According to The Joint Commission (TJC), 50 percent of all sentinel events reported during 2006 were, at least in part, a result of "inadequate or ineffective leadership." In response, TJC issued a Sentinel Event Alert on August 27, 2009, recommending healthcare organization leadership take fourteen specific actions aimed at continually improving safety. Recognizing that human error is inevitable, the recommendations focus on a systemic approach to safety. These recommendations address this human element, through the culture of the organization and its response to adverse events, as well as the system element, through an organization's safeguards and procedures designed to catch human error before patient or employee harm is caused.

Maintaining a Culture of Safety

A "safety culture" is created, TJC suggests, through adoption of a code of conduct for all employees; facilitating regular and frank communication among leadership, risk management and front-line patient care staff on issues of safety; encouraging patient input through communication of their experiences and perceptions to leadership; and recognizing and rewarding staff for work that improves safety. Incorporating safety as a measurable part of evaluations, for staff through senior leadership, and maintaining a transparent, consistent and just process for handling adverse event reports, also are encouraged by TJC as means to address the human aspect of safety.

Evaluation and Strategic Planning

At the system level, TJC advocates both constant evaluation and strategic planning. The organization should regularly monitor and analyze adverse events, conduct root cause analyses, look for patterns, identify latent hazards and weaknesses and revise the policies, procedures and system defenses accordingly. The organization as a whole also should address issues of safety in its strategic planning, by making a visible commitment of time and money to improving safety systems and processes. Such issues should be prioritized and addressed according to a timeline, with the highest priority items getting immediate attention.

Through addressing both the human and system factors affecting safety, TJC believes the healthcare community will move closer to the "zero-defect" approach to safety seen in other high-risk industries such as aviation and nuclear energy, thereby reducing risk and strengthening the defenses against preventable patient harm.