Joint Commission releases 2010 National Patient Safety Goals, updates Universal Protocol
The Joint Commission on Sept. 9 released its pre-publication 2010 National Patient Safety Goals (NPSGs) and revised Universal Protocol.
The final NPSGs will be released in late September. The pre-publication NPSGs do not include scoring information, service applicability or final editorial changes. Several updates to the National Patient Safety Goals and Universal Protocol are effective immediately.
On its Web site, The Joint Commission states “the changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific or detailed over time.”
The Joint Commission’s Perspectives (link to PDF) newsletter has a list of requirements that were deleted or moved to the standards.
The Universal Protocol was revised based on feedback The Joint Commission received since publishing the 2009 version. Changes to the Universal Protocol include:
- Applicability: The Universal Protocol will apply to all surgical and non-surgical invasive procedures. This is a change from “all invasive procedures that put patients at more than minimal risk, regardless of the location within an organization.”
- Pre-procedure verification (UP.01.01.01): References to the location (pre-procedure area and timing of the verification will be removed. The term “checklist” will be replaced by a reference to a standardized list to be used in the verification process. The term “checklist” implied the need to document each step for each patient. A note will be added clarifying that documentation of the use of the standardized list on a per patient basis is not required.
- Site marking (UP.01.02.01): The revised Universal Protocol states: 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, is familiar with the patient, will be present when the procedure is performed, and is either qualified through a medical residency program or is a licensed individual who performs duties requiring collaboration or supervisory agreements with the licensed independent practitioner. These individuals include advanced practice registered nurses (APRNs) and physician assistants (PAs). However, the licensed independent practitioner who delegates responsibility is ultimately accountable for the procedure. This option takes into account the current position of The Joint Commission, National Quality Forum, World Health Organization, and American Academy of Orthopaedic Surgeons and the concern raised by the field that the current requirement is impractical under some circumstances. The Joint Commission will continue to gather input and data on this issue.
- Alternative processes for site marking (UP.01.02.01): The current Universal Protocol describes situations in which exceptions to site marking are allowed. The requirement was modified to allow organizations to develop alternative processes for site marking.
- Time out (UP.01.03.01): The time out will occur prior to incision or the start of the procedure. References in the current Universal Protocol to conducting the time out before the provision of anesthesia were removed. The rationale states that the organization may conduct the time out before providing anesthesia or may choose to do more than one time out. The list of issues to address in the time out was shortened to focus on the correct patient, procedure and site.
Find the National Patient Safety Goals here, and visit www.jointcommission.org for more information.
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