Facts about Patient Safety - Joint Commission

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Facts about Patient Safety - Joint Commission

Facts about patient safety

The Joint Commission is committed to improving health care safety. This commitment is inherent in its

mission to continuously improve health care for the public, in collaboration with other stakeholders, by

evaluating health care organizations and inspiring them to excel in providing safe and effective care of the

highest quality and value. At its heart, accreditation is a risk-reduction activity; compliance with standards

is intended to reduce the risk of adverse outcomes. The Joint Commission demonstrates its commitment

to patient safety through numerous efforts.

Standards: Almost 50 percent of Joint Commission standards are directly related to safety, addressing

such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and

seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and

security. These standards also include specific requirements for the response to adverse events; the

prevention of accidental harm through the analysis and redesign of vulnerable patient systems (e.g. the

ordering, preparation and dispensing of medications); and the organization’s responsibility to tell a patient

about the outcomes of the care provided to the patient – whether good or bad.

Sentinel Event Policy: The Joint Commission’s Sentinel Event Policy, implemented in 1996, is designed

to help health care organizations identify sentinel events and take action to prevent their recurrence. A

sentinel event is an unexpected death or serious physical – including loss of limb or function – or

psychological injury, or the risk thereof. Any time a sentinel event occurs, the health care organization is

expected to complete a root cause analysis, make improvements to reduce risk, and monitor the

effectiveness of those improvements. The root cause analysis is expected to drill down to underlying

organization systems and processes that can be altered to reduce the likelihood of a failure in the future

and to protect patients from harm when a failure does occur. For more information, call the Sentinel Event

Hotline, 630-792-3700.

Sentinel Event Alert: The Joint Commission began publishing its Sentinel Event Alert newsletter in 1998

in order to share “lessons learned” from its sentinel event database and provide important information

relating to the occurrence and management of sentinel events in health care organizations. The

newsletter identifies specific types of sentinel and adverse events and high risk conditions, describes their

common underlying causes, and recommends steps to reduce risk or prevent future occurrences.

Sentinel Event Alert has raised awareness in the health care community and the federal government

about adverse events. Past issues are available on The Joint Commission website. Topics include

medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient

suicides, infant abductions, fatal falls, and intimidating behavior that interferes with a culture of safety.

Patient Safety Advisory Group: In 2002, The Joint Commission appointed an expert panel of widely

recognized patient safety experts, nurses, physicians, pharmacists, risk managers, and other

professionals who have hands-on experience in addressing patient safety issues in a wide variety of

health care settings. The Patient Safety Advisory Group works with Joint Commission staff to identify

emerging patient safety issues, and advises The Joint Commission on how to address those issues in

National Patient Safety Goals, Sentinel Event Alerts, standards and survey processes, performance

measures, educational materials, and Center for Transforming Healthcare projects.

National Patient Safety Goals: In 2002, The Joint Commission established its National Patient Safety

Goals program and the first set of NPSGs was effective January 1, 2003. The NPSGs were established to

help accredited organizations address specific areas of concern in regards to patient safety. The Patient

Safety Advisory Group (see above) advise The Joint Commission on the development and updating of

NPSGs. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer

groups, and other parties of interest, the advisory group determines the highest priority NPSGs and


makes its recommendations to The Joint Commission. NPSGs differ from standards and their

corresponding elements of performance by requiring the surveyor to affirmatively observe compliance of

each NPSG.

The Universal Protocol: The Joint Commission Board of Commissioners originally approved the

Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery in July

2003, and it became effective July 1, 2004, for all accredited hospitals, ambulatory care and office-based

surgery facilities. The Universal Protocol was created to address the continuing occurrence of wrong site,

wrong procedure, and wrong person surgery and other procedures in Joint Commission accredited

organizations. The Universal Protocol drew upon, and expanded and integrated, a series of requirements

under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. The three principal

components of the Universal Protocol include a preprocedure verification, site marking and a time out.

Complaints: The Joint Commission uses information from a variety of sources to improve the quality and

safety of the health care organizations it accredits and certifies. One of these sources is complaints from

patients, their families, government agencies, and the public, as well as from an organization’s own staff

and the media. When we receive a complaint, we will initially evaluate whether it relates to one or more

Joint Commission standards. If so, our evaluation will then focus on assessing the organization’s overall

compliance with those standards. Complaints can be reported online, by e-mail

complaint@jointcommission.org, phone 800-994-6610, fax 630-792-5636, or mail: Office of Quality

Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois, 60181.

Patient safety research: The Joint Commission’s Department of Health Services Research addresses

patient safety research from a variety of perspectives and works with external collaborators to advance

the field of patient safety and adverse event reporting systems. Examples of initiatives include:

• Determining the effect of the use of universal glove and gowning on health care-associated infection

rates and antibiotic resistant bacteria.

• Building an international, collaborative learning network that fosters the sharing of knowledge and

experience in implementing innovative, standardized operating protocols to address patient safety

problems.

• Identifying and disseminating preferred practices and technology to prevent central line-associated

bloodstream infection.

• Optimizing preoperative antibiotic prophylaxis for cardiac and orthopedic procedures to reduce

surgical site infections.

• Accelerating the development and adoption of evidence-based approaches that have the capacity to

prevent or contain antimicrobial resistance, and that support and promote appropriate use of

antimicrobial agents.

Patient safety education and other resources: Joint Commission Resources is a global, knowledgebased

organization that provides innovative solutions designed to help health care organizations improve

patient safety and quality. An affiliate of The Joint Commission, JCR is the official publisher and educator

of The Joint Commission. JCR provides expertise on the many issues organizations face in a challenging

health care environment through a variety of products and services including education programs,

publications and multimedia products; its Continuous Service Readiness program; comprehensive health

care consulting and custom education; and accreditation and consulting for organizations abroad. JCR is

dedicated to helping health care organizations worldwide improve quality and safety of patient care. JCR

publishes a monthly newsletter, Environment of Care News, which focuses on patient and facility safety

issues. For more information or to order, visit the JCR website or call the JCR toll-free customer service

line at 877-223-6866.

Speak Up initiatives: In March 2002, The Joint Commission, together with the Centers for Medicare &

Medicaid Services, launched a national program to urge patients to take a role in preventing health care

errors by becoming active, involved and informed participants on the health care team. The Speak Up

program features brochures, posters and videos on a variety of patient safety topics, including surgery,

infection prevention, medication safety,patient rights, pain management, child safety, doctor visits, falls,


diabetes care in the hospital, dialysis care in the hospital, breastfeeding, and stroke. Speak Up materials

are available for free download on The Joint Commission website.

Quality Check® and Quality Reports: The Joint Commission has a longstanding commitment to

providing meaningful information about the comparative performance of accredited organizations to the

public. The Quality Check® website, www.qualitycheck.org, launched in 1996, fulfills this commitment.

Quality Check allows consumers to search for Joint Commission accredited and certified organizations,

find organizations by type of service provided within a geographic area, download free hospital

performance measure results, and print a list of Joint Commission certified disease-specific care and

health care staffing. Quality Reports include the organization’s accreditation and certification decision,

National Patient Safety Goal compliance, and special quality awards such as the Eisenberg Patient

Safety Award.

Legislative efforts: The Joint Commission continuously monitors legislative initiatives at the state and

federal levels, and advocates for passage of measures leading to improved patient safety. On the state

level, The Joint Commission actively works with state regulatory and patient safety authorities to reduce

duplicative expectations for accredited organizations subject to voluntary or mandatory reporting

requirements. Recent issues addressed at the state level include health care-associated infections and

scope of practice. Federal legislative priorities include care transitions and medical checklists.

Patient safety coalitions: The Joint Commission, Joint Commission Resources and Joint Commission

International participate in a number of collaborations and coalitions to promote patient safety around the

world.

• The Joint Commission and Joint Commission International were re-designated in 2009 by the World

Health Organization (WHO) as the only Collaborating Centre for Patient Safety (the original

designation was in 2005). Collaborating with the WHO Patient Safety Programme, this multi-faceted

initiative primarily focuses on the development and evaluation of standard operating protocols to

address common patient safety problems.

• The Joint Commission and JCI also coordinate the High 5s Project, which was launched by the World

Health Organization (WHO) in 2006 to address continuing major concerns about patient safety

around the world. The High 5s name derives from the project’s original intent to significantly reduce

the frequency of five challenging patient safety problems in five countries over five years. The mission

of the High 5s Project is to facilitate implementation and evaluation of standardized patient safety

protocols within a global learning community to achieve measurable, significant and sustainable

reductions in challenging patient safety problems. The countries participating in the High 5s Project

are Australia, France, Germany, the Netherlands, Singapore, Trinidad and Tobago, and the United

States. The Project has been primarily supported by funding given to the Collaborating Centre by the

U.S. Agency for Healthcare Research and Quality. The major components of the High 5s Project

include the development and implementation of problem-specific standardized operating protocols

(SOPs); creation of a comprehensive impact evaluation strategy; collection, reporting, and analysis of

data; and the establishment of an electronic collaborative learning community. Today, work is being

done toward the protocols of ‘Correct Site Surgery’ and ‘Medication Reconciliation.’

• The Joint Commission helped form and is a member of the National Coordinating Council on

Medication Error Reporting & Prevention (NCC-MERP), a coalition composed of 22 member

organizations. NCC-MERP developed principles for constructing patient safety reporting

programs. The Joint Commission is providing input on several bodies of the Council’s work, including

development of the Council’s website, creating standard terms for adverse drug events and adverse

drug reactions, and updating NCC-MERP statement and recommendation documents.

• The Joint Commission is a founding member of the National Patient Safety Foundation, which has a

clearinghouse of information pertinent to issues in patient safety and funds innovative research

dedicated to reducing risk. The executive vice president of Customer Relations serves on the Board

of Directors, and The Joint Commission’s president emeritus is on the Lucien Leape Institute Board of

Directors.

• The Joint Commission continues to work with the National Quality Forum to create consensus around

nationally agreed-upon measures for quality and safety. The NQF has a steering committee, on which

The Joint Commission participates, that has identified a series of serious reportable events to be


used by organizations that set up adverse event reporting systems. The Joint Commission

participates on the NQF Common Formats Expert Panel. The Common Formats establish a common

method for health care providers to collect and exchange information for patient safety events. The

expert panel considers and makes recommendations regarding comments from health care

stakeholders received through the NQF public comment process. The Joint Commission is also a

member of the NQF National Priorities Partnership, and participates on the NQF’s Measure

Applications Partnership (MAP) Coordinating Committee as a non-voting Accreditation/Certification

Liaison member. The MAP was created to provide input to the Department of Health and Human

Services (HHS) on the selection of performance measures for public reporting and performancebased

payment programs.

• The Joint Commission is an affiliate of Consumers Advancing Patient Safety, a national consumer-led

organization formed to be a collective voice for individuals, families and healers who suffer harm in

health care encounters. The Joint Commission’s senior advisor for health care improvement is a

member of the Founding Advisors Board of CAPS.

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