. (2016). Outcomes of implementing an evidence-based hypertension clinical guideline in an academic nurse managed health center. Worldviews on Evidence-Based Nursing, 13(1), 89–93. https://doi.org/10.1111/wvn.12135
    • Thomas-Hawkins, C. (2020). Registered Nurse staffing, workload, and nursing care left undone, and their relationships to patient safety in hemodialysis units. Nephrology Nursing Journal, 47(2), 133–143. https://doi.org/10.37526/1526-744X.2020.47.2.133
  • QSEN Competencies Descargar QSEN Competencies
    Sherwood, G., & Zomorodi, M. (2016). A new mindset for quality and safety: The QSEN Competencies redefine nurses’ roles in practice. Nephrology Nursing Journal, 41(1), 15–72. 
  • National Patient Safety Goals Effective January 2021 for the Hospital ProgramDescargar National Patient Safety Goals Effective January 2021 for the Hospital Program
    The Joint Commission. (2021). Hospital: National patient safety goals for 2021. https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goal

Note:   As always, please remember to support your statements with in-text citations from the literature. 

2022 Hospital
National Patient Safety Goals

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems
in health care safety and how to solve them.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can
be found at www.jointcommission.org.

Get important test results to the right staff person on time.

Reduce the risk for suicide.

Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the
World Health Organization. Set goals for improving hand cleaning. Use the goals to improve
hand cleaning.

Make sure that the correct surgery is done on the correct patient and at the correct place
on the patient’s body.

Mark the correct place on the patient’s body where the surgery is to be done.

Pause before the surgery to make sure that a mistake is not being made.

Use at least two ways to identify patients. For example, use the patient’s name and date of
birth. This is done to make sure that each patient gets the correct medicine and treatment.

Identify patients correctly

Prevent infection

Improve staff communication

Identify patient safety risks

Prevent mistakes in surgery



Before a procedure, label medicines that are not labeled. For example, medicines in syringes,
cups and basins. Do this in the area where medicines and supplies are set up.

Take extra care with patients who take medicines to thin their blood.

Record and pass along correct information about a patient’s medicines. Find out what
medicines the patient is taking. Compare those medicines to new medicines given to the patient.
Give the patient written information about the medicines they need to take. Tell the patient it is
important to bring their up-to-date list of medicines every time they visit a doctor.

Use medicines safely




Make improvements to ensure that alarms on medical equipment are heard and responded to
on time.

Use alarms safely


Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 15

A New Mindset for Quality and Safety:
The QSEN Competencies Redefine Nurses’
Roles in Practice

mproving the quality and safety of
our healthcare system is the most
pressing issue of our time. Since the
Institute of Medicine (IOM) reveal –

ed the magnitude of quality and safe-
ty outcomes in its report, To Err Is
Human: Building a Safer Health System
(IOM, 2000), there has been a grow-
ing series of efforts for improvements,
including changes to health profes-
sions education. In 2003, the IOM
called for a new framework that would
prepare all health professionals with
six core competencies to be able to
deliver patient-centered care through
teamwork and collaboration, with
evidence-based care from continuous
quality improvement, with a mindset
for safety and employing informatics.
These competencies are the founda-
tion to develop and work in cultures
of quality and safety, and change the
mindset from a focus on individual
provider to a system perspective to
improve outcomes. While the compe-
tencies are familiar terms, they were
redefined for nurses in 2007 by the
Quality and Safety Education for
Nurses (QSEN) project with a new set
of knowledge, skills, and attitudes that
change how nurses work (Cronenwett
et al., 2007).

Gwen Sherwood
Meg Zomorodi

Continuing Nursing

Gwen Sherwood, PhD, RN, FAAN, is Professor
and Associate Dean for Academic Affairs,
University of North Carolina at Chapel Hill,
School of Nursing, Chapel Hill, NC, and Co-
Investigator, Quality and Safety Education for
Nursing (QSEN). She may be contacted directly
via email at [email protected]

Meg Zomorodi, PhD, RN, CNL, is a Clinical
Associate Professor, University of North Carolina at
Chapel Hill, School of Nursing, Chapel Hill, NC.

Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-
tion to this continuing nursing education activity.

Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 23.

This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).

American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.

This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.

Copyright 2014 American Nephrology Nurses’ Association

Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN
competencies redefine nurses’ roles in practice. Nephrology Nursing Journal, 41(1), 15-
22, 72. Retrieved from http://www.prolibraries.com/anna/?select=session&

Preventable errors are a major issue in health care. The complexity of health care
requires interactions among numerous providers for any patient multiple times a day.
Nurses are the constant presence with patients and have an important role in coordi-
nating the contributions of the myriad of caregivers. Nurses are also the last line of
defense. Increasingly, it is recognized that nurses need to be better prepared with quality
and safety competencies to have a leading role in making our healthcare system safer.
This article presents evidence related to quality and safety, describes the six core compe-
tencies from the Quality and Safety Education for Nurses (QSEN) project for integration
in nursing practice, describes a practice based on inquiry and engagement, and presents
a toolkit for developing a new mindset based on new quality and safety science.

Key Words: Quality and Safety Education for Nurses (QSEN), quality improve-
ment, patient safety.

To provide an overview of the role quality and safety competencies have in making our
healthcare system safer via the Quality and Safety Education for Nurses project.

1. Identify the evidence driving the imperative to improve healthcare outcomes.
2. Describe applications in practice of the knowledge, skills, and attitudes for the six com-

petencies defined by the Quality and Safety Education for Nurses (QSEN) project.
3. Discuss the changes in roles and responsibilities for nurses when applying the six

QSEN competencies.

This article highlights the evi-
dence driving the imperative to im –
prove healthcare outcomes; describes
applications in practice of the knowl-
edge, skills, and attitudes for the six
competencies defined by the QSEN
project; and discusses the changes in

roles and responsibilities for nurses.
The article also includes strategies for
developing a new mindset to achieve
the competencies, with embedded
clinical situations and a case study
related to nephrology nursing to illus-
trate integration of the competencies.

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 116

A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice

The Imperative to Improve Quality
And Safety

Healthcare professionals, includ-
ing nurses, are well educated and
highly skilled, yet the healthcare sys-
tem continues to be plagued by quali-
ty and safety issues. Healthcare errors
occur at an alarmingly high incidence
and are the eighth leading cause of
death (IOM, 2000; Landrigan, Parry,
Bones, Goldman, & Sharek, 2010).
More people die each year from med-
ical errors than breast cancer or motor
vehicle accidents (Barach & Berwick,
2003). The Institute for Healthcare
Improvement (IHI) (2007) has esti-
mated there are 40,000 incidents of
medical errors every day. At least 1.5
million preventable medication er rors
occur each year in the United States;
this translates to an average of at least
one medication error per day per
patient (Aspen, Walcott, Bootman,
Cronenwett, & the Committee on
Identifying and Preventing Medi –
cation Errors, 2007). Preventable
errors cost the U.S. approximately $17
billion each year (Landrigan et al.,
2010). The latest report card from
Wachter (2010) shows little progress in
the decade following the 1999 report
by the IOM (2000). Nurses, as one of
the largest groups of providers, have
new roles and responsibilities to
improve patient safety and quality.
What education and preparation to
engage nurses as leaders could
improve our systems of care?

Quality and safety are core val-
ues in health care based on the com-
mitment to uphold ethical principles
to do no harm, always safeguard the
patient, and act with ethical comport-
ment (Egan, 2013). Quality is an in –
herent approach to doing good work;
nurses come to work wanting to per-
form good work, but they sometimes
lack the preparation and tools or may
work in systems where good work is
not recognized or supported. Evi –
dence supports that nurses want to
work in systems that recognize good
work and uphold a work environ-
ment that supports quality and safety
(IOM, 2004; Manojlovich & DeCicco,
2007; Wong & Cummings, 2007). The

MagnetTM recognition program stan-
dards are consistent with a safety cul-
ture through the focus on quality
improvement, strong leadership, and
interdisciplinary collaboration (Di
Bennedetto et al., 2011; Pischke-Winn,
Stratton, Ferket, & Micek, 2013; Triolo,

Changing Perspectives
On Quality and Safety

The new science of quality and
safety shifts from prevailing models
focused on individual actions to a
focus on system improvements.
Quality and safety overlap, and each
contributes to the other, but each has
its own body of knowledge, skills, and

Simply put, quality measures
actual performance of a standard pro –
cess or event ( Johnson, 2012), such as
the number and types of patient falls
over a period of time in a particular
setting. These data are compared with
benchmarks in other departments in
the same organization and/or with
other similar organizations, or against
an ethical standard of zero occur-
rences. In the case of falls, ethically,
no patient should experience a fall, so
quality improvement efforts are
aimed at zero occurrences.

Safety, on the other hand, is pre-
venting errors and negative outcomes
that happen unrelated to the patient
condition being treated, and again,
the goal is zero occurrences. Safety is
constantly scanning the environment
to prevent mistakes from happening
(Barnsteiner, 2012). The mindset is on
prevention; there is constant aware-
ness of the potential for a patient to
fall, and steps are taken for preven-
tion. The individual action is the
nurse including a reminder to check
on a patient at risk for falls in the
day’s task list; a system design is using
a mattress alarm to alert staff that a
patient at risk for falls has gotten out
of bed unattended.

Safety is the watchful eye that
prevents errors. Quality measures
events and seeks improvements
through quality initiatives.

Safety Culture: A System

Safety culture is a subset of orga-
nizational culture defined by the val-
ues and beliefs about health and safety
evident in the way the organization
lives (Reason & Hobbs, 2003). Safety
culture is the visible evidence of how
individuals and the overall organiza-
tion manage risks and hazards to avoid
damage or losses and achieve their
goals. Safety culture reflects the com-
mon understanding about safety and
emerges from the dynamic reciprocal
interaction among people, tasks, and
systems (Feng, Bobay, & Weiss, 2008).

Other high performance indus-
tries, such as aviation, nuclear power,
and railway, have adopted safety as
an essential standard and changed the
culture that drives their systems to
make safety a priority with the focus
on where the next error could occur
(Roberts, Yu, & van Stralen, 2013).
Health care is adopting methods from
these industries that have produced
dramatic safety improvements. In the
past, health care has focused on the
individual performance and estab-
lished blame for the error, and little
information was shared with patients
and families (Ashpole, 2013). Today,
efforts have been made to shift the
focus in the healthcare system to one
of quality and safety, where errors
(safety) are recognized as a break-
down in processes (quality) and
reported to a central database. Then
the errors are investigated to identify
the steps in every related process to
determine where different decisions
or actions could have prevented the
error (Sutcliffe, 2011). The process or
system is then redesigned to mitigate
future occurrences. The mindset is on
preventing errors from happening
through awareness and alertness to
system breakdowns to interrupt the
pathway towards an error (a near

To illustrate a system approach, a
nurse administered an adult dose of a
high-risk medication to an infant. The
mistake was reported and investigat-
ed by the risk management team to
determine what happened from the

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 17

purchasing department, to the phar-
macy, to the unit, to the medication
administration process. The root
cause analysis (RCA) revealed that
both the pediatric and the adult unit
doses came in similar vials, different
only in the small lettering detailing
the dosage, and both were stored in
adjacent bins. To address this prob-
lem, the bins were relocated and
labeling clarified to reduce the likeli-
hood that the wrong vial would be
picked up in a rush. However, the
mindset did not stop there. Additional
organizations that shared benchmark-
ing practices were scanned, revealing
that others had reported a similar mis-
take. Together, the organizations
leveraged the manufacturer to change
the packaging to more clearly distin-
guish the two dosages. Additionally,
there was a search to see if other med-
ications were at similar risk of
misidentification due to similar pack-
aging, thus preventing future errors
from occurring. This process of trans-
parent communication is a key part of
safety culture, so information about
what happened and steps taken to
prevent future occurrences are shared
with patients and families (Sammer,
Lykens, Singh, Mains, & Lackan,
2010). In this scenario, the nurse who
administered the medication was still
accountable, while also updating
her/his knowledge on the evidence-
based standards for safe medication
administration, and system changes
were established to help prevent
future mistakes when human factors
lead to a process breakdown.

A New Mindset to Improve Quality
And Safety: Applying the QSEN

Recognizing the need for changes
in how nurses are educated to meet
practice demands for quality and safe-
ty, the Quality and Safety Education
for Nurses (QSEN) (www.qsen.org)
project (funded by the Robert Wood
Johnson Foundation) established a
national expert panel to define the six
core competencies established by the
2003 IOM report for integrating a
quality and safety framework for

nursing (Cronenwett et al., 2007). The
panel identified knowledge, skills,
and attitudes essential to achieve each
competency stated as objectives for
integration into curricula (Cronenwett
et al., 2007) and are now part of
national nursing education curricula
standards. The definition for each com-
petency with a summary of expecta-
tions for practice are shown in Table 1;
all 162 knowledge, skill, and attitude
statements are available online (www.
qsen.org), in Cronenwett et al. (2007),
and in Sherwood and Barnsteiner
(2012). Graduate competencies reflect
higher order performance expected
of graduate nurses (Cronenwett et al.,
2009) and are embedded in the
American Association for Colleges of
Nursing (AACN) essentials for
Master’s and DNP education; they
were updated in 2012 (AACN, 2012).

Applying the QSEN
Competencies in Practice

The competencies defined by the
QSEN project apply for all of nursing
practice: patient-centered care, team-
work and collaboration, evidence-
based practice, quality improvement,
safety, and informatics (see Table 1).
Each competency is described for
applications in nursing practice with
particular application in nephrology

Patient-centered care. Patient-
centered care is demonstrated through
respect, response, and clear commu-
nication, and always asking patients
their preference for which name they
wished to be called (Walton &
Barnsteiner, 2012). Patient- and family-
centered care was first defined by the
Picker Institute as improving health
care through the eyes of the patient
(Gerteis, Edgman-Levitan, Daley, &
Delbanco, 1993). When patients and
their families are involved in making
decisions about their care, the focus
shifts from “doing to” to “doing with.”
When patients and families are treat-
ed as members of the care team, they
can become safety allies, thus pre-
venting errors. For example, patients
may alert clinicians when care is not
according to their usual routine or by
noticing a different medication. Care

planning is based on cultural aware-
ness and assessments to know patient
values, beliefs, and preferences.
Evidence continues to raise questions
about policies and procedures that
separate patients and families, partic-
ularly visiting hours.

Patient-centered approaches to
pain management is an area of partic-
ular concern to nephrology nurses to
know patient preferences and goals
for managing pain, providing patient-
appropriate education, and knowing
when to administer pharmacologic
agents or use complementary thera-
pies. In the hospital, practical applica-
tions include communication using
white boards in the patient’s room to
identify persons caring for the patient,
daily care goals, and scheduled treat-
ments. Patients and their families like-
wise use the boards to record infor-
mation or register questions for the
care team. Some units have provided
long-term patients and their families
with small journals to maintain a
health history, and keep records of
treatments, medications, or other
health information.

Teamwork and collaboration.
Communication and collaboration
are at the root of teamwork, but the
education of health professionals is by
individual discipline, both formally
and in continuing education (Disch,
2012). Thus, there is little interprofes-
sional contact until new graduates are
thrust into practice settings to work
closely together, often under stressful
conditions. Between 1995 and 2005,
ineffective communication and break-
downs in working together was the
root cause of 66% of healthcare errors
(Hughes, 2008). Adverse drug events
most often occur at transition points
in care or during handoffs, from one
provider to another (Hughes, 2008).

Teamwork and collaboration are
essential for coordinating complex
care involving several health care dis-
ciplines (Simmons & Sherwood, 2010),
which is especially important for
nephrology patients whose care may
involve multiple providers. Knowing
the roles and responsibilities of other
team members can help nurses navi-
gate the complicated web of commu-

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 118

A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice

nication and hierarchy so prevalent in
health care (Disch, 2012). Participa –
ting in interprofessional rounds that
include patients and families helps to
coordinate information, set daily care
goals, and manage schedules for the
various treatments. Nurses need to
know how to speak up when care is
compromised (see Table 2), and to do
this, must have organizational support
to back them up (Manojlovich &
DeCicco, 2007; Wong & Cummings,

2007). Teamwork requires flexible
leadership that shifts to match expert-
ise and role of the team members.

TeamSTEPPS® is an evidence-
based curriculum for developing
teamwork to improve quality and
safety (Agency for Healthcare Research
& Quality [AHRQ], n.d.). Research
shows that the risk of serious adverse
events is reduced when team training
has been implemented (Hughes,
2008). The knowledge and skills

taught in TeamSTEPPS are often
embedded in simulation (Carswell,
2013). Standardized communications
(see Table 2) help reduce risks during
transitions and handoffs, reduce
reliance on memory, assure that criti-
cal information is shared, and help
team members speak up when they
see safety hazards.

Evidence-based practice. Patient
care is based on evidence-based prac-
tice standards and industry best stan-

Table 1
Quality and Safety Competencies Defined by the QSEN Project with Summary Expectations for Nurses

Derived from the Knowledge, Skills, and Attitudes

Competency Definition Examples of Expectations


Recognize the patient or designee as the source of
control and full partner in providing compassionate
and coordinated care based on respect for
patient’s preferences, values, and needs.

• Provides nursing care based on individual and family
needs and preferences.

• Applies cultural awareness in the provision of health
care services, including aspects of nutrition, spiritual
resources, and patient education.

• Uses effective interpersonal communication skills.

Teamwork and

Function effectively within nursing and inter-
professional teams, fostering open communication,
mutual respect, and shared decision-making to
achieve quality patient care.

• Recognizes own strengths and limitations as a team

• Communicates and collaborates effectively in
intranursing and interprofessional teams to achieve
best outcomes for the patient.

• Treats patient and family as active team members.


Integrate best current evidence with clinical
expertise and patient/family preferences and
values for delivery of optimal health care.

• Uses current evidence based standards in care

• Evaluates evidence to determine best practices.
• Determines deviations from standards to

accommodate patient beliefs and preferences.


Use data to monitor the outcomes of care
processes and use improvement methods to
design and test changes to continuously improve
the quality and safety of health care systems.

• Identifies processes or issue for improvement.
• Assists with measurement of the process or issue

against benchmarks.
• Can identify good practice.
• Apply process improvement strategies to improve

process or issue.

Safety Minimize risk of harm to patients and providers
through both system effectiveness and individual

• Applies new safety science for awareness of
breakdowns in processes.

• Recognizes and reports errors and near misses that
compromise patient safety.

• Participates in analysis of adverse events and near
misses for root cause analysis.

Informatics Use information and technology to communicate,
manage knowledge, mitigate error, and support

• Applies skills in data and information management to
access latest evidence.

• Uses decision support tools appropriately.
• Records data and patient information in electronic

health records.

Source: Adapted from Cronenwett et al., 2007.

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 19

dards (Tracey & Barnsteiner, 2012).
Nephrology nurses need to know the
standards of care that guide their
practice and recognize those interven-
tions that carry high risk, such as
managing all types of catheters, pre-
venting infections, and maintaining
fluid balance (Gomez, 2011). In
patient-centered care, nurses recog-
nize when to deviate from standards
to consider patient preferences, val-
ues, and beliefs within an evidence-
based approach. Nurses who practice
from a spirit of inquiry with reflection
on care delivered will use skills in
informatics to seek current evidence
to determine best practices and clari-
fy care decisions. They monitor their
practice, reflecting on when changes
are needed, and formulate clinical
questions to seek new evidence so
practice is constantly developing and

Quality improvement. The
spirit of inquiry promotes an attitude
of continuously improving care every
day with every patient ( Johnson,
2012). Quality improvement first
measures variance between ideal and
actual care, and then implements
strategies to close any gaps. Nurses
use quality improvement tools and
informatics to seek evidence and
measure care outcomes, as well as
benchmark data to assess current
practice. The American Nephrology
Nurses’ Association’s publication,
Applying Continuous Quality Improve –
ment in Clinical Practice, is a resource
for information on quality improve-
ment tools and applications in neph –
rology nursing (Axley & Robbins,
2009). Nurses benchmark in their
local system as well as against nation-
al standards. The National Database
of Nursing Quality Indica tors from
the American Nurses Association
(n.d.) is one example of a benchmark-
ing source where surgical site infec-
tions, pain assessment, pressure ulcer
development, and falls can be exam-

Safety. Safety is the effort to min-
imize the risk of harm to patients and
providers by improving both system
effectiveness and individual perform-
ance (Barnsteiner, 2012). Every nurse,

and in fact, every employee and
patient, is responsible for safety. A
safety culture, discussed earlier, en –
courages asking how one’s actions
affect patient risk, where the next
error is likely to occur, and how to
prevent near misses, and there is a
reporting system for collecting infor-
mation on adverse and sentinel events.
Many goals on the annual list of
National Patient Safety Goals from
The Joint Commission (2013) are rel-
evant for nephrology nursing, such as
medication safety, healthcare-associ-
ated infections, central line-associated
bloodstream infections, pain manage-
ment, responding to changes in
patient condition, communication,
and handoffs.

Standardized communication,
described in Table 2, can assure that
essential information is shared with

the correct providers to overcome
forgetfulness or lack of attention.
Human factors consider the mix of
people, tasks, and the environment;
conditions in the environment, such
as distractions, interruptions, and
other environmental conditions,
impact error potential. Training can
increase skills in situation monitoring,
environmental scanning, and shared
decision-making. Working together,
nurses can develop strategies to better
manage task overloads, staff fluctua-
tions, and interruptions.

Informatics. Informatics is a crit-
ical skill for achieving all the compe-
tencies by helping manage care.
Technology, such as electronic health
records, helps communicate care
coordination by recording and shar-
ing information about a patient
(Warren, 2012). Other applications

Table 2
Standardized Communication Strategies from TeamSTEPPS


Strategy Application

SBAR: Used to
develop and refine

Situation: A statement of what is happening right now
that needs attention.
Background: Information that puts the situation into
context and explains the circumstances that have led to
the situation.
Assessment: Conveys the communicators’ thoughts
about the problem.
Recommendation: What should be done to correct the
problem, when and by whom.

CUS: Used to raise
safety concerns,
moves to next
statement if no action.

C: I am concerned.
U: I am uncomfortable.
S: I think this is a safety issue. (If no action, next step is to
go up the chain of command for help.)

Check back: Used to
clarify communication.

Repeat back an order, a request, or other critical
information to be sure there was clear communication.

Briefings: Plan care? What is the most important thing this patient needs?
What are safety issues?
What are the benchmarks and/or evidence for the care

Huddles: Problem
solve or clarify
strategy, get everyone
on the same page.

What is priority?
What else could it be?
What could we do differently?
What was done well?

Debriefing: Review
and feedback.

What did not go well?
What could be done differently next time?

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 120

A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice

Figure 1
Applying the QSEN Competencies: A Case Study

The following unfolding case study provides an exemplar of
integrating quality and safety in nephrology nursing and poses a
number of provocative questions about the patient’s experience.
The case study is most effective when discussed with nurses,
physicians, and others on the care team to identify opportunities
for safety interventions and for quality improvement.

Mr. Orange is a 45-year-old African-American male who
has been on hemodialysis for the past six months using a cen-
tral venous catheter access following a failed kidney transplant
with chronic allograft nephropathy. His history includes high
blood pressure, diabetes, and allergy to penicillin.

Today, he wants his 10-year-old daughter to remain with
him during his treatment because his wife could not miss any
more days of work. The clinic is crowded, and you are con-
cerned about the presence of a child in the treatment area; clin-
ic policy prevents children from accompanying patients. Yet, it is
obviously very important to Mr. Orange that his daughter
remains with him, and she is providing distraction from the dis-
comfort of his treatment. You recently read an article that chal-
lenged visiting rules, with evidence that patients benefit from
having their family member with them, and there is no impact on
infection rates or disruption to staff when they are provided
space to be with their loved one. As you talk to Mr. Orange about
his diet, his daughter becomes engaged in the information you
are presenting, and begins a conversation with her father that
helps you to better understand his attitudes towards his diet, an
important aspect of his care plan.
• What stands out in this situation?
• What actions are consistent/inconsistent with patient-cen-

tered care?
• What practice implications or quality improvement projects

come to mind when examining this scenario?
Coordinating Mr. Orange’s care requires collaboration

among several specialty physicians, including the transplant
team, physical therapy, social work, and nutritional services.
Appointments in the clinic are a careful scheduling balance with
each provider to coordinate treatment plans.

Prior to initiation of the hemo dialysis treatment, Mr. Orange
mentions there was some blood in the small amount of urine he
passed before coming to the dialysis facility today. As part of
your pre-treatment assessment, you palpate the area of his
transplanted kidney in his iliac fossa, and he squirms as you
apply pressure and admits that it is tender to palpation. You
recall that his im munosuppression has been tapered, and he is
only on a minimal dose of alternate day immunosuppressive

• What stands out? What are priorities? Why, and what are
alternative approaches?
Mr. Orange has now been admitted to the hospital for fur-

ther assessment, and it is determined he requires a transplant
nephrectomy due to more active rejection superimposed on the
chronic allograft nephropathy in the presence of reduced
immunosuppression. He has just been admitted to Room 6222
from the recovery room. The nurse, a new graduate, is taking the
vital signs as ordered every 15 minutes as per protocol of a new
admission. He notices the patient’s blood pressure has fallen
slightly (118/70). Concerned, he pages the resident. When the
resident calls back, the nurse reports the blood pressure to her.
The resident informs the nurse that this is a normal blood pres-
sure and says to not worry. An hour later, the nurse notices that
Mr. Orange is growing agitated and complaining of belly pain.
The nurse checks the blood pressure and notices that it is it is
lower (90/68). The nurse pages the resident.
• What stands out?
• What is the most important action to take? Why?
• What are alternatives?
• How should the nurse communicate with the resident?

The resident informs the nurse that the patient’s blood pres-
sure is lower due to his medication. The nurse, although not con-
vinced, does not push the issue further. As a new graduate, he
is hesitant to challenge the response. The nurse returns to room
6222 and finds Mr. Orange doubled over in pain and growing
increasingly pale. The nurse once again pages the resident and
waits for 15 minutes by the phone. While waiting for the resident
to call him back, the nurse returns to room 6222 to take the next
set of vital signs. The patient is unresponsive.
• What stands out?
• What stands out in the scenario?
• What is the priority? Why? What evidence supports this?
• What are alternatives, what else could it be?
• What went well in the case and what could have been

Discuss aspects of the case related to each of the compe-

tencies: patient centered care, teamwork and collaboration, evi-
dence base practice, quality improvement, safety and informat-
• How do nurses and other care givers, especially physicians,

deal with disagreements in patient status?
• What are lessons to prevent future occurrences?

include safety alerts for the need for
action, decision support tools, litera-
ture searches for the latest evidence,
and management of quality improve-
ment data and strategies. It is impor-
tant that nurses participate in design-
ing applications, making decisions on
purchases, and developing training

materials on using information sys-
tems and patient related technology.

Engagement and Inquiry:
Developing a Quality Safe Practice

Investment in safety is demon-
strated through engagement and in –

quiry. Nurses who bring attention and
mindfulness to their work engage and
focus on each patient, notice break-
downs in care processes and seek solu-
tions, employ best practices, and
participate in lifelong learning
(Sherwood, 2012). Engaged nurses
develop a mindset for safety, use situ-

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 21

ation monitoring to scan the environ-
ment for contextual factors that influ-
ence actions, and watch each other’s
backs to provide mutual support
when needed. Engaged nurses prac-
tice from a spirit of inquiry and ask
questions about their actions, if it is
evidence-based or best practice
(Armstrong & Sherwood, 2012). They
recognize safety issues in work-
arounds when standard operations
break down and act to prevent error,
know how to employ continuous
quality improvement to call a team
meeting to address failures in the sys-
tem and together create new process-
es, and work with the organization in
seeking system-based solutions rather
than relying on individual perform-
ance and skill. Engaged nurses are
more satisfied from doing work well,
which leads to higher satisfaction and
longer retention, and contributes to a
healthy work environment (Armstrong,
Laschinger, & Wong, 2009).

A Tool Kit to Develop
A Quality and Safety Mindset

How do nurses initiate a practice
based on quality and safety? What
tools help with the transformation?
Engaged nurses plan their work
beyond mere memorization of facts
or completing a task list; nurses can
learn from experiences to synthesize
and apply knowledge in advancing
their practice. This is the process of
inquiry in action: asking questions
about their work promotes continu-
ous learning from accumulated expe-
riences through reflection informed
by didactic knowledge. Tanner’s
(2006) clinical judgment model helps
nurses understand how they make
informed decisions in practice. They
notice what is happening, interpret the
meaning and significance, respond in
meaningful evidence based ways, and
reflect on what happened to be able to
improve decision making in the future.

Analyzing case studies, particu-
larly with other disciplines, is an effec-
tive strategy to reframe events and
encourage a spirit of inquiry to exam-
ine what happened, distinguish good
care from compromised care, discuss
conflicting ethical situations, examine

cultural sensitivity, share knowledge,
learn how to provide and accept feed-
back, and promote professional
development. Cases can be used for
both low-fidelity (role play) or high-
fidelity (computerized mannequins)
simulation to be able to practice
teamwork and communication, nego-
tiate problem solving, improve skills,
apply evidence-based best practices,
and increase awareness of the poten-
tial for error. Briefings, huddles, and
debriefings help manage care, keep
everyone on the same page, and learn
from experience (see Table 2).

Reflective practice is the founda-
tion for analyzing unfolding case stud-
ies or simulations. Reflection is a sys-
tematic way of thinking about one’s
actions and responses to improve future
actions and responses (Sherwood &
Horton-Deutsch, 2012). It is a change
process that incorporates experiential
learning by considering what one
knows, believes, and values within
the context of an event. It is also a
personal growth strategy to help nurs-
es cope with the emotional labor of
nursing to make sense of events.
Reflection reframes the situation,
leading to feelings of satisfaction with
work. Reflection can help nurses cope
with confusing workforce issues and
the complicated context of health
care that depletes energy and motiva-
tion. Reflective practice is a habit of
the mind that helps develop profes-
sional maturity through the continued
development of practice knowledge,
constant quality improvement and
attention to safety, and renewal of the
human spirit.

There are always competing pri-

orities that challenge practice. New
definitions of the six quality and safe-
ty competencies developed by the
QSEN project are transforming nurs-
ing education and practice. Case story
analysis and reflective practice can
promote nurse learning to help devel-
op a new mindset and achieve behav-
ior change (see Figure 1). Nurses have
important roles in redesigning health-
care delivery to assure that it is

patient-centered, delivered by inter-
professional teams, based on evi-
dence-based standards with continu-
ous quality im provement, in a culture
of safety, and using informatics. With
a mindset for quality and safety, nurs-
es engage in their work with the
patient as the focus, encourage
inquiry, apply evidence-based stan-
dards and interventions, investigate
outcomes and critical incidents from a
system perspective, and reflect on sit-
uations in their work to continuously
seek to improve care.

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American Nurses Association. (n.d.).
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Retrieved from http://www.nursing
w o r l d . o r g / R e s e a r c h -To o l k i t /

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Armstrong, K., Laschinger, H.K.S., &
Wong, C. (2009). Workplace empow-
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Ashpole, L. (2013). Creating a just culture:
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continued on page 72

Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 23

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A New Mindset for Quality and Safety: The QSEN Competencies
Redefine Nurses’ Roles in Practice

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Mindset for Quality
continued from page 22

Wachter, R.M. (2010). Patient safety at
ten: Unmistakable progress, trou-
bling gaps. Health Affairs, 29(1),

Walton, M.K., & Barnsteiner, J. (2012).
Patient centered care. In G.
Sherwood & J. Barnsteiner (Eds.),
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petency approach to improving out-
comes (pp. 67-90). Hoboken, NJ:

Warren, J. (2012). Informatics. In G.
Sherwood & J. Barnsteiner (Eds.),
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petency approach to improving out-
comes (pp. 171-187). Hoboken, NJ:

Wong, C., & Cummings, G. (2007). The
relationship between nursing lead-
ership and patient outcomes: A
systematic review. Journal of Nursing
Management, 10(2), 285-305.

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download, or email articles for individual use.

Goal 1
Improve the accuracy of patient identification.


Use at least two patient identifiers when providing care, treatment, and services.

–Rationale for NPSG.01.01.01–

Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-
fold: first, to reliably identify the individual as the person for whom the service or treatment is intended;
second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s
name, an assigned identification number, telephone number, or other person-specific identifier.

Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable
features. In addition to well-known misidentification errors such as wrong patient/wrong procedure,
misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which
poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system
among all providers is necessary to prevent errors.

Element(s) of Performance for NPSG.01.01.01

1. Use at least two patient identifiers when administering medications, blood, or blood components; when
collecting blood samples and other specimens for clinical testing; and when providing treatments or
procedures. The patient’s room number or physical location is not used as an identifier.
(See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)

2. Label containers used for blood and other specimens in the presence of the patient.
(See also PC.02.01.01, EP 10)

3. Use distinct methods of identification for newborn patients.
Note: Examples of methods to prevent misidentification may include the following:
– Distinct naming systems could include using the mother’s first and last names and the newborn’s
gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
– Standardized practices for identification banding (for example, using two body sites and/or bar coding
for identification).
– Establish communication tools among staff (for example, visually alerting staff with signage noting
newborns with similar names).

© 2020 The Joint Commission
Page 1 of 14

Report Generated by DSSM
Wednesday, Oct 28 2020

National Patient Safety Goals Effective
January 2021 for the Hospital Program

Goal 2
Improve the effectiveness of communication among caregivers.


Report critical results of tests and diagnostic procedures on a timely basis.

–Rationale for NPSG.02.03.01–

Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate
a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within
an established time frame so that the patient can be promptly treated.

Element(s) of Performance for NPSG.02.03.01

1. Develop written procedures for managing the critical results of tests and diagnostic procedures that
address the following:
– The definition of critical results of tests and diagnostic procedures
– By whom and to whom critical results of tests and diagnostic procedures are reported
– The acceptable length of time between the availability and reporting of critical results of tests and
diagnostic procedures

2. Implement the procedures for managing the critical results of tests and diagnostic procedures.

3. Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

Goal 3
Improve the safety of using medications.


Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other
procedural settings.
Note: Medication containers include syringes, medicine cups, and basins.

–Rationale for NPSG.03.04.01–

Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have
resulted from medications and other solutions removed from their original containers and placed into
unlabeled containers. This unsafe practice neglects basic principles of safe medication management, yet it is
routine in many organizations.

The labeling of all medications, medication containers, and other solutions is a risk-reduction activity
consistent with safe medication management. This practice addresses a recognized risk point in the
administration of medications in perioperative and other procedural settings. Labels for medications and
medication containers are also addressed at Standard MM.05.01.09.

Element(s) of Performance for NPSG.03.04.01

1. In perioperative and other procedural settings both on and off the sterile field, label medications and
solutions that are not immediately administered. This applies even if there is only one medication
being used.
Note: An immediately administered medication is one that an authorized staff member prepares or
obtains, takes directly to a patient, and administers to that patient without any break in the process.
Refer to NPSG.03.04.01, EP 5, for information on timing of labeling.

© 2020 The Joint Commission
Page 2 of 14

Report Generated by DSSM
Wednesday, Oct 28 2020

National Patient Safety Goals Effective
January 2021 for the Hospital Program

2. In perioperative and other procedural settings both on and off the sterile field, labeling occurs when
any medication or solution is transferred from the original packaging to another container.

3. In perioperative and other procedural settings both on and off the sterile field, medication or solution
labels include the following:
– Medication or solution name
– Strength
– Amount of medication or solution containing medication (if not apparent from the container)
– Diluent name and volume (if not apparent from the container)
– Expiration date when not used within 24 hours
– Expiration time when expiration occurs in less than 24 hours
Note: The date and time are not necessary for short procedures, as defined by the hospital.

4. Verify all medication or solution labels both verbally and visually. Verification is done by two individuals
qualified to participate in the procedure whenever the person preparing the medication or solution is
not the person who will be administering it.

5. Label each medication or solution as soon as it is prepared, unless it is immediately administered.
Note: An immediately administered medication is one that an authorized staff member prepares or
obtains, takes directly to a patient, and administers to that patient without any break in the process.

6. Immediately discard any medication or solution found unlabeled.

7. Remove all labeled containers on the sterile field and discard their contents at the conclusion of the
Note: This does not apply to multiuse vials that are handled according to infection control practices.

8. All medications and solutions both on and off the sterile field and their labels are reviewed by entering
and exiting staff responsible for the management of medications.


Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
Note: This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for
preventing venous thromboembolism (for example, related to procedures or hospitalization).

–Rationale for NPSG.03.05.01–

Anticoagulation therapy can be used as therapeutic treatment for several conditions, the most common of
which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant.
However, it is important to note that anticoagulant medications are more likely than others to cause harm due
to complex dosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety
Goal has great potential to positively impact the safety of patients on this class of medications, including
improving patient outcomes.

To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy
program. Effective anticoagulation education includes face-to-face interaction with a trained professional who
works closely with patients to be sure that they understand the risks involved with anticoagulation therapy
and the precautions they need to take. The use of standardized practices for anticoagulation therapy that
include patient involvement can reduce the risk of adverse drug events associated with heparin
(unfractionated), low molecular weight heparin, warfarin, and direct oral anticoagulants (DOACs).

Element(s) of Performance for NPSG.03.05.01

1. The hospital uses approved protocols and evidence-based practice guidelines for the initiation and
maintenance of anticoagulant therapy that address medication selection; dosing, including
adjustments for age and renal or liver function; drug–drug and drug–food interactions; and other risk
factors as applicable.

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2. The hospital uses approved protocols and evidence-based practice guidelines for reversal of
anticoagulation and management of bleeding events related to each anticoagulant medication.

3. The hospital uses approved protocols and evidence-based practice guidelines for perioperative
management of all patients on oral anticoagulants.
Note: Perioperative management may address the use of bridging medications, timing for stopping an
anticoagulant, and timing and dosing for restarting an anticoagulant.

4. The hospital has a written policy addressing the need for baseline and ongoing laboratory tests to
monitor and adjust anticoagulant therapy.
Note: For all patients receiving warfarin therapy, use a current international normalized ratio (INR) to
monitor and adjust dosage. For patients on a direct oral anticoagulant (DOAC), follow evidence-based
practice guidelines regarding the need for laboratory testing.

5. The hospital addresses anticoagulation safety practices through the following:
– Establishing a process to identify, respond to, and report adverse drug events, including adverse
drug event outcomes
– Evaluating anticoagulation safety practices, taking actions to improve safety practices, and
measuring the effectiveness of those actions in a time frame determined by the hospital

6. The hospital provides education to patients and families specific to the anticoagulant medication
prescribed, including the following:
– Adherence to medication dose and schedule
– Importance of follow-up appointments and laboratory testing (if applicable)
– Potential drug–drug and drug–food interactions
– The potential for adverse drug reactions

7. The hospital uses only oral unit-dose products, prefilled syringes, or premixed infusion bags when
these types of products are available.
Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for

8. When heparin is administered intravenously and continuously, the hospital uses programmable pumps
in order to provide consistent and accurate dosing.

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Introduction to Reconciling Medication Information
The large number of people receiving health care who take multiple medications and the
complexity of managing those medications make medication reconciliation an important safety
issue. In medication reconciliation, a clinician compares the medications a patient should be using
(and is actually using) to the new medications that are ordered for the patient and resolves any

The Joint Commission recognizes that organizations face challenges with medication reconciliation.
The best medication reconciliation requires a complete understanding of what the patient was
prescribed and what medications the patient is actually taking. It can be difficult to obtain a
complete list from every patient in an encounter, and accuracy is dependent on the patient’s ability
and willingness to provide this information. A good faith effort to collect this information is
recognized as meeting the intent of the requirement. As health care evolves with the adoption of
more sophisticated systems (such as centralized databases for prescribing and collecting
medication information), the effectiveness of these processes will grow.

This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation.
The elements of performance in this NPSG are designed to help organizations reduce negative
patient outcomes associated with medication discrepancies. Some aspects of the care process that
involve the management of medications are addressed in the standards rather than in this goal.
These include coordinating information during transitions in care both within and outside of the
organization (PC.02.02.01), patient education on safe medication use (PC.02.03.01), and
communications with other providers (PC.04.02.01).

In settings where medications are not routinely prescribed or administered, this NPSG provides
organizations with the flexibility to decide what medication information they need to collect based
on the services they provide to patients. It is often important for clinicians to know what medications
the patient is taking when planning care, treatment, and services, even in situations where
medications are not used.


Maintain and communicate accurate patient medication information.

–Rationale for NPSG.03.06.01–

There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is
intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is
taking (or should be taking) with newly ordered medications. The comparison addresses duplications,
omissions, and interactions, and the need to continue current medications. The types of information that
clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and
purpose. Organizations should identify the information that needs to be collected in order to reconcile current
and newly ordered medications and to safely prescribe medications in the future.

Element(s) of Performance for NPSG.03.06.01

1. Obtain information on the medications the patient is currently taking when he or she is admitted to the
hospital or is seen in an outpatient setting. This information is documented in a list or other format that
is useful to those who manage medications.
Note 1: Current medications include those taken at scheduled times and those taken on an as-needed
basis. See the Glossary for a definition of medications.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good
faith effort to obtain this information from the patient and/or other sources will be considered as
meeting the intent of the EP.

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2. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be
collected in non-24-hour settings.
Note: Examples of non-24-hour settings include the emergency department, primary care, outpatient
radiology, ambulatory surgery, and diagnostic settings.

3. Compare the medication information the patient brought to the hospital with the medications ordered
for the patient by the hospital in order to identify and resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and
changes. A qualified individual, identified by the hospital, does the comparison. (See also
HR.01.06.01, EP 1)

4. Provide the patient (or family, caregiver, or support person as needed) with written information on the
medications the patient should be taking when he or she is discharged from the hospital or at the end
of an outpatient encounter (for example, name, dose, route, frequency, purpose).

5. Explain the importance of managing medication information to the patient when he or she is
discharged from the hospital or at the end of an outpatient encounter.
Note: Examples include instructing the patient to give a list to his or her primary care physician; to
update the information when medications are discontinued, doses are changed, or new medications
(including over-the-counter products) are added; and to carry medication information at all times in the
event of emergency situations. (For information on patient education on medications, refer to
Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

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Goal 6
Reduce patient harm associated with clinical alarm systems.


Improve the safety of clinical alarm systems.

–Rationale for NPSG.06.01.01–

Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not
properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations,
individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous
alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to
miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm
system management include too many devices with alarms, default settings that are not at an actionable
level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within
different units in a single hospital.

There is general agreement that this is an important safety issue. Universal solutions have yet to be
identified, but it is important for a hospital to understand its own situation and to develop a systematic,
coordinated approach to clinical alarm system management. Standardization contributes to safe alarm
system management, but it is recognized that solutions may have to be customized for specific clinical units,
groups of patients, or individual patients. This NPSG focuses on managing clinical alarm systems that have
the most direct relationship to patient safety.
Note: Additional information on alarm safety can be found on the AAMI website

Element(s) of Performance for NPSG.06.01.01

1. Leaders establish alarm system safety as a hospital priority.

2. Identify the most important alarm signals to manage based on the following:
– Input from the medical staff and clinical departments
– Risk to patients if the alarm signal is not attended to or if it malfunctions
– Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm
– Potential for patient harm based on internal incident history
– Published best practices and guidelines
(For more information on managing medical equipment risks, refer to Standard EC.02.04.01)

3. Establish policies and procedures for managing the alarms identified in EP 2 above that, at a
minimum, address the following:
– Clinically appropriate settings for alarm signals
– When alarm signals can be disabled
– When alarm parameters can be changed
– Who in the organization has the authority to set alarm parameters
– Who in the organization has the authority to change alarm parameters
– Who in the organization has the authority to set alarm parameters to “off”
– Monitoring and responding to alarm signals
– Checking individual alarm signals for accurate settings, proper operation, and detectability
(For more information, refer to Standard EC.02.04.03)

4. Educate staff and licensed independent practitioners about the purpose and proper operation of alarm
systems for which they are responsible.

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Goal 7
Reduce the risk of health care–associated infections.


Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the
current World Health Organization (WHO) hand hygiene guidelines.

–Rationale for NPSG.07.01.01–

According to the Centers for Disease Control and Prevention, each year, millions of people acquire an
infection while receiving care, treatment, and services in a health care organization. Consequently, health
care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations.
One of the most important ways to address HAIs is by improving the hand hygiene of health care staff.
Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby
decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an
organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive
program that provides a hand hygiene policy, fosters a culture of hand hygiene, monitors compliance, and
provides feedback.

Element(s) of Performance for NPSG.07.01.01

1. Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease
Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene
guidelines. (See also IC.01.04.01, EP 1)

2. Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 1)

3. Improve compliance with hand hygiene guidelines based on established goals.

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Reduce the risk for suicide.
Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health
conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation
during the course of care.

–Rationale for NPSG.15.01.01–

Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel
event. Identification of individuals at risk for suicide while under the care of or following discharge from a
health care organization is an important step in protecting these at-risk individuals.

Element(s) of Performance for NPSG.15.01.01

1. For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an
environmental risk assessment that identifies features in the physical environment that could be used
to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of
anchor points, door hinges, and hooks that can be used for hanging).

For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the
risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that
pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care,
assessing objects brought into a room by visitors, and using safe transportation procedures when
moving patients to other parts of the hospital.
Note: Nonpsychiatric units in general hospitals do not need to be ligature resistant. Nevertheless,
these facilities should routinely assess clinical areas to identify objects that could be used for self-harm
and remove those objects, when possible, from the area around a patient who has been identified as
high risk for suicide. This information can be used for training staff who monitor high-risk patients (for
example, developing checklists to help staff remember which equipment should be removed when

2. Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health
conditions as their primary reason for care using a validated screening tool.
Note: The Joint Commission requires screening for suicidal ideation using a validated tool starting at
age 12 and above.

3. Use an evidence-based process to conduct a suicide assessment of patients who have screened
positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal
or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that
simultaneously screens patients for suicidal ideation and assesses the severity of suicidal ideation.

4. Document patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

5. Follow written policies and procedures addressing the care of patients identified as at risk for suicide.
At a minimum, these should include the following:
– Training and competence assessment of staff who care for patients at risk for suicide
– Guidelines for reassessment
– Monitoring patients who are at high risk for suicide

6. Follow written policies and procedures for counseling and follow-up care at discharge for patients
identified as at risk for suicide.

7. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and
management of patients at risk for suicide and take action as needed to improve compliance.

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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.

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Conduct a preprocedure verification process.

–Rationale for UP.01.01.01–

Hospitals should always make sure that any procedure is what the patient needs and is performed on the
right person. The frequency and scope of the verification process will depend on the type and complexity of
the procedure.

The preprocedure verification is an ongoing process of information gathering and confirmation. The purpose
of the preprocedure verification process is to make sure that all relevant documents and related information
or equipment are as follows:
– Available prior to the start of the procedure
– Correctly identified, labeled, and matched to the patient’s identifiers
– Reviewed and are consistent with the patient’s expectations and with the team’s understanding of the
intended patient, procedure, and site

Preprocedure verification may occur at more than one time and place before the procedure. It is up to the
hospital to decide when this information is collected and by which team member, but it is best to do it when
the patient can be involved. Possibilities include the following:
– When the procedure is scheduled
– At the time of preadmission testing and assessment
– At the time of admission or entry into the facility for a procedure
– Before the patient leaves the preprocedure area or enters the procedure room

Missing information or discrepancies are addressed before starting the procedure.

Element(s) of Performance for UP.01.01.01

1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the
correct site.
Note: The patient is involved in the verification process when possible.

2. Identify the items that must be available for the procedure and use a standardized list to verify their
availability. At a minimum, these items include the following:
– Relevant documentation (for example, history and physical, signed procedure consent form, nursing
assessment, and preanesthesia assessment)
– Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology
and biopsy reports) that are properly displayed
– Any required blood products, implants, devices, and/or special equipment for the procedure
Note: The expectation of this element of performance is that the standardized list is available and is
used consistently during the preprocedure verification. It is not necessary to document that the
standardized list was used for each patient.

3. Match the items that are to be available in the procedure area to the patient.

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Introduction to UP.01.02.01
Wrong-site surgery should never happen, yet it is an ongoing problem in health care that
compromises patient safety. Marking the procedure site is one way to protect patients; patient
safety is enhanced when a consistent marking process is used throughout the hospital. Site
marking is done to prevent errors when there is more than one possible location for a procedure.
Examples include different limbs, fingers and toes, lesions, level of the spine, and organs. In cases
where bilateral structures are removed (such as tonsils or ovaries) the site does not need to be

Responsibility for marking the procedure site is a hotly debated topic. One position is that since the
licensed independent practitioner is accountable for the procedure, he or she should mark the site.
Another position is that other individuals should be able to mark the site in the interests of work flow
and efficiency.

There is no evidence that patient safety is affected by the job function of the individual who marks
the site. The incidence of wrong-site surgery is low enough that it is unlikely that valid data on this
subject will ever be available. Furthermore, there is no clear consensus in the field on who should
mark the site. Rather than remaining silent on the subject of site marking, The Joint Commission
sought a solution that supports the purpose of the site mark. The mark is a communication tool
about the patient for members of the team. Therefore, the individual who knows the most about the
patient should mark the site. In most cases, that will be the person performing the procedure.

Recognizing the complexities of the work processes supporting invasive procedures, The Joint
Commission believes that delegation of site marking to another individual is acceptable in limited
situations as long as the individual is familiar with the patient and involved in the procedure. These
individuals would include the following:
– Individuals who are permitted through a postgraduate education program to participate in the
– A licensed individual who performs duties requiring collaborative or supervisory agreements with
a licensed independent practitioner. These individuals include advanced practice registered nurses
(APRNs) and physician assistants (PAs).

The licensed independent practitioner remains fully accountable for all aspects of the procedure
even when site marking is delegated.


Mark the procedure site.

Element(s) of Performance for UP.01.02.01

1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are
marked when there is more than one possible location for the procedure and when performing the
procedure in a different location would negatively affect quality or safety.
Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region,
special intraoperative imaging techniques may be used for locating and marking the exact vertebral

2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

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3. The procedure site is marked by a licensed independent practitioner who is ultimately accountable for
the procedure and will be present when the procedure is performed. In limited circumstances, the
licensed independent practitioner may delegate site marking to an individual who is permitted by the
organization to participate in the procedure and has the following qualifications:
– An individual in a medical postgraduate education program who is being supervised by the licensed
independent practitioner performing the procedure; who is familiar with the patient; and who will be
present when the procedure is performed
– A licensed individual who performs duties requiring a collaborative agreement or supervisory
agreement with the licensed independent practitioner performing the procedure (that is, an advanced
practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who
will be present when the procedure is performed.
Note: The hospital’s leaders define the limited circumstances (if any) in which site marking may be
delegated to an individual meeting these qualifications.

4. The method of marking the site and the type of mark is unambiguous and is used consistently
throughout the hospital.
Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after
skin preparation and draping. Adhesive markers are not the sole means of marking the site.

5. A written, alternative process is in place for patients who refuse site marking or when it is technically or
anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).
Note: Examples of other situations that involve alternative processes include:
– Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a
natural orifice
– Teeth
– Premature infants, for whom the mark may cause a permanent tattoo


A time-out is performed before the procedure.

–Rationale for UP.01.03.01–

The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are
identified. This requirement focuses on those minimum features of the time-out. Some believe that it is
important to conduct the time-out before anesthesia for several reasons, including involvement of the patient.
A hospital may conduct the time-out before anesthesia or may add another time-out at that time. During a
time-out, activities are suspended to the extent possible so that team members can focus on active
confirmation of the patient, site, and procedure.

A designated member of the team initiates the time-out and it includes active communication among all
relevant members of the procedure team. The procedure is not started until all questions or concerns are
resolved. The time-out is most effective when it is conducted consistently across the hospital.

Element(s) of Performance for UP.01.03.01

1. Conduct a time-out immediately before starting the invasive procedure or making the incision.

2. The time-out has the following characteristics:
– It is standardized, as defined by the hospital.
– It is initiated by a designated member of the team.
– It involves the immediate members of the procedure team, including the individual performing the
procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other
active participants who will be participating in the procedure from the beginning.

3. When two or more procedures are being performed on the same patient, and the person performing
the procedure changes, perform a time-out before each procedure is initiated.

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4. During the time-out, the team members agree, at a minimum, on the following:
– Correct patient identity
– The correct site
– The procedure to be done

5. Document the completion of the time-out.
Note: The hospital determines the amount and type of documentation.

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# 1

Opportunities & Challenges with Patient Safety Goals

Annerys Velazco

St. Thomas University

NUR 415 AP 1

Dr. Rosa Rousseau



The Joint Commission established the National Patient Safety Goals in 2003 as a program to promote quality and patient safety. The NPSGs were developed to assist accredited organizations in addressing specific patient safety concerns. The selected 2022 NPSG for this study is Goal 3: improving the safety of using medications (NPSG.03.04.01). In perioperative and other procedural settings, all drugs should be labeled, including medication containers, and other solutions on and off the sterile field. In this case, medication containers include syringes, medicine cups, and basins. In the clinical settings, the unlabeled medications and other solutions are usually unidentifiable. As a result, errors, sometimes fatal, have occurred as a result of drugs and other solutions being removed from their original containers and placed in unlabeled containers (Larmené-Beld et al., 2018). This dangerous practice is a direct violation of the basic principles of safe medication administration, and yet, it is common practice in many workplaces. Therefore, this NPSG goal ensures that there is labeling of all pills, medication containers, and other solutions in a process that is risk-reducing and is much compatible with good medication management practices. Further, the goal addresses a known danger point in the delivery and administration of drugs in perioperative and other procedural settings.

To fully achieve this goal there are various elements of performance that need to be achieved. First, the healthcare provider has to label drugs and solutions that are not immediately provided in the perioperative and other procedural settings. This is true even if only one medicine is utilized. According to Bowdle et al. (2018), in the sterile field today, the labelling errors usually involve the mixing of two liquids in labelled containers. As such, the approach that is necessary to prevent these errors, supported by 2022 NPSG goal 3, is straightforward and very simple and that is; correct and full labeling of all solution and drug containers on the sterile field in every procedural area, every time. The second element of performance is that labeling occurs in perioperative and other procedural settings on and off the sterile field when any medical solution is transferred from the original packing to another container. The basic function of a label in this case is to guarantee that healthcare provider and the patient can readily identify the medicine even if it has been placed in a new container. It is essential to note that, there may arise confusion between medications with similar names, labels, or packaging. This has been recognized as a major source of error among healthcare providers who administer medication to patients.

Overall, there has been many cases of medication errors that arise from poor labelling of drug containers which has prompted a national focus on unlabeled medication and solution containers by the Joint Commission and other relevant institutions. It is evident that healthcare professionals are aware of the risks that are linked to labeling of medication solution containers, especially in the preoperative settings. Hence, the recurrence of this error indicates that healthcare providers have lost sight of the risks associated with unlabeled products, have incorrectly believed the risk is justified and minor, or have forgotten to apply effective prevention efforts in all procedural areas. This brings up the aspect of normalcy bias which leads some healthcare providers to make an assumption that an error would never occur when drugs are poorly labeled or a solution is changed into another container. Besides, the unlabeled containers may also be considered as ‘someone else’s problem,’, a phenomenon similar to bystander indifference in which people ignore a problem because they believe it is irrelevant to them, unlikely to happen, something they cannot remedy, or the responsibility of someone else to fix. Further, some providers assume that they have developed the ideal labeling techniques or are able to remember their medication only to discover that the task is onerous, error-prone, or unfeasible without system adjustments. To help identify this issue as significant, the Joint commission came up with the 2022 National Patient Safety Goals where they provide for proper labelling of medical containers in the preoperative settings.


Bowdle, T. A., Jelacic, S., Nair, B., Togashi, K., Caine, K., Bussey, L., … & Merry, A. F. (2018). Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. British Journal of Anaesthesia, 121(6), 1338-1345. https://doi.org/10.1016/j.bja.2018.09.004.

Larmené-Beld, K. H., Alting, E. K., & Taxis, K. (2018). A systematic literature review on strategies to avoid look-alike errors of labels. European Journal of Clinical Pharmacology, 74(8), 985-993. https://doi.org/10.1007/s00228-018-2471-z


# 2

Jacqueline Brown

St. Thomas University

NUR-415: Health Care Issues 

Professor Rosa Rousseau

August 3, 2022

Opportunities & Challenges with Patient Safety Goals

Essential health services must be provided in a safe environment for patients. Preventing and mitigating injury to patients throughout health care is a standardized practice in nursing practice. Constant progress based on comprehensive training and experiences encompassing unfavorable situations is essential for quality health care delivery. Quality health care services should be safe, effective, and oriented to the needs of patients worldwide. Health services must also be timely, integrated, and efficient to reap the advantages of quality health care. Effective patient safety plans need well-defined policies, a capable leadership team, data to guide safety improvements, well-trained medical workers, and active patient participation. Delivery of quality care is in line with the realization of the 2022 National Patient Safety Goals. 

According to Carayon et al. (2018), it is a fundamental idea of systems engineering and human factors to look at the whole system rather than just focusing on a single component. The system’s components and interactions must be improved to achieve this aim. The entire system needs to be considered regarding patient safety practices like preoperative checklists. The check-in tool may favorably or adversely impact system aspects such as team communication and workflow. Engineering and human aspects are rooted in system design concepts, applied through user interaction and diverse analytical approaches in lifelong learning cycles with education and evaluation loops.

One of the 2022 National Patient Safety Goals is to reduce or eliminate mistakes in surgical operations. Systems engineering and health care differ significantly in culture, which is often overlooked or underappreciated. There is a tendency to blame patient safety accidents on the shoulders of individuals in the healthcare industry (World Health Organization, 2018). On the other hand, human factors aim to construct systems and procedures designed to avoid or minimize the impact of mistakes. Systemic methods for patient safety have been called for many times, but individual accountability for errors persists, indicating how entrenched this thinking is in health care. Regarding systems engineering and human aspects, the work style, perspective, and pace might conflict with the quick healthcare improvement initiatives.

Communication in the healthcare context is a very dynamic and complicated process. Including new problems, participants, and venues present another chance to improve patient safety (Ross, 2018). To provide safe patient care, good perioperative communication is essential. It is also a crucial component of effective team collaboration. Communication must be precise in an environment where many obstacles and problems exist, making the task much more difficult. Surgical checklists and time-out procedures have contributed to a uniform, inclusive approach to tackling communication issues in the perioperative setting. These issues can be addressed by postoperative debriefing sessions, which have proven successful in the virtual educational setting.

Patient safety may be improved through systems engineering and human factors, particularly in preventing surgical errors. They cover a wide range of patient safety sectors and have made significant contributions to the design and implementation of technology and procedures in the workplace. All the healthcare facilities must adhere to the National patient safety goals and ensure the patients are safe within the facilities.


Carayon, P., Wooldridge, A., Hose, B. Z., Salwei, M., & Benneyan, J. (2018). Challenges and opportunities for improving patient safety through human factors and systems engineering. Health Affairs, 37(11), 1862-1869. https://doi.org/10.1377/hlthaff.2018.0723 (Links to an external site.) 

Ross, J. (2018). Effective communication improves patient safety. Journal of PeriAnesthesia Nursing, 33(2), 223-225. DOI: https://doi.org/10.1016/j.jopan.2018.01.003 (Links to an external site.) 

World Health Organization. (2018). Patient safety: making health care safer (No. WHO/HIS/SDS/2018.11). World Health Organization. https://apps.who.int/iris/handle/10665/255507 (Links to an external site.) 

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