Guidelines: National Patient Safety Goals 

Below are a list of the 2015 National Patient Safety Goals and our procedures for addressing them
Goal 1: Improve the accuracy of patient identification

   NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment, and services

 In this organization the  following process identifies the patient: Peri-operative personnel identifies patient to the chart utilizing at minimum 2 identifiers. The patient's name and either of the following, birth date, address, or telephone number.  It is very important, that this identification process will also be utilized before taking blood 
samples or other specimens or providing any other treatments or procedures, this includes injections and medications. Containers used for blood and other specimens are labeledin the presence of the patient.

NPSG.01.03.01: Eliminate transfusion errors related to patient misidentification.

This organization does not transfuse blood or blood products.

Goal 2: Improve the safety of using medications

NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the steriled field in perioperative and other procedural settings. Note: Medication containers include syringes, medication cups and basins.

Our organization take measures within reason to ensure staff label medications. Unless a medication is withdrawn and administered in one motion, the container of the medication must be labeled.

Medications are also labeled when transferred to an unlabeled container. Labels will include name, strength, volume (if not indicated on container), dilutent name and expiration is not used within 24hours. Date and time will not be required for our short procedures. Medications will only be administered by the person preparing it. Medications without labels will immediately be discarded.

NPSG.03.06.01: Maintain and communicate accurate patient medication information

Our organization, at every patient encounter, will update all information regarding patient medication history. This will include all of the medications the patient is currently taking, the dose, route, frequency. This medical reconciliation will take place on our Electronic Medical Record where it will be available to any practitioner accessing their chart in our facility. Because it is often difficult to obtain this information from patients, we can only ensure that the medication history will be taken to the best of our ability and with reasonable effort.

Medications patient takes into the practice will be compare with medications we have ordered for the patient. Discrepancies, if present will be identified. These discrepancies will include omissions, duplication's, contraindications, unclear information and changes. A qualified Licensed independent practitioner in the practice will do the comparison. Description of any medications we prescribe will be provided to the patient. these descriptions will include name, dose, frequency and purpose. Patient will be informed about the importance of managing their medication.

Goal 7: Reduce the risk of health care-associated infections

NPSG.07.01.01: Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines. 

Our Organization will comply with CDC Guidlines class IA, IB, and IC. When hands are visible dirty or grossly contaminated with human product, hands will be washed with soap and water. If hands are not visibly soiled, an alcohol based hand rub for routinely decontaminating hands may be used. Hands will always be decontaminated before direct contact with patients, this will include the insertion of vascular catheters and other non-surgical procedures. Hands will need to be decontaminated after contact with patients intact skin, body fluids, and excretions. Hand decontamination will be performed after touching inanimate objects, before eating and after using restroom. Towelettes are not allowed in our practice. Alcohol based hand rubs will be placed throughout the facility for easy access. Expenses will not be spared when selecting these products, and only the highest quality hand rubs will be selected for use. Products will be selected with moisturizing lotion built in to limit the chance of contact dermatitis or dry/eroded skin. Promotional material will be posted throughout the facilities to remind the staff of hand hygiene. Staff will be given periodic education sessions regarding the importance of hand hygiene. All other CDC guidelines for class IA, IB, and IC will be followed. Details can be reviewed here

NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections. 

No procedures are performed in office which violate the sterile cavities of the human body. The procedures we perform at this organization are not eligible for surgical site infection surveillance. We therefore do not anticipate or encounter surgical site infections. However, patients who have procedures performed are followed up with a series of screening questions via phone call within 10 days. 


NPSG UP.01.01.01 through UP.01.03.01: Universal protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Practices can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure.

A timeout preprocedure process is performed before every case to verify the correct procedure, the correct patient at the correct site. This is done before anesthesia in order to involve the patient. Relevant documentation and equipment are made ready before procedure. The correct items for the correct procedure for the correct patient will be available prior to the commencement of the case.

Site markings are not possible with the procedures performed in this organization. We therefore make sure to verify the correct procedure at the correct site verbally before each case. 


1)Time out is performed immediately before procedure.

2)Procedure room technologist announces timeout in the presence of the endoscopist, anesthesiologist, medical assistant and any other staff involved in the care of the patient during the case. Announcement is performed before any anesthesia is administered and patient is fully conscious.

3)Procedure room technologist will verify the patient using three forms of identifiers, the procedure to be performed
Approved By Governing Board    
Control #376.11