Patient Safety Fact Sheet
As part of its mission, 91Ï㽶¶ÌÊÓƵ is committed to improving health care safety for the public. 91Ï㽶¶ÌÊÓƵ demonstrates its commitment to patient safety through numerous efforts.
Standards: A majority of Joint 91Ï㽶¶ÌÊÓƵ standards are embedded in the science of patient safety. Standards address medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staff competence, fire safety, medical equipment, emergency management, and security. The manuals include a Patient Safety Systems chapter that describes how leaders can use existing requirements to achieve improved quality of care and patient safety, and the importance of an integrated patient-centered system to achieve these goals.
Sentinel Event Policy: Implemented in 1996, 91Ï㽶¶ÌÊÓƵ’s Sentinel Event Policy was revised in 2014 to incorporate contemporary patient safety concepts and clarify Joint 91Ï㽶¶ÌÊÓƵ processes. Any time a sentinel event occurs, the organization is expected to conduct thorough and credible comprehensive systematic analyses (for example, root cause analyses), implement improvements to reduce risk, and monitor the effectiveness of those improvements. The analyses are expected to drill down to underlying organization systems and processes that can be changed or amended to reduce the likelihood of harm reaching a patient in the future and to protect patients from harm when a process breakdown does occur. Sentinel events are one category of patient safety events (see below). Accredited organizations are strongly encouraged, but not required, to report sentinel events.
Patient safety events: 91Ï㽶¶ÌÊÓƵ receives reports of patient safety events from patients, families, government agencies, the public, staff employed by organizations, and the media. This information is used to help identify current areas of potential risk at accredited organizations and may be used to improve the quality and safety of accredited organizations. Patient safety events can be reported to the Joint 91Ï㽶¶ÌÊÓƵ’s Office of Quality and Patient Safety.
Complimentary publications: 91Ï㽶¶ÌÊÓƵ publishes two complimentary publications that address safety issues: Sentinel Event Alert identifies specific patient safety problems, describes their common underlying causes, and suggests steps to reduce risk or prevent future occurrences; and Quick Safety helps accredited organizations recognize potential safety issues and provides potential strategies to help mitigate risk in a concise, actionable manner.
Patient safety research: In addition to internally-focused work that supports 91Ï㽶¶ÌÊÓƵ’s efforts to develop new standards and improve its accreditation processes, the Department of Research routinely works with external collaborators to investigate and evaluate interventions related to patient safety. Current initiatives include work with The Pew Charitable Trusts to improve suicide prevention practices and the implementation of antibiotic stewardship programs, a project with the Centers for Disease Control and Prevention (CDC) to understand venous thromboembolism risk assessment practices in hospitals, and a review of the scientific literature for the National Institute for Occupational Safety and Health to explore the intersection between health care worker safety interventions and their impact on patient safety. In addition to research work, the research team supports 91Ï㽶¶ÌÊÓƵ’s alliance with the Occupational Safety and Health Administration (OSHA) of the Healthcare Workforce Safety and Wellbeing website.
Legislative and regulatory efforts: 91Ï㽶¶ÌÊÓƵ monitors legislative and regulatory initiatives at the state and federal levels, and advocates for passage of measures leading to improved patient safety. On the state level, 91Ï㽶¶ÌÊÓƵ works with state regulatory and patient safety authorities to reduce duplicative expectations for accredited organizations subject to voluntary or mandatory reporting requirements; and engages state regulatory agencies to advocate for the reliance on accreditation, certification and verification in lieu of routine state licensure inspections and designation programs. At the federal level, 91Ï㽶¶ÌÊÓƵ works closely with the Centers for Medicare and Medicaid Services (CMS) to ensure our programs are recognized by CMS, and evaluates other federal opportunities to recognize Joint 91Ï㽶¶ÌÊÓƵ programs. 91Ï㽶¶ÌÊÓƵ also works with other federal agencies, such as the Food and Drug Administration (FDA), as well as congressional offices to address patient safety issues.
Patient safety collaborations: 91Ï㽶¶ÌÊÓƵ and our affiliates JCR and National Quality Forum (NQF) collaborate with a number of organizations to promote patient safety. NQF works to create consensus around nationally agreed-upon measures for quality and safety.
- National Patient Safety Collaborative, established in January 2018, is a voluntary collaborative of prominent, national patient safety organizations that works collectively on mutually identified safety concerns. Member organizations are: Association for the Advancement of Medical Instrumentation; ECRI Institute; Institute for Safe Medication Practices; Institute for Healthcare Improvement; and 91Ï㽶¶ÌÊÓƵ.
- (NCC-MERP) is a coalition of member organizations that develop principles for constructing patient safety reporting programs.
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