The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.
The SEA comes with an infographic on the “11 Tenets of a Safety Culture.”
Sentinel Event Alert (SEA) #55, issued by The Joint Commission today, urges healthcare facilities to take action to prevent falls and fall-related injuries.
Falls are routinely in the top 10 sentinel events reported to The Joint Commission each year. The most common causes of falls or fall-related injuries, include poor patient assessment, lack of communication, failure to follow healthcare facility protocols and safety practices, and the absence of strong leadership, according to the SEA.
The Joint Commission recommends the following actions under the command of a strong leadership:
- Raise awareness of the need to prevent falls
- Create an interdisciplinary falls injury prevention team
- Implement a standardized tool to assess possible fall risks
- Develop patient-specific plans of care based on possible fall and injury risks
- Create standardized practices and interventions for healthcare professionals and patients
- Perform a root cause analysis after a fall
Read the SEA for further information on The Joint Commission’s recommendations to prevent falls and fall-related injuries.
The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.
According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.
In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.
The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.
The Joint Commission released today its latest Sentinel Event Alert targeting anticoagulant use and medical errors, the fourth alert this year. There have been a number of high-profile medical errors involving anticoagulants in the national media, and The Joint Commission’s alert is intended to offer methods for preventing further errors.
This is not the first time The Joint Commission has targeted anticoagulants. Requirements introduced into the 2008 National Patient Safety Goals are set to hit the point of full implementation on January 1, 2009. The Joint Commission also addresses anticoagulants under the medication management standards.
Common factors in anticoagulant errors highlighted in The Joint Commission’s report include labeling and packaging issues, documentation errors, communication failures, an inappropriate use of medication.
The alert offers fifteen steps to error prevention, including
-An assessment of the risks involved in using anticoagulants like heparin and warfarin
-Use of best practices or evidence-based guidelines to prevent errors using anticoagulants
-Reassessment of labeling and storing of anticoagulants to avoid errors
-Greater communication and collaboration between staff members
-More extensive education for patients
For more information or to view the Sentinel Event Alert itself, go to The Joint Commission’s Web site here.
I just wanted to make you aware of some breaking news: The Joint Commission has issued its latest Sentinel Event Alert today addressing bad behavior by healthcare professionals.
Disruptive behavior was considered as a possible National Patient Safety Goal for 2008 but was not selected. The Joint Commission has stated in this most recent alert that rude behavior, unpleasant language, hostile attitudes and other bad behaviors does not only create an unpleasant environment but are detrimental to patient safety and quality of care.
This alert ties into new standards going into effect January 1, 2009, which will require healthcare organizations to create a code of conduct defining acceptable and unacceptable behaviors as well as crafting a process for dealing with poor behavior.
The Sentinel Event Alert provides 11 steps to curbing disruptive behavior. These range from providing education and training for healthcare providers about professional behavior and appropriate interactions with coworkers; creating accountability for maintaining appropriate behavior; establishing a zero tolerance policy for disruptive behaviors and a means for enforcing this policy; and crafting non-confrontational methods for reporting and addressing inappropriate behavior.
The Joint Commission’s Sentinel Event Alert can be found online here: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm