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Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. December 10, 2018;(60):1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Journal Article > Commentary
Duthie EA. Nurs Manage. 2018;49:18-21.
A just culture balances organizational context with appropriate accountability after an error. This commentary illustrates the difference between blame and accountability as applied to a near miss. The author highlights how accountability enables individual and organizational learning through constructive examination of error.