Safety

ATI Engage Fundamentals: Safety


The Joint Commission (TJC)

  • Established: 1951.

  • Role: An impartial national organization that accredits hospitals and other health care facilities based on:

    • Safety performance

    • Policy

    • Procedures

    • Practice

    • Outcomes

  • Accreditation: Currently, more than 22,000 health care institutions and programs are accredited by TJC.

TJC Scores

  • Facility Evaluation: Performance scores include monthly submissions of safety and quality performance outcomes to an independent vendor.

  • Analysis: Vendor quantifies and identifies safety trends (both positive and negative) four times a year.

    • These quarterly performance measures can be tracked.

    • Specific action plans are created for each outcome.

National Patient Safety Goals (NPSG) and Standards of Compliance

  • Initiation: 2002 by TJC.

  • Purpose: Identify relevant safety practices that health care institutions should accomplish.

  • Cataloging: Most organizations embrace these goals, leading to the creation of a register of over 250 "Standards of Compliance" that must be met consistently.

National Safety Goals

  • Annual Review: Newly created and approved National Safety Goals are endorsed each year.

  • Basis for Goals: Developed based on trends of adverse and sentinel events in health care facilities.

Unexpected Events Including Sentinel Events

  • Definitions:

    • Near Miss: A potential error or event that could have caused harm but was avoided.

    • Patient Safety Event: An unexpected event that occurred without causing injury to the patient.

    • Sentinel Event: A critical, unexpected adverse event causing severe harm, which may include:

    • Death

    • Dismemberment

    • Permanent injury

    • Severe, temporary injury

Root-Cause Analysis and Event Reporting

  • Definition: The review process to investigate potential or actual errors is known as root -cause-analysis (RCA).

  • Error Review: Determines whether human error or systems failure led to the error.

  • Corrective Action Plan: RCA establishes a plan to address identified problems or system errors.

Responsibility for Reporting

  • Advocacy: Administration, risk management, and nurse leaders should encourage all team members to report unexpected events and near misses.

Barriers to Event and Near Miss Reporting

  • Challenges Identified:

    • Fear of repercussions or backlash against the reporting individual or team.

    • Lack of time to write reports.

    • Unclear facility policies and standards.

    • Bullying.

    • Insufficient education and training on reporting.

    • Lack of understanding of team members’ roles and responsibilities.

    • Influence of favoritism among some employees.