XQ4001 Safety & Quality Fundamentals: National Patient Safety Goals – Sample Completed Assessment

Completed XQ4001 Assessment

The National Patient Safety Goals

Nursing Specialty

Nursing Care Center (LTC, Nursing Home)

Chapter

National Patient Safety Goals for Nursing Care Centers (NCC)

Effective January 1, 2024

NPSG 1 NPSG.01.01.01: Identify patients and residents correctly

Year: 2025

Name & Number: – Use at least two resident identifiers when providing care, treatment, and services.

Brief Description

This aim is in place so no one gets medical or personal care until their identity is verified. The staff should always use at least two identifiers, for example the resident’s full name and date of birth, to be sure of the resident’s identity before giving them medicine, collecting samples or starting procedures. It ensures that things are clear and that residents remain safe.

NPSG 2 NPSG.07.01.01: Prevent infection

Year: 2025

Name & Number: – Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.

Brief Description

Based on the Centers for Disease Control and Prevention, millions of people develop an infection annually as a result of receiving care, treatment, and services from a health care organization. Thus, health care–associated infections (HAIs) are both a patient and resident safety issue for all health care organizations. Maintaining hand hygiene by health care workers is one of the most important ways to decrease HAIs. Compliance with the World Health. WHO and/or CDC hand hygiene guidelines will limit the transmission of infectious agents between staff and patients and residents, thus the occurrence of HAIs will decrease (Biresaw, 2020). In order to accomplish compliance with this National Patient Safety Goal, an organization should measure its compliance with CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, promotes a culture of hand hygiene, provides monitoring for compliance, and provides feedback.

NPSG 3 NPSG .14.01.01: Prevent bed sores

Year: 2025

Name & Number: – Assess and periodically reassess each patient’s and resident’s risk for either developing a pressure injury or worsening of their existing pressure injury. Take action to address any identified risks.

Brief Description

Pressure injuries continue to be problematic in all heath care settings. Most pressure injuries can be prevented, and deterioration at stage I can be halted. The use of clinical practice guidelines can effectively identify patients and residents at risk and define early intervention for prevention of pressure injuries.

NPSG Priority

Chosen Goal: Use medicines safely

NPSG.03.06.01 Use medicines safely
Maintain and communicate accurate patient/resident medication information

Rationale

Many residents at St. Michael’s Long Term Care Centre are elderly and they are usually given combinations of medications by various providers. For this reason, record-checking for medications has become very important.

In our facility, I find that medication errors are especially common any time patients are transitioned from one area to another (e.g., at admissions, discharge times or transfers). The most common example is missing, double listing or inappropriate dosages of drugs, leading to problems like confusion, falls or patients need to be rehospitalized.

Supporting evidence

Since long-term care residents may have many medications and move between settings, using medication reconciliation is very important for everyone’s safety. At admissions, discharges and transfers, avoidable errors are normal; this can lead to more adverse drug events (ADEs).

In a study performed by Vaismoradi et al. (2020), it was found that closely following medication reconciliation rules greatly decreases medication problems and avoids harm to patients. According to their observations, about two-thirds of the differences they found could get worse if left untreated. As a result, it is especially important to communicate and document medications accurately when a resident changes caregivers or physicians.

Also, the Institute for Safe Medication Practices (Vaismoradi et al., 2020) strongly recommended using the same steps to reconcile medications at all types of healthcare facilities such as those for long-term care. The rules say to bring in pharmacists when needed, rely on computers to improve safety and train workers about the risks and supervision needs of sensitive drugs, including insulin or anticoagulants.

Because of these findings, focusing on NPSG.03.06.01 is important at St. Michael’s Long Term Care Centre. Making this goal happen can lead to fewer patients returning to the hospital, better medication use and better resident outcomes.

Reflection

Nurses are responsible for protecting patients in every healthcare setting and in long-term care, where residents are more prone to dangers because of their age, diseases or thinking difficulties, nurses are critical. Because nurses are on the front lines, they are expected to give medicines, do procedures, recognize safety concerns, push for best care and guarantee all care is personal and backed by evidence.

Meeting the National Patient Safety Goals helps build a consistent focus on safety at the hospital. If nurses observe accurate patient ID (NPSG.01.01.01), maintain updated medication information (NPSG.03.06.01) and practice proper hygiene (NPSG.07.01.01), both the chance for errors is much lower and the trust between everyone is higher.

In my practice, I have found that strict medication reconciliation keeps unwanted medication errors from happening and cuts down on people needing to return to the hospital. Auditing hand hygiene and encouraging infection control protocol has greatly lowered the number of infections, most notably during epidemics of flu and COVID-19.

In addition, when nurses support and show these safety standards, they help the wider team work together with responsibility, transparently and for continuous progress. By changing the culture, employees are happier, more willing to report incidents or near misses and there is a higher chance of everyone’s safety.

In short, NPSGs aren’t only things to comply with, but the basis for ensuring safety in the way care is given every day. In order to meet these goals and promote a focused safety culture, nurses regularly educate themselves, maintain close attention to their surroundings and team up with others.

Real-World Example

An 80-year-old patient was taken to the hospital because of hypertension and heart failure. The hospital staff gave the patient a sulfonylurea called glimepiride (Amaryl) instead of the prescribed antihypertensive ramipril (Biresaw, 2021). The wrong medication was given to the patient because medications were not reconciled correctly at the time of discharge. Later, the patient did not react because of low blood sugar and was brought back to the hospital for more care. With all the treatment given, the patient still lost his life due to the complications from their low blood sugar.

Result: A lack of proper reconciliation of medication led to the patient’s death from an adverse drug event. No one from the staff had verified the ticket which allowed the error to happen. Because of what happened, the facility looked again at its reconciliation procedures and recognized the significance of following NPSG.03.06.01.

This case emphasizes the need to do careful medication reconciliation when a patient is admitted or discharged. Reviewing and updating drug lists can keep accidents like these from happening. Sticking to NPSG.03.06.01 helps ensure that patient health is protected when they are transferred to a new care setting.

Safety Grade

Name of facility: St. Michael’s Long Term Care Centre

Overall facility safety grade?

On an overall review of current practices at St. Michael's Long Term Care Centre and their alignment with the 2024 National Patient Safety Goals, the centre would be ranked in total as A-. This rating reflects a steadfast commitment to patient and resident safety, particularly medication reconciliation, which has been suitably prioritized owing to its high-risk factor in long-term care. The facility demonstrates initiative in reducing adverse drug events, ensuring proper resident identification, and maintaining good infection control.

What areas have been identified as needing improvement? Please list the top three areas.

1. Consistency Among Shifts and Staff

There is a need to institute safety processes, namely medication reconciliation and hand hygiene procedures, in a standardized form across all shifts, including weekend and night shifts.

2. Technology Integration and Medication Tracking

Installation or EMR optimization and automated medication management systems can reduce human error, improve accuracy, and aid in transitions of care.

3. Improving the Culture of Incident Reporting:

Empowering every employee to report errors and near-misses safely without fear of retaliation provides a strong, just culture founded on compassion, accountability, and respect. This open and supportive environment promotes collective accountability and continuous learning, ultimately leading to improved patient safety and care quality continuously.

Evidence-Based Interventions

Consider three potential evidence-based interventions that might be implemented based on your local hospital safety grade. Please cite your sources.

1. Implement a Standardized Medication Reconciliation Tool at Care Transitions. By using a reconciled form or electronic list at admissions, discharges, and internal transfers, discrepancies and ADEs can be reduced. This multimodal process is facilitated by nurses, physicians, and pharmacists, and thus there is increased accuracy and accountability (Vaismoradi et al., 2020).

2. Use Electronic Medication Administration Records (eMAR) and Barcode Scanning. The utilization of electronic systems with barcode verification increases drug administration accuracy and guards against errors of wrong dose or wrong patient. eMAR provides instantaneous alerts and ensures all have visibility to updated lists of medications (Huh & Shin, 2021).

3. Implement a Non-Punitive Safety Event Reporting System. Creating a culture where no one will be blamed for reporting incidents and near misses can significantly enhance prevention and learning processes. Ensure this through the utilization of regular staff debriefs and anonymous reporting systems (Labrague et al., 2025).