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New Sentinel Event Alert focuses on leadership's role in culture of safety

The Joint Commission in March unveiled Sentinel Event Alert (SEA) 57, which stresses the role of leadership in developing and sustaining a culture of safety. It goes on to claim that leadership’s failure in this regard contributes to several adverse events, including wrong site surgery and treatment delays. It’s impossible to completely eliminate human and mechanical error completely, the accreditor writes. But leaders can take a role in mitigating and catching these mistakes before they hurt someone.

Steve MacArthur, a safety consultant for The Greeley Company in Danvers, Massachusetts, says that most organizations have already been working toward a culture of safety prior to this SEA.

“I am presuming that the issuing of this SEA at this particular time is some sort of acknowledgment that for all the work done and time passed that we’re probably not quite where we need to be as an industry,” he says. “I guess it’s possible that this might light a fire under folks to move the ball forward with a little more quickness, but organizational culture does not turn on a dime. The real focus of this is that it puts organizational leadership on the hook for making this happen.”

The SEA points to a fear of reprisal as a major detriment to a safety culture. When staff are afraid to bring up mistakes or problems, it says, those problems can snowball into major harm. It goes on to say that a non-punitive approach can improve error reporting and reveal safety gaps in the system.

“I run into a lot of clinicians that preface their questions by saying, ‘I know this is a stupid question’ or something similar,” says MacArthur. “And I always tell them that the only stupid questions are the ones that don’t get asked because folks don’t feel comfortable enough to admit that they don’t know something. If you can develop a process that really gets at the knowledge/skill/competence shortfalls, then you have a real shot at meaningful improvement.”

While that sounds simple, he says it’s a huge undertaking to get everyone to buy into such a huge change.

“This is an enormous paradigm shift,” he says. “Particularly for an industry that is as hierarchal—and has been for as long as it has—as healthcare.”

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