The alert encourages leaders and providers to learn from “close calls” in patient care.
“Close calls happen more frequently than actual harm events,” the accrediting organization said. “Reporting them provides crucial information on active and potential weaknesses in healthcare safety systems from the perspective of healthcare workers in varying positions.”
The alert cites practices and resources from several hospitals, including Boston-based Brigham and Women’s Hospital, Cincinnati Children’s Hospital and Houston-based Memorial Hermann Health System.
The Joint Commission recommends healthcare organizations and leaders:
- Review the alert and the Joint Commission’s Sentinel Event Alert No. 57 – The essential role of leadership in developing a safety culture when creating safety culture protocols.
- Communicate leadership commitment to developing trust and reporting through a safety culture.
- Create a system for reporting incidents, such as close calls or hazardous conditions, that encourages reporting. The system should include a recognition program and give a feedback loop so staff know the flaw is addressed.
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