Since 2003, The Joint Commission (TJC) has published the National Patient Safety Goals (NPSG), an annual list of the top patient safety issues occurring in a variety of healthcare settings. Four of the seven goals for 2014 have been on the list since the program’s inception:

Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
Improve the safety of using medications
Reduce the risk of healthcare-acquired infections

Why are these four still on the list after 11 years? Despite a high level of participation from facilities, the TJC has not seen enough significant improvement (i.e., marked decreases in associated sentinel events) to remove these safety issues from the list.
In the article “High-Reliability Health Care: Getting There from Here,” published September 13, 2013, in The Milbank Quarterly, Joint Commission President and CEO Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., and the late Jerod M. Loeb, Ph.D. suggest that although there have been isolated improvements, the progress in healthcare quality and safety has been “underwhelming” for quite some time. They recommend hospitals take on high-reliability principles, such as those used in commercial air travel and nuclear power, to see significant safety improvements. “We explored three major changes that health care organizations would have to undertake in order to make substantial progress toward high reliability: (1) the leadership’s commitment to the ultimate goal of zero patient harm, (2) the incorporation of all the principles and practices of a safety culture throughout the organization, and (3) the widespread adoption and deployment of the most effective process improvement tools and methods.”
The entire healthcare industry needs to take action. It’s time to reevaluate the patient safety requirements for all healthcare personnel from clinical staff to professional visitors:
– Are employees and visitors receiving the right training? – Are personnel being trained often enough? – Are the right credentials being required? – Is leadership getting regular reports on policies, training and credentials? – Is an effective communication tool in place? – Is it time to consider best practices across industries?
These questions and others need to be asked. We need to take a close look at what the industry is doing right and where improvements can be made. Together, let’s keep patients safe.


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