Patient Safety Goals


Each year, national goals are established to improve patient and healthcare safety by the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a not-for-profit organization that accredits more than 17,000 health care organizations and programs in the United States. The University of Tennessee Medical Center takes these National Safety Goals seriously and works to ensure a safe environment throughout your hospital stay and for all aspects of your care.

Eight of the 16 National Patient Safety Goals apply to hospitals. (You may find all of them listed on the Joint Commission website.) Here are the 2010 National Safety Goals applying to hospitals.

Goal 1 – Improve the Accuracy of Patient Identification
Goal 2 –Improve the Effectiveness of Communication Among Caregivers
Goal 3 – Improve the Safety of Using Medications
Goal 7 – Reduce the Risk of Health Care–associated Infections
Goal 8 – Accurately and completely reconcile medications across the continuum
Goal 15 – The organization identifies safety risks inherent in its patient population

Goal 1 – Improve the Accuracy of Patient Identification

At admission an identification band is placed on your wrist. When a healthcare worker enters your room, and wants to take you for a test, perform a treatment, draw your blood or give you medication they will want to verify who you are. Your healthcare worker will be looking at your patient identification band asking you your name. Additionally, if you are unable to speak, your healthcare provider will verify your identification by your wristband and your medical record number. You are never identified by your room number.

Goal 2 –Improve the Effectiveness of Communication Among Caregivers

UT Medical Center has developed written procedures for managing the critical results of tests and diagnostic procedures. The process involves expediting these critical results to your physician.

Goal 3 – Improve the Safety of Using Medications

Medications often are an important part of your treatment plan.
Part of medication safety includes careful labeling of medications, attention to expiration dates, and the use of sophisticated scanning systems to assist in matching medications to the correct patient.

In procedural areas both on and off the sterile field, medications and solutions that are not immediately administered should be labeled. Additionally, medications and solutions removed from the original packaging / container should be labeled.

Labels need to include the following information

  • medication name,
  • strength,
  • quantity,
  • diluent and volume,
  • preparation date,
  • expiration date when not used within 24 hours, and
  • expiration date when expiration occurs in less than 24 hours.

All medications should be verified verbally and visually. Medications found unlabeled must be discarded.

Another area of medication safety includes a number of precautions that are taken when anticoagulants are being administered.

Goal 7 – Reduce the Risk of Health Care–associated Infections

Hand Washing
Hand washing is one of the most important ways to avoid getting sick and to prevent spreading germs. It is very important both at home and in the hospital.
Millions of microbes are on hands and can cause colds, the flu or diarrhea. These disease causing microbes can be picked up by touching doorknobs, stair railings, telephones and any other surfaces that multiple people touch.
Because hand washing is one of the primary responsibilities of your healthcare team, feel free to ask any member of your healthcare team if they have washed their hands before they have any direct contact with you.

You may see your healthcare workers using a quick drying, alcohol based, waterless hand gel or foam. These gels are fast acting and are a highly effective in killing hospital germs. Waterless gels are an acceptable alternative to washing your hands with soap and water when your hands are not visibly dirty.

Also, remind your visitors to clean their hands with soap and water or an alcohol-based hand rub before they enter and leave your room.

How to Properly Wash Your Hands

  • Wet your hands with clean and preferably warm running water
  • Apply soap and rub your hands together creating lather
  • Scrub all surfaces on your hands for 10 – 15 seconds including under your fingernails and the back of your hands
  • Rinse hands well
  • Dry your hands and if possible use a paper towel and then use your paper towel to turn off the faucet

When to Wash Your Hands with Soap and Water

  • Hands are visibly soiled (dirty)
  • Hands are visibly contaminated with blood or body fluids
  • Before eating
  • After using the restroom
  • After changing diapers or cleaning up a child who has gone to the bathroom
  • Before and after touching someone who is sick
  • Before and after caring for a wound
  • After coughing, sneezing or blowing your nose
  • After handling an animal or animal waste
  • After handling garbage

How to Use an Acohol-based Hand Sanitizer

  • Apply product to the palm of one hand
  • Rub hands together
  • Rub the product over all surfaces of hands and fingers until hands are dry

A number of activities are in progress for preventing Multidrug-Resistant Organism Infections, Central Line–Associated Blood Stream Infections and Surgical Site Infections.


Goal 8 – Accurately and completely reconcile medications across the continuum

When you are admitted to the hospital, it is important that your doctor and healthcare team know which medications you currently are taking. We will make a list of all of the medications and doses you are taking. This includes prescription medication, over-the-counter medications such as aspirin, any herbal or diet supplements and vitamins. It also is important that your doctor knows about allergies or any adverse reactions you may have to medications and food. Certain foods or drink may change the way medications work. Recalling any difficulties you may have had with medications or foods in the past is important to mention to your healthcare team. If your medication looks different than what you’ve been taking ask why. Sometimes brand name medications may be substituted with generic brand medications that work the same way. You will be given a complete list of your medications at discharge.

Goal 15 – The organization identifies safety risks inherent in its patient population

Risk assessments are completed to identify patients who may be at risk for suicide. If identified, these patients are provided a safe environment and a sitter to assist with patient safety. A crisis hotline number also is provided at discharge.

Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™
I. Universal Protocol
A. Conducting a Pre-Procedure Verification Process - All information matches and indicates the person, procedure, and site for the procedure.
B. Marking the Procedure Site - This is completed by the physician doing the procedure any time the site involves laterality of level, as in the spine.
C. Performing a Time-Out - All team members pause an go through a checklist to ensure all is ready for a safe procedure.