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Joint Commission: Leaders are safety culture linchpin

Hospital Safety Insider, March 2, 2017

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Solid leadership is central to promoting and sustaining a culture of safety in any healthcare organization, The Joint Commission said in a Sentinel Event Alert published Wednesday, reminding leaders that it’s their job to identify and mitigate potential pitfalls on an organizational level.

People will err, and equipment will misfire, but a systemic approach to safety will aim to catch mistakes before they harm patients and, in the event of a negative outcome or a close call, see the situation as a learning opportunity, the alert states.

The document, which updates and replaces an alert issued in 2009, outlines actions leaders should take within their organizations to build trust, accountability, an eye for safety hazards, stronger systems, and means of assessment. First on the list is ensuring that the adverse-event reporting process is neither opaque nor focused solely on doling out punishments. This non-punitive approach can increase error reporting, giving organizations more data points to analyze in the never-ending search for weak spots to be patched.

The alert calls for organizations to root out any intimidating behaviors that might discourage workers from reporting problems, and it encourages them to give special recognition to those who spot and report unsafe conditions. The document urges leaders, furthermore, to quantify the health of their safety culture and track it over time.

Details on all 11 recommended actions and related resources are available in the full report.

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