Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.

Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency.

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.

The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.

Poor safety culture and lack of available resources to provide high-quality care can hinder safety in long-term care facilities. This set of regulations will revise requirements for long-term care facilities in areas such as clinical practice standards, service delivery, patient-centeredness, and infection control. The deadline for officially submitting comments on the proposed rule was September 14, 2015.

This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety culture in this setting.

The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues and stimulate innovative approaches to addressing these threats. The overuse of diagnostic imaging, particularly computed tomographic (CT) scans, poses patient safety risks due to excess radiation exposure. More than 70 million CT scans are performed in the United States every year, and the radiation exposure from these scans may lead to thousands of cancer-related deaths. This alert reviews specific strategies organizations should take to minimize radiation risks, including educating physicians on appropriate test utilization, standardizing equipment and radiation dosage, and promoting a culture of safety. An AHRQ WebM&M commentary discusses factors that may contribute to overutilization of diagnostic imaging, with consequent short- and long-term risks to patients.

Despite the past decade's focus on improving patient safety, most health care organizations are still striving to achieve high reliability status—consistently providing high quality care while minimizing adverse events. In this sentinel event alert, the Joint Commission calls for senior health care leaders to establish a culture of safety within their organizations, use just culture principles to establish transparent and fair policies for addressing errors at the sharp end, and maintain robust structures for analyzing and responding to adverse events. Specific suggested actions include involving hospital boards and patients in safety efforts and making safety performance an explicit part of the evaluation for leaders. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys. This Sentinel Event Alert was retired in March 2017. Please review The essential role of leadership in developing a safety culture for updated recommendations.

This final rule outlines how to become a Patient Safety Organization (PSO), and supports AHRQ action to receive applications from qualified entities that wish to become PSOs. 

These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.