Joint Commission's 2010 Patient Safety Goals Reduce Requirements

Heather Comak, for HealthLeaders Media , October 1, 2009

Some of the EPs in the above listed standards were deleted upon their move to the standards.

"The release of the 2010 National Patient Safety Goals (NPSG) rolled back some of the difficult and unclear expectations introduced last year," says Bud Pate, REHS, vice president of content and development with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Pate points to changes, such as eliminating the need to designate an individual to participate in the identification process on behalf of a patient (NPSG.01.01.01) and the need for an immediate pre-transfer checklist process with the Universal Protocol (UP.01.01.01) as good developments with the 2010 NPSGs.

Also an oft-cited requirement (on 38% of 2009 survey reports), NPSG.02.03.01, concerning critical results, has been relaxed. The requirement to monitor critical tests is gone, and the remaining language is intended to allow more flexibility in the way that timeliness of critical result reporting is monitored. These are all positive changes, Pate says.

The revised language addressing the scope of the Universal Protocol has created some initial confusion: the protocol now applies to all invasive procedures, not just those that place the patient at risk.

"On its face, this appears to cover many procedures not currently subject to the time out (the only part of the Protocol that is not a natural part of the treatment process)," says Pate. "However, I also understand that the Joint Commission intends to ease back on the scope of the Universal Protocol. So we're hoping for further clarification."

Another significant change is clarification about the need for two time outs (UP.01.03.01). A second time out during the procedure is only required when the surgeon changes (removing the confusing language about when the procedure requires two consent forms). On the other hand, it now appears that a pre-anesthesia time out is always required. The field is also waiting for clarification about the time out for one-person procedure, says Pate.

In summary, the Joint Commission has taken a significant step back from what many hospitals believed, and had voiced to The Joint Commission, were needlessly prescriptive and impractical solutions to major safety concerns.

"However, as with any complex issue, there are a few 'devilish details' that are up in the air," says Pate.

To find the full version of the 2010 NPSGs, click here.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing

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