1. JCAHO Patient Safety

2. Background 1999 Institute of Medicine report: “To Err is Human: Building a Safer Health System”  Estimated 44,000 – 98,000 medical error deaths annually  More than from highway accidents, breast cancer, or AIDS

3. What Must We Do?  Create Culture of Safety Program development and oversight Program development and oversight  Patient Safety Committee Encourage error reporting Encourage error reporting  Non-punitive system  Don’t tolerate cover-ups  Support employees involved in serious errors

4. Culture of Safety (continued) Root Cause Analysis Root Cause Analysis  Intensely analyze the error  Redesign system

5. Ask Questions Safety Survey: ask for suggestions on improving safety Safety Survey: ask for suggestions on improving safety  Employees  Medical staff  Patients

6. Disclose Unanticipated Outcomes and Errors The attending physician or his designee must tell the patient if: The attending physician or his designee must tell the patient if:  the outcome is significantly different from that anticipated  an error occurred  there is a surgical complication This discussion is documented in the medical record This discussion is documented in the medical record