Joint Commission Issues Sentinel Event Alert 57 - The Essential Role of Leadership in Developing a Safety Culture

PUBLISHED: Mar 1, 2017

The Joint Commission has issued Sentinel Event Alert number 57 addressing the essential role of leadership in developing a safety culture. Organizational leaders are fundamental to the existence of a safety culture. According to TJC, sentinel event data reveals that, “…leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.”

The Sentinel Event Alert reviews the components and importance of a safety culture and addresses the concerning finding of increased reports of retaliation and intimidation of health care team members voicing concern about safety issues. In the Alert, TJC makes several recommendations that can help organizational leaders continuously improve the five components of a safety culture. Below are a selection of TJC’s recommendations:

  • Develop and implement an organizational-wide and easy-to-use reporting system. A “…transparent, non-punitive approach to reporting and learning from adverse events, close calls and unsafe conditions…” is critical to success.
  • Establish clear, just, and transparent risk-based processes for recognizing and separating human error and error arising from poorly designed systems from unsafe or reckless actions that are blameworthy.
  • Ensure that the CEO and Hospital Leadership model appropriate, non-intimidating behaviors and champion those behaviors within the organization.
  • Establish, enforce and communicate to all team members the policies for: supporting the culture of safety, reporting adverse events, close calls, identifying unsafe conditions and submitting safety improvement suggestions.
  • Establish a baseline and continually measure safety culture performance; find opportunities for improvements in quality and safety by analyzing safety culture survey results on both an organization-wide level and a unit-based level.

Please see TJC’s Sentinel Event Alert, link below, to read all of the recommendations. Included with today’s notice are example policies related to creating and sustaining a culture of safety.

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