Developing a Reporting Culture: Learning from Close Calls and Hazardous Conditions

On December 11, 2018, The Joint Commission (JC) published its 60th Sentinel Event Alert. This alert focuses on adverse events and near misses, along with the cultural factors in healthcare organizations that may pose barriers to reporting these events.  These barriers may include fear of repercussions and a lack of interoperability in electronic records systems. The Alert identifies five major areas of focus to assist healthcare entities and providers in avoiding patient harm and providing a safe environment for the delivery of healthcare.  They are:

1. Review Sentinel Event Alert #57 along with this alert and commit to implementing a safety culture at your organization.
2. Communicate leadership’s commitment to building trust and reporting through a safety culture.
3. Develop an incident reporting system, including close call and hazardous conditions, that encourages reporting. This system should include a recognition program and provide a feedback loop, so staff know that action is being taken to address or fix any identified flaws.
4. Hold managers, leaders and (where appropriate) staff accountable for addressing and eliminating errors and hazards identified by reporting and for continually improving the safety of the patient care environment.
5. Assure that leaders at all levels of the organization apply a standardized accountability process to assess the difference between system flaws, which are the cause of most errors and hazardous conditions, and at-risk or reckless behaviors.

A cornerstone of the quality of care provided at any healthcare organization is a culture that provides for the safety of patients and promotes an environment where staff and providers feel comfortable in raising issues or concerns.  MLMIC supports the efforts of The Joint Commission and all healthcare institutions to identify and address patient safety concerns.