PATIENT SAFETY

Alert Emphasizes Leadership Sets Tone for Safety and Quality

“Tone at the top” is a frequent refrain in compliance. It’s also the message of a Sentinel Event Alert (Alert) issued March 1 by The Joint Commission. According to the Joint Commission’s Sentinel Event Database, “leadership’s failure to create an effective safety culture” contributes to adverse events. “Organizations that have a robust safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures,” the Alert explains.

Similar messages were embodied in a 2015 report from the National Academies of Sciences addressing the importance of a culture of safety and avoiding diagnostic errors. That report, titled Improving Diagnosis in Health Care, concluded that “a culture that discourages transparency and disclosure of diagnostic errors” and lack of support for the diagnostic process within the health care system contributed to diagnostic errors. Both the Alert and the 2015 report emphasize the need for transparency, communication, and system-wide strategies and processes that foster a culture of quality and safety.

“Diagnosis is a collective effort that often involves a team of health care professionals—from primary care physicians, to nurses, to pathologists and radiologists,” said John R. Ball, executive vice president emeritus of the American College of Physicians and the chair of the expert committee that worked on the 2015 report. Likewise, in this latest Alert the Joint Commission concludes “[s]afety culture is the sum of what an organization is and does in the pursuit of safety.”

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