JCAHO Patient SafetyJCAHO Patient Safety

BackgroundBackground

1999 Institute of Medicine report:1999 Institute of Medicine report:

““To Err is Human: Building a Safer Health To Err is Human: Building a Safer Health System”System”

Estimated 44,000 – 98,000 medical error deaths Estimated 44,000 – 98,000 medical error deaths annuallyannually

More than from highway accidents, breast More than from highway accidents, breast cancer, or AIDScancer, or AIDS

What Must We Do?What Must We Do?

Create Culture of SafetyCreate Culture of Safety Program development and Program development and

oversight oversight Patient Safety CommitteePatient Safety Committee

Encourage error reportingEncourage error reporting Non-punitive systemNon-punitive system Don’t tolerate cover-ups Don’t tolerate cover-ups Support employees Support employees

involved in serious errorsinvolved in serious errors

Culture of Safety Culture of Safety (continued)(continued)

Root Cause Root Cause AnalysisAnalysis Intensely analyze Intensely analyze

the errorthe error Redesign systemRedesign system

Ask QuestionsAsk Questions

Safety Survey: Safety Survey: ask for ask for suggestions on suggestions on improving safetyimproving safety Employees Employees Medical staffMedical staff PatientsPatients

Disclose Unanticipated Disclose Unanticipated Outcomes and ErrorsOutcomes and Errors

The attending physician The attending physician or his designee must tell or his designee must tell the patient if:the patient if: the outcome is the outcome is

significantly different from significantly different from that anticipatedthat anticipated

an error occurredan error occurred there is a surgical there is a surgical

complicationcomplication This discussion is This discussion is

documented in the documented in the medical recordmedical record