Sentinel Event Alert focuses on developing a reporting culture by learning from close calls

Many health care organizations have started to acknowledge that leadership and structural support for staff who recognize and report unsafe conditions are essential to creating a safety culture—a critical component of high reliability in health care.

Recently, The Joint Commission published Sentinel Event Alert, Issue 60: Developing a reporting culture: Learning from close calls and hazardous conditions, which explores guidance for health care organizations and leaders in establishing a psychologically safe environment that eliminates fear of negative consequences for reporting mistakes and actively encourages learning from “close calls” in patient care.*

Close calls happen more frequently than injurious events. Reporting close calls gives important information on active and potential weaknesses in safety systems from the perspective of care professionals. Furthermore, analysis of these close calls makes it possible to identify system weaknesses and to address daily workflow or systems use.

Creating a safety culture

Surgeons have the opportunity to positively influence safety culture in at least three ways:

  • What we do individually working with patients and staff in the clinic or in the operating room (OR)
  • What we do as leaders of an OR team to establish and advance these principles
  • What we can do in formal leadership positions within our organizations (for example, chairperson, quality assurance chair, or chief medical officer)

According to the alert, The Joint Commission receives annual reports from health care staff about unsafe conditions that exist in their institutions—with the majority indicating that an institution’s leadership was unresponsive to these reports or to other early warnings. However, the alert states that many institutions “have begun to acknowledge or give positive recognition to staff members who report errors or recognize unsafe conditions.”

It further states that to create a safety culture, it is critical to identify and report these unsafe conditions before they can cause harm and to trust that other staff and leadership will act on the report while also taking personal responsibility for one’s own actions.* The alert further states that leadership needs to focus on improving safety culture, emphasizing to staff that the need to report a safety issue outweighs the fear of repercussions.

According to the alert, “In a safety culture, health care organization leaders are ultimately responsible for developing highly reliable systems. In turn, staff members are personally responsible for what is considered largely under their control—making good choices when working within these systems.”

It also is important for leaders in an institution to be strong role models by making themselves accountable for their mistakes. This behavior shows the staff and unit managers that failure is inherent to the human condition and that by recognizing failure and addressing the root causes that led to it, we learn from our own mistakes, and we make the system better. It is what has been called “failing forward.”

Taking action

The alert suggests that leaders at health care institutions take the following actions:†

  • Review Sentinel Event Alert, Issue 57, along with the new alert and commit to implementing a safety culture at your institution.
  • Communicate leadership’s commitment to building trust and reporting through a safety culture.
  • Develop an incident reporting system, including close calls and hazardous conditions, that encourages reporting. This system should include a recognition program and provide a feedback loop so staff know that action is being taken to address or fix the identified flaw.
  • Hold managers, leaders, and, where appropriate, staff accountable for addressing and eliminating errors and hazards identified by reporting and for continually improving the safety of the patient care environment.
  • Ensure that leaders at all levels of the institution apply a standardized accountability process to assess the difference between system flaws, which are the cause of most errors and hazardous conditions, and at-risk or reckless behaviors.

Sentinel Event Alert, Issue 60, and an accompanying infographic on “The 4 Es of a Reporting Culture” are available online. Both the alert and the infographic may be reproduced if credited to The Joint Commission.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Chassin MR, Loeb JM. High-reliability health care: Getting there from here. The Milbank Quarterly. 2013;91(3):459-490.

The Joint Commission. Sentinel Event Alert, Issue 60: Developing a reporting culture: Learning from close calls and hazardous conditions. Available at: Accessed February 1, 2019.

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