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Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. August 27, 2009;(43):1-3.
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.
Journal Article > Commentary
Erickson JI. J Nurs Adm. 2012;42:131-133.
Journal Article > Study
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-1757.
Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.
Weber DO. Hosp Health Networks Daily. February 25, 2014.
This article reports on the pervasive challenges to error disclosure and advocates for establishing a just culture to promote these conversations and enhance safety. The author discusses a study that highlighted the need for a patient-centered approach to facilitate peer-to-peer conversations about errors, along with responses solicited regarding a disclosure scenario.