Joint Commission Alert: Effective Leadership Critical to Preventing Medical Errors

Joint Commission Alert: Effective Leadership Critical to Preventing Medical
Errors

Leaders must take responsibility for patient safety

OAKBROOK TERRACE, Ill., Aug. 27 /PRNewswire-USNewswire/ -- A new Joint
Commission Sentinel Event Alert issued today urges health care 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 Joint Commission
is advocating greater involvement of health care trustees, executives, and
physician leaders, contending that the overall safety and effectiveness of a
health care facility depends on administrative and clinical leaders who set
the tone, create the culture and drive improvements. In safe organizations,
safety is rooted in the culture and the system, rather than in the behavior of
individuals.

"Health care leaders are directly responsible for establishing a culture of
safety," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint
Commission. "This Alert provides leaders with concrete strategies for
demonstrating a commitment to safety and to improving patient outcomes."

To improve patient safety, The Joint Commission's Sentinel Event Alert
recommends that the governing body, chief executive officer, senior managers
and medical staff leaders at health care organizations take a series of 14
specific steps, including the following:

-- Define and establish an organization-wide safety culture that includes
a
code of conduct for all employees.
-- Institute an organization-wide policy of transparency that sheds light
on all adverse events and patient safety issues.
-- Make the organization's overall safety performance a key,
measurable part of the evaluation of the CEO and all leadership.
-- Ensure that caregivers involved in adverse events that result in
unintentional patient harm receive attention that is just, respectful,
compassionate, supportive and timely.
-- Create and communicate a policy that defines behaviors that are to be
referred for disciplinary action and a timeframe for that action to
take
place.
-- Add a human element to safety improvement by having patients
communicate
their experiences and perceptions to leadership.

-- Reward and recognize staff whose efforts contribute to safety.

In addition to specific recommendations contained in the Alert, The Joint
Commission urges health care organizations to use the Leadership section of
its accreditation standards to improve patient safety. The standards require
organizational 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.

The emphasis on the role of leadership in promoting greater patient safety is
part of a series of Alerts issued by The Joint Commission. Much of the
information and guidance provided in these Alerts is drawn from the Joint
Commission's Sentinel Event Database, one of the nation's most comprehensive
voluntary reporting systems for serious adverse events in health care. The
database includes detailed information about both adverse events and their
underlying causes. Previous Alerts have addressed health care technology,
anticoagulants, wrong-site surgery, medication mix-ups, health care-associated
infections, and patient suicides, among others topics. The complete list and
text of past issues of Sentinel Event Alert can be found at
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.

Founded in 1951, The Joint Commission seeks to continuously improve health
care for the public, in collaboration with other stakeholders, by evaluating
health care organizations and inspiring them to excel in providing safe and
effective care of the highest quality and value. The Joint Commission
evaluates and accredits more than 16,000 health care organizations and
programs in the United States, including nearly 9,000 hospitals and home care
organizations, and more than 6,200 other health care organizations that
provide long term care, behavioral health care, laboratory and ambulatory care
services. In addition, The Joint Commission also provides certification of
more than 600 disease-specific care programs, primary stroke centers, and
health care staffing services. An independent, not-for-profit organization,
The Joint Commission is the nation's oldest and largest standards-setting and
accrediting body in health care. Learn more about The Joint Commission at
www.jointcommission.org.

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SOURCE The Joint Commission

Ken Powers, Media Relations Manager of The Joint Commission, +1-630-792-5175,
kpowers@jointcommission.org