ICORP GROUP · INSIGHTS
Patient Safety Chapter and Sentinel Event Policy in JCI 8: Where to Start
JCI 8th Edition adds a Patient Safety chapter and updates the Sentinel Event Policy, with clear guidance supporting non-punitive reporting of safety incidents. A high volume of reports does not always mean a hospital has more problems; it may show that staff feel confident reporting and the organization has more opportunities to learn from incidents.
Starting with creating confidence that reports are valuable.
People report events when they believe that the data is applied to prevent recurrence. Not to find the wrong person alone. The administration should communicate the concept of Just Culture or Learning Culture clearly and separate system errors from behavior that is intended to correctly violate the standards.
Not just to see the serious events.
Near Miss and Unsafe Condition are key sources of information because it helps the organization to see fragile points before real hazards occur. If the system takes on the incident, the hospital will lose the opportunity to protect.
Root Cause Analysis is removed from the answer “personal unattentive”
The analysis is based on the workflow, communication, staffing, technology, environment, training and system design factors. If the final action is repeated every time without a system solution, the chances of repeating may be high.
Action Plan to be measured
After an event analysis, the action with the employer should be defined, the duration and how to measure whether the risk is reduced. The action should be closed because the activity is complete, and it should be proven that the system is safer.
Leadership Review is Important
Important events and risk trends should be summarized to the administrator. To make a decision on resources, policies or new system design in case problems exceed the limit of one agency.
Question should be used for the Patient Safety Assessment System.
- Do you know what to report and how to report?
- Is there feedback back to reporters and agencies?
- Is Near Miss analyzed and applied?
- Action Plan focuses on system or semi-alerting warnings and repetition.
- Managers see the Trend and Recurring Risk or not.
ICORP can support Gap Assessment, Patient Safety System Review, Workshop and Improvement Roadmap to help organizations change Incident Reporting from documentation to a real-world learning system driven by improvements.
Note: This article summarizes the concepts from public information of JCI 8th Edition, not used to replace the Sentinel Event Policy details or JCI method guides.