Transcript JCAHO Patient Safety

JCAHO Patient Safety
Background
1999 Institute of Medicine report:
“To Err is Human: Building a Safer Health
System”
Estimated 44,000 – 98,000 medical error deaths
annually
More than from highway accidents, breast
cancer, or AIDS
What Must We Do?

Create Culture of Safety
 Program development and
oversight
 Patient Safety Committee
 Encourage error reporting
 Non-punitive system
 Don’t tolerate cover-ups
 Support employees
involved in serious errors
Culture of Safety (continued)

Root Cause
Analysis
 Intensely analyze
the error
 Redesign system
Ask Questions
 Safety
Survey:
ask for
suggestions on
improving safety
 Employees
 Medical staff
 Patients
Disclose Unanticipated
Outcomes and Errors

The attending physician
or his designee must tell
the patient if:
 the outcome is
significantly different from
that anticipated
 an error occurred
 there is a surgical
complication

This discussion is
documented in the
medical record