Accreditation

FAQ released on NPSG.01.01.01, Universal Protocol

Accreditation Connection, November 7, 2008

The Joint Commission has released an FAQ on National Patient Safety Goal NPSG.01.01.01 and a series of FAQs on Universal Protocol. The former looks at whether there are any exceptions for active involvement of the patient or responsible caregiver.

The NPSG.01.01.01 FAQ specifically looks at sleeping patients and the nurse’s role in identifying non-communicative or confused patients when another healthcare worker uses two patient identifiers. The Joint Commission states that the purpose behind this is to increase patient safety through such things as medication, diagnostic, and treatment errors. The organization must decide how to assess sleeping/non-communicative/confused patients. The organization must also determine when active involvement is necessary on the part of the responsible nurse or other caregiver.

Obviously, these decisions must be communicated to the staff and be brought about specifically for reasons of patient safety.

The Universal Protocol FAQs address a number of areas of confusion, including pre-procedure verification, site marking, and time outs.

The NPSG.01.01.01 FAQ can be found online here. The Universal Protocol FAQs can be found here.

 

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