Focusing on the International Patient Safety Goals

Introduction

Patient Safety Awareness Week takes place this year from 12 – 18 March 2023. The aim of this week is to encourage everyone to learn more about healthcare safety.

The World Health Organisation (WHO) define patient safety as “the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum”. According to the World Health Organisation (2019) each year, 134 million adverse events occur in hospitals in low and middle income countries, due to unsafe care, resulting in 2.6 million deaths. They also note that globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

The ECRI also recently published their Top 10 Patient Safety Concerns 2023. Among the top 10 patient safety challenges are the pediatric mental health crisis, the impact of clinicians expected to work outside their scope of practice and competencies, medication errors resulting from inaccurate patient medication lists and preventable harm due to omitted care or treatment.

Ensuring patient Safety is an ongoing concern for all healthcare providers as it is a fundamental component to the delivery of safe high-quality healthcare. However, even with the best of healthcare and quality systems in place, adverse events can still occur. This is why during Patient Safety Awareness Week, we feel it would be beneficial to reflect on the International Patient Safety Goals (IPSG). The IPSGs, detailed in the Joint Commission International (JCI) Accreditation Standards for Hospitals, aim to encourage specific improvements in patient safety by focusing on six key problematic areas identified by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO). By focusing on these six key areas, engraining them in everyday practices and getting these working more safely, healthcare providers can improve patient safety and patient outcomes.

What are the International Patient Safety Goals?

• Goal One: Identify patients correctly.
• Goal Two: Improve effective communication.
• Goal Three: Improve the safety of high-alert medications.
• Goal Four: Ensure safe surgery.
• Goal Five: Reduce the risk of health care-associated infections.
• Goal Six: Reduce the risk of patient harm resulting from falls.

Goal One: Identify patients correctly.

Wrong patient errors are common. Therefore, the purpose of this IPSG is to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual. The JCI recommend using at least two identifiers to identify patients such as name or date of birth (DOB). Identifiers such as room number or location should not be used.

Ensuring effective patient identification practices may seem a cumbersome practice but in actual fact, patient identification errors can happen in any aspect of the patient’s journey and can result in negative outcomes for patients. This is why is it crucial that effective patient identification practices are part of everyday routine practices.

Goal Two: Improve effective communication.

This IPSG highlights the importance of effective communication when verbally communicating patient care orders, reporting critical diagnostic results and during handovers of patient care. Ensuring that patient data is communicated accurately and understood by the recipient is critical to reduce errors and improve patient safety. To support this, it is recommended that verbal and telephone orders should be written down when received and read back to the individual providing the information. The hospital should have a consistent and complete handover process for transitions within the hospital.

Goal Three: Improve the safety of high-alert medications.

The objective of this IPSG is to improve patient safety whilst administering High Alert Medications (HAMs). All medications can be dangerous when used inappropriately, but HAMs have the potential to cause harm that is likely to be more serious when they are given in error. To support the reduction of medication related patient safety incidents, hospitals should maintain a list of what they consider HAMs and make sure relevant clinical staff know what is on the list. The hospital also needs to have a process in place to minimise confusion around Look-alike/sound-alike (LASA) medications.

Goal Four: Ensure safe surgery.

Significant patient injury and adverse events can result from wrong-site, wrong-procedure, and wrong-patient surgery. These events can occur from ineffective communication, lack of processes and lack of patient involvement in the site marking. This is an ongoing concern for hospitals. To help minimise these adverse events from occurring, hospitals should use multiple strategies when identifying the correct patient, correct procedure, and correct site.

Goal Five: Reduce the risk of health care-associated infections.

Effective infection prevention and control practices are critical to reducing the spread of health care–associated infections. This has been a major concern for patients and health care practitioners, particularly over the last two years during the COVID-19 pandemic. The focus of this IPSG is on hand hygiene and requires the hospital to adopt and implement an evidence-based hand-hygiene guideline throughout the hospital to reduce risk of health care-associated infections.

Goal Six: Reduce the risk of patient harm resulting from falls.

Falls are the cause of lots of injuries to patients and can occur in both inpatient and outpatient settings. There are multifactorial reasons as to why people are risk of falls, for example healthcare setting, patient history, medications, visual impairments etc. Hospitals should have a process for assessing and reassessing patients for falls risk and implement measures to reduce falls risks for patients.

Conclusion

The purpose of the six IPSGs is to promote specific improvements in patient safety. They highlight 6 of the problematic areas in healthcare and offer evidence-based solutions to address them.

HCI works with many healthcare organisations to support them in building Quality and Safety Management Systems that meet the specific requirements detailed within the JCI Accreditation Standards and drive quality improvement throughout the organisation.

If you are considering working towards accreditation, such as JCI or CHKS, then contact HCI today to see how we can support you on your journey.

Click here to find out more about our Accreditation Support Services.