Joint Commission: Healthcare leaders' failure to create safety culture can lead to adverse events

The Joint Commission issued a Sentinel Event Alert Wednesday calling on healthcare leadership to make forming an effective safety culture a top organizational priority.

A safety culture is the cumulative effort of an organization to keep patients safe from avoidable errors. The failure of healthcare leaders to create sustainable and effective safety cultures within their respective organizations is contributing to adverse events like wrong-site surgeries and treatment delays, according to the alert.

"A strong safety culture begins with leadership; their behaviors and actions set the bar," said Ana Pujols McKee, MD, executive vice president and CMO of The Joint Commission, in an email release. "I urge all healthcare leaders to make safety culture a top priority at their healthcare organization. Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity — because a lack of safety culture can have serious consequences for patients, staff and other stakeholders."

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Here are 11 tenets outlined by The Joint Commission to aid healthcare leaders in establishing a safety culture.

1. Encourage provider reporting and communication around errors by establishing a non-punitive, educational approach to addressing avoidable medical errors.

2. Develop processes to properly distinguish between human errors and errors indicative of systemic shortcomings.

3. Make efforts to eradicate intimidating behaviors in the workplace in regards to errors. Appropriate behaviors should be modeled from top executives down.

4. Communicate and properly enforce established policies designed to eliminate errors.

5. Recognize care team members who identify errors and offer suggestions to improve protocols.

6. Establish an organizational baseline measure to assess safety performance.

7. Disseminate safety culture surveys throughout the organization and analyze them properly to identify improvement opportunities.

8. Use safety assessments to develop unit-based quality and safety improvement initiatives.

9. Embed team training for improved safety into the safety culture.

10. Assess the strength and vulnerabilities of system tools like the EHR and prioritize improvements for these tools.

11. Conduct an organizational assessment of safety culture every 18 to 24 months to track progress ensure the sustainability of the culture.

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