Joint Commission urges health care leaders to prevent errors by taking the zero-defect approach

Leaders must take responsibility for patient safety

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/.