The healthcare community uses RCA to reduce medical errors, but it is reactive in nature. For this reason, Joint Commission collaborates with recognized patient safety experts to develop and implement additional patient safety standards.
These new standards charge healthcare organization leaders to create cultures of patient safety. They emphasize the need for teamwork and effective communication.
They are based on well-known experiences of the aviation industry and they reflect findings from Joint Commission's Sentinel Event Database. They identify communication breakdowns as the most common underlying factor in all types of Sentinel Events.