J-Co alert urges leadership role in medical error prevention

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A new Joint Commission Sentinel Event Alert issued Aug. 27 urged healthcare leaders to step up efforts to prevent errors by taking the zero-defect approach used in other high-risk industries, such as aviation and nuclear energy.

The commission said it is advocating for the involvement of healthcare trustees, executives and physician leaders, contending that the “safety and effectiveness of a healthcare facility depends on administrative and clinical leaders who set the tone, create the culture and drive improvements."

To improve patient safety, the commission's Sentinel Event Alert recommends that the governing body, CEO, senior managers and medical staff leaders at healthcare organizations take a series of 14 specific steps, including:

  • Defining and establishing an organization-wide safety culture that includes a code of conduct for all employees;
  • Instituting an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues;
  • Making the organization's overall safety performance a key, measurable part of the evaluation of the CEO and all leadership;
  • Ensuring that caregivers involved in adverse events that result in unintentional patient harm receive attention in a just, respectful, compassionate, supportive and timely manner;
  • Creating and communicating a policy that defines behaviors that are to be referred for disciplinary action and a timeframe for that action to take place;
  • Adding a human element to safety improvement by having patients communicate their experiences to leadership; and
  • Rewarding and recognizing staff whose efforts contribute to safety.

The commission also urges healthcare organizations to use the “leadership section” of its accreditation standards to improve patient safety.

The standards require leaders to create a culture of safety and to provide the resources necessary for patient safety. The standards also cover reporting systems for adverse events and near misses and the design of processes to support safety.