Poor communication has been the root cause of many sentinel events over the years, and there has been growing recognition of how the work environment and culture influence patient outcomes. In a 2018 Sentinel Event Alert, the Joint Commission stressed the need to develop a “reporting culture”—to make it safe for providers to speak up and either prevent errors from occurring or correct course afterward without fear of punishment.
For me, the answer is easy. For 25 years I…
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