Joint Commission Issues Sentinel Event Alert on Developing a Reporting Culture

PUBLISHED: Dec 11, 2018
Relevant to: All Healthcare Organizations

The Joint Commission (TJC) has published Sentinel Event Alert #60 which reviews the imperative for and actions steps to take to develop a reporting culture. According to TJC, " A reporting culture is one where unsafe conditions are identified and reported as soon as possible with the hope of preventing harm, where leadership and other staff can be trusted to act on the report, and where taking personal responsibility for one’s actions is rewarded. A reporting culture is one where those making and reporting “human errors" will be consoled, those responsible for at-risk behaviors will be coached, and those committing reckless acts will be disciplined fairly and equitably, no matter the outcome of the reckless act.” A reporting culture is created by hospital Leadership and is a critical component of a culture of safety.

In a previous Sentinel Event Alert (#57), The Essential Role of Leadership in Developing a Safety Culture, TJC highlighted the importance of differentiating between human error and reckless at-risk behavior. In that Alert, TJC stressed the need for organizations to cultivate a culture where “…the need to report and do something about a safety issue outweighs the fear of being punished.”

An issue highlighted in this Sentinel Event Alert is the need for leadership to support the reporting of “close calls.” The reporting and subsequent analysis of close calls is important because these incidents:

  • Provide the organization with insight into active and potential system weaknesses,
  • Provide information on events causing harm from the health care workers perspective,
  • Allow organizations to analyze “…high-frequency or high-potential severity near miss reports…” and allow for learning and process improvement from the perspective of daily workflow..

The Joint Commission suggests that organizational leaders take the following actions to “…increase trust, reporting and responsibility/accountability of all staff in support of a safety culture with the ultimate goal to protect patients from harm.”

  • Communicate leadership’s commitment to building trust and reporting through a safety culture. (Note: Sentinel Event Alert #60 provides links to example videos demonstrating ways to communicate such commitment)
  • Develop and implement an incident reporting system that includes close calls and hazardous conditions and that encourages non-punitive reporting. Key aspects of the reporting system should include:
  • An easily accessible system for all staff
  • Communication to all staff about the types of incidents that should be reported and the non-punitive nature of the system.
  • A recognition program for staff appropriately using the system
  • A feedback loop so staff know that action is being taken to address or fix the identified issue/concern
  • Strategic use of data to reinforce the system and highlight successes of staff using the system
  • Managers, leaders, and where appropriate, staff should be held accountable for addressing and eliminating errors and hazards identified by reporting and for continually improving the safety of the patient care environment.
  • Assurance should be provided to all levels of the organization that leaders use a standardized accountability process to determine the difference between a system issue and reckless at-risk behavior.

Included with today’s are example policies and procedures related to the development, implementation and maintenance of a reporting culture.

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