The Joint Commission is urging healthcare leaders to take steps to promote high quality, safe healthcare. They are also encouraging healthcare organizations to apply lessons learned in high-risk industries including aviation, energy and manufacturing. In a Sentinel Event Alert issued in late August, the commission wrote: "Inadequate leadership was a contributing factor in 50 percent of the sentinel events reported to the Joint Commission in 2006."
To promote an increased focus on safety, the Joint Commission has suggested 14 specific steps:
- Define and establish an organization-wide safety culture.
- 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 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.
- Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations.
- Regularly hold open discussions with all relevant personnel to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff.
- Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention.
- Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine.
- Add a human element and a sense of urgency to safety improvements by having patients communicate their experiences and perceptions.
- When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work.
- Regularly measure leadership's commitment to safety.
- When leaders assess managers during annual performance reviews, make sure they ask about the safety issues the manager encountered, how they were handled and the impact their actions had on reducing unsafe conditions.
- Communicate to staff when their work improves safety.
To read the entire Sentinel Event Alert, click here.
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Most hospitals when faced with a medical error work with the affected patient's family through risk managers and attorneys. In contrast, the University of Illinois Medical Center at Chicago is taking a non-traditional approach when it comes to medical errors. The hospital's process has been in the making since 2004 when a consultation service was created to help staff communicate quickly with patients and families after incidents. In 2006, this service evolved into a policy of full disclosure, apology and offer of financial compensation. According to Chief Safety Officer Timothy McDonald, the number of lawsuits has dropped and financial payouts to patients have not increased. The program has also identified safety issues that have led to almost 200 hospital procedure improvements.
McDonald and cardiac anesthesiologist Dave Mayer are taking the message one step further by producing a series of patient safety videos. The main purpose of these videos is patient safety education for hospital staff. The creators also see value in using the videos to teach patients to take a more active role in their healthcare. To see a trailer for the first video: "The Faces of Medical Error: From Tears to Transparency," click here.
To read more about how the University of Illinois Medical Center at Chicago manages patient safety, continue here.
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Almost 200,000 Americans die from preventable medical injuries each year. According to the Centers for Disease Control and Prevention, 99,000 of these patient deaths are the result of hospital-acquired infections.
There is currently no mandatory nationwide reporting system for medical errors. The American Medical Association (AMA) and American Hospital Association have weighed in with the opinion that mandatory reporting would drive medical errors underground. However, AMA officials support voluntary reporting and the American Hospital Association is in favor of disclosing mistakes to families involved in specific incidents. Without a nationwide mandatory reporting system, states are on their own when it comes to collecting and reporting on data. This also puts patients at a loss when making critical healthcare decisions. To read the entire investigative report, click here.
To see how New Jersey is addressing medical errors, read this news brief.
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Every scar has a tale to tell. It might be a short story, quick and to the point or a longer, drawn out epic. Most people have scars dating back to childhood and the cause may be long forgotten. Others have fresh adult scars from surgery or an accident with a kitchen appliance or gardening tool. What do your scars mean to you? Dana Jennings, a New York Times reporter, shares the story of his scars here.
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