Doctor explaining couple in hospital ward. Male is sitting with female patient. Practitioner is gesturing while talking in hospital.
The Journal on Quality and Patient Safety
Published monthly, the Joint Commission Journal on Quality and Patient Safety® is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care.
The journey towards high reliability health care is a challenging but worthwhile venture, physician leaders are key to their organization’s successful achievement of this goal. In mid-April, more than 130 physician leaders from around the country make their way to Oakbrook Terrace, Illinois, to experience The Joint Commission’s annual Physician Leaders Forum.
Reasons you don't want to miss this event:
Opportunity to network and collaborate with fellow physician leaders
Physicians who want to get their organizations on the path to zero harm will want to complete the Oro® 2.0 Assessment. This provides an unmatched opportunity for leadership engagement with foundational aspects of high reliability. Oro 2.0 can help senior leaders not only understand where they stand today on the spectrum of high reliability but also provides an actionable path forward in pursuit of zero harm.
The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. For resources related to sentinel events including our Sentinel Event Alerts click on the button below.
This fictionalized case example follows the failed hand-offs of a suicidal patient through screening and assessment in the ED to admission to a medical-surgical unit. Case examples can be used as learning opportunities for identifying lapses in patient safety and missed opportunities for developing a culture of safety. A follow-up will highlight safety actions and strategies.