Institute: ONC | Component: 1 | Unit: 6 | Lecture: d | Slide: 21
Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:Health Insurance Portability and Accountability Act
Slide content:The Joint Commission Safety Initiatives - 1 Sentinel Event Policy Unexpected death, unexpected serious physical or psychological injury, or the risk of such an event Patient Safety Advisory Group Panel of experts who recommend National Patient Safety Goals Also address newly developing safety issues 21
Slide notes:As discussed earlier in this unit, the Joint Commission, or TJC, is a nonprofit organization that accredits hospitals and other health care organizations. However, TJC also plays a major role in efforts to improve patient safety. In fact, more than half of its activities are directly related to that goal. One of these initiatives is called the Sentinel Event Policy. TJC defines a sentinel event as one that resulted or could have resulted in an unexpected death or serious harm. Some sentinel events relate to the patients health, such as death of an apparently healthy baby or a bad reaction to a blood transfusion. Other sentinel events relate to conditions in the hospital, such as the discharge of a baby to the wrong family, or the abduction or rape of a patient . Whenever a sentinel event occurs, the health care organization is expected to conduct a thorough analysis of the situation that caused it or allowed it, and take steps to prevent the event from happening again. Organizations are encouraged to report sentinel events to TJC, so other health care organizations can learn from the analysis . The Patient Safety Advisory Group is a panel of safety experts, nurses, physicians, pharmacists, and other professionals. Working with TJC staff, this group establishes annual National Patient Safety Goals, which are lists of tips for health care professionals to follow to prevent errors. For example, when taking a blood sample, a health care professional must label the specimen container before moving on to the next patient to avoid inadvertent labeling mistakes . The Patient Safety Advisory Group also helps TJC detect and address newly emerging safety issues. 21