Every year, The Joint Commission reviews reports from health care professionals about unsafe conditions within their organizations.  The most serious often lead to on-site evaluation and work with The Joint Commission to identify and remediate breakdowns to improve quality and safety.

Many organizations have begun to acknowledge that leadership and structural support for staff who recognize and report unsafe conditions creates a safety culture that is critical to delivering highly reliable care, The Joint Commission reports in a new Sentinel Event Alert.

Sentinel Event Alert #60 – Developing a reporting culture: Learning from close calls and hazardous conditions explores guidance for health care organizations and leaders in establishing a psychologically safe environment that eliminates fear of negative consequences for reporting mistakes, and actively encourages learning from “close calls” in patient care.

Close calls happen more frequently than actual harm events. Reporting them provides crucial information on active and potential weaknesses in health care safety systems from the perspective of health care workers in varying positions—analysis makes it possible to identify system weaknesses and address daily workflow or systems use, according to the alert.

The alert cites practices, learning and resources from Adventist Hinsdale Hospital (Illinois), Brigham and Women’s Hospital (Massachusetts), Cincinnati Children’s Hospital (Ohio), Kent Hospital, a member of Care New England Health System, (Rhode Island); Lehigh Valley Health Network (Pennsylvania); Medical University of South Carolina Health; Memorial Hermann Health System (Texas); Montefiore Medical Center (New York); and the Pennsylvania Patient Safety Authority.

Recommended actions for health care organizations and leaders include:

  • Reviewing the alert and The Joint Commission’s Sentinel Event Alert #57 – The essential role of leadership in developing a safety culture while developing a safety for basic guidance and resources.
  • Communicating leadership commitment to building trust and reporting through a safety culture.
  • Developing a system for reporting incidents, including close calls and hazardous conditions, that encourages reporting. The system should include a recognition program and provide a feedback loop so staff know that action is being taken to address or fix the identified flaw.

The Sentinel Event Alert and accompanying infographic are available on The Joint Commission website. Both may be reproduced if credited to The Joint Commission.

Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high-risk conditions, describes their common underlying causes, and recommends actions by health care organizations to reduce risk and prevent future occurrences.

Accredited organizations should consider Sentinel Event Alert information when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.