The Joint Commission has issued a new sentinel event alert urging healthcare leaders to develop a culture of safety at their organizations.
The alert (PDF), published Wednesday, contained 11 tenets (PDF) of a safety culture that include taking a nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions to recognizing care team members for their efforts to improve safety and reduce medical errors.
The Joint Commission said leaders’ top priority must be accountability for effective care and responsibility for protecting the safety of patients, employees and visitors. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture. They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes,” the accreditor said in the alert.
The failure of leaders to create a culture of safety contributes to many types of adverse events at organizations from wrong-site surgery to delays in patient treatment, the alert indicated.
The new alert reemphasizes the importance of leadership’s commitment to safety and updates a 2009 alert on the issue.
The Joint Commission last year measured safety at 3,300 hospitals nationwide and found improvements on a number of measures. However, cultural barriers often impede the efforts to reduce medical errors.