Overview
The ultimate purpose of The Joint Commission’s accreditation process is to enhance quality of care and patient safety. Each requirement or standard, the survey process, the Sentinel Event Policy, and other Joint Commission initiatives are designed to help organizations reduce variation, reduce risk, and improve quality. Health care organizations should have an integrated approach to patient safety so that high levels of safe patient care can be provided for every patient in every care setting and service.
Patient Safety Systems Chapter
The ‘Patient Safety Systems’ chapter provides a framework, rooted in Joint Commission standards, upon which hospitals can build their integrated patient safety system — in which staff and leaders work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from patient safety events.
Sentinel Event Policy
The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.
RCA2
The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm describes methodologies and techniques that an organization or individuals can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their systems to understand what and why the event occurred, and how to prevent future events.
A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility. The National Quality Forum (NQF) coined the term to refer to "preventable, serious, and unambiguous adverse events that should never occur.” SREs are commonly referred to as "never events." An increasing number of states require that SREs are reported.
The NQF has compiled a list of 28 SREs in six categories.
Surgical events include:
• Performing a surgery on the wrong body part
• Performing a surgery on the wrong patient
• Performing the wrong surgery on a patient
• Leaving a foreign object in a patient
Product or device events
include:
• Death or disability as a result of contaminated drugs or faulty devices received through a healthcare facility.
• Patient death or serious disability resulting from the wrong device used or a device functioning other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs
while in care
Patient protection events include:
• Sending an infant home with the wrong parents
• Death or serious harm
suffered when a patient leaves the facility without
permission
• Suicide, or attempted suicide that results in serious harm, while a patient in a healthcare facility
Care management events include:
• Death or serious harm as a result of a medication error, such as the wrong dosage, wrong medication or medication given to the wrong patient
• Death or serious disability as a result of being given incompatible blood or blood products
• In a low risk pregnancy,
maternal death or serious harm as a result of labor or delivery in a healthcare facility
• Stage 3 or 4 pressure ulcers (bed sores) acquired during care
• Artificial insemination conducted using the wrong egg or donor sperm
Environmental events include:
• Death or serious disability as a result of electric shock
• Delivery of the wrong gas in an oxygen line
• Death or serious disability resulting of a fall while in care
• Patient death or significant
disability as a result of the use of restraints or bedrails while
in care
Criminal events include:
• Any patient care conducted by an unauthorized person
• Patient abduction
• Sexual assault of a patient while in care
• Death or serious injury of a patient or staff member as a result of an assault on the grounds of a healthcare facility.
The NQF report Safe Practices for Better Healthcare recommends 30 practices for the reduction of risk to patients.
Learn more:
Beyond eliminating “never events,” quality reporting in general is touted as the path to improved care delivery.
The role of health IT in safety and quality reporting.
Providers increasingly turn to clinical analytics to help identify and reduce adverse events.
This was last updated in May 2010
Continue Reading About serious reportable event (SRE)
- The NQF lists and explains serious reportable events (SREs).
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