Joint Commission Urges Adoption of Systems Approach to Prevent Adverse Events


OAKBROOK TERRACE, Ill. -- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) told Congressional leaders that American healthcare facilities must embrace a systems approach to preventing adverse events that keeps the inevitable errors that caregivers make from reaching patients. 


Testifying yesterday before the Health Subcommittee of the House Energy and Commerce Committee, Joint Commission President Dennis S. OLeary, MD, underscored the fact that healthcare must create an environment in which safety is always top of mind and errors are viewed as opportunities for learning and improvement.  Borrowed from engineering and quality control principles that have been successfully applied in manufacturing, the systems approach mitigates the effects of mistakes by designing systems that anticipate human error and prevent the occurrence of adverse events.  OLeary also commented that the very nature of health care requires continuing vigilance to identify emerging patient safety risks.


The healthcare industry is a victim of the rapid and continuing advances in its capabilities and sophistication.  Much progress has made been in improving patient safety since the Institute of Medicine issued its report, To Err is Human, but we may actually be falling further behind as new drugs, procedures and technologies are introduced every day.  Each of these has inherent safety risks that have not been identified, and they are usually introduced into care delivery settings where patient safety and systems thinking are not constantly top of mind, OLeary testified.


OLeary further noted that the absence of electronic information exchange capabilities to provide decision support makes it virtually impossible for practitioners to maintain a current clinical knowledge base.


The knowledge of what to do differently and how to do it exists but we are we are far closer to the beginning of the journey than we are to the end.  We as a society must ramp up our efforts if we are to successfully bridge the chasm between the current state of health care and what is truly safe, high quality care, he said.


As the accreditor of more than 15,000 healthcare organizations across the country, the Joint Commission has observed changes in how leaders in healthcare organizations talk and think about patient safety issues and how they approach medical errors when they occur.  Moreover, there is broad support across the healthcare industry and among policy-makers for creation of blame-free environments that foster increased reporting of patient safety events. 


In his testimony, OLeary highlighted the major patient safety initiatives undertaken by the Joint Commission over the past decade.  These include the creation of a comprehensive database of adverse events and their underlying causes; the periodic issuance of lessons-learned Sentinel Event Alerts; the annual promulgation of National Patient Safety Goals and related Requirements; a series of ongoing Speak Up campaigns to encourage patients to become actively involved in preventing errors in their care; and the creation of a Patient Safety Events Taxonomy.  In addition, new standards have established expectations for proactive risk assessments of vulnerable patient care processes; transparency in communicating about medical errors with patients and their families; and patient flow systems to decompress overcrowding emergency departments; and existing medication management and infection control standards have been substantially strengthened.  Earlier this year, the Joint Commission launched a new International Center for Patient Safety that will focus on the gathering and dissemination of patient safety solutions and the promotion of organization cultures of safety.


Source: Joint Commission on Accreditation of Healthcare Organizations

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