Joint Commission Center for Transforming Healthcare's Director of Solutions Development Klaus Nether discussed the importance of adverse event reporting in establishing a learning culture in a blog post.
Here's what you should know:
1. Dr. Nether said one of the most important things a center should do after an adverse event is reported is to identify how the error happened and address it so it doesn't happen again.
2. East San Gabriel Valley, Calif.-based Citrus Valley Health Partners implemented an adverse event tracking systems. The system is open to any member of the organization and is reviewed daily. Solutions are developed and shared through the system.
CVHP President and CEO Rob Curry said to Joint Commission, "Our eyes are wide open, and there’s more willingness to stop the line as well as more adherence to safety protocols that are part of our policies. We’re focused on both the practice of the safety initiative and on our response in the reporting of anything that could be adverse, otherwise known as near-misses."
3. The reporting system at CVHP is multi-leveled and not limited to providers. For example, an environmental services employee once filed a report when a wet floor sign wasn't displayed while a floor was wet.
4. The entire organization lives by the mantra, "Zero harm."
Department heads meet with their departments at the beginning of each day reiterating the importance of safety.
"Everything is talked about in the huddle — it's just another affirmation of the zero-harm culture we're seeking," Mr. Curry said.
Note: Dr. Nether is a doctor of health science.
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