Joint Commission suggests patient safety actions
The following are some of the actions suggested by The Joint Commission directed to senior leadership: the governing body, the chief executive, senior managers, and medical and clinical staff leaders:
- Define and establish an organizationwide safety culture that includes a code of conduct for all employees, including contract workers.
- Institute an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
- 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 receive attention that is just, respectful, compassionate, supportive, and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification, and mitigation activities that will prevent future adverse events.
- Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the time frame that the disciplinary action should take place.
- Regularly monitor and analyze adverse events and close calls quantitatively, and communicate findings and recommendations to leadership, the board, and staff. Conduct root-cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors — the holes in the slices of cheese — and make sure they are addressed.
- Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
- Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. For example, some organizations create an emergency patient safety fund.
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