New Patient Safety Educational Resource from Joint Commission
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.
Want to read the full alert and receive alert emails?