The Joint Commission's latest Sentinel Event Alert, which was released this morning, urges healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur.
The alert, titled "Leadership committed to safety," reflects many of the changes made to the leadership chapter in The Joint Commission's 2009 Comprehensive Accreditation Manual for Hospitals, which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.
The alert asks leaders to recognize that if there is a failure in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, the alert reminds leaders that building a culture of safety is part of preventing medical errors. Doing so is something that can only truly happen when leaders buy in to the idea and show that they are not just talking about a culture of safety, but that it is something they live every day. By taking safety into consideration with each decision made about their facilities, leaders can lay the groundwork for making their organizations highly reliable.
"Healthcare leaders are directly responsible for establishing a culture of safety," says Mark R. Chassin, M.D., M.P.P., M.P.H., president of The Joint Commission. "This Alert provides leaders with concrete strategies for demonstrating a commitment to safety and to improving patient outcomes."
The alert lists 14 specific recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility's trouble spots without being penalized.
Similar to this, the alert recommends leaders support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Additionally, allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors.
However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.