A Position Statement of the Joint Commission
The Joint Commission is committed to improving patient safety through its accreditation process. Meaningful improvement in patient safety will eventually be reflected by a significant reduction in the number of medical/health care errors that result in harm to patients. Achieving this significant reduction is dependent upon:
- Identification of the errors that occur.
- Analysis of each error to determine the underlying factors -- the "root causes" -- that, if eliminated, could reduce the risk of similar errors in the future.
- Compilation of data about error frequency and type and the root causes of these errors.
- Dissemination of information about these errors and their root causes to permit health care organizations, where appropriate, to redesign their systems and processes to reduce the risk of future errors.
- Periodic assessment of the effectiveness of the efforts taken to reduce the risk of errors.
The aggregation of data from many health care organizations about their medical/health care errors and the root causes of these errors is necessary in order to set priorities for error reduction activities; to identify priorities for system/process redesign in health care organizations; and to assess the effectiveness of the efforts to reduce errors over time.
Therefore, in order to measurably improve patient safety, the Joint Commission supports the creation of an effective medical/health care error reporting system, whether mandatory or voluntary, having the following characteristics:
- Events to be reported to the system must be well-defined and, if a mandatory system, limited to serious adverse events.
- Reports of serious adverse events must include the findings of the root cause analyses of these events.
- All information reported to the system must be legally protected from disclosure (including by subpoena, discovery, introduction of evidence, testimony, or any other form of disclosure in connection with a civil or administrative proceeding under federal or state law or under the Freedom of Information Act).
- The Joint Commission and other health care oversight bodies having a legitimate "need to know" must have full and timely access to the data in the reporting system, on a health care organization-specific basis. This includes data about the adverse events, their root cause analyses, and the actions taken to reduce future risk. Disclosure of this information to accrediting bodies or other quality oversight bodies must not result in waiver of any protection against disclosure of the information provided by state or federal law.
- The Joint Commission must play a central role in the evaluation of root cause analyses for its accredited organizations, and in the dissemination of information to the health care field that facilitates learning about and implementing actions to improve patient safety.
Approved by the Board of Commissioners, February 4, 2000