Joint Commission
Joint Commission
The mission of The Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.
Updated Sentinel Event Statistics
The Joint Commission’s sentinel event statistics have been updated on the Web site. Since the sentinel event database was implemented in January 1995 through March 31, 2009, The Joint Commission has reviewed 5,901 sentinel events. A total of 6,036 patients were affected by these events, with 4,132, or 68 percent, resulting in patient death. The 10 most frequently reported sentinel events are:
|
|
Total |
2008 |
First Quarter 2009 |
|
Wrong-site Surgery |
784 |
116 |
43 |
|
Suicide |
715 |
102 |
17 |
|
Operative/post-operative Complication |
659 |
63 |
28 |
|
Medication Error |
503 |
46 |
11 |
|
Delay in Treatment |
472 |
82 |
30 |
|
Patient Fall |
367 |
60 |
26 |
|
Unintended retention of foreign object |
252 |
71 |
40 |
|
Assault, rape or homicide |
224 |
41 |
6 |
|
Patient death or injury in restraints |
192 |
13 |
3 |
|
Perinatal death or loss of function |
181 |
32 |
6 |
Since the sentinel event database was implemented in January 1995, the Joint Commission has received 5437 reports of sentinel events. A total of 5565 patients were affected by these events, with 3,855, or 69 percent, resulting in patient death.
This information, along with other sentinel event statistics and detailed reports, can be accessed by going to the Joint Commission website at: http://www.jointcommission.org/SentinelEvents/Statistics/
Behaviors that Undermine a Culture of Safety
Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organization must address the problem of behaviors that threaten the performance of the health care team.
In this alert, they adopted a new leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two of its elements of performance:
- EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive behaviors.
- EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.
Other suggested actions:
- Educate all team members-both physicians and non-physician staff-on appropriate professional behavior defined by the organization's code of conduct. The code and education should emphasize respect. Include training in basic business etiquette and people skills.
- Hold all team members accountable for modeling desirable behaviors.
- Develop and implement policies and procedures/processes appropriate for the organization that address zero tolerance" for intimidating and/or disruptive behaviors. Incorporate the zero tolerance policy into medical staff bylaws and employment agreements as well as administrative policies. Non-retaliation clauses should be included in all policy statements that address disruptive behaviors.
- Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior and conflict resolution.
- Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff.
- Encourage inter-professional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.
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