Joint Commission says healthcare leaders must take responsibility for medical errors

A new Joint Commission Sentinel Event Alert urges healthcare leaders to boost their efforts to prevent medical 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 healthcare trustees, executives, and physician leaders, contending that the overall safety and effectiveness of a healthcare facility depends on administrative and clinical leaders who set the tone, create the culture and drive improvements.

The Alert notes that, in safe organizations, safety is rooted in the culture and the system, rather than in the behavior of individuals.

"Healthcare leaders are directly responsible for establishing a culture of safety," said Mark R. Chassin, MD, president of The Joint Commission. "This Alert provides leaders with concrete strategies for demonstrating a commitment to safety and to improving patient outcomes."

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

• 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, The Joint Commission is also urging healthcare 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 Sentinel Event Alerts are part of a series issued by The Joint Commission. The information provided in the alerts is drawn from the Joint Commission's Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The database includes information about both adverse events and their underlying causes. Previous Alerts have addressed healthcare technology, anticoagulants, wrong-site surgery, medication mix-ups, healthcare-associated infections, and patient suicides, among others topics.

An independent, not-for-profit organization based in Oakbrook Terrace, Ill., The Joint Commission accredits and certifies more than 16,000 health care organizations and programs in the United States.