Joint Commission Incorporates AHRQ Findings in Developing Safe Practice Goals

Patient Safety
November 2005

JCAHO's 2005 National Patient Safety Goals were approved at its July 2004 Board of Commissioners' meeting. Tools and strategies for two safe practices, included among the JCAHO goals, were developed by the Massachusetts Coalition for the Prevention of Medical Errors under an AHRQ-funded grant to the Massachusetts Department of Public Health. The initiatives were developed in collaboration with the Massachusetts Hospital Association (MHA). The grant was designed to study the root causes of medical errors and to devise appropriate strategies for prevention.

The purpose of JCAHO's National Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based solutions to these problems. The two new requirements included among the 2005 goals are Reconciling Medications and Communicating Critical Test Results. As the national group that accredits hospitals, JCAHO now expects hospitals around the country to follow Massachusetts' lead in adopting these safe practices.

Massachusetts was the first state to develop and promote statewide implementation of these two safe practices. The MHA and the Massachusetts Coalition collaborated to develop priorities for its statewide safe practices initiatives, using AHRQ's patient safety research and other sources of data on patient safety problems and effective prevention strategies. The grant then funded the work to develop detailed safe practice recommendations for implementing these two requirements. It also enabled collaborative learning opportunities and the creation of toolkits with materials to support the State's hospitals as they worked to implement these safe practices. The toolkits and set of implementation tips and strategies based on the lessons learned from these hospital teams are now available on the Coalition's Web site for use by any hospital working on the JCAHO National Patient Safety Goals.

The Massachusetts Coalition for the Prevention of Medical Errors was established in 1998 to develop a campaign in the Commonwealth to improve patient safety and reduce medical errors. The goals of the Coalition are to disseminate knowledge and information about the causes of medical errors, develop strategies for prevention, and accelerate adoption of these strategies. The Coalition also provides tips and tools that hospitals can access through its Web site (

The JCAHO National Patient Safety Goals can be viewed at:

Impact Case Study Identifier: 
AHRQ Product(s): Research
Topics(s): Medical Errors
Geographic Location: National
Implementer: JCAHO
Date: 11/01/2005


Ridley N. Reconciling medications collaborative of the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. (HS11928)


Page last reviewed October 2014