Get to know the International Patient Safety Goals

To understand what the International Patient Safety Goals are, think of a situation like this: two patients with similar names receive medications at close times. A mistaken check could result in the wrong administration of an anticoagulant. In other words, a single isolated error has tragic potential in the hospital setting.

For decades, cases like this were treated as inevitable. Only between the 1990s and 2000s did health systems come to understand that these occurrences had clear patterns, repeated causes and possible preventive solutions.

It was in this context that a guide called the International Patient Safety Goals (IPSG) emerged, in Portuguese Metas Internacionais de Segurança do Paciente.

What are the International Patient Safety Goals for?

The six goals aim to establish standardized care practices, consolidated by international bodies, that are measurable and applicable in the daily routine of every hospital in the world.

These goals became the foundation of the modern safety culture in healthcare by turning past mistakes into lessons learned. From correct identification to the safe use of medications, from clear communication between departments to the prevention of infections and falls, everything must be done with patient safety and well-being in mind.

This is one of the elements of maturity found in the best health systems in the world. The goals therefore represent the consolidation of practices developed over decades of research into how errors happen and how they can be prevented.

The six International Patient Safety Goals

According to the World Health Organization (2019), more than 130 million adverse events occur every year in hospitals in low- and middle-income countries as a result of unsafe care, resulting in 2.6 million deaths.

The goals were designed to change this scenario, as a way to universalize simple practices that can prevent some of these incidents. They were first published in 2006 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Portuguese Comissão Conjunta de Acreditação de Hospitais, now known by the shorter name The Joint Commission (TJC).

The six goals are simple, short and direct, and have undergone few adaptations over the years. They are:

Goal 1 — Identify patients correctly (Identificar pacientes corretamente)

Historically, identification errors have been responsible for many adverse events: surgeries performed on the wrong person, mixed-up test samples, incorrect administration of medications and incompatible transfusions.

Studies from the 1990s showed that a significant share of these incidents occurred because of seemingly simple failures, such as illegible wristbands, people with the same first and last name being treated in the unit or the absence of active verification, for example.

The goal reinforces that no intervention should take place without checking at least two identifiers, such as full name and date of birth.

Today, standardized wristbands, barcodes and electronic medication systems (“beep”) have made this process safer, but active checking by the team, confirmed by the patient, remains the essential element of prevention.

Goal 2 — Improve effective communication (Melhorar a comunicação efetiva)

Communication (or the lack of it) is one of the main sources of risk in the hospital environment. Information lost at shift handoffs, ambiguous verbal orders, incomplete phone messages and the absence of structured records have been documented as direct causes of treatment delays, duplicate tests, prescribing errors and failures in clinical follow‑up.

This goal guides hospitals to adopt structured communication methods (such as SBAR), standardize the recording of critical information and require confirmation of verbal orders (read-back). The aim is to turn communication into a traceable, reliable and replicable process.

Goal 3 — Improve the safety of high-alert medications (Melhorar a segurança de medicamentos de alto risco)

High-alert medications (opioids, concentrated electrolytes, insulin, anticoagulants) are more likely to cause serious harm when administered incorrectly.

In the 2000s, the Joint Commission consolidated evidence showing that a large share of serious adverse events was concentrated in these drugs. Mixed-up doses, inadequate dilutions, look-alike vials, prescribing failures or omissions in medication reconciliation were the most common reasons for administration errors.

The goal promotes actions to reduce this risk, such as:

• standardized visual identification;

• restricted and controlled access;

• dosing protocols;

• clear labeling;

• independent double checks;

• medication reconciliation at admission, transfer and discharge.

It is a goal directly connected to clinical pharmacy, medication engineering and operational safety.

Goal 4 — Ensure safe surgery (Garantir cirurgia segura)

Surgeries performed on the wrong part of the body or on the wrong patient, although rare, drew worldwide attention in the early 2000s. Incident analysis showed that these failures did not stem from surgical incompetence but from process problems: inadequate marking, rooms with multiple patients, fragmented communication and the absence of a joint team check.

The goal established the Universal Protocol for surgery, made up of three pillars:

1. Pre-procedure verification (complete data, tests, consent).
2. Surgical site marking with the active participation of the team and the patient.
3. Time out (a pause immediately before the incision to confirm the patient, procedure, laterality, materials and risks).

This makes the operating room a more predictable, standardized and collaborative environment.

Goal 5 — Reduce the risk of health care-associated infections – HAI (Reduzir o risco de infecções associadas ao cuidado de saúde)

Healthcare-associated infections (HAIs) are one of the largest avoidable costs in healthcare and one of the most common causes of longer hospital stays, sepsis and mortality. It has been proven that simple practices (such as hand hygiene) had a direct impact on patient survival.

The goal encourages measures with robust evidence, such as:

• adherence to hand hygiene;

• active epidemiological surveillance;

• safe sterilization and cleaning processes;

• traceability of materials and devices.

Goal 6 — Reduce the risk of patient harm resulting from falls (Reduzir o risco de danos relacionados a quedas)

Falls are an especially complex challenge: they involve clinical, structural, behavioral and environmental factors. Patients who are elderly, sedated, disoriented, have reduced mobility or are taking medications that alter their mental state are more vulnerable.

Many hospitals viewed falls as “inevitable accidents,” until studies showed repeated and predictable patterns. Today, fall prevention is a sensitive indicator of the maturity of the safety culture.

The goal therefore proposes:

• systematic fall risk assessment at admission and daily;

• individualized plans (non-slip socks, supervision, low beds);

• adjusting medications that raise the risk;

• adapting the environment (lighting, accessible call buttons, grab bars);

• recording episodes and root cause analysis.

In an increasingly complex health system, the International Patient Safety Goals work as a guide to reducing predictable risks. When applied with discipline, they turn routines and procedures into real barriers against avoidable harm. This is a culture that helps protect what matters most: people’s lives.