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RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

Monday June 22, 2015


This report describes methodologies and techniques that an organization or individuals can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their systems to understand what and why the event occurred, and how to prevent future events. Download the document.

A complimentary webinar will be held Wednesday, July 15. Register now.

Venous Thromboembolism (VTE) Prevention

Venous Thromboembolism (VTE) Prevention


The Center for Transforming Healthcare announces its eleventh patient safety project, which aims to prevent rates of venous thromboembolism (VTE). VTE is a major cause of morbidity and mortality in the United States. It has been estimated that up to 900,000 VTE’s occur per year resulting in approximately 100,000 deaths. Learn More

Joint Commission Leaders in JAMA

Wednesday May 20, 2015


The May 12, 2015, Journal of the American Medical Association includes a Viewpoint by The Joint Commission’s president and CEO, Mark R. Chassin, MD, FACP, MPP, MPH, and executive vice president for Healthcare Quality Evaluation, David W. Baker, MD, MPH. Read the article to find out why they are calling for a new approach to quality and safety improvement. Listen to Dr. Chassin's Author Reading.

Accelerating the Adoption of a Safety Culture

Monday March 16, 2015


The March/April issue of Healthcare Executive features the Joint Commission's Ana Pujols McKee, M.D., executive vice president and chief medical officer, The Joint Commission, discussing how to build a culture of safety. Read the article to find out why she says it is "probably the most challenging work that a health care organization has do to."  

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Preventing Falls with Injury Project

High-Reliability Health Care: Getting There from Here 

High-Reliability Health Care: Getting There from Here


The article “High-Reliability Health Care: Getting There from Here,” written by Drs. Mark R. Chassin and Jerod M. Loeb, The Joint Commission, urges hospitals to make the substantial changes that will be needed to achieve the ultimate goal of zero patient harm by adapting lessons from high-risk. Learn More




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Texas Health Resources


There are so many opportunities for hand-off communication to go wrong. There are so many people involved and so many different required elements leading to effective communication.
Kenneth Abrams, M.D. - Senior Vice President, Clinical Operations / Chief Quality Officer, Associate Chief Medical Officer
North Shore Long Island Jewish Health System

Mission Statement 

To transform health care into a high-reliability industry by developing highly effective, durable solutions to health care’s most critical safety and quality problems in collaboration with health care organizations, by disseminating the solutions widely, and by facilitating their adoption.

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