Almost 8,000 total sentinel events have been reported to TJC since 1995. The majority of reports were submitted by hospitals (64%), 62% of the total reports resulted in patient death, and the most prevalent types of events reported through this voluntary reporting system are wrong-patient, wrong-site, or wrong-procedure, and unintended retention of a foreign body. Leadership, human factors and communication were identified as the most frequently identified root cause of such events.
Upcoming EventsApr7Tue8:00 pm Just Culture Certification Course @ Wheeler Heart and Vascular Center at CoxHealthJust Culture Certification Course @ Wheeler Heart and Vascular Center at CoxHealthApr 7 @ 8:00 pm – Apr 9 @ 5:00 pmCALL FOR GROUP DISCOUNT – Not Valid With Any Other Discounts. Visit http://events.justculture.org for more information. Your leaders will learn to improve the systems they build around their employees, manage at-risk behavioral choices of their employees, create a more open …Apr9Thu9:00 am EMS Just Culture Manager’s Train... @ Randolph County Ambulance DistrictEMS Just Culture Manager’s Train... @ Randolph County Ambulance DistrictApr 9 @ 9:00 am – 4:00 pmEMS Just Culture training courses are structured toward the providers of emergency medical services and focus on the challenges of the pre-hospital environment. Attendees learn the five skills of Just Culture, the unique differences between Human Error, At Risk Behavior …Apr15Wed11:00 am PSO 101 – Introduction to PSOsPSO 101 – Introduction to PSOsApr 15 @ 11:00 am – 12:00 pmOpen to anyone, this webinar will describe the basics of the Patient Safety and Quality Improvement Act (PSQIA) and provide an introduction to the terminology and concepts of PSO participation. Register here.Apr16Thu8:00 am Long Term Care Just Culture Trai... @ Cardinal Ritter - Mary, Queen and Mother CenterLong Term Care Just Culture Trai... @ Cardinal Ritter - Mary, Queen and Mother CenterApr 16 @ 8:00 am – 4:15 pmJust Culture is a framework that supports the identification of system safety issues while also providing analytical tools to identify and address poor behavioral choices by employees. It supports resident safety and can help improve morale and reduce turnover. This …Jun30Tue12:00 pm SESSION #2 Quality Management in...SESSION #2 Quality Management in...Jun 30 @ 12:00 pm – 1:00 pmFor EMS Leaders and Providers: Center for Patient Safety Presents- EMS Quality and Patient Safety Learning Webinar Series in 2015 The Center for Patient Safety has the opportunity to meet and listen to EMS leaders and providers from around the …
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