jcaho patient safety. background 1999 institute of medicine report: “to err is human: building a...
TRANSCRIPT
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