While the Obama administration is not pushing for required reporting of medical errors in this year’s healthcare legislation, the Joint Commission has spelled out 14 steps that leaders of healthcare institutions should take to prevent errors and improve patient safety. "Healthcare leaders are directly responsible for establishing a culture of safety," says Mark R. Chassin, MD, MPP, MPH, president of the Joint Commission.
The commission’s latest Sentinel Event Alert calls for senior management, institution governing bodies and clinical leadership to take the following steps:
Define a culture of safety that includes a code of conduct.
Create a policy of transparency to shed light on all adverse events and patient safety issues.
Incorporate patient safety statistics into the evaluation of the chief executive and other key leaders.
Ensure that healthcare providers involved in adverse events receive timely, respectful and compassionate attention.
Create a behavior policy that defines unacceptable behavior and calls for offenders to be disciplined in a timely manner.
Reward and recognize staff members who contribute to safety in the institution.
Facilities should incorporate these steps into their policies and follow the Joint Commission’s leadership standards, which already cover many of these issues, says the alert.
Meantime, the Obama administration is hinting that it favors mandatory national reporting of hospital-acquired infections, but not medical errors. Infections, says the administration, are easier to document and investigate than medical errors. "Once you get past the clear cases, it gets a lot harder" to determine who’s at fault, an unnamed senior administration official told Hearst Newspapers. "Many of the cases are much more ambiguous."
—Kent Steinriede
