A new Joint Commission Sentinel Event Alert urges healthcare 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 healthcare trustees, executives, and physician leaders, contending that the overall safety and effectiveness
of a healthcare facility depends on administrative and clinical leaders who set the tone, create the culture, and drive improvements.
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 healthcare 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 time frame 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 Sentinel Event Alert, The Joint Commission urges 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 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.
In Brief
Nurses working more in down economy
As the nation continues to reel from high unemployment and underemployment, nurses currently are putting in more hours than
they did at this time last year, but expect to return to pre-recession work levels once the economy rebounds, according to
a recent survey by staffing company AMN Healthcare.
The survey results: 47 percent of nurses said they have changed their schedules by working more overtime, adding a second
position, or returning to work full-time; 58 percent indicated they are working more hours than they did a year ago; and 20
percent said that the increased work hours are only temporary, as they plan to return to their previous work schedules as
the economy rebounds.
