New Patient Safety Educational Resource from Joint Commission

PUBLISHED: Aug 2, 2018
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has made available a new patient safety resource in the form of a case example that provides a step-by-step case of an aggregate fictional patient scenario. The case example is available at no cost on the TJC website, link below.

The case study takes a patient from the post-operative day 1 period through the patient’s death and the post-code debrief. As the patient decompensates, TJC highlights patient safety issues and missed opportunities that can be addressed by developing a culture of safety. Topics addressed include

  • Clinical alarm management
  • Emergency crash cart supplies, storage and maintenance
  • Culture of Safety

TJC also provides specific steps and strategies that could have been implemented to prevent the patient’s death. According to TJC, this case example is applicable to:

  • Staff nurses
  • Telemetry technicians
  • Code team members
  • Certified registered nurse anesthetists (CRNAs)
  • Managers of these staff
  • Alarm management committees
  • Patient safety and quality care staff
  • Organization leaders

Included with today’s notice are example policies related to issues highlighted in TJC’s case example.

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