Patient safety is a critical issue in the healthcare industry. This area is heavily researched and regulated for good reason. It is one of the primary issues facing the healthcare industry today. This blog will explore patient safety rules that were made to ensure better health.

According to the WHO (World Health Organization, 2019)1:

  • Patient harm due to adverse events is likely to be among the 10 leading causes of death and disability worldwide.
  • Most of these deaths and injuries are avoidable.
  • It is commonly reported that around 1 in 10 hospitalized patients experience harm, with at least 50% being preventable.  
  • Around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death, occur in LMICs.

A study, titled “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I“, published in the journal “The New England Journal of Medicine” in 1991 looked at data from over 30,000 patients who were discharged from hospitals in New York State in 1984. The researchers found that 3.7% of the patients suffered an adverse event, and 27.6% of those adverse events were due to negligence2. In an absurd comparison, a patient in a hospital is 40 percent more likely to be injured because of negligence than an airline passenger is to have his luggage lost.

One of the most prevalent reasons for medical errors results from the lack of adequate information. The inability to access information is the largest challenge. Doctors and nurses don’t set out to make mistakes, but if they don’t have the patient’s medical history at their fingertips, errors can easily be made (Quan, 2014, p. 133)3.

Patients’ medical records are often still maintained in large paper files held in hospital vaults and doctors’ offices. In the event of an emergency, chances of accessing that information in a timely manner are very slim to none. Sometimes it becomes a huge issue (Quan, 2014, p. 133).

Errors in health care stem from several actions. These actions can be errors of execution, such as doing something incorrectly. They can be errors of omission, such as not doing something that needs to be done. And they can be errors of commission, as in doing the wrong thing (Quan, 2014, p. 133).

The National Patient Safety Goals

Several nonprofit organizations have formed and stepped in to study the problem and to establish goals and interventions to help reduce and prevent
medical errors. Accreditation agencies such as The Joint Commission have taken the issue seriously and have established standards that include patient safety goals. Each year, The Joint Commission implements mandatory safety standards throughout the industry for accredited facilities.

The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regard to patient safety. The first set of NPSGs was effective January 1, 2003. For 2023, the patient safety goals include the following (The Joint Commission, 2023)4:

Improve the accuracy of patient identification

Use at least two forms of identification, such as asking the patient to spell his name and tell you his date of birth. Some facilities use bar codes on patient wristbands.

Improve Communication

Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis.

Medication Safety

Improve the safety of using medications.

  • All medications must be labeled. For example, medications in syringes, basins, and cups must be labeled with the name of the medication, the dose, and who prepared it.
  • Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
  • Maintain and communicate accurate patient medication information. Find out all of the medications a patient is taking before adding any medications. Make sure there are not conflicts between the medications or contraindications. Ensure that the patient, caregivers, and all members of his medical team have a current and complete list of medications the patient is taking.

Click to read more about “How to Avoid Medication Errors in a Hospital“.

Clinical Alarm Safety

Reduce patient harm associated with clinical alarm systems. Improve the safety of clinical alarm systems.

Health Care-Associated Infections

Reduce the risk of health care-associated infections. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines

Reduce Falls

Reduce the risk of patient harm resulting from falls. Hospitals and other healthcare organizations must take steps to identify patients at risk for falls, implement interventions to reduce the risk of falls, and educate patients and staff about fall prevention.

Pressure Ulcers

Prevent health care-associated pressure ulcers (decubitus ulcers). Assess and periodically reassess each patient’s and resident’s risk for developing a pressure ulcer and take action to address any identified risks.

Risk Assessment

The organization identifies safety risks inherent in its patient population.

  • Reduce the risk for suicide.
  • Identify risks associated with home oxygen therapy, such as home fires.

Health Care Equity

Improve health care equity. Improving health care equity for the organization’s patients is a quality and safety priority.

In conclusion, to create a culture of patient safety, everyone must be dedicated to it, and mistakes should be viewed as opportunities to learn and do better. Healthcare organizations must continuously strive for improvement to achieve and maintain high levels of patient safety. There are plenty of organizations working towards this goal, and The Joint Commission’s NPSGs are a crucial part of that effort. The 2023 NPSGs concentrate on potential hazards that could result in severe harm to patients. By incorporating these objectives, healthcare organizations can decrease the chances of medical errors and promote patient safety. Of course, patients can also contribute to their safety. By staying informed and engaged, patients can help prevent medical errors from occurring.


  1. World Health Organization. (2019, November 6). Patient safety. World Health Organization. ↩︎
  2. Brennan. (1991, February 7). Incidence of adverse events and negligence in hospitalized patients — results of the harvard medical practice study I. New England Journal of Medicine. ↩︎
  3. Quan, K. (2014). The New Nurse Handbook. Fall River Press, New York ↩︎
  4. The Joint Commission. (2023, January). National Patient Safety Goals. ↩︎

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