Joint Comission: Serious HCW injuries are now sentinel events
'The climate of safety should be very proactive'
In a move that raises the profile of employee health, The Joint Commission accrediting agency is expanding its definition of a "sentinel event" to include serious injury to health care workers.
While once singularly focused on patient safety, The Joint Commission is now embracing the concept of "high-reliability," in which organizations place a priority on all facets of safety. The new sentinel event policy, which becomes effective on July 1, 2013, also includes serious injuries or deaths of visitors and vendors while on hospital property.
"High reliability is at the core of our thinking," says Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement at the Oakbrook Terrace, IL-based organization.
Hospital leadership is responsible for creating a "culture of safety," he says. "The overarching aim is to encourage health care organizations to become safer places, to encourage leadership to look to a high level of accountability toward safety in that organization," he says.
When serious events occur, whether they involve patients or employees, The Joint Commission expects health care organizations to conduct a root cause analysis that is "robust" and non-punitive, Wyatt says. A culture of safety is "a blame-free environment, where staff, visitors, vendors are encouraged to report what may be considered a safety issue," he says.
The Joint Commission action is a significant advance for hospital employee health, says Bill Borwegen, MPH, safety and health director of the Service Employees International Union (SEIU). "Research shows the linkage between worker safety and patient safety is no longer deniable," he says. "Workers can provide the highest quality of patient care when they feel safe themselves in the workplace. This is a very positive evolution of the way The Joint Commission views their jurisdiction."
High reliability: safety for all
The high-reliability concept that is gaining favor in health care has its roots in nuclear power, the airline industry, and other industries that are highly attuned to safety. It calls for organizations to seek out vulnerabilities, including near-misses, and to continually work to reduce risk of failure.
By promoting high reliability, The Joint Commission challenges a paradigm that patient safety is distinct from employee health and safety.
"The principles of high reliability hold leadership accountable to be uncompromising in its commitment to a culture of safety within the organization," according to an article in the December issue of The Joint Commission Perspectives, the organization's official newsletter.
"An organizational culture of safety would encompass all people within an organization and not just one group (that is, patients, residents, or individuals served). The revision to the Sentinel Event Policy supports this principle by not differentiating in its processes and by ensuring a robust review, regardless of who the victim is, of any sentinel event," it said.
Robyn Gershon, DrPH, an expert in safety climate, lauded The Joint Commission's new direction. Hospitals are beginning to understand the importance of establishing an overall culture of safety, she says.
"You can't just say we're making it safe for patients and not make it safe for visitors and employees. It has to be a total commitment," says Gershon, who is a professor of epidemiology and biostatistics at the University of California, San Francisco.
Rape, assault are sentinel events
The Joint Commission defines a "sentinel event" as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." It signals the need for "immediate investigation and response," The Joint Commission says.
The agency also encourages health care facilities to report "reviewable" sentinel events, or those that involve "an unanticipated death or major permanent loss of function." Facilities are expected to conduct a root cause analysis and implement a corrective action plan.
With the broader definition of sentinel events, The Joint Commission added an item to its list of examples of reviewable sentinel events: "Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the health care organization."
"We would hope that if an organization has one of those [reviewable sentinel] events that they would go through the root cause process," says Wyatt.
Health care organizations also define sentinel events that will trigger root cause analysis within their facilities, he says. They might use the same process of root cause analysis for near-misses that reveal a serious safety vulnerability, he says.
"In the world of safety, it's really important to look at near misses," says Gershon. "Minor events can often point the way to things that are much more [significant]."
Be proactive to reduce hazards
It's also important to acknowledge the barriers to safety. Too often, there is lack of leadership commitment, which also translates to inadequate resources — too few safety and occupational health professionals, too little investment in safety training and equipment, Gershon says.
Ideally, the culture of safety evolves from a strong commitment at the top of the organization, she says.
And while The Joint Commission calls for a root cause analysis of serious events, an even better prevention strategy is to seek and address hazards through a hazard vulnerability assessment, she says. Safety and occupational health professionals can then take steps to eliminate hazards or provide protective equipment before a serious event occurs, she says.
For example, a plan to prevent incidents of violence would include an assessment of crime and violence in the surrounding area, tools such as cameras, lighting and security, and staff training and awareness, she says.
"The climate of safety should be very proactive, constantly looking for risks that are in the environment," Gershon says.
In a move that raises the profile of employee health, The Joint Commission accrediting agency is expanding its definition of a "sentinel event" to include serious injury to health care workers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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