Month: October 2016

by David Pillatsch David Pillatsch No Comments

Joint Commission’s New “SAFER™ Matrix”

The lead article in the October 2016 issue of Perspectives discusses the new SAFER Matrix and the many changes planned for 2017. As you will recall from earlier articles on the SAFER Matrix each finding will be color-coded one of 4 colors by order of significance and scope. The lowest level findings will be bright yellow, or lemon colored. The somewhat moderate level findings will be a pale yellow/orange sort of like French’s mustard. The next highest ranking is a darker golden/orange color, somewhat like Guldens spicy mustard. Lastly there is a red color for the highest significance and most widespread scope. (Dare we say the color of ketchup?) The way in which these different levels will be handled during the ESC is different also, with the 2 highest levels requiring:

Leadership involvement

Preventative analysis

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by David Pillatsch David Pillatsch No Comments

Summary of Hospital Sentinel Event Statistics for 2016

The August 2016 issue of The Joint Commission Perspectives summarizes the sentinel event statistics for the first half of 2016. The top 5 most common sentinel events identified so far in 2016 are:

1. Unintended retention of a foreign object
2. Falls
3. Wrong patient, site or procedure
4. Suicide
5. Delay in treatment.

Each of these 5 issues also has a recent reference from TJC either as a Sentinel Event Alert, a Quick Safety Newsletter or Targeted Solutions reference. We would encourage all of our readers to look at the references and discuss their own risks and what might be done to reduce them. Read more