Press Interview with JCAHO on Patient’s Safety

 While our national campaign to reduce medical errors continues, despite active efforts to prevent errors, barriers still exist at every level of intervention within health-care institutions. These barriers have slowed down expected advancement in reducing medical errors. By interviewing the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), perhaps more light can be shed on ways to speed the process of medical error reduction.

 Like a hospital official said in our interview in response to health-care administration’s reaction to medical error prevention, “Some hospital officials know that the system is broken and is not working. They don’t want to do anything to fix it! And they sometimes block the way for those working to fix the systemic problems.” Since we ignited the campaign to work with health-care institutions to fix systemic failures, the project has been confronted with many challenges, slowing down the progress of reducing medical errors. Accepting that there is problem within the institution is not enough, but working to fix it and creating a conducive atmosphere to foster effective implementation of solution is another issue.

 Evaluating the Compliance of Each Health Care Institution to the National Safety Goals

The National Patient Safety Goals (NPSG) are supposed to have been implemented by all hospitals by January of 2002. The compliance of each medical institution to the safety guidelines will be evaluated during the triennial accreditation surveys, including an unannounced random survey of accredited organizations. JCAHO believes that if these simple guidelines are adhered to, they will have major impact in reducing the frequency of devastating medical errors affecting thousands each year.

 Frequency and Types of Medical Errors

What are the leading types and frequency of medical errors? The Joint Commission responded from the data collected from the voluntary reporting of the Sentinel Event Database of close to two thousand incidents. Sentinel events are those voluntary reporting from health-care institutions due to medical errors causing harm of death or patients. From this database, the most common errors are; patient suicide, post-operative complications, wrong-side surgery, medication errors, and delay in treatment.

Message From the JCAHO’s Chairman: Dr. Denis O’Leary

“Human beings will continue to be fallible, and human errors cannot always be predicted. However, we have tremendous opportunities to make considerable progress on how we design systems that minimize both the likelihood of adverse events and the impact of their effects.”

 How Hospital Administration Can Help Reduce Medical Errors

In response to this question, JCAHO believes that health-care leaders must create a culture of safety in their organization. Such an atmosphere should foster open discussion of errors and designed efforts to help find solutions and their implementation.

 Failure to Comply with JCAHO’s Safety Goals

There has always been a question by the consumers about how JCAHO will force each health-care organization to comply with the safety standards. Failure of an organization to implement any of the recommendations or acceptable alternatives will result in a special Requirement for Improvement. In 2004, the JCAHO will begin releasing information on individual organization compliance in publicly available Quality Reports. All organizations not meeting the requirements will be informed about their need to meet the NPSG-related recommendations. In addition, JCAHO is presently switching to unannounced inspections of health-care institutions in a couple of years.

 Who Should Be Involved in Patient Safety?

Every health care professional - - including nurses, doctors, techs and even patients is responsible for patient safety. Patients and their family members have been told to report any health-care organization with questionable practices under the program “Speak Up.”

 How Can Health-Care Organizations Share Information About Best Practices to Help Reduce Errors?

 The Joint Commission supports the creation of an effective medical-care-error reporting system with the following guidelines:

 Is JCAHO in support of a non-punitive approach as the best way to achieve an error-free health-care environment?

 Yes. The JCAHO’s Sentinel Event Policy seeks to create a non-punitive reporting environment. The commission had also advocated federal legislation that would encourage the voluntary reporting of health-care errors.

 Should Health-Care workers be criminalized for medical errors?

JCAHO believes blame-and-shame orientation drives medical errors underground. The commission urges health-care organizations to create a protected, blame-free environment that encourages spontaneous reporting of serious adverse events.

 Are the thousands of health-care institutions across the nation ready for a bioterrorism attack?

The Joint Commission addresses this issue in the latest publication titled, Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness System. This report amplifies an outcry and is warning of, “a brewing cataclysm” of underfunding, inexperience, and unpreparedness of emergency-response capacities across America’s communities. The JCAHO position on national preparedness in case of bioterrorism attack is also supported from the result of our ongoing study that the nation is not prepared for such emergency.

 Which works better to reduce medical errors, “process redesign” or “education” of the staff?

The JCAHO believes that both process redesign and education work to reduce medical errors. The JCAHO’s patient-safety standards create requirements for the proactive analysis and, where appropriate, redesign of systems identified as having potential to contribute to errors.

 This question is crucial because during our study, different levels of resistance were encountered during the implementation of solutions from some health-care managers. They were of the false impression that process redesign can solve the problem of medical errors without measuring the importance of educating the staff. Some managers even implied that education was unnecessary. They were banking on only process redesign to do the trick. All problems cannot be solved by process redesign, just as all problems cannot be solved by education. Both educating the staff and redesigning the process-line where necessary will both help to achieve the goal of reducing medical errors.

 Above all, the JCAHO concluded this interview with the statement that, “It is incumbent on organization leaders to create a culture of patient safety within the institution to reduce the chances of medical errors.”

 Interview by ‘Yinka Vidal, author, 101 Ways to Prevent Medical Errors

Information is provided by JCAHO through the office of Dr. Denis O’Leary with press assistance from Mark Forstneger

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Last modified: July 17, 2010