The Joint Commission launched the National Patient Safety Goals in 2003

Sample Solution

The focus of the National Patient Safety Goals (NPSGs) has evolved from a foundational emphasis on preventing basic, acute medical errors to a more comprehensive, systems-based approach that addresses complex issues, particularly those related to technology, communication, and equity.  

Evolution of NPSG Focus

  In their early years, the goals were a direct response to the 1999 report, "To Err is Human," which highlighted the high rate of preventable medical errors. The initial goals were very direct and focused on core processes:

• Patient Identification: Ensuring the correct person receives the correct care.
• Medication Safety: Focusing on labeling and avoiding medication mix-ups.
• Communication: Improving the effectiveness of communication between caregivers.
• Surgical Safety: Preventing wrong-site, wrong-procedure, and wrong-patient surgeries.

In the intervening years, while these core issues remain, the focus has broadened and deepened. The goals have shifted from simply identifying problems to requiring systemic, evidence-based solutions. For example, the goals now include:

• Suicide Prevention: Identifying patients at risk for suicide and implementing mitigation strategies.
• Infection Control: Moving beyond simple hand hygiene to addressing specific hospital-acquired infections (HAIs) like CAUTIs (catheter-associated urinary tract infections).
• Alarm Management: Addressing "alarm fatigue" by reducing patient harm associated with clinical alarm systems, which have become a major issue with the proliferation of technology.

Most recently, the goals have begun to address an even broader scope of patient safety, including a strong emphasis on healthcare equity. This new focus requires organizations to identify healthcare disparities within their patient population and create a written plan to improve equity. This represents a significant shift from a focus on preventing individual errors to addressing the systemic and social determinants of health that contribute to unsafe care.