Clinical Corner: Joint Commission Sentinel Event Alert 57 — Role of Leadership in Safety Culture

Safety First

The Joint Commission’s Sentinel Event Alert 57 concerns the importance of adequate leadership to safety in healthcare facilities.

Hospital leadership has the crucial responsibility of protecting the safety of patients, staff, and visitors. That’s the inspiration behind The Joint Commission’s Sentinel Event Alert 57, which aims to help establish and improve safety culture in health care.

The Joint Commission periodically — though somewhat rarely — releases Sentinel Event Alerts about issues they find to be of concern.

This recent alert was spurred by the finding that within The Joint Commission’s Sentinel Event Database that “leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events — from wrong site surgery to delays in treatment.”

Additionally, Sentinel Event Alert 57 gives a few examples of adverse events that can be caused by inadequate leadership, including:

  • Insufficient support of patient safety event reporting
  • Lack of feedback or response to staff and others who report safety vulnerabilities
  • Allowing intimidation of staff who report events
  • Refusing to consistently prioritize and implement safety recommendations
  • Not addressing staff burnout

Whew — that’s a lot to address! Thankfully, as far as staff burnout goes, Travel Nursing can be of help when it comes to that issue. So, if you’re a Travel Nurse: Thank you — you are part of the solution!

Joint Commission Sentinel Event Alert 57The Joint Commission defines a “Safety Culture” as follows: “Safety culture is the sum of what an organization is and does in the pursuit of safety. The Patient Safety Systems (PS) chapter of The Joint Commission accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.”

The Sentinel Event Alert 57 details these 11 steps that health care leaders can implement in order to properly address safety culture:

  1. Transparent, non-punitive approaches to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Clear, risk-based processes for recognizing and separating human error and error arising from poorly designed systems from unsafe or reckless actions.
  3. Adoption of appropriate behaviors and championing efforts to eradicate intimidating behaviors.
  4. Establishment, enforcement and communication of all policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.
  5. Recognition of care team members who report adverse events, close calls and unsafe conditions or who have suggestions for safety improvements.
  6. Establishment of an organizational baseline measure on safety culture performance.
  7. Assessment of safety culture survey results from across the organization to find opportunities for improvement.
  8. Development and implementation of unit-based quality and safety improvement initiatives in response to information gained from safety assessments and/or surveys.
  9. Implementation of safety culture team training into quality improvement projects.
  10. Proactive assessment of system (such as medication management and electronic health records) strengths and vulnerabilities, and prioritizing them for enhancement or improvement.
  11. Organizational reassessment of safety culture every 18 to 24 months to review progress and sustain improvement.

Click here to see The Joint Commission’s infographic on 11 Tenets of a Safety Culture.

You can view the entire publication here.

About the Author

Hi, I'm Sarah Wengert, a creative content writer for the amazing Medical Solutions based in Omaha, Nebraska. While I'm not a Travel Nurse, I love to travel and I truly appreciate the hard, important work that nurses do. I'm very happy to represent a company that cares so much about its people. Thanks for reading!

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