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April 2011 Clinical Laboratory News: The 2011 Joint Commission National Patient Safety Goals

Patient Safety Focus

The 2011 Joint Commission National Patient Safety Goals 
Why Laboratories Need to Pay Close Attention

By Teresa Darcy, MD, MM

The Joint Commission (JC) created its National Patient Safety Goals (NPSG) in 2002 to stimulate health care organizations’ focus on several of the most challenging patient safety issues. Today, those goals, which are updated annually, have become the primary driver of hospitals’ patient safety initiatives.

Although no new goals were added in 2011 that directly relate to laboratories, significant revisions in the 2010 NPSGs that do affect laboratories were kept in place. Even if your laboratory is not accredited by JC, because of the high visibility of the NPSGs in health care today, laboratorians should at least be knowledgeable about the goals. Oftentimes, laboratorians are called upon to assist other parts of their organization that are accredited by JC. Therefore, knowing the basic thrust of the goals is valuable.

The Basics of the 2011 National Patient Safety Goals for Labs

The 2011 laboratory accreditation program has only three applicable NPSGs.

Goal 1: Improve the accuracy of patient identification.

Goal 2: Improve the effectiveness of communication among caregivers.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 1: Patient and Specimen Identification

Identification errors occur in all stages of patient diagnosis and treatment. Therefore, it is no accident that the first NPSG relates to patient identification. This is one of the most persistent challenges to patient safety we face in the laboratory. Clearly, unlabeled or mislabeled specimens represent a significant risk of patient harm.

The intent of this goal is to reliably identify the individual as the person for whom the service/treatment is intended, and second, to correctly match the service/treatment to the individual. The performance elements of this goal call for the use of at least two patient identifiers, neither of which can be a room or patient location. The goal also requires that specimens be labeled in the presence of the patient.

One of The Joint Commission’s NPSGs targets error 
such as this mislabeled specimen. 
Fictitious case courtesy of

Goal 2: Effective Communication

The second goal focuses on another widespread problem in healthcare. An estimated 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off.

Laboratorians are most familiar with this goal as it relates to communicating critical test results. In 2010, JC updated this goal and eliminated widespread confusion by removing the requirements related to the “critical test.” The new language, now part of both the hospital and laboratory programs, is quite simple: report critical results of tests and diagnostic procedures on a timely basis.

To meet this goal, laboratories and hospitals need to develop written procedures for managing the critical results of tests and diagnostic procedures and implement those procedures. Most importantly, such procedures must define what constitutes critical results of tests and diagnostic procedures, by whom and to whom critical results of tests and diagnostic procedures are reported, and the acceptable length of time between the availability and reporting of critical results.

In general, most clinical laboratories already have robust processes and procedures surrounding critical value reporting and monitoring. Laboratorians could be helpful in this respect by assisting other departments, such as imaging, interventional radiology, cardiac catherization, and pulmonary function.

Goal 7: Reducing Healthcare-associated Infections

Reducing the risk of healthcare-associated infections is a common goal to all programs of JC. The hand hygiene requirement is fundamental to these programs, but studies show that healthcare workers’ adherence to guidelines is poor. Laboratories need to ensure that staff consistently and appropriately practice adequate hand hygiene.

Help Prevent Medical Test Mistakes

The Joint Commission’s “Speak Up” campaign gives consumers guidance on how to protect their safety in healthcare.

Here are the sections related to laboratory test results:

  • How to ensure that test results are yours.
  • How to ensure the test was ordered by your doctor.
  • What to do if your test results are abnormal.
  • What to do if you have a bad lab testing experience at the lab or hospital.
  • Why no news regarding your test result is not good news.
  • Questions to ask your doctor and the workers who collect your specimens.

Free downloadable files of all brochures and posters are available online.

Additional Goals

While not a requirement in JC’s laboratory program, laboratorians should be aware of new standards in NPSG Goal 3 on improving safe use of medications. The requirement specifically calls for organizations to reduce the likelihood of patient harm associated with the use of anticoagulation therapy. In 2011, there were very minor changes to the language in the eight performance elements included in this standard. These call for using guidelines, protocols, education, as well as measuring the effectiveness of actions, to improve safety of anticoagulant therapy.

New requirements focused on the safety of blood transfusions in JC’s hospital program may also apply to laboratorians called upon to assist their hospital in meeting this goal. Contained in NPSG 1, three simple steps are aimed at eliminating transfusion errors related to patient misidentification. Before initiating any blood or blood component transfusion, the goal requires hospitals to: 1) match the blood or blood component to the order; 2) match the patient to the blood or blood component; and 3) use a two-person verification process.

Laboratories whose services include invasive procedures also should be aware of the requirements in JC’s Universal Protocol, a checklist that was created to prevent the occurrence of wrong-site, wrong-procedure, and wrong-person surgery. Laboratory staff who assist at procedures, such as bone marrow aspiration or fine needle aspiration, should be trained in the organization’s specific Universal Protocol procedures.

Patient in Bed
After reading The Joint Commission’s materials on what 
patients should expect while in the hospital, 
this patient asks to see her medical information 
to ensure it is correct.

Resources for Labs

In addition, JC has created several NPSG initiatives that laboratories may find useful in their efforts to improve patient safety. The first is a project called “Speak Up” aimed at increasing patients’ involvement in safety while undergoing treatment in healthcare facilities. These materials are designed to educate patients about their care, but laboratorians would do well to look these over for ideas.

For example, part of the campaign specifically discusses how patients can prevent medical test mistakes. The brochure gives information on what patients should expect regarding proper identification of samples when they have blood or other specimens collected. The materials go on to encourage patients to track their results and not to assume that lack of communication from providers means the result was normal.

The second initiative is the Center for Transforming Healthcare. This JC online resource contains information on patient safety projects related to the NPSGs, such as hand hygiene and hand-off communication. The information posted on the website not only provides an in-depth analysis of the problem, but also identifies root causes and suggests targeted solutions that have been or are being piloted in hospitals all over the country. In the hand-off communication project, for example, the center worked with 10 pilot hospitals and ultimately identified 20 root causes for hand-off communication failure.

Another useful resource is the frequently asked questions section of the NPSG website. Here you will find insight into not only the intent of the NPSG from JC’s perspective, but also the challenges faced by organizations attempting to meet the goals.

Meeting the Challenge

In summary, 2011 saw only minor changes in existing NPSGs for clinical laboratories and no new goals. Increasingly, laboratories, even those not accredited by JC, have a significant role to play in helping their hospitals meet the requirements of the NPSGs for the hospital program. The future holds more challenges for patient safety, especially when it comes to the electronic health record and other forms of digital communication.

DarcyDr. Darcy is associate professor of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, and medical director of Clinical Laboratories, University of Wisconsin Hospital and Clinics in Madison. Email:

Patient Safety Focus Editorial Board

Michael Astion, MD, PhD
Seattle Children's Hospital
Seattle, Washington

Peggy A. Ahlin, BS, MT(ASCP) 
Salt Lake City, Utah 

Corinne Fantz, PhD
Emory University
Atlanta, Georgia

James S. Hernandez, MD, MS
  Mayo Clinic Arizona 
Scottsdale and Phoenix

Brian R. Jackson
ARUP Laboratories
Salt Lake City, Utah

Sponsored by ARUP Laboratories, Inc.