In sentinel event alert No. 60, the accrediting body recommended several actions for creating an environment “that eliminates fear of negative consequences for reporting mistakes” and encourages learning from mistakes in patient care.
Here are the key recommendations:
1. Review sentinel event alert No. 57 and commit to implementing an organization-wide safety culture.
2. Communicate leadership’s commitment to building trust and reporting safety problems.
3. Develop an incident-reporting system that encourages reporting. The system should include a recognition program and a feedback loop showing staff that action is taken to fix reported issues.
4. Hold leaders and staff accountable for addressing and eliminating errors and hazards reported, as well as for continually improving patient safety.
5. Ensure leaders at all levels of the organization apply a standardized accountability process to examine the difference between system flaws and at-risk or reckless behaviors.
Access the full sentinel event alert here.
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