A complimentary publication of The Joint Commission Issue 60, Dec.

11, 2018

Developing a reporting culture: Learning from close calls and hazardous conditions
While a pharmacy technician was preparing a pediatric nutritional solution, a two- Published for Joint Commission
accredited organizations and
liter sterile water bag she was using ran out. She obtained another bag that she
interested health care
presumed also was sterile water but was instead a similar looking bag containing professionals, Sentinel Event
Travasol, a highly concentrated amino acid that should not be used on pediatric Alert identifies specific types of
patients. She proceeded to prepare the nutritional solution with the Travasol. As sentinel and adverse events
the incorrect solution was being delivered to multiple locations, she realized that and high risk conditions,
describes their common
she hung the wrong bag. underlying causes, and
recommends steps to reduce
“For a few seconds, I couldn’t move, I felt panicked,” she remembered. “I went to risk and prevent future
my pharmacist right away and I told her I made a mistake, a big mistake.” The occurrences.
deliveries were stopped, and all the bags were retrieved prior to reaching any
Accredited organizations should
patients. Later, using an objective accountability assessment tool to determine consider information in a
how the error occurred, hospital leaders determined that the error was a system Sentinel Event Alert when
error and not a blameworthy act. The system error was fixed, and rather than designing or redesigning
being punished, the pharmacy technician was consoled and thanked for processes and consider
implementing relevant
reporting her mistake and saving the lives of patients. “I didn’t care what suggestions contained in the
happened to me; I cared about what would happen to the patients,” she said.1 alert or reasonable alternatives.

Establishing trust is essential to improving reporting Please route this issue to

appropriate staff within your
The pharmacy technician trusted that her organization would fairly assess the
organization. Sentinel Event
causes of the close call and make just decisions without undue punitive action. Alert may be reproduced if
Her story is an excellent illustration of the need to thoroughly evaluate all adverse credited to The Joint
events, particularly close calls (also called near misses or no-harm events) and Commission. To receive by
hazardous conditions, and to use lessons learned from them as opportunities for email, or to view past issues,
visit www.jointcommission.org.
quality and safety improvement.

Leaders* can help create the personal responsibility demonstrated by the

pharmacy technician by establishing trust and clear performance expectations
among employees within a psychologically safe environment in which there is no
fear of negative consequences for reporting mistakes.2 When staff report close
calls and hazardous conditions, leaders can act by addressing concerns,
resulting in improvement and safety.

Every year, The Joint Commission receives reports from health care staff of
unsafe conditions in their organizations. The majority of these reports indicate
that leadership had not been responsive to these and to other early warnings,
even though their response may have prevented harm events from occurring.
Typically, the most serious of these reports lead to an on-site evaluation by The
Joint Commission.

*The Joint Commission accreditation manual glossary defines a leader as “an individual who sets
expectations, develops plans, and implements procedures to assess and improve the quality of the
organization’s governance, management, and clinical and support functions and processes. At a
minimum, leaders include members of the governing body and medical staff, the chief executive officer
and other senior managers, the nurse executive, clinical leaders, and staff members in leadership
positions within the organization.”

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 2

However, the inaction of organization leadership

to staff reports of unsafe conditions Sidebar 1: Examples of establishing trust
demonstrates an unacceptable complacency
toward risk. This kind of culture seeps down to Memorial Hermann Health System calls it a “good
the front lines where a “no harm, no foul” catch” when a report causes clinicians to identify a
attitude may leave a near miss or at-risk potentially harmful action and intervene prior to causing
behavior unreported, fostering conditions that harm. Good catches occur about 1,000 times a month in
may eventually result in harm.3 the system’s hospitals.

Many organizations have begun to acknowledge Medical University of South Carolina Health (MUSC
or give positive recognition to staff members who Health) issues a daily email highlighting a near-miss,
report errors or recognize unsafe conditions. error or unsafe condition and each month recognizes
“Good catch” programs and similar types of “safety stars” – employees who have made these
initiatives, which have become more common at reports. If care team members want closure in the
organizations across the nation, reinforce this reporting structure, they can ask to be personally
notion. These programs also include notified with a result at the conclusion of the review.
mechanisms that close the feedback loop by
giving reporters information on how their report employees with the psychological safety to speak
led to improvement in the organization (see up and engage in process improvement can have
suggested action #3). a positive impact on these efforts.7 This
psychological safety does not currently exist in
“It’s been said that change progresses at the most health care settings, according to the U.S.
speed of trust,” according to Peter Pronovost,4 Agency for Healthcare Research and Quality
which is why leaders must engage all staff in an (AHRQ) Patient Safety Surveys. Its 2018
effort to promote trust and improve reporting database report indicated that 47 percent of
results. respondents said that it feels like unsafe event
reports are held against them. Fifty percent of
Identifying and reporting unsafe conditions respondents indicated that, after an event is
before they can prevent harm, trusting that other reported, it feels like the person is being written
staff and leadership will act on the report, and up, not the problem.8
taking personal responsibility for one’s actions
are critical to creating a safety culture and All staff must see that those making human
nurturing high reliability within a health care errors will be consoled, those responsible for at-
organization.5,6 See Sidebar 1 for examples. risk behaviors will be coached, and those
committing reckless acts will be disciplined fairly
Adopting a just culture is critical to eliminating and equitably,3,9 no matter the outcome of the
fear of punishment reckless act. Senior leaders, unit leaders,
“The single greatest impediment to error physicians, nurses, and all other staff must be
prevention in the medical industry is that we held to the same standards.10,11
punish people for making mistakes,” said Lucian
Leape, a professor at the Harvard School of The use of objective accountability evaluation/
Public Health. assessment tools can help determine what
happened as well as whether actions taken were
The importance of drawing clear lines between blameless or blameworthy. Two just culture
human error and at-risk or reckless behaviors as decision trees – one developed by James
part of a just culture is discussed in Sentinel Reason12 and the second by David Marx9 –
Event Alert #57, “The essential role of leadership serve as a primary basis for distinguishing
in developing a safety culture.” Leadership must between errors that occur because we are
gradually change the culture so that the need to imperfect humans who make mistakes and
report and do something about a safety issue actions considered to be at-risk or reckless. To
outweighs the fear of being punished. Providing make these decision trees work best within their

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 3

particular settings, many health care

organizations have modified them and built upon Sidebar 2: Examples of adopting a just culture to
them by developing additional tools. See Sidebar encourage reporting
2 for examples.
Montefiore Medical Center created a user-friendly
Close calls reveal more than you know – better version of the just culture decision tree to encourage its
reporting is needed use in everyday situations. The use of this tool and the
Sentinel Event Alert #57, “The essential role of rollout of an electronic event reporting system were a
leadership in developing a safety culture,” part of a transformational change to a just and learning
introduced the concept of a reporting culture and culture that improved reporting of adverse events from
stressed its importance in suggested action #1: 6,097 in 2014 to nearly 9,000 in 2017, including
“Absolutely crucial is a transparent, non-punitive increased reporting by groups that traditionally would
approach to reporting and learning from adverse not be involved in reporting, such as attending
events, close calls and unsafe conditions.” physicians, who made 542 reports in 2017. Through
training and empowering staff across the health system,
Reporting close calls is a step toward developing including members of 50 peer review committees,
the ability to respond to “weak signals” or poorly Montefiore increased root cause analyses from 60 a
detected risks. Close calls are defined as unsafe year to several every day. Near miss and unsafe
acts or conditions — errors, procedure violations conditions reporting went up from 681 in 2014 to 2,493
or hazards — that could have seriously harmed a in 2017. This improved reporting has saved lives and
patient but did not because they were identified, has pointed to additional systemic safety issues that the
reported, and addressed or eliminated. organization can address and improve.

Reporting close calls is important for these Medical University of South Carolina Health (MUSC
reasons: Health) first engaged what it refers to as the “just culture
• They provide information on active and backbone” of human resources, risk management, legal
potential weaknesses in health care and compliance because these four teams are the ones
safety systems. usually consulted for advice when the cause of an error
• They are more frequent than events or hazardous condition is being determined. These four
causing harm and provide information teams make sure all policies and procedures are in
about errors from the perspective of alignment with just culture protocols. After embedding a
health care workers in different just culture algorithm into its online reporting system,
positions. the center increased its reporting 20 to 30 percent per
• Analysis of high-frequency or high- year for the last few years, now averaging about 1,400
potential-severity near miss reports reports per month. During the same time period, the
makes it possible to identify system center decreased the percentage of the reports that
weaknesses and learn from them in the represent harm, showing that the reporting is catching
context of daily workflow or systems errors before they reach the patient.
use.13
Kent Hospital, a Care New England Health System
See Sidebar 3 for an example of learning from a member organization, revised human resources policies
close call report. Learning from adverse events, and procedures to add just culture language to them.
close calls and unsafe conditions requires This careful use of language contributed toward making
analyzing data, communicating what was its just culture initiative into an anchor supporting
learned, and taking effective actions to reduce performance management and safety improvements.
risk; otherwise there is no incentive for staff to
report. After gathering data from close calls and should consider frequency and potential
hazardous conditions, use it to: severity to determine what to address.
• Identify error-prone situations within the • Identify how the people and system
organization. Specifically, organizations succeeded in preventing an event from
occurring. This learning will help

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 4

determine ways to strengthen protective

Sidebar 3: Examples of learning from close call
processes and help staff identify the
reporting
factors that lead up to a situation and
what to look out for in similar situations
The Pennsylvania Patient Safety Authority emphasizes
in the future.
the power of one close call report in its “Why Reporting
Matters” program. One hospital reported that staff
For more information, see the Pennsylvania
nearly failed to rescue a patient who had suffered a
Patient Safety Authority Good Catch program.
heart attack and had mistakenly been designated as
DNR (do not resuscitate) with a yellow wristband. A
Leadership engagement encourages reporting
nurse had placed this wristband on the patient because
Sentinel Event Alert #57, “The essential role of
yellow signified “restricted extremity” (do not use arm
leadership in developing a safety culture,”
for drawing blood) at a facility where she previously
focused on the role of leaders in establishing
worked. Another clinician identified the mistake and
and continuously improving the five components
rescued the patient. As a result of this close call report,
of a safety culture defined by Chassin and Loeb:
Pennsylvania adopted a standardized system for color-
trust, accountability, identifying unsafe
coded wrist bands and, subsequently, 41 states and the
conditions, strengthening systems, and
U.S. military have adopted standardized colors.14
assessment.5 While leaders may know about a
safety concern, they may discount the severity of
the risk, since harm has not occurred. This is
confirmed by increasing recommendations for Sidebar 4: Examples of leadership engagement and
improvement (RFIs) in the area of leadership accountability
during Joint Commission surveys.
Adventist Hinsdale Hospital improved its error and
It’s important for leaders to be strong role near-miss reporting and decreased events causing harm
models and be among the first to raise their own after senior leader communication, access and visibility
hands and say "I made a mistake.” Staff and unit increased. Senior leaders began rounding regularly on
managers will start to model this accountability all three shifts to assess and respond to safety concerns,
when they see the engagement of and they began advocating for stopping the line,
leadership.8,15,16 See Sidebar 4 for examples of implementing the chain of command, and other staff-
leadership engagement. driven safety interventions. Senior leaders also regularly
attended staff meetings, worked with nurses side by
In a safety culture, health care organization side, and publicized decisions made for safety purposes
leaders are ultimately responsible for developing in multiple forums. As a result, the culture of safety
highly reliable systems. In turn, staff members survey demonstrated an improvement in the senior
are personally responsible for what is considered leadership domain in four of six units. Another survey
largely under their control – making demonstrated that staff members recognized changes
good choices when working within these that senior leaders had made and felt that these
systems. changes positively impacted the culture of safety.16

By building trust and encouraging reporting, Cincinnati Children’s Hospital assigns all root cause
leaders empower an organization’s most analyses of adverse events to teams, each led by two
valuable resource – its people – to be always clinical leaders and sponsored by a senior leader who
vigilant for hazards in the face of varying reports to the CEO and holds the team accountable.
conditions.17 Showing or making a video is an Each team reports to a safety oversight group on the
excellent way for chief executives to results of their analysis, how the safety issue is being
communicate their commitment to just, reporting addressed, and how safety measures were improved.
and learning cultures. See Sidebar 5 for some Anyone within the organization can attend these
videos that illustrate this type of commitment. monthly, hour-long presentations. Attendees are
What matters is that each leader finds a method challenged to find ways to improve safety in their units.
Over the past 10 years, this process has decreased
adverse events by 90 percent and increased reporting by
more than 300 percent.

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 5

to convey this important message throughout the

organization. Sidebar 5: Videos communicating leadership
commitment to just, reporting and learning cultures
Actions suggested by The Joint Commission
The Joint Commission recommends that Montefiore Medical Center: This video explains
organizational leaders take the following actions Montefiore’s just culture initiative; it includes the story
to increase trust, reporting and responsibility/ of the pharmacy technician used at the beginning of this
accountability of all staff in support of a safety alert, and a second story about how a staff member
culture with the ultimate goal to protect patients admitting a medication error led to the improved
from harm. organization of a unit’s medication drawer.

1. Review Sentinel Event Alert #57 along with Brigham and Women’s Hospital: This video describes
this alert and commit to implementing a safety Brigham and Women’s just culture initiative.
culture at your organization. These two alerts
provide basic guidance and resources that can Lehigh Valley Health Network: This video is an excellent
help. example of how to explain and introduce a just culture
commitment organization-wide to staff. The video
2. Communicate leadership’s commitment to explains the difference between human errors, at-risk
building trust and reporting through a safety behaviors and reckless behaviors and the differences in
culture (see Sidebar 5). Making this the consequences of each.
commitment, with the support of governance,
provides an excellent opportunity for an incidents causing harm becomes part of
organization to explain to employees how a just, the organization’s culture.
reporting and learning culture work together to • Define what incidents should be
form the main elements of a safety culture.18 reported. Staff may not recognize that a
The Joint Commission Center for Transforming daily annoyance is actually an unsafe
Healthcare’s Oro® 2.0 is an online organizational event or unsafe condition.
assessment that guides leadership through the • Use the data to identify error-prone
high reliability journey, specifically in the areas of situations, the frequency at which they
leadership commitment, safety culture, and occur, and their potential severity. Also
Robust Process Improvement® (see Resources). use the data to identify successes of the
staff and the system. These learnings
3. Develop an incident reporting system, help determine what to address,
including close calls and hazardous conditions, strengthen the protective processes
that encourages reporting. This system should within the system, and help staff identify
include a recognition program (see Sidebar 1), the factors that lead up to a situation
and provide a feedback loop so staff know that and what to look out for in similar
action is being taken to address or fix the situations in the future.
identified flaw.
• Make the incident reporting system 4. Hold managers, leaders, and where
accessible by all staff, easy to use, and appropriate, staff, accountable for addressing
enable data analysis to be done in a and eliminating errors and hazards identified by
timely fashion. Make sure that staff reporting and for continually improving the
members understand that those who safety of the patient care environment (see
report human errors and at-risk Sidebar 4).
behaviors will not be punished so that • Sustain continual improvement and
the organization can learn and make support robust reporting by recognizing
improvements.3 the contributions of those who report
• Prepare for an increased volume of adverse events and by communicating
reports as reporting close calls and safety improvement success stories,
hazardous conditions as well as especially success stories about errors

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 6

or unsafe conditions that were reported

by staff. LD.03.01.01: Leaders create and maintain a
• Encourage staff to find and test culture of safety and quality throughout the
solutions to everyday problems. organization.
Engaging those at the point of care not
only involves those with the best EP 1: Leaders regularly evaluate the culture of
knowledge of the process (deference to safety and quality using valid and reliable tools.
expertise), it also results in local
ownership that contributes to adoption EP 2: Leaders prioritize and implement changes
and sustainability. identified by the evaluation.
• When errors or unsafe conditions are
not reported prior to patient harm or if EP 4: Leaders develop a code of conduct that
staff express trepidation in making defines acceptable behavior and behaviors that
reports via safety culture surveys, undermine a culture of safety.
examine why events are not being
reported. Consider if staff understand EP 5: Leaders create and implement a process
what to report and whether or not for managing behaviors that undermine a culture
managers or superiors previously of safety.
punished or intimidated those making
reports. [Note: The following requirements include
revised EPs that are effective Jan. 1, 2019.]
5. Assure that leaders at all levels of the LD.03.03.01: Leaders use organizationwide
organization apply a standardized planning to establish structures and processes
accountability process to assess the difference that focus on safety and quality.
between system flaws, which are the cause of
most errors and hazardous conditions, and at- EP 1: Planning activities focus on the following:
risk or reckless behaviors. -Improving patient safety and health care quality
• Examples of this kind of process are the -Supporting a culture of safety and quality
Reason and Marx just culture decision -Adapting to changes in the environment
trees mentioned earlier in this alert. [Applies to all accreditation programs, except for
• To produce a fair result when using a Nursing Care Centers.]
decision tree, provide formal training in
its use and incorporate the perspective EP 2: Planning is organizationwide, systematic,
of staff working within the system where and involves designated individuals and
the error or action occurred. Because information sources.
the decision tree may point to a system
flaw, avoid having the manager in LD.03.09.01: The [organization] has an
charge of the system administer the tool organizationwide, integrated patient safety
(see Sidebar 2). program within its performance improvement
activities.
Related Joint Commission requirements
The Leadership (LD) chapter of the Joint EP 1: The leaders implement an
Commission’s accreditation manuals for all organizationwide patient safety program as
accreditation programs provide detailed follows:
information on designing or redesigning a -One or more qualified individuals manage the
patient-centered system to improve quality of safety program.
care and patient safety, an approach that aligns -All departments, programs, and services within
with the Joint Commission’s mission and its the organization participate in the safety
standards. The LD chapter includes the following program.
standards and elements of performance (EP) -The scope of the safety program includes the
that are specific to leadership: full range of safety issues, from potential or no-

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 7

harm errors (sometimes referred to as close calls Resources

[“near misses”] or good catches) to hazardous The Joint Commission: Sentinel Event Alert #57,
conditions and sentinel events. “The essential role of leadership in developing a
[Applies to all accreditation programs, except for safety culture.”
Laboratories.]
Joint Commission Center for Transforming
EP 2: As part of the safety program, the leaders Healthcare: Oro® 2.0 High Reliability
create procedures for responding to system or Organizational Assessment and Resources tool —
process failures. (See also PI.03.01.01, EP 10) The ability to feel comfortable enough to report
Note: Responses might include continuing to mistakes in an effort to protect patients from
provide care, treatment, or services to those harm is one of the characteristics of an
affected, containing the risk, and preserving advancing safety culture, according to the Oro®
factual information for subsequent analysis. 2.0 High Reliability Organizational Assessment
and Resources tool, which includes a safety
EP 3: The scope of the safety program includes culture maturity model.
the full range of safety issues, from potential or
no-harm errors (sometimes referred to as close Pennsylvania Patient Safety Authority: Good
calls [“near misses”] or good catches) to Catch program — Following aggregate event
hazardous conditions and sentinel events. analysis and facility interviews, the Pennsylvania
[Applies to all accreditation programs, except for Patient Safety Authority concluded that good
Laboratories.] catch programs can help hospitals more
effectively analyze reported data and implement
EP 4: All departments, programs, and services risk reduction strategies.
within the [organization] participate in the safety
program. [Applies to all accreditation programs, “Managing the Risks of Organizational Accidents,
except for Laboratories.] by James Reason, 1997, Ashgate.

EP 5: As part of the safety program, the leaders “Whack A Mole. The Price We Pay for Expecting
create procedures for responding to system or Perfection,” by David Marx, 2009, By Your Side
process failures. Studios.
Note: Responses might include continuing to
“Dave’s Subs: A Novel Story about Workplace
provide care, treatment, and services to those
Accountability,” by David Marx, 2015, By Your
affected, containing the risk to others, and
Side Studios.
preserving factual information for subsequent
analysis. References
[Applies to all accreditation programs, except for 1. Montefiore Health System. What is Just Culture?
Laboratories.] video.
2. Frankel A, et al. A Framework for Safe, Reliable,
EP 6: The leaders provide and encourage the use and Effective Care. White Paper. Cambridge, MA:
of systems for blame-free internal reporting of a Institute for Healthcare Improvement and Safe &
system or process failure, or the results of a Reliable Healthcare; 2017.
proactive risk assessment. (See also 3. David Marx. “Whack A Mole. The Price We Pay for
Expecting Perfection.” By Your Side Studios,
LD.03.04.01, EP 5; LD.04.04.03, EP 3;
2009.
PI.01.01.01, EP 8)
4. Pronovost PJ. “Why hospital peer-to-peer
Note: This EP is intended to minimize staff assessments are crucial for patient care,” The
reluctance to report errors in order to help an Wall Street Journal, Feb. 26, 2017.
organization understand the source and results 5. Chassin MR & Loeb JM. “High-reliability health
of system and process failures. The EP does not care: Getting there from here.” The Milbank
conflict with holding individuals accountable for Quarterly, 2013;91(3):459-490.
their blameworthy errors. 6. Joint Commission Resources. “Safety Culture
Assessment: Improving the Survey Process.” The

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org
Sentinel Event Alert, Issue 60
Page 8

Joint Commission Perspectives, June

2018:38(6):1-4.
7. Nembhard IM & Edmondson AC. “Making it safe:
The effects of leader inclusiveness and
professional status on psychological safety and
improvement efforts in health care teams.”
Journal of Organizational Behaviour,
2006;27:941-966.
8. Famolaro T, et al. Hospital Survey on Patient
Safety Culture 2018 User Database Report.
(Prepared by Westat, Rockville, MD, under
Contract No. HHSA 290201300003C). Rockville,
MD: Agency for Healthcare Research and Quality.
AHRQ Publication No. 18-0025-EF; 2018.
9. The Just Culture Algorithm™. Outcome
Engineering, LLC; 2008.
10. Mathews SC, et al. “A model for the departmental
quality management infrastructure within an
academic health system.” Academic Medicine,
2017;92:608-613.
11. Austin JM, et al. “From board to bedside: How the
application of financial structures to safety and
quality can drive accountability in a large health
care system.” The Joint Commission Journal on
Quality and Patient Safety, 2017;43:166-175.
12. James Reason. “Managing the Risks of
Organizational Accidents.” Ashgate, 1997.
13. Institute for Healthcare Improvement, Tools
webpage, RCA2: Improving root cause analyses
and actions to prevent harm.
14. Pennsylvania Patient Safety Authority. “Why
Reporting Matters.”
15. Pronovost PJ, et al. “Demonstrating high
reliability on accountability measures at The
Johns Hopkins Hospital.” The Joint Commission
Journal on Quality and Patient Safety,
2013;39(12):531-544.
16. O’Connor S & Carlson E. “Safety culture and
senior leadership behavior.” Journal of Nursing
Administration, 2016;46(4):215-220.
17. European Organization for the Safety of Air
Navigation (EUROCONTROL). “From Safety-I to
Safety-II: A White Paper.” September 2013.
18. The Joint Commission. “The essential role of
leadership in developing a safety culture.”
Sentinel Event Alert, 2017(57).

_____________________________________________
Patient Safety Advisory Group
The Patient Safety Advisory Group informs The Joint
Commission on patient safety issues and, with other
sources, advises on topics and content for Sentinel Event
Alert.

© 2018 The Joint Commission | May be copied and distributed | Division of Healthcare Improvement jointcommission.org