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Facts about patient safety

March 30, 2016

As part of its mission, The Joint Commission is committed to improving health care safety for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission demonstrates its commitment to patient safety through numerous efforts.

Standards: A majority of Joint Commission standards are related to safety, addressing medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staff competence, fire safety, medical equipment, emergency management, and security. The standards also include requirements for preventing accidental harm; responding to patient safety events; and telling patients about the outcomes of their care. The hospital manual now includes a Patient Safety Systems chapter that describes how leaders can use existing requirements to achieve improved quality of care and patient safety, and the importance of an integrated patient-centered system to achieve these goals. The chapter can serve as a road map for implementing a fully integrated patient safety system in which staff and leaders work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from patient safety events.

Sentinel Event Policy: Implemented in 1996, The Joint Commission’s Sentinel Event Policy was revised in 2014 to incorporate contemporary patient safety concepts and clarify Joint Commission processes. Any time a sentinel event occurs, the health care organization is expected to conduct thorough and credible comprehensive systematic analyses (for example, root cause analyses), make improvements to reduce risk, and monitor the effectiveness of those improvements. The analyses are expected to drill down to underlying organization systems and processes that can be altered to reduce the likelihood of a failure in the future and to protect patients from harm when a failure does occur. Accredited organizations are strongly encouraged, but not required, to report sentinel events to The Joint Commission. Organizations benefit from self-reporting in the following ways:

  • The Joint Commission can provide support and expertise during the review of a sentinel event.
  • The opportunity to collaborate with a patient safety expert in The Joint Commission’s Sentinel Event Unit of the Office of Quality and Patient Safety. 
  • Reporting raises the level of transparency in the organization and promotes a culture of safety.
  • Reporting conveys the health care organization’s message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future.

Reporting also enables “lessons learned” from the event to be added to The Joint Commission’s Sentinel Event database, contributing to the general knowledge about sentinel events and to risk reduction of such events. For more information, call the Sentinel Event Hotline, 630-792-3700.

Complimentary publications: The Joint Commission publishes two complimentary publications that address safety issues: Sentinel Event Alert identifies specific patient safety problems, describes their common underlying causes, and suggests steps to reduce risk or prevent future occurrences. Quick Safety helps Joint Commission accredited organizations recognize potential safety issues. 

Patient safety events: The Joint Commission receives reports of patient safety events from patients, their families, government agencies, the public, staff employed by organizations, and the media. This information is used to help improve the quality and safety of accredited and certified organizations. Each patient safety event report is evaluated to determine whether it relates to one or more Joint Commission standards. If so, the evaluation focuses on assessing the organization’s compliance with those standards. Patient safety events can be reported online, by e-mail patientsafetyevent@jointcommission.org, phone 800-994-6610, fax 630-792-5636, or mail: The Office of Quality and Patient Safety, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois, 60181.

Patient safety research: The Joint Commission’s Department of Health Services Research works with external collaborators to investigate and evaluate interventions related to patient safety. Current initiatives are focused on ambulatory, hospital and nursing care settings. Projects include efforts to improve surgical safety through monitoring and improved implementation of the Universal Protocol™, development and dissemination of infection control guidance, research on respiratory protection programs and exploration of the worker safety-pateitn safety relationship.

Patient safety efforts worldwide: An affiliate of The Joint Commission, Joint Commission Resources (JCR) provides a variety of products and services, including education programs, publications and online software; its Continuous Service Readiness program; consultative technical assistance services; and accreditation and consulting for organizations abroad. JCR is dedicated to helping health care organizations worldwide improve quality and safety across all sites of patient care. JCR publishes a monthly newsletter, Environment of Care News, which focuses on patient and facility safety issues.

Quality Check® and Quality Reports: The Joint Commission has a longstanding commitment to providing meaningful information about the performance of accredited organizations to the public. The Quality Check® website, www.qualitycheck.org, launched in 1996, allows consumers to search for Joint Commission accredited and certified organizations, and find organizations by type of service provided within a geographic area. Quality Reports include the organization’s accreditation and certification decision, National Patient Safety Goal compliance, and special quality awards, such as the Eisenberg Patient Safety Award.

Legislative efforts: The Joint Commission monitors legislative initiatives at the state and federal levels, and advocates for passage of measures leading to improved patient safety. On the state level, The Joint Commission works with state regulatory and patient safety authorities to reduce duplicative expectations for accredited organizations subject to voluntary or mandatory reporting requirements; and engages state regulatory agencies to advocate for the reliance on accreditation in lieu of routine state licensure inspections. Recent issues addressed at the state level include healthcare-associated infections and scope of practice. Federal legislative priorities include modernizing the deeming relationship to reduce duplication and to focus survey activities on improving quality and safety; and aligning Medicare life safety requirements with the current edition of the National Fire Protection Association’s Life Safety Code®. 

Patient safety collaborations: The Joint Commission and JCR collaborate with a number of organizations to promote patient safety.

  • High 5s Project was launched by the World Health Organization in 2006 to address patient safety problems around the world. The Joint Commission and JCR coordinated the project, along with the Agency for Healthcare Research and Quality. The project ended in October 2014, and WHO will publish a final report on project results in 2016.
  • Institute of Medicine Roundtable on Health Literacy is comprised of leaders from academia, industry, government, foundations and associations, and representatives of patient and consumer interests.
  • National Coordinating Council on Medication Error Reporting & Prevention (NCC-MERP) is a coalition of member organizations that develop principles for constructing patient safety reporting programs. 
  • National Patient Safety Foundation includes a clearinghouse of information pertinent to issues in patient safety and funds innovative research dedicated to reducing risk.
  • National Quality Forum works to create consensus around nationally agreed-upon measures for quality and safety.
  • Consumers Advancing Patient Safety is a national consumer-led organization formed to be a collective voice for individuals, families and healers who suffer harm in health care encounters.  

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